Malnutrition: A Community Multi-Disciplinary Approach

This article was published in NHD Magazine, August/September 2016 issue.

Malnutrition is a significant issue in the UK which has been gaining more attention since the release of the NHS England Guidance in October 2015 “Commissioning Excellent Nutrition and Hydration 2015 – 2018”¹.

In the UK malnutrition is thought to affect more than three million people at any given time, malnutrition costs the government in excess of £13 billion per year and it has been found that malnourished patients require roughly twice as many healthcare resources than adequately nourished patients^2,3. Of those at risk or affected by malnutrition, 93% are living in the community, 5% are found in care homes and 2% are found in hospital ¹. On an individual level the consequences of malnutrition can be devastating and can result in a considerably impaired quality of life (see ‘Consequences of Malnutrition’ below).

Part of my current role (at the time of writing this article) involves working in a close MDT within a community setting. I have found this to be extremely useful when treating malnourished patients as the root causes of malnutrition can be multi-factorial (see ‘Causes of Malnutrition’ below); therefore a holistic approach to treatment tends to improve health outcomes in a patient centered way.

Table adapted from the Manual of Dietetic Practice 5^th edition.

The Role of the Dietitian

Dietitians are evidently the key health care professionals involved in the treatment of malnutrition as we provide expert knowledge into the aetiology of malnutrition, stay up to date with relevant evidence based guidelines and utilise specific skills of nutritional assessment prior to formulating an individual treatment plan for the malnourished patient.

Due to financial constraints, reduced staffing levels can contribute to increased caseload demands; therefore it is also vital that Dietitians are involved in training other health care workers so that patients are adequately screened for malnutrition risk in the community. Appropriate screening improves the quality of dietetic referrals, therefore maximising resources, and also assists in appropriate caseload prioritisation. Improving nutritional screening is a national priority as the National Institute for Clinical Excellence (NICE) report that: “improving the identification and treatment of malnutrition is estimated to have the third highest potential to deliver cost savings to the NHS”⁴.

The Role of the GP

The GP is often the first point of contact for malnourished individuals, with roughly 10% of patients attending GP practices being affected by malnutrition⁵, therefore their role in identifying this and appropriately referring to Dietetics is crucial.

There are various approaches to screening and managing malnutrition in the community; some NHS Trusts use guides such as the ‘Managing Adult Malnutrition in the Community’ document⁵ or other Trust specific management pathways. In terms of medicines management, liaising with pharmacists based at GP surgeries can also be very useful.  The GP often plays a key role in treating the underlying reasons for malnourishment such as: chronic illness, nausea or constipation. Furthermore, communication with GPs can be essential in order to rule out medical red flags, as weight loss is often a warning sign or symptom of an underlying condition.

Although nutrition is currently a core part of junior doctor’s first year medical training; further training at GP level may be useful in some areas to highlight the importance of Dietetic treatment for malnourished patients.

The Role of Nurses and Health Care Assistants (HCAs)

Monitoring for malnutrition is supported by the Royal College of Nurses (RCN) principles of nursing⁶.  As 35% of patients admitted to care homes have been reported to be affected by malnutrition in the UK¹, Nurses and HCAs perform the vital role of monitoring for malnutrition and carrying out nutritional screening in this setting. Nursing staff also have frontline daily interactions with patients which fosters an important understanding of the patient’s overall condition including nutritional factors such as: bowel habits, mood, skin integrity, weight history, food preferences, ability to self-feed and current oral intake.

In a care home setting the importance of working closely with catering staff as well as nursing staff shouldn’t be underestimated, as the catering team can provide fortified meal options presented in a palatable manner to maximise the nutritional intake of the residents.

Liaising with specialist nurses such as Tissue Viability Nurses and Diabetes Specialist Nurses and can also be vital when managing risks associated with malnutrition such as poor skin integrity or altering insulin regimens when carbohydrate intake has reduced. Where malnourished individuals live in their own home District Nurses can be a useful point of contact.

The Role of Speech and Language Therapy (SALT)

SALT have a fundamental role in assessing a patient’s swallowing function in order to recommend the safest texture for diet and fluid intake. In some cases this can promote nutritional intake via ease of ingestion, however in other cases texture modified diets can be found unpalatable. In cases where an individual doesn’t have a safe route for oral feeding, decisions need to be made between the patient, family members, GP, SALT and Dietetics to determine whether enteral feeding or pragmatic oral feeding recommendations in acceptance of aspiration risks are in the patients best interests. Working with SALT to ensure maximum fortification of texture modified options can greatly increase a patient’s nutritional intake.

