Clinical Dietitians Who we are and what we do… Petra Teufl, NZRD

Aims To gain an understanding of the role of Dietitians and the multi-disciplinary team To increase awareness of how certain conditions impact on nutritional status To increase awareness of how malnutrition is assessed and treated To improve understanding of the link between wound healing and nutrition

What do Dietitians do? Registered health professionals Assess, diagnose and treat diet and nutrition problems Individuals and groups Public Health, Primary Health, Foodservice, Food Industry Evidence based practice Translate research into practical guidance Nutrition experts! GPs, hospitals, health trusts, watties, 3

Dietitians and Nutritionists What’s the difference? Scope of practice Medical nutrition Lifestyle nutrition Practice based on current scientific evidence Lifestyle nutrition only May or may not be based on current scientific evidence Government regulation Yes (Dietitian Act 1950) No Training required Undergraduate degree in Human Nutrition Post Graduate/Masters in Dietetics May have a qualification in Human Nutrition Registration Yes mandatory under the Health Practitioners Competence Assurance (HPCA) Act 2003 No, voluntary Licensing body NZ Dietitians Board Nutrition Society of NZ

Who do we see? At risk or Malnourished patients Patients with known disease states Liver disease, IBS, CRF, COPD, Diabetes, Cancer, Diverticular disease. Increased nutritional requirements Wound healing Texture modified diets Micronutrient deficiencies Nutrition education At waitemata dhb we have specialist dietitians working in paediatrics, renal, diabetes, surgical as well as general medical. We also have a specialist nutrition support team (TPN) made up of a dietitian, Nutrition nurse specialist, pharmacist and consultant. We cover both inpatient, outpatient and community. Talks-weight, cardaic, pulmonary and bariatric talks On-call Dietitian

Hospital Menus 21 different menus, currently 2 week cycle Standard (suitable for Diabetics) Sufficient to facilitate weight loss for overweight/obese patient if not eating food from home HEP (High energy and protein menu) Vegan, Dairy free, Renal specific, Low sodium Texture modified Soft Dysphagic, Minced and moist, Pureed Mildly / Moderately thickened fluids

Malnutrition – a hospital problem

Malnutrition costs more than obesity Malnutrition at WDHB 28% admitted at med-high risk Of those, 36% referred to dietitian Consequences of Malnutrition?? ↑ length hospital stay ↑ risk of infection ↑ depression, apathy, self neglect ↓ recovery from illness ↓ wound healing capacity ↓ respiratory muscle function ↓ muscle strength (poorer performance at physio) ↓ function / quality of life Malnutrition costs more than obesity

Malnutrition screening This form should be in every patient’s medications folder or observations and assessment part of the patient file. If you cant find it in the ob’s folder, there will be a copy on your ward somewhere. This actually only takes 5mins to do and can be done in stages at different times or done while you are measuring ob’s or walking them to the shower etc

Section One Measure weight and height Actual weight measurement always preferred Unable to measure height? Try measuring the ulna length Unable to do either? Try MUAC Work out BMI (see chart on the back)

Section Two Unintentional weight loss in the last 6 months While weighing the patient ask what they usually weigh and if they think they have lost weight. If a patient doesn’t know their usual weight – ask if jewellery is looser, clothes baggier etc Rule of thumb: no weight loss = <5% some weight loss= 5-10% lots of weight loss = >10% % wt loss chart available to help work it out We are worried about those who haven’t been trying to lose weight. If your patient tells you they have lost 20kg but that’s because they have been exercising more and eating healthily then that is ok. You may want to write it on the form though if you wish. It is always useful to document. Make sure you say ‘in the last 6 months’. If they lost weight unintentionally 3 years ago and have been maintaining it since its not an acute problem.

