Developing evidence based strategies and tools for the use of

oral nutritional support in the community

Vera Todorovic

Consultant Dietitian in Clinical Nutrition

Doncaster and Bassetlaw Hospitals NHS Foundation Trust

vera.todorovic@bhcs-tr.trent.nhs.uk

Common issues for primary care and the community

Every PCT will indicate that there have been increases in the volumes of oral nutritional supplements prescribed for patients and this is reflected in increased costs.

There is an assumption that inappropriate prescribing occurs and that there are no ‘controls’ in place.

practitioners are unclear as to who should receive oral nutritional supplements and what the benefits of these are.

Robust guidance to help clinicians make informed decisions is not always available

Building the evidence for nutritional support in the community

identify key policy initiatives nationally and locally that could have an impact on the nutritional care of patients

Profile the local health and social care community

identify clinical evidence that demonstrates the burden of malnutrition in the community and the benefits that can be associated with nutritional support.

work in partnership with other staff and different agencies

to identify high risk patient groups

link all elements together to develop best practice and evidence based strategies and guidelines for patient care.

Key policy drivers

GMS contract- chronic disease management– COPD, stroke, cancer, mental health

Payment by results - tariff system for commissioning care for patients

New Pharmacy contract and enhanced services

Major national initiatives Essence of Care ( hospital and community )

– pressure ulcers- assessment– food and nutrition

National Service Frameworks ( NSF’s)

NICE Guidelines– Nutrition support in adults:oral supplements, enteral

and parenteral feeding (first draft May 2005 )– The NICE guidance on the management of patients with

COPD ( 2004 ) Long term conditions and new ways of working -

case managers Supplementary prescribing

National Service Frameworks

Older people - falls, stroke, mental health, intermediate care, single assessment, promotion of health

Cancer,- dietitians have a valuable role

Long term conditions - multidisciplinary approach to improve care

Coronary heart disease - heart failure, CABG

National Institute of Clinical Excellence ( NICE ) guidelines

The NICE guidance on the management of patients with COPD ( 2004 ) recognises the importance of addressing poor nutrition

in vulnerable individuals with COPD and highlights the importance of carrying out nutritional screening on these individuals. For those individuals with a low BMI it suggests commencing them on nutritional supplements.

NICE guidelines

Nutrition support in adults:oral supplements, enteral and parenteral feeding (first draft May 2005 )

Key elements nutritional screening on admission to care homes, at hospital out-patients,

when patients register with general practices nutrition support and patient selection snacks and supplements offered to patients should aim

to ensure that overall nutritient intake is balanced in energy, protein, minerals and vitamins

Key driversPerformance Monitoring

Healthcare Commission- Standards for Health Patient Environment Action Team ( PEAT) Essence of Care QIS- Quality Improvement Scotland

Food, Fluids and Nutritional Care in Hospitals

Welsh Risk Pool

National minimum standards for care homes for older people ( 8.9 )

Essence of Care Nutrition Benchmark

10 factors

Screening and assessment-patients ‘at risk’ are given a full assessment

planning, implementation and evaluation of care

a conducive environment to eat in patients are given assistance to eat

and drink when they require it. obtaining food-patients have sufficient

information to obtain food food provided meets the needs of

individual patients food is available for patients at all

times and replacements are offered. Food presentation is appealing patients food intake is monitored patients are encouraged to eat to

promote their own health

Links to

PEAT

Healthcare Commission Standards

Patient Environment Action Team - (PEAT)

Reviewing quality issues in England relating to cleanliness, ward environment and food

now includes a standard on nutritional care

50% patients to have a recorded nutritional risk score and body weight

50% wards observing protected meal times.

