Management of Adult Malnutrition With Food First & Guidelines on the Prescribing of Oral Nutritional Supplements in the Community

• Background & Purpose
• Exclusions
• Quick Guide: 6 steps to management of malnutrition & appropriate prescribing of ONS in adults
• STEP 1: Malnutrition Screening using MUST
• STEP 2: Assessment of causes of malnutrition - Signposting
• STEP 3: Offering ‘food first ‘dietary advice, setting food first goals and undertaking a 4-weekly review of food first
• STEP 4: Prescribing Oral Nutritional Supplements alongside food first principles, setting ONS treatment goals
• and undertaking a 4-weekly review of ONS prescribing
• Leeds ONS Primary Care Prescribing - 1st Choice List
• Disease and Condition Specific Guidance & Signposting
• Care Homes & ONS Prescribing
• STEP 5: Reviewing and discontinuing Oral Nutritional Supplements prescriptions
• STEP 6: Referral to Leeds Community Nutrition & Dietetic Service
• Palliative care and ONS prescribing
• Substance misuse
• Further Reading and References
• Food First - Advice for adult with a poor appetite - Leaflet 
• QUICK GUIDE: 6 Steps to Appropriate Management of Malnutrition in Adults 16yr+

BACKGROUND

Malnutrition can have serious negative health consequences including poor recovery from illness and surgery; impaired immune function; reduced muscle strength with consequent risk of falls; impaired psychosocial function; impaired wound healing and increased susceptibility to pressure ulcers. Therefore it is important to promptly identify and treat those who are malnourished or at risk of becoming malnourished. Effective treatment of such patients involves providing adequate oral nutrition support.

Oral nutrition support is defined in the NICE clinical guideline CG32 as ‘the modification of food and fluid by fortifying food with protein, carbohydrate and/or fat plus minerals and vitamins; the provision of snacks and/or oral nutritional supplements as extra nutrition to regular meals, changing meal patterns or the provision of dietary advice to patients on how to increase overall nutrition intake by the above’.

Oral Nutritional Supplements (ONS) should only be provided to patients who are classed as malnourished or at risk of malnutrition (using NICE definitions), where dietary intervention alone has not led to an improvement in nutritional status or is highly unlikely to do so. In order to ensure the clinically and cost effective use of ONS, they should only be prescribed for specific Advisory Committee on Borderline Substances (ACBS) indications and should be prescribed appropriately in line with relevant guidelines.

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PURPOSE

The purpose of these guidelines is to support primary care to standardise the identification and management of adult patients with or at risk of malnutrition in Leeds. It includes guidance on how to use the Malnutrition Universal Screening Tool (MUST), the implementation of food first advice and how to initiate a prescription for Oral Nutritional Supplements as appropriate.

The guidelines advise on:

• Malnutrition Screening using MUST (step 1)
• Assessing underlying causes of malnutrition (step 2)
• Offering ‘food first’ dietary advice, setting food first goals and undertaking a 4-weekly review of food first (step 3)
• Prescribing Oral Nutritional Supplements alongside food first principles, setting ONS treatment goals and undertaking a 4-weekly review of ONS prescribing (step 4)
• Reviewing and discontinuing Oral Nutritional Supplements prescriptions (step 5).
• Referral to Leeds Community Nutrition & Dietetic Service (step 6)
  Advice is also offered on when prescribing is inappropriate, prescribing for palliative care, prescribing for those with substance misuse and prescribing for those in Care Homes.

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EXCLUSIONS

These guidelines are NOT suitable for patients with the following conditions:

• Chronic Kidney Disease Stage 4 and 5. Patients with high potassium and/or high phosphate
• Severe Liver disease
• Dysphagia
• Cystic Fibrosis
• Inherited Metabolic Conditions
• Eating disorders
• Patients at risk of refeeding syndrome (see risk criteria in table below) - Hospitalisation is required to safely manage patients at risk of refeeding syndrome (Click HERE for NICE Guidance on refeeding – see section 1.4)

Criteria for determining people at high risk of developing refeeding problems

• Enterally (tube) fed patients.

