Treating malnutrition

This is the 2nd blog post in support of Malnutrition Awareness Week 2020 and aims to provide more information about the treatment of malnutrition and some practical tips to follow if you or a loved one is experiencing malnutrition.

As we get older there can be the expectation that losing weight is normal and part of the ageing process. This is not true. Any unintentional weight loss should be taken seriously.

It is not uncommon for our appetites to change as we get older therefore it is important to manage these changes so that it does not result in an inadequate nutritional intake and unintentional weight loss.

10 tips that can help to address a small appetite

  1. Introduce small snacks in-between your meals such as cheese and crackers
  2. Choose higher fat containing foods such as full fat milk, butter, as these will provide more energy
  3. Add butter, cream or cheese to meals and sauces as this will increase the energy content without increasing the volume of food
  4. Have a nourishing drink before bed such as a hot chocolate made with full fat milk
  5. Have regular meals and snacks – aim for 6 small meals and snacks instead of 3 big meals a day
  6. Don’t forget about fluid – aim to have 6-8 drinks a day. This can include tea and coffee, glasses of milk and fruit juice.
  7. Avoid not eating at all, even if its only something small
  8. Don’t be afraid to ask for help with cooking and food shopping
  9. Tinned foods such as rice pudding or tinned fruit are useful staple cupboard foods
  10. If you continue to struggle with your appetite and are losing weight, please discuss with your GP or a healthcare professional

This advice is intended to provide general advice on treating malnutrition. If you are concerned about yourself or a loved one in regards to unintentional weight loss and changes in appetite, please speak with a healthcare professional.

Dietitians play a key role in the identification, management and treatment of malnutrition. Following specialist nutritional assessment, a tailored nutritional care plan will be provided. Ongoing monitoring of the care plan will ensure that the intervention is working and whether any adjustments to the plan are required. Dietitians will work with the wider multidisciplinary team to ensure implementation of the nutritional care plan.

I provide 1-1 online video consultations. Please click here if you would like to arrange a free call with me to see how I could help you.

Malnutrition Awareness Week 2020

This week (5th-12th October 2020) is Malnutrition Awareness Week in the UK and is run by BAPEN (British Association for Parenteral and Enteral Nutrition) and the Malnutrition Task Force.

Did you know that 1 in 10 people over the age of 65 are malnourished or at risk of malnutrition?

Let’s start at the beginning by explaining what we mean by malnutrition. Malnutrition is the inadequate intake of nutrition that results in negative effects on an individuals health and wellbeing. One of the most common signs of malnutrition is unintentional weight loss i.e. weight loss that occurs without any specific action being taken to result in this change.

Other signs and symptoms of malnutrition include:

  • loss of appetite
  • tiredness and fatigue
  • reduced ability to perform normal tasks
  • reduced physical performance – for example, not being able to walk as far or as fast as usual
  • altered mood – malnutrition can be associated with lethargy and depression
  • poor concentration

Some of these signs may be easy to spot but others may be less obvious to spot. Therefore, it is important we are aware of these signs and symptoms and how to detect changes that may increase someone risk’s of malnutrition.

Unintentional weight loss can occur gradually and sometimes be difficult to spot and recognise. However, these are some simple tips you can use to help recognise it, including:

  • dentures feeling loose or moving when talking/eating
  • jewellery i.e. rings and watches, feeling loose
  • clothes becoming loose

What are the consequences of malnutrition?

Malnutrition effects every part of the body therefore it can have serious effects on our body functions. It can slow down our recovery, increase our susceptibility to illness, increase complications and if left untreated, may lead to death.

  1. The immune system: our immune system becomes impaired during states of malnutrition which can lead to a loss of immune function. This results in increased susceptibility to illness and not being able to fight off infections.
  2. Muscle strength: in a state of malnutrition, loss of muscle strength and function is observed. This occurs due to an inadequate dietary intake of protein and energy and our body compensates by using the protein in our muscles as an alternative source of energy. Loss of muscle strength and function may result in an increased risk of falls, reduced ability to perform daily activities such as cooking, reduced ability to cough may predispose to chest infections, and heart failure.
  3. Wound healing: Optimal wound healing requires adequate nutrition. Malnutrition will delay, inhibit and complicate the wound healing process. Our protein needs in particular, increase during wound healing. Therefore, malnutrition coupled with not meeting these increased nutritional needs can have serious and detrimental effects to wound healing.

So what can we do to identify malnutrition?

1 in 10 people over the age of 65 are malnourished or at risk of malnutrition. Unintentional weight loss can be a sign of malnutrition, therefore self-screening in older people can be a useful tool to check that you are not losing too much weight.

