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SPECIAL REPORT

The Role of Oral Nutritional Supplements for the Management of Adult Malnutrition Improving Oral Nutritional Supplements for the Management of Adult Malnutrition Your Patients and Malnutrition Nutritional Supplements, Vitamins and Micro-Nutrients Taste, Smell, Flavour, Nutrition, Palatability and Supplements Using Technology to Transform the Delivery of Dietetic Services

Sponsored by

Published by Global Business Media


SPECIAL REPORT

The Role of Oral Nutritional Supplements for the Management of Adult Malnutrition Improving Oral Nutritional Supplements for the Management of Adult Malnutrition Your Patients and Malnutrition

THE ROLE OF ORAL NUTRITIONAL SUPPLEMENTS IN THE MANAGEMENT OF ADULT MALNUTRITION

Contents

Nutritional Supplements, Vitamins and Micro-Nutrients Taste, Smell, Flavour, Nutrition, Palatability and Supplements Anorexia, Eating Disorders and Extreme Malnutrition

Foreword

2

Dr Charles Easmon, Editor

Improving Oral Nutritional Supplements 3 for the Management of Adult Malnutrition Dr Charles Easmon, Editor

The Creation of a Better Product for Malnutrition

Sponsored by

Published by Global Business Media

Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom Switchboard: +44 (0)1737 850 939 Fax: +44 (0)1737 851 952 Email: info@globalbusinessmedia.org Website: www.globalbusinessmedia.org

Added Value Services The Personal Importance of Nutrition The Community and Financial Importance of Nutrition Summary

Your Patients and Malnutrition

8

Dr John O’Connell, Medical Correspondent

Testing for Malnutrition – A Whole Team Effort on all Patients

Publisher Kevin Bell

How to Help the Malnourished

Business Development Director Marie-Anne Brooks

Summary

Editor Dr Charles Easmon MBBS MRCP MSc Public Health DTM&H DOccMed

Nutritional Supplements, Vitamins and Micro-Nutrients 10

The Obese Malnourished

Dr Charles Easmon, Editor

Senior Project Manager Steve Banks

Vitamins

Advertising Executives Michael McCarthy Abigail Coombes

Micronutrients Summary

Production Manager Paul Davies

Taste, Smell, Flavour, Nutrition, Palatability and Supplements

For further information visit: www.globalbusinessmedia.org

13

Dr John O’Connell, Medical Correspondent

The Tongue, the Nose and the Brain The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated. Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles. © 2016. The entire contents of this publication are protected by copyright. Full details are available from the Publishers. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical photocopying, recording or otherwise, without the prior permission of the copyright owner.

Types of Taste Why Nutrition Supplements Should be Palatable

Using Technology to Transform the Delivery 15 of Dietetic Services Catherine McShane, Clinical project manager dietitian, County Durham and Darlington NHS Foundation Trust catherinemcshane@nhs.net

Introduction Health Call Undernutrition Case Study Conclusion

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THE ROLE OF ORAL NUTRITIONAL SUPPLEMENTS IN THE MANAGEMENT OF ADULT MALNUTRITION

Foreword M

ALNUTRITION in the form of under nutrition

by encouraging a fortified diet and ‘Food for Special

is a major problem worldwide. In the UK it

Medical Purposes7’ (FSMPs). This will often be in

is estimated to cost more than £19.6 billion3 and

the form of a drink or if required a texture modified

affects more than 3 million people. A lot of research,

product like a yoghurt. The key issues with the

education tools and detecting tools have been

choice of nutritional supplement are taste and cost.

developed by the British Association for Parenteral

Traditional nutritional supplements have had a low

and Enteral Nutrition4 (BAPEN).

level of palatability and hence high wastage and cost.

In General Practice it is easy to miss many of your

Fortunately the team at Nualtra had a different vision

patients with malnutrition and BAPEN recognises a

and developed the highly palatable (96%8) Nualtra

‘malnutrition carousel ’, where the malnutrition leads

range of nutritional supplements, which have already

to higher hospitalisations, who when discharged are

saved the National Health Service (NHS) £8 million

not properly re-nourished and end up back in hospital

in costs and of course have lead to much happier

earlier and more ill than they should be.

patients with better quality of life and reduced illness.

5

Every General Practitioner practice should think of

Think of all your chronic illness, disabled,

a team wide effort to detect and manage all cases

impoverished, isolated, mental health patients and

of malnutrition. The best way to do this would be to

many more who are at risk of malnutrition. Remind

introduce a validated malnutrition assessment tool

yourself that many of your obese patients will also be

for ALL patients on all visits and to roll this out for

malnourished because despite eating a lot it is not a

those who do not attend the surgery. An easy to use

lot of the ‘right’ stuff. ‘Think Malnutrition and Improving

validated tool for this use is provided by BAPEN. This

Health, think Nualtra’9.

is the ‘Malnutrition Universal screening Tool’6 ‘MUST’. Those assessed as malnourished should ideally see a dietitian. The dietitian can advise on nutrition

Dr Charles Easmon Editor

Dr Charles Easmon is a medical doctor with 30 years’ experience in the public and private sectors. After qualifying as a physician, he developed his interests in occupational medicine, public health and travel diseases. His interest in liver disease is from both the public health

References: http://www.allianceforeatingdisorders.com/portal/osfed Accessed 17/5/16

1 2

http://emedicine.medscape.com/article/89260-overview Accessed 17/5/16

3

http://www.bapen.org.uk/malnutrition-undernutrition/introduction-to-malnutrition?showall=&start=5 Accessed 22/5/2016

4

http://www.bapen.org.uk/ Accessed 22/5/2016

5

http://www.bapen.org.uk/malnutrition-undernutrition/introduction-to-malnutrition?showall=&start=1 Accessed 22/5/2016

6

http://www.bapen.org.uk/screening-and-must/must/introducing-must Accessed 22/5/2016

