Objectives
 Identify the CQC regulation for nutrition & hydration
 Discuss the dietary management of diabetes
 Introduction to dietary advice for overweight &
malnourished patients
 Outline the importance of screening for malnutrition with
examples
Regulation 14: Meeting nutritional & hydration needs
(2014)
 People must have enough to eat & drink to meet their
needs
 People must have nutritional needs assessed & food
provided to meet their individual needs
 Must receive support with nutrition & hydration if
needed
 Provide a variety of nutritious & appetising food
 Appropriate temperature
 Culturally appropriate
 Preference & choice
 Prompts, encouragement, eating aids
 Follow prescribing plan for supplements
 Regular assessment of needs
 Staff should know when specialist nutritional advice is
needed & how to refer
Regulation 14: Meeting nutritional & hydration needs
(2014)
 When avoidable harm or exposure to significant risk of
harm is identified….
 CQC can prosecute for breach of regulation 14 without
serving a warning notice
 CQC will refuse registration if providers cannot provide
evidence of compliance
Points to consider…
 Priority of the person’s diabetes management
 Individualised assessment & treatment
 No ‘one size fits all’ approach
 Diagnosis, prognosis & quality of life
 Social aspects of eating
 Pleasure from eating
 Respect individuals’ choices
Which Nutrient Affects Blood Glucose?
All affect blood glucose!
Which Nutrient Affects Blood Glucose?
 Food is chewed to start
breaking it down
 Food is broken down further
in the stomach
 Carbohydrate is broken down
into glucose
 Shortly after eating
carbohydrate blood glucose
starts to rise
 Body cells use the glucose for
fuel or store it for later
Why is Diet Important?
Major influence on diabetes management & health
 Blood glucose control
 Long & short term complications
 Body fat and insulin resistance
 Risk of other diet related diseases
 Vitamins, Minerals, Protein & Fats are essential for good
health
Diet Myths – True or False
 People with diabetes shouldn't have:
 Bananas, grapes, melon & mango
 Sweet foods and puddings
 Lots of sugary drinks
 People with diabetes should:
 Use diabetic products
 Always snack between meals
 Follow a ‘special’ or ‘diabetic’ diet
Healthy Eating
Healthy Eating in Care Homes
 Regular & Balanced Meals
 Portion control
 Healthy menu planning & cooking
 Appetising meals & variety
 Healthier snack & pudding options
 Limit processed or ‘junk’ foods
 Avoid sugary drinks & added sugars
 Occasional ‘treat’ foods are fine
Healthy Eating
How much is important
 Regular meals spreads carbs out
 Avoid added sugars & sugary food/drinks
 Fruit & fruit juices
 Don’t double up on starches
 Smaller portions of puddings
The type is also important
 Porridge, basmati rice, new potatoes, seeded bread,
whole grain starches & cereals
Weight Management
Simple Tips for weight management in care settings
 Regular Meals
 Portion Control – even healthy food can affect weight!
 Healthy, tasty menu choices and healthy snack options
 Healthier puddings & desserts or small portions
 Avoid added sugars (drinks & foods)
 Non restrictive approach with occasional ‘treat’ foods
Simple swaps and small changes
 Swap Chocolate pudding for chocolate Muller light
 Swap Shortcake biscuits for rich tea
 Change drinks to diet, sugar free, no added sugar
 Swap sugar for sweeteners
Weight Management
What would you change?
Breakfast:
Large bowl of cereal with milk, 2 Toast with butter, 1
glass of fruit juice
Mid morning: 3 plain digestives with cup of tea
Lunch:
Tuna mayo sandwich, 2 slices granary bread with 5
teaspoons mayonnaise and packet of crisps
Evening Meal: Beef casserole with large portion of mashed potato
(made with butter) and full portion sponge pudding
with custard
Supper:
3 plain digestives with cup of tea
Weight Management
What would you change?
Breakfast:
Large bowl of cereal with milk, 2 Toast with butter, 1
glass of fruit juice
Mid morning: 3 plain digestives with cup of tea
Lunch:
Tuna mayo sandwich, 2 slices granary bread with 5
teaspoons mayonnaise and packet of crisps
Evening Meal: Beef casserole with large portion of mashed potato
(made with butter) and full portion sponge pudding
with custard
Supper:
3 plain digestives with cup of tea
Weight Management
What would you change?
Breakfast:
Large bowl of cereal with milk, 2 Toast with butter, 1
glass of fruit juice
Mid morning: 3 plain digestives with cup of tea
Lunch:
Tuna mayo sandwich, 2 slices granary bread with 5
teaspoons mayonnaise and packet of crisps
Evening Meal: Beef casserole with large portion of mashed potato
(made with butter) and full portion sponge pudding
with custard
Supper:
3 plain digestives with cup of tea
Weight Management
What would you change?
