The guideline was developed by a multi-professional consensus panel representing a number of professional associations. Members share both an interest and expertise in the management of malnutrition. It has been endorsed by BAPEN, RCGP, RCN, RPS, BDA, PCPA, BPNG, NNNG, PCSG, and the Patients Association. BAPEN, PCPA, and the NNNG have reviewed and approved the publication of this summary.

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Overview

This Guidelines summary covers the identification and management of individuals at risk of malnutrition, including the appropriate use of oral nutritional supplements (ONS).

For more information, refer to the full guideline.

The process of managing disease-related malnutrition can be broken down into four key steps, covered in this summary:

  • Step 1: Identification of malnutrition: nutrition screening
  • Step 2: Assessment: identifying the underlying cause of malnutrition
  • Step 3: Management: identifying treatment goals and optimising nutritional intake
  • Step 4: Monitoring the intervention.

Identification of malnutrition: nutrition screening

When to screen

  • Opportunistically —on first contact within a new care setting, for example, upon registration with GP practice, outpatient appointment, on admission to a hospital or care setting, contact with community/district nurse, practice/primary care network pharmacist structured medicine review or community pharmacist medicine use review, annual disease reviews, pre-operatively, or specialist clinics for at risk groups
  • Upon clinical concern— examples include unplanned weight loss, loose fitting clothes, appearing thin, fragile skin, poor wound healing, pressure ulcers, apathy, muscle wasting (sarcopenia, including in obese individuals), reduced physical function, frequent falls, recurrent infections, poor appetite, altered taste sensation, difficulty swallowing, altered bowel habit or gut function, prolonged intercurrent illness, during and after cancer treatment, chronic condition or surgery, deteriorating medical conditions, or side effects to medicines.

Groups at risk of malnutrition include those needing support because of:

  • chronic diseases: for example, chronic obstructive pulmonary disease (COPD), cancer, gastrointestinal disease, renal or liver disease, rheumatoid arthritis, inflammatory bowel disease. Consider acute episodes and exacerbations
  • progressive neurological disease: for example, dementia, Parkinson’s disease, stroke, motor neurone disease
  • acute illness: where adequate food is not consumed for more than 5 days
  • frailty: for example, immobility, old age, recent discharge from hospital, and sarcopenia (including sarcopenia in both frail and obese patients)
  • prehabilitation: to optimise nutritional status prior to surgery
  • rehabilitation: to provide ongoing support in the community after an acute episode of care, for example, after surgery, stroke, injury, cancer treatment, hospital admission, an episode involving intensive care
  • neurodisability: for example, cerebral palsy, learning disabilities
  • end-of-life requirements/palliative care needs: tailor and adjust advice according to phase of illness, maintaining patient comfort, and respecting choice, particularly towards the end of life. For further information, see rcplondon.ac.uk/projects/outputs/supporting-people-who-have-eating-and-drinking-difficulties
  • people with impaired swallow (dysphagia).

NB Patients with socio-economic issues and environmental issues, that is, with little or no support, who are housebound, or who experience difficulty accessing or preparing food, are at increased risk of malnutrition. Malnutrition risk may be further compounded if patients with existing disease-related malnutrition also fall into this group.

  • Once an individual has been highlighted at risk of malnutrition, further assessment, treatment, and repeat screening are recommended to evaluate improvement, deterioration, and the need for further action (see Algorithm 1)
  • Frequency of screening will depend on the individual and their requirements, needs, and treatment goals (see the section, Identifying treatment goals) and should reflect local and national policy and guidance. Consider how nutrition screening and the Malnutrition Pathway resources might be embedded into existing care pathways to trigger early action in conditions that pose a high risk of malnutrition, for example, COPD, frailty.

Assessment: identifying the underlying cause of malnutrition

  • For all individuals who are malnourished, or at risk, it is important to consider the underlying cause to help identify the most appropriate nutritional care. Remember that some treatments and medications can have side effects, which can impact on nutritional status, eating, and drinking
  • Dietary advice leaflets to provide further ideas on managing the diet-related problems/symptoms may be available from local nutrition and dietetic departments
  • In some cases referral to relevant specialities may be required
  • Identifying the causes and symptoms that are interfering with the ability to eat and drink, and addressing those that can be reversed or modified, should be an integral component of the treatment plan
  • Table 1 contains some examples of factors that can interfere with eating and drinking, and some ideas on actions and dietary modifications that may help.

