Issue 131 malnutrition

IN ASSOCIATION WITH THE BDA’S OLDER PEOPLE SPECIALIST GROUP (OPSG)

MALNUTRITION: AN INDIVIDUAL PERSPECTIVE Dr Mabel Blades RD Freelance Registered Dietitian and Nutritionist Mabel is a member of the BDA’s Older People Specialist Group. All aspects of food and nutrition interest and enthuse her and the dissemination of information on these topics remains her main career aim in life.

MALNUTRITION MATTERS

Specialist Group

Malnutrition is defined by the British Association for Parenteral and Enteral Nutrition (BAPEN), as ‘a state of nutrition in which a deficiency, excess or imbalance of energy, protein and other nutrients causes measurable adverse effects on body function and clinical outcome’.1 While most of the focus on malnutrition is on obesity, under nutrition is a major problem in the UK and costs the health and social care budgets billions each year.

There are numerous consequences associated with malnutrition including weight loss, impaired temperature control due to the loss of insulating body fat and increased muscle loss (sarcopenia). Other risks include weakness and fatigue, apathy, depression and self-neglect, impaired immune response, increased tissue breakdown and impaired wound healing, osteoporosis and increased risk of fracture, constipation and anaemia.

ASSESSMENT

The Malnutrition Advisory Group2 describes malnutrition as a Body Mass Index (BMI) <18.5kg/m2 and unintentional weight loss greater than 10% within the last three to six months, or BMI <20kg/m2 and unintentional weight loss greater than 5% within the last three to six months.

The MUST (Malnutrition Universal Screening Tool) is easy to complete, with adequate training support. It is based on five simple steps using a chart to evaluate the scores: 1. Calculate or estimate the patient’s BMI score.

2. Note percentage unplanned weight loss and assign score.

3. Establish acute disease effect and score.

4. Add scores together to obtain overall malnutrition risk.

5. Develop care plan using management guidelines or local policy.

A score of 0 indicates a low clinical risk and repeat screening is recommended. This should be weekly in a hospital and monthly in the residential care, or annually for those in special groups, such as those over 75 years of age.

A score of 1 indicates a medium risk and observations are recommended, including observing and documenting food intake for three days. If the intake is good, then repeat screening is recommended. This should be weekly in a hospital and monthly in the residential care, or every three months for those in the community. If the three-day intake is inadequate, it is recommended to follow local clinical policies.

A score of 2 or more indicates a high risk and treatment is recommended.

Such treatment can include referral to a registered dietitian or nutritional support team, increasing and improving nutritional intake and monitoring by regular MUST screening. (Obviously if death is imminent or nutritional support is detrimental, then such steps to increase intake are inappropriate.) It should also be remembered that people who are obese can also suffer from under nutrition and the impact that this has on health should be considered. While the MUST is commonly used alongside the criteria detailed earlier in this article, there has been an update in 2015 from the European Society of Clinical Nutrition and Metabolism (ESPEN) who issued a consensus statement on www.NHDmag.com February 2018 - Issue 131

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References 1. Wright C. CN Focus 2012;4(3):17-19. 2. Sharma M et al. Colorectal Disease 2013;15: 885-891. 3. Data on file. 4. Malnutrition Advisory Group (MAG) 2011.Malnutrition Universal Screening Tool. www.bapen.org.uk/pdfs/must/must_full.pdf. Accessed September 2016. *Of those who were at medium or high risk of malnutrition at baseline, 67% were at low risk of malnutrition on study completion.

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NHD0218

MALNUTRITION MATTERS the diagnostic criteria for malnutrition.2 This consensus recommends: • Individuals at risk of malnutrition are identified by validated screening tools and should be assessed and treated accordingly.

• Risk of malnutrition should have its own ICD code.

• There should be two options for the diagnosis of malnutrition.

1. Option one requires a BMI <18.5kg/m2 to define malnutrition.

2. Option two requires the combined finding of unintentional weight loss (mandatory) and at least one of reduced BMI or a low fat free mass index. Weight loss could be either more than 10% of habitual weight indefinite of time or more than 5% weight loss over three months.

Reduced BMI is more than 20kg/m2 in subjects younger than 70 years and below 22kg/m2 in those older than 70 years.

RESIDENTIAL AND CARE HOMES

Food First has an initiative which trains staff to identify residents at risk of malnutrition and provides appropriate support in care homes.3 In a survey of malnutrition in 2015, it was found that 28% of those in residential homes and 38% of those in care homes suffered from malnutrition.4 PERSON-CENTRED CARE

Behind all of the figures, there are individuals with their varied backgrounds, plus likes and dislikes and they should be at the centre of everything.

Some individuals who are over the age of 80 and who have always been slim who have a BMI which falls in the range of 18kg/m2, can find it both intrusive and upsetting to be encouraged to gain weight, especially for example, when some very elderly patients still like to choose their own food from the local shops. I know one lady who is over 100 years old, who still likes to do just that!

It is not just about assessing those at risk of malnutrition, but doing something about it . . .

It must be remembered that obese people can suffer from malnutrition and this should be taken into consideration and is covered to an extent in the consensus statement. Also some older people do wish to lose weight if they are obese for other health reasons and this needs to be properly considered and documented.

Some individuals do not like to be regularly weighed and for them a MUAC (Mid Upper Arm Circumference) is helpful.

IN CONCLUSION

It is not just about assessing those at risk of malnutrition, but doing something about it, which means increasing the nutritional content of a person’s diet in an acceptable and enjoyable manner for the individual.

Whilst oral nutritional supplements have a place, they also need to be regularly reviewed, as sometimes people can find them off putting and after tastes and feelings of fullness stop them from enjoying a meal. This is an area where dietitians can provide appropriate and invaluable advice for each individual.5

References 1 BAPEN (2003). The ‘MUST’ Explanatory Booklet. Members of the Malnutrition Action Group (MAG), a Standing Committee of the British Association for Parenteral and Enteral Nutrition: Edited by Todorovic V, Russell C and Elia M 2 Cederholm T et al (2015). Diagnostic Criteria for malnutrition - An ESPEN Consensus statement. Clin Nutr. Jun 34 (3) 335-40 3 Forbes C (2014). The Food First approach to malnutrition. Nursing and Residential Care. 24th July 4 BAPEN (2015). Malnutrition survey of care homes. December 2015 5 Blades M (2017). The dietitian’s role in the care of older people and malnutrition risk. Dietetics Today. March 2017

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