Managing Adult Malnutrition

Including a pathway for the appropriate use of
oral nutritional supplements (ONS)


News

From time to time we will publish relevant news articles on this section of the website. News and updates regarding the management of adult malnutrition in the community are published throughout the year in our PATHWAY NEWSLETTER


COMMUNITY HEALTHCARE PROFESSIONAL GUIDE LAUNCHED TO AID IN THE NUTRITIONAL MANAGEMENT OF PATIENTS DURING AND AFTER COVID-19 ILLNESS

19 June 2020

The Malnutrition Pathway team has created and launched GUIDANCE AND RESOURCES to assist healthcare professionals address nutritional issues of patients with COVID-19 who they may be supporting in the community.

The new guidance, which is endorsed by the British Dietetic Association (BDA), the Royal College of Nursing (RCN) and the British Association for Parenteral and Enteral Nutrition (BAPEN) highlights the importance of providing good nutritional care during this pandemic including suggestions for assessing and identifying nutritional issues when conducting remote consultations. It incorporates the recently updated information from BAPEN regarding subjective criteria that can be used to help form an overall clinical impression of an individual’s malnutrition risk category when weighing may not be feasible1.

The Community Healthcare Professional Guide to the Nutritional Management of Patients During and After COVID-19 Illness includes a care pathway which guides professionals to appropriate patient / carer leaflets according to the patient’s nutritional status and symptoms related to the COVID-19 infection.

With the recognition of a range of symptoms, social distancing and isolation that we know adversely affects dietary intake, the resources have been specifically designed to provide a range of ideas to help patient and carers deal with the array of factors that can affect metabolism and dietary intake during the COVID-19 infection, including advice on eating and drinking in the presence of coughing, breathlessness, loss of taste and smell, loss of appetite, fatigue, and at a time when social restrictions are affecting access to food.

“Professionals are likely to be seeing patients who have experienced serious COVID-19 illness in the community, whether they have been suffering at home or have returned home after a hospital stay” says Liz Anderson, Nutrition Nurse Specialist, Nurse Representative on the Malnutrition Pathway and BAPEN Executive Officer. “Those at risk of a severe COVID-19 infection, the elderly and those with multiple morbidities, people with lower socio economic status, are equally those in whom malnutrition is already prevalent.”

“Although COVID-19 is a new pandemic and data on the nutritional status during infection and in recovery is only beginning to emerge, it is evident from knowledge acquired to date, and parallels with conditions that present with similar symptoms and disease trajectory, that patients who have moderate to severe infections of COVID-19, are at risk of malnutrition and diet-related distress. If these issues remain unaddressed they can affect function, rehabilitation and quality of life” says Anne Holdoway, Consultant Dietitian, Chair of the Malnutrition Pathway and Chair of the BDA COVID-19 Clinical Guidance Group. “Patients who have spent a period in intensive care should as a minimum receive tailored nutritional advice from a registered dietitian. There are however many patients recovering in the community who for a variety of reasons may not have access to a dietitian in a timely manner. These new resources provide the toolkit to help members of the multidisciplinary team, including the physiotherapists supporting rehabilitation, provide dietary advice to aid recovery and refer to dietetics when necessary.”

Underlying malnutrition impairs the immune system2, potentially making people more vulnerable to infections such as COVID-19 and impacting recovery. Patients recovering from severe illness are likely to have muscle wasting or feel weak and may have increased protein needs3. In addition individuals who have been discharged from hospital may need ongoing nutritional rehabilitation.

Malnutrition left undetected and untreated can increase length of hospital stay, result in readmissions and impede recovery4, it is therefore fundamental to patient outcomes that nutritional screening and appropriate nutritional care are an integral component of holistic care for people who have or have had COVID-19 illness.