Table 1: Factors that can interfere with eating and drinking

 Examples of problems/symptoms Considerations 
 NB In all cases, consider whether dietary modifications will be enough to improve dietary intake
Early satiety, reduced appetite, feeling full after small amounts Eating nutrient dense/nutritious foods, little and often, e.g. high calorie/energy, high protein foods Consider if any medications are causing or aggravating symptoms and whether they can be stopped or if a new medication may help—seek advice from a pharmacist       
Dry mouth, sore mouth, fatigue, chewing difficulties Soft, easy-to-chew, moist diet with added sauces
Consider whether issues are caused by external factors, e.g. poor dentition, oral thrush, and refer as appropriate
Loss of taste, taste changes  Enhance taste with sauces, marinating, trying new foods, adding herbs, spices, or zest 
Swallowing issues  Consider referral to a speech and language therapist; in the meantime, refer to advice on managing dysphagia
Altered bowel habit, vomiting Check for causes, e.g disease itself, side effects of treatment, infection—seek further advice on treatment; consider referral to a dietitian
Pain  Identify cause; seek advice on management and suitable medication 
Anxiety, depression  Undernourishment can be a cause and/or a consequence of anxiety/depression. Consider referral to other services where appropriate 

Management of disease-related malnutrition

Algorithm 1: Managing malnutrition according to risk category using ‘MUST’

BAPEN Managing malnutrition according to risk category v5

  • Management of malnutrition should be linked to the level of malnutrition risk (see Algorithm 1). In most cases, malnutrition can be managed using dietary advice to optimise food intake, with ONS being used when food intake has been demonstrated to be insufficient, or when it is anticipated food alone will not meet nutritional requirements
  • All patients at risk of malnutrition should have a care plan; where applicable, this should link to their overall disease management pathway
  • Consider a multidisciplinary team approach to determine the optimal nutritional strategy, according to the individual’s clinical condition and social situation. The team may include GP, dietitian, nurse, occupational therapist, physiotherapist, speech and language therapist, practice pharmacist, community pharmacist, and social prescriber.

Identifying treatment goals

  • Co-creating and agreeing realistic goals with the patient and carers should be an integral component of management. When setting goals, it is important to consider disease stage and treatment. Table 2 outlines some examples of goals to consider in a range of medical conditions.

Table 2: Goals to consider in a range of medical conditions

 Goals to considerExamples by medical condition 
Abbreviations: COPD=chronic obstructive pulmonary disease; IBD=inflammatory bowel disease; ICU=intensive care unit; MND=motor neurone disease
Optimise recovery, promote healing Pressure ulcer treatment and post-surgery/discharge
Optimise response and tolerance to treatment  Patients with cancer 
Improve mobility and reduce risk of falls  Frailty in older people
Prevent further weight loss and preserve function  Palliative care 
Improve strength/increase muscle mass  Patients with sarcopenia or sarcopenic obesity 
Increase nutritional status and promote weight gain  Any patients with disease-related loss of appetite and eating difficulties 
Improve quality of life or ability to undertake activities of daily living  Frailty, rehabilitation 
Reduce infections, recurrence, or exacerbation of a chronic condition  COPD 
Reduce severity of disease  IBD 
Improve/restore function  Post-stroke, post-ICU 
Slow deterioration in physical and mental function  MND 
Reduce hospital admissions and length of stay  Applicable to a range of conditions 

Optimising nutritional intake

  • Oral nutritional support can comprise some or all of the following: 
    • fortifying food and fluids with protein, carbohydrate, and/or fat, plus minerals and vitamins
    • the use of snacks, nourishing drinks, and/or ONS in addition to regular meals
    • changing meal patterns
    • practical measures such as assistance with eating, shopping (physical and financial), and preparation of food
    • texture modification
  • The intervention and goals should be determined through a thorough assessment and an understanding of what is feasible, acceptable, and practical to the patient and carers
  • When determining the intervention, it is important to note that the disease itself, along with associated treatments (including medications), can cause physiological changes that suppress appetite, reduce the desire to eat, trigger early satiety (a feeling of fullness after a small amount of food), affect taste, and alter metabolism, which in turn alters body composition (such as muscle mass). These effects may limit the effectiveness of a food-only approach, and the use of ONS may need to be considered earlier in the management pathway to avoid unnecessary deterioration and to minimise any loss of muscle and function that at a later time may be irreversible
  • Take into account the trajectory of the disease, that is, curative or palliative, to guide how assertive the intervention should be and manage patient and carer expectations of what can be achieved.

