Slide set for Workshop 4 Recognising and treating malnutrition Acknowledgments R Pryke.
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Introductory Certificate in Obesity, Malnutrition and Health
Slide set for Workshop 4Recognising and treating malnutrition
Acknowledgments R Pryke
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
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
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