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Managing adult malnutrition in the community

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, BPNG, NNNG, PCSG, PCPA, and the Patients Association. An unrestricted educational grant was obtained from Nutricia Advanced Medical Nutrition to cover the cost of development. 

Identification of malnutrition—nutrition screening

  • Malnutrition can be identified using a validated screening tool such as the ‘Malnutrition Universal Screening Tool’ (‘MUST’). NB: Healthcare professionals using screening tools should have appropriate skills and training 

When to screen

  • Opportunistically—on first contact within a new care setting e.g. upon registration with GP, first home visit, first outpatients appointment, on admission to a hospital or residential care setting
  • Other opportunities for screening include contact with district nurse or community pharmacist, for example at medication usage review
  • Upon clinical concern, e.g. unplanned weight loss, appearing thin, fragile skin, poor wound healing, pressure ulcers, apathy, muscle wasting, poor appetite, altered taste sensation, difficulty swallowing, altered bowel habit, loose fitting clothes, or prolonged intercurrent illness 
  • Groups at risk of malnutrition include:
    • chronic disease (consider acute episodes): 
      • chronic obstructive pulmonary disease (COPD)
      • cancer
      • gastrointestinal disease
      • renal or liver disease
      • inflammatory conditions, such as rheumatoid arthritis, inflammatory bowel disease
    • progressive neurological disease: 
      • dementia
      • Parkinson’s disease
      • motor neurone disease
  • Acute illness—where adequate food is not being consumed for more than 5 days (more commonly seen in a hospital than a community setting)
  • Debility—frailty, immobility, old age, depression, recent discharge from hospital
  • Social issues—poor support, housebound, difficulty obtaining or preparing food
  • Rehabilitation—after stroke, injury, cancer treatment
  • End of life/palliative care—tailor and adjust advice according to phase of 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
  • Frequency is determined by risk category as per ‘MUST’ score

Management of malnutrition

Managing malnutrition according to risk category using ‘MUST’

Managing malnutrition according to risk category using ‘MUST’

  • 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 
  • People who are malnourished or at risk of malnutrition should have a care plan
  • For all individuals:
    • record risk
    • correct/manage underlying causes
    • advise
    • agree goals of intervention
    • monitor
  • When possible treat or manage the factors contributing to the cause of malnutrition
  • 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, community matron and community pharmacist
  • Management options, also known as oral nutritional support, may include providing advice on a balanced diet, dietary advice to maximise oral intake (including food fortification, snacks and nourishing fluids), ONS to complement dietary strategies as well as practical measures such as assistance with eating, addressing social issues, ensuring ability to shop (physical and financial) and prepare food and texture modification
  • Screening and monitoring for malnutrition should be in line with your organisational policy and follow national guidance where possible

Goal setting

  • Agree goals of intervention with individual/carer
  • Set goals to assess the effectiveness of intervention (see examples below)
  • Consider disease stage and treatment, adjusting goals of intervention accordingly. For example nutritional interventions in some groups, such as palliative care and patients undergoing cancer treatment, may not result in improvements in nutritional status, but may provide a valuable support to slow decline in weight and function
  • Discuss intervention with patient/carer to ensure that it is feasible for them to implement/tolerate

Examples of goals

  • Goals are not limited to but can include:
    • to optimise recovery e.g. pressure ulcers, post-operatively
    • improving mobility
    • reducing risk of frailty and falls
    • preventing further weight loss
    • increase weight/muscle mass
    • improving strength
    • increasing nutritional intake
    • improving the individual’s quality of life or ability to undertake activities of daily living
    • reduce infections, recurrence or exacerbation of a condition

Monitoring the intervention

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

Optimising nutritional intake

Pathway for using oral nutritional supplements in the management of malnutrition

Pathway for using oral nutritional supplements in the management of malnutrition

NICE guidance

  • NICE CG32 recommends considering oral nutrition support to improve nutritional intake for people who can swallow safely and are malnourished or at risk of malnutrition (based on high quality/A-grade evidence)
  • NICE QS24 emphasises the need for all care services to take responsibility for the identification of people at risk of malnutrition, to provide nutritional support for everyone who needs it and to take an integrated approach to the provision of services

