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1. Christine Russell SRDon behalf of MAG
3. Understanding malnutrition No universally accepted definition but the
following working definition is suggested
‘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 structure and function and clinical outcome’
4. Malnutrition is undetected and untreated Hospitals inpatients
70% unrecognised (Kelly et al, 2000)
62% unrecognised (Mowe et al 1991)
Hospital outpatients
45-100% of patients unrecognised (Miller et al 1990)
Nursing homes Almost 100% of patients unrecognised (26 nursing homes) (Abbasi & Rudman 1990)
Community e.g 15-50% of children with failure to thrive are unrecognised (Wright et al 1998; Bachelor 1990)
5. Prevalence of malnutrition % underweight adults (BMI<20kg/m2 ) living freely in the community, hospital & residential accommodation Elia/MAG 2003
General population:
England 5.2%
Scotland 5.5%
Wales 5.0%
Patients in the community:
Major surgery previous 6 wks >10.6%
Chronic diseases 12.2%
Residential accommodation:
In UK >65 yrs 16.0%
In Scotland >65yrs 29.0%
Hospital: 13-40%
6. Percentage of people aged 65+ at medium/high risk of malnutrition
9. Consequences of malnutrition Increased morbidity
Increased length of stay
Increased dependency
Increased mortality
Increased costs of care
10. Increased health care utilisation with malnutrition risk (Stratton et al 2002)
11. Financial issues Up to Ł266m (1992 figs) could be saved by NHS each year if malnourished patients identified and treated
Malnutrition in patients >65yrs costs ~Ł2-4b more than well nourished elderly
Malnourished elderly more likely to be admitted to hospital and discharged to nursing homes
Undernutrition costs NHS more than obesity
12. Why screen for malnutrition? Malnutrition is frequently unrecognised and untreated
Effective management of malnutrition reduces the burden on health & care resources
Regular screening is the only way that malnourished individuals can be identified and appropriate action taken
13. What has this got to do with me? Nutrition/malnutrition now a priority in policy initiatives and practice
1992 A Positive approach to nutrition as treatment (King Fund Centre)
1996 Malnutrition in Hospital (BDA)
1997 Eating Matters (DH)
1997 Hungry in Hospital (Ass Community Health Councils)
2000 Managing Nutrition in Hospital: a recipe for quality (DH)
2000 Detection and Management of Malnutrition (BAPEN)
2001 The National Service Framework for Older People (DH)
2001 Essence of Care (DH)
2001 Acute Hospital Portfolio: Hospital Catering report (DH)
2001 National Nutritional Audit of Elderly Individuals in Long-term Care (Scottish Executive – CRAG)
2001 National Care Standards Commission / National Minimum Standards for Older People in Care Homes (DH)
2002 Food and Nutritional Care in Hospitals: how to prevent undernutrition (Council of Europe)
2002 Nutrition & patients: a doctors responsibility (Roy Col Phys)
2002 Improving Health in Wales, Nutrition and Catering Framework. (WAG)
2003 Food , Fluid and Nutritional Care in Hospitals (NHSQIS)
2004 PEAT (DH)
14. What has this got to do with me? Nutrition/malnutrition now a priority in policy initiatives and practice
1992 A Positive approach to nutrition as treatment (King Fund Centre)
1996 Malnutrition in Hospital (BDA)
1997 Eating Matters (DH)
1997 Hungry in Hospital (Ass Community Health Councils)
2000 Managing Nutrition in Hospital: a recipe for quality (DH)
2000 Detection and Management of Malnutrition (BAPEN)
2001 The National Service Framework for Older People (DH)
2001 Essence of Care (DH)
2001 Acute Hospital Portfolio: Hospital Catering report (DH)
2001 National Nutritional Audit of Elderly Individuals in Long-term Care (Scottish Executive – CRAG)
2001 National Care Standards Commission / National Minimum Standards for Older People in Care Homes (DH)
2002 Food and Nutritional Care in Hospitals: how to prevent undernutrition (Council of Europe)
2002 Nutrition & patients: a doctors responsibility (Roy Col Phys)
2002 Improving Health in Wales, Nutrition and Catering Framework. (WAG)
2003 Food , Fluid and Nutritional Care in Hospitals (NHSQIS)
2004 PEAT (DH)
15. Prevalence of malnutrition using different tools
16. Definitions Nutritional screening
Rapid, simple general procedure done at first contact with subject to detect risk of malnutrition, done by nurses, doctors or other HCWs
Nutritional Assessment
