1. Managing Malnutrition
Andrea Ralph BSc (hons) RD
Senior Medical Affairs Advisor, Nutricia

2. Identifying malnutrition
NICE Clinical Guideline 32, 2006 section 1.2.1
Recommends screening across all care settings
Health care professionals should screen
All hospital inpatients on admission
All outpatients at there first appointments
All people in care homes on admission
All people on registration at GP surgeries
And all of the above upon clinical concern

3. Appropriate management of malnutrition
NICE Clinical Guideline 32, 2006
1.6.6
Healthcare professionals should consider oral nutrition support to improve nutritional intake for people who can swallow safely and are malnourished or at risk of malnutrition.
‘A-grade’ recommendation
… should contain a balanced mixture of nutrients (including protein, energy, vitamins, minerals)
… should continue until the patient is established on adequate oral intake from normal food
….take care when using food fortification as this tends to supplement energy and not other nutrients

4. Why we should manage malnutrition
Adverse consequences for the patient
Muscle wasting (skeletal, cardiac, respiratory)
Reduced immune function - Increased risk of infection
Poor / delayed wound healing / pressure ulcers / reduced mobility
Apathy and depression
Reduced QOL, increased complications
Increased health care costs
(Stratton et al 2003)

5. Why we should manage malnutrition
Adverse consequences for the health economy
People with malnutrition have higher use of health care:
More GP visits (65%)
More hospital admissions (82%)
More hospital readmissions
More deaths post-discharge
More support post-discharge
(Elia 2005, Elia 2006, Stratton et al 2006)

6. Significant savings are possible.
NICE cost saving guidance – Dec 2009
CG32
Nutrition support in adults
Costs arising:
improving systematic screening,
assessment and treatment of malnourished patients.
If this guideline was fully implemented and resulted in better-nourished patients:
Reduced complications such as secondary chest infections, pressure ulcers, wound abscesses and cardiac failure.
Reduced admissions
Reduced length of stay for admitted patients
Reduced demand for GP and outpatient appointments
Significant savings are possible.
-£28,472
3rd highest of 19 reviewed guidelines for potential cost saving per 100,000 people

7. Identifying and managing malnutrition

8. Malnutrition risk identified – what next?
Document screening details
Identify and manage reason for decreased nutrition intake
Disease symptoms / side effects
Take action! Develop care plan (refer to local policy)
Consider:
Aims of intervention
Short term / long term goals
Route of intervention (oral / enteral / parenteral)
Practicalities
Monitor progress and adapt care plan appropriately
Weekly for all inpatients

9. Managing malnutrition

10. Enteral tube feeding Enteral tube feeding NG Gastrostomy
Nutritionally complete
Wide range available for adults and children
Available in hospital and on prescription
In the community, home care nursing and delivery service provided for patients
Involve a dietitian or nutrition support team

11. Oral nutrition support
Definition of : Oral nutrition support (NICE CG 32)
Practical support for people unable to feed themselves (e.g. modified feeding aids), altered meal patterns (e.g. small meals and snacks)
Fortified food with protein, carbohydrate, fat, vitamins, minerals
Dietary advice from a dietitian
Oral nutritional supplements (ONS).

12. Practicalities of improving oral intake
Assistance
Ensure food ordered is the food received
Assist with menu choices (high energy / modified texture where required)
Clear table of distractions
Ensure table, food, utensils and drinks are within reach
Offer assistance to cut up meals if needed
Adapted cutlery / plates
Altered meal patterns
Small meals and snacks (‘drip-feeding’ nutrition)
Nourishing drinks

13. What is food fortification?
Adding everyday foodstuffs to meals to increase the nutrient content, without increasing volume
Butter, oil
Full cream milk
Cheese
Skimmed milk powder
Jam
Syrup
Honey
Sugar
Caution – can increase just energy and protein without micronutrients

14. Evidence – food fortification
Cochrane review, 36 studies (n=2614):
Evidence for nutrition support in malnourished adults:
dietary advice
no advice and
dietary advice plus ONS in adults with malnutrition
Evidence suggests weight gain, grip strength, improved MUAC are greater with dietary advice + ONS rather than dietary advice alone
‘lack of evidence for the provision of dietary advice in managing illness-related malnutrition’
‘dietary advice plus nutritional supplements maybe more effective than dietary advice alone or no advice’
Baldwin and Weeks 2009 14

15. There was no data on the cost-effectiveness of these approaches.
There was insufficient evidence for NICE to assess the effect of dietary advice and / or other food strategies (snacks, food fortification) on mortality, complications and weight
There was no data on the cost-effectiveness of these approaches.

