Managing Malnutrition Andrea Ralph BSc (hons) RD Senior Medical Affairs Advisor, Nutricia

Identifying malnutrition NICE Clinical Guideline 32, 2006 section 1.2.1 Recommends screening across all care settings Health care professionals should screen All hospital inpatients on admission All outpatients at there first appointments All people in care homes on admission All people on registration at GP surgeries And all of the above upon clinical concern

Appropriate management of malnutrition NICE Clinical Guideline 32, 2006 1.6.6 Healthcare professionals should consider oral nutrition support to improve nutritional intake for people who can swallow safely and are malnourished or at risk of malnutrition. ‘A-grade’ recommendation … should contain a balanced mixture of nutrients (including protein, energy, vitamins, minerals) … should continue until the patient is established on adequate oral intake from normal food ….take care when using food fortification as this tends to supplement energy and not other nutrients

Why we should manage malnutrition Adverse consequences for the patient Muscle wasting (skeletal, cardiac, respiratory) Reduced immune function - Increased risk of infection Poor / delayed wound healing / pressure ulcers / reduced mobility Apathy and depression Reduced QOL, increased complications Increased health care costs (Stratton et al 2003)

Why we should manage malnutrition Adverse consequences for the health economy People with malnutrition have higher use of health care: More GP visits (65%) More hospital admissions (82%) More hospital readmissions More deaths post-discharge More support post-discharge (Elia 2005, Elia 2006, Stratton et al 2006)

Significant savings are possible. NICE cost saving guidance – Dec 2009 CG32 Nutrition support in adults Costs arising: improving systematic screening, assessment and treatment of malnourished patients. If this guideline was fully implemented and resulted in better-nourished patients: Reduced complications such as secondary chest infections, pressure ulcers, wound abscesses and cardiac failure. Reduced admissions Reduced length of stay for admitted patients Reduced demand for GP and outpatient appointments Significant savings are possible. -£28,472 3rd highest of 19 reviewed guidelines for potential cost saving per 100,000 people

Identifying and managing malnutrition http://www.bapen.org.uk/must_tool.html

Malnutrition risk identified – what next? Document screening details Identify and manage reason for decreased nutrition intake Disease symptoms / side effects Take action! Develop care plan (refer to local policy) Consider: Aims of intervention Short term / long term goals Route of intervention (oral / enteral / parenteral) Practicalities Monitor progress and adapt care plan appropriately Weekly for all inpatients

Managing malnutrition

Enteral tube feeding Enteral tube feeding NG Gastrostomy Nutritionally complete Wide range available for adults and children Available in hospital and on prescription In the community, home care nursing and delivery service provided for patients Involve a dietitian or nutrition support team

Oral nutrition support Definition of : Oral nutrition support (NICE CG 32) Practical support for people unable to feed themselves (e.g. modified feeding aids), altered meal patterns (e.g. small meals and snacks) Fortified food with protein, carbohydrate, fat, vitamins, minerals Dietary advice from a dietitian Oral nutritional supplements (ONS).

Practicalities of improving oral intake Assistance Ensure food ordered is the food received Assist with menu choices (high energy / modified texture where required) Clear table of distractions Ensure table, food, utensils and drinks are within reach Offer assistance to cut up meals if needed Adapted cutlery / plates Altered meal patterns Small meals and snacks (‘drip-feeding’ nutrition) Nourishing drinks

What is food fortification? Adding everyday foodstuffs to meals to increase the nutrient content, without increasing volume Butter, oil Full cream milk Cheese Skimmed milk powder Jam Syrup Honey Sugar Caution – can increase just energy and protein without micronutrients

Evidence – food fortification Cochrane review, 36 studies (n=2614): Evidence for nutrition support in malnourished adults: dietary advice no advice and dietary advice plus ONS in adults with malnutrition Evidence suggests weight gain, grip strength, improved MUAC are greater with dietary advice + ONS rather than dietary advice alone ‘lack of evidence for the provision of dietary advice in managing illness-related malnutrition’ ‘dietary advice plus nutritional supplements maybe more effective than dietary advice alone or no advice’ Baldwin and Weeks 2009 14

There was no data on the cost-effectiveness of these approaches. There was insufficient evidence for NICE to assess the effect of dietary advice and / or other food strategies (snacks, food fortification) on mortality, complications and weight There was no data on the cost-effectiveness of these approaches.

