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Managing patients with malnutrition in the community

Sarah Schenker
BSc SRD PhD
Dietitian
British Nutrition Foundation

Malnutrition is the consequence of a dietary intake that does not meet nutritional needs as a result of one or more of the following:

  • Decreased dietary intake.
  • Increased nutritional requirements/losses.
  • Impaired ability to absorb or utilise nutrients.

Malnutrition usually has a slow onset, resulting from a period of weeks or months where intake has not matched requirements. However, in conditions of acute metabolic stress, where nutritional demands are high, utilisation of energy and nutrients is disturbed and oral intake is likely to be compromised, nutritional depletion can occur rapidly and be severe.

Malnutrition can adversely affect every system of the body, such as the muscular system (resulting in fatigue, lethargy and decreased peripheral and respiratory muscle strength), the immune system (predisposing to and delaying recovery from infection) and psychosocial function (causing anxiety, depression and self-neglect).

As a consequence, malnutrition uses a disproportionate amount of healthcare resources. It is estimated that 70% of malnutrition in the UK goes unrecognised and untreated. The Malnutrition Universal Screening Tool (MUST) is a practical screening tool for detecting malnutrition and risk of malnutrition in community-based patients. The British Association for Enteral and Parenteral Nutrition (BAPEN) indicate that a score of 1 or 2 may require action (dietetic referral or locally agreed policy implementation). A score of 1 may require action in the absence of improvement after two to three months of observation, while a score of 2 requires
immediate action.

Often, access for health professionals is limited to dietetic services; in which case, community nursing staff may be required to take action to offer basic practical guidance for patients or implement a locally agreed policy to
treat malnutrition.

Establishing the aim of treatment
It is essential to establish the aim of any treatment in order to monitor progress. Weight gain will not be an appropriate goal for all patients; weight maintenance or prevention of further weight loss may be more realistic. Non-anthropometric goals should also be considered; for example, promoting healing of a pressure sore or improving physical functions, such as transferring or activities of daily living. More specific goals around improving nutritional intake should also be considered, such as the establishment of regular meals.

Dietary assessment
Obtaining a diet history is a logical starting point and provides the basis for treatment. Ask patients or their carers to detail what has been consumed during the previous 24 hours, including meals, snacks and drinks. Particular attention should be paid to the following points.

General eating pattern
Establish if meals are being missed, portion size of meals and how much is being left; whether snacks are eaten between meals and at what time of day the person eats the most.

Energy (kcal) intake
Low energy intake is often an indicator for general malnutrition, as it is unlikely that other nutrient requirements are being met. If very small portions are being eaten at meal times, or if meals are being shared, it is probably safe to assume that energy intake is inadequate. Over-reliance on low-energy foods, such as soup, jelly, fruit, tea, or confectionery at the expense of more substantial foods, are also good indicators of a low energy intake.

Protein intake
An inadequate protein intake will compromise immune function and wound healing. It is important to check that two portions of high biological value protein are consumed per day (see Table 1).

[[Tab 1 mal]]

Fluid intake
Dehydration contributes to confusion, constipation, urinary tract infections, poor skin integrity, and ultimately exacerbates malnutrition. In general a person should drink a minimum of eight cups of fluid per day to remain hydrated.

Nutrition-related problems
Before any nutritional intervention is initiated it is important to consider the causes of malnutrition and current barriers to improving nutritional status.

Obviously, any underlying disease may be the main determinant of nutritional status, and improvements in general clinical condition are often reflected in appetite and anthropometric measures. However, attention to the following common problems will make nutritional intervention more effective.

Poor dental health
Ensure dental health is adequate to support good nutrition. A common consequence of recent weight loss is ill-fitting dentures, which can restrict food choice, make eating painful and prolong the malnutrition cycle. Poor dentition can also contribute to lengthy mealtimes, cold food and poor micronutrient intake. Plate covers may help.

Dysphagia
Suspected swallowing problems require assessment by a speech and language therapist. Symptoms include food or drink dribbling from the corner of the mouth; reduced oral food clearance; coughing/choking when eating or drinking; repeated chest infections; a "bubbly" sounding voice after eating; and
weight loss.

