CPD
4 Page 60
Malnutrition in prison multiple choice questionnaire
CONTINUING PROFESSIONAL DEVELOPMENT
4 Page 61
Read Rose Gallacher’s practice profile on early stage dementia
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Guidelines on how to write a practice profile
Preventing malnutrition in prison NS726 Leach B, Goodwin S (2014) Preventing malnutrition in prison. Nursing Standard. 28, 20, 50-56. Date of submission: May 19 2013; date of acceptance: October 7 2013.
Abstract Vulnerable patient groups are at increased risk of malnutrition. This article focuses on the importance of ensuring that the nutritional needs of those in institutional settings, in particular prisons, are met. Offenders often present with a number of health and social factors which can lead to a high risk of malnutrition. The consequences of malnutrition are significant, ranging from delayed recovery to increased mortality. The treatment of malnutrition is discussed in this article from detection through to management and monitoring. Adequate nutrition is a basic human right and those in prison should be provided with healthy food choices to optimise health.
Authors Bethan Leach Dietitian for offender health, Oxford Health NHS Foundation Trust, East Oxford Health Centre, Oxford. Sarah Goodwin Independent healthcare adviser, The Oxford Healthcare Partnership, Oxford. Correspondence to: [email protected]
Aims and intended learning outcomes The aim of this article is to emphasise the importance of ensuring that the nutritional needs of those in prison are met to prevent malnutrition and promote healthy lifestyles among offenders. It identifies the need to support individuals in improving their own health, and the role of prison health care and prison authorities in achieving this. After reading this article and completing the time out activities you should be able to: Identify screening tools that can be used to identify individuals in the prison population who are at risk of malnutrition. Describe the effects of malnutrition on the physical and mental health of those in prison. the nutrient and food-based standards Explain for prisons and assess how these standards can be met in an institutional environment. Examine challenges and constraints in managing malnutrition in prisons.
Keywords
Introduction
Food and nutrition, health inequalities, health promotion, malnutrition, offender health, prison nursing, undernutrition
This article examines malnutrition in the context of the prison environment. It is aimed at nurses who work with patients in penal or young offender settings and places where nutrition is institutionally organised. Those working in such settings need to recognise the importance of promoting health among offenders and preventing health inequalities. Complete time out activity 1
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
50 january 15 :: vol 28 no 20 :: 2014
Malnutrition has been described as ‘a state of nutrition in which a deficiency or excess or imbalance of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition), and function, and clinical outcome’ (Todorovic et al 2003). This article
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focuses on malnutrition in the context of insufficient energy to maintain a healthy body weight, or undernutrition. The World Health Organization (WHO) (2012) states that poor nutrition is one of the greatest threats to public health worldwide. It is estimated that there are more than three million people in the UK at risk of malnutrition (Elia and Russell 2009). Despite this, malnutrition often goes undetected in community and acute settings and can lead to substantial health and financial costs (British Dietetic Association (BDA) 2012). The Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis 2013) highlighted the limited approach to meeting the nutritional needs of patients in hospital. Poor nutritional care was found to delay recovery, and increase the risk of pressure ulcers, weight loss and mortality. By instigating robust nutritional screening and appropriate malnutrition management plans in any environment, including prison, the risk of harm to patients will be reduced (Royal College of Nursing (RCN) 2013). Unrecognised malnutrition can affect a person’s ability to engage in purposeful activity, for example work or education, which is expected of offenders in prison (Ministry of Justice 2012). Malnutrition can lead to disease, delayed recovery, delayed wound healing, poor immune function, reduced muscle strength, low mood, difficulty keeping warm, increased visits to the GP, and increased frequency and length of stay in hospital (BDA 2011, BAPEN 2013a). These factors can also make people more vulnerable to developing malnutrition, highlighting a cycle in which malnutrition causes problems that in turn may lead to further malnutrition. Therefore, it is essential that nurses are able to recognise malnutrition, provide nutritional advice and where appropriate, refer individuals to dietetic services for further assessment and treatment.