7

http://www.efsa.europa.eu/en/press/news/151126 Accessed 22/5/2016

8

https://www.nualtra.com/about-us/ Accessed 22/5/2016

9

https://www.nualtra.com/ Accessed 22/5/2016

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THE ROLE OF ORAL NUTRITIONAL SUPPLEMENTS IN THE MANAGEMENT OF ADULT MALNUTRITION

Improving Oral Nutritional Supplements for the Management of Adult Malnutrition Dr Charles Easmon, Editor

T

HE NATIONAL Health Service (NHS) has budgetary constraints, which you as General Practitioners (GPs), Dietitians, and Medicines Management see every day. If there was a professionally sanctioned way to save money for the NHS whist benefiting your patients and the wider community, you would take it. If the required action meant that a significant number of your patients had better health outcomes, reduced hospital stays and less hospital readmissions, depending on your temperament, you would either jump for joy or at least allow yourself a satisfied smile. Fortunately, such an option exists in regards to the management of malnutrition, which is a major problem for the NHS, your practice and your patients. Malnutrition is a significant contributor to illness, hospitals stays and readmissions. Successful treatment of malnutrition is the solution. However, as with many of your drug remedies, there is a known compliance problem with many malnutrition treatments or remedies. This poor compliance issue has some logical basis. Put yourself in the shoes of your patient. If you were offered a tasteless or bland liquid or the equivalent of ‘cardboard chicken’ as the solution to your nutrition needs, no amount of exhortation would get you to drink or eat more than a certain amount no matter how much you were told by enthusiastic medical staff that is was ‘good for you’. In fact, the very prospect of this tasteless or poor tasting therapeutic regime would be likely to adversely affect your mental health in a way that might further reduce your appetite to eat and drink.

The Creation of a Better Product for Malnutrition Dietitian Paul Gough1 for years had seen the lack of enthusiasm of his patients for the existing nutrition supplements first hand. Many patients felt their prescribed supplements were difficult

to finish as the taste wasn’t good, so it meant that compliance was low and wastage was high. Coupled with the high price companies were charging the NHS for community oral nutrition, it didn’t represent good value for money at all. Paul set off with a simple goal to produce a better tasting product at less cost to the NHS. The ‘desirable but less expensive’ mantra was behind the foundation of Nualtra. The currently available Nualtra range of supplements and desserts is the product of many years of research, taste trials, safety and consumer testing before the Nualtra product range launched in 2012. Published clinical studies have shown Nualtra’s range of supplements: •A  chieve compliance rates up to 96% one of the highest rates in the industry •P  erform better than competitor products for flavour •P  erform better than the competitor products for texture •P  erform better than the competitor products for odour Once Paul and his Nualtra team felt that the taste frontier (which includes gluten free/lactose free hazel chocolate, banana, vanilla, strawberry, and chocolate orange) had been conquered, he and his team realised that the battle was not over. How could costs be driven down and maintained as affordable to Clinical Commissioning Groups (CCGs) and NHS Trusts? This was achieved by strict control of ingredients and manufacturing costs. Since Nualtra has been introduced (2012), it has already saved the NHS more than £8 million and its presence in the market has led to the competition reducing their own prices. As a CCG or an NHS organisation, you can access the Nualtra Saver (www.nualtrasaver. com) to estimate how much you could save financially by making simple switches with your Oral Nutritional Supplement products. *Data on file. Calculation based on direct product cost savings and competitor price reductions.

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THE ROLE OF ORAL NUTRITIONAL SUPPLEMENTS IN THE MANAGEMENT OF ADULT MALNUTRITION

Malnutrition is a

four flavours (Hazel Chocolate, Vanilla, Strawberry, Banana) Powdered – Foodlink Complete – high protein (18.5g) 385kcals made with 200ml whole milk in 5 flavours (Chocolate, Strawberry, Banana, Natural, Vanilla (with fibre)) Dessert – Nutricrem – nutritionally complete (125g) 225kcals ready-to-eat in 3 flavours (Chocolate Orange, Strawberry, Vanilla, Altraplen Compact and Altraplen Protein) Protein Enriched – Altraplen Protein – high protein (20g) 300kcals in 200ml with 2 flavours (Vanilla, Strawberry) In addition to the current range of supplements, Nualtra have an exciting pipeline of New Product Development planned with at least another 2 products being launched in 2016.

significant contributor to illness, hospitals stays and readmissions. Successful treatment of malnutrition is the solution

The Personal Importance of Nutrition

Added Value Services

Malnutrition is 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 form (body shape, size and composition) and function and clinical outcome2.

In addition to direct product savings, Nualtra also works closely with NHS organisations to deliver added value support services to help them achieve their own goals and objectives. A recent example of this is the development of an online academy programme that allows nursing staff and healthcare assistants to upskill on malnutrition, nutritional supplements, dysphagia and many other topics related to nutrition, taking some of the training responsibilities away from the NHS. Elsewhere, Nualtra are working closely with a number of large CCGs to help them implement active switching programmes where they can realize large savings opportunities in a shorter time period. After all, if you knew you could save £500,000 for your CCG, why wouldn’t you want to release this sooner rather than later? As well as assisting during the implementation phase, Nualtra also provide key insights and usage analysis to meds management and prescribing support dietitian customers within CCGs so they can build their own business cases and develop a better understanding of the value they’re bringing to the organisation. Nualtra is currently the fastest growing medical nutrition company in the UK and Ireland and their products are now used in more than 200 CCGs (UK) and 150 nursing homes (Ireland) with supplements available in four major categories: High Energy – Altraplen Compact – low volume (125ml) 300kcals ready-to-drink supplement in

