Often these issues and their solutions are complex and multifactorial and need a multidisciplinary discussion
Daily reference intakes for adults are
- Energy: 8,400kJ/2,000kcal
- Total fat: less than 70g
- Saturates: less than 20g
- Carbohydrate: 260g
- Total sugars: 90g
- Protein: 50g
- Salt: less than 6g
- BMI is < 18.5
- BMI is < 20 with unintentional weight loss of > 5% in the last 3-6 months
- If BMI is < 20 with unintentional weight loss of > 10% in the last 3-6 months
- Ability to chew (any issues with dentition) and swallowing issues
- Total food and drink intake
- Physical symptoms e.g. pain, vomiting, constipation, diarrhoea, oral thrush, wound
- Impact of medication (consider taste changes/any that may suppress appetite)
- Medical prognosis (appropriate intervention)
- Environmental and social issues, Psychological issues
- Substance or alcohol misuse
- Is the patient frail and reaching end of life
- These should be documented and agreed with patients.
- Goals should be realistic and measurable and may include:
- Target weight, target weight gain or target BMI over a period of time
- Weight maintenance where weight gain is unrealistic or undesirable
- Reduced rate of weight loss where weight maintenance is not realistic (e.g. cancer cachexia, end of life care)
- Improvement in oral nutritional intake
- Optimising nutritional intake during acute illness
- Wound healing if relevant
- Biochemical, functional, psychological or behavioural symptoms e.g.improvement in strength, physical appearance, appetite, ability to perform activities of daily
Measure height and weight to get a BMI score using the chart provided.
If unable to obtain
height and weight, use the alternative procedures shown in this guide.
||BMI kg/m2 (weight divided by height squared)
>20 (>30 Obese)= 0
Note percentage unplanned weight loss and score using tables provided.||Unplanned weight loss in 3-6 months
||Establish acute disease effect and score.
||If patient is acutely ill and there has been or is likely to be no nutritional intake for >5 days Score 2
Add scores from steps 1, 2 and 3 together to obtain the overall risk of malnutrition.
||Add Scores together to calculate overall risk of malnutrition
Score 0 Low Risk
Score 1 Medium Risk
Score 2 or more High Risk
Use management guidelines and/or local policy to develop a care plan
0:Low risk - routine clinical care
1:Medium Risk: observe - document intake and continue to monitor
2 or more: High risk so involve dietitian, set goals, ensure nutritional support.
Managing Weight loss
- Baseline weight and history of weight, diet sheets recording intake
- Exclude dietary intake/dementia/ environmental limits to food, Alcoholism, malabsorption
- Able to swallow
- Encourage Oral Intake and offer supplements
- Full fat milk and high calorie food
- Tasty familiar foods, ensure no dental issue
- Consider steroids to boost appetite
- Treat depression - Mirtazepine etc even ECT
- Encourage snacking
- involve family and staff in protecting and supporting feeding time
- Unable to swallow (Enteral means uses gut)
- Nasogastric tube (Enteral) is useful as a temporary measure. Risks are still aspiration of gastric contents and resiteing tube in wrong place.
- Percutaneous endoscopic gastrostomy (enteral) usually when feed needed for more than 30 days
- Unable to use the Gut
- Parenteral feeding is higher risk with increased risk of significant complications. Enteral should always be the first line for those with a functioning gut. Consider either Central venous line insertion usually via infraclavicular subclavian vein or via via large peripheral line in the mid arm.
- Cautions "at risk feeding" in those entering the dying phase. The aim is for comfort and allowing patient to eat and drink as they wish.