Section Three “There has been or is likely to be little/no nutritional intake for >5 days and acutely unwell” Looking for patients consistently eating <1/3 meals, or patients been on NBM/Preoperative clear fluids for a long time and not progressing Patients who aren’t eating because they don’t like the food, or don’t have their dentures are not necessarily going to score a yes on this question – are there things you can do as their nurse to help this out? This can be quite a tricky question to answer as we don’t have a crystal ball and everyone has different view of what is a ‘little oral intake’ What factors are impacting on their ability to improve intake? –constipated-talked to med team about laxatives. Nausea-talk to med team about anitmetics

Practice: Ulna length to height

Identifying High Risk Patients Underweight (BMI < 18.5kg/m2) Unplanned weight loss >10% NBM / no nutrition > 5 days i.e. Must score 2 or greater refer to Dietitian MUST Screen: Refer to Dietitian ASAP

What can you do? Ask: patient’s weight/height of usual reported weight Have they lost weight recently without meaning to? O/E - Do they look very thin or wasted? Visible signs of subcutaneous fat and muscle wasting Weigh your patient regularly, complete MUST screening Monitor: How long have they been NBM? If in doubt, discuss with Dietitian

Other scores Score 0- no intervention. Re-screen weekly Score 1-place on HEP menu, start food diaries for 3 days and re-screen weekly

Factors affecting nutritional status Neurology patients Factors affecting nutritional status

Impact of neurological conditions Memory Appetite control Hemiplegia Ataxia Psychological effects Dysphagia Perception Planning & sequencing Neglect Behaviour Aphasia Apraxia Aphasia – impairment in language ability Apraxia – loss of ability to perform tasks Ataxia – Lack of co-ordination of muscle movements Hemiplegia – Paralysis of arm, leg and trunk of same side 18

Screening and assessment Malnutrition risk screening1, 2 High risk patients referred to dietitian Patients with dysphagia 1,3 Often referred by SLTs Assessment: Anthropometry Biochemistry Clinical Dietary intake Estimate requirements - predictive equations (Schofield, Harris Benedict), ESPEN/ASPEN guidelines Monitoring The European Society for Clinical Nutrition and Metabolism 1NICE Stroke (2008), 2Stroke Foundation Guidelines (2010) 3 New Zealand Guideline for management of stroke 19

Oral Nutrition Support Patient will not receive supplements unless Dietitian referral made Ensures patients receive correct supplement for their disease state (eg. CRF, Liver disease, Diabetes, wound healing, malnutrition – different disease states may require different dose/type/times of administration) Allows full nutritional assessment to be completed Ensures requirements for special authority applications fulfilled Food first approach prior to supplementation Ensures prescriptions correctly provided, follow up arranged Different strengths / formulations 1 kcal/ml : Ensure/ Fortisip Powder, Diasip 1.2kcal/ml : Cubitan 1.5kcal/ml : Fortisip, Ensure plus, concentrated Ensure/Fortisip powder 2 kcal/ml : 2 Cal HN (high nitrogen formula) 4.5kcal/ml : Calogen (fat emulsion) Please refer to Dietitian if you feel your patient may require supplementation

Oral nutrition support in dysphagia Identification of all factors contributing to poor nutrition status – MDT approach Food first – strategies to improve nutritional density of modified texture diets Fortification strategies Prepared supplementary products e.g. sip feeds Standards & Definitions for Texture Modified Foods and Fluids (2007) NICE Adult Nutrition Support (2006) 21

Considering artificial nutrition support? CAN PATIENT SWALLOW? YES NO NORMAL DIET OR SLT RECOMMENDS TEXTURE MODIFIED DIET & FLUIDS IS GUT FUNCTIONING? YES NO YES IS ORAL INTAKE SUFFICIENT? TPN OR COMFORT CARES ENTERAL TUBE FEEDING NO NO LONG TERM >6-8 weeks SHORT TERM DIETITIAN ASSESSMENT & ADVICE TO ACHIEVE ADEQUATE INTAKE NG TUBE FEEDING PEG FEEDING

