1. First Line Management of Malnutrition in the Community Education Session Facilitated by Community Dietitian – Sharon Kennelly Dublin Mid-Leinster

2. Topics 1. Malnutrition-Introduction 2. Use of the MUST screening tool for adults and Referral to community dietetics services 3. Giving dietary advice to patients with poor appetite 4. The appropriate use of Oral Nutritional Supplements (ONS) 5. Monitoring patients 6. Strategies for dealing with underlying causes ?

3. Background Definition of Disease Related Malnutrition Definition of Disease Related Malnutrition Incidence of Malnutrition in the Community Incidence of Malnutrition in the Community High cost of treatment- High cost of treatment- –Malnourished consume more resources ONS project - baseline data ONS project - baseline data Need for a more evidence based approach Need for a more evidence based approach

4. Cost Considerations ? Cost Considerations ? Between Aug 2003 and August 2004 € 314,000 was spent on Oral Nutritional Supplements in this county. 2 cartons/day for 1 year = € 1600 approx.

5. CONTRIBUTING FACTORS TO MALNUTRITION IN THE COMMUNITY SOCIAL Poverty- Inability to shop and /or cook Inability to feed self Living alone MEDICAL Chronic Disease States Malignancy G.I Disease Medications 3+ per day Affect appetite Other G.I Disturbances Poor Detention PSYCHOLOGICAL Alcoholism Bereavement Depression Dementia Food aversions

6. Signs and Symptoms related to possible risk of malnutrition-what to look out for ? VISUAL VISUAL –Clothes or jewellery lose not fitting properly,belt notch change –Obvious thin/Wasted appearance MOBILITY MOBILITY –History of decreased activity, decreased ADL score CHANGE IN EATING BEHAVIOUR CHANGE IN EATING BEHAVIOUR –History of decreased intake/poor appetite, portion sizes changed –Altered taste/smell –Change in food preferences avoiding food e.g. meat –Poor appetite/disinterest in food reported –GI DISTURBANCES-SMALL APPETITE : –Nausea, early satiety, diarrhoea, constipation, dry mouth, lack of appetite difficulty swallowing

7. Levels of risk of malnutrition? High risk: More pre-disposed to longer term chronic ill-health High risk: More pre-disposed to longer term chronic ill-health Low risk: Less pre-disposed to chronic ill-health Low risk: Less pre-disposed to chronic ill-health

8. Introduction to Malnutrition Universal Screening Tool (MUST) Tested and verified as a quick and easy to use tool Tested and verified as a quick and easy to use tool Developed by a multidisciplinary group in the UK including doctors, dietitians, nutritionists and nurses for adults Developed by a multidisciplinary group in the UK including doctors, dietitians, nutritionists and nurses for adults Validated as an effective method of identifying and managing malnutrition Validated as an effective method of identifying and managing malnutrition Takes approx 3-5 minutes to complete for initial assessments and as little as 1 minute for reviews Takes approx 3-5 minutes to complete for initial assessments and as little as 1 minute for reviews

9. How to use the MUST Nutritional screening tool The MUST tool can be used an for initial assessment or as a monitoring tool The MUST tool can be used an for initial assessment or as a monitoring tool It is designed for use with adults only It is designed for use with adults only 5 steps to follow: 5 steps to follow: Aim is to add 3 scores to get a total risk score and then follow management guidelines Aim is to add 3 scores to get a total risk score and then follow management guidelines It is important to record scores for future reference and to have a planned review It is important to record scores for future reference and to have a planned review

10. Who is MUST not suitable for ? Children and young adults (<18 years) Children and young adults (<18 years) Athletes –people with high muscle mass Athletes –people with high muscle mass Patients with fluid retention/Oedema Patients with fluid retention/Oedema Post-amputation Post-amputation Pregnancy/Lactation Pregnancy/Lactation

11. STEP 1-BMI score Body Mass Index (BMI) is a weight for height measurement that gives a rapid interpretation of chronic protein energy status. Body Mass Index (BMI) is a weight for height measurement that gives a rapid interpretation of chronic protein energy status. Measure the person’s height in metres (m) Measure the person’s height in metres (m) Measure the persons weight in kilograms (kg) Measure the persons weight in kilograms (kg) If calculating it’s the weight /(height) 2 If calculating it’s the weight /(height) 2 Use the BMI chart to determine Use the BMI chart to determine their BMI Score (kg/m²) their BMI Score (kg/m²) Alternative measurements Ulna length can be used to determine height, see instructions Ulna length can be used to determine height, see instructions You can also used patient reported height You can also used patient reported height Mid Upper Arm Circumference can be used to determine BMI-see instructions Mid Upper Arm Circumference can be used to determine BMI-see instructions

