Christine Russell SRD on behalf of MAG

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Christine Russell SRDon behalf of MAG
Identification of Malnutrition using the
Malnutrition Universal Screening Tool ( MUST)
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Kings Fund Report (1992)

• only when the assessment of every patients
  nutritional status has become routine will the
  full benefits of nutrition treatment be realised

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Understanding malnutrition

• No universally accepted definition but the
• following working definition is suggested
• A state of nutrition in which a deficiency or
  excess (or imbalance) of energy, protein and
  other nutrients causes measurable adverse effects
  on tissue/body structure and function and
  clinical outcome

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Malnutrition is undetected and untreated

• Hospitals inpatients
• 70 unrecognised (Kelly et al, 2000)
• 62 unrecognised (Mowe et al 1991)
• Hospital outpatients
• 45-100 of patients unrecognised (Miller et al
  1990)
• Nursing homes Almost 100 of patients
  unrecognised (26 nursing homes) (Abbasi Rudman
  1990)
• Community e.g 15-50 of children with failure to
  thrive are unrecognised (Wright et al 1998
  Bachelor 1990)

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Prevalence of malnutrition

• underweight adults (BMIlt20kg/m2 ) living freely
  in the community, hospital residential
  accommodation Elia/MAG 2003
• General population
• England 5.2
• Scotland 5.5
• Wales 5.0
• Patients in the community
• Major surgery previous 6 wks gt10.6
• Chronic diseases 12.2
• Residential accommodation
• In UK gt65 yrs 16.0
• In Scotland gt65yrs 29.0
• Hospital 13-40

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Percentage of people aged 65 at medium/high
risk of malnutrition
North England 19.4
Central England 12.3
Wales 11
South England 11.3
Source further analysis of 1998 NDNS Survey data
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Consequences of malnutrition

• Increased morbidity
• Increased length of stay
• Increased dependency
• Increased mortality
• Increased costs of care

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Increased health care utilisation with
malnutrition risk (Stratton et al 2002)
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Financial issues

• Up to 266m (1992 figs) could be saved by NHS
  each year if malnourished patients identified and
  treated
• Malnutrition in patients gt65yrs costs 2-4b more
  than well nourished elderly
• Malnourished elderly more likely to be admitted
  to hospital and discharged to nursing homes
• Undernutrition costs NHS more than obesity

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Why screen for malnutrition?

• Malnutrition is frequently unrecognised and
  untreated
• Effective management of malnutrition reduces the
  burden on health care resources
• Regular screening is the only way that
  malnourished individuals can be identified and
  appropriate action taken

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What has this got to do with me?

• Nutrition/malnutrition now a priority in policy
  initiatives and practice
• 1992 A Positive approach to nutrition as
  treatment (King Fund Centre)
• 1996 Malnutrition in Hospital (BDA)
• 1997 Eating Matters (DH)
• 1997 Hungry in Hospital (Ass Community Health
  Councils)
• 2000 Managing Nutrition in Hospital a recipe for
  quality (DH)
• 2000 Detection and Management of Malnutrition
  (BAPEN)
• 2001 The National Service Framework for Older
  People (DH)
• 2001 Essence of Care (DH)
• 2001 Acute Hospital Portfolio Hospital Catering
  report (DH)
• 2001 National Nutritional Audit of Elderly
  Individuals in Long-term Care (Scottish
  Executive CRAG)
• 2001 National Care Standards Commission /
  National Minimum Standards for Older People in
  Care Homes (DH)
• 2002 Food and Nutritional Care in Hospitals how
  to prevent undernutrition (Council of Europe)
• 2002 Nutrition patients a doctors
  responsibility (Roy Col Phys)
• 2002 Improving Health in Wales, Nutrition and
  Catering Framework. (WAG)
• 2003 Food , Fluid and Nutritional Care in
  Hospitals (NHSQIS)
• 2004 PEAT (DH)

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What has this got to do with me?

