Rehabilitation & Assessment Directorate

Nutrition and Dietetic Service

A guide to the Use of the MUST ( Malnutrition Universal Screening Tool)

for Care Home Residents

Nutrition and Dietetic Service Old Johnstone Clinic 1 Ludovic Square Johnstone 01505821823 updated April 2012

Contents

1. Introduction

2. MUST Guidance Notes

3. MUST Tool (including Body Weight Calculation in Amputees guidance)

4. Nutritional Support Pathway – Local policy

5. Nutritional Support : First line dietary advice

6. Sample Food Fortification Menus

7. Weekly Food intake Chart

8. Ideas for Finger Food Meals

9. Use of Oral Nutritional Supplements (ONS)

10. First line advice for other dietary conditions: Constipation

Diabetes Weight Management Iron deficiency anaemia 11. Dietetic Referral Guidance and Referral Form

Updated April2012

Introduction

A Nutrition and Dietetic Service Review Group within Renfrewshire was set up in 2008 with a remit to :

• Ensure a clinically effective service is available to meet the needs of residents in care homes

• Promote the recommendations of NHS Greater Glasgow and Clyde, Quality improvement Scotland, Food, Fluid and Nutritional Standards and the Care Commission Standards

As a result it was agreed:

• MUST ( Malnutrition Universal Screening Tool) would be the preferred screening tool for residents in all Care Homes within the area.

• Each care home unit would be provided with resources to ensure the use of the appropriate care pathway for residents requiring nutritional support

• Care homes would Identify ‘Nutrition Link’ staff to be trained in use of MUST, local care pathway and implementation of 1st line nutritional support for residents. These staff would be responsible for informing and training other staff their care home.

• Details of the available training programme would be issued regularly to care homes and also from the address listed in the front of this folder.

This pack contains the MUST papers and supporting resources for use within the Care Home Please note that additional copies of MUST and other resources can be obtained from Renfrewshire CHP’s website at www.chps.org.uk/renfrewshire

Updated April 2012

‘MUST’ Guidance Notes The Care Commission (now known as the Care Inspectorate) recognises that nutrition in care homes is fundamental to good care and residents should have access to varied and nutritious foods, which meet the individuals requirements. The National Care standards state that care homes should provide nutritious meals, which reflect food preferences and special dietary needs. They also state that Nutritional Screening should be part of every resident’s care planning. Purpose of these guidance notes These notes are to enable the consistent use and interpretation of ‘MUST’ (Malnutrition Universal Screening Tool) What is ‘MUST’ The Malnutrition Universal Screening Tool (‘MUST’) has been designed to help identify adults who are underweight and at risk of malnutrition, as well as those who are obese. It has not been designed to detect deficiencies in or excessive intakes of vitamins and minerals. When should MUST be used? MUST is designed to be used for all new residents and thereafter for review of residents as indicated by the pathway. Who should fill out the MUST tool? The tool should be filled out by a member of staff who has full access to the resident’s :

• Current Height & Weight

• BMI ( Body Mass index)

• Previous weight (preferably over several weeks or months)

• Previous and current dietary intake either by observation, discussion with resident / relatives / other staff or by use of weekly food intake charts.

• Any medical condition affecting dietary intake What preparation is required prior to using the MUST?

• Obtain copy of MUST assessment tool – either specific tool within residents care plan or obtain from website www.chps.org.uk/renfrewshire

• Have all appropriate patient information as above. Using MUST Complete assessment tool:-

• Step 1 Obtain score for BMI

• Step 2 Obtain score for weight loss

• Step 3 Obtain score for Acute Disease Effect ( Note that this refers to an ‘ acute’ episode of illness where there is NO nutritional intake for several days, it does not apply to patients with small intake of food or drink or those with chronic disease affecting food intake)

What next? Follow the Local Nutritional Support Pathway to decide the appropriate action that should be taken. Must Guidelines page 1

When should I request advice from Dietitian? The Local Nutritional Support Pathway will guide you to when you should refer a resident to the dietitian. This will normally be after you have tried 1st line advice for at least 4 weeks without improvement. However if you have concerns regarding a resident you can telephone the dietetic department for further advice on 01505 821823 What about residents who are not underweight but have other dietary concerns? MUST should be used for all residents to assess the need for dietary advice Advice is available for conditions other than weight loss / poor appetite including (SEE SECTION 10);

• Diabetes

• Weight management

• Constipation

• Iron deficiency anaemia What if I follow the Nutritional support pathway and it advises me to refer resident to Dietitian?

• You will be required to arrange for the Nutrition and Dietetic Service Referral Form to be completed and sent to the Old Johnstone Clinic. This form can be completed by the Nurse in Charge, manager or the residents General Practitioner It is important that all parts of the form are completed otherwise the referral will be returned to the referrer and this will delay treatment for the resident.

• Continue to provide 1st line Dietary advice until you are contacted by the dietitian. What will the Dietitian do when referral received?

• The referral will be checked to ensure that all the necessary information has been included and the resident will be placed on a waiting list for assessment.

• Within a short period of time the care home will be contacted by telephone by someone from the Dietetic service.

• At this time you will be asked to provide a summary of the 1st line Dietary advice that has already been carried out and information about resident’s weight over the previous few weeks. If you do not have access to this information ask the Dietitian to call back at a time when the information will be available.

• After discussing the resident with staff the Dietitian will agree a plan of action with you and if appropriate arranged to visit the care home to discuss further.

