Big Story | Malnutrition NICE highlighted that to achieve optimal


nutritional care, nutrition screening and the management of malnutrition should be an integral part of care across all healthcare settings.1


Where


malnutrition risk is identified appropriate oral nutrition support should be implemented for those who can eat and drink (‘A-grade’ recommendation- supported by the highest level of evidence).1


Oral


nutrition support includes: altered meal patterns, increasing energy and protein content of everyday foodstuffs, nutrient dense food choices, assistance to eat, and oral nutritional supplements (ONS).1 Identifying people with malnutrition or those at


risk of developing malnutrition is the first step towards tackling this largely treatable problem. Appropriate nutrition intervention can improve clinical outcomes with associated cost benefits.1, 6-8 The most vulnerable nutritionally at risk groups include those with chronic diseases, the elderly, those recently discharged from hospital, and those who are economically deprived or socially isolated.2 As much malnutrition develops in the community, it is not surprising that the emphasis on screening and management should be a key focus in community settings. Whilst dietitians are skilled in providing


tailored dietary advice and nutrition support, with three million of the population affected at any time and limited availability of community dietitians, it is only appropriate that other healthcare professionals are empowered to undertake screening and basic first line oral nutritional support, particularly to patients at low to medium risk of malnutrition. Dietetic skills can then be spent on informing local policy, guiding other healthcare professionals to provide first line management and preserving time for the dietitian to deliver care to patients with complex needs who require more specialist interventions.9


GP knowledge of malnutrition


and use of guidance National online surveys of GPs were recently undertaken to assess knowledge of malnutrition prevalence, awareness of nutrition support guidance (local and national), nutrition screening and management of malnutrition. The surveys illustrated (see Table One) that there was a limited awareness and application of NICE guidelines for nutrition support, lack of screening and inconsistent approaches to managing malnutrition.10, 11


Evaluation of nutrition support pathways and guidance


available In 2011, internet searches were performed using the ‘Google’ search engine. Searches for available nutrition support guidelines were undertaken using search terms which included ‘oral nutritional support’, ‘oral nutritional supplements’, ‘malnutrition’, ‘treating malnutrition’ and ‘managing malnutrition’. Overall 38 documents on the management of malnutrition and use of ONS in the community were identified from across the UK; all four countries were represented. The guidance documents reviewed were freely available over the internet and do not include those that may only be available as hard copies. Each document was reviewed and a summary of the contents collated. The majority were written by dietitians, almost


a quarter were developed by a multi-professional team including nurses, pharmacists, dietitians and doctors (see Figure 1). Two thirds of the guidance documents were intended for use across community settings; a third applied to both primary and secondary care, one was specific to care homes. Document length varied considerably from two


to 79 A4 pages. Some included links to other resources or electronic files containing further advice and information (e.g. local food first advice). A pathway of care (flowchart) was included


in only 63 per cent of the guidance documents. The majority of the pathways started from the point at which a patient was identified as ‘at risk’ of malnutrition, then guided the user on actions to take, time periods for review and escalation or discontinuation of intervention depending on progress.


Screening NICE recommend that nutrition screening is carried out to identify malnutrition using a nutrition screening tool that considers BMI, percentage unintentional weight loss and the time over which nutrient intake has been unintentionally reduced and/or likelihood of future impaired nutrient intake. NICE suggests ‘MUST’ may be used to do this.1 Nutrition screening was recommended in all guidelines, the ‘Malnutrition Universal Screening Tool’ ('MUST') (www.bapen.org.uk)12


was most


frequently recommended (87%), but the tool itself was not routinely included within the guidelines nor was a direct link to ‘MUST’. A small number of


Table One: Summary of Results of GP Surveys10, 11


• A large proportion of GPs are unaware of the NICE nutrition support guidelines • Malnutrition is largely undetected and undertreated in GP practices • Validated screening tools, such as ‘MUST’, are not routinely used to identify malnutrition risk in GP practices


•


Monitoring and reviewing patients requiring oral nutrition support, including prescribed ONS, is often inconsistent


• A clear evidence-based pathway to identify and manage malnutrition is required and could lead to improved clinical outcomes with potential for significant cost savings.


Despite published guidelines, recommendations and clear benefits of identifying and managing malnutrition, the problem remains under-detected and undertreated in the UK.1


guidelines (3/38) recommended using other locally developed nutritional screening tools.


Risk scores and recommended actions Twenty-four documents (63%) included recommendations based on risk category (e.g. low, medium or high risk according to ‘MUST’). Eighteen documents included some advice for low risk; this was generally a recommendation for review period and varied from one month to one year. Fourteen provided guidance for just those ‘at risk’, thereby grouping medium and high risk patients into the same category and managing them in the same way.


Recommended actions to manage malnutrition risk There has been a longstanding debate in the dietetic and medical profession on the most effective means to treat malnutrition. With a focus on budgets, the treatment of malnutrition has become a target for savings. Whilst it is crucial to promote the appropriate use of ONS, it should be remembered that ONS are an effective method of nutrition support and can be used in addition to dietary advice for patients unable to achieve adequate intake through diet alone.1, 6


The actual


expenditure on ONS is a fraction of the total prescribing budget (1.2%) and is just 2.5 per cent of the £13 billion annual expenditure on malnutrition.13 Appropriate use of ONS in malnourished patients can result in cost savings and improvements in clinical outcomes.1, 6-8


‘Medium risk’ of malnutrition Based on ‘MUST’, individuals at ‘medium risk’ of malnutrition will be thin as a result of disease/condition (18.5-20kg/m2


), or have a history


of unplanned weight loss in the past three to six months (5-10%).


Management should include a


review of nutritional intake and action taken where inadequate intake identified.12 In the documents identified the most common


course of action for patients at ‘medium risk’ was a ‘Food First’ (dietary advice) approach (n=15). Food first plus over the counter (OTC) nutritional supplements, such as Complan and Build Up (n=7), was the second most frequent recommended action. Information on dietary advice was variable with links to electronic files, check lists or reference to a local leaflet. The review period was most often four weeks;


if there was no improvement upon review, escalation of management included ONS (n=15), OTC nutritional supplements (n=3) or referral to a dietitian (n=2; 1 in addition to ONS prescription). Although the majority of guidance documents recommended food first, there is variation in opinion as to whether this includes OTC nutritional supplements.


‘High risk’ of malnutrition Individuals identified at ‘high risk’ of malnutrition using ‘MUST’ will be very thin (<18.5kg/m2


), or have


substantial unplanned weight loss in the past three to six months (>10%). They could also be thin as a result of disease/condition (18.5-20kg/m2


) with a 12 | CN Focus Vol.4 No.1 April 2012


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47