Detailed, more specific in depth evaluation of subject’s nutritional status, done by those with nutritional expertise
17. The Malnutrition Advisory Group (MAG)
The Malnutrition Advisory Group (MAG) is an independent standing committee of BAPEN
Formed in 1998 with a multidisciplinary membership of healthcare professionals
18. Aims of the MAG Raise awareness of malnutrition among health and social care professionals, policy makers and the media
Ensure health & social care professionals give priority to combating malnutrition
Communicate the benefits of timely use of nutritional supplements
Develop a screening tool & produce definitive guidelines for the detection and management of malnutrition
19. Why is screening a ‘MUST’?Malnutrition Universal Screening Tool To provide a validated, reliable, and practical tool for nutritional screening
To develop a tool to allow comparable nutritional screening across different care settings by different health professionals
To identify individuals who are undernourished or obese
20. Development of the ‘MUST’ The MAG community screening tool (launched in 2000) adapted and extended to care homes and hospitals
Validated and piloted across all care settings
Alternative methods of measurement determined
Field tested for overall look and ‘use-ability’
21. Where the ‘MUST’ can be used
25. Components of ‘MUST’ Flow chart – visual layout of procedure
BMI chart and weight loss tables– showing clearly the risk scores
Alternative measurements
Explanatory notes
Evidence based, referenced report
27. The 5 ‘MUST’ Steps Body Mass Index (BMI) Score – height and weight
Weight Loss Score - unplanned weight loss in past 3-6 months
Acute Disease Effect Score
Overall Risk of Malnutrition - Add Scores
Results: 0 = low risk; 1 = medium risk; 2 or more = high risk
Subjective judgement if measurements not possible
5. Recommended Management Guidelines – to form appropriate care plan in line with local policy
28. BMI (kg/m2) Indicates chronic protein-energy status
Protein-energy malnutrition is ‘probable’ at a BMI <18.5 kg/m2 and ‘possible’ at a BMI of 18.5-20.0 kg/m2
Adverse physiological and clinical effects occur with a BMI <20 kg/m2
BMI is a simple, objective and reproducible measurement
? Age specific
BMI is an attractive index because it is linearly related to fat and inversely
related to the proportion of body weight due to lean tissues which carry
out a variety of physiological functions and the proportion of body weight
due to body fat, which is a risk factor for premature death.
Relationship between BMI and body composition is only approx and is
affected by gender, age and race.
BMI is an index relating to risk and is not a diagnostic tool for malnutrition.
It should be used to provide an approx guide to the probability or risk of PEM
rather than to identify malnutrition per se.
BMI has been recorded in a wide range of studies in relation to mortality
and body function in a variety of circumstances.
This makes possible a comparison of extensive amounts of data obtained
from different parts of the world and different healthcare settings.
ASPEN Board of Directors (2002)suggest 18.5kg/m2 to indicate underweight
in their report on evidence based best approach to practice of nutritional
support.
The Office of Population Census and Surveys in the UK uses <20 to indicate
underweight even in people >75yr.
BMI is an attractive index because it is linearly related to fat and inversely
related to the proportion of body weight due to lean tissues which carry
out a variety of physiological functions and the proportion of body weight
due to body fat, which is a risk factor for premature death.
Relationship between BMI and body composition is only approx and is
affected by gender, age and race.
BMI is an index relating to risk and is not a diagnostic tool for malnutrition.
It should be used to provide an approx guide to the probability or risk of PEM
rather than to identify malnutrition per se.
BMI has been recorded in a wide range of studies in relation to mortality
and body function in a variety of circumstances.
This makes possible a comparison of extensive amounts of data obtained
from different parts of the world and different healthcare settings.
ASPEN Board of Directors (2002)suggest 18.5kg/m2 to indicate underweight
in their report on evidence based best approach to practice of nutritional
support.
The Office of Population Census and Surveys in the UK uses <20 to indicate
underweight even in people >75yr.
