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Chefs' Club Slideshow Session 3
- 1. DCHC Chefs’ Club Nutrition and Hydration Champion Course Session 3: Malnutrition screening – MUST Actions: “Food First” - Fortification, Snacks, Smoothies “Food for Fingers” Tim Radcliffe East Lancs Hospital NHS Trust
- 3. ‘Malnutrition’ (medium + high risk ‘MUST’) is common within care homes.. with a prevalence of about 35% among residents admitted in the previous 6 months… Bapen 2020 (This data pre-dates the pandemic)
- 4. Malnutrition – Malnutrition can mean both undernutrition and overnutrition. Undernutrition is: “an insufficient intake of energy and nutrients to meet an individual's needs to maintain good health. “ Who is at Risk? • Social factors –poverty, social isolation, grief • Drug or alcohol abuse • Over 65 especially if admitted to Hospital or Care home • Long term condition eg diabetes, copd • Covid 19 • Progressive illness eg dementia, cancer, parkinsons.. • Physical eg painful mouth or teeth, difficulty swallowing, loss of smell or taste, reduced mobility or dexterity, loss of independence
- 5. Consequences of Malnutrition • Immune system • Muscles • Skin • Kidneys • Brain • Temperature regulation • Frailty • Increased GP appointments & hospital admissions/length of stay
- 6. The best way to detect malnutrition is using malnutrition screening tools, such as the ‘Malnutrition Universal Screening Tool’ (‘MUST’). This tool assesses residents as being at low, medium or high risk of malnutrition and guides the user to develop individualised care plans for treatment if required and further monitoring. Mandatory to screen all nursing home residents – other screening tools are available NICE clinical guideline 32 (CG32)
- 7. MUST Screening Tool – 5 Steps: 1. Gather Height and Weight to determine BMI 2. Measure recent un-planned weight loss 3. Consider effect of acute disease 4. Add Step 1, 2 & 3 to determine overall risk – High, Medium, Low ( may need to be subjective if you are unable to measure height or weight) 5. Create/update Care Plan appropriate to the risk identified Carry out on Admission and repeat Monthly. Note: Covid may impact on your ability to use the MUST tool.
- 8. Nutrition Checklist. • A Screening tool developed and validated by the Patients Association that may be a first line of defence in residential care and the community. • Can help raise awareness and identify the potential risk of undernutrition and offer guidance on next steps. • Primarily intended for people over 65 living in the community • Potential for early identification of undernutrition risk, as it identifies people in the earlier stages of unintentional weight loss, and people whose appetite has been recently compromised. • Provides opportunity for people identifying themselves as possibly at risk to self- screen and/or seek advice and for staff to follow up using NICE guidance (including potentially the use of ‘MUST’ by trained practitioners) and offer earlier signposting to dietary advice and appropriate health and social care support
- 9. Residential/Community Nutrition Checklist https://www.patients- association.org.uk/ 1. Are you concerned your resident may be underweight or need nutrition advice? 2. Has your resident lost a lot of weight unintentionally in the last 3 – 6 months? 3. Have you noticed their clothes or rings become loose recently? 4. Have you noticed your resident has lost appetite and/or interest in eating? Answering yes or don’t know to any of the answers indicates your resident is likely to be at risk of malnutrition and you should take action following local guidance.
- 10. Covid 19 & Malnutrition © BAPEN. MAG Covid-19 Update, May 2020 • Symptoms e.g. breathlessness, fatigue, loss of appetite/taste/smell.. • Physical restrictions eg social distancing, infection control • Social & psychological effects MAG recommends estimate risk if unable to use MUST: • If acutely ill (unable to eat for 5 days + eg ICU) categorise High risk • Use resident reported values or subjective criteria Create nutrition action plan linked to your local policy
- 11. How to Spot Malnutrition? • Hard to spot for example if resident is obese • Clothes, belt, watch or rings may become loose • Dentures may become loose or there may be tooth loss • May walk slower, sleep more, have difficulty coughing • Shoes or slippers may fall off and be left behind • Wounds may be slow to heal or more chronic infections • Appearance may become gaunt, bones more prominent, skin and hair thinner and more dry • May appear depressed, withdrawn, more expressive behaviours.
