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Nutrition Issues and Nutrition Issues and Challenges in the Care of Challenges in the Care of the Older Personthe Older Person

Julian Jensen, Registered DietitianJulian Jensen, Registered Dietitian

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OutlineOutline

Weight loss, malnutrition and Weight loss, malnutrition and screeningscreening

Menus, standards, guidelines and RDI’sMenus, standards, guidelines and RDI’s Modified diets – texture modifications Modified diets – texture modifications

& pureed diets& pureed diets Resourcing food and nutrition services.Resourcing food and nutrition services.

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IntroductionIntroduction

Nutrition is a key component in Nutrition is a key component in successful ageingsuccessful ageing

Malnutrition is a growing problem in Malnutrition is a growing problem in the older person, particularly in the older person, particularly in hospital level care.hospital level care.

The dietitian is a key member of the The dietitian is a key member of the multi-disciplinary healthcare team multi-disciplinary healthcare team when nutrition issues are under when nutrition issues are under review.review.

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Issue 1: Weight LossIssue 1: Weight Loss Weight loss is not a normal phenomenon Weight loss is not a normal phenomenon

of ageingof ageing

In the US, more nursing homes are cited In the US, more nursing homes are cited for inadequate care re weight loss than for inadequate care re weight loss than any other nutritional issueany other nutritional issue

Malnutrition is defined as Malnutrition is defined as – BMI <18.5 kg/mBMI <18.5 kg/m2 2 OROR– Unintentional weight loss of >10% within the Unintentional weight loss of >10% within the

previous 3-6 months previous 3-6 months OROR– BMI <20 kg/mBMI <20 kg/m22, , andand unintentional weight loss unintentional weight loss

>5% within the previous 3-6 months>5% within the previous 3-6 months

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Malnutrition Risk Based on BAPEN Malnutrition Risk Based on BAPEN Malnutrition Advisory Group GuidelinesMalnutrition Advisory Group Guidelines

High High RiskRisk

BMI < 18.5BMI < 18.5 BMI 18.5-20 BMI 18.5-20 + weight loss + weight loss of 3.2 kg or of 3.2 kg or more in last 6 more in last 6

monthsmonths

BMI >20 + BMI >20 + weight loss of weight loss of 6.4 kg or 6.4 kg or more in last 6 more in last 6

monthsmonths

Medium Medium RiskRisk

BMI 18.5-20 BMI 18.5-20 + weight loss + weight loss of less than of less than 3.2 kg in last 3.2 kg in last 6 months6 months

BMI >20 + BMI >20 + weight loss of weight loss of 3.2 - 6.4 kg in 3.2 - 6.4 kg in

last 6 monthslast 6 months

Low RiskLow Risk BMI >20 and BMI >20 and no weight lossno weight loss

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Undernutrition of Older People Undernutrition of Older People using MNAusing MNA©© screen (US data) screen (US data)

MalnutritionMalnutrition At riskAt risk Well Well nourishednourished

(%)(%) (%)(%) (%)(%)

At homeAt home 55 1515 8080

HospitalHospital 1010 2525 6565

Long Long term careterm care

4040 4545 1515

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Poor Oral Intake predisposes to Poor Oral Intake predisposes to Malnutrition:Malnutrition:

Unable to feed themselvesUnable to feed themselves Dysphagia – may be on pureed dietsDysphagia – may be on pureed diets Poor dentition, mouth problemsPoor dentition, mouth problems

– Sjogrens DiseaseSjogrens Disease– TumoursTumours

Lack of appetiteLack of appetite Multiple medicationsMultiple medications DepressionDepression DementiaDementia Underlying disease e.g. renal failureUnderlying disease e.g. renal failure

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Significant malnutrition Significant malnutrition co-morbiditiesco-morbidities

Renal impairmentRenal impairment

Congestive heart failureCongestive heart failure

Chronic obstructive respiratory diseaseChronic obstructive respiratory disease

Peripheral vascular diseasePeripheral vascular disease

Ischaemic heart diseaseIschaemic heart disease

Post-strokePost-stroke

DiabetesDiabetes

Neurological diseases – PD, MS, MND, HuntingdonsNeurological diseases – PD, MS, MND, Huntingdons