Identifying malnutrition The National Institute for Health and Care Excellence (NICE) (2012) advises that patients in institutional care settings should be screened for malnutrition using a validated screening tool. Screening is a brief assessment that indicates risk and directs management for those who most need it. Many nutritional screening tools have been developed for use in the general population and for specific patient groups (Ferguson et al 1999). The Mini Nutritional Assessment (Nestlé Nutrition Institute 2013)
for older people and the Malnutrition Universal Screening Tool (MUST) (Todorovic et al 2003) are validated tools that have been researched extensively (Todorovic et al 2003, Guigoz 2006). MUST was developed by a group of healthcare professionals representing several disciplines, including nurses and dietitians. It can be used to identify adults who are malnourished, at risk of malnutrition (undernutrition) or obese. MUST has been trialled, validated and adapted for ease of use. MUST uses readily available anthropometric measurements such as height, weight and percentage weight loss to predict risk of malnutrition. Some of the main advantages include the universal nature of the tool – it is designed to be used by any member of the healthcare team who has been trained in its use – and ease of use. MUST includes five main steps (BAPEN 2013b): 1 – measure weight and height to Step calculate the person’s body mass index (BMI) score (BMI=weight (kg) divided by height (m)2). Step 2 – establish whether the person has lost any weight unintentionally to calculate his or her weight-loss score. 3 – establish the effect of the person’s Step illness on his or her ability to eat and drink to calculate the person’s illness score. Step 4 – add up the scores from steps 1, 2 and 3 to identify overall risk of malnutrition. Step 5 – use management guidelines and/or local policy to develop a care plan. The risk score obtained from MUST is used to guide treatment. Early screening and treatment are essential to ensure that poor outcomes and malnutrition are avoided. Complete time out activity 2
Health and nutrition in prison In 2003, health care in prisons became the responsibility of the NHS, with the main aim ‘to provide prisoners with access to the same quality and range of healthcare services as the general public receives from the NHS’ (Department of Health (DH) 2007). People in prison may be at increased risk of physical and mental health problems as a result of several factors, including (Prison Reform Trust 2012): Around 24% of offenders had been in care as children. Approximately 29% of offenders had been subject to abuse as children, thereby influencing self-esteem and sense of personal control.
1 Reflect on how you assess a patient’s nutritional status in your area of practice. What signs do you look for to identify malnutrition? What information do you record in the patient’s clinical records? 2 Familiarise yourself with MUST (BAPEN 2013b). List the baseline patient data you require to be able to complete this score. How does this compare with the data you stated that you collected in answer to time out 1? Obtain baseline data for five patients and calculate each patient’s BMI to identify his or her risk of malnutrition.
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CPD nutrition Around 64% of offenders abused substances before going to prison. 15% of offenders were Approximately homeless before being sentenced. Rates of anxiety and depression, self-harm and suicide are higher in the prison population than in the general population (Bradley 2009). There are increased rates of chronic disease in offenders, for example in relation to coronary artery disease, diabetes, long-term neurological conditions and renal disease (RCN 2009). Many of these individuals will also experience chronic pain (Harris and Stannard 2012). Infectious diseases such as tuberculosis (TB) and human immunodeficiency virus (HIV) are also more common in people in prison (Cornford et al 2012). TB rates are up to 15 times higher among prisoners than in the general population (Health Protection Agency 2010), and higher than average rates of blood-borne viruses, communicable diseases and genito-urinary diseases are evident (RCN 2009). Since nutritional requirements often increase with disease, and because some treatments often decrease appetite, weight loss, malnutrition and further ill health could result. The effects of pre-existing conditions, limited exercise and access to fresh air, and the psychological stress of incarceration compound the poor health and wellbeing of the prison population (Ministry of Justice 2013). The number of older people in prison is rising, and a combination of previous poor diet, lack of consistent or ongoing medical care, and the experience of incarceration can have a detrimental effect on health and wellbeing (BDA 2012, Ginn 2012). Since malnutrition rates are also higher in older people (Elia 2013), there is a need to pay particular attention to this group of people. As with many other areas of health, risk factors can be multiple and those who misuse