29. BMI categories for chronic protein energy status Roy Coll Phys Lond, MAG(BAPEN) BMI (kg/m2 ) Weight category
--------------------------------------------------------------
<18.5 Underweight (probable PEM*)
18.5-20 Underweight (possible PEM*)
20-25 Desirable weight
25-30 Overweight
>30 Obese
* PEM = Protein-Energy Malnutrition
30. Step 1: BMI Obtain weight and height
Calculate BMI or use BMI chart provided to get score
Use recalled height and weight or recommended alternative methods of measurement if actual values cannot be obtained
31. BMI Score BMI Score
>20 kg/m2 0
18.5-20 kg/m2 1
<18.5 kg/m2 2
>30 kg/m2 ( obese ) 0
32. Unintentional weight loss over 3-6 months
<5% body weight: normal intra-individual variation
5-10% body weight: of concern
decrease in voluntary physical activity
increase in fatigue
less energetic
>10% body weight: of significance
changes in muscle function
disturbances in thermoregulation
poor response or outcome to surgery and chemotherapy
Clinical studies have demonstrated that recent weight change is one of the
most important components of malnutrition screening tools. It contributes
to clinical outcomes independently to BMI.
Rapidity of weight loss is probably more important than actual time periodClinical studies have demonstrated that recent weight change is one of the
most important components of malnutrition screening tools. It contributes
to clinical outcomes independently to BMI.
Rapidity of weight loss is probably more important than actual time period
33. Step 2: Weight Loss Score Unplanned weight loss over 3 – 6 months Indicates acute or recent-onset malnutrition
Score
<5% body weight: 0
5-10% body weight: 1
>10% body weight: 2
34. Step 3: Acute Disease Effect Patients who have had or are likely to have no nutritional intake for more than 5 days
Most likely to apply to patients in hospital
Add 2 to score
35. Step 4: Overall Risk of Malnutrition
Total of scores from Steps 1, 2 and 3
Document score
0 = Low risk
1 = Medium risk
2 or more = High risk
36. Alternative measurements
Measure between the point of the elbow (olecranon process) and the midpoint of the prominent bone of the wrist (styloid process). Use the left arm if possible.Measure between the point of the elbow (olecranon process) and the midpoint of the prominent bone of the wrist (styloid process). Use the left arm if possible.
37. BMI Category The subject’s left arm should be bent to 90° angle with the upper arm held parallel to the body.
Measure the distance between the bony protrusion on the shoulder and the point of the elbow.
Mark the mid point.
Ask the subject to let the arm hang loose and measure around the upper arm at the mid point.
Make sure the tape is snug but not tight.The subject’s left arm should be bent to 90° angle with the upper arm held parallel to the body.
Measure the distance between the bony protrusion on the shoulder and the point of the elbow.
Mark the mid point.
Ask the subject to let the arm hang loose and measure around the upper arm at the mid point.
Make sure the tape is snug but not tight.
38. Subjective Criteria If height or weight cannot be obtained, consider the following subjective criteria :
BMI
Is subject , thin acceptable weight or overweight?
Weight loss
Are clothes or jewellery loose?
Has there been a change in appetite?
Any swallowing difficulties?
Underlying disease or psychosocial / physical disabilities
Acute disease
No nutritional intake >5 days
39. The old ones are the best
40. Step 5: Recommended management guidelines Low risk
Repeat screening ( weekly,monthly,annually)
Medium risk
Document food intake for 3 days, if no improvement follow local policy
Re screen (weekly,monthly)
High risk
Seek expert advice, monitor and review (weekly, monthly) in line with local policy
42. Care plan Set aims and objectives
Treat underlying conditions
Improve nutritional intake
Monitor and review
Reassess subjects at nutritional risk as they move through care settings
43. Nutritional interventions Provide help and encouragement with eating and drinking
Offer tasty, nutritious and attractive meals
Provide pleasant environment in which to eat
Consider oral nutritional supplements if unable to meet requirements
Monitor and review
44. Oral Nutritional Support for the ‘at risk’ patient Good food
Dietary counselling and fortification
Oral nutritional supplements (ONS)
45. Oral Nutritional Support for the ‘at risk’ patient Good food
Dietary counselling and fortification
Oral nutritional supplements (ONS)
46. Maximise food intake Help with feeding
Help with shopping or cooking
Ensuring good dentition
Suitable feeding equipment
Avoiding unnecessary NBM
Multidisciplinary involvement
47. Dietary counselling Very few trials (< 10) have shown that dietary counselling can improve food intake (energy and protein intakes) and nutritional status (body weight) in the treatment of malnutrition
Most trials do not mention who did the counselling, what form this took (written, oral instructions/advice), compliance with advice
48. Dietary counselling Very few trials (< 10) have shown that dietary counselling can improve food intake (energy and protein intakes) and nutritional status (body weight) in the treatment of malnutrition
Most trials do not mention who did the counselling, what form this took (written, oral instructions/advice), compliance with advice
49. Food ‘fortification’ Oil
Cream
Sour cream
Butter
Milk
Cheese
Sugar
Skimmed milk powder
Commercial CHO/protein powder or liquids
50. Food ‘fortification’ What do we want to achieve?
Improve the intake of a range of nutrients?