Traumatic brain injuryTraumatic brain injury

Cancer CachexiaCancer Cachexia

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Challenge 1: Screening for Challenge 1: Screening for Malnutrition RiskMalnutrition Risk

Nutrition screening is the process of discovering Nutrition screening is the process of discovering characteristics known to be associated with characteristics known to be associated with dietary or nutritional problemsdietary or nutritional problems

It identifies individuals who are at high risk of It identifies individuals who are at high risk of nutritional problems, or who have poor nutritional nutritional problems, or who have poor nutritional status.status.

Role of nutrition screening is to identify residents Role of nutrition screening is to identify residents who are currently malnourished, or who are at who are currently malnourished, or who are at risk, so that they can be referred for further risk, so that they can be referred for further assessment and nutritional intervention as assessment and nutritional intervention as appropriateappropriate

CAVEATCAVEAT: Screening should never : Screening should never replacereplace clinical clinical judgement, but it should judgement, but it should supportsupport it it

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Key Features of Nutrition Key Features of Nutrition ScreeningScreening

Food intakeFood intake AnthropometryAnthropometry Dietary modificationsDietary modifications Medical conditionsMedical conditions Biochemical dataBiochemical data General observations/commentsGeneral observations/comments Decision Flow chart/Action planDecision Flow chart/Action plan Nutrition Care PlanNutrition Care Plan

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Ethics of screeningEthics of screening A screen is a means of identifying or predicting A screen is a means of identifying or predicting

riskrisk

Resources must be available to act on the Resources must be available to act on the results of the screenresults of the screen

Failure to act appropriately constitutes Failure to act appropriately constitutes unethical behaviourunethical behaviour

Therefore, in establishing a screening process, Therefore, in establishing a screening process, allowance for registered dietitian intervention allowance for registered dietitian intervention for the high risk categories must be madefor the high risk categories must be made

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Measuring weight and Measuring weight and heightheight

WeightWeight– Use clinical scalesUse clinical scales– Weigh person in Weigh person in

light clothing and light clothing and without shoeswithout shoes

– Record weight – Record weight – enter on a graph so enter on a graph so trends can be easily trends can be easily seenseen

– Recheck if weight Recheck if weight loss or gain seems loss or gain seems unrealisticunrealistic

HeightHeight– The most reliable The most reliable

height is self-height is self-reported height.reported height.

– Use a stadiometer Use a stadiometer (height stick). (height stick). However this gives However this gives current height, and current height, and we want the normal we want the normal height, before height, before shrinkage!shrinkage!

– Use alternative Use alternative height measuresheight measures

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Alternative Height measuresAlternative Height measures

DemispanDemispan– From sternal notch to base of ring fingerFrom sternal notch to base of ring finger

Knee heightKnee height– From top of bent knee to heel flat on the From top of bent knee to heel flat on the

groundground Ulna lengthUlna length

– Measure between the point of the elbow and Measure between the point of the elbow and the midpoint of the prominent bone of the wristthe midpoint of the prominent bone of the wrist

These measure all need interpreting from These measure all need interpreting from formulas, or from a tableformulas, or from a table

All height measures have limitationsAll height measures have limitations

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Calculating BMI – Body Mass Calculating BMI – Body Mass IndexIndex

Weight in kg, divided by height in mWeight in kg, divided by height in m22

– e.g. a person weighing 45 kg and 1.65 me.g. a person weighing 45 kg and 1.65 m– 1.65 x 1.65 = ht1.65 x 1.65 = ht22 = 2.72 = 2.72– 45/2.72 = BMI = 16.545/2.72 = BMI = 16.5

Ideal Range: 22-27 acceptable for older peopleIdeal Range: 22-27 acceptable for older people