FIGURE 1 Local malnutrition management guidance
MUST step 5: care pathway
0 Low risk No action required
1-2* Medium risk Monthly weights MUST score monthly Provide eatwell leaflet
3 or more High risk MUST score weekly Provide eatwell leaflet Refer to the GP Refer to the dietitian
*Use clinical discretion and refer on if % weight loss is high (weight loss score of 1 or more)
52 january 15 :: vol 28 no 20 :: 2014
substances often experience mental health problems (Royal College of Psychiatrists 2013), infectious diseases and poor dental health (Degenhardt and Hall 2012). Around 90% of patients in prison have some form of mental health difficulty, including psychosis, personality disorder, neurosis, hazardous drinking and drug dependence (DH 2007). The effects of this on a patient’s nutritional health can be various and severe. For example, poor food intake is often caused by the chaotic lifestyle and loss of appetite experienced by people who misuse substances, and weight loss and malnutrition result, causing further ill health. All offenders are given a health assessment on arrival at prison (Ministry of Justice 2006). The assessment has two components. Initially, a first-night health assessment is undertaken, paying particular attention to self-harm, mental health difficulties, substance misuse, and any health conditions requiring immediate referral, assessment and treatment. This is followed by a full health assessment conducted within seven days of entering prison. The format and content of this assessment will vary between prisons, but usually includes physical checks such as blood pressure, blood glucose levels, height and weight, as well as health promotion questions relating to lifestyle and risk of infectious disease (Shaw et al 2008). The introduction of SystmOne (an electronic clinical recording system) in prisons across England has enabled some standardisation of data collection, including physical measurements. This is important because the individual’s health can be monitored over time, particularly if he or she is transferred to another establishment.
Managing malnutrition Once an individual has been identified as being at risk of malnutrition, an appropriate management plan can be discussed with the patient and commenced. Management plans will differ between organisations, however Figure 1 shows an example of a management plan developed by the prison healthcare team in the area where the authors work. The plan is based on local NHS provider guidance, clinical guidance (Todorovic et al 2003, NHS Grampian 2011), audit results and best practice. These plans provide nutritional advice and support to those whose nutritional status does not improve while in prison. Malnutrition management plans, such as that shown in Figure 1, will mean that the
© NURSING STANDARD / RCN PUBLISHING
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care of patients who cannot meet their own nutritional needs is consistent and targeted. Patients at high risk of malnutrition should also be monitored regularly (weekly weights) and seen by the dietitian who can provide menu and food fortification advice before oral nutritional supplements are considered. Offenders should also be reviewed by the GP to investigate any clinical cause for being underweight. This is in line with NICE (2006) guidance and BAPEN recommendations (Todorovic et al 2003).
Case study 1
William is a 63-year-old male. He had been in prison the previous year, and during this time underwent tests for frequent loose stool – it is not uncommon for there to be a change in bowel habits with alterations in diet, lifestyle and medications when offenders arrive at prison. William was concerned that his loose stool had not improved after a few weeks, and he requested to see the prison GP. Blood tests showed that he had anaemia. William was released on licence from prison before his follow-up appointment. He did not consent to correspondence with his GP because he did not want to disclose his incarceration. Three weeks later, William returned to prison on recall (this happens when an individual has broken early-release regulations). The nurse conducting the health screening observed that William looked pale and gaunt, and on checking his healthcare records identified that he had been losing weight: 2008: height = 1.74m; 106kg – data May from initial health screening. 2009: 110kg. July 2011: 104kg. November 2012: 101kg. May 2012: 95kg – released from prison. June 2012: height = 1.74m; 90kg – on recall. July Weight loss greater than 10% over three months is considered clinically significant (Todorovic et al 2003) (Table 1). Therefore, William was referred urgently to the GP for further investigation of his weight loss. Following relevant tests, he was diagnosed with colon cancer. Alongside treatment for colon cancer, a dietitian worked with William to develop a nutritional care plan to ensure that he was receiving essential nutrients to aid his recovery. Weight loss can be a sign of illness and identifying it early can lead to timely diagnosis, provision of nutritional support and improved treatment outcomes (Power et al 2011). Nurses working in this setting, with patients such as William, are well placed to