Where appropriate SALT can provide dysphagia therapy to help to improve a patient’s swallow function; studies have found that this can significantly improve nutritional intake⁷.

If a patient has communication difficulties SALT communication therapy can be a vital aspect of improving a patient’s mood which may in turn result in an improved appetite. Use of communication aids as advised by SALT can also be very useful to improve the exchange of information as part of nutritional care planning.

The Role of Occupational Therapy (OT)

OT’s involvement in supporting meaningful engagement in activities can greatly affect an individual’s mood and enthusiasm levels which can have a positive effect on appetite.

From a functional point of view, strategies and equipment to improve self-feeding and independent meal preparation can greatly enhance a person’s overall intake. Examples of specific feeding equipment include: easy-grip cutlery, non-slip mats, keep warm plates and deep rimmed plates. Enjoyment related to eating and drinking can be increased by modifying the dining environment by providing pleasant tablecloths, ensuring tables are an appropriate height, limiting background noise and encouraging a social environment for meal times.

Issues with memory and cognition may impair meal planning and preparation, therefore strategies for meal scheduling can also be really useful when individuals are struggling in this respect.

The Role of Psychology

As there is a well-established connection between food and mood, and a strong correlation between depression and malnutrition in specific^8,9, working with clinical psychologists can be extremely useful in terms of resolving malnutrition when mental health issues are present.

Training provided by psychologists for dietitians in techniques related to behaviour change such as motivational interviewing and cognitive behavioural therapy can be invaluable for improving patient interaction and helping patients to implement important lifestyle changes, including prioritising their nutritional intake.

The Role of Physiotherapy

Nutrition and physical function go hand in hand, as a poor nutritional status can lead to muscle wasting and low energy levels which can impair mobility, increase falls risk and impair engagement in physiotherapy. Equally, poor mobility and movement can impair a patient’s mood, independence and ability to self-feed which can lead to an impaired appetite and nutritional status.

Furthermore, physiotherapy recommendations for transfers and mobility are important to be aware of when deciding the most appropriate method of monitoring a patient’s anthropometry; such as deciding which type of weighing scales to use or opting to monitor hand grip strength or mid-upper arm circumference for bed bound patients.

The Role of Social Work

Liaising with social work can be important in order to improve an individual’s level of support with activities of daily living including meal provision and assistance with feeding. Living in a safe, well supported and positive environment with a suitable care package in place promotes the best possible setting to maximise nutritional outcomes. Carers can also provide insightful information into a patient’s food preferences and eating habits in order to improve their dietary intake.

Conclusion

There is a vast network of support available for malnourished patients from a variety of healthcare professionals in the community. It is essential that Dietitians are aware of scope of each professional’s role and how we can work together synergistically as part of an MDT with the ultimate aim of tackling malnutrition in the community and improving our patients’ overall wellbeing and quality of life.

References:

1. NHS England “Commissioning Excellent Nutrition and Hydration (2015-2018)” https://www.england.nhs.uk/wp-content/uploads/2015/10/nut-hyd-guid.pdf
2. Elia M and Stratton RJ (2009) “Calculating the cost of disease-related malnutrition in the UK in 2007 (public expenditure only) in: Combating Malnutrition” BAPEN. http://www.bapen.org.uk/pdfs/reports/advisory_group_report.pdf
3. Guest et al. (2011) “Health economic impact of managing patients following a community-based diagnosis of malnutrition in the UK” http://www.ncbi.nlm.nih.gov/pubmed/21406315
4. National Institute for Clinical Excellence (NICE). Nutrition Support in Adults (32) Cost Saving Guidance (2011) http://publications.nice.org.uk/nutrition-support-in-adults-cg32/guidance
5. Brotherton et al. (2012) “Managing Adult Malnutrition in the Community” http://malnutritionpathway.co.uk/downloads/Managing_Malnutrition.pdf
6. RCN “Principles of Nursing Practice” Accessed 2016 via: https://www.rcn.org.uk/professional-development/principles-of-nursing-practice
7. Sura et al. (2012) “Dysphagia in the elderly: management and nutritional considerations” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3426263/
8. Pereira et al. (2014) “Malnutrition among cognitively intact, non-critically ill older adults in the emergency department”. Annals of Emergency Medicine, 65(1), 85–91.
9. Yoshimura et al. (2013) “Relationship between depression and risk of malnutrition among community-dwelling young-old and old-old elderly people”.