Nutrition and Nutritonal Supplements in Primary Care

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Nutrition and Nutritonal Supplements in Primary
Care

• Rob Hadman ST1

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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.

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NICE guidance (26)
Nutrition Support in Adults February 2006
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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

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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

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Recognition- MUST score
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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)

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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.

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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.

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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.

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Treatment Prescription

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

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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.

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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

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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.

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Prescription Pathway (1)
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Prescription Pathway (2)
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Prescription Pathway (3)
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Which supplement?
Milk based Yoghurt based Powdered Juice based High Fibre
Resource shake Resource energy Fresubin energy Ensure Plus Fortisip bottle Fortisip compact Ensure plus yog Fortisip yoghurt Enshake Calshake Scandishake Complan Forti-juice Etc. Fortisip multi-fibre
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References/further reading

• www.bapen.org.uk/pdfs/toolkit-for-commissioners.pd
  f
• 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/documen
  ts/editorfiles/howto/Prescribed nutritional
  supplements/Care_Pathway_(GENERIC_V.3)_Watermark_F
  oU1.019.1.2.pdf