If a car runs out of fuel it fails to run. However, the car’s problem is confined to the engine, in that the rest of the car does not start to consume itself or fall apart. After some time in the wrong climate it will rust, but months later the steering wheel is still more or less intact as is the dashboard. However, if a human receives inadequate nutrition some degree of motive function is preserved but the body starts to catabolise (cannibalise itself in some ways) to get the needed energy and nutrients. In the non-obese, the weight loss in malnutrition affects all organs from muscle to bone and in the obese similar changes occur which may be less visible. The signs and symptoms of malnutrition in the non-obese patient may be both difficult to recognize and gradual but include: • Visible weight loss • Loosening of clothes, rings and jewellery • Tiredness and loss of energy •R  educed ability to perform normal tasks and to concentrate •R  educed physical performance in duration and speed •L  ethargy, depression and other mood alterations • Osteoporosis or osteomalacia • In a child poor growth, rickets, delayed sexual development and impaired intellectual development. Unlike the car comparison, malnutrition in the body affects every system, which ultimately,

ALTRAPLEN COMPACT - LOW VOLUME GREAT-TASTING SUPPLEMENT

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THE ROLE OF ORAL NUTRITIONAL SUPPLEMENTS IN THE MANAGEMENT OF ADULT MALNUTRITION

in the case of the dessert) contain 385 kcals and 12-20 grams of protein per serving.

The Community and Financial Importance of Nutrition It has been estimated that malnutrition (or “undernutrition”) affects over 3 million people in the UK. Of these about 1.3 million are over the age of 65. Whilst most of those affected are living in the community (about 93% or 2.8 million people) BAPEN’s Nutrition Screening Week surveys (2007-11) have shown that: • 25-34% of patients admitted to hospital are at risk of malnutrition • 30-42% of patients admitted to care homes are at risk of malnutrition • 18-20% of patients admitted to mental health units are at risk of malnutrition Surveys of the 700,000 people living in sheltered housing… have shown that 10-14% are at risk of malnutrition5. ALTRAPLEN PROTEIN - GREAT TASTING PROTEIN ENRICHED SUPPLEMENT

if untreated, could lead to death. The immune system has a reduced ability to counter infection. Effects on muscles may contribute to falls, chest infections, heart failure, pressure ulcers, blood clots and reduced activities of normal daily living such as shopping, cooking, self-care and work. Wounds take longer to heal. Altered kidney function may lead to dehydration or even over-hydration. Impaired thermoregulation can contribute to hypothermia under appropriate conditions. In pregnancy, we are now more aware of the longer-term effects of on the foetus of poor prenatal care and nutrition3 in both sexes. Micronutrient deficiencies may lead to big or small red cell anaemias (Vitamin B12 or iron deficiency respectively). Zinc deficiency can cause skin rashes and contributes to poor immune function. Extremes of Vitamin C deficiency will cause scurvy for which James Lind found the cause and led to British sailors being called ‘Limeys’. Rarely seen Vitamin A deficiency can cause night blindness and this would particularly affect any child caught up in a measles epidemic (Bitot’s spots4). The restoration of nutrition to a human is not the same as just adding petrol or diesel to a dried out car engine. The relevant product must at least combine calories and protein and be supplemented by the relevant trace elements, vitamins and minerals. Nualtra products ranging from 125-200mls (or 125g

Malnutrition has been estimated to cost the NHS more than £19.6 billion per year and this is actually more than the cost of treating and managing obesity. The high costs are because patients who are malnourished get ill more often, take longer to get well and will have higher rates of illness recurrence and readmission. A vicious circle can develop where an ill malnourished individual is hospitalised and not adequately re-nourished before being sent home only to return too soon to the hospital for the cycle to start again. It is possible that an obese person may still be malnourished, while a slim person, while appearing malnourished, may be perfectly fine. Unless you do nutritional screening on your patients, you will rarely know their actual nourishment status. Agencies as far and wide

FOODLINK COMPLETE - DELICIOUS POWDERED SUPPLEMENT *Data on file. Calculation based on direct product cost savings and competitor price reductions.

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THE ROLE OF ORAL NUTRITIONAL SUPPLEMENTS IN THE MANAGEMENT OF ADULT MALNUTRITION

The currently available Nualtra range of supplements and desserts is the product of many years of research, taste trials, safety and consumer testing before the Nualtra product range launched in 2012 NUALTRA SAVER - FIND OUT HOW MUCH YOUR CCG CAN SAVE

as the National Institute for Clinic Excellence6 (NICE), The British Dietetic Association7 (BDA), the Care Quality Commission8 (CQC) and the Royal College of Nurses all advocate regular, systematic assessment of nutrition in your patients both in primary and secondary care. The excellent charity the British Association of Parenteral and Enteral Nutrition (BAPEN) has provided a clinically validated tool to make the job of nutrition assessment easier and more standardised. This tool is called the ‘Malnutrition Universal Screening Tool’ (‘MUST’). ‘Malnutrition Universal Screening Tool’ (‘MUST’).This tool consists of three parts: • Body Mass Index (BMI) – this is calculated from an individual’s weight and height. A BMI of less than 18.5kg/m2 suggests a significant risk of malnutrition. • A history of recent weight loss that has happened without any intention to lose weight. The unintentional loss of more than 10% of normal body weight in the last 3 -6 months suggests a significant risk of malnutrition. • An “acute disease effect” associated with being acutely ill and unable to eat for more than five days. This tool assesses patients as being at low, medium or high risk of malnutrition and guides the user to develop individualised care plans for treatment if required and further monitoring9,10.