References
  1. British Association of Parenteral and Enteral Nutrition (BAPEN). Practical guidance for using ‘MUST’ to identify malnutrition during the COVID-19 pandemic: Malnutrition Action Group (MAG) update. May 2020 https://www.bapen.org.uk/pdfs/covid-19/covid-mag-update-may-2020.pdf
  2. Stratton RJ et al. Disease-related malnutrition: an evidence-based approach to treatment. Oxford: CABI publishing; 2003
  3. Deutz NE et al. Protein intake and exercise for optimal muscle function with aging: Recommendations from the ESPEN Expert Group. Clinical Nutrition. 2014; 33: 929-936.
  4. Elia M, on behalf of the Malnutrition Action Group (BAPEN) and the National Institute for Health Research Southampton Biomedical Research Centre. The cost of malnutrition in England and potential cost savings from nutritional interventions (full report). 2015. http://www.bapen.org.uk/pdfs/economic-report-full.pdf
  5. NB: Production of the COVID-19 Nutritional materials was made possible by an unrestricted educational grant from Nutricia Advanced Medical Nutrition.


    30 April 2020

    NEW INFORMATION LEAFLETS TO ADVISE THOSE WITH COVID-19 ILLNESS ON GOOD NUTRITION FOR RECOVERY

    While most people infected with COVID-19 will experience mild to moderate illness and recover without requiring special treatment, some may develop more serious illness. Older people and those with underlying medical problems like high blood pressure, heart disease, diabetes, chronic respiratory disease and cancer are more at risk of developing serious disease.

    There are no specific foods or vitamin or mineral supplements that will prevent you from catching COVID-19 and good hygiene practice remains the best means of avoiding infection. However, eating a well-balanced diet can help support the normal functioning of the immune system to help fight off infection.

    The Managing Adult Malnutrition in the Community team has worked with the British Dietetic Association (BDA) and the British Association for Parenteral and Enteral Nutrition (BAPEN) to develop a range of patient information leaflets to advise those who have COVID-19 illness, or who are recovering after the illness, on eating well to assist in their recovery.

    “Dietary advice for people who have or have had COVID-19 illness needs to be considered in relation to a number of factors including severity of their illness, any underlying conditions they have, whether their appetite has been affected and if they are overweight or underweight“ says Anne Holdoway, Consultant Dietitian. “One size does not fit all when it comes to diet and for this reason we have developed a number of different resources to enable people to access the dietary advice most suited to their need. For those who needed support on intensive care I would emphasise the need for individualised dietary advice by a registered dietitian.”

    Three different nutritional information leaflets have been developed, each tailored to the differing nutritional requirements of individuals who have been affected by COVID-19. The leaflets aim to help those who have had a mild/moderate illness and have been coping at home and also for those who have been in hospital with a more serious illness. THE LEAFLETS ARE FREE TO DOWNLOAD.

    A USEFUL TOOL has been developed on the website to enable people who have or have had COVID-19 to identify the nutritional advice leaflet that is most suitable to their needs

    “Fighting off infection can increase your body’s needs for energy, protein, vitamins and minerals, but being unwell can make it difficult to eat and drink enough”, says Liz Anderson, Nutrition Nurse Specialist, “because of this, you may need to think differently about you are eating and drinking. Those who have had a serious case of COVID-19 and particularly those leaving hospital may require additional dietary support in order to regain lost muscle mass. These leaflets offer practical nutritional advice for people who have been affected by the illness.”

    Nutritional information for people during and after COVID-19 illness

    The three leaflets include tips on for coping with symptoms related to COVID-19 illness and encouraging activity combined with good nutrition:

    GREEN LEAFLET - ‘Eating Well During and After COVID-19 Illness’

    An information leaflet about eating a balanced diet to help maintain your strength and fitness, as well as help your body fight infection

    YELLOW LEAFLET - ‘Improving your Nutrition During and After COVID-19 Illness’

    An information leaflet for those with a poor appetite and/or recent unintentional weight loss, including tips to help get the most from their food.

    RED LEAFLET - ‘Nutrition Support During and After COVID-19 Illness’

    An information leaflet for those who have been very unwell. Aimed at those who have recently been discharged from hospital after COVID-19 illness or who are struggling to eat enough and are underweight and/or have lost quite a bit of weight due to their illness. This information leaflet gives advice on increasing nutritional intake and how to incorporate oral nutritional supplements into the diet if they are prescribed.

    Information for those who have not had COVID-19 but are concerned about their nutritional health

    For individuals who have not had COVID-19 but are concerned about your overall nutritional health there are a number of LEAFLETS AVAILABLE to help you with healthy eating on the malnutrition pathway website

    The British Dietetic Association also offers advice on HEALTHY EATING DURING SOCIAL ISOLATION

    Anyone who is concerned about any aspect of their diet or any symptoms of their illness should speak to a healthcare professional for further advice.

