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NGSIG Position Paper
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Assessment & Planning
Nutritional Screening should alert health and social care staff to the need for more detailed nutritional assessment by a dietitian. Decisions about the appropriateness and effectiveness of nutritional support should then be made by the multidisciplinary team.
Thanks are due to many healthcare professionals who provided copy for this area of the BAPEN website. Among them are...
- Nicki Simmonds
- Stacey Jones
- Eleanor Gratton
- Tim Wilson
With thanks also to the PENG committee of 2016 who reviewed content.
Nutritional assessment is the systematic process of collecting and interpreting information in order to make decisions about the nature and cause of nutrition related health issues that affect an individual (British Dietetic Association (BDA), 2012).
This differs from nutritional screening (link to Screening and MUST page) which is a brief risk assessment which can be carried out by any healthcare professional and which may lead to a nutritional assessment by a dietetician.
Following a structured assessment path enables health professionals to carry out a quality nutritional assessment in order to identify those who need nutritional intervention, and to improve clinical decision making using a person centred approach. The process promotes consistent quality of practice; is user friendly; and allows effective monitoring of patients. A structured assessment pathway does not remove autonomy; it encourages professional judgement and informed decision making at every stage. The process provides a rationale for the nutritional intervention, and allows for revision of the plan as individual circumstances change over time.
BDA nutrition and dietetic care process (BDA, 2012)
Anthropometry allows for an assessment of the different component parts of the human body. Body composition refers to the anatomical makeup of the body in terms of bone, muscle, water and fat. A single measure will not provide a comprehensive overview of the patients’ condition and so a number of measurements are required to form a more reasoned assessment. In malnutrition, changes in body composition lead to Introduction to Malnutrition.
Anthropometric measurements that can be used to assess body composition.
|Measurement||Equation/ method||Interpretation of results|
|Weight and % weight change||% weight change = (current weight - previous weight/ current weight) x 100||
A patient is indicated for nutrition support if they have:
|Body mass index (BMI)||BMI (kg/m2) = weight (kg) / height 2 (m2)||
|Mid upper arm circumference (MUAC)||Involves measuring the circumference of the mid-point on upper arm using a tape measure. This is a surrogate measure of both fat mass and fat free mass. It is a useful measure when a person cannot be weighed or if their weight is not likely to be a true reflection of the persons’ actual weight, e.g. if the patient has oedema or ascites.||
|Skin fold thickness||Measurement requires a trained person using skin fold callipers which have been calibrated. Skin fold measurements can be taken at 4 different sites: suprailliac, subscapular, biceps, triceps (TSF; most commonly used). Measurement should be repeated 3 times and the mean result recorded. This is a surrogate measure of total fat mass. Longitudinal measurements can be used to identify any changes in fat mass.||Centile tables can be used to interpret skin fold thickness measurements.|
|Mid arm muscle circumference (MAMC)||
MAMC is a surrogate measure of fat free mass and is calculated using MUAC and TSF.
MAMC (cm) = MUAC (cm) – 3.14 x TSF (cm)
|Centile tables allow assessment of changes in total body muscle mass over time.|
Other visual signs may indicate recent weight loss such as loose jewellery, baggy clothes, extra notch in belt, ill-fitting dentures, loose or thin looking skin, and prominent bony features.
The blood tests conducted within a nutrition assessment are interpreted in conjunction with a clinical examination; previous medical history; and current medications. Biochemistry tests measure levels of chemical substances present in the blood. Functional tests measure the function of vital organs such as the kidneys or liver.