16. Dietary advice from a dietitian
Individual assessment and advice
Meal pattern alteration
Food fortification
ONS
Nutritional adequacy related to condition / nutritional requirements
Clinical indication e.g. renal disease, liver disease
Ideal for individuals where first line actions have not improved nutritional intake
Preparation for discharge to home setting
Dietetic resource can vary from trust to trust
Check local policy

17. What are oral nutritional supplements (ONS)?
Produced by nutrition companies (range available)
Mostly liquids (some puddings)
Multi nutrient supplements
Most are nutritionally complete
Energy (fat and carbohydrate), protein, micronutrients)
Milk, yoghurt, juice style ready made
Ready made usually gluten and lactose free
Available in hospital and on prescription (FP10)
Supplements you make up with milk
Supplements designed specifically for children
Some disease specific

18. Practicalities of using ONS
ONS ( kcal) can be used to improve clinical outcome in a range of hospitalised patients.
(Stratton2007)
2 x standard 1.5 kcal/ml ONS
kcal
24–28g protein
Consider individual preferences for flavour
(sweet, savoury, fruit preferences)
ONS can be served chilled, at room temperature or warmed
From bottle with straw, decant into cup / beaker
Add to food
Neutral / vanilla flavoured ONS in porridge, soups
Dessert style served with ice cream
Ensure patient understands why they are receiving ONS and encourage intake

19. NICE review of the evidence - oral nutritional supplements
Proprietary oral nutritional supplements:
Significantly reduce mortality
Significantly reduce complications
Significantly improve weight
Functional benefits
Better energy and protein intakes in supplemented patients in all trials
Acceptable to patients

20. Age UK ‘Still Hungry to be heard’
Update on the campaign launched 4 years ago
- 85% of hospitals engaged with the campaign
- 55% have taken action towards the 7 steps.
Age UK 7 steps to end malnutrition
Hospital staff must listen to older people, their relatives and carers and act on what they say.
All ward staff must become ‘food aware’.
Hospital staff must follow their own professional codes and guidance from other bodies.
Older people must be assessed for the signs or danger of malnourishment on admission and at regular intervals during their stay.
Introduce ‘protected mealtimes’.
Implement a ‘red tray’ system and ensure that it works in practice.
Use volunteers where appropriate.
Age UK - ‘Still hungry to be heard’ The scandal of people in later life becoming malnourished in hospital.
Released: 30th August 2010
Age UK (formerly know as Age Concern) launched the ‘Hungry to be heard’ campaign 4 years ago, outlining the problem of malnutrition in hospitals and 7 recommended steps to combat the problem.
‘Still hungry to be heard’ is an update on the progress of the campaign. The document is written from a patient’s perspective, to give a powerful message about the ongoing problem of malnutrition in hospital. This is followed by a reminder of the 7 recommended steps, together with negative patient experiences and good practice examples.
4 years of ‘Hungry to be heard’ campaign has focused on:
Improving hospital meals and meal times.
Calling for effective identification and management systems for malnutrition.
Lobbying government.
Producing a resource pack, including guidance documents for carers and relatives.
Increasing public awareness through media campaigns.
Progress:
82% of hospitals have engaged with the ‘Hungry to be heard’ campaign and over half of these (55%) have taken action in line with the 7 recommended steps.
Despite the campaign, malnutrition remains a problem in hospitals. Challenges facing the success of the campaign:
Inconsistencies in identification, management and monitoring of malnutrition across and within hospitals.
Basic issues still being raised from patient’s hospital stay experiences.
Government action needed.
Where the campaign is going now (‘what we want’)
All wards to implement Age UK’s 7 recommended steps.
Government must introduce compulsory recording of malnutrition rates.
CQC (Care Quality Commission) must complete a comprehensive review of hospital mealtimes.
The ‘Still hungry to be heard’ campaign wraps up by calling for action:
Tell friends and family.
Share experiences from hospital stays.
Lobby local MP’s.
Find out more about the campaign.