Algorithm 2: Pathway for using oral nutritional supplements in the management of malnutrition

BAPENRCGP - Pathway for using oral nutritional supplements in management of malnutrition v4

Dietary advice to optimise nutritional intake

  • Encourage small, frequent meals and snacks with a focus on nutrient rich foods and drinks
  • Care should be taken when using food fortification to ensure that requirements for all nutrients including protein and micronutrients are met
  • Consider a multivitamin and mineral supplement
  • Advise on the following to increase energy and protein content without increasing volume of food consumed, for example:
    • adjusting portions at a meal to increase intake of nutrient dense foods
    • choosing higher rather than lower calorie foods, fortifying milk with milk powder, aiming to increase energy and protein content without increasing volume of food consumed
  • Dietary restrictions, for example, low fat, low sugar that was previously advised upon to manage comorbidities may need to be relaxed to increase the energy (calorie) content of the diet, particularly when appetite is poor
  • Provide patients and carers with the yellow leaflet ‘Your guide to making the most of your food’. Consider obtaining diet advice leaflets on common problems, for example, taste changes, from your local nutrition and dietetic team
  • If in doubt about the suitability of dietary advice because the patient has a number of medical conditions that require dietary modification, for example, swallowing problems or diabetes, seek further advice from a dietitian.

In all patients, care should be taken to ensure advice on adequate hydration is given.

The importance of protein

  • Patients should be encouraged to eat 3–4 portions of high-protein foods per day—for further information/ideas on protein, see malnutritionpathway.co.uk/proteinfoods
  • For patients with sarcopenia (loss of muscle mass and strength) emphasise the importance of protein-rich foods and drinks
  • For patients with sarcopenic obesity, focus on protein intake and resistance exercises with a goal of gaining muscle (lean) mass as opposed to fat mass; that is, the goal will be weight maintenance, not weight gain.

See malnutritionpathway.co.uk/library/factsheet_sarcopenia.pdf for further information.

ONS to optimise oral intake

  • ONS are typically used to supplement the diet when diet alone is insufficient to meet daily nutritional requirements. They are not intended as a food replacement
  • The additional multi-nutrient content from ONS can improve weight and contribute to functional benefits (for example, improved hand grip strength and quality of life)
  • Clinical benefits of ONS include reductions in complications (for example, pressure ulcers, poor wound healing, infections), mortality (in acutely ill older people), hospital admissions, and readmissions. Such benefits are often seen with 300–900kcal/day (1–3 ONS servings/day), with benefits seen in the community typically with 2–3 months’ supplementation
  • ONS should be given in accordance with an evidence-based pathway (see Algorithm 1 and Algorithm 2)
  • A patient should be encouraged to take ONS when they most feel like taking them; this may be between meals, like a snack, first thing in the morning, or before bed. Alternatively, ONS can be incorporated into everyday foods, for example, in jellies and sauces.

Choosing the appropriate ONS for the patient

  • There are a wide range of ONS styles (milk, juice, yogurt, savoury), formats (liquid, powder, pudding, pre-thickened), types (see the section below), energy densities (1–2.4 kcal/ml), and flavours available to suit a wide range of needs and individual preferences. Check for local guidance and see Managing malnutrition with ONS  for more detail on preferred products and indication for prescribing
  • Standard ONS provide ~300 kcal, 12 g of protein, and a full range of vitamins and minerals per serving
  • The majority of people requiring ONS can be managed using the most commonly used standard ONS (1.5–2.4 kcal/ml)
  • Other types include:
    • high protein ONS:  can be suitable for individuals with high protein needs, for example, COPD, wounds, post-operative patients, some types of cancer, older people with frailty, patients who have been in intensive care units, and patients with sarcopenia
    • fibre-containing ONS:  can be useful for those with gastrointestinal disturbances (not suitable for those requiring a fibre-free diet)
    • pre-thickened ONS and puddings:  available for individuals with dysphagia or an impaired swallow. Seek speech and language therapist advice before prescribing
    • low-volume, high-energy ONS: may aid compliance and may be better tolerated by patients who cannot consume larger volumes, for example, those with COPD