Will the Dietitian visit the care home until patient reaches an optimum weight?

• No, the dietitian will provide whatever support is appropriate for your resident. This may involve visits to the care home or it may be support to staff via telephone. Once the dietitian is satisfied the resident is progressing, everything that can be done is being done or that contact is no longer appropriate, this will be discussed with care home staff and a future action plan / discharge from dietetic service agreed.

Who do I contact if I am unsure whether referral is required or what has been previously agreed with dietitian? If you need advice contact Nutrition & Dietetic Service Old Johnstone Clinic 1 Ludovic Square JOHNSTONE PA5 8EE 01505-821823

Must Guidelines page 2

A full copy of the MUST screening tool can be downloaded from the following website:-

www.bapen.org.uk/pdfs/must/must_full.pdf

Body weight calculations in amputees:

For amputations, increase weight by the percentage below for

contribution of individual body parts to obtain the weight to use to determine Body Mass Index

Body Part % of body weight

Upper Limb 4.9

Upper arm 2.7 Forearm 1.6 Hand 0.6

Lower Limb 15.6

Thigh 9.7 Lower Leg 4.5 Foot 1.4 Table reproduced from Manual of Dietetic Practice

Fourth edition published 2007 by Blackwell Publishing Ltd

Nutritional Support care pathway - Local Policy (Care Homes)

Intake adequate or Improved no improvement

or intake found to be inadequate

Intake good or improved Weight stable or increased No improvement. Weight / intake continues to deteriorate

Patient identified as requiring nutritional support via MUST screening

Respite residents -social situation limited support, Problems with food preparation or shopping

MUST score 0 – Low Risk

MUST score 1 – Medium risk

Refer to Dentist

Follow First Line Dietary Advice and record weekly food chart. Check weight weekly if possible

MUST score 2 or more – High Risk

Re asses at least monthly

Reinforce First Line Dietary Advice

Refer to Dietitian

Non Nutritional factors present

Problems with Chewing

Refer for Home

Support or other Social

Services

Swallowing difficulties

Refer to Speech & Language Therapist

Observe and document dietary intake for 3 days

Little clinical concern -Repeat screening: Hospital – weekly Care Homes – monthly Community – annually for special groups e.g over 75’s

Clinical concern : Treat unless

detrimental or no benefit is expected e.g imminent death

Other medical condition requiring dietary change e.g Diabetes, overweight – refer to appropriate information leaflet

NUTRITIONAL SUPPORT: First Line Dietary Advice

If screening identifies patient or resident requires nutritional support the following measures should be taken.

1) Weigh weekly to establish extent of weight loss & record food intake chart 2) Start FOOD FORTIFICATION and encourage ‘ little and often’ (see table below for ideas) 3) If a modified consistency has been advised, ensure the CORRECT CONSISTENCY for food and fluids

continues to be provided when fortifying food and drinks (use thickeners if prescribed) 4) RE ASSESS at least monthly and if no improvement in appetite, food intake or weight-refer to

Dietitian.

WHAT? WHY? WHEN?

FORTIFIED MILK

1 pint of full cream milk with 4 tablespoons of dried milk powder added

• Almost nutritionally equivalent to 2 pints : Significantly increases energy & protein content without more volume.

USE PINT OVER THE DAY IN HOT DRINKS, CEREALS, PORRIDGE, MILK SHAKES & PUDDINGS

PORRIDGE & CEREALS

Add honey*, sugar*, dried fruit, double cream or yogurt

• Adds extra calories

• Good alternative if resident dislikes cooked food & refusing main meals & sandwiches.

CAN OFFER AT ANYTIME, NOT JUST AT BREAKFAST e.g. supper or mid-morning.

MAIN or COOKED MEALS

Add butter, margarine, cream or cheese to potatoes. Add grated cheese over vegetables, in sauces or scrambled egg. Add mayonnaise, salad cream and dressings generously. Add butter, margarine or a creamy sauce

to vegetables.

• Adds extra calories

• Adds taste to meals

• Helps encourage vegetable intake to increase fibre, vitamins & minerals to help immune system and wound healing.

IF QUANTITY EATEN AT MEAL TIMES IS SMALL PORTION. AIM FOR 1-2 VEGETABLES DAILY IN MEALS OR SOUPS

SMALL MEALS and SNACKS

Try small sandwiches with cold meat , cheese or tuna, toast with cheese or cheese spread, yogurts, mousses, scone, cake, cereal bar, milky drink, toast & banana, cheese & biscuits

• It is often difficult to get enough in at meal times.

• Easier to eat than main / cooked meals.

• Reduces need for Prescribed Nutritional Supplements

IF MAIN MEALS REFUSED REGULARLY OR NOT FINISHED. AIM FOR 3 SMALL MEALS & 3 SNACKS PER DAY.

SOUPS & PUDDINGS

Soups - add fortified milk, double cream, or cheese. Puddings - make with or add fortified milk, add evaporated milk, double cream, honey*, or jam*. Offer small carton of custard or rice pudding as a snack. Add stewed or tinned fruit

• Increase energy & protein content.

• Even average portions of soup & pudding will have a significant nutritional value if fortified.

• More appealing than a large meal.

• Fruit and vegetables help ensure adequate fibre, vitamin & mineral intake to help immune system & wound healing.