See for signposting links for these excluded conditions

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QUICK GUIDE: 6 Steps to Appropriate Management of Malnutrition in Adults 16yr+

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STEP 1 - MALNUTRITION SCREENING USING MUST (Malnutrition Universal Screening Tool)

Before a recommended treatment path for a patient can begin, screening of the individual’s risk of malnutrition must be undertaken. The Malnutrition Universal Screening Tool (MUST) is a validated screening tool used to identify those at risk. It was developed by the Malnutrition Advisory Group of the British Association of Parenteral and Enteral Nutrition (BAPEN). The tool takes the form of a 5 Step flow-chart, collating information on a person's current BMI, weight loss over the last 3 to 6 months, and the presence of acute disease. A score is then calculated, the final total indicating the individual's risk of malnutrition, which can be used as a guide for care.

NICE Clinical Guideline 32, Nutrition Support in Adults, suggests the following criteria are used to identify people who are malnourished:

• Malnutrition Universal Scoring Tool (MUST) score of 2 or more or;
• a body mass index (BMI) of less than 18.5 kg/m2 or;
• unintentional weight loss greater than 10% within the last 3–6 months or;
• a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months.

NICE Clinical Guideline 32, suggests the following criteria are used to identify people at risk of malnutrition:

• eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for more than 5 days or;
• a poor absorptive capacity and/or high nutrient losses

NOTE: Weight, BMI changes and the identification of nutritional status are compromised in individuals with fluid weight changes, e.g. in patients with chronic kidney disease (CKD), heart failure, oedema or ascites.

MUST Video (6min) is available via
https://www.youtube.com/watch?v=NB3DfMqEqoM&feature=youtu.be

The online MUST calculator is available via
http://www.bapen.org.uk/screening-for- malnutrition/must-calculator

MUST charts and alternative measurements and considerations to MUST are available via
http://www.bapen.org.uk/screening-for-malnutrition/must/must-toolkit/the-must-itself

Smart phone App is available to download, which provides a simple to use MUST calculator.
http://www.bapen.org.uk/screening-for-malnutrition/must/must-app

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STEP 2 - ASSESSMENT OF CAUSES OF MALNUTRITION

Once nutritional risk has been established, the underlying cause and treatment options should be assessed and appropriate action taken. Review the treatment plan in respect of these issues and if needed make appropriate referrals.

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STEP 3 – OFFER ‘FOOD FIRST’, SET FOOD FIRST GOALS & UNDERTAKE A 4-WEEKLY REVIEW OF FOOD FIRST

Oral nutritional supplements (ONS) should not be used as first line treatment. A ‘food first’ approach should be used initially. This means offering advice on food fortification to increase calories and protein in everyday foods. Additional snacks will be needed to meet requirements for those with a small appetite.

Follow the daily 1-2-3 advice:

1 pint of fortified milk – add 4 tablespoons of dried milk powder to 1 pint whole milk, use in drinks, on cereal, sauces, milk based soups

2 high energy snacks

3 fortified meals i.e. Breakfast, lunch, evening meal

2-Page Printable Fact Sheet for patients and carers on malnutrition: https://www.bda.uk.com/foodfacts/MalnutritionFactSheet.pdf

Patient & Carer 2-Page Printable Food Fact Sheet “Your guide to making the most of your food”: http://www.malnutritionselfscreening.org/pdfs/advice-sheet.pdf

Further Information for healthcare providers, patients and carers on managing malnutrition: https://www.bda.uk.com/foodfacts/malnutrition

Additional Advice:

• In malnourished patients or those at risk of malnutrition, high calorie and protein meals and snacks overrides any ‘healthy eating advice’ for Long Term Conditions
• Encourage nourishing drinks (e.g. whole milk based drinks)
• Over the counter products can be purchased by patients for fortification of foods e.g. dried milk powder

Setting Treatment Goals:
Clear treatment goals and a care plan should be agreed with patients. Treatment goals should be documented on the patient record and should include the aim of the nutritional support, timescale, and be realistic and measurable. This could include:

• Prevent further weight loss
• Maintain weight (if weight gain is unrealistic or undesirable)
• 5-10% weight gain in 6 months. Target weight or target BMI
• Wound healing
• Pressure ulcer healing / prevention
• Improve strength / mobility
• Reduce falls risk
• Reduce admission risk

The target weight may sometimes be lower than an optimal ‘healthy’ weight since the latter may be impossible or inappropriate to achieve in ill patients (especially those with gastrointestinal dysfunction). Occasionally, the target weight may be higher than that considered optimal for health since it is not always reasonable to expect severe weight reduction in obese patients with illness and eating difficulties.