Summary In the same way you cannot diagnose malaria by just putting your hand on a patient’s forehead, you cannot assess and diagnose malnutrition just by looking at your patient. Your clinical teams have an excellent, validated and useable tool for assessing all your patients. The importance of testing all is that without doing so many treatable cases will be missed and lead to all or some of the complications already discussed. Sadly, in many cases when secondary care has got its act together and is screening appropriately for nutrition, the same patients do not have this assessment when they return to the community and if they fall off the ‘nutrition wagon’ they get ill again and end up back in hospital at great cost to themselves, their families, loved ones, society and the NHS. A term for this has been coined by BAPEN – ‘the malnutrition carousel11”. The British Association of Parenteral and Enteral Nutrition (BAPEN) have provided the screening tools (‘MUST’) and the on-line education regarding malnutrition. The General Practitioner and the CCG together need to implement these as soon as possible, if not already doing so, for the benefit of their health care communities. Since 2012, Nualtra have provided the cost-effective, high compliance, great-tasting solution to providing nutrition for your patients at home, in care and in hospital. Find out more at www.nualtra.com Find out how much your CCG could save at www.nualtrasaver.com

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THE ROLE OF ORAL NUTRITIONAL SUPPLEMENTS IN THE MANAGEMENT OF ADULT MALNUTRITION

In the same way you cannot diagnose malaria by just putting your hand on a patient’s forehead, you cannot assess and diagnose malnutrition just by looking at NUTRICREM - NUTRITIONALLY COMPLETE DESSERT SUPPLEMENT

your patient

References: 1

https://www.nualtra.com/about-us/ Accessed 8/5/2016

2

http://www.bapen.org.uk/malnutrition-undernutrition/introduction-to-malnutrition Accessed 8/5/2016

http://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/pregnancy-nutrition/art-20045082 Accessed 8/5/2016 3

4 5

http://bjo.bmj.com/content/85/3/371.2.full Accessed 8/5/2016 http://www.bapen.org.uk/malnutrition-undernutrition/introduction-to-malnutrition?showall=&start=4 Accessed 8/5/2016

6

https://www.nice.org.uk/guidance/qs24 Accessed 8/5/2016

7

https://www.bda.uk.com/news/view?id=92 Accessed 8/5/2016

8

9

http://www.cqc.org.uk/sites/default/files/documents/guidance_about_compliance_summary.pdf Accessed 8/5/2016 http://www.bapen.org.uk/malnutrition-undernutrition/introduction-to-malnutrition?showall=&start=3 Accessed 8/5/2016

10

http://www.malnutritionselfscreening.org/ Accessed 8/5/2016

11

http://www.bapen.org.uk/malnutrition-undernutrition/introduction-to-malnutrition?showall=&start=1 Accessed 8/5/2016

*Data on file. Calculation based on direct product cost savings and competitor price reductions.

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THE ROLE OF ORAL NUTRITIONAL SUPPLEMENTS IN THE MANAGEMENT OF ADULT MALNUTRITION

Your Patients and Malnutrition Dr John O’Connell, Medical Correspondent

The rise of male anorexia has recently been flagged in the news and is often well hidden by the sufferer

M

ANY of your patients in primary care will be malnourished and without making the appropriate assessment you will miss them. The obese malnourished can be a particularly difficult group to assess. The British Association for Parenteral and Enteral Nutrition (BAPEN) informs us as below: It has been estimated that malnutrition (or “under nutrition”) affects over 3 million people in the UK. Of these about 1.3 million are over the age of 65. Whilst most of those affected are living in the community (about 93% or 2.8 million people) BAPEN’s Nutrition Screening Week surveys (2007-11) have shown that: • 25-34% of patients admitted to hospital are at risk of malnutrition • 30-42% of patients admitted to care homes are at risk of malnutrition • 18-20% of patients admitted to mental health units are at risk of malnutrition Surveys of the 700,000 people living in sheltered housing using ‘MUST’ criteria have shown that 10-14% are at risk of malnutrition1. The elderly may have many reasons for malnourishment including poverty, loneliness, neglect, mental illness, dementia or early onset, stroke and physical impairment in shopping or feeding. We all hear the apocryphal tale of those in hospital whose food has been left to one side and then removed because they are ‘obviously not hungry’. Well these malnourished people get discharged and then the ‘malnourishment carousel2’ restarts. Your cancer patients can easily be malnourished by the illness itself or the therapy used to treat it. One significant problem for many of those with chemotherapy and/or radiotherapy is oral mucositis3. This condition leads to a dry, sore mouth and physical and mental impairment in eating and drinking. There are many possible causes of dysphagia and within this group are those autoimmune disorders that decrease salivation like Sjogren’s syndrome4, which can be part of conditions such as sarcoidosis.

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In children there may be many predisposers to malnutrition from poverty, illness, parental mental illness or ignorance to actual eating disorders. The rise of male anorexia5,6 has recently been flagged in the news and is often well hidden by the sufferer.

Testing for Malnutrition – A Whole Team Effort on all Patients Malnutrition is a classic situation of ‘if you don’t ask, you don’t find’. No matter how clear you are as a clinician, you cannot just ‘know’ who is malnourished by looking or speaking for a maximum of the 10 allocated minutes. One of your team must do a validated nutrition score. The one designed and recommended by BAPEN is the ‘Malnutrition Universal Screening Tool’7, which abbreviates to ‘MUST’, and this seems the easiest to apply using calibrated tools in your surgery. BAPEN have made life easier with the creation of an app, clear website instructions and e-learning training tools8 that any General Practitioner or Clinical Commissioning Group (CCG) can sign up for. To emphasise the importance of a systematic approach to assessing all your patients, a survey of hospital nurses, who assumed that they had done a nutritional screen on close to 100% of their patients, found that they had actually done it on less than 50%. ‘Systematising’ the ‘MUST’ is important and should be linked to each preconsultation registration process to maximize implementation. This process itself can be part of a clinical audit and, with the appropriate feedback loop, can be constantly improved for the benefit of all your patients.

How to Help the Malnourished Once you have identified which of your patients is malnourished, ideally you should refer them to a dietitian (whether in-house or external) for an assessment of degree, cause and treatment. A key part of the treatment is education, information and communication and, fortunately, organisations such as BAPEN have appropriate tools for this. To ‘plug the deficit’ in malnutrition, some form of supplement is likely to be needed. Ideally such nutritional supplements should


THE ROLE OF ORAL NUTRITIONAL SUPPLEMENTS IN THE MANAGEMENT OF ADULT MALNUTRITION

be palatable and of the right texture for your patients. Wasted nutritional supplements are a significant cost to your surgery and CCG and the unpalatable ones are the most likely to be wasted. One school of thought is that (within reason) clinicians should try the things that they recommend to their patients. It is harmless and no great hardship to actually try out the options in nutritional supplements and to work on a simple basis that if it is unpalatable to you, it is likely to be unpalatable to your patients and vice versa. Some nutritional supplement companies will provide you as the General Practitioner with free samples of their drinks, yoghurts and powders to try. The available supplements will range from 200300 kcal and 10-20 grams of protein per portion.

