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Oxfordshire Clinical Commissioning Group Guidelines for the Management of Undernutrition for Adults in Primary Care: Updated May 2014 Quick Reference Summary Nutritional screening – use MUST (MUST calculator) and check for dysphagia as per NICE Guidance Nutrition Support in Adults 2006 If patient has a safe swallow: Improve food intake Ensure optimal food intake Provide patient with dietary information booklet ‘Common problems and helpful hints if you have a small appetite’ Re-assess at 2 – 4 weeks (or more frequent if required) Weigh patient and record in notes If patient has a specific indication they may be appropriate for prescribable oral nutritional supplement – How to Manage Patients on Prescribed Oral Nutritional Supplements: Ensure patient has clear specified indication which is ACBS approved Do not give as the sole source of nutrition except following consultation with a dietitian Patients should be prescribed 1.5kcal / ml supplements as standard Powdered shake are cost effective milk based sip feeds and should be suitable for most patients: the current first line choice is Aymes Shake 57g powder sachet with 200ml whole milk (see page 4 and 5 for all options and prices) Initial prescription should be limited to one week’s supply and marked mixed flavours – provide ‘Advice on taking your dietary supplement’ After a week trial the patient should then contact the surgery with the details of the preferred supplements Prescriptions should have clear directions for use e.g. ‘one to be taken twice daily between meals’- ‘As directed’ should not be used Subsequent prescriptions should be for a maximum of four weeks Nutritional supplements should not be used on a long-term basis without regular monitoring and assessment of the patient’s nutritional status Once the set aim of treatment has been reached reduce nutritional supplement prescriptions to once daily If patient’s weight is stable after an additional month discontinue and remove from medication list Continue to monitor and record weight monthly for at least 3 months Deterioration: e.g. continuing weight loss Monitor food intake and compliance with supplements Refer to Community Dietetics Department, East Oxford Health Centre, Manzil Way, Cowley Road, Oxford OX4 1XD (Tel: 01865 264920 / Fax: 01865 264939) Guidelines for the Management of Undernutrition in Adults in Primary Care: Updated May 2014 Approved by APCO July 2014. Review due July 2016 1 Oxfordshire Clinical Commissioning Group Guidelines for the Management of Undernutrition for Adults in Primary Care: Updated May 2014 Nutritional screening Using the ‘Malnutrition Universal Screening Tool’ (MUST) adult patients can be identified as low, medium or high risk of malnutrition (www.bapen.org.uk). Record weight and outcome of MUST Patient identified as either medium or high risk: Set aim of treatment e.g. weight / Body Mass Index (BMI) target and record Check for Dysphagia as per NICE Guidance Nutrition Support in Adults 2006 (http://www.nice.org.uk/guidance/cg32) Refer people with any obvious or less obvious indicators of dysphagia to healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing. Obvious indicators of dysphagia *Difficult, painful chewing or swallowing *Regurgitation of undigested food *Difficulty controlling food or liquid in the mouth *Drooling *Hoarse voice *Coughing or choking before, during or after swallowing *Globus sensation *Nasal regurgitation *Feeling of obstruction *Unintentional weight loss – for example in people with dementia Less obvious indicators of dysphagia *Change in respiration pattern *Unexplained temperature spikes *Wet voice quality *Tongue fasciculation (may be indicative of motor neurone disease) *Xerostomia *Heartburn *Change in eating habits – for example, eating slowly or avoiding social occasions *Frequent throat clearing *Recurrent chest infections *Atypical chest pain If patient has a safe swallow: Improve food intake Advise on high calorie / high protein diet; - enrich food, use butter, cream, cheese, skimmed milk powder and sugar as appropriate - use full fat diary products and encourage milk based drinks - encourage small frequent meals and snacks Ensure optimal food intake Treat contributory symptoms e.g. constipation, poor dentition, pain Can patient’s environment be changed to help improve their oral intake e.g. modified eating aids, convenience / ready made meals Provide patient with dietary information booklet Common problems and helpful hints if you have a small appetite If there is concern regarding micronutrient deficiency and the patient is not receiving any additional nutritional supplementation consider recommending a complete multivitamin and mineral supplement. Re-assess at 2 – 4 weeks (or more frequent if required) Weigh patient and record in notes Guidelines for the Management of Undernutrition in Adults in Primary Care: Updated May 2014 Approved by APCO July 2014. Review due July 2016 2 Oxfordshire Clinical Commissioning Group Improvement e.g. no further weight loss, improved nutritional status Reinforce dietary advice