monitor alterations in body weight. Weighing regularly, documenting weight and monitoring the weight trend over time are important in treating malnutrition and identifying underlying reasons for weight loss. Complete time out activity 3
Case study 2
Adam is a 21-year-old male. He arrives in prison following offences relating to substance misuse. The nurse on reception records that he is taking 40mL of methadone once daily as prescribed. Adam admits that despite prison regulations he continues to use heroin, crack cocaine and other substances in addition to methadone. He appears thin and reports that he has little interest in food. He is also constipated. Because of his chaotic lifestyle, maintaining adequate nutrition has been challenging for Adam. Loss of appetite and constipation are common effects of substance misuse and the medications used in its treatment, for example methadone or buprenorphine (Daeninck and Bruera 1999, Yuan et al 2000). Although these symptoms often resolve with decreasing methadone use, provision of regular meals and a stable environment, while food intake and weight are low Adam is still at risk of malnutrition. By looking at Adam’s prison healthcare records it is clear that he is underweight (December 2012: height = 1.84m; 60kg – data from initial health screening). Adam does not know his normal weight and does not report any relevant medical conditions. With a BMI of 18, Adam is considered to be underweight (Table 2) and is therefore at risk of malnutrition. Adam was provided with some general information about healthy eating and was booked in for monthly weight monitoring. Adam was also given the
3 Use the MUST five steps (BAPEN 2013b) to see if you can identify whether William (case study 1) is malnourished or at risk of malnutrition. Would you have the right baseline data to make the relevant calculations?
TABLE 1 Weight loss score Score
Unplanned weight loss in the past 3 to 6 months (% body weight)
Significance
2
>10
Clinically significant
1
5-10
More than normal intra-individual variation – early indicator of increased risk of undernutrition
0
4 Page 60
Malnutrition in prison multiple choice questionnaire
CONTINUING PROFESSIONAL DEVELOPMENT
4 Page 61
Read Rose Gallacher’s practice profile on early stage dementia
4 Page 62
Guidelines on how to write a practice profile
Preventing malnutrition in prison NS726 Leach B, Goodwin S (2014) Preventing malnutrition in prison. Nursing Standard. 28, 20, 50-56. Date of submission: May 19 2013; date of acceptance: October 7 2013.
Abstract Vulnerable patient groups are at increased risk of malnutrition. This article focuses on the importance of ensuring that the nutritional needs of those in institutional settings, in particular prisons, are met. Offenders often present with a number of health and social factors which can lead to a high risk of malnutrition. The consequences of malnutrition are significant, ranging from delayed recovery to increased mortality. The treatment of malnutrition is discussed in this article from detection through to management and monitoring. Adequate nutrition is a basic human right and those in prison should be provided with healthy food choices to optimise health.
Authors Bethan Leach Dietitian for offender health, Oxford Health NHS Foundation Trust, East Oxford Health Centre, Oxford. Sarah Goodwin Independent healthcare adviser, The Oxford Healthcare Partnership, Oxford. Correspondence to: [email protected]
Aims and intended learning outcomes The aim of this article is to emphasise the importance of ensuring that the nutritional needs of those in prison are met to prevent malnutrition and promote healthy lifestyles among offenders. It identifies the need to support individuals in improving their own health, and the role of prison health care and prison authorities in achieving this. After reading this article and completing the time out activities you should be able to: Identify screening tools that can be used to identify individuals in the prison population who are at risk of malnutrition. Describe the effects of malnutrition on the physical and mental health of those in prison. the nutrient and food-based standards Explain for prisons and assess how these standards can be met in an institutional environment. Examine challenges and constraints in managing malnutrition in prisons.