An oxymoron10 is defined as the juxtaposition of two words that are or seem opposite. The obese malnourished seems like an oxymoron but sadly it is not. Your patients can bulk up to obesity by eating a lot of the wrong things that do not ‘nourish’ but rather harm the body. In these circumstances, which are not ‘under nutrition’, there are excess kilocalories but the wrong stuff and to assess this can be difficult. BAPEN again comes to the rescue. The diagnosis is also made by ‘MUST’. Treatment will consist again of the famous Education, Information and Communication (EIC), dealing with co-morbidities and motivational interviewing.

The Obese Malnourished

All of your patients deserve the best you can provide. Opportunistic screening can be both a lifesaver and a life enhancer. Nutritional screening using validated tools like the ‘MUST’ should be part of you routine surgery practices and those who do not visit should be called in for this and other opportunistic screening. Using the right supplements can save the National Health Service (NHS) millions and diagnosing and treating those with malnutrition can save society billions.

I saw few die of hunger; of eating, a hundred thousand9. Benjamin Franklin “The key for doctors is to recognise that malnutrition co-exists with obesity – and it’s just as important to treat it… That will make a huge difference.” Dr Simon Gabe, chair of BAPEN.

Summary

References: http://www.bapen.org.uk/malnutrition-undernutrition/introduction-to-malnutrition?showall=&start=4 Accessed 16/5/16

1

2

http://www.bapen.org.uk/malnutrition-undernutrition/introduction-to-malnutrition?showall=&start=1 Accessed 16/5/16

3

http://www.nhs.uk/conditions/mucositis/Pages/Introduction.aspx Accessed 16/5/16

4

http://www.nhs.uk/Conditions/Sjogrens-syndrome/Pages/Introduction.aspx Accessed 16/5/16

5

http://www.rcpch.ac.uk/news/male-eating-disorders-rise Accessed 16/5/16

6

https://www.b-eat.co.uk/about-beat/media-centre/information-and-statistics-about-eating-disorders Accessed 16/5/16

7 8 9 10

http://www.bapen.org.uk/screening-and-must/must/introducing-must Accessed 16/5/16 http://www.bapen.org.uk/e-learning-portal Accessed 16/5/16 http://www.brainyquote.com/quotes/authors/b/benjamin_franklin_7.html Accessed 16/5/16 http://www.merriam-webster.com/dictionary/oxymoron Accessed 16/5/16

*Data on file. Calculation based on direct product cost savings and competitor price reductions.

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THE ROLE OF ORAL NUTRITIONAL SUPPLEMENTS IN THE MANAGEMENT OF ADULT MALNUTRITION

Nutritional Supplements, Vitamins and Micro-Nutrients Dr Charles Easmon, Editor

For those who are malnourished, it is clear that, unless they can eat regularly the right things required, then some form of nutritional supplementation will be needed for energy and protein

Nutrition is a science that entails the study of all processes of growth, maintenance and repair of the living body, which depend on the intake of food. Food is,… any solid or liquid which, when swallowed, can provide the human body with material enabling it to function in one or more of the following ways: a) p  roduction of heat or other manifestations of energy b) g  rowth, repair or reproduction, i.e., body-building c) p  articipation in the mechanisms regulating the production of energy or the process of growth, repair and reproduction. The foods in this group are sometimes known as the protective foods because they help to maintain health1. ‘Food supplements that contain familiar substances like vitamins, amino acids or minerals are generally subject to food safety and food labelling legislation rather than medicines control2.’ The world of nutritional supplements, vitamins and micro-nutrients is confusing with many unsubstantiated and unscientific claims in a strange legal and regulatory framework. Things that are seen as drugs or medical devices are regulated in the UK by The Medicines and Healthcare products Regulatory Agency (MHRA), in Europe by the European Medicines Agency3 (EMA) and in the United States by the U.S. Food and Drug Administration4 (FDA). ‘Food products, in particular food supplements’ are labeled by the MHRA as ‘borderline products’. These ‘borderline products’ that are not labeled as drugs or medicines but may have a health benefit are restricted as to what claims they can make to the public and how they can be promoted. For those without malnutrition a key question is whether any nutritional supplements are required

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and would they be best just to manage their food and how it is made better to ensure maximum bio-availability of the right ingredients? Many dietitians would agree that supplements are only necessary for those who are malnourished5. However, many nutritionists train in institutes that promote supplements and hence they become peddlers of ‘product’ rather than advisers on best practice. For unbiased advice about food, nutrition and supplementation, resources such as the British Association for Parenteral and Enteral Nutrition6 (BAPEN) and the British Dietetic Association7 (BDA) are available. It may be wise to choose those with a qualification as a dietitian8 (more tightly regulated) than those who call themselves ‘nutritionists9’. For those who are malnourished, it is clear that, unless they can regularly eat the right things required, then some form of nutritional supplementation will be needed for energy and protein, but vitamins and micro-nutrients needs must not be forgotten.