    NB: Production of the COVID-19 Nutritional materials was made possible by an unrestricted educational grant from Nutricia Advanced Medical Nutrition.

    • Anne Holdoway, Consultant Dietitian is:
    • • Chair of the Managing Adult Malnutrition in the Community and Managing Malnutrition in COPD panels
    • • Chair of the British Dietetic Association (BDA) COVID-19 Clinical Guidance Group
    • • Education Officer for the British Association of Parenteral and Enteral Nutrition (BAPEN)
    • Liz Anderson, Nutrition Nurse Specialist is:
    • • Nurse member of the Managing Adult Malnutrition in the Community and Managing Malnutrition in COPD panels
    • • Executive Officer at the British Association of Parenteral and Enteral Nutrition (BAPEN)
    Archived news items
    • Updated guidance: combat malnutrition in patients with COPD
      Updated guidance to help combat malnutrition in patients with COPD

      With research showing that around 1 in 3 inpatients1 and 1 in 5 outpatients2 with Chronic Obstructive Pulmonary Disease (COPD) are at risk of malnutrition, the ‘Managing Malnutrition in COPD’ multi-professional panel has updated its guidance for healthcare professionals and supporting patient information leaflets. It is hoped that the document based on clinical evidence, clinical experience and best practice will raise awareness amongst the multi-disciplinary team of incorporating nutrition screening and nutritional care into management pathways for patients with COPD.

      The causes of malnutrition in patients with COPD are varied and include not only the physiological effects of the disease such as breathlessness and fatigue interfering with appetite and the ability to eat but also psychological, social and environmental factors such as depression, social isolation and living conditions. In addition, individuals with COPD may have increased energy requirements arising from systemic inflammation and increased effort associated with breathing. Malnutrition can develop over several years or be precipitated and continue following an acute exacerbation. Sarcopenia (loss of skeletal muscle mass and strength) affects 15% of patients with stable COPD and impairs function and health status3. In addition, nearly a quarter of all individuals with COPD will develop cachexia (loss of lean tissue mass due to chronic illness)4.

      The consequences of malnutrition in COPD are significant and contribute to increased healthcare useage and costs, higher mortality, longer hospital stays, more frequent readmissions as well as reduced muscle strength and respiratory muscle function5-14.

      ‘Managing Malnutrition in COPD’

      ‘Managing Malnutrition in COPD’ is a practical guide that aims to assist healthcare professionals in identifying and managing people with COPD who are at risk of disease-related malnutrition and includes a pathway for the appropriate use of Oral Nutritional Supplements (ONS) to support community healthcare professionals. The second edition has been updated to include guidance from NICE NG115 Chronic obstructive pulmonary disease in over 16s: diagnosis and management)15 and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy16 as well as including revised guidance on energy and protein requirements for patients with COPD17-19 and advice on nutritional intervention alongside pulmonary rehabilitation programmes which have been found to be associated with improved patient outcomes15, 20-23.

      The first edition of the guidance was launched in 2016 and it complements the ‘Managing Adult Malnutrition in the Community’ guidelines (www.malnutritionpathway.co.uk)24 which were launched in 2012.

      Patient leaflets

      The guidance is accompanied by three complementary colour-coded patient leaflets all of which contain dietary advice, advice on eating and physical activity. They also contain tips on coping with common symptoms of COPD including dry mouth, taste changes and shortness of breath. In addition the red (high risk) leaflet includes advice for patients on incorporating oral nutritional supplements into their diet. The three leaflets are:

      • GREEN LEAFLET – ‘Eating Well for Your Lungs’ – for patients at low risk of malnutrition
      • YELLOW LEAFLET – ‘Improving Your Nutrition in COPD’ – for patients at medium risk of malnutrition
      • RED LEAFLET – ‘Nutrition Support in COPD’ – for patients at high risk of malnutrition
      • ‘Managing Malnutrition in COPD’ and the complimentary patient leaflets have been developed by a multi-professional panel, with expertise and an interest in malnutrition and COPD, and is endorsed by ten key professional and patient organisations including the British Dietetic Association (BDA), The British Association For Parenteral And Enteral Nutrition (BAPEN), the Association of Respiratory Nurse Specialists (ARNS), the British Lung Foundation (BLF), the Royal College of Nursing (RCN) and the Royal College of General Practitioners (RCGP)25. The document is based on clinical experience and evidence alongside accepted best practice. All materials can be downloaded for free HERE

