Managing adult malnutrition in the community

BAPEN and RCGP


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This guideline was developed by a multi-professional consensus panel with expertise and an interest in malnutrition, representing a number of professional associations. It has been endorsed/supported by BAPEN, RCGP, RCN, RPS, BDA, PSNC, BPNG, NNNG, PCSG, and PCPA. An unrestricted educational grant was obtained from Nutricia Advanced Medical Nutrition to cover the cost of development.

Identification

  • Malnutrition can be identified using a validated screening tool such as the Malnutrition Universal Screening Tool ('MUST')
  • 'MUST' is a 5 step screening tool that can be used across care settings to identify adults who are malnourished or at risk of malnutrition. 'MUST' includes management guidelines and alternative measures when body mass index (BMI) cannot be obtained by measuring weight and height
  • Groups at risk of malnutrition include those with:
    • chronic disease:
      • chronic obstructive pulmonary disease (COPD)
      • cancer
      • inflammatory bowel disease (IBD)
      • gastrointestinal disease
      • renal or liver disease
    • chronic progressive disease:
      • dementia
      • neurological conditions, e.g, Parkinson's disease, motor neurone disease
    • acute illness-where food is not being consumed for more than 5 days
    • debility:
      • depression
      • immobility
      • old age
      • frailty
      • recent discharge from hospital
    • social issues:
      • poor support
      • housebound
      • inability to cook and shop
      • poverty

Recommended screening frequency

  • First contact within care setting, e.g. upon registration with GP, first home visit, on admission to care home or hospital. Other screening opportunities include contact with community pharmacist or district nurse
  • Upon clinical concern e.g. unintentional weight loss, thin, fragile skin, poor wound healing, pressure ulcers, wasted muscles, poor appetite, altered taste sensation, impaired swallowing, altered bowel habit, loose clothes, or prolonged illness
  • Once an individual has been highlighted at risk of malnutrition, regular screening and monitoring is recommended to determine any improvement or deterioration and action required

Management

  • In most cases malnutrition is a treatable condition that can be managed using first -line dietary advice to optimise food intake and oral nutritional supplements (ONS) where necessary
  • Management of malnutrition should be linked to the level of malnutrition risk (see below):
    • for all individuals-record risk, agree goals of intervention, monitor
    • if appropriate, treat the underlying cause of malnutrition
  • Members of the multidisciplinary team including dietitians, occupational therapists, speech and language therapists, community matrons and community pharmacists may need to be involved according to clinical condition
  • Management options can include dietary advice to maximise nutritional intake, good food, assistance with eating, addressing social issues, ensuring ability to shop (physical and financial) and prepare food, texture modification, and ONS (see below) to complement dietary strategies

Goal setting

  • Agree goals of intervention with individual/carer:
    • set goals to assess the effectiveness of intervention, e.g. prevent further weight loss, maintain nutritional status, optimise nutrient intake during acute illness, healing of wounds or pressure ulcers, improve mobility
    • consider disease stage and treatment; adjust goals of intervention accordingly, e.g. nutritional interventions in patients in advanced stages of illness, undergoing palliative care, cancer treatment and with progressive neurological conditions may not result in improvements in nutritional status but may help to slow decline in weight and function

Monitoring the intervention

  • Monitor progress against goals and modify intervention appropriately
  • Consider weight, strength, physical appearance, appetite and ability to perform activities of daily living compared with goals set
  • Frequency of monitoring depends on setting and treatment

Managing malnutrition according to risk category using 'MUST'

Managing malnutrition according to risk category using 'MUST'

Pathway for using oral nutritional supplements in the management of malnutrition*

Pathway for using oral nutritional supplements in the management of malnutrition

Optimising oral intake

  • The psychosocial benefits of eating and drinking should not be overlooked. Dietary advice to optimise intake from food and drink should underpin all oral nutrition support approaches even when ONS are indicated
  • Dietary advice ('food first')
    • add everyday foods (e.g. cheese, full fat milk) to diet to increase energy and protein content without increasing volume of food consumed
    • offer small frequent meals and snacks, with food and fluids high in energy and protein
    • overcome potential barriers to oral intake: physical (e.g. dentition), mechanical (e.g. need for modified texture diets), and environmental (e.g. unable to prepare food). Consider referral to other healthcare professionals such as dietitian, occupational therapist, speech and language therapist
    • when using food fortification ensure that requirements for all nutrients including protein and micronutrients are met. Consider a multivitamin and mineral supplement
    • acute and chronic disease may adversely affect appetite and the ability to source and prepare meals and drinks. Dietary advice can only be effective if acceptable and feasible to the individual
  • ONS:
    • typically used in addition to the normal diet, when diet alone is insufficient to meet daily nutritional requirements
    • increase total energy and protein intake (can improve weight and have functional benefits-e.g. improved hand grip strength)
    • increase micronutrient intake
    • do not reduce intake of normal food
    • are available in a range of styles (milk, juice, yogurt, savoury), formats (liquid, powder, pudding, pre-thickened) and flavours
  • Evidence from systematic reviews including from NICE demonstrate that ONS are a clinically and cost-effective way to manage malnutrition particularly among those with a low BMI (BMI<20kg>
  • Clinical benefits of ONS:
    • include reductions in complications (e.g. pressure ulcers, poor wound healing, infections), mortality (in acutely ill older people), hospital admissions/readmissions
    • are often seen with 300-900 kcal/day (e.g. 1-3 ONS servings per day) with benefits seen in the community typically with 2-3 month's supplementation; supplementation periods may be shorter or longer (up to 1-year) according to clinical need
  • Most ONS provide ~300kcal, 12 g of protein and a full range of vitamins and minerals per serving. A range of energy densities (1-2.4kcal/ml) are available—the majority of people requiring ONS can be managed using standard ONS (1.5-2.4kcal/ml)
  • Different types of ONS may benefit specific groups:
    • high protein ONS—suitable for individuals with wounds, post-operative patients, some types of cancer, and the elderly
    • fibre-containing ONS—useful for those with constipation (not suitable for those requiring a fibre-free diet)
    • puddings—for individuals with neurological conditions that affect swallowing
    • small-volume high energy-dense ONS may aid compliance and be better tolerated by patients who cannot consume larger volumes
  • Commencing ONS:
    • aim to establish preferred flavours, likes and dislikes, e.g. milk or juice, sweet, or savoury
    • test preferences and compliance with a prescribable 'starter pack '
    • prescribe preferred product or range of products/flavours; 2 ONS per day (1-3 per day), initially for up to 3 months
    • for those that require ONS as a sole source of nutrition/with complex nutritional needs, referral to a dietitian is recommended
    • modular ONS that provide only one or two nutrients should be used under dietetic supervision

References

full guidelines available from...www.malnutritionpathway.co.uk

BAPEN and RCGP. Managing adult malnutrition in the community. May 2012, reviewed June 2014


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Development Group: Usmani, Capstick, Chowhan, & Scullion.
This management algorithm was developed by a multidisciplinary expert panel: Usmani O et al with the support of a grant from Chiesi Ltd.



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