Dietary advice from a dietitian Individual assessment and advice Meal pattern alteration Food fortification ONS Nutritional adequacy related to condition / nutritional requirements Clinical indication e.g. renal disease, liver disease Ideal for individuals where first line actions have not improved nutritional intake Preparation for discharge to home setting Dietetic resource can vary from trust to trust Check local policy

What are oral nutritional supplements (ONS)? Produced by nutrition companies (range available) Mostly liquids (some puddings) Multi nutrient supplements Most are nutritionally complete Energy (fat and carbohydrate), protein, micronutrients) Milk, yoghurt, juice style ready made Ready made usually gluten and lactose free Available in hospital and on prescription (FP10) Supplements you make up with milk Supplements designed specifically for children Some disease specific

Practicalities of using ONS ONS (200-600kcal) can be used to improve clinical outcome in a range of hospitalised patients. (Stratton2007) 2 x standard 1.5 kcal/ml ONS 600-660kcal 24–28g protein Consider individual preferences for flavour (sweet, savoury, fruit preferences) ONS can be served chilled, at room temperature or warmed From bottle with straw, decant into cup / beaker Add to food Neutral / vanilla flavoured ONS in porridge, soups Dessert style served with ice cream Ensure patient understands why they are receiving ONS and encourage intake

NICE review of the evidence - oral nutritional supplements Proprietary oral nutritional supplements: Significantly reduce mortality Significantly reduce complications Significantly improve weight Functional benefits Better energy and protein intakes in supplemented patients in all trials Acceptable to patients

Age UK ‘Still Hungry to be heard’ Update on the campaign launched 4 years ago - 85% of hospitals engaged with the campaign - 55% have taken action towards the 7 steps. Age UK 7 steps to end malnutrition Hospital staff must listen to older people, their relatives and carers and act on what they say. All ward staff must become ‘food aware’. Hospital staff must follow their own professional codes and guidance from other bodies. Older people must be assessed for the signs or danger of malnourishment on admission and at regular intervals during their stay. Introduce ‘protected mealtimes’. Implement a ‘red tray’ system and ensure that it works in practice. Use volunteers where appropriate. www.ageuk.org.uk Age UK - ‘Still hungry to be heard’ The scandal of people in later life becoming malnourished in hospital. Released: 30th August 2010 Age UK (formerly know as Age Concern) launched the ‘Hungry to be heard’ campaign 4 years ago, outlining the problem of malnutrition in hospitals and 7 recommended steps to combat the problem. ‘Still hungry to be heard’ is an update on the progress of the campaign. The document is written from a patient’s perspective, to give a powerful message about the ongoing problem of malnutrition in hospital. This is followed by a reminder of the 7 recommended steps, together with negative patient experiences and good practice examples. 4 years of ‘Hungry to be heard’ campaign has focused on: Improving hospital meals and meal times. Calling for effective identification and management systems for malnutrition. Lobbying government. Producing a resource pack, including guidance documents for carers and relatives. Increasing public awareness through media campaigns. Progress: 82% of hospitals have engaged with the ‘Hungry to be heard’ campaign and over half of these (55%) have taken action in line with the 7 recommended steps. Despite the campaign, malnutrition remains a problem in hospitals. Challenges facing the success of the campaign: Inconsistencies in identification, management and monitoring of malnutrition across and within hospitals. Basic issues still being raised from patient’s hospital stay experiences. Government action needed. Where the campaign is going now (‘what we want’) All wards to implement Age UK’s 7 recommended steps. Government must introduce compulsory recording of malnutrition rates. CQC (Care Quality Commission) must complete a comprehensive review of hospital mealtimes. The ‘Still hungry to be heard’ campaign wraps up by calling for action: Tell friends and family. Share experiences from hospital stays. Lobby local MP’s. Find out more about the campaign.

