NUTRITION
Causes of malnutrition in older adults and what can be done to prevent it Aimee McEvilly Bsc, Msc, RD
Paediatric Community Dietitian, Birmingham Community Healthcare NHS Trust [email protected]
474
Malnutrition Taskforce (2013) has found only half (51%) of health care professionals regard malnutrition as a priority. Less than half (47%) also felt confident that they had enough knowledge and skills to help people most at risk.With all of this in mind it should be a priority for community teams to understand the local burden of malnutrition and respond by appropriate commissioning of services.
Contributing factors of malnutrition and how they can be tackled Malnutrition is particularly common in groups of people who have chronic disease, neurodegenerative disease, acute illness, debility and people with social issues including inability to cook and shop (Elia and Russell, 2009). It is therefore understandable that most cases of malnutrition exist in the community, where community members of staff are empowering older adults with chronic diseases to live independently. Generally, there is not a single contributing factor that causes malnutrition and it could be a combination of social and physiological factors. It may not be possible to alleviate all of these factors; however, addressing what can be influenced earlier on could prevent or reduce the risk of malnutrition (Malnutrition Taskforce, 2013). Some of the social contributing factors of malnutrition include the following (Malnutrition Taskforce, 2013): ww Difficulty in getting to the shops due to poor mobility, poor public transport links or fear of leaving their home because of frailty ww Common misconceptions that ‘it is normal to lose weight as you age’ or family and carers presuming a very small appetite is normal in later life ww Low income and reluctance to purchase high-calorie snacks or foods used for food fortification, which have been recommended ww Lack of support because of lack of friends or family who could encourage better eating and drinking ww Low mood and lack of interest in food as a result of living with a chronic disease
© 2017 MA Healthcare Ltd
M
alnutrition affects over 3 million people in the UK alone, and 93% of these people are living in the community (Elia and Russell, 2009). Malnutrition can be treated. Early identification and intervention is vital. This article aims to give a brief overview of the potential contributing factors of malnutrition. It will briefly discuss how these factors can be addressed and what can be done to prevent or manage them. This article will also discuss how and when screening for malnutrition should take place in the community and the appropriate actions to take when malnutrition is identified. Finally this article aims to motivate and encourage local communities to look again at their services and ensure the nutrition and hydration needs of older people are being met. The most recent nutritional screening week (NSW) surveys in England estimated that 35% of care home residents and 30% of adults on admission to hospital scored either a medium or high risk of malnutrition using the Malnutrition Universal Screening Tool (MUST) (Russell and Elia, 2012). Malnutrition is both a cause and consequence of disease, and can lead to adverse effects including: increased mortality and morbidity, delayed recovery from illness and impaired body function, which detrimentally affects activities of daily living (Stratton et al, 2003). The associated economic burden of malnutrition was reported to be £19.8 billion in England in 2011–2012. Furthermore, the incremental cost of treating a malnourished individual was 2–3 times greater than that for a nonmalnourished individual (Elia, 2015).With an ageing population, the groups of people at risk of malnutrition are likely to grow and consequently so will the burden of malnutrition. Identifying malnutrition early and improving how malnutrition is treated is estimated to have the sixth highest potential to deliver cost savings to the NHS (National Institute for Health and Care Excellence (NICE), 2012a). Implementing NICE guideline CG32 and quality standard QS24 results in better nourished patients, fewer hospital admissions, reduced length of stay for admitted patients, and reduced demand for general practitioners (GPs) (NICE 2006; NICE, 2012b). Despite these shocking statistics, new research by the
British Journal of Community Nursing October 2017 Vol 22, No 10 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 154.059.124.102 on October 3, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
NUTRITION These factors can be addressed by asking simple questions such as ‘how do you get your shopping?’, ‘do you leave the house?’,‘are you managing financially?’ and asking about support networks and mood. It would be useful to know the local supermarket availability and cost of high-energy snacks or food items used to fortify foods, and to write them down so they can give the list to a carer or family member to get for them. It is also useful to compile a list of local services that are available for shopping and transport, including ‘ring and ride’ services, food banks, lunch clubs and ‘meals on wheels’. These can be handed to patients with a list of contact numbers providing they are kept up to date regularly.Younger family members or carers may also be willing to do an online weekly or 2-weekly shop.With regards to financial difficulty, they can also be signposted to local benefits advice. The physiological contributing factors of malnutrition include the following (Malnutrition Taskforce, 2013): ww Decreased sensation of thirst, decreased taste and decreased appetite due to less energy expenditure ww Illness and disease including dementia ww Reduced physical ability to eat e.g. tremor or poor muscle tone impacting on being able to use cutlery ww Dysphagia ww Difficulty chewing due lack of dentition ww Surgery These factors can be addressed by ensuring referrals to other multidisciplinary team members have been made where appropriate. For example, refer to speech and language therapy when signs of dysphagia are identified; refer to occupational therapists who could provide adapted cutlery if difficulties have been identified with self-feeding. It may be helpful to suggest alarms are set for meal and drink times to help with short-term memory loss, or to prompt people to eat and drink despite not feeling hungry or thirsty. It may also be helpful to suggest soft meal options, which could be eaten with a spoon or to request carers or family members chop up food so it is easier to eat a meal.