BMI < 21 BMI < 21 → increased frailty→ increased frailty

Higher BMI minimises mortality risk in older peopleHigher BMI minimises mortality risk in older people– Women – Women – 30-3330-33– Men Men – – 27–3027–30

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MNAMNA® - Mini Screen® - Mini Screen

6 questions6 questions– Has appetite and food intake declined in Has appetite and food intake declined in

the past 3 monthsthe past 3 months– Weight loss in past 3 monthsWeight loss in past 3 months– MobilityMobility– Acute illness or major stress in last 3 Acute illness or major stress in last 3

monthsmonths– Dementia or depressionDementia or depression– Body mass indexBody mass index

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MNA® ScoresMNA® Scores

Screen – 6 questionsScreen – 6 questions– Max score = 14Max score = 14– ≥ ≥ 12 – Normal; not at risk12 – Normal; not at risk– ≤ ≤ 11 – Possible malnutrition – proceed 11 – Possible malnutrition – proceed

to assessmentto assessment Assessment – 12 questionsAssessment – 12 questions

– Max score = 16; combined max score = Max score = 16; combined max score = 3030

– 17-23.5 – at risk of malnutrition17-23.5 – at risk of malnutrition– < 17 - malnourished< 17 - malnourished

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What can we do to reduce risk What can we do to reduce risk of malnutrition?of malnutrition?

Modify diet to meet their needs – modified Modify diet to meet their needs – modified textured diet if dysphagiatextured diet if dysphagia

Small frequent meals- poor appetite or Small frequent meals- poor appetite or nauseanausea

Assist with oral intakeAssist with oral intake Review medicationsReview medications Increase energy value of mealsIncrease energy value of meals Utilise appropriate nutritional supplements in Utilise appropriate nutritional supplements in

addition to usual intakeaddition to usual intake Prescribe these on medication chartsPrescribe these on medication charts

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What about Malnutrition? - What about Malnutrition? - Some adverse effectsSome adverse effects

Impaired immune responseImpaired immune response

↓ ↓ muscle strength and fatigue → risk of falls muscle strength and fatigue → risk of falls

↓ ↓ respiratory muscle function → difficulty respiratory muscle function → difficulty breathing → risk of chest infection and breathing → risk of chest infection and respiratory failurerespiratory failure

Impaired thermoregulationImpaired thermoregulation

Impaired wound healing and delayed recovery Impaired wound healing and delayed recovery from illnessfrom illness

Apathy, depression and self-neglectApathy, depression and self-neglect

↑ ↑ risk of admission to hospital and length of risk of admission to hospital and length of staystay

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Treatment of MalnutritionTreatment of Malnutrition Use a dietitian for a full nutritional assessment Use a dietitian for a full nutritional assessment

and reviewand review May need aggressive, but controlled treatment – May need aggressive, but controlled treatment –

especially if previous intake has been poor or especially if previous intake has been poor or very limitedvery limited

Nutrition support most likely to be requiredNutrition support most likely to be required– OralOral

SupplementsSupplements Fortified foods/beveragesFortified foods/beverages

– TubeTube Because of the range of nutritionals available, it Because of the range of nutritionals available, it

should be the dietitian’s responsibility to should be the dietitian’s responsibility to prescribe the most appropriate.prescribe the most appropriate.

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Issue 2: Menus in Residential Issue 2: Menus in Residential CareCare

Health and Disability standards require Health and Disability standards require evidence that menus meet nutritional evidence that menus meet nutritional standards for older people in carestandards for older people in care

NZ Guidelines for Healthy Older People are NZ Guidelines for Healthy Older People are out of date, and not always relevant for out of date, and not always relevant for people with compromised healthpeople with compromised health

Just released are new Nutrient Reference Just released are new Nutrient Reference Values for Australia and New ZealandValues for Australia and New Zealand

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Challenge 2: Assuring potential Challenge 2: Assuring potential Nutritional AdequacyNutritional Adequacy

The NZDA has responded to a call from your The NZDA has responded to a call from your predecessor – Residential Care Association – to predecessor – Residential Care Association – to develop a standard audit tool for menu evaluation.develop a standard audit tool for menu evaluation.

