Introductory Certificate in Obesity, Malnutrition and Health

Slide set for Workshop 4Recognising and treating malnutrition

Acknowledgments R Pryke

WORKBOOK PAGES 33 - 38

Workshop 4 Recognising and

treating malnutrition

Aims

To increase awareness of the risk of malnutrition in practice and use a screening tool

To consider a variety of ways malnutrition can be addressed

To understand the clinical benefits this can bring

Assessment should include biopsychosocial

not just biochemical aspects.

Social issues important – Affordability/Availability/Will to eat/drink

Red flag: If not managing to eat sufficiently, a person may also be neglecting other basic aspects of health

Holistic risk

BMI

Poverty

Swallow

Functional ability

MUST score

Alcohol intake

Dental check

Mental state examination

Vision assessment

Which of the following do we consider when assessing malnutrition?

Assessing Malnutrition - Testing

No biochemical marker perfectly assesses general nutritional status. Multiple micronutrient deficiencies are not uncommon

Key lab tests FBC/MCV

Ferritin

Folate, B12

Vitamin D

Ca

Phosphate

Don’t forget to considerCo-existing dehydration

Malabsorptive disorders: Coeliac disease, Pancreatic insufficiency, Crohn’s

Thyroid disease HIV

TB

Current attitudes in primary care

Weight loss is well recognised as a red flag of active disease, e.g. cancer: We ask, we register, we investigate – but do we treat?

Deficiencies e.g. iron, B12, folate, vit D, are commonly viewed independently of a possible nutritional component

Weight loss and malnutrition are accepted as ‘normal parts of ageing’.

It remains unclear who is responsible for managing the social determinants of malnutrition

The same patients risk both conditions

The same patients benefit from simple interventions to address both, i.e.

Recognition of risk

Assessment of barriers to self-efficacy, e.g. continence problems that encourage patients to fluid restrict

Help in addressing those barriers, e.g. practical and emotional support at mealtimes, social support to help with food and fluid provision

Addressing hydration protects renal health and reduces risk of acute kidney injury

Nutrition and hydration are uniquely inter-related

The healthy eating ‘low-fat’ agenda risks unintended consequences including malnourished patients inappropriately choosing low fat, low calorie foodsTraffic light food labelling discourages high fat/high calorie foods but does not indicate who this information is targeted at.Over-emphasis on lowering cholesterol in elderly people may be contributing to malnutrition. Reduced dairy intake risks reducing protein and fat soluble vitamin intake

‘Healthy eating’ means different things to different people

Conflicting messages: What does food labelling convey?

Would patients and carers consider these foods healthy or unhealthy?

Poorer clinical outcomesImpaired immune system

Delayed wound healing

Reduced muscle strength/falls risk

Increased healthcare use (13)

more GP visits (68.8% vs 59.3% with low risk malnutrition)

Increased admission and readmission rate

Longer hospital stay

Costly to health economy

Impact of Malnutrition - both a cause and consequence of ill health (3,4,5)

Groups at risk of malnutrition3

Chronic disease COPD, cancer, inflam bowel disease, GI disease, renal or liver disease

Chronic progressive disease

Dementia, neurological conditions (Parkinson’s disease, MND) arthritis

Acute illness No food for more than 5 days (e.g. postoperative)

Debility Frailty, immobility, old age, depression, convalescence

Social issues Poor support, housebound, inability to shop or cook, poverty

What should GPs do?

Screen – Use MUST Malnutrition Universal Screening Tool www.malnutritionpathway.co.uk (6)

Assess causes – isolation, dentures, food availability, intercurrent illness, poverty

Give ‘Food First’ advice for those at low to medium risk. May need to unpick ‘healthy eating’ ideas

Evidence for dietary advice show improvements in muscle mass and hand grip strength with dietary advice9

Ensure balanced nutrients provided e.g. follow Managing Malnutrition in the Community guidelines(7) or local pathways, and review progress

‘MUST’

Improved nutrition helps wound healing, reduces length of hospital stay and rates of hospital readmission. 3,4,5,13

Quality of life can improve particularly in presence of chronic co-morbidities

Uncertainties around addressing malnutrition are heightened when patients are dying.

Guidance re nutritional support in lung cancer is at www.lungcancernutrition.com

Whilst malnutrition should not be considered a normal part of ageing, it is commonly an acceptable part of dying.

Be clear about aims of nutritional interventions

‘Food First’ or food fortification

Texture modification – puree or minced,

Thickening liquids – for dysphagia

Calorie fortification – to increase energy density of foods• Fat is highest – 9 cals per gram• Alcohol is high – 7 cals per gram• Protein and carbohydrate both have 4 cals per gram• Fibre is low - 2 cals per gram

Increase high calorie snacks between meals

Increase social support at mealtimes to promote enjoyment from eating

Address difficulty with feeding utensils

Nausea – consider antiemetics

ONS prescribing goals

Consider ONS prescribing for established malnutrition especially if illness related or prior to surgery.