Goals should be person centred and individualised: involve patients in setting their own goals. Within the SystmOne template goals can be further categorised as likely, unlikely or uncertain.
If unable to weigh the patient, use other subjective measures to assess if weight has changed, see MUST alternative measurements (narrative and illustrations) http://www.bapen.org.uk/screening-for-malnutrition/must/must-toolkit/the-must-itself

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STEP 4 – PRESCRIBING ONS ALONGSIDE FOOD FIRST, SETTING ONS TREATMENT GOALS & UNDERTAKING A 4-WEEKLY REVIEW OF ONS PRESCRIBING

If a ‘food first’ approach has failed to achieve a positive change towards meeting goals after one
month, consider prescribing ONS in addition to the ‘food first’ changes which should be maintained or where it is evidence that a patient cannot meet their nutritional requirements via food first dietary advice alone.

AND

Patients must meet at least one of the ACBS criteria below to be eligible for prescribed ONS:

• Short bowel syndrome
• Intractable malabsorption
• Pre-operative preparation of patients who are undernourished
• Proven inflammatory bowel disease
• Following total gastrectomy
• Dysphagia
• Bowel fistulae
• Disease related malnutrition

The aim of ONS is to improve the overall nutritional intake in order to improve clinical outcomes. Prescribing for no clinical benefit is not appropriate. ONS should not be used as a substitute for food unless there is a clinical reason e.g. gut rest in inflammatory bowel disease.

A leaflet for patients and carers on ONS is available from BAPEN HERE
(http:/www.malnutritionpathway.co.uk/files/uploads/Nutrition_Drinks_2014.pdf)

LEEDS Oral Nutritional Supplements FIRST CHOICE LIST 2019

ONS Primary Care Prescribing Formulary – use in conjunction with 6 Steps to Appropriate Prescribing of ONS in Adults (18yr+)
*If patient has made positive change towards agreed goals after 1 month of food first alone, ONS is NOT indicated*

Milkshake Style & Savoury Soup

Juice Style

*flavours contain E120 a red food colouring called cochineal derived from insects 
** flavours contain traces of alcohol 

NOTE: Low volume products are in general, less palatable and should be reserved for patients unable to manage 200ml volume

Low Volume Milkshake Style

*flavours contain E120 a red food colouring called cochineal derived from insects
** flavours contain traces of alcohol

ALL OTHER ONS SHOULD NOT ROUTINELY BE INITIATED IN PRIMARY CARE AND SHOULD ONLY BE PRESCRIBED WHEN REQUESTED BY A DIETITIAN FOR CLINICAL REASONS

The reason these are not formulary products could be that they are:

• Lower calorie i.e. 1kcal/ml and not cost effective e.g. Ensure® cans, Fresubin® original
• Modular ONS which do not provide a balance of nutrients e.g. Pro-Cal shot, Calogen®, Fresubin® 5kcal Shot
• Specialist products e.g. for patients with renal disease, dysphagia, GI disorders
• Desserts – reserve for patients with dysphagia. Should usually be possible for homemade products to be fortified or full calorie dessert options e.g. mousse/trifle/custard available to buy from supermarket
• Less cost effective than formulary products

Prescribing & Reviewing ONS on discharge from Hospital:

• Not all patients commenced on ONS during their inpatient episode will have been referred for dietetic assessment, they may have required ONS whilst acutely unwell, but once home and eating normally the need may be negated
• It is recommended that ONS are not prescribed following hospital discharge without first re-
  assessing need or unless specifically requested by a dietitian
• If ONS are still required, a switch to first line community products is recommended unless otherwise requested on the discharge summary or dietetic discharge letter
• It is accepted that the like-for-like switches detailed in this first choice list are acceptable for the majority of patients
• Low volume products are, in general, less palatable and should be reserved for patients unable to manage 200ml volume
• Alternative ONS products may sometimes be recommended by dietitians where first line products are not sufficient to meet individual patients’ nutritional needs or are not suitable e.g. :

Contact the Leeds Community Nutrition & Dietetic Service or the dietitian who recommended the ONS if you have queries about other oral nutritional supplements

Counselling on preparing shakes with fresh milk:
Consider use of shakes providing the patient has access to a supply of whole milk and is physically able to (or carer etc) make up the shakes.

If additional counselling is required around the preparation of the shakes, the community pharmacist dispensing the prescription will be able to offer advice.