Dietitians in NZ are trained in both Nutrition and Dietitians in NZ are trained in both Nutrition and Foodservice, and are ideally placed to audit your Foodservice, and are ideally placed to audit your menu.menu.

The standards are intended to assess the potential The standards are intended to assess the potential of the menu to meet the nutritional needs and of the menu to meet the nutritional needs and standards for dietary variety for the residents, but standards for dietary variety for the residents, but cannot be used to guarantee the intakes of cannot be used to guarantee the intakes of individual residents.individual residents.

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The menu audit tool looks atThe menu audit tool looks at– Nutritional adequacyNutritional adequacy– Special dietary requirementsSpecial dietary requirements– Dietary varietyDietary variety– Purchasing patterns of key itemsPurchasing patterns of key items

Meat, fish, poultryMeat, fish, poultry Eggs and dairyEggs and dairy BreadBread Vegetables and FruitVegetables and Fruit

– Budget, if a comment is requested.Budget, if a comment is requested.

Items in the audit tool are assessed as Items in the audit tool are assessed as compliant/not yet compliant; and there is room compliant/not yet compliant; and there is room for comments and recommendations to be noted.for comments and recommendations to be noted.

You should expect your dietitian to use this tool – You should expect your dietitian to use this tool – many auditors these days are looking for itmany auditors these days are looking for it

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More menu challengesMore menu challenges

Nutrient Reference Values (NRVs)Nutrient Reference Values (NRVs)– Increased Recommended Daily Intakes Increased Recommended Daily Intakes

forfor ProteinProtein CalciumCalcium Vitamin DVitamin D Vitamin BVitamin B1212

FolateFolate IronIron ZincZinc MagnesiumMagnesium

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Comparisons of RDIsComparisons of RDIs

WhatWhat ThenThen NowNow

Protein (g)Protein (g) M=55; F=45M=55; F=45 M=81; F=57M=81; F=57

Calcium (mg)Calcium (mg) M=800; F=1000M=800; F=1000 13001300

Vitamin D Vitamin D (µg)(µg)

1010 1515

Vitamin Vitamin BB1212(µg)(µg)

2.02.0 2.42.4

Folate (µg)Folate (µg) 200200 400400

Iron (mg)Iron (mg) M=7; F=5-7M=7; F=5-7 88

Zinc (mg)Zinc (mg) 1212 M=14; F=8M=14; F=8

Magnesium(mMagnesium(mg)g)

M=320; F=270M=320; F=270 M=420; F=320M=420; F=320

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What does this means for our What does this means for our menus? (Main food groups)menus? (Main food groups)

Importance of good protein intakeImportance of good protein intake– 2 servings lean meat, fish, chicken, egg, 2 servings lean meat, fish, chicken, egg,

cooked dried peas, beans or lentils most cooked dried peas, beans or lentils most days (average at least 100 cooked/day days (average at least 100 cooked/day (~125-130 g raw)(~125-130 g raw)

– Milk and dairy – use in cooking, and Milk and dairy – use in cooking, and incidental table use, BUT also strongly incidental table use, BUT also strongly recommend a daily milk drink (morning recommend a daily milk drink (morning tea and supper) for all – no choice tea and supper) for all – no choice ☺. ☺. Make with trim milk – higher calcium & Make with trim milk – higher calcium & protein.protein.

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Breads and cerealsBreads and cereals– Whole grain and fortified are a good Whole grain and fortified are a good

source of Folatesource of Folate– Try to use more wholemeal flour in Try to use more wholemeal flour in

baking and dessertsbaking and desserts

Vegetables and fruitsVegetables and fruits– Guidelines say 5 +; most facilities I Guidelines say 5 +; most facilities I

check easily meet this. But to improve check easily meet this. But to improve folate encourage more – even up to 8 folate encourage more – even up to 8 serves serves ☺☺. Use dark coloured fruits and . Use dark coloured fruits and vegetables – ‘eat a rainbow’. Offer some vegetables – ‘eat a rainbow’. Offer some raw daily.raw daily.