Constipation
This can suppress the appetite and cause abdominal discomfort or nausea. It is important to establish the cause eg, combination of reduced gut motility due to analgesia/disease, reduced food intake and immobility. An adequate fluid intake is paramount and the use of laxatives or stool softeners should be considered.

Pain
Appetite is unlikely to improve unless pain is well controlled. Evidence exists of an association between pain intensity and perceived pain-related appetite impairment; however, it is difficult to separate the effect exerted by pain and any anorexic effect of the disease itself, and unfortunately analgesia can create new barriers to eating.2

Poor emotional/psychological health
Depression, anxiety or low mood can have a profound effect on appetite and create apathy around meal times. Medical or counselling interventions are worth considering if this is contributing to malnutrition. Addiction and dependency are also challenging barriers to improving nutritional intake.

Medications with nutrition-compromising side-effects
Some medications may cause nausea, taste changes, reduced appetite and constipation. Discuss with the GP the possibility of alternatives, or further medications which can be prescribed to counteract the problem; for example, antiemetics for nausea or antacid oral solutions for mucositis.

Practical issues
Some patients will have compromised dexterity, weakness, visual impairment or limited range of movement in arms. Adapted cutlery and equipment can be useful and often help enable greater independence, which in itself can improve nutritional intake.

Nutritional intervention
Eating pattern
Aim to stabilise the eating pattern if food intake is irregular. Eating little and often is often more manageable for people with a poor appetite rather than focusing on large hot meals. If appropriate foods are used this can also result in a greater overall energy intake.

Convenience foods, ready meals, meals-on-wheels or alternatives should be encouraged if cooking is tiring or difficult. A helpful daily strategy to suggest is for the patient to eat three small/light meals interspersed with three small energy-dense snacks (see Box 1 for an example menu). Identify the time of day at which the person has the best appetite and encourage them to maximize food intake then. Older people often eat very well at breakfast time and can sometimes tolerate a cooked breakfast, which can contribute significantly to daily energy and protein intake.

[[Box 1 mal]]

Increasing energy intake
In addition to extra snacks, encourage everyday foods of a higher energy density, such as whole milk (full fat) and dairy products rather than reduced fat versions (see Box 2 for some practical tips). Meals can also be fortified using common foods such as milk powder, butter, cream, and vegetable-based oils (see Table 2). This is an economic way of increasing energy intake and is palatably acceptable to most people. Some patients with a cardiac history or high cholesterol may express concerns about increasing saturated fat intake, in which case using milk powder and vegetable oils will be more acceptable to them.

[[Box 2 mal]]

[[Tab 2 mal]]

Ensuring adequate protein intake
Encourage at least two small daily portions of high biological value protein (containing all essential amino acids). Some patients will find the texture of meat difficult but fish and eggs may be better tolerated. Dairy products such as milk, cheese, yogurt and soya-based alternatives all make very useful contributions to protein requirements and are easy to consume - food fortification is one way of achieving this. Protein foods with a low biological value contain an incomplete range of essential amino acids and therefore must be combined with other foods containing amino acid, such as baked beans on toast.

Ensuring adequate fluid intake
Fluid includes tea, coffee, squash, fruit juice and milky drinks. Nutritious fluids are important for malnourished people rather than drinking large volumes of water, which can impair appetite and lacks calorific value. Malted drinks such as Horlicks, Ovaltine or Milo have the added advantages of being familiar, comforting and fortified with some vitamins and minerals. Some older people have a reduced thirst sensation so may need to be encouraged to have regular planned drinks. Reluctance to drink more may be due to a fear of nocturia; increasing fluid intake gradually earlier in the day helps to avoid this. A large glass of milk or juice should be encouraged with medications. Most laxatives are less effective without sufficient fluid intake.

Over-the-counter supplements
These include drinks such as Complan® and Build Up, which are made up from powder sachets with milk. They are not prescribable but have the advantage of being readily available familiar brands for many older people, which may improve compliance. They will help to increase energy and protein intake and provide some vitamins and minerals, but not trace elements. Many patients find the taste of these supplements more acceptable than the proprietary products, probably due to the lower micronutrient profile. Neutral flavours are available which can be added to savoury foods without altering the taste.