Self-screening can take many forms but asking yourself or your loved ones the following questions can be a good starting point:

  1. Are you or your family concerned that you may be underweight or need nutritional advice?
  2. How you lost weight unintentionally in the last 3-6 months?
  3. Have you noticed that your clothes or rings have become loose recently?
  4. Have you recently found that you have lost your appetite and/or interest in eating?

If you answered YES to these questions, it is important that you discuss this with your GP.

Further information about self-screening and a range of different tools that can help have been produced by the Malnutrition Task Force, click here.

Identification of malnutrition or risk of malnutrition is key to ensuring appropriate action is taken. There may be simple changes that can be taken at home or you may require further support from a dietitian.

My next blog post will discuss how malnutrition is managed. However, if you are concerned about unintentional weight loss and loss of appetite, please discuss with a healthcare professional.

I provide 1-1 online video consultations for a range of different dietary needs. If you would to discuss how I can could help you, please click here.

Hydration in dysphagia management

Dysphagia can can affect the ability to eat and drink and inability to maintain nutrition and hydration which can impact on health and quality of life. The role of the dietitian in dysphagia management is to ensure adequate nutrition and hydration.

Among those with dysphagia, the prevalence of dehydration ranges from 44% to 75% depending on the patient population, setting, and criteria used to define dehydration1

The importance of fluid

Fluid is important for our bodies as it plays many roles and is essential for life.

Fluid has many vital functions including:

  • regulation of body temperature
  • removal of waste materials from the body such as salts and urea
  • transports water soluble vitamins such as B vitamins

What is dehydration?

Dehydration occurs due to your body losing more fluid than you are taking in. It can result in the following:

  • constipation
  • kidney stones
  • falls
  • urinary tract infections
  • pressure sores
  • confusion
  • drowsiness

What are the signs of dehydration2?

  • feeling thirsty
  • dark yellow and strong-smelling pee
  • feeling dizzy or lightheaded
  • feeling tired
  • a dry mouth, lips and eyes
  • peeing little, and fewer than 4 times a day

Why is dehydration a complication of dysphagia?

Dehydration is commonly a problem in people with dysphagia for a number of reasons but is usually due to inadequate fluid intake. Thickened fluids which are usually recommended for people with dysphagia can play a role. Depending on the severity of the swallowing problems, there may be other reasons alongside using thickened fluids that may be contributing to a reduced fluid intake such as pain on swallowing fluids or requiring assistance from others with their drinks. Other factors independent of dysphagia may also be a feature, including:

  • loss of thirst sensation
  • unable to communicate needs
  • fear of incontinence
  • memory issues e.g. forgetting to drink

How can dehydration be managed in people with dysphagia?

  1. Choice of thickener
  2. Cognitive challenges
  3. Physical barriers

Choice of thickener

Thickened drinks are used to alter the flow rate of a liquid allowing more time for the person with dysphagia to swallow the drink safely. The level of thickened fluid required will be determined following a speech and language therapy assessment. Not only may the thickness of the drink change but the amount recommended may also be limited. As a dietitian both these factors are particularly important, especially if oral nutritional supplements are being considered.

It is important that the thickener chosen to alter the consistency of the drink to improve the safety of the drink for the person with dysphagia has the following features:

  • does not alter the taste of the drink to be thickened
  • does not alter the appearance of the drink to be thickened i.e. no change in colour or clarity of the drink
  • can be safely used across a variety of different drinks to increase patient choice

All of these features will aid improve compliance with thickened fluids. It is important to work with the person with dysphagia to implement a care plan that is person centred, whilst balancing risk of aspiration with quality of life.

Cognitive challenges

Communication difficulties that arise due to medical conditions that are common among people with dysphagia include stroke, dementia and brain injury. These communication challenges may make it difficult for the person with dysphagia to express the need for help with a drink, give a preference over drink choice or indicate they are thirsty.

Physical barriers

Dysphagia that has been diagnosed due to conditions such as stroke, brain injury and head and neck cancers, may also pose physical challenges. These include requiring assistance to drink, unable to prepare and serve their own drinks and changes to fluid thickness and volume. These factors may limit a persons overall fluid intake resulting in dehydration.

Overcoming all of these factors in dysphagia management to prevent dehydration are extremely important. Not only is it the responsibility of the dietitian and speech and language therapist to work together to address these challenges, the wider multidisciplinary team are essential. For example, in a care home environment, this responsibility will extend to all care home staff. Education is key alongside clear communication of care plans.

Summary

Management and treatment of dysphagia is multidisciplinary with both the speech therapist and dietitian working closely to reduce the complications of dysphagia such as malnutrition and dehydration. It is important that dehydration is detected early to minimise the risk of complications.