- 13. The nutritional value of food left un-eaten is nil… BDA Digest 2019
- 15. ACTION PLAN: Weight loss is NOT inevitable “These approaches have been shown to positively impact upon a patient’s nutritional status (Elia, 2015)” 1. Commence food and fluid record charts to establish actual intake, times and patterns of eating and drinking, preferences including cultural and social needs, ( what, when, where and how much?) 2. Using Food First approach • Add fortification and/or food toppers to all meals and drinks • Offer 2 nutrient dense snacks daily • Offer 2 homemade milkshakes or nutrient dense puddings daily (avoid offering before main meals) 3. Weigh weekly and re-screen using MUST after 1 month 4. Update Care Plan with MUST score, risk level and actions, including noting preferences, best interest decisions etc. 5. Inform Care and Catering team, involve resident, family, dining assistants/activities, professionals. 6. Remember to check and treat any potential barriers to oral intake – eg toothache, oral thrush, dysphagia, covid 19, UTI, environmental or social, etc..
- 17. Menu: Provides choice for the Nutritionally well & Nutritionally vulnerable Based on the “Eatwell Plate” (PHE 2016) Need to meet high energy needs, but also offer healthier eating choices (for overnutrition).
- 20. Menu composition https://www.bda.uk.com/uploads/assets/c24296fe-8b4d-4626-aeebb6cf2d92fccb/NutritionHydrationDigest.pdf Table 1: Nutrient Standards for Adults Nutrient (/day) Nutritionally Vulnerable Provided Energy (Kcal) 1840 - 2772 Daily Protein (g) 56* *For females of the same age bracket the RNI is 45g. 66 - 83 Daily
- 21. “Day Parts” Menu Nutrient Targets for Practical Menu Planning (BDA Digest 2017) Complete Meal Targets (Starter + Main + Dessert) % of daily nutrition Nutritionally Well Energy (kcal) Nutritionally Vulnerable Midday meal: Energy (kcal) 30% 552 831 Protein (g) 15 25 Evening meal: Energy (kcal) 30% 552 831 Protein (g) 15 25 Breakfast: Energy (kcal) 400 545 Protein (g) 10 16 Snacks – minimum 2 recommended Energy (kcal) 150 300 Protein (g) 2 4 Milk for beverages (400ml min) Energy (kcal) 184 264 Protein (g) 14 13 Combined: 40%
- 22. Example of Menu meeting nutritional guidelines in Care/Nursing Homes Caroline Walker Trust Breakfast Prunes. Porridge or High Fibre cereal & Milk. Toast with butter/spread & Jam/Marmalade Tea or Coffee & Milk Mid Morning Tea or Coffee & Milk. Digestive biscuit Lunch Fruit Juice. Lancashire Hot-Pot, Green Beans, Cauliflower, Mashed Potato. Plum Tart & Custard. Tea or Coffee & Milk or Water Mid Afternoon Tea or Coffee with Milk. Toasted Tea cake & Butter/Spread Tea-Time Macaroni Cheese & Ham. Canned peaches & Ice-cream. Banana. Water or Fruit Juice Evening Hot milky drink eg Horlicks, Chocolate etc Note: residents should be offered additional drinks after meals aiming at a minimum of 8 a day
- 23. Food First Actions for those identified as MUST score 1 or over, at risk of malnutrition. Note: check IDDSI texture for Dysphagia diets 1. Offer 2 additional Snacks a day = @ 150 kcals each 2. Offer 2 additional fortified drinks/milkshakes a day 3. Add Food Toppers or fortification to each dish (@ 50kcals) aim for 5 a day Examples: Examples: Examples: Slice of cake, muffin, malt loaf + butter Fortified Milkshake or fortified fruit juice/squash Level tablespoon double cream Small pot full-fat creamy yoghurt Fortified cream shot Heaped teaspoon mayonnaise Large banana Complan or equivalent Heaped teaspoon butter ½ small tinned fruit + 2 tablespoons double cream or condensed milk If resident prefers savoury or fruit based drinks find alternative – see recipes Level tablespoon honey or syrup 1 slice wholemeal bread & peanut butter, chocolate hazelnut spread Homemade fortified milkshake can provide as many calories as ONS in a more palatable way ½ oz 12gm Cheddar ( size of a matchbox) 30g Cheese & 2 Crackers Heaped tablespoon milk powder
- 24. Fortified Diet Plan • Eat ‘little and often • Use full cream milk: aim for 1 pint / 600mls per day • Fortify your milk: add 2-4 heaped tablespoons of dried skimmed milk powder and blend into 1 pint full cream milk. Chill in the fridge and then use on cereals, in porridge, to make up sauces, soups, desserts, jellies, milky drinks etc • Add dried skimmed milk powder to soups, milk puddings, custards, mashed potatoes: try adding 2-3 teaspoons per portion of food • Choose full fat and full sugar* products rather than ‘diet’ ‘reduced/low fat’ ‘low sugar’ or ‘healthy eating’ varieties as these provide more calories • Add knobs of butter and margarine to vegetables, potatoes etc and add grated cheese to soup, mashed potato, jacket potato, scrambled eggs etc