IF MAIN MEAL REFUSED CAN OFFER SOUP & PUDDING TWICE A DAY IF NOTHING ELSE TAKEN. MAKE SOUPS WITH PLENTY VEGETABLES AND PULSES AIM FOR 2-3 PORTIONS OF FRUIT A DAY e.g MASHED BANANA, TINNED FRUIT, SMOOTHIES

DRINKS

MILKY - add extra fortified milk in tea & coffee, make Ovaltine* / Horlicks* or hot chocolate* with fortified milk. FRUIT JUICE or ORDINARY DILUTING JUICE* ( try to use one with added Vitamin C and aim for 1-2 glasses a day) BUILD-UP / COMPLAN (buy in)

• Cups of tea & coffee alone have little nutritional value.

• Reduces need for Prescribed Nutritional Supplements.

N.B. It is still important to ensure adequate fluids are taken over the day.

BETWEEN OR AFTER MEALS AVOID DRINKS JUST BEFORE OR WITH MEALS AS CAN REDUCE APPETITE. FRUIT JUICE AT BREAKFAST OR MID MORNING- TRY ‘SMOOTHIES’ ADD SUGAR* OR HONEY* TO DRINKS WHERE POSSIBLE TO INCREASE ENERGY CONTENT.

• Not advised routinely if patient Diabetic - contact a Dietitian if concerned about a Diabetic resident. Nutrition and Dietetic Service, Old Johnstone Clinic, 1 Ludovic Square, Johnstone PA5 8EE tel 01505821823

Sample Food Fortification Menus

Below you will find three sample menus:- Menu 1 – Not fortified Menu 2 – Partly fortified: adds additional 24.7g protein and 988 kcalories Menu 3 – Fully fortified: adds additional 43g protein and 1731 kcalories These menus show the benefit from fortifying a diet to increase both protein and calorie content. This can be compared with providing one bottle of a nutritional supplement which only adds 13.8g Protein and 320 calories.

Menu 1 – Not fortified

Meal Time Standard Food Protein (g)

Kcals

Breakfast Porridge made with water 2.1 65

Mid Morning

Lunch Homemade soup White roll Small banana

4.3 4.1 1

211 114 76

Mid afternoon

Evening meal Minced meat and gravy 1 boiled potato carrots Tinned peaches in juice

24 1 0 0

230 50 10 40

Evening snack 2 x Plain Biscuits 2 140

Milk in tea and coffee

½ pint of semi-skimmed milk 9 125

Total 47.5 1061 Fortified diet menu page 1

Menu 2 – Partly fortified

Meal Standard Food Protein(g) Kcals

Breakfast Porridge made with full cream milk and 2 teaspoons sugar

7 265

Mid Morning

Lunch Homemade soup with added double cream White roll and butter ½ banana and 1 scoop ice cream

5.3 4.1 3

346 230 151

Mid afternoon

Evening meal Minced meat and gravy 1 scoop of mashed potato with butter and milk Carrots with butter Milk pudding with Tinned fruit in syrup and cream

24 3.3 0 4

230 70 45 181

Evening snack 1 slice toast with butter and jam 2.5 145

Additional milk over the day

1 pint of full cream milk for teas / coffees and one milky drink

19 386

Total 72.2 2049

Menu 3 – Fully fortified

Meal Time Fully Fortified Foods Protein(g) Kcals

Breakfast Porridge made with fortified full cream milk and 2 teaspoons sugar

13.6 305

Mid Morning 2 x crackers thickly spread with butter 2 192

Lunch Homemade soup with added double cream White roll and butter ½ banana and 1 scoop ice cream Orange Juice

5.3 4 3 1

346 230 151 72

Mid Afternoon Malt loaf and thickly spread butter Glass of full cream fortified milk

2.9 13.6

168 200

Evening Meal Minced meat and gravy 1 scoop of mashed potato with butter and cream Carrots with extra butter Milk pudding with Tinned fruit in syrup and cream

24 1 0 4

230 136 74 181

Evening snack 1 slice toast with butter and jam 2.5 145

Additional milk over the day

1/3 pint of fortified full cream milk for teas / coffees etc

13.6 200

Total 90.5 2792 Fortified diet menu page 2

Weekly Food Intake Chart

Name_____________________________ Week Beginning___________ Weight _________kg

sample Monday Tuesday Wednesday

Food offered Amount Eaten

Food Offered Amount Eaten

Food Offered Amount Eaten

Food Offered Amount Eaten

Break-fast

porridge with fortified milk & cream Fresh Orange Juice

1 bowl 1/2

Mid am glass fortified milk plain biscuit

all 2

Lunch Homemade soup with full cream milk. milk pudding with puree fruit and double cream

½ bowl ½ bowl 1 TBSP

mid pm Scone with butter cup of tea with milk & 2 tsp sugar

1/4 all

Evening Meal

macaroni cheese glass fortified milk

none none

early evening

1 build up or complan drink

all

supper tea with milk & sugar 1 slice white bread toasted with butter jam

1/2 1/2

* Please also record any nutritional supplements offered and amount taken e.g Ensure plus, Calogen

Thursday Friday Saturday Sunday

Food Offered Amount Eaten

Food Offered Amount Eaten

Food Offered Amount Eaten

Food Offered Amount Eaten

Break-fast

Mid am

Lunch

mid pm

Evening Meal

early evening

supper

Any other relevant Information ______________________________________________________________________________________________

Nutrition & Dietetic Service, Old Johnstone Clinic, 1 Ludovic Square, Johnstone PA5 8EE tel. 01505 821823 updated April 2012

IDEAS FOR FINGER FOOD MEALS Finger Foods are useful for clients ‘on the move’ or those who have difficulty with cutlery but still wish to be able to eat independently.

