Download Guidelines for the Management of Under Nutrition in Primary Care

Oxfordshire
Clinical Commissioning Group
Guidelines for the Management of Undernutrition for Adults in Primary Care:
Updated May 2014
Quick Reference Summary
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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:
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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)
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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
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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
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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
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Treat contributory symptoms e.g. constipation, poor dentition, pain
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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
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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
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Reinforce dietary advice and encourage patient to continue
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If patient is receiving nutritional supplements review compliance and monitor
intake
Continued Improvement e.g. weight / BMI target reached or aim of intervention achieved
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Continue to encourage dietary intake
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Reduce any nutritional supplement prescriptions to once daily. If patients
weight is stable after an additional month discontinue and remove from
medication list
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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.
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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