© 2017 MA Healthcare Ltd
Identifying malnutrition The NICE CG32 guideline recommends regular screening for malnutrition across all settings and implementation of nutritional care pathways for patients identified as being at risk (NICE, 2006; NICE, 2012b). However, nutritional care in the community remains inadequate (Elia, 2015). There are currently no diagnostic tools or criteria for the diagnosis of malnutrition (Brotherton et al, 2012). In addition, it is not likely that individuals will go to their GP because of malnutrition alone. It is therefore important that all health care professionals look for signs of malnutrition, particularly in vulnerable populations, and consider nutrition as part of their assessments at every contact. The NICE CG32 guideline advises using a validated screening tool, with MUST being the most commonly used and recognised screening tool in the UK. MUST is a simple, quick, 5-step screening tool, which includes advice on what actions to take when individuals score low, medium or high risk of malnutrition. For more details on how to use this screening tool, visit www.bapen.org.uk.
Table 1. Subjective indicators of malnutrition (Stratton et al, 2003) ww Physical appearance, i.e. visibly emaciated or thin ww Reported history of weight loss from patient or family ww Loose-fitting clothing/jewellery/loose-fitting dentures ww Loss of appetite ww Clinical condition puts the patient at risk of malnutrition, e.g. dysphagia ww Increased nutritional needs due to clinical condition, e.g. COPD, cancer ww Reduced oral intake
NICE (2006) advises routine screening in the community as follows: ww On admission to care homes and when there is clinical concern ww On initial registration at GP practices and when there is clinical concern ww First contact within a care setting, e.g. district nurse ww Once an individual has been identified as being at risk of malnutrition, regular screening and monitoring is recommended to determine any deterioration or improvement and action required There can be difficulties in obtaining a MUST score in the community, particularly in bed-bound individuals who are unable to weight bear. In addition, the time pressures and added time it takes to carry equipment and weigh individuals. However, there are various subjective measures that can be used to identify indications of malnutrition as shown in Table 1. Also, using clinical judgement we can allocate a MUST score as shown in Table 2.
Managing malnutrition The recent Global Nutrition Report (2016) highlighted the urgent need to end all forms of malnutrition by 2030, given it is the biggest risk factor for the global burden of disease. Early interventions in community health and social care settings are crucial in this vision. One initiative produced by the Malnutrition Taskforce ‘The Malnutrition Prevention Program’ (2012) identities five main principles, which build the foundation for delivering best practice nutrition and hydration care: 1. Raising awareness to prevent and treat malnutrition and dehydration through education to older people, their families and frontline staff 2. Working together within teams, across organisational
Table 2. MUST score allocation using clinical judgement (Malnutrition Pathway, 2012) Risk of malnutrition
Physical appearance
Unlikely (low)
Not thin, weight stable or gaining weight (no unplanned weight loss), no change in appetite
Possible risk (medium)
Thin as a result of disease/condition or history of unplanned weight loss in the last 3–6 months, reduced appetite/ability to eat
Likely (high)
Thin/very thin and/or substantial unplanned weight loss in the last 3–6 months, no oral intake for 5 days in the presence of acute disease (unlikely to be seen in the community)
British Journal of Community Nursing October 2017 Vol 22, No 10
475
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 154.059.124.102 on October 3, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
NUTRITION
Creating individualised care plans In order to make screening effective the most important stage is to implement the appropriate nutritional care plan. Refer to your local policy for advice on this, alternatively the MUST screening tool provides care plans which can be implemented according to the degree of malnutrition. However if MUST is not being used in your area pathways and care plans can also be found at www.malnutritionpathway.org.uk (Malnutrition Pathway, 2012). The following steps should be taken if someone is identified as being malnourished: ww Monitor dietary intake ww Commence first-line dietary advice (more details on first-line advice can be found at www.malnutritionpathway.org.uk) ww Dietary goals should be set, e.g. maintain weight or promote weight gain of 5–10% body weight, improve or increase overall intake, promote wound healing.These goals should be realistic, e.g. patients who have end-stage dementia, palliative or undergoing cancer treatment are not likely to have improvement in nutritional status; however, minimising further decline in nutritional status is still beneficial and realistic ww Monitor and review care plan regularly, which should involve looking at progress according to the goals set For a MUST score of 2, i.e. high risk of malnutrition, all of the above actions should be taken and it is advised to refer to a dietitian and commence 1–2 nutritional supplements. However, this is dependent on your local policy. There may