Tips

� Try to supervise meals & snacks where possible & give prompting and assistance if required. � Some finger foods may be too dry or hard for client therefore provide sauces & gravy for savoury foods / cream, evaporated milk or milk puddings for sweet

foods to be used as a ‘dip’ therefore making food more moist. � Offer milk & milky drinks between meals at suppertime. � Try leaving snacks near client & in room so they can help themselves. � Aim for 3 small meals and 3 snacks each day

BREAKFAST BETWEEN MEAL SNACKS LUNCH EVENING MEAL Chopped fruit Toast fingers with butter & cheese spread, smooth peanut butter or meat paste French Toast & slices of tomato Toast fingers with small sausages Cereal bar. Bowl of dry breakfast cereal Served with separate drink of milk or fruit juice

Pancake with butter & jam 2 Digestives with butter & jam Scone with butter & jam Toast fingers & smooth peanut butter Crackers & cheese Crisps Bread sticks & dip Popcorn Toast fingers with butter & jam Malt loaf & butter Banana sandwich Toasted teacake with butter & jam

Sandwiches made with egg mayo, cheese & coleslaw. Chopped apple & grapes. or Mini quiche & chopped salad & vegetables. New potatoes. Ginger cake. or Cheese & ham toastie Crisps. Fruit chunks. or Tortilla wrap with various fillings. Iced sponge cake.

Fish fingers & potato croquettes. Broccoli. or Chicken drumsticks Bread & butter. Carrot sticks (boiled or raw). or Cold meat. Potato wedges. Salad vegetables. or Snack pizza. Cold pasta salad or salad vegetables. Ice-cream cone/Jelly cubes/ Individual fruit pie/Meringue /Tinned fruit

Remember to include a glass of fresh fruit juice and 1 pint of milk / milky drinks daily and ensure other fluids are offered regularly throughout the day . Aim for 6 -8 mugs or glasses of e.g. tea, coffee, squash, water. Nutrition & Dietetic service, Old Johnstone Clinic, 1 Ludovoc Square, Johnstone. PA5 8EE tel 01505 821823 updated April 2012

USE OF ORAL NUTRITIONAL SUPPLEMENTS (ONS)

A drug is not prescribed unless its function is known, what effect it should have on the body, possible side-effects and what the outcome is likely to be. Newly commenced medications are reviewed and it is often expected that they will be stopped once a satisfactory outcome is achieved or if patient complains of problems -The same should apply to Oral Nutritional Supplements (ONS) and they should always be used as part of a treatment plan. Appropriate Prescribing of Oral nutritional Supplements (ONS)

• In some instances a resident may be unable to achieve their nutritional requirements from fortified diet even with encouragement from staff. When this happens it may be recommended to prescribe an oral nutritional supplement

• For some care home residents it can be appropriate to prescribe a small supply of supplements when they experience poor food intake as a result of a period of illness when they are unable to achieve their nutritional requirements from fortified diet.

• Nutritional supplements may be indicated in residents receiving active treatment for palliative care where supplements could improve clinical / nutritional outcome and quality of life. The nutritional screening tool and care pathway should still be used for this group of patients. Where treatment has been withdrawn and a patient’s condition is deteriorating the Dietitian can be contacted to discuss whether further advice or whether ONS are required.

What is inappropriate prescribing?

• Prescribing supplements not suitable to a resident's condition.

• Repeated prescribing for long period of time without review.

• Prescribing before dietary advice is tried (unless exceptional circumstances)

• Prescribing supplements without clear instructions on how to use them and for how long.

• Prescribing without regular review to monitor dietary and supplement compliance.

• It may be inappropriate to use or suggest ONS in residents who are terminal, especially in the last few days of life. Normal food that the resident enjoys should always be encouraged as much as possible. The aim should be to minimise stress at meal times.

• It has been shown that that ONS have little or no value in weight stable residents with a BMI 20-25 or those who are overweight BMI >25.

What are the risks of inappropriate prescribing?

• ONS can in many situations simply replace food and have no real benefit to the resident.

• They could result in drug-nutrient interactions, which could reduce the effectiveness of the drug and the ONS

• Some ONS can cause side-effects such as diarrhoea, nausea and vomiting. Monitoring the use of Oral Nutritional Supplements (ONS) Ideally a Dietitian should monitor patients taking ONS but as this is not always possible the following should be carried out to ensure proper use.

• The residents should be weighed weekly, food intake charts recorded daily and compliance with ONS prescribed should be noted

• Staff should review resident’s progress at least monthly as per the Nutritional support Pathway – Local policy.

• Ensure resident is taking the amount of ONS advised. Discontinuing Oral Nutritional Supplements (ONS) Long term use of ONS is not recommended . Once the aim of the treatment is reached, ONS should be gradually reduced while the patient's weight is monitored :-

• Review the reason for the resident taking ONS and if appropriate reduce the dose over a period of time

• Re check weight and food intake, then reduce dose further until they can be stopped.

• Remove prescription from repeat if this was arranged.

• Review progress in 3 months.

Updated April 2012

First Line Advice for Other Dietary conditions

If MUST screening identifies no concern with residents appetite or weight but patient has another condition requiring dietary modification the attached leaflets may be useful for First line Advice before referring to the Dietitian. Leaflets Included Diabetes Weight management Constipation Iron deficiency anaemia

Updated April 2012

Here are some meal ideas.