• Nutrition/malnutrition now a priority in policy
  initiatives and practice
• 1992 A Positive approach to nutrition as
  treatment (King Fund Centre)
• 1996 Malnutrition in Hospital (BDA)
• 1997 Eating Matters (DH)
• 1997 Hungry in Hospital (Ass Community Health
  Councils)
• 2000 Managing Nutrition in Hospital a recipe for
  quality (DH)
• 2000 Detection and Management of Malnutrition
  (BAPEN)
• 2001 The National Service Framework for Older
  People (DH)
• 2001 Essence of Care (DH)
• 2001 Acute Hospital Portfolio Hospital Catering
  report (DH)
• 2001 National Nutritional Audit of Elderly
  Individuals in Long-term Care (Scottish
  Executive CRAG)
• 2001 National Care Standards Commission /
  National Minimum Standards for Older People in
  Care Homes (DH)
• 2002 Food and Nutritional Care in Hospitals how
  to prevent undernutrition (Council of Europe)
• 2002 Nutrition patients a doctors
  responsibility (Roy Col Phys)
• 2002 Improving Health in Wales, Nutrition and
  Catering Framework. (WAG)
• 2003 Food , Fluid and Nutritional Care in
  Hospitals (NHSQIS)
• 2004 PEAT (DH)

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Prevalence of malnutrition using different tools
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Definitions

• Nutritional screening
• Rapid, simple general procedure done at first
  contact with subject to detect risk of
  malnutrition, done by nurses, doctors or other
  HCWs
• Nutritional Assessment
• Detailed, more specific in depth evaluation of
  subjects nutritional status, done by those with
  nutritional expertise

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The Malnutrition Advisory Group (MAG)

• The Malnutrition Advisory Group (MAG) is an
  independent standing committee of BAPEN
• Formed in 1998 with a multidisciplinary
  membership of healthcare professionals

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Aims of the MAG

• Raise awareness of malnutrition among health and
  social care professionals, policy makers and the
  media
• Ensure health social care professionals give
  priority to combating malnutrition
• Communicate the benefits of timely use of
  nutritional supplements
• Develop a screening tool produce definitive
  guidelines for the detection and management of
  malnutrition

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Why is screening a MUST?Malnutrition Universal
Screening Tool

• To provide a validated, reliable, and practical
  tool for nutritional screening
• To develop a tool to allow comparable nutritional
  screening across different care settings by
  different health professionals
• To identify individuals who are undernourished or
  obese

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Development of the MUST

• The MAG community screening tool (launched in
  2000) adapted and extended to care homes and
  hospitals
• Validated and piloted across all care settings
• Alternative methods of measurement determined
• Field tested for overall look and use-ability

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Where the MUST can be used
THE COMMUNITY
ACUTE
Emergency or routine admission
Routine monitoring/ discharge planning
HOME VISITS
Screening can be undertaken by any member of the
multidisciplinary team
Assessments
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Components of MUST

• Flow chart visual layout of procedure
• BMI chart and weight loss tables showing clearly
  the risk scores
• Alternative measurements
• Explanatory notes
• Evidence based, referenced report

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Malnutrition Universal Screening Tool (
Schematic )
Step 1 BMI
Step 2 Weight loss
Step 3 Acute disease score
Subjective criteria
Step 4 Overall Risk Of Malnutrition
0 Low risk
1 Medium Risk
2 or more High Risk

• Step 5
• Consider using suggested management guidelines
• Reassess risk category as subject moves through
  care settings

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The 5 MUST Steps

• Body Mass Index (BMI) Score height and weight
• Weight Loss Score - unplanned weight loss in past
  3-6 months
• Acute Disease Effect Score
• Overall Risk of Malnutrition - Add Scores
• Results 0 low risk 1 medium risk 2 or
  more high risk
• Subjective judgement if measurements not
  possible
• 5. Recommended Management Guidelines to form
  appropriate care plan in line with local policy