        What the experts say about ‘Managing Malnutrition in COPD’

        “Patients with COPD are particularly susceptible to loss of muscle mass so dietary advice is paramount and in many cases nutritional interventions may be necessary to ensure loss of weight and muscle mass are minimised particularly when patients are undergoing acute exacerbations,” says panel member Dr Peter Collins, Registered Dietitian and Senior Lecturer in Nutrition & Dietetics. “By working closely with the multi-professional team we can make sure that patients at risk of malnutrition are identified and that an appropriate nutritional care plan is put in place whilst ensuring and that those who require a more detailed dietetic assessment are referred on to the Dietitian. I hope that these guidelines will raise awareness of the importance of nutritional intervention in patients with COPD and assist healthcare professionals in incorporating nutrition screening and management advice into the care pathway of patients with COPD.”

        “I think GPs are becoming aware of the role that good nutrition plays in achieving better disease outcomes but it is not routinely seen as a priority to incorporate nutrition into treatment plans” says panel member Dr Anita Nathan, General Practitioner/Member of the GPs Interested in Nutrition Group. “With growing numbers of elderly patients and those with multi-morbidities we are going to see a larger group of malnourished patients in our surgeries. We therefore need to work more closely with our dietetic colleagues to ensure nutrition screening and monitoring is integrated into current pathways of care, particularly targeting high risk groups, such as patients with COPD. I hope that these guidelines will assist GPs and other members of the primary care team to facilitate better care for our patients.”

        “ARNS has been delighted to be involved with the development and update of these guidelines” says Joanne King, Consultant Respiratory Nurse and panel representative for the Association of Respiratory Nurse Specialists (ARNS). “The first edition of the guidelines and the complimentary patient leaflets have been taken up widely by respiratory nurses across the UK and I hope they will find the updates in the guidance of assistance. By engaging with the multi-professional team in identifying and treating malnutrition we can offer continuity of nutritional care for patients leading to better outcomes and quality of life for patients.”

        “Pulmonary rehabilitation plays a key role in the management of individuals with COPD and research suggests that if we can incorporate nutrition intervention alongside exercise programmes we get improved patient outcomes” says Sally King, Respiratory Specialist Physiotherapist and member of the ‘Managing Malnutrition in COPD’ panel. “It is important that we work closely with our dietetic colleagues and the multi-professional team to identify and treat malnutrition to ensure a better quality of life for patients. I hope this guidance will assist physiotherapists in giving appropriate dietary information to support the effectiveness of exercise programmes in patients who are malnourished.”

        NB: Production of the ‘Managing Malnutrition in COPD’ materials was made possible by an unrestricted educational grant from Nutricia Advanced Medical Nutrition

        References

        1. Steer J et al. P117 Comparison of indices of nutritional status in prediction of in-hospital mortality and early readmission of patients with acute exacerbations of COPD. Thorax. 2010; 65(4): A127-A.

        2. Collins PF et al. Prevalence of malnutrition in outpatients with chronic obstructive pulmonary disease. Proc Nut Soc. 2010; 69(Issue OCE2): E148

        3. Jones et al. Sarcopenia in COPD: prevalence, clinical correlates and response to pulmonary rehabilitation. Thorax 2015;70 (3).

        4. Wagner PD. Possible mechanisms underlying the development of cachexia in COPD. ERJ 2008; 31: 492-501

        5. Collins PF et al. An economic analysis of the costs associated with weight status in chronic obstructive pulmonary disease (COPD). Proc Nut Soc. 2011; 70(OCE5): E324

        6. Ezzell L and Jensen GL. Malnutrition in chronic obstructive pulmonary disease. Am J Clin Nut. 2000;72(6):1415-16

        7. Gupta B et al. Nutritional status of chronic obstructive pulmonary disease patients admitted in hospital with acute exacerbation. J Clin Med Res 2010 Mar 20;2(2):68-74

        8. Collins PF et al. ‘MUST’ predicts 1-year survival in outpatients with chronic obstructive pulmonary disease. Clin Nutr. 2010;5(2): 17.

