COMMUNITY
A FOOD-FIRST APPROACH TO EATING AND DRINKING WELL
Gill Hooper Freelance Registered Nutritionist Gill works in training and education around nutrition and hydration to provide quality dementia and frailty care. She is currently working with Bournemouth University looking at the impact of improving nutritional care for people with dementia.
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With an ageing population and increasing numbers of people at risk of undernutrition, it is important to identify those at risk and encourage food and drink intake through a food-first approach. It is estimated that over three million people in the UK are affected by malnutrition, or ‘undernutrition’ and of those, approximately 1.3 million are over the age of 65. Most of these people are living in their own homes in the community. According to BAPEN nutrition screening week surveys (200711), 30-42% of people admitted to care homes are at risk of malnutrition.1 A report, The cost of malnutrition in England and potential cost savings from nutritional interventions, published by the National Institute for Health Research, Southampton Biomedical Research Centre (NIHR Southampton BRC) and BAPEN, says that the estimated cost of malnutrition in both adults and children in England in 2011-12 was £19.6 billion.2 With an ageing population and rising costs of health and social care, this figure is likely to increase and is an issue which needs to be addressed. WHY IS THERE A PROBLEM?
There are a number of factors which increase the risk of malnutrition, from social factors such as living in isolation and poverty, having little knowledge of nutrition, or inability to cook, to medical factors including mental health conditions, cancer, dementia and dysphagia. Physical factors, such as poor dental care and limited mobility, may also increase the risk of malnutrition. An older person living alone may be socially isolated, unable to get out to the shops to buy food because of reduced 42
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mobility, have difficulty eating due to a loss of ability, or may have a loss of appetite. For someone living with dementia, eating and drinking can become increasingly difficult as the dementia progresses; there may be confusion recognising food, or remembering how to eat, difficulties with chewing and swallowing, or a change in food preferences. There is a widely held belief that weight loss is a normal part of ageing, but this is a myth. Unexplained, or unintentional weight loss, is a serious issue and can lead to the risk of malnutrition. This in turn can result in a greater susceptibility to illness and disease, a delay in recovery, reduced muscle strength and the risk of falls. At least 25% of people admitted to hospital are at risk of malnutrition,1 resulting in further deterioration and poor clinical outcomes. This vicious spiral is demonstrated by the ‘Malnutrition Carousel’ (see Figure 1). As we have seen, over one million people in the UK over the age of 65 and living in the community are undernourished. How can we reduce malnutrition and encourage food and drink intake for those at risk? Nutritional support should always be appropriate to individual needs, but generally, a ‘food-first’ approach is best. For people who are undernourished, underweight or at risk of malnutrition, it is important that food and drinks contain
COMMUNITY Figure 1: The ‘Malnutrition Carousel’ (BAPEN)3
as much energy and protein as possible. Advice should be given on how to adapt meals and snacks by adding small amounts of high energy and protein foods to increase the energy and nutrient content without increasing portion sizes. Much of this advice goes against traditional ‘healthy eating’ messages. However, a food-first approach is the best way to help prevent weight loss. But, how can we identify those at risk and begin conversations about good nutrition and hydration and avoid the vicious spiral described above? THE PAPERWEIGHT ARMBAND
In 2013, Salford, in Greater Manchester was chosen as a pilot area to be part of the Malnutrition Prevention Programme4 for 12 months. The programme encouraged a whole community approach to tackle malnutrition, including local NHS Trusts, GPs, hospitals, care homes and community groups; its aim being to significantly reduce the number of people aged 65 and over who are malnourished.4 Five key principles to providing good nutrition and hydration care were identified:4 1 Raise awareness of malnutrition. 2 Work together. 3 Identify older people who are malnourished or at risk. 4 Provide support, care and treatment and monitor progress. 5 Monitor and evaluate your activities.