Breakfast:
Small bowl of cereal with milk, 1 Toast with butter, 1
glass of fruit juice
Mid morning: 3 rich tea biscuits with cup of tea
Lunch:
Tuna mayo sandwich, 2 slices granary bread with 5
teaspoons light mayonnaise and packet of crisps
Evening Meal: Beef casserole, extra veg with medium portion of
mashed potato (made with butter) and small portion
sponge pudding with custard
Supper:
3 rich tea biscuits with cup of tea
Weight Management
Reducing the portions with some simple
swaps saves approximately
900 - 1000 calories per day!
Balance the Plate
Malnutrition
 The priority is getting the patient to eat
 At this stage healthy eating is not a priority
 Aim to provide nutritious foods which are high
in calories & protein
 Control Blood glucose with medications during
this period
Consequences of malnutrition
• Poor wound healing and higher risk of infections
• Frequent hospital admissions
• Muscle wasting, Lack of energy/Depression
• Dehydration
• Vitamin and mineral deficiencies
Recognising Malnutrition
• Mobility: weakness, impaired movement
• Mood: apathy, lethargy, poor concentration
• Current intake: reduced appetite, changes in meal
pattern and food choice
• Physical appearance: loose clothing, rings or dentures,
sunken eyes, dry mouth, emaciation, pale complexion,
hair loss
• Screening tools: e.g. MUST
Why Screen for malnutrition?
• Early identification of patients
at risk
• Early intervention
• When repeated weekly allows
monitoring where nutritional
care plans in place
• Audit practice
‘MUST’
Benefits of using MUST
• Easy to use, rapid and reproducible
• Any care worker can be trained to use ‘MUST’
• Can be used with patients who can’t be weighed
and measured
• Available on line from www.bapen.org, as well as
paper format in a variety of sizes
MUST
 Toolkit is freely available to use for non-commercial purposes
and available for download from the BAPEN website:
http://www.bapen.org.uk/screening-formalnutrition/must/must-toolkit/the-must-itself
‘Acute Disease is unlikely to apply outside hospital’
Case Study: Jane
 75 years old
 Type 2 diabetes: Diet controlled
 5’ 4” or 1.62m
7st 12lb or 50kg
 Resident for 2 weeks
 Not eating well, managing small amounts of meals, no
snacks but says ‘I’ve always had a small appetite’
 No previous weights available despite checking with
family and available medical documentation
Case Study: Steve




80 years old
Type 2 diabetes: Gliclazide & Metformin
5’ 9” or 1.76m 13st 5lb or 85kg
Long term resident, normally has a good appetite but
slowly lost his appetite, staff are concerned
 Eating one small meal per day and struggling with snacks
despite being encouraged
 Gliclazide was stopped by the DSN due to hypos
 Concerned staff check his weight history and discover he
weight 98kg only 2 months ago = 13kg weight loss
What to do If you feel a resident is at risk of
malnutrition:
Inform a staff nurse
Monitor food and fluids on food
charts
Monitor weight weekly
Encourage oral intake – additional
snacks, food fortification
If no improvement consider referral to
a dietitian
Ideas for Food fortification
• Sprinkle 2-3 tablespoons of dried milk powder into a pint of full fat
milk
• Full fat yoghurts, full fat milk, milky drinks, ice creams, milkshakes
• Add margarine or butter to vegetables, potatoes, bread and
chapattis. Don’t use a low fat spread!
• Sprinkle grated cheese onto savoury dishes such as soup & potatoes
• Add sugar, honey or syrup to puddings, cereals, drinks and
milkshakes
• Double cream can be added to a variety of savoury and sweet foods
such as casseroles, curries, soup, mashed potato, sauces, custard,
milky puddings and drinks.
Fortified menu
Menu 1
Breakfast
Porridge (made with water), bread + butter,
cup of tea
Lunch
Cup a soup, banana
Evening meal
Poached cod, jacket potato, yoghurt
Extras
Tea between meals, Horlicks at supper
Menu 2 – Fortified menu
Breakfast
Porridge (whole milk, syrup)
bread + butter (+ jam), cup of tea
(+ orange juice)
Lunch
Soup (creamy + bread),
banana (+ custard)
Evening meal
Poached cod (+cheese sauce) jacket
potato (+ butter), yoghurt (trifle)
Extras
Tea between meals, Horlicks at supper
(made with milk (+ 2 biscuits, cake)
Comparison
Menu 1
Menu 2
Energy
980 kcals
2070 kcals
Protein
48g
75 g
Hydration
Good hydration can help with
Mental performance
Headaches
Urinary tract infections
Falls
Pressure sores and wounds
Constipation
Concentration
Kidney stones Gall stones
Tiredness Lethargy
Oral health
Oral Nutritional Supplements
 Prescribed supplements – Ensure Plus, Pro Cal Shot
 High energy, high protein in small volume
 Expensive to use & compliance is poor
 Quick & Easy to use
 Follow prescribing information
 Timing
 Flavours
Referring to the Dietitian
 Community Matron ( Nursing Homes)
 District Nurses (Residential Homes)
 GP