Developing evidence based strategies and tools for the use of oral nutritional support in the community Vera Todorovic Consultant Dietitian in Clinical Nutrition Doncaster and Bassetlaw Hospitals NHS Foundation Trust

Common issues for primary care and the community l Every PCT will indicate that there have been increases in the volumes of oral nutritional supplements prescribed for patients and this is reflected in increased costs. l There is an assumption that inappropriate prescribing occurs and that there are no controls in place. l practitioners are unclear as to who should receive oral nutritional supplements and what the benefits of these are. l Robust guidance to help clinicians make informed decisions is not always available

Building the evidence for nutritional support in the community l identify key policy initiatives nationally and locally that could have an impact on the nutritional care of patients l Profile the local health and social care community l identify clinical evidence that demonstrates the burden of malnutrition in the community and the benefits that can be associated with nutritional support. l work in partnership with other staff and different agencies to identify high risk patient groups l link all elements together to develop best practice and evidence based strategies and guidelines for patient care.

Key policy drivers lGMS contract- chronic disease management –COPD, stroke, cancer, mental health lPayment by results - tariff system for commissioning care for patients lNew Pharmacy contract and enhanced services

Major national initiatives lEssence of Care ( hospital and community ) –pressure ulcers- assessment –food and nutrition lNational Service Frameworks ( NSFs) lNICE Guidelines –Nutrition support in adults:oral supplements, enteral and parenteral feeding (first draft May 2005 ) –The NICE guidance on the management of patients with COPD ( 2004 ) lLong term conditions and new ways of working - case managers lSupplementary prescribing

National Service Frameworks l Older people - falls, stroke, mental health, intermediate care, single assessment, promotion of health l Cancer,- dietitians have a valuable role l Long term conditions - multidisciplinary approach to improve care l Coronary heart disease - heart failure, CABG

National Institute of Clinical Excellence ( NICE ) guidelines lThe NICE guidance on the management of patients with COPD ( 2004 ) recognises the importance of addressing poor nutrition in vulnerable individuals with COPD and highlights the importance of carrying out nutritional screening on these individuals. For those individuals with a low BMI it suggests commencing them on nutritional supplements.

NICE guidelines Nutrition support in adults:oral supplements, enteral and parenteral feeding (first draft May 2005 ) lKey elements nutritional screening on admission to care homes, at hospital out-patients, when patients register with general practices nutrition support and patient selection snacks and supplements offered to patients should aim to ensure that overall nutritient intake is balanced in energy, protein, minerals and vitamins

Key drivers Performance Monitoring lHealthcare Commission- Standards for Health lPatient Environment Action Team ( PEAT) lEssence of Care lQIS- Quality Improvement Scotland Food, Fluids and Nutritional Care in Hospitals lWelsh Risk Pool lNational minimum standards for care homes for older people ( 8.9 )

Essence of Care Nutrition Benchmark 10 factors l Screening and assessment-patients at risk are given a full assessment l planning, implementation and evaluation of care l a conducive environment to eat in l patients are given assistance to eat and drink when they require it. l obtaining food-patients have sufficient information to obtain food l food provided meets the needs of individual patients l food is available for patients at all times and replacements are offered. l Food presentation is appealing l patients food intake is monitored l patients are encouraged to eat to promote their own health Links to l PEAT l Healthcare Commission Standards

Patient Environment Action Team - (PEAT) l Reviewing quality issues in England relating to cleanliness, ward environment and food l now includes a standard on nutritional care l 50% patients to have a recorded nutritional risk score and body weight l 50% wards observing protected meal times.

Healthcare commission- Assessment for Improvement-the annual health check l Standards to performance monitor all Organisations in England that provide care for patients l core standards reflect expected basic standards of care l standard C15 focuses on food and nutrition l key elements where food is provided patients are provided with a balanced diet and one that meets their nutritional, personal and clinical dietary requirements l assessors will expect to see evidence from a variety of sources eg Essence of care Patient meal survey Protected mealtimes PEAT

Local profiling

Prevalence of malnutrition in the community

Costs of malnutrition Malnutrition in the UK is an important clinical and public health issue Underweight individuals (BMI <20kg/m 2 ) l have been shown to consume more healthcare resources than those with a BMI between 20 and 25kg/m 2 l require more prescriptions (9%) l have more GP visits (6%) l have more hospital admissions (25%) l have higher death rates Source: Martyn et al. Effect of nutritional status on healthcare resources by clients with chronic disease living in the community. Clin Nutr (17):119-23

Significant functional and clinical outcome improvements – hospital and community patients receiving oral nutritional supplements

Clinical outcome improvements in the community for patients using oral nutritional supplements Systematic reviews by Stratton and Elia l Reduction in rates of infection, frequency of hospitalisation, reduction in the length of hospital stay, mortality. l Improvement in energy and nutrient intake,some evidence to suggest suppression of food intake but overall increase. l Improvements in body weight, greater with patients with BMI 20kg/m2 but weight losing. Stratton RJ, Elia M. A critical systematic analysis of the use of oral nutritional supplements in the community. Clin. Nutr. 1999; 18(2):1-84

Unintentional weight loss over three to six months l <5% body weight: normal intra-individual variation l loss 5% body weight: l less energetic l decrease in voluntary physical activity l increase in fatigue l loss 10% body weight: l changes in muscle function l disturbances in thermoregulation l poor response or outcome to surgery and chemotherapy

Formulating a plan l nutritional screening to identify at risk patients l determine goals and outcomes l care planning and treatment options l monitoring

Who requires nutritional support? Offer nutritional support to individuals who: l have unintentional weight loss of >10% over previous 3-6 months or l have a BMI 5% or l have a BMI < 18.5 or l no nutritional intake for 5 days and not likely to be eating in the near future NICE (2005)

Defining outcomes lfunctional eg improvements in respiratory muscle function increase walking distances increase activities of daily living Decrease in falls lbody composition eg improve muscle mass fat mass ldietary eg improve qualitative and quantitative aspects of diet

Care planning lWeight goals Maintain Prevent further loss Increase lDietary goals Continue Improve Increase lDietary interventions –Improve –Enrich –Use of supplements Vera Todorovic

Rationale for use of oral nutritional sip feeds/supplements l Supplement current oral intake to improve nutritional intake, aiming to meet nutritional requirements. Evidence suggests ONSs are additive to food. l Sole source of nutrition,replacing oral intake where nutritional intake is poor. l Improves clinical outcomes for the patient.

What to give? l Fortified foods, snacks, texture modified and dietary counselling l Limited data available to suggest what daily quantities of ONSs confer benefits for patients but a daily intake of kcal has been shown to be of value( Delmi et al 1990;Larson et al 1990;Rana et al 1992 ) l individuals with a BMI 20kg/m2 but losing weight are more likely to benefit from the provisional of ONSs ( Stratton and Elia 1999; Stratton et al 2003 ) l when choosing supplements it is probably more effective to choose a variety of different flavours, textures and consistencies to avoid taste fatigue ( Stratton and Elia 1999 )

What to monitor? l clinical and nutritional status l functional goals l acceptability of diet and supplements l review after stopping supplements to see if any deterioration

Care pathway for nutritionally at risk patients

Conclusion l Using a variety of sources of data and information helps to build robust strategies for the nutritional management of patients in the community l nutritional protocols will differ depending on the patient group and should be customised to meet their needs. l Working in partnership with other staff and agencies is key in defining the nutritional needs of their population.