References

  1. Reber E, Gomes F, Dähn IA, Vasiloglou MF, Stanga Z. Management of Dehydration in Patients Suffering Swallowing Difficulties. J Clin Med. 2019;8(11):1923. Published 2019 Nov 8. doi:10.3390/jcm8111923
  2. https://www.nhs.uk/conditions/dehydration/

Dysphagia…the role of a dietitian

This blog post was written as a guest blog post for Speech Therapy Works (www.speechtherapyworks.co.uk) run by Sandra Robinson.

As the result of swallowing difficulties, it is highly likely that a person’s eating and drinking is affected. The degree to which their eating and drinking is affected will vary on an individual basis. One of the major consequences of dysphagia not being identified and/or not being managed appropriately is malnutrition.  

Malnutrition is the result of an imbalance of the energy, protein and other important nutrients in the body resulting in the following:

  • loss of muscle mass
  • weight loss
  • reduced ability to fight infection
  • increased risk of falls
  • impaired wound healing

Malnutrition is a severe complication of dysphagia and studies suggest up to 50% individual with dysphagia are at risk of malnutrition and 16% are malnourished1.

Why does malnutrition occur in people with dysphagia?

There are numerous reasons why a person with dysphagia becomes malnourished or is at increased risk of malnutrition. These reasons may include:

  • inadequate food and fluid intake following changes to the recommended consistency of food and fluid that is safe to consume as advised by a speech and language therapist
  • inadequate provision of nutritious texture modified food and fluid
  • taking longer to eat a meal therefore a person may lose interest, or the meal goes cold therefore the meal becomes unappetising

What role does a dietitian play in helping people with dysphagia?

Following diagnosis of dysphagia, it is important that a dietitian works closely with speech and language therapists to ensure any nutritional concerns are addressed. As discussed earlier there may be numerous reasons why a person with dysphagia may become nutritionally compromised and identifying these reasons will be key to improving someone’s nutritional intake.

  1. Texture modified diets and fluids

Management strategies for dysphagia can include texture modification of diet and fluids.  The IDDSI framework is a globally developed standardised set of terminology to describe texture modified foods and thickened liquids2.

Depending on the recommendations set out by the speech and language therapist, the degree of nutritional support required will vary. For some individuals they may be able to manage for example 80% of their nutritional intake from texture modified diet but require oral nutritional supplements to provide the deficit. When considering the use of oral nutritional supplements there are several things a dietitian will need to consider:

  • does the person need their drinks thickened?
  • does the person like milk?
  • is the person able to make a drink or do they need a ready to drink version?

Dependent on these factors will determine the type and format of oral nutritional supplement recommended.  It may be appropriate to consider a pre-thickened oral nutritional supplement if the person requires thickened fluids as these products offer a safe solution to ensure that the recommended thickened fluid consistency is received.

Before or alongside the use of oral nutritional supplements, food fortification is usually recommended and is a way of improving the nutritional value of food and can be used in texture modified diets.  For example:

  • Using cream or whole milk instead of water to puree the food
  • Add butter or cheese into food before preparing to the correct consistency e.g. mashed potato
  • Add cream or custard to fruit before it is pureed.

In addition to addressing nutritional concerns, dietitians will also look at the hydration status of an individual.  It is common for people with dysphagia to have inadequate fluid intake which can lead to dehydration.  

The major consequences of dehydration include:

  • Low blood pressure
  • Urinary tract infections
  • Constipation
  • Confusion
  • Dizziness

Maintaining adequate hydration in people with dysphagia can be challenging due to a number of reasons.

Thickened fluids are commonly used as part of texture modification strategies to reduce the risk of aspiration.  However, it is important that the extent to which the fluid is thickened is balanced alongside risk of dehydration, compliance with thickened fluids and the safety aspect for a safe swallow.  This is where collaboration between dietitians and speech and language therapist is essential to ensure the risk of dehydration is minimised whilst also managing the risk of aspiration.

Strategies to reduce the risk of dehydration in people with dysphagia could include the following:

  • Offered flavoured thickened drinks rather than thickened plain water
  • The use of gum-based thickeners over starch-based thickeners may be preferable to improve the visual appeal and palatability of the thickened drink
  • Pre-thickened drinks may play a role particularly if the person also requires nutritional supplementation

2. Provision of safe and nutritious food and drink

Dysphagia management is everyone’s responsibility and once a plan has been outlined about how to manage dysphagia, it is important all key individuals are involved in the plan. Once recommendations are in place for a texture modified diet, it is important that those who prepare and serve the food and drink are aware of these recommendations.. 

Texture modified foods can be self-prepared or ready meals can be purchased.  When preparing homemade texture modified it is important that the preparation of the food is in line with the IDDSI framework descriptors for the recommended level advised by the speech and language therapist.