|Measurement||Rationale||Normal range (note that different laboratories may use different reference ranges)|
|Haemoglobin (Hb)||Assess for iron status or indicate anaemia.||
Women = 12.0 to 15.5 g/dl
Men = 13.5 to 17.5 g/dl
|Albumin (Alb)||A low level may indicate inflammation or infection is present, therefore should not be used to determine nutritional status.||35 - 50 g/L (3.5 - 5.0 g/dL)|
|C-Reactive Protein (CRP)||This is an inflammatory marker which is raised when infection or inflammation is present.||Ideally <10 mg/L|
|White cell count (WCC)||Immune system marker; is raised if infection is present.||4-11 x109/L (4000-11,000 per cubic millimetre of blood)|
|Glycated Haemoglobin (HbA1c)||Indicates an average blood sugar level over a period of months.||Ideally <48 mmol/mol or <6.5% (Diabetes UK)|
|Sodium (Na)||This is an indication of hydration status and kidney function. A raised sodium level may indicate dehydration.||135-145 mmol/L|
|Urea (Ur)||Used to assess kidney function. High urea and other markers levels in combination may indicate dehydration.||2.5-7.1 mmol/L|
|Calcium and Phosphate||Used as a baseline when assessing risk of refeeding syndrome Calcium is adjusted for albumin level||
Adjusted Ca 2.0-2.6 mmol/l
Phosphate 0.7-1.4 mmol/l
|Magnesium||Likely to be low if there are large GI losses||0.7-1.0 mmol/l|
|Micronutrients||Include vitamins and trace elements. These are affected by the acute phase response if inflammation or infection is present and so best measured when CRP is low|
A person’s disease state may increase the risk of malnutrition due to increased energy requirements; reduced energy intake; or increased nutritional losses. Examples of diseases/conditions where this may occur include:
- Chronic Obstructive Pulmonary Disease
- Heart failure
- Gastrointestinal disorders such as Crohns disease, liver disease, coeliac disease
- Neurological conditions such as stroke, Motor Neurone Disease, Parkinsons Disease, multiple sclerosis, dementia
- Burns, surgery or trauma
- Mental health conditions (such as depression)
Symptoms that may impact on a person’s nutritional status either through reducing nutritional intake or increasing nutritional losses include:
- altered bowel movements e.g. diarrhoea, constipation
- upper gastrointestinal upset e.g. reflux, bloating, nausea, and vomiting.
- early satiety
- Estimate Basal Metabolic Rate (BMR) using Henry Equations (2005) based on age, gender and weight (Henry, 2005) or estimate requirements for stable patients using 25-35kcal/kg (NICE 2006).
- Add factor when patient is metabolically stressed
- Add factor for activity and diet induced thermogenesis
- If aiming for weight gain, add 400-600 kcal/day. Only add this for patients who are metabolically stable (i.e. not acutely unwell).
- There are a number of alternative methods to calculate energy requirements in patients who are obese, with care required not to over-estimate requirements.
(Weekes and Soulsby, 2011)
Aged >60 years = 30ml/kg body weight
Aged <60 years = 35ml/kg body weight (Todorovic and Micklewright, 2011)
An estimation of the total daily calorie intake, as well as overall quality of diet should be assessed. Asking the patient (or their family/carer if patient unable) about their daily dietary intake will help understand patterns of eating, portion sizes, cooking methods and types of food and drink taken. Consider asking the following questions to help form a better understanding of the patients’ overall diet:
- What is the patients’ typical food and fluid intake? This can be recorded using food record charts; 24-hour recall; 3-day food diary; or typical day diet history.
- Is the patient eating 3 meals a day?
- Do they have pudding after at least one meal per day?
- Are they eating snacks in between meals?
- Are they eating smaller meals than they used to when they were feeling well?
- Are they having regular drinks, at least 6-8 glasses of fluid/ day?
- Are they having nutritious drinks such as milky tea/coffee, fruit juice, milky drinks?
- Are they having carbohydrate foods (bread, potatoes, pasta, rice, breakfast cereals etc) and protein foods (meat, cheese, beans, egg, fish, milk, yoghurt, cream) at each meal time? Portion sizes should be at least the size of the patient’s fist and amount to 1/3 each on the plate (carbohydrate, protein, vegetables).
- Are they eating at least one portion of fruit or vegetable each day?
- If food is being blended, are they adding nutritious liquids such as milk, cream or gravy to aid blending, rather than water?
- Are they able to cook for themselves?
- Do they have access to essentials such as bread, milk and cheese on a daily basis?
- Do they have a hot/cooked meal each day?
- Are they taking any nutritional supplements? Do they take them as recommended? Do they like them?
|Ability to shop, cook, assistance with eating and drinking, mobility, budget restraints, limited storage facilities, meal timings, family support.||Appetite, dentures, dexterity, use of cutlery, sight, taste changes, nausea, vomiting, heart burn, bloating, early satiety, diarrhoea, constipation, pain, breathing difficulties, dysphagia (swallowing problems), food intolerances, special diets, diminished thirst, taste preferences.|
Assessment of risk of re-feeding syndrome:
Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients on refeeding following a period of starvation (NICE, 2006). This is particularly common in patients receiving artificial refeeding, but is possible with oral refeeding (particularly if oral nutritional supplements are prescribed). The patient should be considered at risk of refeeding syndrome if they meet the following criteria (NICE 2006).