Keywords
Introduction
Food and nutrition, health inequalities, health promotion, malnutrition, offender health, prison nursing, undernutrition
This article examines malnutrition in the context of the prison environment. It is aimed at nurses who work with patients in penal or young offender settings and places where nutrition is institutionally organised. Those working in such settings need to recognise the importance of promoting health among offenders and preventing health inequalities. Complete time out activity 1
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
50 january 15 :: vol 28 no 20 :: 2014
Malnutrition has been described as ‘a state of nutrition in which a deficiency or excess or imbalance of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition), and function, and clinical outcome’ (Todorovic et al 2003). This article
© NURSING STANDARD / RCN PUBLISHING
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focuses on malnutrition in the context of insufficient energy to maintain a healthy body weight, or undernutrition. The World Health Organization (WHO) (2012) states that poor nutrition is one of the greatest threats to public health worldwide. It is estimated that there are more than three million people in the UK at risk of malnutrition (Elia and Russell 2009). Despite this, malnutrition often goes undetected in community and acute settings and can lead to substantial health and financial costs (British Dietetic Association (BDA) 2012). The Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis 2013) highlighted the limited approach to meeting the nutritional needs of patients in hospital. Poor nutritional care was found to delay recovery, and increase the risk of pressure ulcers, weight loss and mortality. By instigating robust nutritional screening and appropriate malnutrition management plans in any environment, including prison, the risk of harm to patients will be reduced (Royal College of Nursing (RCN) 2013). Unrecognised malnutrition can affect a person’s ability to engage in purposeful activity, for example work or education, which is expected of offenders in prison (Ministry of Justice 2012). Malnutrition can lead to disease, delayed recovery, delayed wound healing, poor immune function, reduced muscle strength, low mood, difficulty keeping warm, increased visits to the GP, and increased frequency and length of stay in hospital (BDA 2011, BAPEN 2013a). These factors can also make people more vulnerable to developing malnutrition, highlighting a cycle in which malnutrition causes problems that in turn may lead to further malnutrition. Therefore, it is essential that nurses are able to recognise malnutrition, provide nutritional advice and where appropriate, refer individuals to dietetic services for further assessment and treatment.
Identifying malnutrition The National Institute for Health and Care Excellence (NICE) (2012) advises that patients in institutional care settings should be screened for malnutrition using a validated screening tool. Screening is a brief assessment that indicates risk and directs management for those who most need it. Many nutritional screening tools have been developed for use in the general population and for specific patient groups (Ferguson et al 1999). The Mini Nutritional Assessment (Nestlé Nutrition Institute 2013)
for older people and the Malnutrition Universal Screening Tool (MUST) (Todorovic et al 2003) are validated tools that have been researched extensively (Todorovic et al 2003, Guigoz 2006). MUST was developed by a group of healthcare professionals representing several disciplines, including nurses and dietitians. It can be used to identify adults who are malnourished, at risk of malnutrition (undernutrition) or obese. MUST has been trialled, validated and adapted for ease of use. MUST uses readily available anthropometric measurements such as height, weight and percentage weight loss to predict risk of malnutrition. Some of the main advantages include the universal nature of the tool – it is designed to be used by any member of the healthcare team who has been trained in its use – and ease of use. MUST includes five main steps (BAPEN 2013b): 1 – measure weight and height to Step calculate the person’s body mass index (BMI) score (BMI=weight (kg) divided by height (m)2). Step 2 – establish whether the person has lost any weight unintentionally to calculate his or her weight-loss score. 3 – establish the effect of the person’s Step illness on his or her ability to eat and drink to calculate the person’s illness score. Step 4 – add up the scores from steps 1, 2 and 3 to identify overall risk of malnutrition. Step 5 – use management guidelines and/or local policy to develop a care plan. The risk score obtained from MUST is used to guide treatment. Early screening and treatment are essential to ensure that poor outcomes and malnutrition are avoided. Complete time out activity 2
Health and nutrition in prison In 2003, health care in prisons became the responsibility of the NHS, with the main aim ‘to provide prisoners with access to the same quality and range of healthcare services as the general public receives from the NHS’ (Department of Health (DH) 2007). People in prison may be at increased risk of physical and mental health problems as a result of several factors, including (Prison Reform Trust 2012): Around 24% of offenders had been in care as children. Approximately 29% of offenders had been subject to abuse as children, thereby influencing self-esteem and sense of personal control.