Evidence demonstrates a range of clinical and health economic benefits10, 12 but check indications – 57-75% prescribed inappropriately

Set goals:• To prevent further weight loss• Optimise nutrient intake during acute illness• Improve healing of wounds or pressure ulcers• Improve mobility

Acute illness/recent hospital discharge? • Short term prescribing may be required – 1-3 ONS per day in addition to

oral intake

Chronic conditions ? • 2 ONS per day in addition to oral intake with regular review

ACBS – prescribable indications (11)

Disease related malnutrition

Short bowel syndrome

Intractable malabsorption

Pre-operative preparation of undernourished patients

Inflammatory bowel disease

Total gastrectomy

Dysphagia

Bowel fistulae

Caution in

Alcoholics

Substance misuse

Eating disorders require psychiatric assessment

Refer dietician if

Complex nutritional needs – renal disease, poorly controlled DM, GI disorder

Prescribing

Acute illness/recent hospital discharge Short term prescribing may be required – 1-3 ONS per day in addition to oral intake

Chronic conditions 2 ONS per day in addition to oral intake with regular review

Terminal conditions - consider whether ONS would give symptomatic support and slow down weight loss and functional decline

palliative care

progressive neurological conditions

advanced illness

The formal definition of cachexia is the loss of body mass that cannot be reversed nutritionally: Even if the affected patient eats more calories, lean body mass will be lost, indicating a primary pathology is in place.

Distinguishing treatable malnutrition from end-stage cachexia enables different management approaches to be taken with confidence

Treating malnutrition may improve quality of life but not influence duration of life

ONS can give symptomatic support and slow down weight loss and functional decline

What is cachexia?

Ethical dilemmas

PEG feeding may remove the natural mechanism of dying from someone who has had, for example, a profound stroke.

Should death, if artificial feeding were not commenced, be considered management failure or natural outcome?

Is it more acceptable to die from an untreated bronchopneumonia than from the effects of food withdrawal in terminal illness?

Inquire, investigate AND treat malnutrition

Use a validated screening tool - MUST

Malnutrition is not a normal part of ageing but may be an accepted part of dying.

Assess hydration in addition to malnutrition

Brave debate is needed to ensure that malnutrition treatment in the elderly is driven by genuine goals to promote quality of life rather than just to postpone death.

Follow your local malnutrition pathway with regards to food fortification and ONS prescribing

Summary points for primary care

For guidance on screening, (including use of Malnutrition Universal Screening Tool), dietary advice and appropriate community prescribing of ONS www.malnutritionpathway.co.uk

CG32 Nutrition support in adults: quick reference guide 20 February 2006. http://guidance.nice.org.uk/CG32/QuickRefGuide/pdf/English

RCGP malnutrition webpages - search on ‘RCGP Nutrition’ http://www.rcgp.org.uk/clinical-and-research/clinical-resources/nutrition.aspx

Resources

1. Elia M, Russell C. Combating Malnutrition: Recommendations for Action. Report from the advisory group on malnutrition, led by BAPEN. 2009.

2. Russell CA and Elia M. Nutrition Screening Survey in the UK and Republic of Ireland in 2011. A report by BAPEN. 2012.3. Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: an evidence-based approach to treatment. Oxford: CABI

publishing; 2003.4. Elia M. Nutrition and health economics. Nutrition 2006; 22(5):576-578.5. Guest JF et al. Health Economic impact of managing patients following a community-based diagnosis of malnutrition

in the UK. Clin Nutr 2011; 30(4): 422-429.6. The "MUST" report. Nutritional screening for adults: a multidisciplinary responsibility. Elia M, editor. 2003. Redditch,

UK, BAPEN. 7. Multi-professional consensus panel. Managing Adult Malnutrition in the Community. 2012.8. Manual of Dietetic Practice. 5th ed. Wiley Blackwell; 2014.9. Baldwin C, Weekes CE. Dietary advice with or without oral nutritional supplements for disease related malnutrition in

adults (review). Cochrane Database of Systematic Reviews. 2011. 10. National Institute for Health and Clinical Excellence (NICE). Nutrition support in adults: oral nutrition support, enteral

tube feeding and parenteral nutrition. Clinical Guideline 32. 2006. 11. BMJ Group And Royal Pharmaceutical Society of Great Britain. British National Formulary; 2011. 12. Stratton RJ, Elia M. A review of reviews: a look at the evidence for oral nutritional supplements. Clin Nutr Supp 2007;

2, 5-23.13. McGurk P, Cawood A, Walters E et al. The burden of malnutrition in general practice

http://gut.bmj.com/content/61/Suppl_2/A18.2

References