Healthcare commission- Assessment for Improvement-the annual health

check Standards to performance

monitor all Organisations in England that provide care for patients

core standards reflect expected basic standards of care

standard C15 focuses on food and nutrition

key elements where food is provided

patients are provided with a balanced diet and one that meets their nutritional, personal and clinical dietary requirements

assessors will expect to see evidence from a variety of sources eg

Essence of care Patient meal survey Protected

mealtimes PEAT

Local profiling

Factors for consideration Rationale

Population with age profiles To identify local characteristics Including ethnic minority groups

Geographical layout eg rural, urban, transport systems

Gives an overview of locality eg access to shops, problems with isolation,

Deprivation index Highlights eg degree of poverty, percentage of individuals working, long term sickness

Health and social care provision Highlights support available eg hospitals, care homes, day centres, Leisure facilities

Health of the population Identifies the problem areas eg proportion of long term illnesses eg COPD, cancers, mental illness

Prevalence of malnutrition in the community

Malnutrition in patients in the community with a BMI<20 kg/m2

Prevalence of up to (%)

COPD

30

Fractured neck of femur 50

Cancer 35

CVA/stroke 31

Other neurological problems 60

Elderly patients with a variety of conditions

36

Stratton et al. Disease related malnutrition: an evidence based approach to treatment.2003. Cabi Publishing

Costs of malnutrition

Malnutrition in the UK is an important clinical and public health issue

Underweight individuals (BMI <20kg/m2)

have been shown to consume more healthcare resources than those with a BMI between 20 and 25kg/m2

require more prescriptions (9%) have more GP visits (6%) have more hospital admissions (25%) have higher death rates

Source: Martyn et al. Effect of nutritional status on healthcare resources by clients with chronic disease living in the community. Clin Nutr. 1998 (17):119-23

Significant functional and clinical outcome improvements – hospital and community patients receiving

oral nutritional supplements Disease/patient group Functional/clinical outcome

COPD Improved respiratory muscle function Improved hand grip strength Improved walking distance

Older people Immunological benefits Reduced number of falls Increased activities of daily living

HIV/AIDS Improved cognitive function

Liver disease Lower incidence of severe infections Lower frequency of hospitalisation

Malignancy Immunological benefits

Pressure ulcers Improved healing

Pre and postoperative lower gastrointestinal tract surgery

Lower minor complications

Source: Stratton et al. Disease related malnutrition: an evidence based approach to treatment.2003. Cabi Publishing

Smedley et al Randomised controlled trial of the effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care. Br J Surg (2004)91(8):983-90

Clinical outcome improvements in the community for patients

using oral nutritional supplements

Systematic reviews by Stratton and Elia

Reduction in rates of infection, frequency of hospitalisation, reduction in the length of hospital stay, mortality.

Improvement in energy and nutrient intake,some evidence to suggest suppression of food intake but overall increase.

Improvements in body weight, greater with patients with BMI <20kg/m2 or BMI >20kg/m2 but weight losing.

Stratton RJ, Elia M. A critical systematic analysis of the use of oral nutritional supplements in the community. Clin. Nutr. 1999; 18(2):1-84

Unintentional weight loss over three to six months

<5% body weight: normal intra-individual variation loss 5% body weight:

less energeticdecrease in voluntary physical activityincrease in fatigue

loss 10% body weight: changes in muscle functiondisturbances in thermoregulationpoor response or outcome to surgery and chemotherapy

Formulating a plan

nutritional screening to identify ‘at risk’ patients

determine goals and outcomes

care planning and treatment options

monitoring

Who requires nutritional support?

Offer nutritional support to individuals who:

have unintentional weight loss of >10% over previous 3-6 months or

have a BMI < 20 with unintentional weight loss of >5% or

have a BMI < 18.5 or

no nutritional intake for 5 days and not likely to be eating in the near future

NICE (2005)

Defining outcomes

functional eg improvements in respiratory muscle function increase walking distances increase activities of daily living Decrease in falls

body composition eg improve muscle mass fat mass

dietary eg improve qualitative and quantitative aspects of diet

Care planning Weight goals

Maintain Prevent further loss Increase

Dietary goals Continue Improve Increase

Dietary interventions– Improve– Enrich– Use of supplements

Vera Todorovic

Rationale for use of oral nutritional sip

feeds/supplements Supplement current oral intake to improve

nutritional intake , aiming to meet nutritional requirements. Evidence suggests ONS’s are additive to food.

Sole source of nutrition ,replacing oral intake where nutritional intake is poor.

Improves clinical outcomes for the patient.

