Treatment by a dietitian for a patient diagnosed with malnutrition in the community
The treatment is based on a risk profile that has been filled out by the patient him/herself. Together
with the dietitian the patient discusses his/her risk profile and determines which problems he /she
wants to tackle first.
The risk profile and the action plan are also published on this website.
This documents describes the possible steps that the dietitian can take to help a patient.
Time schedule
o
o
o
o
o
≤ 1 working day after diagnosis of (the risk of) malnutrition: referral to a dietitian
≤ 2 working days: assess intake by telephone (explaining the risk profile and nutritional diary)
≤ 5 working days after the telephone contact: plan a consultation
≤ 2 working days after the consultation: start treatment
≤ 2-10 working days after the start of treatment: evaluate and adjust (if necessary)
Example of a treatment scheme
These examples are based on the Dutch reimbursement rules for consultations by a dietitian. A
patient is reimbursed for a maximum of 4 hours of dietetic consultations per year.
Consultation at the dietitian’s office
o Intake assessment by telephone
o First consultation
o Three follow-up consultations
o Three contacts by telephone
o Follow-up consultation after 5 months
o Final consultation after x months
o Mailing tips and tricks
o Registration and administration
Total
15 minutes
45 minutes
3 x 15 minutes
3 x 5 minutes
15 minutes
15 minutes
5 minutes
90 minutes
4 hours
Home visit
o Intake assessed by telephone
o Home visit/ first consultation
o Two follow-up consultations
o Three contacts by telephone
o Follow-up consultation after 5 months
o Final consultation after x months
o Mailing tips and tricks
o Registration and administration
Total
15 minutes
45 minutes
2 x 30 minutes
3 x 5 minutes
30 minutes
10 minutes
5 minutes
90 minutes
4 ½ hours
Notes:
- Patients lose motivation after approximately 6 months
- The consultations consist of a combination of telephone consultations, face-to-face contact,
reminders (letter, e-mail)
- Tips: think of recipes, show patients the advantages of keeping to their dietary advice.
Intake by telephone
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o
o
o
Get an impression of the degree of malnutrition
Explain the risk profile chart (see the following pages ) and nutrition diary
Make an appointment
Answer any questions
First consultation
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Personal data
Medical background (medical diagnoses, medical history, clinical observations by the referring
doctor, medical treatment, medication, prognosis, other relevant information)
Psychosocial data (living situation, education, school, work, ethnicity)
Reason for referral to the dietitian
Other referrals (social worker, home care, physiotherapist etc.)
Check and discuss risk profile:
o Did you manage to fill out the profile: what struck / impressed you most?
o Has the patient fillled out the profile in correctly?
o Discuss any unexpected /abnormal scores
o Explore any reasons for the unexpected scores
o Discuss the significance of the problem with the patient
o Explain the reasons for and consequences of any unexpected / abnormal scores
Calculate requirements
o Protein: 1,2-1,7 gram/kg/day (in case of overweight, use the weight assigned to BMI 27)
o Energy: H&B (1984) + 30% extra for activities
o Give advice about Vitamin D and Calcium (> 65 years)
Take into account the possible risk of the Refeeding Syndrome1, especially in patients with very
low body weights (BMI<17 kg/m2 ) or in patients with involuntary weight loss who have not
eaten for the last 7 days.
Summarise the findings of the risk profile with the patient
Discuss what the patient would like to do (patient’s wishes)
Which risk factor would the patient like to begin with?
Give general advice
Explain the action plan
Make new appointments
1. Refeeding syndrome is a syndrome consisting of metabolic disturbances that occur as a result of
reintroducing nutrition to patients who are starved or severely malnourished. Refeeding syndrome usually
occurs within four days of starting to feed. Patients can develop fluid and electrolyte disorders, especially
hypophosphatemia, along with neurological, pulmonary, cardiac, neuromuscular and
haematologicalcomplications.
During refeeding, insulin secretion resumes in response to increased glycemia, resulting in increased glycogen,
fat and protein synthesis. This process requires phosphates, magnesium and potassium which are already
depleted and the stores are rapidly used up. In patients at risk of refeeding, treatment should start with
thiamine supplementation and complete nutrition should be (re)introduced slowly.