      NB Check product ingredients for specific allergies and intolerances.
  • In addition to ready-to-use ONS, a number of powdered nutritional supplements are available on prescription (and for self-purchase) and can be useful in addition to the diet
  • Clinical, practical, and social issues that may affect adherence should be considered when deciding on the most appropriate product; such considerations may include taking into account dietary intolerances (for example, lactose), the presence of diabetes (for example, medication may need to be adjusted) and renal function, cost and affordability, palatability, and the ability of the individual to buy milk and make up a powdered product
  • Before recommending powdered ONS to patients, consider the following: 
    1. clinical appropriateness, for example, nutritional content, volume
    2. does the patient or carer have the physical ability to make up powdered ONS as directed on the package and to ensure safe handling practice?
    3. does the patient have access to both a fridge and fresh milk, and have adequate storage for milk and boxes of powder?
  • If there is concern with points 1–3, a ready-made ONS may be more appropriate. The above considerations will also apply to self-purchase powdered ONS, which are available in supermarkets, pharmacies, and online.

Commencing ONS

See Managing malnutrition with ONS for further information on products available.

  • Aim to establish preferred flavours, likes and dislikes, for example, milk or juice, sweet or savoury
  • Test preferences and compliance with a ‘starter pack’, which offers a range of products/flavours free from manufacturers, which should be prescribed once only
  • Having checked flavour preferences, prescribe preferred product or range of products/flavours; 2 ONS per day (1–3 per day), initially for up to 3 months (see Algorithm 2)
  • Always issue ONS with clear instructions (for example, one to be taken twice a day between meals for 1 month until review) to support adherence and discuss and manage expectations
  • For those that require ONS as a sole source of nutrition and those with complex nutritional needs, referral to a registered dietitian is recommended
  • ONS that provide only one or two nutrients, for example, protein or carbohydrate (modular products) should be used under the supervision of a registered dietitian
  • Add a prompt on repeat prescriptions to review the ongoing need for ONS and evaluate compliance. If there is poor compliance to ONS, explore reasons and refer to a dietitian or other healthcare professional if appropriate.

Based on a comprehensive nutritional assessment, a dietitian may request a specific product for a patient. Should there be a reason or desire to amend the prescription, for example, it is not included in the local formulary, the rationale for the specific product recommended should be sought, as multiple factors are likely to have guided decision-making regarding the most suitable ONS.

For patients discharged from hospital on ONS, the prescription should be continued following dietetic advice given on the discharge summary or correspondence. If ONS have been initiated in hospital and the patient has not been reviewed by a dietitian, it is suggested that the patient is reassessed following the management pathway (see Algorithm 1). Pay particular attention to patients in high risk groups (see the box in the section, When to screen, for details of groups at risk of malnutrition).

Monitoring the intervention

  • Monitor progress against goals and modify intervention appropriately. Maintain communication channels and adjust care plan according to patient feedback:
    • consider weight, strength, physical appearance, mood, appetite, and ability to perform activities of daily living and compare with the goals originally set
    • frequency of monitoring depends on nutritional status of patient (see Algorithm 1 and Algorithm 2), care setting, treatment, disease prognosis, and organisational policy.

Discontinuing ONS

  • After the initial prescription, the need for ONS should be reviewed. Discontinue ONS when adequate oral intake is established, goals/targets are achieved, and the individual is stable and no longer at risk of malnutrition
  • Continue to monitor/make regular assessment of progress to check individual remains stable (consider relapsing conditions, for example, COPD, inflammatory bowel disease).

 

Full guideline:

BAPEN. Managing adult malnutrition in the community.  3rd edition: 2021. Available at malnutritionpathway.co.uk.

Published date: 2021.

Credit:

Lead image: Daniel Krasoń/stock.adobe.com