What to give? Fortified foods, snacks, texture modified and dietary

counselling Limited data available to suggest what daily quantities of

ONS’s confer benefits for patients but a daily intake of 250-600kcal has been shown to be of value( Delmi et al 1990;Larson et al

1990;Rana et al 1992 ) individuals with a BMI<20kg/m2 or with a BMI >20kg/m2 but

losing weight are more likely to benefit from the provisional of ONS’s ( Stratton and Elia 1999; Stratton et al 2003 )

when choosing supplements it is probably more effective to choose a variety of different flavours, textures and consistencies to avoid taste fatigue ( Stratton and Elia 1999)

New legislation in the form of The European Commission Directive 1999/21/EC on Dietary Foods for Special Medical Purposes has formalised the categorisation of nutritional products into 3 principal groups ( Article 1.3 ):

1. “Nutritionally complete foods with a standard nutrient formulation

which……may constitute the sole source of nourishment”

2. “Nutritionally complete foods with a nutrient adapted formulation specific

for a disease, disorder or medical condition which …..may constitute the

sole source of nourishment”

3. “Nutritionally incomplete foods with a standard formulation or a nutrient-

adapted formulation……not suitable to be used as the sole source of

nourishment”

Some examples of prescribable sip feeds and supplements ( Taken from Todorovic 2004, Nurses’ Index of Medicines and Products) . Type of supplement

Category of product

Examples Nutritional profile

Comments

Milk tasting 1 Fortisip , Fortisip savoury, Ensure Plus, Clininutrin 1.5, Resource Shake, Fresubin energy

1.5-1.75kcal/ml

most commonly used sip feeds

Milk tasting Fibre enriched

1 Fortisip Multi Fibre, Enrich Plus Fresubin Energy Fibre

1.5 kcal/ml Useful for individuals with constipation or clinical conditions affecting bowel action

Specialist feeds and supplements

2

Juice tasting

3 Fortijuce, Enlive, Provide Xtra , Clinutren Fruit, Resource Fruit Flavour Drink

1.25-1.5 kcal/ml Most suitable for individuals who do not like milk

High protein 3 Fortimel, Fortisip Protein, Protifar ( powder ), Forceval protein ( powder )

Approx 20g protein in 200ml

Modular Energy supplements

3 Polycal, Maxijul, Caloreen, Calogen, Calsip, Polycose, Pro-Cal, Scandishake, Calshake

mainly carbohydrate or fat or mixtures of both

These are more appropriate for use with individuals who need to increase their energy intake but cannot tolerate other supplements or in renal patients where fluid intake needs to be restricted.

What to monitor?

clinical and nutritional status

functional goals

acceptability of diet and supplements

review after stopping supplements to see if any deterioration

Care pathway for nutritionally at risk patients

food fortific ation

monitor to assess ifgoals being met.

If met s top s ip feedsIf not met refer to d ietitian

c hoos ing s ip feeds-1-2 p lus d iet-c ategory 1 ( nut c omp lete)- mixed flavours as may need for months

food fortific ationand sip feeds

sip feedsas sole sourc e of

nutrition(c onsult dietitian )

Dec ide on the typeof nutritionalintervention

S et goals for treatment eg weight gain improve overall nutritional intake

Develop a c linic a l c are p lan- patients in med ium and high r isk

c ategories w ill need some form of nutr itiona l intervention.H igh r isk may need d ietetic intervention

Identify nutr itiona lly at r isk patientsthrough use of a nutritional sc reening tool

'MU S T '

DiqPCT\copd\nutritional pathwyaDi

Nutritional Management of Individuals with COPD

Low risk Score = 0

Medium risk Score = 1

High risk Score = 2

Management Plan

Monitor weight and weight changes at visits. If changes – consider appropriate action

Management Plan Encourage use of

higher energy foods

Initiate use of oral nutritional supplements 1-2/day (300 – 600 kcal) For examples consult Nurses Index 2004 Select from Category 1 products

Review monthly If weight

decreases refer to dietitian

Management plan Encourage use

of higher energy foods

Commence oral nutritional supplements as per med risk

Refer to dietitian for full assessment

Nutritional Screening using the ‘Malnutrition Universal Screening Tool’( ‘MUST’ )

Conclusion

Using a variety of sources of data and information helps to build robust strategies for the nutritional management of patients in the community

nutritional protocols will differ depending on the patient group and should be customised to meet their needs.

Working in partnership with other staff and agencies is key in defining the nutritional needs of their population.