Nutritional Supplements in Management of Undernutrition

Link to ‘Nutrition and Blood’ guidelines: http://www.enhertsccg.nhs.uk/nutrition-and-blood

This pathway ONLY relates to the Oral Nutritional Supplement aspects of the management of nutrition

Clinical presentation

Patient discharged from hospital with identified

nutritional risk

Identification of nutritional risk

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Nutritional assessmentnot conducted

Calculate MUST Score and BMI

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Other ConsiderationsClick for

more info

Conduct nutritional assessment

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Make appropriate adaptations/ referrals including social/

voluntary

Nutrition Intake ChartSee appendix 2:

http://www.enhertsccg.nhs.uk

Results of MUSTscore

Full nutritional assessment has been conducted including

a MUST score

MUST score = 1 – Medium Risk

Overall improvement with little clinical concern

Adequate oral intake with little clinical concern

(eating >50% of meals)

MUST score = 0 - Low Risk· Weigh

· Hospital – weekly

· Care Homes – monthly

· Set goals with patient (realistic and

measureable)

MUST score = ≥ 2 – High Risk

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If deterioration or no improvement

(eating < 50% of meals/ weight loss)

· Repeat screening every 2 weeks

· If further clinical concern follow

high risk score box

Re-screen after two weeks or move to next step if

'Food First' approach is not appropriate

Already on oral nutritionalsupplements

Acute illness/ Recent hospital discharge: Short-term nutritional support

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Chronic conditionsClick for

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Monitor progress and compliance after 6 weeks· amend type/ flavour if

necessary to maximise intake

Goals met / Good progressGoals not met / Limited

progress

Consider oral nutritional supplements

Monitor progress after 4-6 weeks

If deterioration or no improvement

(eating < 50% of meals/weight loss)

Improvement with adequate intake and little

clinical concern(eating >50% of meals and

a snack)

Monitor progress

Repeat screening every 3 months until at low risk

Repeat screening if there are changes that cause concern or

new episode of care

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Review goals set before intervention

Consider weight change, strength, physical

appearance, appetite, ability to perform

activities of daily living

Monitor monthly or sooner if clinical concern

Refer to dieticianClick for

more info

Agreed patient specific management goals have

been met

Consider discontinuing ONS and monitor progress

When to stop ONSClick for

more info

The dietetic service is accessed through referrals made by health professionals to the Nutrition and Dietetic Service.

Lister Hospital Coreys Mill Lane Stevenage SG1 4ABorQEII Hospital Howlands Welwyn Garden City AL7 4HQ

The dietetic service is accessed through referrals made by health professionals to the Nutrition and Dietetic Service.

Lister Hospital Coreys Mill Lane Stevenage SG1 4ABorQEII Hospital Howlands Welwyn Garden City AL7 4HQ

When to stop ONSClick for

more info

Monitor progress after 4-6 weeks

Review goals set before intervention

Consider weight change, strength, physical

appearance, appetite, ability to perform

activities of daily living

Monitor monthly or sooner if clinical concern

Monitor progress after 12 weeks

Review goals set before intervention

Consider weight change, strength, physical

appearance, appetite, ability to perform

activities of daily living

Monitor Every 3 months or sooner if clinical concern

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Back to pathway Identification of nutritional risk

NICE quality statements relating to nutrition support in adults: https://www.nice.org.uk/guidance/qs24Quality statement number one recommends that 'people in care settings are screened for risk of malnutrition using a validated screening tool' e.g. MUST score

Identification of nutritional risk

NICE quality statements relating to nutrition support in adults: https://www.nice.org.uk/guidance/qs24Quality statement number one recommends that 'people in care settings are screened for risk of malnutrition using a validated screening tool' e.g. MUST score

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MUST Calculator: http://www.bapen.org.uk/screening-and-must/must-calculator

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Other Considerations

For all individuals:

· Consider whether dietetic assessment is indicated due to underlying illness e.g. diabetes, COPD

· Consider underlying symptoms and cause of malnutrition (e.g. nausea, infections) and treat if appropriate

· Consider nutritional intake e.g. eating little or nothing for more than five days

· Consider poor absorptive capacity or high nutrient losses

· Agree goals of intervention with individual/carer and record details of the malnutrition risk

· Reassess individuals identified at risk as they move through care settings

Treat, unless detrimental or no benefit is expected from nutritional support.