and encourage patient to continue If patient is receiving nutritional supplements review compliance and monitor intake Continued Improvement e.g. weight / BMI target reached or aim of intervention achieved Continue to encourage dietary intake Reduce any nutritional supplement prescriptions to once daily. If patients weight is stable after an additional month discontinue and remove from medication list Continue to monitor and record weight monthly for at least 3 months No Improvement e.g. further weight loss, continued poor oral intake Reinforce dietary advice Over the counter supplements may be advised. Build up and Complan are available in a powdered form and need to be reconstituted with milk. A patient requiring supplements generally only requires an additional 250 – 600kcal per day (approx. 1-2 sachets). For most patients supplements should be used in addition to their food intake. Should an individual decide to self purchase, they are still advised to follow the guidance above of making lifestyle changes, enriching foods, using full fat diary products and having small frequent meals and increasing intake of milk based drinks. If patient has a specific indication they may be appropriate for prescribable oral nutritional supplement – if so provide written information ‘Advice on taking your supplements’ – available from the Community Dietitians. Over the products counter Complan Milkshake and Soup styles available Nestle Nutren Build up Nutrition Shake Nestle Nutren Build up Nutrition Soup Presentation 4 x 57g powder sachet Serving: 57g sachet with 200ml of: water semi skimmed milk whole milk 4 x 38g powder sachet Serving: 38g sachet with 200ml whole milk 4 x 49g powder sachet Serving: 49g sachet with 150ml water Calories per serving Protein (g) per serving Approx. Retail Cost 250 320 380 8.8 15.4 15.4 £3.49 (4 sachets) 263 14.9 £3.59 (4 sachets) 200 6.9 - 7.6 £3.59 (4 sachets) Nestle Nutrition Build up Original 400g re-closable pack; neutral flavour 144 9.6 £4.99 Serving: 40g / 4 tbsp (1 pack) See further advice on managing these patients below Useful resources: http://www.nhs.uk/Livewell/healthy-eating/Pages/Healthyeating.aspx NHS choices www.nutrition.org.uk/healthyliving The British Nutrition Foundation www.bapen.org.uk (MUST) British Association for Parenteral & Enteral Nutrition Deterioration e.g. continuing weight loss Monitor food intake and compliance with supplements Refer to: Community Dietetics Department, East Oxford Health Centre, Manzil Way, Cowley Road, Oxford OX4 1XD (Tel:01865 264920 / Fax:01865 264939) Guidelines for the Management of Undernutrition in Adults in Primary Care: Updated May 2014 Approved by APCO July 2014. Review due July 2016 3 Oxfordshire Clinical Commissioning Group Oral Nutritional Supplement Prescribing Guidance Nutritional supplements should only be used when dietary advice has failed to improve nutritional status (except for specific medical conditions such as malabsorptive disorders or severe dysphagia where they may be needed as first-line treatment). Supplements available on FP10 must be prescribed for approved conditions as advised by the Advisory Committee on Borderline Substances (ACBS). These conditions include short bowel syndrome, intractable malabsorption, pre-operative preparation of malnourished patients, inflammatory bowel disease, total gastrectomy, dysphagia, bowel fistulae and disease related malnutrition. How to Manage Patients on Prescribed Oral Nutritional Supplements Set aim of treatment e.g. weight / BMI target and record Ensure patient has clear specified indication which is ACBS approved A patient requiring prescribable supplements generally only requires an additional 250 – 600kcal / day (approx. 1-2 cartons) Do not give as the sole source of nutrition except following consultation with a dietitian (especially non milk ones which are fat free) Patients should be prescribed 1.5kcal / ml supplements as standard Provide written information – ‘Advice on taking your dietary supplement’ The most commonly used nutritional supplements are sip feeds: These are available in either a powder form or ready to drink bottles and come in a variety of sweet and savoury flavours:Powdered Shake are cost effective milk based sip feeds; the current first line choice is Aymes Shake. This should be a suitable first choice option for many patients; this switch is not suggested for patients under the care of a dietician. (e.g. Shakes are not suitable for renal patients with CKD stage 4/5 or on dialysis; they are also not suitable for tube feeding). Milk based Product Presentation Calories per Protein (g) per Cost per serving serving serving Aymes 57g powder sachet 384 16 £0.78 Shake with 200ml whole milk (1 box= 7 sachets) Fresubin 62g powder sachet 397 18 £0.80 Powder with 200ml whole Extra milk (1 box = 7 sachets) Ensure 57g powder sachet 389 17 £0.88 Shake with 200ml whole milk (1 box = 7 sachets) Complan 57g powder sachet 387 16 £0.95 Shake with 200ml whole milk (1 box = 4 sachets) Fresubin 200ml bottle 300 11.2 £1.48 Energy Resource 200ml bottle 300 11.2 £1.91 Energy Ensure Plus 220ml bottle 330 13.8 £2.02 Fortisip 200ml bottle 300 12 £2.06 Nualtra 125ml bottle 300 12 £1.45 Nutriplen Ensure 125ml bottle 300 13 £2.02 Compact Guidelines for the Management of Undernutrition in Adults in Primary Care: Updated May 2014 Approved by APCO July 2014. Review due July 2016 4 Oxfordshire Clinical Commissioning Group Fortisip 125ml bottle 300 12 £1.85 Compact Nualtra 200ml bottle 300 20 £1.45 Nutriplen Protein Fresubin 200ml bottle 400 20 £1.85 2kcal Drink Ensure 200ml bottle 400 16.8 £2.22 Twocal They are also available in yoghurt style drinks e.g. Ensure Plus Yoghurt (£2.02), Fortisip Yoghurt (£2.02) and with added fibre e.g. Ensure Plus Fibre (£2.02), Fresubin Energy Fibre (£1.98), Fortisip Multi Fibre (£2.09). All costs are quoted per serving. Fruit juice based Product Presentation Resource Fruit Fresubin Jucy Ensure Plus Juce Fortijuice 200ml bottle 200ml bottle 220ml bottle Calories per serving 250 300 330 Protein (g) per serving 8 8 10.6 Cost per serving £1.84 £1.88 £1.97 200ml bottle 300 8 £2.02 Patients with special dietary requirements e.g. renal, malabsorption may require specialised products and should be referred to the dietitian. The initial prescription should be limited to one week’s supply of the daily amount required. The prescription should be marked mixed flavours so that a selection can be dispensed for the patient to try. After the weeks trial the patient should then contact the surgery with the details of the preferred supplements. This will help to reduce wastage as compliance is enhanced if patients can choose a product they find palatable. Prescriptions should have clear directions for use e.g. ‘one to be taken twice daily between meals’. As directed should not be used. For most patients supplements should be used in addition to their food intake. Subsequent prescriptions should be for a maximum of four weeks after which the patient should be reviewed and compliance measured – monthly weights recorded. Nutritional supplements should not be used on a long-term basis without regular monitoring and assessment of the patient’s nutritional status. Once target weight reached / aim of intervention achieved reduce nutritional supplement prescriptions to once daily. If patient’s weight is stable after an additional month discontinue and remove from medication list. Continue to monitor and record weight monthly for at least 3 months. Please contact the Community Dietetic Department if you require further information: Community Dietetics Department, East Oxford Health Centre, Manzil Way, Cowley Road, Oxford OX4 1XD Tel: 01865 264920 Fax: 01865 264939 Contact details for Adult Speech and Language: NORTH: Adult Speech and Language Therapy Dept.., Horton Hospital, Oxford Road, Banbury OX16 9AL Tel: 01295 229133 CENTRAL: Adult Speech and Language Therapy Dept., East Oxford Health Centre, Manzil Way, Cowley, Oxford, OX4 1XD, Tel: 01865 264969 Fax: 01865 264901 SOUTH: Adult Speech and Language Therapy Dept., Abingdon Hospital, Marcham Road, Abingdon, Oxon, OX14 9AG Tel: 01235 205775 Fax: 01235 205735 Guidelines for the Management of Undernutrition in Adults in Primary Care: Updated May 2014 Approved by APCO July 2014. Review due July 2016 5 Oxfordshire Clinical Commissioning Group References Advancing Clinical Nutrition; Malnutrition Advisory Group A Standing Committee of BAPEN, (2003). The Malnutrition Universal Screening Tool (MUST). British Association for Parenteral & Enteral Nutrition (BAPEN) British National Formulary, September 2009. Appendix 7 Borderline Substances Denny A (2007). Tackling malnutrition among older people in the community British Journal of Community Nursing, 12, (3): 98 Dunne, A. (2007). Malnutrition: supplements and food fortification in the older population. British Journal of Community Nursing 12, (11) Dunne A. (2008). Malnutrition and the older adult: care planning and management. British Journal of Nursing 7, (20): 1269-1273 Jones J. (2003). Tackling undernutrition through appropriate supplement prescribing. British Journal of Community Nursing 8, (8): 343-350 NICE Guidelines (2006). Nutrition support in adults; Oral nutrition support, enteral tube feeding and parenteral nutrition. Available at http://www.nice.org.uk/guidance/cg32 Todorovic V (2005). Evidence-based strategies for the use of oral nutritional supplements British Journal of Community Nursing, 10, (4):158-162 Scott A. (2008). Acting on screening results: a guide to treating malnutrition in the community British Journal of Community Nursing 13, (10): 450-6 Silver HJ (2009). Oral strategies to supplement older adults’ dietary intake: comparing the evidence. Nutrition Reviews 67, (1): 21-31 Stratton, Rebecca J. and Elia, Marinos (2007) Who benefits from nutritional support: what is the evidence? European Journal of Gastroenterology & Hepatology, 19, (5): 353-358. The Community Nutrition and Dietetic Department, Oxfordshire, January 2004. Nutritional Supplements in Primary Care; Prescribing Guidelines for Oxfordshire Guidelines for the Management of Undernutrition in Adults in Primary Care: Updated May 2014 Approved by APCO July 2014. Review due July 2016 6