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““Eat a Rainbow” – anti-Eat a Rainbow” – anti-oxidantsoxidants– RedRed

Tomatoes, strawberries, red peppers, raspberriesTomatoes, strawberries, red peppers, raspberries– OrangeOrange

Pumpkin, carrots, oranges, apricots, pawpawPumpkin, carrots, oranges, apricots, pawpaw– YellowYellow

Banana, pineapple, sweet corn, kumara, swede, grapefruitBanana, pineapple, sweet corn, kumara, swede, grapefruit– GreenGreen

Broccoli, spinach, peas, kiwifruit, bok choi, brussels sproutsBroccoli, spinach, peas, kiwifruit, bok choi, brussels sprouts– BlueBlue

BlueberriesBlueberries– IndigoIndigo

Blackberries, prunes, black cherries, black currantsBlackberries, prunes, black cherries, black currants– PurplePurple

Eggplant, plums, red cabbage, beetrootEggplant, plums, red cabbage, beetroot– WhiteWhite

Apples, pears, cauliflower, potato, onionsApples, pears, cauliflower, potato, onions

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Issue 3: Modified DietsIssue 3: Modified Diets

Advice re modified diets in extended care Advice re modified diets in extended care facilities is to be as liberal as possible, to facilities is to be as liberal as possible, to enable residents to achieve a diet of enable residents to achieve a diet of sufficient energy and protein to sustain sufficient energy and protein to sustain good nutritional statusgood nutritional status

Ask for a dietitian review of any restricted Ask for a dietitian review of any restricted diet, including diabetes, diverticulitis vs diet, including diabetes, diverticulitis vs diverticulosis, vegetarianism, self-imposed diverticulosis, vegetarianism, self-imposed weight control.weight control.

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Modified texture dietsModified texture diets– Soft, Modified soft, pureedSoft, Modified soft, pureed

– Do you distinguish between soft and puree?Do you distinguish between soft and puree?

– Do you distinguish between modified soft and Do you distinguish between modified soft and puree?puree?

– And the biggie! Do your pureed diet patients And the biggie! Do your pureed diet patients get enough? We know people on pureed diets get enough? We know people on pureed diets have a higher risk of malnutrition, due tohave a higher risk of malnutrition, due to Need for assistance with feeding not fully metNeed for assistance with feeding not fully met Between meal choices not always suitableBetween meal choices not always suitable Increasing frailtyIncreasing frailty Limited food choicesLimited food choices Inappropriate pureed diet production methodsInappropriate pureed diet production methods

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Classifying texture modified Classifying texture modified dietsdiets

Soft:Soft:– Soft foods with plenty of gravy and sauce – e.g. Soft foods with plenty of gravy and sauce – e.g.

casseroles, fish, mince; sauce based items e.g. casseroles, fish, mince; sauce based items e.g. cauliflower cheese; spaghetti; Most veges, cauliflower cheese; spaghetti; Most veges, except hard ones, e.g. raw.except hard ones, e.g. raw.

– Most residential care menus tend to be soft – Most residential care menus tend to be soft – not many chops, steaks and schnitzelnot many chops, steaks and schnitzel

Modified soft:Modified soft:– Here the meat is minced, but most other soft Here the meat is minced, but most other soft

foods are used as above. Serve with plenty of foods are used as above. Serve with plenty of sauce or gravysauce or gravy

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Pureed: Pureed: – All foods, except very tender foods, are pureed All foods, except very tender foods, are pureed

(separately), until smooth and lump free.(separately), until smooth and lump free.

– These diets should not be used unless they are These diets should not be used unless they are really needed because of a physiological or really needed because of a physiological or mechanical need. They should not be used for mechanical need. They should not be used for management purposes – e.g. because they are management purposes – e.g. because they are easier or quicker to feed.easier or quicker to feed.

– A Canadian study some years ago suggested A Canadian study some years ago suggested that 25% were on pureed diets for this reason.that 25% were on pureed diets for this reason.