12. Example :BMI SCORE A man’s weight is 58 kg and his height is 1.78m A man’s weight is 58 kg and his height is 1.78m What is his current BMI ? What is his current BMI ? Using the BMI Score Guide his BMI..... 18.5 kg/m² Using the BMI Score Guide his BMI..... 18.5 kg/m² What is his BMI Score ?................. What is his BMI Score ?................. His score is 1

13. Step 2- Weight Loss Score Weight loss refers to unintentional weight loss in the last 3-6 months Weight loss refers to unintentional weight loss in the last 3-6 months Weight loss is an important clinical sign Weight loss is an important clinical sign Ask the patient or examine the medical records for previous weight history Ask the patient or examine the medical records for previous weight history Previous weight –Current Weight = weight loss. Previous weight –Current Weight = weight loss. Then use tables to establish weight loss score. Then use tables to establish weight loss score.

14. Example: Weight Loss Score The same man has a previous weight of 62kg in his chart from 4 months ago. The same man has a previous weight of 62kg in his chart from 4 months ago. What is his Weight Loss Score -Using the % unplanned weight loss table ? What is his Weight Loss Score -Using the % unplanned weight loss table ? 62-58 kg = 4kg 62-58 kg = 4kg 5-10% weight loss 5-10% weight loss SCORE 1 for Weight Loss SCORE 1 for Weight Loss

15. Step 3: Acute Disease Score Generally not applicable to community dwelling patients Generally not applicable to community dwelling patients Apply this score if the patient is affected by an acute Apply this score if the patient is affected by an acute patho-physiological or psychological condition patho-physiological or psychological condition Example :Acute pancreatitis Example :Acute pancreatitis There should be very little or no food intake for the last five days or there is likely to be no intake for the next five days There should be very little or no food intake for the last five days or there is likely to be no intake for the next five days The Score is always 2 The Score is always 2

16. Step 4 : Calculate The Overall Risk of Malnutrition Add the Scores From Step 1,2 and 3 = MUST TOTAL SCORE = MUST TOTAL SCORE 0 =Low risk 1 = Moderate/Medium risk 2+ = High Risk

17. STEP 5 : Follow the Management Plans LOW RISKMEDIUM RISK HIGH RISK Routine Clinical Management Treat Underlying Causes Give basic dietary advice REVIEW If no progress commence ONS Refer to Community Dietitian

18. Management of ‘Low Risk’ Continue routine clinical treatment Continue routine clinical treatment As a guide these patients do not require Oral Nutritional Supplement Prescriptions unless they are part of ‘exception group’ As a guide these patients do not require Oral Nutritional Supplement Prescriptions unless they are part of ‘exception group’ NOTE:If you are concerned about a patient’s nutritional status even with a MUST score of 0 - contact Community Dietitian NOTE:If you are concerned about a patient’s nutritional status even with a MUST score of 0 - contact Community Dietitian

19. Management of ‘Moderate Risk’ Identify underlying medical causes and treat if possible Identify underlying medical causes and treat if possible Liase with appropriate community voluntary services/public health nurse Liase with appropriate community voluntary services/public health nurse Give basic diet advice for small appetite/weight loss using patient leaflet Give basic diet advice for small appetite/weight loss using patient leaflet Make plans to review Make plans to review If no improvement consider prescription of ONS -liase with Community dietitian If no improvement consider prescription of ONS -liase with Community dietitian

20. Management of ‘HIGH RISK’ These patients can be referred directly to the Community Dietitian and will be generally be assessed within 2-4 weeks These patients can be referred directly to the Community Dietitian and will be generally be assessed within 2-4 weeks A referral form which can also be used to record the MUST results can be faxed or posted to the Community dietitian A referral form which can also be used to record the MUST results can be faxed or posted to the Community dietitian Liase with the public health nurse if there are social concerns regarding the patient Liase with the public health nurse if there are social concerns regarding the patient