In the absence of height and weight (measured or recalled), the following subjective indicators* can be used collectively to identify individuals at risk of malnutrition

· Physical appearance e.g. thin or very thin

· History of recent unplanned weight loss

· Loose fitting clothing/jewelry, need for assistance with feeding, changes in appetite and problems with dentition

· Risk of under nutrition due to current illness

· Increased nutritional needs as a result of disease

· Presence of swallowing difficulties which could impact on ability to eat and drink

· The individual’s ability to eat and drink; how does current intake compare with 'normal' intake?

*For more guidance on the use of subjective criteria, see the ‘MUST’ explanatory booklet: http://www.bapen.org.uk/screening-and-must/must/must-toolkit/the-must-explanatory-booklet

If only using clinical judgment, the following may act as a guide:

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Conduct nutritional assessment

Assess underlying causes of malnutrition and identify problems with reduced or altered food intake relating to:

• Ability to chew (consider dental assessment) and swallowing issues (consider speech therapy assessment)

· Impact of medication (e.g. any that may suppress appetite)

· Physical symptoms (e.g. vomiting, pain, GI symptoms)

· Medical prognosis (proactive nutritional support may not be appropriate in terminal illness)

· Environmental and social issues

· Psychological issues/ poor mental health e.g. dementia, depression

· Substance/alcohol misuse

· Pressure sores

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MUST score = 1 – Medium Risk

Observe and Monitor Food Intake· Start MUST weight chart· Start food & fluid record chart · Offer 'Food First' advice - Guidelines for the Appropriate Use of Oral Nutritional Supplements (ONS) for Adults in Primary Care: http://

www.enhertsccg.nhs.uk/nutrition-and-blood

· Give & discuss ‘Making More of Your Food’ leaflet: http://malnutritionpathway.co.uk/leaflets-patients-and-carers

· Set goals with patient (realistic and measureable)

· Agree aims of nutrition support treatment and timescales including:

· Attaining target BMI

· Preventing further weight loss/weight maintenance

· Wound healing

· Repeat screening weekly in hospital or monthly for 3 months:

· at home or

· in surgery or

· in care home· Repeat earlier if serious concern

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MUST score = ≥ 2 – High Risk

Observe and Monitor Food Intake· Start MUST weight chart· Start food & fluid record chart · Offer 'Food First' advice - Guidelines for the Appropriate Use of Oral Nutritional Supplements (ONS) for Adults in Primary Care:

http://www.enhertsccg.nhs.uk/nutrition-and-blood

MUST score = ≥ 2 – High Risk

Observe and Monitor Food Intake· Start MUST weight chart· Start food & fluid record chart · Offer 'Food First' advice - Guidelines for the Appropriate Use of Oral Nutritional Supplements (ONS) for Adults in Primary Care:

http://www.enhertsccg.nhs.uk/nutrition-and-blood

· Consider/ prescribe 2 sip feeds per day for 2 weeks using ‘Supplement Drinks’ leaflet

· Dietary advice to maximise nutritional intake. Record intake for 3 days, encourage small frequent meals and snacks, with high energy and protein food and fluids

· If 'Food First' approach is clinically inappropriate then consider next step in the pathway

· Set goals with patient (realistic and measureable)

· Agree aims of nutrition support treatment and timescales including:

· Attaining target BMI

· Preventing further weight loss/weight maintenance

· Wound healing

· Give & discuss 'Supplement Drinks' leaflet (Appendix 5): http://www.enhertsccg.nhs.uk/nutrition-and-blood

· Give & discuss ‘Making More of Your Food’ leaflet: http://malnutritionpathway.co.uk/leaflets-patients-and-carers

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Acute illness/ Recent hospital discharge: Short-term nutritional support

Re-evaluate need for ONS - is individual able to manage adequate nutritional intake from food alone?Where intake remains inadequate issue ONS as an acute prescription for 4-6 weeks (1-3 ONS per day, some individuals mayrequire more than 3 ONS per day) seek dietician advice - in addition to oral intake.If a continuation from hospital prescription, confirm need using screening tool: http://malnutritionpathway.co.uk/health-resourcesConsider ACBS (Advisory Committee for Borderline Substances) indications when prescribing standard ONS:

· Disease related malnutrition

· Short bowel syndrome

· Intractable malabsorption

· Pre-operative preparation of undernourished patients

· Inflammatory bowel disease

· Total gastrectomy

· Dysphagia

· Bowel fistulae

For patients who do not meet the ACBS criteria then over the counter nutritional supplements are recommended

Discontinuing ONS Discontinue ONS when adequate oral intake is established, targets are achieved, the individual is stable and no longer at risk of malnutrition. Continue to monitor to check individual remains stable (consider relapsing remitting conditions e.g. COPD, IBD).