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Issues with Pureed DietsIssues with Pureed Diets Production IssuesProduction Issues

– How is the correct consistency reached?How is the correct consistency reached?– How is the food ‘pureed’How is the food ‘pureed’

Issues with serviceIssues with service Between meal snacksBetween meal snacks

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Challenge 3: Pureed dietsChallenge 3: Pureed diets Food-based RecommendationsFood-based Recommendations

– Foods cooked for pureed diets must reach safe Foods cooked for pureed diets must reach safe temperatures and be treated carefully during processing temperatures and be treated carefully during processing for consumption to maintain microbiological safety.for consumption to maintain microbiological safety.

– Those on full pureed diets should be monitored and Those on full pureed diets should be monitored and assisted with feeding to ensure adequate intakeassisted with feeding to ensure adequate intake

– Portion sizes of pureed meals need to be standardised to Portion sizes of pureed meals need to be standardised to ensure sufficient food is offered ensure sufficient food is offered

– High energy, high protein between meal snacks, such as High energy, high protein between meal snacks, such as ice cream, yoghurts, complan drinks should be provided ice cream, yoghurts, complan drinks should be provided and encouraged for people on full pureed dietsand encouraged for people on full pureed diets

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– Foods must not be pureed with water or thin juices. Use Foods must not be pureed with water or thin juices. Use mashed potato, white sauce, gravy, soup tomato and mashed potato, white sauce, gravy, soup tomato and other sauces, custard and cream—to enhance, rather other sauces, custard and cream—to enhance, rather than dilute, the nutritional value.than dilute, the nutritional value.

– Micronutrients, such as vitamins and minerals, may Micronutrients, such as vitamins and minerals, may need supplementing; check with your dietitian. need supplementing; check with your dietitian.

Food Safety-based RecommendationsFood Safety-based Recommendations– Facilities should ensure they have good food safety Facilities should ensure they have good food safety

procedures in place, and be working towards a procedures in place, and be working towards a registered Food Safety Programmeregistered Food Safety Programme

– All equipment used in the final preparation of pureeing All equipment used in the final preparation of pureeing cooked food needs to be cleaned and sanitised carefully.cooked food needs to be cleaned and sanitised carefully.

– All parts of the equipment should be detached and All parts of the equipment should be detached and washed separately from other dishes in clean hot soapy washed separately from other dishes in clean hot soapy waterwater

– Equipment should be rinsed in clean hot water. If Equipment should be rinsed in clean hot water. If equipment is dishwasher-safe, sanitise in commercial equipment is dishwasher-safe, sanitise in commercial dishwasher at 82 C. It should be sprayed with food-safe dishwasher at 82 C. It should be sprayed with food-safe chemical sanitiser solution and allowed to air dry.chemical sanitiser solution and allowed to air dry.

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Issue 4: Resourcing to ensure Issue 4: Resourcing to ensure adequate nutritionadequate nutrition

Do you have ready access to a dietitian?Do you have ready access to a dietitian?

Does the cook have enough time available Does the cook have enough time available to provide the extra requirements for your to provide the extra requirements for your frail elderly residents, e.g. a milk pudding frail elderly residents, e.g. a milk pudding at the secondary meal, extra sandwiches, at the secondary meal, extra sandwiches, milk shakes, smoothies?milk shakes, smoothies?

Do you have enough staff to assist with Do you have enough staff to assist with feeding those who need it (even if for part feeding those who need it (even if for part of the meal when they tire of feeding of the meal when they tire of feeding themselves).themselves).

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IANA Conference 2005IANA Conference 2005 The 3The 3rdrd International Academy of Nutrition and International Academy of Nutrition and

Aging Conference, St Louis 2005.Aging Conference, St Louis 2005.

John Schnelle reported that even though John Schnelle reported that even though assistance with feeding was claimed, on assistance with feeding was claimed, on observation, it was far less than claimed – about observation, it was far less than claimed – about 25% of what was claimed. 25% of what was claimed.