- 25. Fortified Diet Plan contd. • Serve main meals with a creamy sauce eg. cheese sauce, parsley sauce • Make sure your sandwiches have additional fillings such as mayonnaise, coleslaw, cream cheese, chutney, etc. • Serve jam, honey, syrup on bread, milk puddings etc. • Ice your cakes or fill with jam, and use biscuits with a chocolate or cream filling • Have snacks between meals and at bedtime. Try toast with butter and jam, cheese sandwich, cereal with milk, creamy or Greek yogurt, cake, biscuits, full fat mousse, cream cheese and crackers, dried fruit and nuts, or try a nourishing drink • A little alcohol before a meal can stimulate appetite, but check with your GP first if you take any medications • For a balanced diet choose a wide variety of foods. At each meal try to have a protein food (meat, fish, egg, cheese, milk, vegetarian alternative ie Quorn, soya) and a starchy food (bread, cereals, potato, rice, pasta). Eat fruit and vegetables every day – puree or take as juice if easier
- 26. Make every mouthful count! For example: 1 glass of water 0 calories 1 glass sugar free squash 0 calories 1 cup of tea 15 calories 1 glass fresh fruit juice 60 calories 1 cup milky coffee 110 calories 1 cup fortified hot chocolate 386 calories & 19g protein 1 glass fortified milkshake 300 calories & 18g protein
- 28. Diabetes – will be specific to the person • Food first • Evenly spaced meals with consistent portions of starchy foods – ideally wholegrain which are more slowly absorbed. • First thing in the morning and last thing at night. • Limit sugar and sugary foods – not sugar-free! Use sugar free drinks eg sugar free crusha, squash, options. Use cream instead of buttercream icing on cakes, include more fresh fruit
- 29. Read the label!
- 30. Extra Nutrients already added to some foods Eg Folic acid, Vitamin D etc
- 31. Secret Weapon! • Source of calcium, vitamin A & D • High protein • Adds calories • Great in tea, coffee, milkshakes, cream soups • Use in bread making, porridge, custard & cooking • Suitable for vegetarians
- 32. Fortified Milk Recipe • 200mls full fat milk • 4 tablespoons skimmed milk powder • Mix the milk powder in to a little of the milk until dissolved. Stir in the rest of the milk • Mix with flavourings, ice-cream, fruit puree etc • Make up to 3 litre jugs. Label, cover and chill. Use within
- 33. Eating and Drinking Opportunities • Kitchenettes & Snack stations • Lunch box, frequented places • Within easy reach • Finger foods, Nosey cups • Favourite food and drink/preferences • Water coolers • Special events • First thing when you wake, last thing before bed • Night-time • Medicine rounds
- 34. Tim Radcliffe “Food for Fingers”
- 35. Actions from today 1. Consider sharing today’s presentations with your team. Discuss with them some of the food first actions and strategies and how you can use them in your setting. 2. Make sure the kitchen team know who has a MUST score of 1 or above and those peoples’ preferences including diet needs such as texture modification 3. E-mail 1 snack, meal or drink recipe to add to the “DCHC Fortify your diet Recipe resource” to sue@devoncarehomes.org
- 40. Next session: Thursday 11th November 1.45 – 3.15pm Menu Planning Choice – culture, personal preferences, religion, lifetime Vegetarian for life Special occasions End of life
Editor's Notes
- Welcome to session 3. this week is about malnutrition, how do we screen for it and what actions do we take if it is identified? We are looking at food first actions such as fortification, snacks and smoothies and we are delighted to welcome Tim Radcliffe from East Lancashire nhs trust to speak to us about his highly successful food for fingers initiative. I don’t know about you, but I spend my life enjoying good food and then trying to lose weight! We are bombarded with messaging about obesity and healthy eating. But what does eating for health look like for the people living in our care settings?
- We usually think of malnutrition as a third world problem associated with poverty, famine and war
- But research shows that malnutrition affects around 35% of people admitted to care homes in the previous 6 months. It is thought that 70% of undernutrition goes unrecognised in the UK, and malnutrition and dehydration were identified as underlying causes and contributing factors in the deaths of more than 650 care home residents between 2005 and 2009
- Often by the time someone comes into our care setting they may have been ill in hospital or becoming increasingly frail and unable to cope at home. They may have a long term health condition or progressive disease. Of course malnutrition can mean both over and undernutrition, but in today’s session we are going to focus on Undernutrition.
