Emma Binnie Senior Dietitian Intermediate Care Using Food First Emma Binnie Senior Dietitian Intermediate Care

Introduction Malnutrition Assessing malnutrition - MUST Treatment of malnutrition Food first approach Practical examples Appropriate use of oral nutritional supplements

Malnutrition A common clinical and public health problem, affecting all ages and all care settings Definition: ‘ A state in which a deficiency of nutrients such as energy, protein, vitamins and minerals causes measurable adverse effects on body composition, function or clinical outcome’ NICE [CG32]– Nutritional Support for Adults, February 2006

Those at risk of malnutrition: Sick, frail and elderly Cancer, Stroke Acute/chronic pain Chronic respiratory disorders, i.e. COPD Poor dentitian Clinical consequences include: Reduced muscle strength Impaired wound healing Longer recovery from illness/surgery Poorer clinical outcomes More frequent GP visits and hospital admissions

Facts Tackling malnutrition can improve In 2010, 34% of hospital in-patients on admission were medium/high risk of malnutrition 93% of those at risk from malnutrition, live in the community Malnutrition costs £13b per year and affects at least 2 million people in the UK Effective and regular screening to identify malnutrition or risk of malnutrition is essential Tackling malnutrition can improve nutritional status, clinical outcomes and reduce health care use BAPEN, 2010

Malnutrition Universal Screening Tool (‘MUST’) What is ‘MUST’? A five-step malnutrition screening tool for adults in hospital and the community, including care homes, outpatient clinics and general practice What does ‘MUST’ do? Identify those who may be malnourished or at risk of malnutrition MUST Score of: 0 – low risk 1 – medium risk 2 or above – high risk

How often should patients be screened? All Hospital in-patients to be screened within 24hours of admission, then weekly All outpatients at their first appointment All people in care homes on admission, then monthly All people on registration at GP surgeries And for all, upon clinical concern, including: unintentional weight loss, loose fitting clothes, wasted muscles fragile skin, poor wound healing poor appetite, altered taste sensation, impaired swallowing altered bowel habit; or prolonged illness

Medium and High Risk of Malnutrition (MUST Score >1) Should not automatically be prescribed Oral Nutritional Supplements (ONS) Instead think “Food First!” Many already doing this, but everyone needs to put this into practice.

Guidelines for the Appropriate Use of Oral Nutritional Supplements (ONS) for Adults on Primary Care Nov 2012 (Sept 2015 update) Aim to promote the appropriate, rational and cost effective prescribing of ONS Involves ‘7 steps to prescribing’, including: Identification of nutritional risk (e.g. MUST) Assessment of causes of malnutrition Set treatment goals Offer ‘FOOD FIRST’ advice (to increase calories and protein in everyday foods, aswell as additional snacks). Review after 1 month Prescribing ONS Reviewing ONS Discontinuing ONS and follow up

What is Food First Optimising oral intake Food Fortification: For those at medium or high risk of malnutrition adding ordinary, household ingredients to normal food to increase its nutritional content, without increasing the amount of food which needs to be eaten. Aim – to add energy and protein intake (food fortification plus 2-3 small between meal snacks and milky drinks

How to fortify Identify foods and drinks the patient likes and manages well Identify the best ingredients to use to fortify Use the most nutritious ingredients, not just butter and cream Use enough to make a difference Ensure the food still tastes nice after fortifying

How to Fortify Can be added to: Calories added Protein added 4 tablespoon dried, skimmed milk powder 1 pint of Milk 212kcal per pint 21.2g per pint 1 tablespoon dried, skimmed milk powder Porridge, soup, mashed potato, rice pudding, custard 53kcal 5.4g 1 tablespoon evaporated milk Rice pudding, semolina, tea, coffee 24kcal 0.6g 1 heaped teaspoon jam/honey Porridge, toast 49kcal 0g 1 tablespoon ground almonds Porridge, soup 95kcal 3g 1 tablespoon double cream Soup, puddings 70kcal 1 dessertspoon condensed milk Custard 1.0g 1 tablespoon grated cheese Soup, mashed potato 62kcal 3.8g 1 teaspoon butter/spread Mashed potato 37kcal 1 tablespoon desiccated coconut Puddings 0.8g 1 tablespoon dried fruit Porridge, puddings 43kcal 1 scoop Ice cream 105kcal 2g 1 dessertspoon peanut butter Toast, bagel 99kcal 3.7g 1 tablespoon mayonnaise Sandwich