Breakfast

� Branflakes, Weetabix or reduced sugar muesli with banana and

semi-skimmed milk.

� Granary/High fibre or wholemeal toast and reduced sugar marmalade. Healthy choice yoghurt with chopped fresh fruit.

� Porridge with semi-skimmed milk and a small glass of orange juice.

Snack meal

� Lentil soup, bread roll and a banana.

� Baked beans on toast. Healthy choice yoghurt and an apple.

� Cold meat and tomato sandwiches. Fresh fruit. Main Meal � Lean mince with potatoes, carrots and cabbage.

� Chicken and vegetable casserole, potatoes.

� Pasta with tomato and vegetable sauce.

� Breaded haddock (oven baked) with oven chips, peas and

tomato.

Compiled by Nutrition and Dietetic Service,

Renfrewshire CHP August 2008

Diabetes page 1

First line advice for diabetes

• If the patient or resident has been recently diagnosed with diabetes a referral to the dietitian should be arranged. The advice in this leaflet can be followed until an initial assessment by the dietitian is carried out

• If the patient or resident has had diabetes for some time use the information in this leaflet to ensure the correct diet is provided, referral to the dietitian is only required if the patient or resident has difficulty following this advice or if their doctor has identified that control is poor.

The picture above shows the correct balance of foods for a healthy diet. The diet for people with diabetes is a normal healthy diet – low in fat, sugar and salt, with plenty starchy foods, fruit and vegetables.

Here are some tips to help control diabetes. � Eat regular meals including breakfast, a snack meal and a main

meal each day � Include starchy foods such as bread, cereals, potatoes, rice or

pasta at every meal. High fibre varieties are best. � Encourage a variety of fruit, vegetables and pulses (such as

beans, peas and lentils) every day – Aim for 5-a-day (older residents with small appetites may only manage 3 -4 portions).

� Provide fewer fried and fatty foods such as full cream milk,

cheese, chips, pies and pastries. Offer semi-skimmed milk and reduced fat cheese

� Reduce use of butter and margarines use low fat spreads

instead or spread butter or margarine thinly. � Choose lower fat desserts e.g yoghurt, � Use only a little salt in cooking and discourage the adding of salt

at the table � Alcohol should only be taken in moderation

Diabetes page 2

Use less sugar

It is not necessary to avoid sugar completely, however, foods and drinks that contain a lot of sugar can make the blood glucose rise too quickly

so :- Use diet or sugar free drinks and avoid adding sugar to drinks and food.

� Change to low sugar and sugar free foods such as healthy choice yoghurts, sugar free jelly and fruit tinned in juice (not syrup).

� There is no need to buy special ‘diabetic foods’ as they can be

expensive, have a laxative effect and will not help weight control.

� Losing weight can help to control sugar levels . Even a

small weight loss will make a difference.

� Increasing activity levels can also help with control of sugar levels and weight – encourage where possible e.g walking, chair aerobics, carpet bowls.

How Much Weight Could I Lose ?

A resident may wish to know how reducing snacks and fatty or sugary foods will affect their weight and it is important to explain that small changes can really make a difference. This list shows how much weight can be lost in a year by cutting down on high fat / high sugar foods. Cut this out each day: In 1 year you could lose: 1 tablespoon of oil 23lbs (10kg) 1oz butter or margarine 23lbs (10kg) 2teaspoons sugar in 6 daily cuppas 25lbs (11kg) 1 iced cake 21lbs (9.5kg) 2 thinly buttered cream crackers 16.5lbs (7.4kg) 1 buttered scone 27lbs (13kg) 1 chocolate biscuit 13.5lbs (6kg) 1 packet crisps 14.5lbs (6.5kg) 1 chocolate bar 30 lbs (13.6kg) 1 packet boiled sweets (50g) 17 lbs (8kg) 1 glass cola 12.5lbs (5.5kg) 1 large measure spirits 11.5lbs (5kg) 1 glass wine 11lbs (5kg) 1 pint beer/lager 16lbs (7kg) 3 plain biscuits 20lbs (9kg) Average portion chips 31lbs (14kg) 1 slice cheddar cheese (if eaten in addition to meals) 17lbs (8kg) 1/3pint(200ml)full fat milk (if taken in addition to that required for tea/cereal) 13lb (6kg)

Produced by the Nutrition and Dietetic Department,

Renfrewshire CHP, August 2008

Weight management page 1

First line advice for weight

Management

� If the patient or resident has been gaining excess weight

and it has been identified that their BMI ( Body Mass index) is above 25, the advice in this leaflet can be followed initially.

� For many residents no other intervention will be required

but if First Line Advice fails to stop weight gain after 2 – 3 months, a referral to the Nutrition and Dietetic service may be appropriate.

The picture above shows the correct balance of foods for a healthy diet. The diet for people who are trying to lose weight is a normal healthy diet – low in fat, sugar and salt, with plenty of starchy foods, fruit and vegetables.