21. How will this system work in practice ? Practice Nurses G.P Public Health Nurses Role of Community Dietitian: Manage and arrange review of high risk patients Gate keeper for ONS prescriptions Support, advice & nutrition resources to the primary care practice Nurses in Nursing Homes Identify and screen patients using MUST tool Take steps to manage ‘moderate risk’ patients Refer ‘high risk patients’ directly to the Community Dietitian

22. Patients who can be referred directly to the Community dietitian ‘Exception Groups’ Renal disease –chronic renal failure Renal disease –chronic renal failure Active inflammatory bowel disease –Crohns, Ulcerative Colitis Active inflammatory bowel disease –Crohns, Ulcerative Colitis Patients with chronic wounds or sores Patients with chronic wounds or sores Pancreatic Disease Pancreatic Disease Liver disease Liver disease Head and Neck Cancers, GI Cancers Head and Neck Cancers, GI Cancers Chronic Respiratory Diseases Chronic Respiratory Diseases

23. Dietary Advice for Patients with Poor Appetite Dietary Advice for Patients with Poor Appetite ‘ ‘FOOD FIRST’ Use the Patient Leaflet : ‘Eating when you have a small appetite’ as a guide – –3 small meals plus 3 snacks –Little and often approach’ – –Choose protein and energy dense foods at each meal- meat, chicken, fish, dairy products, fats,sugars – –Drink at least 1 pint of full fat milk/milky drinks per day

24. Food Enrichment Adding protein and energy dense foods/products to their normal meals Adding protein and energy dense foods/products to their normal meals –Dairy Products: milk cream, yoghurt, cheese, skimmed milk powder –Fats: butter,oil (frying), margarine –Sugars: sugar, jam, honey Example :Adding skimmed milk powder to fresh milk, adding honey to porridge, cream to soup etc. Example :Adding skimmed milk powder to fresh milk, adding honey to porridge, cream to soup etc.

25. Food enrichment example – NORMAL DIET Breakfast Porridge with water Slice brown bread and butter Cup of tea with milk Lunch Two slices brown bread with butter 1 Slice of ham and 1 tomato Cup of tea with milk Dinner 2 small boiled potatoes Breast Chicken 1 tablespoon boiled vegetables Glass of milk

26. Food enrichment example – ENRICHED DIET Breakfast Porridge with milk and 2 teaspoon sugar Slice brown bread and butter and jam Cup of tea with milk Lunch Two slices brown bread with butter 1 Slice of ham and 1 tomato & 30g cheese Cup of tea with milk Dinner 2 scoops mashed potatoes plus 2 pats butter Breast Chicken 1 tablespoon boiled veg Glass of fortified milk 1 custard style yoghurt 600 KCALS EXTRA !

27. Oral Nutritional Supplements Sip Feeds: Milk,juice, yoghurt or savoury based drinks Sip Feeds: Milk,juice, yoghurt or savoury based drinks Disease Specific formulation sip feeds Disease Specific formulation sip feeds Desert /Mouse type products Desert /Mouse type products Modular Products- Liquid and powder varieties Modular Products- Liquid and powder varieties

28. 2)Different Ways to use ONS FOOD ENRICHMENT PRODUCTS SUPPLEMENTARY DRINKS (SIP FEED STYLE) Powders and liquids Protein, Fat and Sugar Come in Neutral Flavours Neutral Flavoured SIP Feeds Milk,yoghurt and juice flavours Sweet and savoury flavours Tetra packs,Bottles, Powders to add to milk (See Recommended SIP Feeds Chart in resource pack)

29. Oral Nutritional Supplements - evidence of benefits ? ONS can produce improved clinical and functional outcomes as well as overall decreased mortality ONS can produce improved clinical and functional outcomes as well as overall decreased mortality E.g. Liver disease : Their use is associated with lower incidence of severe infections, and lower frequency of hospitalisation E.g. Liver disease : Their use is associated with lower incidence of severe infections, and lower frequency of hospitalisation Among patients in the community, showed that their benefits are greatest in patients with a BMI< 20kg/m² (High Risk of malnutrition) Among patients in the community, showed that their benefits are greatest in patients with a BMI< 20kg/m² (High Risk of malnutrition)