High Impact Actions for Nursing and Midwifery 8 ‘High impact actions’ identified by nurses and midwives ‘Keeping nourished getting better’ focuses on: identifying individuals at risk of malnutrition providing good nutritional care, stopping inappropriate weight loss and dehydration in NHS provided care. To ensure patients are screened for malnutrition and get the right amount of nutrition and hydration needed for a speedy recovery, dietitians and nurses need to work together. http://www.institute.nhs.uk High impact actions for nursing and midwifery. 8 areas identified from website submissions by nurses and midwives: Your skin matters Staying safe - preventing falls Important choices - where to die when the time comes Fit and well to care Promoting normal birth Ready to go - no delays Protection form infection Keeping nourished getting better This ‘high impact action’ is about identifying individuals at risk of malnutrition, providing good nutritional care, stopping inappropriate weight loss and dehydration in NHS provided care. The document outlines that malnutrition is a common and costly problem in the UK and introduces ‘Hospital Hydration Best Practice Toolkit’. To ensure patients are screened for malnutrition and get the right amount of nutrition and hydration needed for a speedy recovery, dietitians and nurses need to work together. The document includes some ‘good practice’ examples, 2 of which focus on reducing ONS prescribing and project a negative image of ONS prescribing in terms of cost, without measuring the benefits and potential cost saving of using ONS effectively. Summary available on Medical Affairs Intranet

Essence of Care: Benchmarks for food and drink 10 factors in the food and drink section Screening and assessment Best Practice: People who are screened and identified at risk receive a full nutritional assessment Screening takes place on first contact with health care providers and is repeated regularly for those at risk of malnutrition or upon clinical concern. Validated tool such as the Malnutrition Universal Screening Tool (MUST) A full assessment and appropriate referral is undertaken for people who are identified initially as at risk of malnutrition or as morbidly obese. Screening, assessment and nutrition support is undertaken in partnership with people. Department of Health Essence of care 2010 – Benchmarks for the fundamental aspects of care 1st October 2010 The updated Essence of Care 2010 was developed in partnership with people and carers and supports and reflects a number of the themes in Equality and Excellence: Liberating the NHS and provides a suite of benchmarks to drive forward best practice in delivering the fundamentals of care and improving the experiences of people who use services. It identifies best practice and highlights how it can be achieved. A benchmark is: ‘a standard of best practice and care by which current practice and care is assessed or measured.’ The benchmarks are designed to be used wherever health and social care is planned, managed and/or delivered, including but not limited to hospital, care homes, peoples own homes, GP surgeries. The updated document has 12 main sections including one on food & drink: Bladder, Bowel and Continence Care Care Environment Communication Food and Drink Prevention and Management of Pain Personal Hygiene Prevention and Management of Pressure Ulcers Promoting Health and Well-being Record Keeping Respect and Dignity Safety Self Care http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_119969

Summary Nutritional screening using a reliable and valid tool, such as ‘MUST’, is an essential first step in the management of malnutrition As part of the screening process, a plan for management of malnutrition risk should be developed There are a number of oral nutrition support strategies to improve nutrition intake Local policy should be in place for the appropriate evidence based management of malnutrition There is limited evidence for the use of dietary advice and food first strategies in clinical practice Evidence shows that ONS can improved clinical and functional outcomes which may reduce health care costs.

Some Key References NICE CG32. February 2006. Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Includes Costing Report. Elia M, Russell C (2009). Combating Malnutrition: Recommendations for Action. Report from the advisory group on malnutrition, led by BAPEN. Stratton RJ, Elia M. (2007). A review of reviews: A new look at the evidence for oral nutrition supplements in clinical practice. Clinical Nutrition Supplements (2); 5-23 Elia M. (2006). Nutrition and Health Economics. Nutrition (22); 576-578. Elia M, Stratton R, Russell C et al. (2005) The cost of disease-related malnutrition in the UK and economic considerations for the use of oral nutritional supplements (ONS) in adults. A report by The Health Economic Group of The British Association for Parenteral and Enteral Nutrition (BAPEN). Baldwin C and Weeks CE (2009) Dietary advice for illness-related malnutrition in adults (Review). Cochrane database of systematic reviews 2008, Issue 1. Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: an evidence-based approach to treatment. Oxford: CABI publishing, 2003.