Vitamins Until the beginning of the twentieth century it was assumed that the diet would be adequate if sufficient protein, fat, carbohydrate and inorganic elements were supplied. This view was changed when it was shown that natural unrefined foods contain substances essential to life and health, which the body is unable to form for itself. The organic substances were called vitamins and were found to be present in very minute amounts in food. Some of the vitamins, i.e., A, D, E and K, are found mainly in fatty foods and are called fat-soluble vitamins; the others, i.e., the vitamins of the B group and Vitamin C, are water-soluble vitamins. Manual of Nutrition published by Her Majesty’s Stationery Office (HMSO), Ministry of Agriculture, Fisheries and Food The word Vitamin is derived from two words, vital and amines. Vital refers to something


THE ROLE OF ORAL NUTRITIONAL SUPPLEMENTS IN THE MANAGEMENT OF ADULT MALNUTRITION

essential to life that cannot be synthesised by the body and amines refers to a chemical structure. Since the term vital amines (vitamins) was first conceived, the following thirteen have been identified10 : • Vitamin A • Vitamin C • Vitamin D • Vitamin E • Vitamin K • Vitamin B1 (thiamine) • Vitamin B2 (riboflavin) • Vitamin B3 (niacin) • Pantothenic acid • Biotin (B7) • Vitamin B6 • Vitamin B12 (cyanocobalamin) • Folate (folic acid and B9) The role of vitamins has been elucidated over time by deficiency syndromes, in deprivation, disease, war or odd behaviours. Scurvy from Vitamin C deficiency was common amongst sailors on long trips. Rickets caused by Vitamin D deficiency will occur in those whose bodies are not exposed to adequate sunlight. Pellagra11 was seen in prisoners of war fed rice without husks and is caused by a lack of niacin or trytophan. Wernicke’s encephalopathy12 was noted in alcoholics and is caused by thiamine deficiency.

Micronutrients The same processes have helped define the role of micro-nutrients, which as the name implies, are substances required in very small amounts for key bodily functions and confusingly include all the vitamins above. The World Health Organisation (WHO) describes them as ‘the “magic wands” that enable the body to produce enzymes, hormones and other substances essential for proper growth and development13.’ The range of micro-nutrients includes all the vitamins as well as minerals such as iron and zinc14. Iodine15 the trace element16 is also a micro-nutrient. Folic acid deficiency in pregnant women leads to birth defects and in adults is associated with heart disease. Iodine deficiency in adults leads to the ‘bull neck’ goitre and in children leads to a level of underdevelopment that used to be called in a non-politically correct world ‘cretinism’. Iron deficiency contributes to deaths in childbirth and to children’s mental retardation. Zinc deficiency contributes to childhood diarrhoea and respiratory illnesses worldwide.

Summary The global problem of vitamin and micronutrient dietary shortages is very significant17. In the UK the specific problems may occur in impoverished areas and in those who have odd behaviours, disease or food poverty. Most well people eating a healthy balanced diet18 with ‘rainbow’ colours should not need any additional nutritional supplementation but those assessed as malnourished will require energy and protein supplementation with consideration needed for the vitamins and *Data on file. Calculation based on direct product cost savings and competitor price reductions.

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THE ROLE OF ORAL NUTRITIONAL SUPPLEMENTS IN THE MANAGEMENT OF ADULT MALNUTRITION

The group of your patients who need medical nutrition as ‘Food for Specialised Medical Purposes ’ (FSMP) will always be more than expected and often more than detected

micro-nutrients. The group of your patients who need medical nutrition as ‘Food for Specialised Medical Purposes19’ (FSMP) will always be more than expected and often more than detected. Many patients who you may not think about in the malnutrition space actually do have a problem and dealing with this can improve their quality of life, reduced disease severity,

save life and save money. At the point of cancer diagnosis, many of your patients will already have lost weight and be malnourished and, as you can imagine, it is harder to fight a debilitating disease like cancer without the bodily resources to do so. Another example is children and adults with cerebral palsy who often need lifetime oral nutritional support and/or tube feeds.

References: Manual of Nutrition published by Her Majesty’s Stationery Office (HMSO), Ministry of Agriculture, Fisheries and Food

1

2

https://www.gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-agency Accessed 11/5/2016

3

http://www.ema.europa.eu/ema/ Accessed 11/5/2016

4

http://www.fda.gov/ Accessed 11/5/2016 http://www.nhs.uk/conditions/vitamins-minerals/Pages/Vitamins-minerals.aspx Accessed 9/5/2016

5

http://www.bapen.org.uk/ Accessed 17/5/2016

6 7

https://www.bda.uk.com/about/home Accessed 9/5/2016

8

https://www.bda.uk.com/improvinghealth/trustadietitian/whytrustdietitians Accessed 17/5/2016 https://www.bda.uk.com/publications/dietitian_nutritionist.pdf Accessed 17/5/2016

9

https://www.nlm.nih.gov/medlineplus/ency/article/002399.htm Accessed 9/5/2016

10 11

http://emedicine.medscape.com/article/794583-overview Accessed 11/5/2016

13

http://www.who.int/nutrition/topics/micronutrients/en/ Accessed 11/5/2016

14 15

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https://www.nlm.nih.gov/medlineplus/ency/article/000342.htm Accessed 11/5/2016

12

http://projecthealthychildren.org/why-food-fortification/micronutrients/ Accessed 11/5/2016 https://ods.od.nih.gov/factsheets/Iodine-HealthProfessional/ Accessed 11/5/2016

16

http://www.dictionary.com/browse/trace-element Accessed 11/5/2016

17

http://www.who.int/nutrition/topics/launching_globalnutritionpolicyreview_essentialnutritionactions/en/ Accessed 11/5/2016

18

http://www.nhs.uk/Change4Life/Pages/five-a-day.aspx Accessed 11/5/2016

19

http://www.bsna.co.uk/documents/BSNA%20The%20Value%20of%20FSMPs%20May%202016.pdf


THE ROLE OF ORAL NUTRITIONAL SUPPLEMENTS IN THE MANAGEMENT OF ADULT MALNUTRITION

Taste, Smell, Flavour, Nutrition, Palatability and Supplements Dr John O’Connell, Medical Correspondent

What is generally categorized, as “taste” is basically a bundle of different sensations: it is not only the qualities of taste perceived by the tongue, but also the smell, texture and temperature of a meal that are important. The “colouring” of a taste happens through the nose... Only after taste is combined with smell is a food’s flavour produced. If the sense of smell is impaired, by a stuffy nose for instance, perception of taste is usually dulled as well. Like taste, our sense of smell is also closely linked to our emotions. This is because both senses are connected to the involuntary nervous system. That is why a bad taste or odour can bring about vomiting or nausea…. and flavours that are appetizing increase the production of saliva and gastric juices, making them truly mouth-watering1. When it comes to our food and drink, we think we taste them but more often we smell them and assume it is taste. Our senses can fool us. The most classic example of these is synaesthesia2,3,where some people ‘see’ colours and ‘taste’ sounds etc. Our taste mechanism is mainly on the tongue but research now shows that many foods are ‘tasted’ by a retro nasal process of smell, which we then assume is taste. Emotions play a key part in taste and taste plays a key part in memory as anyone who has struggled through their Proust4 remembers well. This should not surprise us on an evolutionary level and reminds of us of our humanity rather than seeing our senses as mechanism A which does, not relate to mechanism B, C or D.