476
be local prescribing committees who have developed national formularies. In this case, there will be guidance on the type of oral nutritional supplement, which should be recommended as first line and adhering to this will achieve cost savings for the NHS. Alternatively, access to www.malnutritionpathway. co.uk can provide a useful guide on the amount of oral nutritional supplements to prescribe, for what duration, and a realistic time frame for monitoring dietary goals. I will conclude this article with a quote from Janine Roberts, the programme director of the Malnutrition Taskforce Group, who states:‘Organisations have to deal with so many competing priorities and may ask, ‘why should we prioritise nutrition and hydration care?’ The answer is simple. Without food and water, people will die.’ Malnutrition cannot be tackled by an individual or a single team it needs to be a whole service approach, involving all health care professionals and public at the frontline facing malnutrition. The tools and resources are available to prevent and tackle malnutrition; they just need to be utilised. BJCN Brotherton, A, Holdoway, A, Stroud M. Malnutrition in the UK: appropriate prescribing of oral nutritional supplements. 2012 Elia M and Russell CA. Combating Malnutrition: Recommendations for Action. Report from the advisory group on malnutrition, led by BAPEN. 2009. http:// www.bapen.org.uk/pdfs/reports/advisory_group_report.pdf (accessed 12 September 2017) Elia M, Stratton R. Calculating the cost of disease-related malnutrition in the UK in 2007 (public expenditure only). In: Combating Malnutrition: Recommendations for Action. Report from the advisory group on malnutrition, led by BAPEN. 2009. http://www.bapen.org.uk/pdfs/reports/advisory_group_report.pdf (accessed 12 September 2017) Elia M, Stratton R, Russell C, et al. The cost of disease-related malnutrition in the UK and economic considerations for the use of oral nutritional supplements (ONS) in adults. A report by BAPEN. 2005. https://eprints.soton. ac.uk/61084/ (accessed 12 September 2017) Elia M. The cost of malnutrition in England and potential cost savings from nutritional interventions (short version). 2015. http://www.bapen.org.uk/ pdfs/economic-report-short.pdf (accessed 12 September 2017) Global Nutrition Report. From Promise to Impact: Ending Malnutrition by 2030. 2016. http://ebrary.ifpri.org/utils/getfile/collection/p15738coll2/id/130354/ filename/130565.pdf (accessed 12 September 2017) Malnutrition Pathway. Managing Adult Malnutrition in the Community. 2012. http://malnutritionpathway.co.uk/downloads/Managing_Malnutrition.pdf (12 September 2017) Malnutrition Taskforce. Malnutrition in later life: Prevention and early intervention. Best practice principles and implementation guide. A community approach. 2013. http://www.malnutritiontaskforce.org.uk/wp-content/ uploads/2014/07/COM-Prevention_Early_Intervention_Of_Malnutrition_ in_Later_Life_Local_community.pdf (accessed 12 September 2017) National Institute for Health and Care Excellence. Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical Guideline 32. 2006. https://www.nice.org.uk/guidance/cg32 (accessed 12 September 2017) National Institute for Health and Care Excellence.. NICE support for commissioners and others using the quality standard on nutrition support in adults. 2012a. https://www.nice.org.uk/guidance/qs24/resources/support-forcommissioners-and-others-using-the-quality-standard-on-nutrition-support-inadults-252372637 (accessed 12 September 2017) National Institute for Health and Care Excellence. QS24 Nutrition support in adults. Quality standard 24. 2012b. https://www.nice.org.uk/guidance/qs24 (accessed 12 September 2017) Russell CA, Elia M. Nutrition Screening Survey in the UK and Republic of Ireland in 2011. 2012. http://www.bapen.org.uk/pdfs/nsw/nsw-2011-report. pdf. (accessed 12 September 2017) Stratton R, Green C, Elia M. Disease-related malnutrition: an evidence-based approach to treatment. Clinical Nutrition. 2003;22(6):585 Stratton R, Hackston A, Longmore D, et al. Malnutrition in hospital outpatients: prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (‘MUST’) for adults. Br J Nutrition. 2004;92:799–808. Thomas B and Bishop J. Manual of Dietetic Practice. 4th ed. Blackwell Publishing Ltd; 2007