Some tips to help residents lose weight � Eat regular meals including breakfast, a snack meal and a

main meal each day. � Fill up with plenty of starchy foods such as bread,

potatoes, rice and pasta � Encourage a variety of fruit and vegetables every day –

aim for 5-a-day (older residents with smaller appetites may only manage 3-4 portions)

� Reduce use of butter and margarines, use low fat spreads

instead or spread butter and margarine thinly. � Choose lower fat desserts e.g yoghurt � Provide fewer fried and fatty foods such as full cream milk,

cheese, chips, pies and pastries. � Encourage resident to cut out sugar added to tea, coffee

or cereals. � Offer fresh fruit or bread instead of cakes and biscuits. � Advise resident only to eat sweets and chocolate

occasionally. � Aim for weight maintenance or weight loss of 1lb per week

depending on residents initial BMI, mobility and age. � Keeping food intake charts can help to show where

changes could be made.

Weight management page 2

Here are some meal ideas. Breakfast � Branflakes, Weetabix or reduced sugar muesli with banana and

semi-skimmed milk.

� Granary/High fibre or wholemeal toast and reduced sugar marmalade. Healthy choice yoghurt with chopped fresh fruit.

� Porridge with semi-skimmed milk and a small glass of orange juice.

Snack meal

� Lentil soup, bread roll and a banana.

� Baked beans on toast. Healthy choice yoghurt and an apple.

� Cold meat and tomato sandwiches. Fresh fruit. Main Meal Lean mince with potatoes, carrots and cabbage. � Chicken and vegetable casserole, potatoes.

� Pasta with tomato and vegetable sauce.

� Breaded haddock (oven baked) with oven chips, peas and

tomato.

What if I Resident is get hungry between meals? � Offer a tomato or banana sandwich, soda scone, potato

scone or fruit instead of biscuits or crisps.

Low calorie chocolate drinks or soups are also useful.

MENU IDEAS BREAKFAST: Branflakes with milk and banana Wholemeal Toast Glass of fruit juice LUNCH: 2 slices wholemeal bread Tuna and cucumber or tomato Fruit or muesli bar MID-PM: Fruit or wholemeal scone EVENING MEAL: Minced beef or roast chicken Carrots and broccoli Jacket potatoes SUPPER: Oatcakes with tomato OR

Wholemeal toast with reduced sugar jam

CHECKLIST FOR CHANGE • Do not make too many changes at once but gradually increase

the fibre intake to avoid flatulence and bloating

• Try making one change at a time

• After about one month check if you are doing the following: � Encouraging breakfast, especially high fibre cereals � Offering more bread, especially wholemeal (aim for 3-6

slices daily) � Providing potatoes, rice or pasta at mealtimes � Offering 5 portions of fruit and vegetables daily � Ensuring 6-8 mugs of fluid daily

Compiled by Nutrition and dietetic Service,

Renfrewshire CHP August 2008

Constipation page1

First Line Advice for Constipation

• Being constipated is enough to make anyone feel miserable – it is uncomfortable, causes bloated and results in a resident spending long sessions in the toilet.

• Although laxatives and other medication may be prescribed it is essential that the resident’s diet contains sufficient dietary fibre and fluids.

• This leaflet gives advice on the types of foods that will increase the fibre in a resident’s diet.

• The attached Fibre Counter will help you check how much fibre a resident is taking – check this initially and then gradually increase as required. Never increase fibre content of the diet suddenly, changes should be made over a period of a few weeks to prevent bloating and discomfort.

WHAT IS FIBRE? Fibre is the part of cereals, fruit and vegetables which is not digested and passes through the body without being absorbed. It absorbs liquid which provides a soft bulk that is easy to pass when we go to the toilet.

WHY EAT FIBRE? Fibre in the diet helps to keep the bowels moving regularly and so prevents constipation. It also adds bulk to the diet, making us feel full for longer and so helps to control appetite. Too little fibre also seems to be related to other bowel disorders including piles and diverticulitis. In addition to the high fibre foods it is important to take extra fluid to help the fibre to swell. Try to encourage the resident to take at least 6-8 mugs of fluid daily.

WHICH FOODS ARE HIGH IN FIBRE? There are different types of fibre which have different effects on the body. It is therefore important to encourage residents to choose foods every day from each of the groups listed below.

� STARCHY FOODS Try to include generous portions from this group at every meal.

� Bread, especially wholemeal and high fibre white. Try to take 3-6 slices daily.

� Fruit loaf and wholemeal / fruit scones

� Wholegrain breakfast cereals e.g. weetabix, branflakes,

porridge

� Rice and pasta, especially the brown varieties

� Wholegrain biscuits e.g. digestive, oatcakes, wholegrain crackers

� Potatoes – keep the skins on where possible – a baked

potato with skin has twice as much fibre as one without � PULSES, LEGUMES AND SEEDS

These include peas, beans, lentils and nuts. All kinds are suitable –fresh, frozen, tinned or dried

� Soups – lentil, pea and ham � Baked beans on toast � Chilli with kidney beans � Peanut butter on bread � Add beans and peas to mince or stews � Sprinkle seeds e.g. sunflower onto cereals or stews

Constipation page2

� FRUIT & VEGETABLES

Try to include at least 5 portions daily

Include one or two helpings of vegetables with meals e.g. carrot, cabbage, turnip, salad

� Add salad to sandwiches

� Add carrot, onion, mushrooms or peppers to mince or stews

� Include plenty of vegetables in soup e.g. lentil, broth

� Put chopped fresh fruit into yoghurt, milk puddings or

cereals

� Make fruit salad and provide a handy snack – chop a variety of fruit, put in a bowl and keep moist by adding a sugar free fizzy drink

� DON’T FORGET THE FLUIDS!