Dietary advice to optimise nutritional intake

  • Check with local dietitian or local policy and guidance
  • Give yellow leaflet—‘Your Guide to Making the Most of Your Food’—see www.malnutritionpathway.co.uk/leaflets-patients-and-carers
  • Advise on adjusting choices of everyday foods (e.g. cheese, full fat milk) added to the diet to increase energy and protein content without increasing volume of food consumed
  • Encourage small, frequent meals and snacks with a focus on nutrient rich foods and fluids
  • Overcome potential barriers to oral intake: physical (e.g. dentition, illness related loss of appetite, changes in taste), mechanical (e.g. need for modified texture diet/thickened fluids following a swallow assessment) and environmental (e.g. unable to prepare food, financial issues). Consider referral to other healthcare professionals such as a dietitian, occupational therapist, speech and language therapist
  • While there is some evidence for managing malnutrition with dietary advice alone, data on clinical outcomes or cost is limited
  • 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
  • Acute and chronic disease may adversely affect appetite and the ability to consume, source and prepare meals and drinks. Dietary advice can only be effective if it is feasible, acceptable and acted on by the individual or carer

Oral nutritional supplements to optimise oral intake

  • ONS are typically used in addition to the normal diet, and not as a food replacement, when diet alone is insufficient to meet daily nutritional requirements
  • An individual 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. ONS can also be incorporated into everyday foods, e.g. in jellies and sauces
  • ONS not only increase total energy and protein intake, but also the intake of micronutrients
  • Evidence shows that ONS do not reduce intake of normal food over a 12 week period
  • Evidence from systematic reviews including work by NICE demonstrate that ONS are a clinically and cost effective way to manage malnutrition particularly amongst those with a low BMI (BMI<20 kg/m2)
  • ONS increase energy and protein intakes, can improve weight and have functional benefits (e.g. improved hand grip strength and quality of life)
  • Clinical benefits of ONS:
    • include reductions in complications (e.g. pressure ulcers, poor wound healing, infections), mortality (in acutely ill older people), hospital admissions, and 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, however supplementation periods may be shorter, or longer (up to 1 year) according to clinical need

Range and selection of products

  • There are a wide range of ONS styles (milk, juice, yogurt, savoury), formats (liquid, powder, pudding, pre-thickened), types (high protein, fibre containing, low volume), energy densities (1–2.4 kcal/ml), and flavours are available to suit a wide range of needs and individual preferences. Check for any local guidance
  • 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); these are often used for people who are frail, elderly or with diagnoses of dementia, COPD, and cancer
  • Different types of ONS may benefit specific groups: the type chosen will depend on the specific individual, their condition and circumstances:
    • high protein ONS—suitable for individuals with COPD, wounds, post-operative patients, some types of cancer, and older people with frailty
    • fibre-containing ONS are useful for those with GI disturbances (not suitable for those requiring a fibre-free diet)
    • pre-thickened ONS and puddings are available for individuals with dysphagia or an impaired swallow. Seek speech and language therapist advice
    • low volume high energy ONS may aid compliance and may be better tolerated by patients who cannot consume larger volumes, e.g. those with COPD
  • 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
  • Social, clinical and practical issues that may affect adherence should be considered when deciding on the most appropriate product; such considerations may include renal function and dietary intolerances (e.g. lactose), cost and affordability, palatability, and the ability of the individual to buy milk and make up a powdered product

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’ (offers a range of products/flavours) or samples
  • 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 and those with complex nutritional needs, referral to a registered dietitian is recommended
  • ONS that provide only one or two nutrients e.g. protein or carbohydrate (modular products) should be used under the supervision of a registered dietitian
  • If poor compliance to ONS, explore reasons and refer to a dietitian or other healthcare professional if appropriate

Discontinuing ONS

  • Discontinue ONS when adequate oral intake is established, targets are achieved and the individual is stable and no longer at risk of malnutrition. Continue to monitor to check individual remains stable (consider relapsing remitting conditions e.g. COPD, IBD)

full guideline and patient leaflets available from…

www.malnutritionpathway.co.uk

BAPEN. Managing adult malnutrition in the community. April 2018.

First included: August 2018.