If the patient has one or more of the following:
- Body mass index <16 kg/m2
- Unintentional weight loss >15% in the past three to six months
- Little or no nutritional intake for >10 days
- Low levels of potassium, phosphate, or magnesium before feeding
Or the patient has two or more of the following:
- Body mass index <18.5 kg/m2
- Unintentional weight loss >10% in the past three to six months
- Little or no nutritional intake for >5 days
- History of alcohol misuse or drugs, including insulin, chemotherapy, antacids, or diuretics
If the patient is considered to be at high risk of refeeding syndrome, the following steps are advised by NICE (2006):
- Start nutrition support at a maximum of 10 kcal/kg/day, increasing levels slowly to meet or exceed full needs by 4–7 days
- Restore circulatory volume and monitoring fluid balance and overall clinical status closely
- Provide immediately before and during the first 10 days of feeding: oral thiamine 200–300 mg daily, vitamin B co strong 1 or 2 tablets, three times a day (or full dose daily intravenous vitamin B preparation, if necessary) and a balanced multivitamin/ trace element supplement once daily
- Provide oral, enteral or intravenous supplements of potassium (likely requirement 2–4 mmol/kg/day), phosphate (likely requirement 0.3–0.6 mmol/kg/day) and magnesium (likely requirement 0.2 mmol/kg/day intravenous, 0.4 mmol/kg/day oral) unless pre-feeding plasma levels are high. Pre-feeding correction of low plasma levels is unnecessary
Nutritional/Dietetic Diagnosis (BDA, 2012)
The information gathered as part of the assessment should be reviewed and synthesised and from this a nutritional diagnosis should be determined.
The alterations in the client/group/populations' nutritional status.
The related factors contributing to the existence of, or maintenance of pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental problems.
Signs and Symptoms
The defining characteristics are a cluster of subjective and objective signs and symptoms established for each nutritional diagnosis. The defining characteristics are gathered during the assessment phase and provide evidence that nutrition related problem exist.
The next phase of the care process is the intervention, which is divided into the plan and implementation.
Identify the overall aim of treatment. It may be minimise further losses, prevent further weight loss, maintain nutritional status, increase weight or improve nutritional status.
Identify several short term goals/ action points that will be changed as a result of the assessment.
These should be written as SMART goals (Specific, measurable, achievable, realistic, and timely). The goals should be negotiated and agreed between the health care professional and the patient or carer.
A timeframe for follow up and review should be agreed upon.
The implementation and monitoring phases of the care process will be discussed in subsequent sections.
British Association of Parenteral and Enteral Nutrition (BAPEN) Malnutrition Universal Screening Tool (MUST) http://www.bapen.org.uk/pdfs/must/must_full.pdf
British Dietetics Association (BDA) (2012) Model and Process for Nutrition and Dietetic Practice. https://www.bda.uk.com/publications/professional/model
Henry (2005) Basal metabolic rate studies in humans: measurement and development of new equations. Public Health Nutrition. 8: 1133-1152
National Institute of Clinical Excellence (NICE) (2006) Nutritional Support in Adults https://www.nice.org.uk/guidance/cg32/resources/nutrition-support-for-adults-oral-nutrition-support-enteral-tube-feeding-and-parenteral-nutrition-975383198917
Scientific Advisory Committee on Nutrition (SACN) (2011) Dietary Reference Values for Energy. London: TSO
Todorovic, V.E., and Micklewright, A. (2011) A pocket guide to clinical nutrition fourth edition. Parenteral and Enteral Group of the British Dietetic Association.
Weekes, L and Soulsby C (2011), in Todorovic, V.E., and Micklewright, A. (2011) A pocket guide to clinical nutrition fourth edition. Parenteral and Enteral Group of the British Dietetic Association.