- Malnutrition affects all the organs of the body. The person becomes weaker due to loss of muscle. They may experience falls, lethargy, poor healing, increased infections, It can lead to a vicious circle of decline
- The MUST tool was developed as a way of screening people at risk of malnutrition
- It has 5 steps. Steps 1 – 4 calculate the overall risk by adding the BMI. Unplanned weight loss score and acute illness score. Step 5 directs us to develop an individualised plan of nutritional support based on the level of risk identified. The nutrition and hydration care plan should include their weight, nutrition risk and resulting plan of nutrition care including their personal preferences, any cultural, lifetime or religious beliefs, any special dietary needs such as texture modification and ideally a target hydration intake too. This should be freely accessible to the whole team and the kitchen should be aware of anyone identified as at risk of malnutrition. It is mandatory to screen for malnutrition on admission to a nursing home and then routinely every month.
- In the community or residential settings other screening tools may be used such as the patients association Nutrition checklist
- This asks 4 simple questions. Answering yes or don’t know to any of these questions could indicate the person is at risk of malnutrition and should prompt referral for further assessment.
- Covid 19 has thrown up many challenges around the risk of malnutrition and how to continue screening. Covid symptoms impact on appetite and the ability to eat and drink. Physical restrictions such as infection control and social distancing cause difficulties for example around weighing and supporting mealtimes. Being unable to eat and drink together or see family and friends have also had a significant impact on well-being and increased the risk of malnutrition during the pandemic. If it is not possible to collect weights then other methods of screening should be employed such as MUAC, mid upper arm circumference, using resident reported values or subjective criteria .
- These are some of the signs we can see. I think we have all witnessed some if not all of these in our residents at some time.
- So, when you are able to weigh regularly and spot a change, don’t delay. Take action! The first thing is to check accuracy by re-weighing. Make sure the same scales are used, in the same place, ideally at the same time of day. Investigate why it is the person might have lost weight. Have they recently been unwell? Are they starting to have a problem swallowing? Are they progressing on their dementia journey and no longer registering hunger or thirst?
- Start a food and drink record to identify what, when and how much they are eating and drinking. Remember, no matter how good your food is, the nutritional value of food that is not eaten is nil.
- This is an example of a MUST Care Pathway. It may vary slightly in your area so do check your local area pathway. For those with a score of 1 or above a Food First Action Plan is advised. Food supplements rather than prescribed oral nutrition supplements are thought to be not only more cost effective but also more palatable and are therefore used as the first course of action.
- So, Food first approaches have been shown to positively impact on a patient’s nutritional status. We should not accept that weight loss is inevitable. The problem should be identified and the desired outcome agreed. Of course in certain circumstances such as end of life the aim no longer becomes weight maintenance of gain, rather comfort and reassurance.
- The resident should be at the heart of any decision making and their preferences and beliefs should be taken in to account. Mental Capacity may need to be assessed when making a decision around diet or fluids. The community dietician is highlighted as the key professional to advise on under or over-nutrition, but you may also need to involve other professionals, family and of course your wider team in carrying out assessments and making evidence based decisions.
- Your menu should provide choice for both the nutritionally well and the nutritionally vulnerable. It should be based on the eat well plate and meet high energy needs but also offer healthier eating options. The nutritional recommendations for the majority of people aged 65 or over are to follow similar patterns of eating and lifestyle to those advised for maintaining health in younger adults. However, the older persons requirements need tailoring in this life stage as they have very diverse health and nutritional needs being nutritionally well or nutritionally vulnerable at times. (BDA digest 2017 older people)
- In short, your daily menu should provide all the macro and micro nutrients essential for good health.
- The eat-well plate illustrates the right proportion of the different food groups for a healthy diet. The proportions will be slightly different for the nutritionally vulnerable who may require a higher calorie and protein intake.