        9. Collins PF et al. The impact of malnutrition on hospitalisation and mortality in outpatients with chronic obstructive pulmonary disease. Proc Nutr Soc 2010; 69(OCE2)

        10. Landbo C et al. Prognostic value of nutritional status in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999; 160(6):1856-1861.

        11. Vestbo J et al. Body mass, fat-free body mass, and prognosis in patients with chronic obstructive pulmonary disease from a random population sample: findings from the Copenhagen City Heart Study. Am J Respir Crit Care Med 2006; 173(1):79-83.

        12. Vermeeren MA et al. Prevalence of nutritional depletion in a large outpatient population of patients with COPD. Respir Med, 2006 Aug;100(8):1349-55

        13. Ingadottir AR et al. Two components of the new ESPEN diagnostic criteria for malnutrition are independent predictors of lung function in hospitalized patients with chronic obstructive pulmonary disease (COPD). Clinical Nutr 2018; 37(4): 1323-1331

        14. Ingadottir AR et al. Association of energy and protein intakes with length of stay, readmission and mortality in hospitalised patients with chronic obstructive pulmonary disease. Br J Nutr 2018; 119(05): 543-551

        15. National Institute for Health and Clinical Excellence (NICE) Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE Guideline NG115. Dec 2018 https://www.nice.org.uk/guidance/ng115/chapter/Context

        16. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2019. https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf

        17. Gandy J. Manual of Dietetic Practice. 6th Ed. Blackwell Publishing; 2019.

        18. Parenteral and Enteral Nutrition Group (PENG). Pocket Guide to Clinical Nutrition. British Dietetic Association (BDA). 2019.

        19. Bauer J et al. Evidence-based recommendations for optimal dietary protein intake in older people: A position paper from the PROT-AGE study group.J Am Med Dir Assoc. 2013; 14(8): 542–559.

        20. Collins PF et al. Nutritional support and functional capacity in chronic obstructive pulmonary disease: a systematic review and meta-analysis.Respirology 2013; 18:616-629.

        21. Sugawara K et al. Effects of nutritional supplementation combined with low intensity exercise in malnourished patients with COPD. Resp Med. 2010 Dec;104(12):1883-9

        22. Van Wetering CR et al. Efficacy and costs of nutritional rehabilitation in muscle-wasted patients with chronic obstructive pulmonary disease in a community-based setting: a pre-specified subgroup analysis of the INTERCOM trial. J Am Med Dir Assoc. 2010 Mar;11(3):179-87

        23. Schols AM et al. Nutritional assessment and therapy in COPD: a European Respiratory Society statement. Eur Respir J 2014; 44:1504-1520

        24. Managing Adult Malnutrition in the Community. Holdoway A. (panel chair). 2012. United Kingdom. www.malnutritionpathway.co.uk

        25. The ‘Managing Malnutrition in COPD’ document and supporting patient materials have been supported by 10 key professional and patient associations:

        • The Association of Chartered Physiotherapists in Respiratory Care (ACPRC)
        • The Association of Respiratory Nurse Specialists (ARNS)
        • The British Association For Parenteral And Enteral Nutrition (BAPEN)
        • The British Dietetic Association (BDA)
        • The British Lung Foundation (BLF)
        • Education for Health
        • The National Nurses Nutrition Group (NNNG)
        • The Primary Care Respiratory Society (PCRS)
        • The Royal College Of General Practitioners (RCGP)
        • The Royal College Of Nursing (RCN)

        In addition the guidance also includes the following NICE endorsement statement:

        ‘This guide (www.malnutritionpathway.co.uk/copd) accurately reflects some of the recommendations on malnutrition in the NICE guidelines on nutrition support in adults (www.nice.org.uk/Guidance/CG32) and chronic obstructive pulmonary disease in over 16s (www.nice.org.uk/guidance/ng115). It also supports statements 1,3 and 5 in the NICE quality standard for nutrition support in adults (www.nice.org.uk/guidance/qs24). This resource is intended for use with adults and not children.

        National Institute for Health and Care Excellence. Renewed, December 2019

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