World Health Organisation (WHO) 2016 http://apps.who.int/bmi/index.jsp?introPage=intro_3.html
Ethics & Decision Making
BAPEN has several resources on ethics and decision making in nutrition. As part of the free access “Essentials of Clinical Nutrition” series, see the e-Learning module at www.bapen.org.uk/bapenlearning/vle/doctors.php
If you are a BAPEN member you may wish to hear Dr Rodney Burnham’s Keynote Lecture from BAPEN conference 2014:
- “Feed me with food convenient to me. Nutritional Support towards the end of life.” www.bapen.org.uk/bapenlearning/vle/conference2014.php
You might also wish to hear some other presentations on similar topics from the same conference:
- Professor Mike Stroud’s presentation on “Chronic IF to the end – how to manage end of life on PN” from the symposium “A safe pass”
- Dr Mani Nagibi’s presentation on “HPN treatment during the palliative phase of malignancy – a UK single centre case series with analysis of survival prediction.”
From 2015 DDF meeting, there are also sessions covering palliative care:
- Dr Rachel Burman presenting on “appropriate nutritional support: feeding dilemmas at the end of life.”
- Dr Jeremy Woodward presenting on “Palliative HPN: how to select the patient”
Both of these in the symposium “Feeding in Cancer: prolonging life or prolonging death”.
If you are not a BAPEN member it is possible to pay for access to these presentations but look at the Join BAPEN page to see the costs to become a member!
Enteral and Parenteral Nutrition
When patients have problems with eating or digestion, it is sometimes necessary to provide nutrition with artificial food, which is specially formulated to provide the right balance of fats, proteins, sugars, vitamins and minerals. These artificial preparations can be delivered into the gut to be absorbed in the usual way, which is known as Enteral Nutrition. Alternatively, they may be delivered into the blood stream through a drip to bypass the gut, which is known as Parenteral Nutrition.
If the gut is working normally to absorb food and nutrients, then Enteral Nutrition is the preferred way of delivering nutritional support. In some patients, enteral nutrition may have to be delivered into the gut through a tube, but in others it may be possible for them to take this by mouth.
Enteral nutrition by mouth
This form of nutrition support is used for patients who are unable to eat enough food, either because they have a poor appetite, eating is difficult or because their body requires additional energy because of illness. Nutritional products can be eaten or drunk in addition to any food or drink that the patients may be able to manage. These products provide more energy and nutrition than normal food, so patients don’t have to consume a large amount.
Enteral nutrition through a tube
Enteral nutrition delivered into the gut by a tube is used where nutrition cannot be taken normally by mouth, but the gut is otherwise working. Common reasons for the use of this type of nutrition include
- Strokes or other neurological conditions which impair swallowing
- After some types of operations on the face, neck, throat, gullet or stomach
- Blockages of the gullet or stomach
- After radiotherapy to the throat or gullet
In the first instance, feeding tubes are usually placed through the nostril to pass down the gullet to lie in the stomach or small bowel. Liquid nutrition is then slowly pumped down the tube. If it is likely that the patient’s ability to eat will not recover quickly or may not recover at all, then a feeding tube can be placed through the abdominal wall into the directly into the stomach (gastrostomy).
If the patients gut cannot be used to absorb nutrients, then nutrition must be delivered into the patient’s blood stream, bypassing the gut. Reasons for this type of feeding include
Blockage of the gut (obstruction) or the gut failing to work (ileus)
Perforations of the gut where feeding will result in worsening infections
Where a large part of the gut has been removed and the patient cannot absorb enough food (short bowel syndrome)
Where parts of the bowel are diseased and not able to absorb properly (functional short bowel)
Parenteral nutrition is slowly pumped into the blood stream through a drip. As it can be very irritant to blood vessels, it is normally given into a large vein near the heart though a central venous line placed into the upper arm, chest or neck. Using parenteral nutrition can sometimes result in serious problems such as blood infections or an upset in biochemistry. Therefore, patients need intensive monitoring. If the problem with gut function is permanent or likely to persist for a long time some patients may be taught how to manage their own parenteral nutrition at home (Home Parenteral Nutrition).
The choice between enteral and parenteral nutrition
In general, enteral nutrition is preferred to parenteral nutrition as it is more physiological, simpler, cheaper and less complicated. However even nasogastric feeding needs care and the more complex types of enteral nutrition such as gastrostomy and jejunostomy need significant interventions. It is therefore important that any institution using artificial nutrition follows strict protocols and procedures for its use.
Sometimes the choice between enteral and parenteral nutrition is difficult and at different stages in an illness a patient may need different types and amounts of artificial nutritional support. At some stages both enteral and parenteral nutrition may be needed. The ongoing advice of a nutrition support team is vital in this area.
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