Improve recovery?
51. Dietary advice and food fortification in COPD ( Weekes 2004) Malnourished patients with COPD
Dietary advice plus milk powder for 6mths
Written advice on food fortification
Followed up for one year
52. Dietary counselling or supplements A Cochrane review (4 trials) (Baldwin 2002)
Supplemented patients had significantly greater weight gain (or less loss) and significantly greater energy intakes than patients given dietary counselling, over 3 months These were relatively short term studies and there is a need for more comparative studies that are well designed. The efficacy of using dietary counselling to improve outcome has not been investigated either. These were relatively short term studies and there is a need for more comparative studies that are well designed. The efficacy of using dietary counselling to improve outcome has not been investigated either.
55. Summary – evidence base
ONS can effectively increase total energy, protein and micronutrient intakes. They tend not to substantially replace food intake
ONS can produce significant clinical and functional benefits in some patient groups in hospital and in the community
The benefits to outcome may be due to improved body weight and muscle mass or the critical supply of nutrients during recovery
The current evidence base is incomplete, it needs to be regularly updated and developed So lets summarise the 4 main issues that we have addressed relating to the efficacy of ONSSo lets summarise the 4 main issues that we have addressed relating to the efficacy of ONS
56. ‘MUST’ 1 year on Gradual adoption / implementation
Frequently Asked Questions on BAPEN website
Articles
Symposia
Training sessions and resources
Translation into other languages
MAG moving from ‘Advisory’ to ‘Action’
57. In Summary Malnutrition in UK is common and costly
Screening is a ‘MUST’
‘MUST’ is a valid yet simple and quick to use tool suitable for use across all care settings
Appropriate nutritional interventions can be effective in preventing and treating the problem
59. Lower boundary BMI (kg/m2) values ASPEN(2002) suggest <18.5 kg/m2 to indicate underweight in their report on evidence based best approach to practice of nutritional support
OPCS in the UK uses <20kg/m2 to indicate underweight even in people of >75yr
USA edition of Dietary Guidelines(1990) suggested age specific BMI reference ranges but withdrew in the 1995 edition
Influence on mortality of confounding variables eg smoking, pre existing disease, drug and alcohol ingestion, poverty
smoking and pre existing disease known to reduce weight and increase risk of premature death
BMI is an attractive index because it is linearly related to fat and inversely
related to the proportion of body weight due to lean tissues which carry
out a variety of physiological functions and the proportion of body weight
due to body fat, which is a risk factor for premature death.
Relationship between BMI and body composition is only approx and is
affected by gender, age and race.
BMI is an index relating to risk and is not a diagnostic tool for malnutrition.
It should be used to provide an approx guide to the probability or risk of PEM
rather than to identify malnutrition per se.
BMI has been recorded in a wide range of studies in relation to mortality
and body function in a variety of circumstances.
This makes possible a comparison of extensive amounts of data obtained
from different parts of the world and different healthcare settings.
ASPEN Board of Directors (2002)suggest 18.5kg/m2 to indicate underweight
in their report on evidence based best approach to practice of nutritional
support.
The Office of Population Census and Surveys in the UK uses <20 to indicate
underweight even in people >75yr.
BMI is an attractive index because it is linearly related to fat and inversely
related to the proportion of body weight due to lean tissues which carry
out a variety of physiological functions and the proportion of body weight
due to body fat, which is a risk factor for premature death.
Relationship between BMI and body composition is only approx and is
affected by gender, age and race.
BMI is an index relating to risk and is not a diagnostic tool for malnutrition.
It should be used to provide an approx guide to the probability or risk of PEM
rather than to identify malnutrition per se.
BMI has been recorded in a wide range of studies in relation to mortality
and body function in a variety of circumstances.
This makes possible a comparison of extensive amounts of data obtained
from different parts of the world and different healthcare settings.
ASPEN Board of Directors (2002)suggest 18.5kg/m2 to indicate underweight
in their report on evidence based best approach to practice of nutritional
support.
The Office of Population Census and Surveys in the UK uses <20 to indicate
underweight even in people >75yr.