30. GUIDELINES FOR USING ORAL NUTRITIONAL SUPPLEMENTS SECTION 4 RESOURCE PACK SECTION 4 RESOURCE PACK 1) Identify a clear need for ONS USE THE MUST NUTRITIONAL TOOL 2)Pick the right type of product -Food enrichment Vs Sip feeds 3)Use Patient Leaflet advice how to use ONS 4)The type of ONS used can make a difference to cost. – –Food fortification type ONS offer better value for money – –1.5kcal/ml products offer better value for money

31. How long should ONS be prescribed for ? Compliance decreases the longer ONS are used Compliance decreases the longer ONS are used Long term use > 2 months may be associated with decreased overall energy intake Long term use > 2 months may be associated with decreased overall energy intake ONS may begin replace some normal foods ONS may begin replace some normal foods If a patient has been using ONS for > 2 months with no improvement in appetite/weight/MUST score –refer to the community dietitian If a patient has been using ONS for > 2 months with no improvement in appetite/weight/MUST score –refer to the community dietitian

32. How much to prescribe ? As a general guideline a patient needs approx.... As a general guideline a patient needs approx.... 500-600kcals extra to promote weight gain. 2 cartons of an energy type sip feed (1.5kcals/ml) per day as an initial prescription. 2 cartons of an energy type sip feed (1.5kcals/ml) per day as an initial prescription. If using food enrichment ONS a similar amount of energy (kcals ) would be prescribed If using food enrichment ONS a similar amount of energy (kcals ) would be prescribed See info in the resource pack. See info in the resource pack. 2 cartons per day

33. Avoid ‘Once off’ Prescriptions May have a big impact on total spending at your practice May have a big impact on total spending at your practice NOT EVIDENCE BASED USE NOT EVIDENCE BASED USE Special cases :post op patients with poor appetite and those with short term decreased mobility Special cases :post op patients with poor appetite and those with short term decreased mobility Resist the temptation to prescribe ONS as a tonic Resist the temptation to prescribe ONS as a tonic

34. Dealing with potential problems with ONS prescribing Inappropriate patient use of ONS Inappropriate patient use of ONS Patient and family demands Patient and family demands

35. Dealing with potential problems with ONS prescribing Collection and Storage of ONSCollection and Storage of ONS Powdered products and food enrichment ONS can be less bulky easier to carry but require more preparationPowdered products and food enrichment ONS can be less bulky easier to carry but require more preparation PackagingPackaging Sip style products come in tetra packs and some come in plastic bottles –ease of useSip style products come in tetra packs and some come in plastic bottles –ease of use Taste fatigue Taste fatigue Patients who require longer term use of ONS > 2 months will may require changes to their prescription type, flavours to improve compliancePatients who require longer term use of ONS > 2 months will may require changes to their prescription type, flavours to improve compliance

36. Dealing with potential problems with ONS prescribing Inappropriate patient use of ONS Inappropriate patient use of ONS Patient and family demands Patient and family demands

37. Monitoring Why :Monitoring is key to evaluating the success the success any nutritional intervention Why :Monitoring is key to evaluating the success the success any nutritional intervention Who is responsible for monitoring ? Depends on the patient location and local roles Who is responsible for monitoring ? Depends on the patient location and local roles What should be monitored: MUST score, compliance with dietary advice and ONS use, any problems What should be monitored: MUST score, compliance with dietary advice and ONS use, any problems When : how frequently should they be monitored ? depends on the level of risk and location When : how frequently should they be monitored ? depends on the level of risk and location

38. Monitoring Patient Location Patient Location Nursing home patients -staff nurses in liaison with the GP and dietitian Nursing home patients -staff nurses in liaison with the GP and dietitian Home bound patients- Public Health Nurses in liaison with the GP and community dietitian Home bound patients- Public Health Nurses in liaison with the GP and community dietitian Patients who visit the surgery frequently can be reviewed by appointment at GP surgery (ideal) or opportunistically when they attend the surgery by the GP or Practice Nurses Patients who visit the surgery frequently can be reviewed by appointment at GP surgery (ideal) or opportunistically when they attend the surgery by the GP or Practice Nurses Level of risk High risk patients will be seen in primary care clinics for review, or visited at home by the Community Dietitian High risk patients will be seen in primary care clinics for review, or visited at home by the Community Dietitian High risk patients will need to be reviewed at least every 2 months, moderate risk can be reviewed at two –four months. High risk patients will need to be reviewed at least every 2 months, moderate risk can be reviewed at two –four months.

39. Questions