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

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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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.

9. 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

10. 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

11. 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

12. 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

13. 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 kg per week and aid wound healing
Suggest ways to optimise oral intake by adding to patients diet history, with puddings, snacks and food fortification

14. Diet History Breakfast: Porridge made with water and a little salt.
200ml cup of tea (with semi-skimmed milk and 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

15. Feedback

16. 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

17. 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

18. 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

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

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

21. 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

22. 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

23. Thanks you for listening and taking part Any Questions?