Over the counter products e.g. Complan®, Aymes® Retail, Nurishment® Meritene Energis®
Patients can purchase over the counter products if they do not wish to make fortified drinks or soups themselves.
Patients who do not meet ACBS prescribing criteria can also be advised to purchase supplements over the counter or prepare homemade nourishing drinks. Patients should be reviewed one month after being offered this advice to assess the progress with a ‘food first’ approach. If there is a positive change towards meeting goals, the changes should be encouraged and maintained and a further monthly review arranged until goals are met.

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DISEASE OR CONDITION SPECIFIC GUIDANCE

Obesity: malnutrition is a risk factor even for people who are overweight or obese if MUST criteria are met. Please note that if your patient has a BMI over 25 when you implement a nutrition plan, you would need to aim for a stable BMI rather than aiming to reduce their BMI to the healthy range as they are already in a compromised nutritional state.

Renal: Food First advice should not be used in patients with raised serum potassium or phosphate. Refer to specialist renal dietetic team. All powder based shakes mixed with milk will be higher in potassium and phosphate. Use in caution/on dietician advice only in patients with CKD (stages 4/5) or post AKI

Diabetes; see guidance below:

• Poorly controlled diabetes should be ruled out as the cause of weight loss. This could be due to raised blood glucose levels, frequent episodes of hypoglycaemia followed by high blood glucose levels after hypo treatments or a rising Hba1c.
• Investigate potential causes of elevated blood glucose e.g. infection, steroid use ,concurrent illness, under-treatment of diabetes, frequent episodes of hypoglycaemia followed by high blood glucose levels after hypo treatments
• In elderly people with diabetes minimise the risk of hypoglycaemia, if taking medication which could increase risk. Aim for blood glucose range 8-12mmol (Use hba1c to guide this if blood glucose is not routinely checked)
• Avoid sugary fizzy drinks, juices and sweets to minimise large fluctuations in blood glucose levels.
• Do NOT restrict puddings - these can be a good source of calories and protein if a patient's appetite is poor. The carbohydrate content of a piece of cake or a pudding is often similar to a main meal and may be enjoyed more
• If using nutritional supplements, juice-style products should NOT be prescribed first line
• Patients should be advised to sip any nutritional supplements slowly – to minimise large fluctuations in blood glucose levels
• Review weight, oral intake and glycaemic control after 1 month (or sooner if deemed that diabetes medication needs reviewing or as clinical condition dictates )
• Dietitian Referral criteria: Continued weight loss, or no weight gain, despite improved diabetes control.

Dysphagia: Patients with swallowing problems will require assessment by a Speech and Language Therapist before ONS can be safely prescribed and before dietetic input.

Severe Liver Disease, Inflammatory Bowel Disease and other Gastroenterology Patients under the care of hospital specialists: May require more specialised products because of altered metabolism, malabsorption etc. These patients should be referred to the LTHT Nutrition & Dietetic service for specialist assessment.

Eating Disorders: Patients should be referred to a specialist Eating Disorders Multidisciplinary Service via The Leeds Single Point of Access (SPA) (CONNECT: The West Yorkshire and Harrogate Adult Eating Disorders Service. Click HER to view website). View the exclusion/inclusion criteria on the referral & admissions tab on the first page. Tel: (0113) 855 6400). Other signposting links to consider are BEAT, The Retreat , Insight Eating and River Grange

Enterally (Tube) Fed Patients: These patients may already be under the care of a specialist dietitian, if so, check for further details re ONS or enteral feeds on correspondence from dietitian. Consider contacting the Home Enteral Feeding Team (Tel: (0113) 843 0892)

Pressure Ulcers: Patients should be referred to the Leeds Community Nutrition & Dietetic service if they require nutritional supplementation to support wound healing. MUST score 2 or above, or where it is evident that patients cannot meet their nutritional requirements via food first dietary advice.

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CARE HOMES AND ONS PRESCRIBING

Care Homes should provide adequate quantities of good quality food and a supportive environment so that the use of unnecessary ONS is avoided. ONS should not be used as a substitute for the provision of food. Care homes should be able to provide fortified foods and snacks and prepare homemade fortified milkshakes. Food fortifying care plans should be discussed with catering and care staff and inserted into the patient’s care plan to instruct on food fortification.

Practical guidance and nutritional guidelines for care homes is available from The Caroline Walker Trust ‘Eating well: Supporting older people and older people with dementia - Practical guide’
(http://www.cwt.org.uk/wp-content/uploads/2014/07/EW-Old-Dementia-Practical-Resource.pdf) provides simple guidance on what eating well really means, and to offer help and advice where there may be particular difficulties around eating, drinking or accessing food.