Enteral nutrition support in dysphagia Ethical considerations Consent MDT approach – prognosis? Methods of enteral nutrition support Nasogastric (NGT) vs Percutaneous endoscopic gastrostomy (PEG) Timing of initiation of enteral nutrition support Hours of feeding and rehab Withdrawal of enteral nutrition support 23

Routes of enteral feeding

Wound Healing and Nutrition

Wound healing and nutrition Malnourished patients are at high risk of developing pressure areas. Good nutrition has been shown to be effective at facilitating wound healing October 2011 November 2011 December 2011                                              

The role of Arginine Arginine, the substrate for nitric oxide synthase, was first noted to enhance wound healing in 1978 Dietary arginine supplementation has been shown to improve collagen deposition and wound strength in human and animal models Studies have clearly indicated the role of L-Arginine in wound healing. The evidence is strongest in the treatment of Pressure Ulcers.

Practice time If you can try and work individually through the practice case and then we will go through it all together at the end. I will give you a few minutes to do it.

Mrs S Mrs S has been in hospital for the last three days with pneumonia. She has been managing to eat about ½ her meals. While you are helping her change she comments on her cardigan being too big now. You weigh her later in the day and she is 48kg, but thinks when she was at the doctors in December she was 52kg. Her height is 1.54m. BMI = 20.3 (Must score 0 ) Weight loss Percentage = 7.7% (MUST score = 1) Eating adequately (MUST score 0) Score 1 - HEP menu/Food Diaries/Re-screen in 1 week Ask around the room people to tell you what they got for each section. Ask if anyone got anything different and why they put what they put. Once determined what the score is then ask them what they would do from there.

Mr T Mr T was admitted with abdominal pain and underwent a cholecystectomy 5 days ago. He had seen a dietitian last year and his weight had decreased from 110kg to 90kg with dietary changes and exercise. He currently is NBM as he has had some complications post surgery. He is 1.8m tall. Question 1– Score 0 Question 2 – Score 0 Question 3 – Score 2 Needs a referral to the dietitian.

Case Study

Case Study Feb 2011 SLT Dietitian Discharge planning started ?PH 84yr female, found by family at home on floor after collapsing approx two days prior Left sided paralysis and slurred speech Admitted to acute stroke ward Malnutrition risk screen = 4+ Weight 36.5kg, BMI 16.2kg/m2 Weight loss of 12% over previous 2 months SLT NBM Dietitian Nasogastric feed Discharge planning started ?PH Transferred to stroke rehab ward mid-March 32 32

Initial Dietetic Assessment How many days NBM so far? Calculate risk, prevent, monitor and treat refeeding syndrome Ability and speed of feeding to meet fluid and nutritional requirements Current weight/previous weight/ weight history Biochemistry Na, PO4, K+, Mg2+, Ca2+, Glucose, Albumin, prealbumin Hydration – IVF/SCF Pressure areas prevention and monitoring, provision of nutrients Time, rate, duration of feeding

Case Study 4 weeks post admission Commenced oral trials with SLT, little progress Team wanting to discharge patient Gastrostomy (PEG) – overnight feed 5 weeks post admission -trialled puree diet Titrated feed + fortified puree diet & moderately thickened fluids Food diary – reduced feed accordingly Poor intake of thickened fluids – top up PEG water flushes 7 weeks post admission – Minced and moist diet Fatiguing quickly during meals High calorie yoghurt/snacks, high energy and protein thickened supplement Bolus PEG feeds 34 34

Case Study Discharged to daughter’s home Sitting in a wheelchair Communicating Dysphagia continuing to improve Able to self feed Minced and moist, thickened fluid education from SLT & DT PEG Care and instructions Referral to community DT and SLT PEG was removed 3 months post-discharge Weight 42kg, BMI 18.6kg/m2

Summary Dietitians assess, diagnose and treat nutrition problems Neurological conditions increase risk of undernutrition Undernutrition has a negative effect on outcomes – eg pressure areas, rehab potential Treatment is individualised Teamwork allows better coordination of care for the patient 36

Questions?