In Salford, a nutrition committee was established and along with Age UK Salford, the PaperWeight Armband was developed.5 The armband is a non-intrusive intervention that can be implemented quickly and easily by healthcare providers and the voluntary sector. It is a simple strip of paper used to measure the upper arm; if it can slide up and down easily, there is a high risk of malnutrition. The Armband was piloted by Age UK Salford with support workers using it on their home visits. If someone was identified at risk, further information, advice and support was given on simple dietary changes that could be made to increase energy intake. The Armband was launched at Food Matters Live in 2015 and is now promoted throughout Greater Manchester by the Greater Manchester Nutrition and Hydration Programme, which aims to make sure older people are eating and drinking well enough to keep healthy and remain independent. They are doing this by raising awareness of undernutrition in the community through various activities, providing training and using the paperweight armband to identify those who are risk of undernutrition. Activities have included a ‘Lunch and Learn’ group where over-65s come together for a meal with children from a local nursery and all learn about eating and drinking well. A 76-year-old woman, whose malnutrition was identified through the Armband, said: “I was www.NHDmag.com May 2019 - Issue 144
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COMMUNITY Table 1: Suggestions for high energy snacks and drinks10 Crisps Sausage rolls Toasted crumpets and cheese Dried fruit Small chocolate bar Scones with jam and cream Chocolate digestives Fruit and custard Ice-cream Mousse Hot chocolate and marshmallows Fruit juice Regular fizzy drinks
Savoury Handful of nuts Pork pie Creamy soup Sweet Banana Malt loaf Jelly sweets Croissant/pain au chocolate Dessert Trifle Full fat yoghurt Rice pudding Drinks Milky coffee Fruit smoothies
Hummus and bread sticks Cheese and biscuits
Shortbread Cakes Flapjack Muffins Cream meringues Milk jelly Tinned fruit in syrup Hot malted milk Milk shake
It is important to remember that some of the sugary snacks and drinks listed may not be suitable for people with diabetes. Table 2: How to increase energy content through food fortification10 Food to be fortified
Amount
Energy before (Kcal)
Whole milk
568ml
375
4 tablespoons dried skimmed milk powder
583
Custard
125ml
148
Add 1 tablespoon of dried skimmed milk powder and 2 tablespoons of double cream
349
Milk-based soup
125ml
80
Add 1 tablespoon of dried skimmed milk powder and 2 tablespoons of double cream
280
Porridge with whole milk
200g
226
Add 1 tablespoon of dried skimmed milk powder and 2 tablespoons of double cream
426
1 scoop
70
Add 1 tablespoon of butter & 1 tablespoon double cream
183
Mashed potato Vegetables
Add these ingredients to increase energy content (Kcal)
Energy after addition (Kcal)
2tbsp
15
Add 1 teaspoon of butter
52
Baked beans
80g
67
Add 1 teaspoon butter and 20g grated cheese
188
Scrambled egg with whole milk
120g
308
Add 1 teaspoon of butter, 2 teaspoons dried skimmed milk powder and 45g cream cheese
603
Rice pudding
125ml
106
Add 1 tablespoon of dried skimmed milk powder & 2 tablespoons double cream and 2 teaspoons of jam
332
admitted to hospital because I was dehydrated and was there for four days. After this, I was not able to go out and buy my own food and I lost a lot of weight. I was down to 7 stone.” After using the Paperweight Armband this lady was referred to the Lunch and Learn group and subsequently gained 2.5 stone. She said, “It gets me out and got me talking to people because I never talked before, I was just on my own.”6 44
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Most importantly, the programme promotes a food-first approach and a number of useful resources have been produced, including diet sheets7 and a booklet entitled, Are you eating enough?.8 In November 2018, Greater Manchester Health and Social Care Partnership reported that, “In the three years since the ‘PaperWeight Armband was introduced in Salford, it has resulted in a 50% increase in cases of malnutrition
COMMUNITY Table 3: Suitable ingredients for fortifying food10 Add this food
Quantity
Dried skimmed milk powder
1 tablespoon (15g)
Double cream
1 tablespoon (15g)
74
Crème fraiche
2 tablespoons (30g)
113
Butter
1 teaspoon (5g)
37
Olive oil
1 teaspoon (4g)
36
Cheddar cheese
25g
104
Mayonnaise
1 tablespoon (15g)
104
Dates
4 medium (30g)
81
Jam
1 tablespoon (20g)
52
Sugar
1 teaspoon (5g)
20
Honey
1 tablespoon (18g)
52
being identified and a reduction of £300,000 spent on nutrition supplements by GPs”.9 FOOD FIRST
Increasing the energy density of meals and making small changes can make a massive difference to someone identified at risk of weight loss and undernutrition. The following advice can be given to increase calorie and nutrient content without increasing the amount of food eaten. However, it is important to note that if someone is still losing weight after 12 weeks of trying some of these suggestions, or experiences sudden weight loss, they should be referred to their GP: • Eat little and often – try to eat three small meals a day with two or three snacks in between, ideally every two to three hours. (See Table 1 for some suggestions.) • Fry meat, chicken and fish where possible, or add creamy sauces, batter or breadcrumbs. • Use full fat, full cream and sugar products to add extra calories – whole milk in place of semiskimmed, butter rather than low fat spreads. • Add high energy and protein foods such as butter, cream, cheese, or jam to increase the calorie and protein content. For example, stir two tablespoons of crème fraiche into a bowl of soup for a further 113 calories. (See Tables 2 and 3). • Include nutritious drinks to increase calorie intake, such as milk-based drinks, fruit juice and fortified soups.
Kcals 53
SUMMARY
With an ageing population and increasing numbers of people at risk of undernutrition, we have seen the importance of identifying those at risk and raising awareness of a food-first approach, thus avoiding clinical intervention and the ‘malnutrition carousel’. It is important to dispel the myth that weight loss is a normal part of ageing. The PaperWeight Armband is an excellent example of a non-intrusive nutritional intervention. It can be helpful in starting a conversation about food and drink intake, which otherwise might be difficult, and offers signposting to further information and advice. It can be used in a health and social care setting, but has a wider potential and can be used by family members, domiciliary carers, community pharmacists and volunteers at community groups, such as lunch clubs and church groups. A food-first approach goes against ‘healthy eating’ messages, but is the best way to encourage food and drink intake in those at risk of undernutrition. The final words go to Alf, an 82-year-old man, whose malnutrition was identified through the PaperWeight Armband. He says, “I’ve just started taking notice of what I’m eating, building myself back up again. When I want to put on weight, I start eating things you’re not supposed to eat when you are slimming and I have the blue milk, which I prefer anyway.”6 www.NHDmag.com May 2019 - Issue 144
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