Follow-up consultations
This schedule can be used as a guideline for the dietitian, but must be adapted according to a
patient’s personal circumstances
Intake and
requirements
Nutritional
intervention
Evaluation and next steps
Patient meets
100% of
his/her
requirements
Advise a protein and
energy enriched
diet (if necessary
advise oral
nutritional
supplements)
The patient is asked to monitor his/her own intake and
body weight. The patient should contact the dietitian if
there are any problems with his/her diet.
Patient meets
75-100% of
his
requirements
Advise protein and
energy enriched
diet (if necessary
advise oral
nutritional
supplements)
The dietitian evaluates intake and monitors body weight
within 10 working days. If necessary, he/she will advise
starting or continuing oral nutritional supplements
Patient meets
50-75% of his
requirements
Advise protein and
energy enriched
diet and oral
nutritional
supplements (or
tube feeding)
The dietitian evaluates intake and monitors body weight
within 5 working days. If necessary he/she will advise
starting or continuing tube feeding
Patient meets
< 50% of his
requirements
Advise protein and
energy enriched
diet combined with
tube feeding.
Consider complete
tube feeding
The dietitian evaluates intake and monitors body weight
within 2 working days. He/she will adapt the tube
feeding or supplement regimen if necessary
The dietitian contacts the patient within 10 working days
(by telephone)
Check and discuss risk profile:
o Did you manage to fill out the profile: what struck / impressed
you most?
o Has the patient filled out the profile in the correctly?
o Discuss any unexpected / abnormal scores
o Explore the reasons for any unexpected / abnormal scores
o Discuss the significance of the problem with the patient
o Explain the reasons for and consequences of any unexpected /
abnormal scores
Risk
Points of attention
1. Involuntary weight loss
- use SNAQ65+ or other objective criteria for
assessing malnutrition to diagnose any (risk of)
malnutrition
- register the present weight and usual weight of
the patients, calculate involuntary weight loss
- discuss the consequences of involuntary weight
loss with the patient
- calculate the optimum body weight (based on
BMI BMI 22-28 ≥ 65 or BMI 20-25 <65)
- determine the mid arm muscle circumference
- if possible determine the FFMI
- discuss the consequences of low body weight
with the patient
- check the specific problems , their seriousness,
frequency, and any reason(s) for them
- check if there is a relationship between the
problems and the nutritional intake
2. Body weight is too low
3 Reduced intake
4.Gastrointestinal
complaints
5. Unbalanced diet
6. Difficulties shopping
and cooking (including
poverty)
7. Other complaints such
as tiredness, loneliness,
depression, pain
-
- check medication(s) if there is nausea
- refer to a dentist if there are dental problems
- consult with a speech therapist if there are
swallowing problems
- check the specific problems , their seriousness,
frequency and any reason(s) for them
- check if there is a relationship between the
problems and the nutritional intake
- check medication(s)
- discuss the nutritional diary with the patient
- is the diary representative of the last month
- discuss any findings about completeness,
amounts eaten and altered food intake
- check the specific problems , their seriousness,
frequency and any reason(s) for them
- check if there is a relationship between the
problems and the nutritional intake
- discuss possible solutions (meals on wheals,
eating facilities in nearby community homes etc)
- check the specific problems , their seriousness,
frequency and any reason(s) for them.
- check if there is a relationship between the
problems and the nutritional intake
- check medication(s), especially in case of pain
or depression
- check the pain score in case of pain
- consult with the GP to discuss treatment(s) by
other professionals
-
Summarise the risk profile with the patient
Fill out an action plan with the patient
Ask the patient which issue he/she would like to be dealt with first
Give initial general advice
VAS score
Pain may influence nutritional intake. To assess pain, you can use a visual analogue scale.
VAS (Visual Analogue Scale)
The scale is a horizontal line of 10 cm. Ask the patient to rate his/her pain at that moment, 0
indicating no pain at all and 10 indicating unbearable pain. A score of 4 points or more indicates
significant pain. Refer to the GP for further treatment of pain.
No pain
Unbearable pain
Depression
Patients with signs of depression are at higher risk of malnutrition due to decreased appetite and loss
of interest in food. The diagnosis and treatment of depression should be carried out by a GP. If the
patient reports depression or if a dietitian suspects this , refer the patient to the GP.