1 Reflect on how you assess a patient’s nutritional status in your area of practice. What signs do you look for to identify malnutrition? What information do you record in the patient’s clinical records? 2 Familiarise yourself with MUST (BAPEN 2013b). List the baseline patient data you require to be able to complete this score. How does this compare with the data you stated that you collected in answer to time out 1? Obtain baseline data for five patients and calculate each patient’s BMI to identify his or her risk of malnutrition.
©Downloaded NURSINGfrom STANDARD / RCN PUBLISHING january 15 :: vol 28 no 20 :: 2014 51 RCNi.com by ${individualUser.displayName} on Nov 24, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
CPD nutrition Around 64% of offenders abused substances before going to prison. 15% of offenders were Approximately homeless before being sentenced. Rates of anxiety and depression, self-harm and suicide are higher in the prison population than in the general population (Bradley 2009). There are increased rates of chronic disease in offenders, for example in relation to coronary artery disease, diabetes, long-term neurological conditions and renal disease (RCN 2009). Many of these individuals will also experience chronic pain (Harris and Stannard 2012). Infectious diseases such as tuberculosis (TB) and human immunodeficiency virus (HIV) are also more common in people in prison (Cornford et al 2012). TB rates are up to 15 times higher among prisoners than in the general population (Health Protection Agency 2010), and higher than average rates of blood-borne viruses, communicable diseases and genito-urinary diseases are evident (RCN 2009). Since nutritional requirements often increase with disease, and because some treatments often decrease appetite, weight loss, malnutrition and further ill health could result. The effects of pre-existing conditions, limited exercise and access to fresh air, and the psychological stress of incarceration compound the poor health and wellbeing of the prison population (Ministry of Justice 2013). The number of older people in prison is rising, and a combination of previous poor diet, lack of consistent or ongoing medical care, and the experience of incarceration can have a detrimental effect on health and wellbeing (BDA 2012, Ginn 2012). Since malnutrition rates are also higher in older people (Elia 2013), there is a need to pay particular attention to this group of people. As with many other areas of health, risk factors can be multiple and those who misuse
FIGURE 1 Local malnutrition management guidance
MUST step 5: care pathway
0 Low risk No action required
1-2* Medium risk Monthly weights MUST score monthly Provide eatwell leaflet
3 or more High risk MUST score weekly Provide eatwell leaflet Refer to the GP Refer to the dietitian
*Use clinical discretion and refer on if % weight loss is high (weight loss score of 1 or more)
52 january 15 :: vol 28 no 20 :: 2014
substances often experience mental health problems (Royal College of Psychiatrists 2013), infectious diseases and poor dental health (Degenhardt and Hall 2012). Around 90% of patients in prison have some form of mental health difficulty, including psychosis, personality disorder, neurosis, hazardous drinking and drug dependence (DH 2007). The effects of this on a patient’s nutritional health can be various and severe. For example, poor food intake is often caused by the chaotic lifestyle and loss of appetite experienced by people who misuse substances, and weight loss and malnutrition result, causing further ill health. All offenders are given a health assessment on arrival at prison (Ministry of Justice 2006). The assessment has two components. Initially, a first-night health assessment is undertaken, paying particular attention to self-harm, mental health difficulties, substance misuse, and any health conditions requiring immediate referral, assessment and treatment. This is followed by a full health assessment conducted within seven days of entering prison. The format and content of this assessment will vary between prisons, but usually includes physical checks such as blood pressure, blood glucose levels, height and weight, as well as health promotion questions relating to lifestyle and risk of infectious disease (Shaw et al 2008). The introduction of SystmOne (an electronic clinical recording system) in prisons across England has enabled some standardisation of data collection, including physical measurements. This is important because the individual’s health can be monitored over time, particularly if he or she is transferred to another establishment.