Summary

Due to the overlap between dysphagia and malnutrition, it is important that speech and language therapists and dietitians work together.  The role of the dietitian in dysphagia management is to ensure adequate nutrition and hydration, particularly when texture modified food and diet recommendations are in place.  This will help to improve a person’s nutritional status, aid recovery and improve quality of life.

References:

  1. Tagliaferri S, Lauretani F, Pelá G, Meschi T, Maggio M. The risk of dysphagia is associated with malnutrition and poor functional outcomes in a large population of outpatient older individuals. Clinical Nutrition [Internet]. 2019;38(6):2684–9. 
  2. Cichero JAY, Lam P, Steele CM, Hanson B, Chen J, Dantas RO, et al. Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework. Dysphagia [Internet]. 2016/12/02. 2017 Apr;32(2):293–314.

Dysphagia…the basics

This is the first of series of blog posts on the topic of dysphagia and the link with nutrition, specifically malnutrition and the role a dietitian plays in the management of dysphagia. This first blog post will cover the basics of dysphagia. Look out for further blog post in this series including a guest blog post by a speech and language therapist.

What is dysphagia?

Dysphagia is the medical term given to swallowing difficulties and can occur in both children and adults. These swallowing difficulties usually arise due to an associated medical condition. It is estimated that approximately 8% of the world’s population are affected by dysphagia.

Dysphagia may not necessarily be an initial presenting symptom of a medical condition but may occur as the medical condition progresses such as neurological disorders e.g. Parkinson’s disease.

What are the signs and symptoms of dysphagia?

  • Coughing or choking when eating or drinking 
  • A ‘gurgly’ wet sounding voice 
  • A sensation that food is stuck in the throat 
  • Reduced ability to chew 
  • Taking a long time to finish a meal 
  • Persistent drooling of saliva 

What medical conditions are associated with dysphagia?

  • Stroke 
  • Neurological conditions such as Parkinson’s disease, motor neurone disease and Alzheimer’s 
  • Head & neck or oesophageal cancer 
  • Respiratory conditions such as chronic obstructive pulmonary disease  
  • Learning disabilities 
  • Traumatic brain injury 

What are the consequences of dysphagia?

If not identified or appropriately managed, the following consequences may arise:

  • dehydration
  • malnutrition or weight loss
  • chest infections
  • aspiration pneumonia
  • longer hospital stays or admission into hospital

How is dysphagia treated?

Treating dysphagia depends on what underlying condition or conditions a person may have. Some people experience dysphagia for only a short period of time, whereas others might have it for a longer period of time.

A speech and language therapist is the key healthcare professional for management of dysphagia. The role of a speech and language therapist includes:

  • Diagnosis of dysphagia
  • Help people regain their swallowing through exercises, techniques and positioning 
  • Promote patient safety through modifying the texture of food and fluids, reducing the risk of malnutrition, dehydration and choking
  • Promote quality of life, taking into account an individual’s and their families’ preferences and beliefs, and helping them adjust to living with swallowing difficulties
  • Work with other healthcare staff, particularly dietitians, to optimise nutrition and hydration
  • Educate and train others in identifying, assessing and managing dysphagia, including families and the wider health and care workforce

[Source: Royal College of Speech and Language Therapists]

Once an assessment by a speech and language therapist has taken place, advice may be provided on how to promote patient safety through the modification of the texture of food and fluids and swallowing exercises, technique and positioning.

What are texture modified diet and fluids?

Texture modification is common practice in dysphagia management.  The aim of texture modification is to prevent or reduce aspiration and potentially subsequent pneumonia. 

In April 2019 the UK implemented the International Dysphagia Diet Standardisation Initiative (IDDSI) framework. This framework was developed by a global team of experts with the aim of improving patient safety for those individuals with dysphagia by standardising the terminology and definitions for texture-modified foods and liquids applicable to individuals with dysphagia of all ages, in all care settings, and all cultures.

The International Dysphagia Diet Standardisation Initiative 2016 @https://iddsi.org/framework/
Attribution is NOT PERMITTED for derivative works incorporating any alterations to the IDDSI Framework that extend beyond language translation. Supplementary Notice: Modification of the diagrams or descriptors within the IDDSI Framework is DISCOURAGED and NOT RECOMMENDED. Alterations to elements of the IDDSI framework may lead to confusion and errors in diet texture or drink selection for patients with dysphagia. Such errors have previously been associated with adverse events including choking and death.

As mentioned above, dietitians work closely with Speech and Language Therapists once a diagnosis of dysphagia is made. Dietetic input will involve ensuring adequate nutrition and hydration particularly if texture modification of diet and fluids has been recommended.

A later blog post in this mini series about dysphagia, will discuss the role of the dietitian in dysphagia management.