CLINICAL
ORAL NUTRITIONAL SUPPLEMENTS: NUTRITION SUPPORT IN THE OBESE HOSPITAL INPATIENT Jessica Coates Acute Dietitian, Wirral University Hospital NHS Foundation Trust Jess works as an Acute Dietitian in a large district general hospital. She sees patients with a variety of needs, often focusing on nutrition support. Gastroenterology is becoming one of her main interests. @JessCoatesRD
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As obesity continues to become a growing problem in the UK and across the world,1 an increasing emphasis is being placed on all aspects of hospital treatment for this patient group. This article will look into the screening and assessment of nutritional risk, as well as use of oral nutritional supplements (ONS), in the obese hospital inpatient. As an Acute Dietitian, I am only too aware of the consequences of malnutrition. Increased risk of infection, poor wound healing and increased length of hospital stays are just a number of the negative effects experienced by patients. Rapid weight loss in hospitalised patients is associated with increased complications and poor outcomes, regardless of original body mass index (BMI).2 So, what happens when an obese patient is malnourished? Are they screened in the same way as a ‘frail’ patient? Are they offered the same assessment and treatment as their neighbour on the ward? NUTRITIONAL SCREENING
Current NICE guidelines state that all hospital inpatients should be screened for malnutrition on their admission and weekly thereafter.2 NICE also suggests that unintentional weight loss and period of reduced intake should be considered, using validated tools such as BAPEN’s Malnutrition Universal Screening Tool (MUST). In those with a BMI of >20kg/m2, malnutrition risk is heightened by: • unintentional weight loss greater than 10% within the last three to six months; • having eaten little or nothing for more than five days and/or are likely to eat little or nothing for the next five days or longer; • a poor absorptive capacity and/ or have high nutrient losses and/ or have increased nutritional needs from causes such as catabolism.2
www.NHDmag.com April 2018 - Issue 133
Early identification of this risk facilitates appropriate management to be instigated without delay and can avoid a patient’s nutritional status deteriorating further. The most recent data available from BAPEN’s Nutritional Screening Week project shows that 49% of patients with a MUST score of 2 or more (usually triggering referral to Dietetic departments), had a BMI of <20kg/m2.3 Could this be because those patients with a higher BMI are not being properly screened? We know that some healthcare professionals (HCPs) tasked with screening for malnutrition would prefer to use their own clinical judgement when assessing risk, rather than using valuable time to fully complete a screening tool.4 In a small study on a medical admission unit, it was found that many nurses were reluctant to weigh patients, feeling that it was ‘unnecessarily invasive’ and made them feel uncomfortable.5 This is despite the fact that research has shown high risk of malnutrition is a common finding in obese hospital inpatients, leading to similar negative outcomes to those patients who have a low BMI.6 Anecdotally, a further barrier can be lack of appropriate and available bariatric weighing equipment. Many hospital scales have a maximum weight of 200kg and some clinical areas can struggle to access chair, bed or hoist scales. Regardless that any hospital inpatient is at risk of protein wasting and muscle loss,7 obesity on admission