Practical Frail, elderly patient with a MUST Score of 2: Height: 1.60m, Weight: 49kg (was 52.5kg) BMI: 19.14kg/m2 6.7% weight loss (3.5kg) Aim: stop further weight loss, regain 0.5-1.0kg per week and aid wound healing Suggest ways to optimise oral intake by adding to patients diet history, with puddings, snacks and food fortification

Diet History Breakfast: Porridge made with water and a little salt. 200ml cup of tea (with semi-skimmed milk and 2 teaspoons of sugar) AM: Cup of tea Lunch: Corned beef sandwich made with 2 slices of bread. Plus cup of tea PM: Cup of tea and a small pork pie Dinner: Small portions of Shepherds pie. Plus cup of tea Evening: Cup of tea Additional 150ml water with medication Energy Intake: 1094kcal Requirements: 1440kcal (weight maintenance) 1840kcal (for weight gain) Fluid Intake: 1350ml Requirements: 1470ml

Feedback

Suggested Changes Breakfast: Porridge made with water and a little salt. 200ml cup of tea (with semi-skimmed milk and 2 teaspoons of sugar) Swap to fortified whole milk in porridge: 184kcal. In tea: 31kcal AM: Cup of tea Swap to fortified whole milk in tea: 31kcal Add small scone (223kcal) with jam (40kcal) Lunch: Corned beef sandwich (2 slices of bread). Plus cup of tea Add full fat yoghurt: 175kcal

Suggested Changes PM: Cup of tea and a small pork pie Swap to fortified whole milk in tea: 31kcal Dinner: Small portions of Shepherds pie. Plus cup of tea Add 2 tablespoon of grated cheese: 125kcal Swap to fortified while milk in tea: 31kcal Evening: Cup of tea Swap to cup Horlicks: 93kcal (made with 200ml fortified whole milk): 204kcal In addition: All cups of tea to increase from 200ml to 250ml

Requirements: 1840kcal for weight gain, 1470ml Previous energy intake: 1094kcal Previous fluid intake: 1350ml New total energy: 2084kcal New total fluid: 1650ml Total added calories: 990kcal Total added fluid: 300ml

Resources Food and Fluid Chart Making More of Your Food – fortifying foods and drinks Nourishing Drinks Food First Advice Fabulous Fortified Feasts - recipes

Food models Gives an idea of the volume of extra 100 calorie snacks Aim to choose options manageable by patients Savoury and sweet options

Cost of ONS in the Community PRODUCT COST PER DOSE (£) COST IF PRESCRIBED BD (£) COST OVER 1 MONTH (£) COST OVER 3 MONTHS (£) COST OVER 6 MONTHS 1st Line AYMES SHAKE 0.61 1.22 34.16 102.48 204.96 Complan Shake 0.70 1.40 39.20 117.60 235.20 2nd Line AYMES Complete 1.12 2.24 62.72 188.16 376.32 Ensure Plus Milkshake 2.80 78.40 470.40 Ensure Compact 1.45 81.20 243.60 487.20 3rd Line Ensure Plus Juce 1.84 3.68 103.04 309.12 618.24

Overview Ensure MUST is undertaken correctly, and as often as appropriate Those identified with, or at risk of malnutrition – early intervention is essential Think ‘Food First’: What foods does your patient enjoy? What could be added to foods and drinks they currently have? What extra foods and drinks could be added to optimise intake? Monitor your patient – if Food First and food fortification not enough, refer to Nutrition and Dietetic Service

Thanks you for listening and taking part Any Questions?