Managing malnutrition Once an individual has been identified as being at risk of malnutrition, an appropriate management plan can be discussed with the patient and commenced. Management plans will differ between organisations, however Figure 1 shows an example of a management plan developed by the prison healthcare team in the area where the authors work. The plan is based on local NHS provider guidance, clinical guidance (Todorovic et al 2003, NHS Grampian 2011), audit results and best practice. These plans provide nutritional advice and support to those whose nutritional status does not improve while in prison. Malnutrition management plans, such as that shown in Figure 1, will mean that the
© NURSING STANDARD / RCN PUBLISHING
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 24, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
care of patients who cannot meet their own nutritional needs is consistent and targeted. Patients at high risk of malnutrition should also be monitored regularly (weekly weights) and seen by the dietitian who can provide menu and food fortification advice before oral nutritional supplements are considered. Offenders should also be reviewed by the GP to investigate any clinical cause for being underweight. This is in line with NICE (2006) guidance and BAPEN recommendations (Todorovic et al 2003).
Case study 1
William is a 63-year-old male. He had been in prison the previous year, and during this time underwent tests for frequent loose stool – it is not uncommon for there to be a change in bowel habits with alterations in diet, lifestyle and medications when offenders arrive at prison. William was concerned that his loose stool had not improved after a few weeks, and he requested to see the prison GP. Blood tests showed that he had anaemia. William was released on licence from prison before his follow-up appointment. He did not consent to correspondence with his GP because he did not want to disclose his incarceration. Three weeks later, William returned to prison on recall (this happens when an individual has broken early-release regulations). The nurse conducting the health screening observed that William looked pale and gaunt, and on checking his healthcare records identified that he had been losing weight: 2008: height = 1.74m; 106kg – data May from initial health screening. 2009: 110kg. July 2011: 104kg. November 2012: 101kg. May 2012: 95kg – released from prison. June 2012: height = 1.74m; 90kg – on recall. July Weight loss greater than 10% over three months is considered clinically significant (Todorovic et al 2003) (Table 1). Therefore, William was referred urgently to the GP for further investigation of his weight loss. Following relevant tests, he was diagnosed with colon cancer. Alongside treatment for colon cancer, a dietitian worked with William to develop a nutritional care plan to ensure that he was receiving essential nutrients to aid his recovery. Weight loss can be a sign of illness and identifying it early can lead to timely diagnosis, provision of nutritional support and improved treatment outcomes (Power et al 2011). Nurses working in this setting, with patients such as William, are well placed to
monitor alterations in body weight. Weighing regularly, documenting weight and monitoring the weight trend over time are important in treating malnutrition and identifying underlying reasons for weight loss. Complete time out activity 3
Case study 2
Adam is a 21-year-old male. He arrives in prison following offences relating to substance misuse. The nurse on reception records that he is taking 40mL of methadone once daily as prescribed. Adam admits that despite prison regulations he continues to use heroin, crack cocaine and other substances in addition to methadone. He appears thin and reports that he has little interest in food. He is also constipated. Because of his chaotic lifestyle, maintaining adequate nutrition has been challenging for Adam. Loss of appetite and constipation are common effects of substance misuse and the medications used in its treatment, for example methadone or buprenorphine (Daeninck and Bruera 1999, Yuan et al 2000). Although these symptoms often resolve with decreasing methadone use, provision of regular meals and a stable environment, while food intake and weight are low Adam is still at risk of malnutrition. By looking at Adam’s prison healthcare records it is clear that he is underweight (December 2012: height = 1.84m; 60kg – data from initial health screening). Adam does not know his normal weight and does not report any relevant medical conditions. With a BMI of 18, Adam is considered to be underweight (Table 2) and is therefore at risk of malnutrition. Adam was provided with some general information about healthy eating and was booked in for monthly weight monitoring. Adam was also given the
3 Use the MUST five steps (BAPEN 2013b) to see if you can identify whether William (case study 1) is malnourished or at risk of malnutrition. Would you have the right baseline data to make the relevant calculations?
TABLE 1 Weight loss score Score
Unplanned weight loss in the past 3 to 6 months (% body weight)
Significance
2
>10
Clinically significant
1
5-10
More than normal intra-individual variation – early indicator of increased risk of undernutrition
0