� All residents should be offered at least 6 – 8 mugs of fluid per day ( The total minimum recommendation of fluid is 1500mls daily)

� Recommended fluids include water, flavoured water, fruit juices, squash, milk, tea and coffee.

� Residents identified ‘at risk’ of dehydration should be on a fluid balance chart to ensure sufficient fluids are being taken

FIBRE COUNTER CHART .

FOOD QUANTITY FIBRE

(g) STARCHY FOODS Bread – wholemeal

2 med. Slices/rolls

4.5

Bread – white 2 large slices/rolls 1.5 Bread – whole-white 2 med. slices/rolls 3 Porridge Medium bowl 1.5 Cereal – wholegrain e.g. Branflakes, muesli

Small bowl 4.0

Potato with skin 2 medium size 4.0 Potato without skin 2 medium size 2.0 Pasta – wholemeal Average portion 7.0 Pasta – white Average portion 2.0 Rice – brown or savoury Average portion 1.5 FRUIT/VEGETABLES Apple, orange, banana etc.

1 medium

2.0

Dried fruit e.g. raisins 2 tablespoons 1.0 Tinned fruit 1 small tin 1.0 Green Vegetable / cauliflower 2 tablespoons 2.0 Root vegetable e.g. carrot 2 tablespoons 1.5 Peas, sweetcorn 2 tablespoons 3.0 Tomatoes 2 medium or ½ tin 1.5 salad Small portion 2.0 BISCUITS / CAKES Digestives 3 average 1.0 Oatcakes 2 round 1.0 Fruit cake / loaf 1 slice 1.0

Scone – wholemeal 1 medium 2.5 Scone – plain 1 medium 1.0 SOUPS, BEANS, PULSES, LEGUMES & SEEDS Lentil, split pea, broth

1 bowl

3.0

Minestrone, vegetable 1 bowl 2.0 Baked or kidney beans 2 tablespoons 8.0 Chick peas 2 tablespoons 3.0 Butter beans 2 tablespoons 5.5 Peanuts/peanut butter 1 tablespoon 1.5 Seeds e.g. sunflower 2 tablespoons 1.5

Constipation page3

Fibre Counter Chart and Menu Form

Use this table to record the food eaten in one day. Estimate quantity of each food and calculate the fibre content using the list on the chart.

N.B. Some foods do not contain any fibre e.g. chicken, meat, fish, milk, cornflakes, white rice

Meal Food eaten Quantity Fibre content

Breakfast

Mid-morning

Lunch

Mid-afternoon

Evening meal

Bed-time

Other

You should aim to increase gradually to approximately 18g fibre per day for elderly residents. If constipation persists you can increase gradually to 20 -25g per day. Remember to include 6-8 mugs of fluid daily

INCREASING THE IRON

IN YOUR DIET

Iron is needed to make healthy blood cells and we need to eat some every day. It has been should that the elderly are at more risk of Iron deficiency anaemia.

There are 2 types of iron :- Haem iron is the more easily absorbed type and is found in red meat ,oily fish and dark meat from poultry.

Non-Haem iron is not so easily absorbed and is found in cereals , pulses and some vegetables. Absorption of iron from these foods can be increased by taking a source of vitamin C along with them e.g. fruit juice, tomatoes, citrus fruit, or green leafy vegetables.

What Foods will increase Iron Intake?

Red Meat e.g. Mince, stew, chops, lamb, liver, liver pate, kidney, black pudding, corned beef. Poultry - Dark meat of chicken and turkey. Fish -tinned sardines, pilchards, fish paste,clams & oysters. Breakfast cereals with added iron e.g. Branflakes, Cornflakes ,Cheerios. Dried fruits e.g.prunes, raisins, apricots, dates. Bread especially wholemeal and brown. Egg yolk Beans and pulses including baked beans, kidney beans, butter beans, lentils,soya beans,tofu and chickpeas Spinach, kale and spring greens Chocolate (milk & plain) Treacle and liquorice. Increasing Iron page1

MEAL IDEAS

Breakfast

Branflakes, milk & glass of grapefruit juice or Prunes & yoghurt, wholemeal toast & orange juice or Cornflakes ,milk and glass of tomato juice Snack Meal Lentil & tomato soup with wholemeal bread or Baked beans on wholemeal toast with glass of fruit juice or Corned beef & tomato sandwiches or Sardines on toast & fresh fruit salad Main meal Mince ,potatoes and peas or Liver casserole ,potatoes and broccoli or Spaghetti Bolognaise with salad or Chicken drumsticks , sweetcorn and potatoes or Potato & spinach curry with boiled rice and salad Useful tips

• Include a source of haem iron at meal times whenever possible i.e red meat, tinned fish ,dark poultry meat.

• Provide foods containing vitamin C along with iron containing foods e.g. fruit ,fruit juice and vegetables.

• Offer breakfast cereals fortified with iron every day.

• Advise resident to avoid taking tea or coffee with iron containing foods as these drinks can reduce the absorption of iron.

• If the doctor has advised the resident to take iron tablets offer a glass of fruit juice at the same time to help absorption.

Compiled by Nutrition and Dietetic Service Old Johnstone Clinic 1 Ludovic Square, Johnstone. PA5 8EE tel 01505 821823 Updated April 2012 Increasing Iron page2

Rehabilitation & Assessment

Directorate

South Clyde Nutrition & Dietetic Service

Referral Guidance

Background

The Health Professions Council (HPC) allows dietitians to accept referrals from any health or social care professional. However, prior to assessing and advising a patient the dietitian must have all the relevant information to ensure compliance with the HPC Standards of conduct, performance and ethics.