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Chronic conditions

For example:

· COPD

· Cancer

· Frail elderly

Longer term nutritional support with food alone approaches maybe insufficient; hence consider prescribing in line with dieticians and HMMC recommendations:

· Consider ACBS (Advisory Committee for Borderline Substances) indications when prescribing standard ONS:

· Disease related malnutrition

· Short bowel syndrome

· Intractable malabsorption

· Pre-operative preparation of undernourished patients

· Inflammatory bowel disease

· Total gastrectomy

· Dysphagia

· Bowel fistulae

For patients who do not meet the ACBS criteria then over the counter nutritional supplements are recommended

Discontinuing ONSDiscontinue ONS when adequate oral intake is established, targets are achieved; the individual is stable and no longer at risk of malnutrition. Continue to monitor to check individual remains stable (consider relapsing remitting conditions e.g. COPD, IBD).

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Goals met / Good progress· Encourage oral intake and dietary advice

· Consider reducing to 1 ONS per day for 2 weeks before stopping if clinically appropriate

· Maximise nutritional intake; consider powdered nutritional supplements to be made up with water or milk· Monitor progress; consider managing as 'medium risk' as defined by MUST score

Goals met / Good progress· Encourage oral intake and dietary advice

· Consider reducing to 1 ONS per day for 2 weeks before stopping if clinically appropriate

· Maximise nutritional intake; consider powdered nutritional supplements to be made up with water or milk· Monitor progress; consider managing as 'medium risk' as defined by MUST score

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Goals not met / Limited progress

· Check ONS compliance: http://www.enhertsccg.nhs.uk/nutrition-and-blood and amend prescription as necessary

· Reassess clinical condition, consider more intensive nutrition support or seek advice from a dietician

· Consider goals of intervention, ONS may be provided as support for individuals with deteriorating conditions

· If no improvement, seek advice from a dietician· Review individuals on ONS every 3-6 months or upon change in clinical condition

Goals not met / Limited progress

· Check ONS compliance: http://www.enhertsccg.nhs.uk/nutrition-and-blood and amend prescription as necessary

· Reassess clinical condition, consider more intensive nutrition support or seek advice from a dietician

· Consider goals of intervention, ONS may be provided as support for individuals with deteriorating conditions

· If no improvement, seek advice from a dietician· Review individuals on ONS every 3-6 months or upon change in clinical condition

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Consider oral nutritional supplements

· Consider prescribing ONS in line with HMMC guidance: http://www.enhertsccg.nhs.uk/nutrition-and-blood and monitor:

· On improvement, consider managing as ‘medium risk’· If no improvement or more specialist support is required, refer to dietician

Consider oral nutritional supplements

· Consider prescribing ONS in line with HMMC guidance: http://www.enhertsccg.nhs.uk/nutrition-and-blood and monitor:

· On improvement, consider managing as ‘medium risk’· If no improvement or more specialist support is required, refer to dietician

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Refer to dietician

The dietetic service is accessed through referrals made by health professionals to the Nutrition and Dietetic Service.

Please send a written referral giving full clinical details, GP details and reason for referral to:Lister Hospital Coreys Mill Lane Stevenage SG1 4ABorQEII Hospital Howlands Welwyn Garden City AL7 4HQ

Refer to dietician

The dietetic service is accessed through referrals made by health professionals to the Nutrition and Dietetic Service.

Please send a written referral giving full clinical details, GP details and reason for referral to:Lister Hospital Coreys Mill Lane Stevenage SG1 4ABorQEII Hospital Howlands Welwyn Garden City AL7 4HQ

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When to stop ONS prescription

· Goals of intervention have been met and individual is no longer at risk of malnutrition

· Individual is clinically stable/acute episode has abated

· Individual is back to their normal eating and drinking pattern

· If no further clinical input would be appropriate

When to stop ONS prescription

· Goals of intervention have been met and individual is no longer at risk of malnutrition

· Individual is clinically stable/acute episode has abated

· Individual is back to their normal eating and drinking pattern

· If no further clinical input would be appropriate

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Information for patients

Link to Irritable bowel syndrome (IBS) information for patients: http://www.nhs.uk/conditions/Irritable-bowel-syndrome/Pages/Introduction.aspx

Link to HMMC leaflets: http://www.enhertsccg.nhs.uk/nutrition-and-blood