© 2017 MA Healthcare Ltd
boundaries and across communities 3. Identifying malnutrition in the individual and prevalence within organisations and across local communities 4. Personalising care, support and treatment for every individual 5. Monitoring and evaluating the individual and the processes in place to address malnutrition A good starting point is to find out the local prevalence of the at-risk population in your area. This can be done using the BAPEN nutritional care tool, www.data.bapen.org.uk, or NICE quality statement 24. This tool can also be used to assess how your community is screened for malnutrition and the provision of nutritional care.You can then establish whether the practices in place are having the desired effect in the community. It may be necessary to start viewing malnutrition and dehydration as safeguarding more often and to incorporate this into local improvement plans (Malnutrition Taskforce, 2013). It is crucial that training needs are identified and provided particularly around enhancing skills and competencies with identifying malnutrition and being able to put the appropriate care plan into action. It is also important to raise awareness of malnutrition in the public, service users and their carers. In particular, dispelling myths that it is normal to lose weight or to be underweight in old age. Don’t reinvent the wheel and consider using existing information and leaflets to raise awareness. Furthermore, it should be compulsory to alert staff on admission to hospital if the patient is at risk of malnutrition and to hand over any nutritional care plan which is in place in the community (Malnutrition Taskforce, 2013).
British Journal of Community Nursing October 2017 Vol 22, No 10 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 154.059.124.102 on October 3, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
Causes of malnutrition in older adults and what can be done to prevent it Aimee McEvilly Bsc, Msc, RD
Paediatric Community Dietitian, Birmingham Community Healthcare NHS Trust [email protected]
474
Malnutrition Taskforce (2013) has found only half (51%) of health care professionals regard malnutrition as a priority. Less than half (47%) also felt confident that they had enough knowledge and skills to help people most at risk.With all of this in mind it should be a priority for community teams to understand the local burden of malnutrition and respond by appropriate commissioning of services.
Contributing factors of malnutrition and how they can be tackled Malnutrition is particularly common in groups of people who have chronic disease, neurodegenerative disease, acute illness, debility and people with social issues including inability to cook and shop (Elia and Russell, 2009). It is therefore understandable that most cases of malnutrition exist in the community, where community members of staff are empowering older adults with chronic diseases to live independently. Generally, there is not a single contributing factor that causes malnutrition and it could be a combination of social and physiological factors. It may not be possible to alleviate all of these factors; however, addressing what can be influenced earlier on could prevent or reduce the risk of malnutrition (Malnutrition Taskforce, 2013). Some of the social contributing factors of malnutrition include the following (Malnutrition Taskforce, 2013): ww Difficulty in getting to the shops due to poor mobility, poor public transport links or fear of leaving their home because of frailty ww Common misconceptions that ‘it is normal to lose weight as you age’ or family and carers presuming a very small appetite is normal in later life ww Low income and reluctance to purchase high-calorie snacks or foods used for food fortification, which have been recommended ww Lack of support because of lack of friends or family who could encourage better eating and drinking ww Low mood and lack of interest in food as a result of living with a chronic disease
© 2017 MA Healthcare Ltd
M
alnutrition affects over 3 million people in the UK alone, and 93% of these people are living in the community (Elia and Russell, 2009). Malnutrition can be treated. Early identification and intervention is vital. This article aims to give a brief overview of the potential contributing factors of malnutrition. It will briefly discuss how these factors can be addressed and what can be done to prevent or manage them. This article will also discuss how and when screening for malnutrition should take place in the community and the appropriate actions to take when malnutrition is identified. Finally this article aims to motivate and encourage local communities to look again at their services and ensure the nutrition and hydration needs of older people are