1. Method of referral / Where to send referral Preferred method of referral: The Nutrition and Dietetic Service accepts electronic referrals through the SCI Gateway. This type of referral provides the dietitian with the information requested above and is the preferred method of referral from General Practitioners.

Other methods of referral

Referrals to the Nutrition & Dietetic Service can also be made in writing to: Nutrition and Dietetic Service Old Johnstone Clinic 1 Ludovic Square, Johnstone PA5 8EE (Standard referral forms can be obtained from this address or by telephoning 01505 821823) Urgent referrals for Housebound patients Please note that if the referral is for a housebound patient and it is considered that a “lack of dietetic intervention will lead to condition deteriorating to potentially life threatening status” or hospital admission then an urgent referral should be made via ASeRT (the Adult Service Request Team) on 0141 207 7878. (see ‘apponitment category’ below for guidance on urgent outpatients) Obesity Management referrals Please note we are unable to accept out patient referrals for adults who require advice to manage their obesity. These patients should be referred to the Glasgow and Clyde Weight Management Service (GCWMS). If your patient would be unable to attend outpatient / clinic appointments even with the use of the NHS patient transport service (which is available for patients who are referred to the GCWMS), please contact us to discuss their case before referring.

2. Acceptance of Referrals All referrals received by the Nutrition & Dietetic Service are screened by a dietitian who will check to ensure that the referral is appropriate for the Nutrition & Dietetic Service and that it contains all required patient information as indicated overleaf. Once the referral has been checked and accepted, the dietitian will confirm the priority of the patient and place on our waiting list for the first available appointment. For written referrals, referrers can opt to receive notifiation that their referral has been received and accepted by the service on the referral form. Referrers using the SCI gateway can ascertain if the referral has been received by the service using the

icon within the gateway. If you wish, you can also phone the service to confirm that the referral has been received and accepted referral guidance page 2

Appointment category - You can indicate a preferred appointment category which the service will use to help inform a final decision on the patient’s priority. To help you do this, it may be helpful for you to know that urgent is defined as “lack of dietetic intervention that will lead to a condition deteriorating to potentially life threatening status” and routine is defined as “lack of dietetic intervention that will lead to compromised nutritional status” 3. Detail to include on referral The following information is mandatory for all referrals. If any of this information is not available the referral should state this and include reason why it is not available, or contact the service on 01505 821823 to discuss this, otherwise referral will be returned to the referrer requesting the missing information. � Date

� Name, address and post code of patient

� 10 digit Community Health Index (CHI) (this can be obtained from GP records)

� Type of appointment required i.e. out-patient or domicilary (if patient is house-bound only)

� Any known risk factors for lone working, e.g. alcohol/drug use, violence

� Details of referring person

� Details of GP

� Diagnosis and reason for referral

� Previous medical history

� Current medication

Additional information is also required for some patients:

� Blood results e.g HbA1c or blood glucose for diabetes, U’s & E’s for liver problems, EGFR for renal problems or iron level for anaemia.

� Height, weight & BMI, weight history - required for overweight or underweight children, adults with

unexplained weight loss or other conditions where weight is significant e.g diabetes, lipid alteration � Relevant social information e.g lives alone, receives community meals, wheelchair user, literacy or

speech problems, hearing impairment � MUST score (Malnutrition Universal Screening Tool) and details of any first line advice already carried

out should be provided for patients referred for nutritional support and / or unplanned weight loss

4. Rejected Referrals

Referrals will only be rejected if a dietitian identifies that essential information is missing. In order to ensure effective and efficient dietetic assesssment and treatment for your patient we will return the referral along with a request for the information required. It is important to highlight that the patient will not be placed on our waiting list until completed referral is returned. If you are unsure if your patient would benefit from dietary intervention or you would like to discuss where your referral should be sent please contact us on 01505 821823 to discuss with the dietitian. April 2012 referral guidance page 2

Rehabilitation & Assessment Directorate

Patient Referral to Nutrition and Dietetic Service All Fields are mandatory, however if any of the requested information is not available please either indicate

reason or contact us on 01505 821823 to discuss before referring

Date: Appointment Category: routine � or urgent � see referral guidance for definition of urgent patient

Patient Name:

Address:

Postcode:

Appointment Type: out-patient � in patient �

*housebound patient � day patient �

*If patient is housebound is there any lone working risk

when visiting at home? Yes � No � Not Known �

If YES give details

10 digit CHI Number: This can be obtained from GP or Hospital notes and must be

included in referral Patient Telephone Number:

Referrer Name:

Address:

Postcode:

Telephone Number:

GP Name:

Address:

Postcode:

Telephone Number:

Designation/ Job title:

Referrer’s Signature:

Do you require notification that the service have received and accepted this referral? Yes � No �

Diagnosis and Reason for Referral

Height: Weight: BMI: MUST Score: (for those at risk of malnutrition)

Details of any 1st line advice or intervention already carried out:-

Previous medical and weight history:

Current medication:

Relevant blood results: See referral guidance

Any additional relevant information e.g social factors, psychiatric or mental health issues:

Please send to The Nutrition and Dietetic Service, Old Johnstone Clinic, 1 Ludovic Square, Johnstone. PA5 8EE April 2012