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BMI (kg/m2)

• Indicates chronic protein-energy status
• Protein-energy malnutrition is probable at a
  BMI lt18.5 kg/m2 and possible at a BMI of
  18.5-20.0 kg/m2
• Adverse physiological and clinical effects occur
  with a BMI lt20 kg/m2
• BMI is a simple, objective and reproducible
  measurement
• ? Age specific

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BMI categories for chronic protein energy status
Roy Coll Phys Lond, MAG(BAPEN)

• BMI (kg/m2 ) Weight category
• --------------------------------------------------
  ------------
• lt18.5 Underweight (probable PEM)
• 18.5-20 Underweight (possible PEM)
• 20-25 Desirable weight
• 25-30 Overweight
• gt30 Obese
• PEM Protein-Energy Malnutrition

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Step 1 BMI

• Obtain weight and height
• Calculate BMI or use BMI chart provided to get
  score
• Use recalled height and weight or recommended
  alternative methods of measurement if actual
  values cannot be obtained

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BMI Score

• BMI Score
• gt20 kg/m2 0
• 18.5-20 kg/m2 1
• lt18.5 kg/m2 2
• gt30 kg/m2 ( obese ) 0

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Unintentional weight loss over 3-6 months

• lt5 body weight normal intra-individual
  variation
• 5-10 body weight of concern
• decrease in voluntary physical activity
• increase in fatigue
• less energetic
• gt10 body weight of significance
• changes in muscle function
• disturbances in thermoregulation
• poor response or outcome to surgery and
  chemotherapy

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Step 2 Weight Loss Score Unplanned weight loss
over 3 6 months

• Indicates acute or recent-onset malnutrition
• Score
• lt5 body weight 0
• 5-10 body weight 1
• gt10 body weight 2

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Step 3 Acute Disease Effect

• Patients who have had or are likely to have no
  nutritional intake for more than 5 days
• Most likely to apply to patients in hospital
• Add 2 to score

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Step 4 Overall Risk of Malnutrition

• Total of scores from Steps 1, 2 and 3
• Document score
• 0 Low risk
• 1 Medium risk
• 2 or more High risk

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Alternative measurements
Estimating height from ulna length
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BMI Category
Estimating BMI from mid upper arm circumference
(MUAC)
If MUAC is lt23.5 cm, BMI is likely to be lt20
kg/m2 If MUAC is gt32.0 cm, BMI is likely to be
gt30 kg/m2
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Subjective Criteria

• If height or weight cannot be obtained, consider
  the following subjective criteria
• BMI
• Is subject , thin acceptable weight or
  overweight?
• Weight loss
• Are clothes or jewellery loose?
• Has there been a change in appetite?
• Any swallowing difficulties?
• Underlying disease or psychosocial / physical
  disabilities
• Acute disease
• No nutritional intake gt5 days

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The old ones are the best
It is not for the sake of piling up
miscellaneous information or curious facts, but
for the sake of saving life and increasing health
and comfort
F Nightingale 1859
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Step 5 Recommended management guidelines

• Low risk
• Repeat screening ( weekly,monthly,annually)
• Medium risk
• Document food intake for 3 days, if no
  improvement follow local policy
• Re screen (weekly,monthly)
• High risk
• Seek expert advice, monitor and review (weekly,
  monthly) in line with local policy

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Care plan

• Set aims and objectives
• Treat underlying conditions
• Improve nutritional intake
• Monitor and review
• Reassess subjects at nutritional risk as they
  move through care settings

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Nutritional interventions

• Provide help and encouragement with eating and
  drinking
• Offer tasty, nutritious and attractive meals
• Provide pleasant environment in which to eat
• Consider oral nutritional supplements if unable
  to meet requirements
• Monitor and review

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Oral Nutritional Support for the at risk
patient

• Good food
• Dietary counselling and fortification
• Oral nutritional supplements (ONS)

