2. 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

3. 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

4. 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

5. 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

7. 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

8. Which Nutrient Affects Blood Glucose? All affect blood glucose!

9. 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 Which Nutrient Affects Blood Glucose?

10. 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

11. 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

12. Healthy Eating

13. 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

14. Healthy Eating

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. Weight Management Reducing the portions with some simple swaps saves approximately 900 - 1000 calories per day!

22. Balance the Plate

24. 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

25. 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

26. 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

28. 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

29. ‘MUST’

31. 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

32. 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-for- malnutrition/must/must-toolkit/the-must-itself http://www.bapen.org.uk/screening-for- malnutrition/must/must-toolkit/the-must-itself

36. ‘Acute Disease is unlikely to apply outside hospital’

39. 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

40. 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

42. 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

44. 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.

45. 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)

46. Comparison Menu 1 Energy 980 kcals Protein 48g Menu 2 2070 kcals 75 g

47. Hydration Good hydration can help with Mental performance Headaches Urinary tract infectionsFalls Pressure sores and wounds Constipation Concentration Kidney stones Gall stones TirednessLethargy Oral health

48. 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

49. Referring to the Dietitian Community Matron ( Nursing Homes) District Nurses (Residential Homes) GP