- Actual nutritional values can only be calculated by a nutrition specialist or special software. But referencing specialist literature such as the BDA nutrition and hydration digest or the Caroline walker trust can help us to design menus that meet the nutritional requirements of a balanced diet. This involves catering for the ‘Nutritionally well’ - normal nutritional requirements and normal appetite or those with a condition requiring a diet that follows healthier eating principles ‘Nutritionally vulnerable’ - normal nutritional requirements but with poor appetite and/or unable to eat normal quantities at mealtimes; or with increased nutritional needs. (BDA Digest 2017)
- The BDA suggests breaking down the menu into “Day Parts” to illustrate the spread of calories and protein across the different food and drink offerings during the day. I have shown it here really to illustrate that if, for example, a food and drink record shows someone is regularly missing breakfast, then this will have a massive impact on their daily intake and could contribute to them being more at risk of malnutrition. But breaking the menu up like this also shows the opportunities for adding back in those essential nutrients if they are missed.
- This example of a daily menu from the Caroline Walker trust presents a balanced diet. However, for someone who has been identified with a risk of malnutrition you will want to increase the calorie and protein content to the upper end of the scale we saw in table 1 earlier. Using our existing menus we can do this by following the food first actions on the MUST pathway
- In addition to fortification, specific actions include: 1 – offer 2 additional snacks a day of @ 150 calories. Offer 2 additional fortified drinks a day. 3. Add food toppers such as cheese, or cream @ 50 calories each. Monitoring will continue to ensure goals are met, or if this is unsuccessful further referral may be needed to the GP or dietician and the plan reviewed.
- The normal menu can be readily fortified, and opportunities to eat little and often rather than 3 big meals a day supported.
- For someone with a MUST score of 1 or above it is important to make every mouthful count. So check their preferences and rather than offering the usual cup of tea, why not try a fortified hot chocolate which offers a significant amount of extra calories and protein.
- What about diabetics? How should we manage their diet if they are at risk of malnutrition?
- There is no one size fits all for people who have diabetes. They may be well controlled on just a normal healthy diet, they may have unstable blood sugar levels, they may need regular insulin injections. They may also live with other health problems such as dementia or chronic infections. It is really important their diet is specific to their needs and the advice of the GP, specialist nurse or dietician is sought if there is any uncertainty about their diet. However, in general, there is no specific “diabetic diet” and it is important to balance the risk of malnutrition against the risks from their diabetes. If they are losing weight the food first actions should be followed in conjunction with any advice from the diabetic team. Snacks don’t have to be sugar-loaded, for example cheese and crackers, crumpet and butter, cup a soup with cream. Evenly spaced meals are important – no long gaps without any food such as between evening meal and breakfast. Consistent portions of ideally wholegrain starchy foods which absorb more slowly are recommended. Sugar is not banned, but look at how you can reduce the most sugary foods like soft drinks, jams and marmalade. Look for some low sugar alternatives like low sugar squash or Options hot chocolate. Serve a small portion of pudding with cream instead of sugary custard. Include plenty of fresh fruit.
- If you buy in snacks, always read the label. For example the majority of yoghurts and other dairy desserts on supermarket shelves are of the low fat variety and contain less calories than their full fat counterparts. Consider buying large pots of full fat yoghurt and mixing in additional toppers or flavours such as fruit puree, honey, toffee sauce, lemon curd etc.
- Some foods such as bread and cereals have nutrients such as vitamins added. Check the labels.
- And your new best friend in the war against weight loss! Skimmed milk powder adds not only calories but also protein and some vitamins and minerals. Make up fortified milk and use it in your hot and cold beverages. You are immediately elevating the calorie intake from @ 15 kcals and 1g protein for a cup of coffee, no sugar, semiskimmed milk to @ 75kcals and 3.5g protein for cup of coffee with 2 sugars and fortified whole milk
- You can make up fortified milk ready to use at coffee and tea-time. There is a cost-implication and also some effect on taste – for example some people may not like it in tea. So label it and use it for those with a MUST score of 1 or over, or those who are currently unwell and with a poor appetite or recent weight-loss. Or for your new admissions who may have a recorded or reported weight loss prior to admission.
- Of course we can take all these food actions, but the food and drink has to be easily and frequently accessible like at home! Don’t just send out a tea trolley a couple of times a day, these are some strategies to try:
- So now I would like to hand you over to our guest speaker today Tim Radcliffe who has very kindly joined us to share his knowledge and experience of introducing his food for fingers initiative across the east Lancashire nhs hospital trust. Thankyou.
- So thank you everyone for joining us today and I hope you will all take away something useful from the session. I will put together a short recipe resource for you to access on the website, so if any of you would like to share any of your ideas that would be great! Do add pictures too if you are making any of the recipes. The session will be available on the resources page of the website and I will send out a short survey and quiz for feedback and to answer if you would like a certificate at the end of the course. To finish I have a few more slides of some high energy snacks to share with you.