The Tongue, the Nose and the Brain Computer analogies and the human nervous system5 only work up to a point and key issues often ignored are our emotions and consciousness that are a key part of our humanity. To those who see the brain as a Central Processing Unit (CPU), taste is a good example of the limitations of this approach since, what we define as ‘tastes’ may start with a sense

detected in the tongue but this will be mixed with smells from the olfactory cells and interpreted by a brain prone to evolutionary preferences, emotions, memory and sensory interactions. Perfectly good food if coloured blue will be found to be’ disgusting’ and lead to a loss of appetite6. Taste cells send a sensory stimulus to the brain. In adults they are found mainly on the tongue but are also in the oral cavity, the back of the throat, the epiglottis, the nasal cavity and the upper part of the oesophagus. Infants and young children may have additional sensory cells on the mucous membranes of their lips, cheeks and on their hard palate. Taste cells on the tongue are positioned in three key geographic areas 1) the general surface of the tongue 2) the base of the tongue and 3) the sides of the tongue.

Types of Taste “Taste really refers to four, really five I suppose, sensitivities and that’s sweet, sour, salt, bitter – the four well known ones – and a relatively new taste sensation called umami,” Flavour, on the other hand – or what we refer to when we say something tastes good or bad – is a different animal altogether. “Flavour is what we call a hedonic sense in that it is really a combination of several different senses, the five tastes, but also in a very important contribution from your olfactory or smell system. In fact, it’s estimated that about 85% of what we perceive of as flavour is really olfactory7,” Professor Stuart Firestein, Columbia University neurobiologist Before a 5th taste (umami) was officially recognized in the 1980s (despite a Professor Ikeda8 of Japan noting it as early as 1912) it was assumed that we had just four. There is debate now as to whether we have more than even these five tastes. The four well known before umami are sweet, sour, salty and bitter. *Data on file. Calculation based on direct product cost savings and competitor price reductions.

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THE ROLE OF ORAL NUTRITIONAL SUPPLEMENTS IN THE MANAGEMENT OF ADULT MALNUTRITION

What we define as ‘tastes’ may start with a sense detected in the tongue but this will be mixed with smells from the olfactory cells and interpreted by a brain prone to evolutionary preferences, emotions, memory and sensory interactions The sweet taste is usually caused by sugar and its derivatives such as lactose or fructose. Alcoholic drinks, alcohols in fruit juices and some amino acids can also affect the sensory cells that activate to sweetness. Acidic solutions or organic acids mostly activate the sour taste with hydrogen ions dissolving in watery solutions. Salty tastes are not surprisingly caused by salt chemicals of sodium and chloride as well as potassium or magnesium salts. The umami9 taste which has been described as similar to ‘meat broth’ is most often caused by glutamic or aspartic acid. Tasting tests in a clinical setting are undertaken by ‘palatability’ tests10. These tests focus on whether the mouth, mind and feelings find the product acceptable.

Why Nutrition Supplements Should be Palatable Good food is the basis of true happiness11 The pleasures of the table belong to all times and ages, to every country and every day; they go hand in hand with all our other pleasures, outlast them, and remain to console us for their loss12. Good food and drink can be part of pleasure and none of us would eat cardboard for the whole or part of our life by choice and especially when not well – nor would we drink something with an unpleasant or no taste. Sadly, our clinical approach to nourishment over the years has often ignored taste and palatability, which predictably leads to wastage. Fortunately, this is now being challenged by new options within the nutritional supplement ranges and any General Practitioner concerned about their patients’ welfare should research and address these issues as soon as possible with the added bonus of saving money.

References: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072592/ Accessed 9/5/2016

1 2

http://tiny.cc/7h7pby Accessed 16/5/2016

3

https://www.sciencedaily.com/releases/2015/04/150413214343.htm Accessed 16/5/2016

4

http://www.britannica.com/biography/Marcel-Proust Accessed 17/5/2016

5

https://www.technologyreview.com/s/511421/the-brain-is-not-computable/ Accessed 17/5/2016

6

http://www.colormatters.com/color-and-the-body/color-and-appetite-matters Accessed 16/5/2016

7

https://www.s.u-tokyo.ac.jp/en/research/alumni/ikeda.html Accessed 17/5/2016

9

http://www.umamiinfo.com/2011/02/the-discovery-of-umami.php Accessed 16/5/2016

10

http://www.ema.europa.eu/docs/en_GB/document_library/Presentation/2012/01/WC500121607.pdf

Accessed 16/5/2016

11

http://www.azquotes.com/author/31091-Auguste_Escoffier Accessed 17/5/2016

12

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http://bigthink.com/the-voice-of-big-think/what-is-taste Accessed 16/5/2016

8

http://www.azquotes.com/author/13032-Jean_Anthelme_Brillat_Savarin Accessed 17/5/2016


THE ROLE OF ORAL NUTRITIONAL SUPPLEMENTS IN THE MANAGEMENT OF ADULT MALNUTRITION

Using Technology to Transform the Delivery of Dietetic Services Catherine McShane, Clinical project manager dietitian, County Durham and Darlington NHS Foundation Trust catherinemcshane@nhs.net

Introduction The NHS is facing its biggest challenge of an ageing population, increased numbers of people living with long term conditions and increased cost of treatments with the background of a flat budget and a need to transform the way services are delivered.1, 2, 3 Undernutrition costs the English economy over £19 billion annually4 and affects an estimated three million individuals, 93% of which live in the community.5 Not only is there the cost to the health economy but undernutrition has ‘substantial impact on the health, disease and well-being in community, residential care and hospital settings’.6 Yet despite NICE clinical guidelines7 and Quality Standards8 undernutrition remains poorly recognised and therefore poorly treated and monitored and unfortunately many nutrition and dietetic services don’t have the capacity to provide the high quality treatment and monitoring that they want to.