21. High Impact Actions for Nursing and Midwifery
8 ‘High impact actions’ identified by nurses and midwives
‘Keeping nourished getting better’ focuses on:
identifying individuals at risk of malnutrition
providing good nutritional care,
stopping inappropriate weight loss and dehydration in NHS provided care.
To ensure patients are screened for malnutrition and get the right amount of nutrition and hydration needed for a speedy recovery, dietitians and nurses need to work together.
High impact actions for nursing and midwifery.
8 areas identified from website submissions by nurses and midwives:
Your skin matters
Staying safe - preventing falls
Important choices - where to die when the time comes
Fit and well to care
Promoting normal birth
Ready to go - no delays
Protection form infection
Keeping nourished getting better
This ‘high impact action’ is about identifying individuals at risk of malnutrition, providing good nutritional care, stopping inappropriate weight loss and dehydration in NHS provided care.
The document outlines that malnutrition is a common and costly problem in the UK and introduces ‘Hospital Hydration Best Practice Toolkit’. To ensure patients are screened for malnutrition and get the right amount of nutrition and hydration needed for a speedy recovery, dietitians and nurses need to work together.
The document includes some ‘good practice’ examples, 2 of which focus on reducing ONS prescribing and project a negative image of ONS prescribing in terms of cost, without measuring the benefits and potential cost saving of using ONS effectively.
Summary available on Medical Affairs Intranet

22. Essence of Care: Benchmarks for food and drink
10 factors in the food and drink section
Screening and assessment
Best Practice: People who are screened and identified at risk receive a full nutritional assessment
Screening takes place on first contact with health care providers and is repeated regularly for those at risk of malnutrition or upon clinical concern.
Validated tool such as the Malnutrition Universal Screening Tool (MUST)
A full assessment and appropriate referral is undertaken for people who are identified initially as at risk of malnutrition or as morbidly obese.
Screening, assessment and nutrition support is undertaken in partnership with people.
Department of Health Essence of care 2010 – Benchmarks for the fundamental aspects of care
1st October 2010
The updated Essence of Care 2010 was developed in partnership with people and carers and supports and reflects a number of the themes in Equality and Excellence: Liberating the NHS and provides a suite of benchmarks to drive forward best practice in delivering the fundamentals of care and improving the experiences of people who use services. It identifies best practice and highlights how it can be achieved.
A benchmark is: ‘a standard of best practice and care by which current practice and care is assessed or measured.’ The benchmarks are designed to be used wherever health and social care is planned, managed and/or delivered, including but not limited to hospital, care homes, peoples own homes, GP surgeries.
The updated document has 12 main sections including one on food & drink:
Bladder, Bowel and Continence Care
Care Environment
Communication
Food and Drink
Prevention and Management of Pain
Personal Hygiene
Prevention and Management of Pressure Ulcers
Promoting Health and Well-being
Record Keeping
Respect and Dignity
Safety
Self Care

23. Summary
Nutritional screening using a reliable and valid tool, such as ‘MUST’, is an essential first step in the management of malnutrition
As part of the screening process, a plan for management of malnutrition risk should be developed
There are a number of oral nutrition support strategies to improve nutrition intake
Local policy should be in place for the appropriate evidence based management of malnutrition
There is limited evidence for the use of dietary advice and food first strategies in clinical practice
Evidence shows that ONS can improved clinical and functional outcomes which may reduce health care costs.

24. Some Key References
NICE CG32. February Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Includes Costing Report.
Elia M, Russell C (2009). Combating Malnutrition: Recommendations for Action. Report from the advisory group on malnutrition, led by BAPEN.
Stratton RJ, Elia M. (2007). A review of reviews: A new look at the evidence for oral nutrition supplements in clinical practice. Clinical Nutrition Supplements (2); 5-23
Elia M. (2006). Nutrition and Health Economics. Nutrition (22);
Elia M, Stratton R, Russell C et al. (2005) The cost of disease-related malnutrition in the UK and economic considerations for the use of oral nutritional supplements (ONS) in adults. A report by The Health Economic Group of The British Association for Parenteral and Enteral Nutrition (BAPEN).
Baldwin C and Weeks CE (2009) Dietary advice for illness-related malnutrition in adults (Review). Cochrane database of systematic reviews 2008, Issue 1.
Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: an evidence-based approach to treatment. Oxford: CABI publishing, 2003.