Eating and Drinking with Care’ training for care home staff is delivered regularly by LCH dietitians and SLTs – Email lchdieteticsadmin@nhs.net to register your interest in attending the next training
PrescQIPP NHS Midlands and East. Fabulous Fortified Feasts – a collection of fortified recipes, 2012.

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STEP 5 - REVIEWING AND DISCONTINUING ONS

Patients on ONS should be reviewed regularly, ideally every 1-3 months, to assess progress towards goals and whether there is a continued need for ONS on prescription. The
following parameters should be monitored:

• Weight/BMI/wound healing depending on goal set – if unable to weigh patient, record other measures to assess if weight has changed e.g. mid-upper arm circumference, clothes/rings/watch looser or tighter, visual assessment
• Changes in food intake
• Compliance with ONS and stock levels at home/care home

The establishment of a clear treatment plan at the outset enables the identification at which point prescribed supplements can be discontinued.

When conducting general medication reviews, ONS should be included as above.

Discontinuing prescriptions

When treatment goals are met, it is recommended ONS prescriptions are reduced in a staged approach. Follow up is essential to discontinue sub-therapeutic intake of ONS for extended periods e.g. 1 per day

When to stop ONS prescription:

• Goals of intervention have been met and patient is no longer at risk of malnutrition
• Patient has transitioned back to a normal diet, with satisfactory eating and drinking pattern and weight is acceptable
• If no further concerns and MUST score indicates no further clinical input required

How to stop ONS:

• Encourage oral intake and maximise nutritional intake. ‘Food First’ advice continues
• Consider staged reduction of ONS as oral diet intake increases (e.g. from 2 per day to 1 per day or from 3 per day to 2 per day) for 2 weeks and then reduce again/discontinue after further 2 weeks if appropriate

Follow up:

• Follow up is essential to discontinue sub-therapeutic intake of ONS for extended periods (>1 month, 1 per day)
• Review 1 month after discontinuation to ensure no recurrence
• If patient no longer meets ACBS criteria but wishes to continue ONS, recommend OTC products as in step 3

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STEP 6 - REFERRAL TO LEEDS COMMUNITY NUTRITION & DIETETIC SERVICE

The following patients are at very high nutritional risk and will require a full nutritional
assessment from a dietitian

• When ONS is the sole source of nutrition
• Dysphagia with MUST score 2
• Any grade of Pressure ulcer with MUST score 2
• On ONS for more than 3 months without the ability to transition to a normal diet to meet
  requirements
• MUST of 3 or above
• Malnourished or at risk of malnutrition with no improvement or progress towards agreed goals
  using the 6 steps to appropriate prescribing
• Risk of developing re-feeding problems: BMI of 16kg/m² or less or have had nothing for 5 days
  or little nutritional intake for the last 10 days or have lost more than 15% body weight within
  the last 3-6 months, NICE CG 32 Nutritional Support in Adults (excluding end of life, see p16
  palliative care)

SystmOne users will be able to refer electronically. A referral form is available on Leeds Health
Pathways or via the embedded document link below for non SystmOne users.

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PALLIATIVE CARE AND ONS PRESCRIBING

Use of ONS in palliative care should be assessed on an individual basis. Appropriateness of ONS will be dependent upon the patient’s health and their treatment plan. Emphasis should always be on the enjoyment of nourishing food and drinks and maximising quality of life. The Gold Standard Framework (GSF) is used to classify palliative care patients into three prognostic codes: green (6-12 months), amber (short/months), red (last days to short weeks).

Loss of appetite is a complex phenomenon that affects both patients and carers. Health and social care professionals need to be aware of the potential tensions that may arise between patients and carers concerning a patient’s loss of appetite. This is likely to become more significant through the palliative stages and patients and carers may require support with adjusting and coping. Weight loss due to cachexia is unlikely to be reversible. It is important to consider the benefits vs burden of recommending the nutritional strategies in this document.

The patient should always remain the focus of care. Carers should be supported in consideration of the environment, social setting, food portion size, smell and presentation and their impact on appetite.

http://www.goldstandardsframework.org.uk

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SUBSTANCE MISUSE

Substance misuse (drug and alcohol misuse) is not a specified ACBS indication for ONS prescription. It is an area of concern both due to the cost and appropriateness of prescribing.

For referrals to Forward Leeds Substance Misuse Services https://www.forwardleeds.co.uk/contact/

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