Health Call Undernutrition Treating undernutrition is a matter of quality and safety for some of our most vulnerable patients, Health Call Undernutrition (HCUN) allows nutrition and dietetic services to transform the way services are delivered to enable them to provide high quality care that meets the needs of the patient at the right time. Up to 1/3 of community dietetic referrals can be for nutritional support advice, placing significant burden on the service and delaying treatment to our patients. HCUN has been developed by dietitians at County Durham and Darlington NHS Foundation Trust, in response to their concern about not being able to provide a responsive service to patients. HCUN has been designed to be simple and easy to use for patients, carers and health care staff. Using simple automated phone calls or a secure web based portal patients provide information regarding their weight, appetite and if they are tolerating their oral nutritional supplements (ONS) or other diet therapy e.g. nourishing

snacks or homemade fortified drinks. Dietitians are alerted if any information is outside of predetermined parameters, for example if there is poor compliance with the diet therapy. HCUN has not been designed to replace dietitians, it allows for triaging of patients so that our limited resources can focus on patients when they need our input. Health Call Undernutrition has been shown to increase the capacity and efficiency of a nutrition and dietetic department as well as realising cost benefits due to improved appropriate prescribing of ONS. It provides a framework for safe caseload management through highlighting patients that require dietetic input. As well as the known efficiencies that HCUN has delivered to the dietetic service it has also had impact on the wider health and social care services. As the information can be pulled through to electronic patient records we have reduced duplication of work of community nurses having to visit patients to weigh them and screen for risk of undernutrition. When contacting a care home you already have the information in front of you and you are only contacting the home about the patients that need it. Traditional service delivery would mean either telephoning or visiting the home to assess or review an entire caseload and requiring a member of the staff with you while this takes place. As a clinician the more important added value is that patients and carers feel better supported and cared for, they have confidence that a dietitian is looking at the information they are providing and responding to it when needed. It empowers patients to manage their own nutritional health through an improved understanding of the impact of the dietetic advice on not only their weight but also their well-being.

Case Study Mr C lives in a care home and was referred for nutritional support advice, he was assessed within a week of the referral, and found to be at high *Data on file. Calculation based on direct product cost savings and competitor price reductions.

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THE ROLE OF ORAL NUTRITIONAL SUPPLEMENTS IN THE MANAGEMENT OF ADULT MALNUTRITION

“Staff know that if there are any problems a dietitian will call� - Care Home Manager, County Durham and Darlington Foundation Trust (CDDFT)

risk of undernutrition. Advice included taking two ONS per day and he was registered on HCUN with the care home inputting information using the secure web portal. The information received from the home the following week highlighted that the prescription for the ONS was not correct and he had only been prescribed one per day. The dietitian was able to liaise with the GP surgery and have this amended. His weight has since increased and he is now low risk of undernutrition. Under the traditional service delivery model he would still be waiting for an assessment which could take up to three months

and the error in the prescription would have been unlikely to be highlighted until the following review appointment in another three months meaning that Mr C would have continued to lose weight, making the dietetic input more complex and exposing him to potential health complications as a result of undernutrition.

Conclusion Health Call Undernutrition has been demonstrated to improve the quality of care to patients whilst improving the capacity and efficiency of the dietetic services.

References: Department of Health (2013). The Mandate. A mandate from the Government to the NHS Commissioning Board April 2014 to March 2015 https://www.gov.uk/government/uploads/system/uploads/attachment_ data/file/256497/13-15_mandate.pdf (Accessed June 2016)

1

Monitor (2013). Closing the NHS funding gap: how to get better value care for patients. https://www. gov.uk/government/uploads/system/uploads/attachment_data/file/284044/ClosingTheGap091013.pdf (Accessed June 2016)

2

NHS England 2014: Five Year Forward View http://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf (Accessed June 2016)

3

Elia M (2015): The cost of malnutrition in England and potential cost savings from nutritional interventions (full report). A report on the cost of disease-related malnutrition in England and a budget impact analysis of implementing the NICE clinical guidelines/quality standard on nutritional support in adults. BAPEN http://www.bapen.org.uk/pdfs/economic-report-full.pdf (accessed June 2016)

4

Brotherton A, Simmonds N, Stroud M (2012) Malnutrition matters: meeting quality standards in nutritional care. A toolkit for commissioners and providers in England. Redditch: British Association for Parenteral and Enteral Nutrition

5

NHS England 2015; Guidance - Commissioning Excellent Nutrition and Hydration 2015-2018 https://www.england.nhs.uk/wp-content/uploads/2015/10/nut-hyd-guid.pdf (accessed June 2016)

6

Nutrition support for adults: Oral nutrition support, enteral tube feeding and parenteral nutrition, Clinical Guideline 32, National Institute for Health and Clinical Excellence (NICE) 2006

7

NICE Quality Standards for Nutrition Support in Adults (QS24). National Institute for Health and Clinical Excellence 2012 http://publications.nice.org.uk/quality-standard-for-nutrition-support-in-adults-qs24 (Accessed June 2016)

8

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Primary Care Reports – The Role of Oral Nutritional Supplements in Management of Adult Malnutrition  

The Role of Oral Nutritional Supplements in the Management of Adult Malnutrition – Nualtra limited

Primary Care Reports – The Role of Oral Nutritional Supplements in Management of Adult Malnutrition  

The Role of Oral Nutritional Supplements in the Management of Adult Malnutrition – Nualtra limited