When more assistance provided, and people When more assistance provided, and people assisted in small groups of 3-4, intakes increased assisted in small groups of 3-4, intakes increased by up to 80%.by up to 80%.

Assistance with between meal snacks led to a Assistance with between meal snacks led to a 100% increase in intake 100% increase in intake

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For the very frailFor the very frail

In the US, 1 aid per 8-10 residents. Not In the US, 1 aid per 8-10 residents. Not validated, but is an industry standardvalidated, but is an industry standard

Need 1 aid for 4-6 residents. Need 1 aid for 4-6 residents.

4.1 hours per resident day has been 4.1 hours per resident day has been validatedvalidated

Staffing levels are a significant predictor of Staffing levels are a significant predictor of qualityquality

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Foodservice staff – Foodservice staff – Guidelines for cooksGuidelines for cooks We suggest that for every 100 subsisted, there We suggest that for every 100 subsisted, there

should be 1 cook, + 1: e.g for 250 people, 2.5+1 should be 1 cook, + 1: e.g for 250 people, 2.5+1 = 3.5 FTE’s; for 75 people 0.75 +1 = 1.75 FTE’s= 3.5 FTE’s; for 75 people 0.75 +1 = 1.75 FTE’s

This means that for your 250 residents, you will This means that for your 250 residents, you will have 20 hours per day of cooks available (2.5 x 8 have 20 hours per day of cooks available (2.5 x 8 hours, or 2 x 10 hours); for your 75 residents, you hours, or 2 x 10 hours); for your 75 residents, you will have 10 hours per day of cooks.will have 10 hours per day of cooks.

Cooks assistants are required over and above this Cooks assistants are required over and above this requirement. Annual leave and special cover is requirement. Annual leave and special cover is also extra to this establishment.also extra to this establishment.

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What about the Dietitian?What about the Dietitian?

Role:Role:– To provide professional expertise in the field To provide professional expertise in the field

of nutrition and dieteticsof nutrition and dietetics

– To assess patients identified as being at To assess patients identified as being at high risk of malnutrition (under- or over-high risk of malnutrition (under- or over-nutrition)nutrition)

– To develop nutritional care plansTo develop nutritional care plans

– To assess need for nutritional modification – To assess need for nutritional modification – diet modification, supplementation etcdiet modification, supplementation etc

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When to call in the When to call in the dietitiandietitian When nutrition screening identifies When nutrition screening identifies

a resident at riska resident at risk– Low BMI, malnutritionLow BMI, malnutrition– Recent significant, unintentional Recent significant, unintentional

weight changeweight change– Poor appetite/dysphagiaPoor appetite/dysphagia– Inappropriate modified diets (e.g. Inappropriate modified diets (e.g.

historical low fat or nutrient restricted historical low fat or nutrient restricted diets) that have not been reviewed diets) that have not been reviewed for many years.for many years.

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Type 1 diabetesType 1 diabetes To review residents on tube feeds (at To review residents on tube feeds (at

least 6 monthly)least 6 monthly) To provide nutrition in-serviceTo provide nutrition in-service To audit your menuTo audit your menu

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Challenge 4: Resourcing for Challenge 4: Resourcing for adequate nutritionadequate nutrition Don’t leave to chance!Don’t leave to chance!

Budget for this!Budget for this!– At the personal levelAt the personal level

– At the organisational levelAt the organisational level

– At the professional levelAt the professional level

The Canadian experienceThe Canadian experience

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In SummaryIn Summary

Today we have looked at 4 major issues Today we have looked at 4 major issues and challenges!and challenges!

Take-home messages:Take-home messages:– Malnutrition – screen for it and actMalnutrition – screen for it and act– Menus – the tool to nutritional adequacyMenus – the tool to nutritional adequacy– Modified diets – allow for them in aged care, but Modified diets – allow for them in aged care, but

be as liberal as possible to encourage adequate be as liberal as possible to encourage adequate intake.intake.

– Resources – budget for these – it makes them Resources – budget for these – it makes them easier to achieve.easier to achieve.

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