being met. The most recent nutritional screening week (NSW) surveys in England estimated that 35% of care home residents and 30% of adults on admission to hospital scored either a medium or high risk of malnutrition using the Malnutrition Universal Screening Tool (MUST) (Russell and Elia, 2012). Malnutrition is both a cause and consequence of disease, and can lead to adverse effects including: increased mortality and morbidity, delayed recovery from illness and impaired body function, which detrimentally affects activities of daily living (Stratton et al, 2003). The associated economic burden of malnutrition was reported to be £19.8 billion in England in 2011–2012. Furthermore, the incremental cost of treating a malnourished individual was 2–3 times greater than that for a nonmalnourished individual (Elia, 2015).With an ageing population, the groups of people at risk of malnutrition are likely to grow and consequently so will the burden of malnutrition. Identifying malnutrition early and improving how malnutrition is treated is estimated to have the sixth highest potential to deliver cost savings to the NHS (National Institute for Health and Care Excellence (NICE), 2012a). Implementing NICE guideline CG32 and quality standard QS24 results in better nourished patients, fewer hospital admissions, reduced length of stay for admitted patients, and reduced demand for general practitioners (GPs) (NICE 2006; NICE, 2012b). Despite these shocking statistics, new research by the
British Journal of Community Nursing October 2017 Vol 22, No 10 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 154.059.124.102 on October 3, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
NUTRITION These factors can be addressed by asking simple questions such as ‘how do you get your shopping?’, ‘do you leave the house?’,‘are you managing financially?’ and asking about support networks and mood. It would be useful to know the local supermarket availability and cost of high-energy snacks or food items used to fortify foods, and to write them down so they can give the list to a carer or family member to get for them. It is also useful to compile a list of local services that are available for shopping and transport, including ‘ring and ride’ services, food banks, lunch clubs and ‘meals on wheels’. These can be handed to patients with a list of contact numbers providing they are kept up to date regularly.Younger family members or carers may also be willing to do an online weekly or 2-weekly shop.With regards to financial difficulty, they can also be signposted to local benefits advice. The physiological contributing factors of malnutrition include the following (Malnutrition Taskforce, 2013): ww Decreased sensation of thirst, decreased taste and decreased appetite due to less energy expenditure ww Illness and disease including dementia ww Reduced physical ability to eat e.g. tremor or poor muscle tone impacting on being able to use cutlery ww Dysphagia ww Difficulty chewing due lack of dentition ww Surgery These factors can be addressed by ensuring referrals to other multidisciplinary team members have been made where appropriate. For example, refer to speech and language therapy when signs of dysphagia are identified; refer to occupational therapists who could provide adapted cutlery if difficulties have been identified with self-feeding. It may be helpful to suggest alarms are set for meal and drink times to help with short-term memory loss, or to prompt people to eat and drink despite not feeling hungry or thirsty. It may also be helpful to suggest soft meal options, which could be eaten with a spoon or to request carers or family members chop up food so it is easier to eat a meal.
© 2017 MA Healthcare Ltd
Identifying malnutrition The NICE CG32 guideline recommends regular screening for malnutrition across all settings and implementation of nutritional care pathways for patients identified as being at risk (NICE, 2006; NICE, 2012b). However, nutritional care in the community remains inadequate (Elia, 2015). There are currently no diagnostic tools or criteria for the diagnosis of malnutrition (Brotherton et al, 2012). In addition, it is not likely that individuals will go to their GP because of malnutrition alone. It is therefore important that all health care professionals look for signs of malnutrition, particularly in vulnerable populations, and consider nutrition as part of their assessments at every contact. The NICE CG32 guideline advises using a validated screening tool, with MUST being the most commonly used and recognised screening tool in the UK. MUST is a simple, quick, 5-step screening tool, which includes advice on what actions to take when individuals score low, medium or high risk of malnutrition. For more details on how to use this screening tool, visit www.bapen.org.uk.