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Oral Nutritional Support for the at risk
patient

• Good food
• Dietary counselling and fortification
• Oral nutritional supplements (ONS)

Evidence-based practice?
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Maximise food intake

• Help with feeding
• Help with shopping or cooking
• Ensuring good dentition
• Suitable feeding equipment
• Avoiding unnecessary NBM
• Multidisciplinary involvement

Protected meal-times?
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Dietary counselling

• Very few trials (lt 10) have shown that dietary
  counselling can improve food intake (energy and
  protein intakes) and nutritional status (body
  weight) in the treatment of malnutrition
• Most trials do not mention who did the
  counselling, what form this took (written, oral
  instructions/advice), compliance with advice

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Dietary counselling

• Very few trials (lt 10) have shown that dietary
  counselling can improve food intake (energy and
  protein intakes) and nutritional status (body
  weight) in the treatment of malnutrition
• Most trials do not mention who did the
  counselling, what form this took (written, oral
  instructions/advice), compliance with advice

There are no well-designed randomised controlled
trials addressing the impact of dietary
counselling by a dietitian on patient outcome in
the clinical setting
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Food fortification

• Oil
• Cream
• Sour cream
• Butter
• Milk
• Cheese
• Sugar
• Skimmed milk powder
• Commercial CHO/protein powder or liquids

Aims to increase the energy and protein density
of the diet
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Food fortification

• What do we want to achieve?
• Improve the intake of a range of nutrients?
• Improve recovery?

Randomised controlled trials assessing the
impact of dietary fortification on clinical
outcome, compared with routine care, are lacking
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Dietary advice and food fortification in COPD (
Weekes 2004)

• Malnourished patients with COPD
• Dietary advice plus milk powder for 6mths
• Written advice on food fortification
• Followed up for one year

Dietary advice and food fortification resulted in
weight gain, increase fat mass and improved
dyspnoea, QoL and ADL but no changes in lung
function or muscle strength.
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Dietary counselling or supplements

• A Cochrane review (4 trials) (Baldwin 2002)
• Supplemented patients had significantly greater
  weight gain (or less loss) and significantly
  greater energy intakes than patients given
  dietary counselling, over 3 months

No evidence for the use of dietary advice in the
management of malnutrition
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Oral nutritional supplements
Whats the evidence ?
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Disease-related malnutrition an evidence-based
approach to treatment RJ Stratton CJ Green M
Elia CABI Publishing
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Summary evidence base

• ONS can effectively increase total energy,
  protein and micronutrient intakes. They tend not
  to substantially replace food intake
• ONS can produce significant clinical and
  functional benefits in some patient groups in
  hospital and in the community
• The benefits to outcome may be due to improved
  body weight and muscle mass or the critical
  supply of nutrients during recovery
• The current evidence base is incomplete, it needs
  to be regularly updated and developed

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MUST 1 year on

• Gradual adoption / implementation
• Frequently Asked Questions on BAPEN website
• Articles
• Symposia
• Training sessions and resources
• Translation into other languages
• MAG moving from Advisory to Action

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In Summary

• Malnutrition in UK is common and costly
• Screening is a MUST
• MUST is a valid yet simple and quick to use
  tool suitable for use across all care settings
• Appropriate nutritional interventions can be
  effective in preventing and treating the problem

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Lower boundary BMI (kg/m2) values

• ASPEN(2002) suggest lt18.5 kg/m2 to indicate
  underweight in their report on evidence based
  best approach to practice of nutritional support
• OPCS in the UK uses lt20kg/m2 to indicate
  underweight even in people of gt75yr
• USA edition of Dietary Guidelines(1990) suggested
  age specific BMI reference ranges but withdrew in
  the 1995 edition
• Influence on mortality of confounding variables
  eg smoking, pre existing disease, drug and
  alcohol ingestion, poverty
• smoking and pre existing disease known to reduce
  weight and increase risk of premature death