Proprietary supplements
Helping to improve an individual's nutritional intake through food is the ultimate goal. However, if a patient is unable to improve or maintain an appropriate nutritional status through diet alone, prescribable nutritional supplement drinks are indicated. These have the benefit of containing a balanced combination of macronutrients (energy, protein and fat) and micronutrients (vitamins, minerals and trace elements). As such, they are "complete" when prescribed appropriately. They should be presented to the patient as an important part of their medical treatment, with an explanation of the potential benefits.

There is evidence from systematic reviews and meta-analyses that proprietary nutritional supplements can improve total nutritional intake and weight gain in the community setting, especially in those with a body mass index (BMI) of less than 20.3,4 Weight gain is associated with improved physical function such as muscle strength, walking distances and activities of daily living. Evidence-based benefits of using nutritional supplements in other care settings/patient populations include reduced complications and reduced mortality.3

Sip feeds are designed to complement food rather than replace it. As such, they should be encouraged between meals to avoid affecting appetite.

Compliance will be greatly improved if the patient is involved in flavour and style selection; but even then, flavour fatigue is likely to occur after time. If patients have an aversion to sweetness, try a yogurt-based drink that is more tart, or consider a savoury soup that can be warmed. If the drinks are found to be too rich, consider diluting with milk or still/sparkling water. The drink should be served in a way that is acceptable to the patient. For example, some older people may find drinking through a straw undignified, and respond better if the drink is served from a glass. Some people may prefer chilled sip feeds, whereas some flavours are ideal for gentle warming (do not boil as this will damage vitamins), such as coffee or chocolate. Pudding-style supplements can be very useful for patients requiring very thick fluid modification. They are also ideal if fluid intake is already very poor.

Monitoring
Like any other prescription, nutritional supplements should be monitored for efficacy. Unmonitored prescriptions may become inappropriate prescriptions; research has demonstrated that improved monitoring, via GP and community nurse education, can significantly reduce inappropriate prescriptions of supplements.5 Monitoring may include:

  • Aim of intervention, which may need modifying.
  • Weight or other anthropometric changes.
  • Changes in nutritional or fluid intake.
  • Compliance with current recommendations.
  • Changes in speech and language therapy (SLT) recommendations regarding modified consistency diets/fluids.

If the aim of the intervention has been achieved, a gradual reduction in supplements and increase in food intake should be encouraged.

Micronutrients
Housebound patients and patients over 65 years  should be offered vitamin D supplementation (10 mcg/day). If the diet is inadequate and general micronutrient intake cannot be improved through diet or sip-feeds consider a complete multivitamin and mineral preparation.

Healthy eating
Healthy eating recommendations are designed for the general healthy population and are not appropriate for malnourished individuals. A fairly common finding in clinical practice is older people who received healthy eating advice following a cardiac event. Twenty years on, despite having lost weight, now struggling with a poor appetite and entering the eighth or ninth decade of their life, they are still using skimmed milk, low-fat margarine, avoiding cheese and using low-fat cooking methods.

The main aspects of the current healthy eating guidance are partly designed to reduce current public health problems, particularly obesity.6 As such, plenty of fruit, vegetables and high-fibre foods are encouraged. Although these foods are rich in micronutrient, they will not encourage weight gain as they provide too few calories. Variety should be encouraged if possible, including some fruit and vegetables, but the priority is to increase overall energy and protein intake.

References
1. British Association for Enteral and Parenteral Nutrition (BAPEN). Malnutrition Universal Screening Tool (MUST). Redditch: BAPEN; 2003.
2. Bosley BN, Weiner DK, Rudy TE, Granieri E. Is chronic nonmalignant pain associated with decreased appetite in older adults? Preliminary Evidence. J Am Geriatr Soc 2004;52(2):247-51.
3. National Institute for Health and Clinical Excellence. Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. London: NICE; 2006.
4. Stratton RJ. Summary of a systematic review on oral nutritional supplement use in the community. Proc Nutr Soc 2000;59(3):469-76.
5. Gall MJ, Harmer JE, Wanstall HJ. Prescribing of oral nutritional supplements in primary care: can guidelines supported by education improve prescribing practice? Clin Nutr 2001;20(6):511-15.
6. Food Standards Agency. The Eatwell Plate. London: FSA; 2007.