Nutrition and Nutritonal Supplements in Primary Care

1. Nutrition and Nutritonal Supplements in Primary Care Rob Hadman ST1

2. Introduction/Evidence • Nutrition support in adults has important implications in both health and social care settings. When people are malnourished, their basic health and social care outcomes are significantly affected, making malnutrition an important patient safety issue. It continues to be both under-detected and undertreated, with potentially fatal consequences. • Malnutrition is both a cause and an effect of ill health. Good nutrition support services are crucial in treating a number of other conditions. • Appropriate identification and treatment of undernutrition reduces the clinical complications associated with it by 70% and mortality by 90%.

3. NICE guidance (26) ‘Nutrition Support in Adults’ February 2006

4. Screening • Screen • All people in care homes upon admission • All people upon registration at GP surgeries • Upon clinical concern: • Examples may include unintentional weight loss, fragile skin, poor wound healing, apathy, wasted muscles, poor appetite, altered taste sensation, impaired swallowing, altered bowel habit, loose fitting clothes or prolonged intercurrent illness. • Screening should be carried out by skilled health professionals

5. Recognition 1) Malnutrition • BMI less than 18.5 kg/m2 • Unintentional weight loss of greater than 10% within 3-6 months • BMI less than 20kg/m2 and unintentional weight loss of greater than 5% within 3-6 months 2) Those at risk of malnutrition • Eaten little or nothing for more than 5 days and/or likely to eat little or nothing for next 5 days or longer • Poor absorptive capacity, and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism

6. Recognition- MUST score

7. Treatment • Check for dysphagia: • If dysphagic and functional GI tract, for enteral feeding (NG/PEG) • If dysphagic and non-functional GI tract, for parenteral feeding (TPN)

8. Treatment: General advice • Simple measures such as exercise and fresh air can increase appetite. • Eating in the company of others, eg at day centres or luncheon clubs, may stimulate patients to eat more. • Alcohol, in moderation, can be an effective appetite stimulant. • Although some drugs, eg corticosteroids, can stimulate the appetite, effects are not always immediate or long-lasting and they may cause serious adverse effects. Use is mainly confined to those receiving palliative care and is not usually recommended outside specialist centres.

9. Treatment: General advice • First-line measures should include the use of appropriate standard foods. • General advice includes encouragement to eat small frequent meals and snacks that are high in energy and protein, but which address the special requirements of the patient, eg diabetes or renal impairment • Small snacks between meals increase nutritional intake, eg cheese and biscuits, whole-milk yoghurts or toast and peanut butter. • Patients could also use full-fat, instead of low-fat dairy products.

10. Treatment: General advice • Milk powder may be added to fortify ordinary milk and drinks, tinned soups, mashed potatoes, cereals and puddings (this is not appropriate for infants and young children). • Fortified whole milk or milk shakes between meals should be encouraged. Cream, butter and cheese can also be used to fortify foods such as soups and mashed potatoes Energy sources such as sugar, honey, jam and dried fruit can be added to cereals and puddings. Pure fruit juices may also be useful.

11. Treatment: Prescription • Refer to dietician before embarking on prescription for malnutrition in Primary Care • Exceptions to this most commonly include palliative care.

12. Treatment: Prescription • For people who are not severely ill or injured, nor at risk of re-feeding problems, nutritional prescription should usually provide: • 25-35kcal/kg/day total energy • 0.8-1.5g protein (0.13-0.24g nitrogen)/kg/day • 30-35ml fluid/kg/day • Adequate electrolytes, minerals, micronutrients and fibre, if appropriate.

13. Treatment- nutritional supplements • Nutritional supplements should not be prescribed without: • Trialling a fortified diet for at least one month • Being identified as high risk of undernutrition according to MUST and having ongoing weight loss despite following a fortified diet for a month

14. Evidence • A 2009 Cochrane review of 62 trials looking into the efficacy of protein and energy supplementation concluded that the practice appears to produce a small but consistent weight gain, with possible benefit on mortality in undernourished patients and a likely reduction in complications. There was variable tolerability of the products, with nausea and diarrhoea commonly reported. • Evidence indicates that nutritional supplements improve clinical outcomes in patients who are at high risk of undernutrition when they supplement their nutritional intake by 600kcals daily.

15. Prescription Pathway (1)

16. Prescription Pathway (2)

17. Prescription Pathway (3)

18. Which supplement?

19. References/further reading • www.bapen.org.uk/pdfs/toolkit-for-commissioners.pdf • Oral Nutritional Supplements to Tackle Malnutrition | Appetite For Life : Abbott Nutrition, specialists in Tube feeding, Sip Feed, High Calorie drink, fortification, nutritional supplements, lactose intolerance, enteral feeding • Nutricia • Abbott • NICE • www.focusonundernutrition.co.uk/repository/documents/editorfiles/howto/Prescribed nutritional supplements/Care_Pathway_(GENERIC_V.3)_Watermark_FoU1.019.1.2.pdf