Table 1. Subjective indicators of malnutrition (Stratton et al, 2003) ww Physical appearance, i.e. visibly emaciated or thin ww Reported history of weight loss from patient or family ww Loose-fitting clothing/jewellery/loose-fitting dentures ww Loss of appetite ww Clinical condition puts the patient at risk of malnutrition, e.g. dysphagia ww Increased nutritional needs due to clinical condition, e.g. COPD, cancer ww Reduced oral intake
NICE (2006) advises routine screening in the community as follows: ww On admission to care homes and when there is clinical concern ww On initial registration at GP practices and when there is clinical concern ww First contact within a care setting, e.g. district nurse ww Once an individual has been identified as being at risk of malnutrition, regular screening and monitoring is recommended to determine any deterioration or improvement and action required There can be difficulties in obtaining a MUST score in the community, particularly in bed-bound individuals who are unable to weight bear. In addition, the time pressures and added time it takes to carry equipment and weigh individuals. However, there are various subjective measures that can be used to identify indications of malnutrition as shown in Table 1. Also, using clinical judgement we can allocate a MUST score as shown in Table 2.
Managing malnutrition The recent Global Nutrition Report (2016) highlighted the urgent need to end all forms of malnutrition by 2030, given it is the biggest risk factor for the global burden of disease. Early interventions in community health and social care settings are crucial in this vision. One initiative produced by the Malnutrition Taskforce ‘The Malnutrition Prevention Program’ (2012) identities five main principles, which build the foundation for delivering best practice nutrition and hydration care: 1. Raising awareness to prevent and treat malnutrition and dehydration through education to older people, their families and frontline staff 2. Working together within teams, across organisational
Table 2. MUST score allocation using clinical judgement (Malnutrition Pathway, 2012) Risk of malnutrition
Physical appearance
Unlikely (low)
Not thin, weight stable or gaining weight (no unplanned weight loss), no change in appetite
Possible risk (medium)
Thin as a result of disease/condition or history of unplanned weight loss in the last 3–6 months, reduced appetite/ability to eat
Likely (high)
Thin/very thin and/or substantial unplanned weight loss in the last 3–6 months, no oral intake for 5 days in the presence of acute disease (unlikely to be seen in the community)
British Journal of Community Nursing October 2017 Vol 22, No 10
475
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 154.059.124.102 on October 3, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
NUTRITION
Creating individualised care plans In order to make screening effective the most important stage is to implement the appropriate nutritional care plan. Refer to your local policy for advice on this, alternatively the MUST screening tool provides care plans which can be implemented according to the degree of malnutrition. However if MUST is not being used in your area pathways and care plans can also be found at www.malnutritionpathway.org.uk (Malnutrition Pathway, 2012). The following steps should be taken if someone is identified as being malnourished: ww Monitor dietary intake ww Commence first-line dietary advice (more details on first-line advice can be found at www.malnutritionpathway.org.uk) ww Dietary goals should be set, e.g. maintain weight or promote weight gain of 5–10% body weight, improve or increase overall intake, promote wound healing.These goals should be realistic, e.g. patients who have end-stage dementia, palliative or undergoing cancer treatment are not likely to have improvement in nutritional status; however, minimising further decline in nutritional status is still beneficial and realistic ww Monitor and review care plan regularly, which should involve looking at progress according to the goals set For a MUST score of 2, i.e. high risk of malnutrition, all of the above actions should be taken and it is advised to refer to a dietitian and commence 1–2 nutritional supplements. However, this is dependent on your local policy. There may
476
be local prescribing committees who have developed national formularies. In this case, there will be guidance on the type of oral nutritional supplement, which should be recommended as first line and adhering to this will achieve cost savings for the NHS. Alternatively, access to www.malnutritionpathway. co.uk can provide a useful guide on the amount of oral nutritional supplements to prescribe, for what duration, and a realistic time frame for monitoring dietary goals. I will conclude this article with a quote from Janine Roberts, the programme director of the Malnutrition Taskforce Group, who states:‘Organisations have to deal with so many competing priorities and may ask, ‘why should we prioritise nutrition and hydration care?’ The answer is simple. Without food and water, people will die.’ Malnutrition cannot be tackled by an individual or a single team it needs to be a whole service approach, involving all health care professionals and public at the frontline facing malnutrition. The tools and resources are available to prevent and tackle malnutrition; they just need to be utilised. BJCN Brotherton, A, Holdoway, A, Stroud M. Malnutrition in the UK: appropriate prescribing of oral nutritional supplements. 2012 Elia M and Russell CA. Combating Malnutrition: Recommendations for Action. Report from the advisory group on malnutrition, led by BAPEN. 2009. http:// www.bapen.org.uk/pdfs/reports/advisory_group_report.pdf (accessed 12 September 2017) Elia M, Stratton R. Calculating the cost of disease-related malnutrition in the UK in 2007 (public expenditure only). In: Combating Malnutrition: Recommendations for Action. Report from the advisory group on malnutrition, led by BAPEN. 2009. http://www.bapen.org.uk/pdfs/reports/advisory_group_report.pdf (accessed 12 September 2017) Elia M, Stratton R, Russell C, et al. The cost of disease-related malnutrition in the UK and economic considerations for the use of oral nutritional supplements (ONS) in adults. A report by BAPEN. 2005. https://eprints.soton. ac.uk/61084/ (accessed 12 September 2017) Elia M. The cost of malnutrition in England and potential cost savings from nutritional interventions (short version). 2015. http://www.bapen.org.uk/ pdfs/economic-report-short.pdf (accessed 12 September 2017) Global Nutrition Report. From Promise to Impact: Ending Malnutrition by 2030. 2016. http://ebrary.ifpri.org/utils/getfile/collection/p15738coll2/id/130354/ filename/130565.pdf (accessed 12 September 2017) Malnutrition Pathway. Managing Adult Malnutrition in the Community. 2012. http://malnutritionpathway.co.uk/downloads/Managing_Malnutrition.pdf (12 September 2017) Malnutrition Taskforce. Malnutrition in later life: Prevention and early intervention. Best practice principles and implementation guide. A community approach. 2013. http://www.malnutritiontaskforce.org.uk/wp-content/ uploads/2014/07/COM-Prevention_Early_Intervention_Of_Malnutrition_ in_Later_Life_Local_community.pdf (accessed 12 September 2017) National Institute for Health and Care Excellence. Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical Guideline 32. 2006. https://www.nice.org.uk/guidance/cg32 (accessed 12 September 2017) National Institute for Health and Care Excellence.. NICE support for commissioners and others using the quality standard on nutrition support in adults. 2012a. https://www.nice.org.uk/guidance/qs24/resources/support-forcommissioners-and-others-using-the-quality-standard-on-nutrition-support-inadults-252372637 (accessed 12 September 2017) National Institute for Health and Care Excellence. QS24 Nutrition support in adults. Quality standard 24. 2012b. https://www.nice.org.uk/guidance/qs24 (accessed 12 September 2017) Russell CA, Elia M. Nutrition Screening Survey in the UK and Republic of Ireland in 2011. 2012. http://www.bapen.org.uk/pdfs/nsw/nsw-2011-report. pdf. (accessed 12 September 2017) Stratton R, Green C, Elia M. Disease-related malnutrition: an evidence-based approach to treatment. Clinical Nutrition. 2003;22(6):585 Stratton R, Hackston A, Longmore D, et al. Malnutrition in hospital outpatients: prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (‘MUST’) for adults. Br J Nutrition. 2004;92:799–808. Thomas B and Bishop J. Manual of Dietetic Practice. 4th ed. Blackwell Publishing Ltd; 2007
© 2017 MA Healthcare Ltd
boundaries and across communities 3. Identifying malnutrition in the individual and prevalence within organisations and across local communities 4. Personalising care, support and treatment for every individual 5. Monitoring and evaluating the individual and the processes in place to address malnutrition A good starting point is to find out the local prevalence of the at-risk population in your area. This can be done using the BAPEN nutritional care tool, www.data.bapen.org.uk, or NICE quality statement 24. This tool can also be used to assess how your community is screened for malnutrition and the provision of nutritional care.You can then establish whether the practices in place are having the desired effect in the community. It may be necessary to start viewing malnutrition and dehydration as safeguarding more often and to incorporate this into local improvement plans (Malnutrition Taskforce, 2013). It is crucial that training needs are identified and provided particularly around enhancing skills and competencies with identifying malnutrition and being able to put the appropriate care plan into action. It is also important to raise awareness of malnutrition in the public, service users and their carers. In particular, dispelling myths that it is normal to lose weight or to be underweight in old age. Don’t reinvent the wheel and consider using existing information and leaflets to raise awareness. Furthermore, it should be compulsory to alert staff on admission to hospital if the patient is at risk of malnutrition and to hand over any nutritional care plan which is in place in the community (Malnutrition Taskforce, 2013).
British Journal of Community Nursing October 2017 Vol 22, No 10 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 154.059.124.102 on October 3, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
