Managing adult malnutrition in the community Including a pathway - - PowerPoint PPT Presentation

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Managing adult malnutrition in the community Including a pathway - - PowerPoint PPT Presentation

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Managing adult malnutrition in the community Including a pathway for the appropriate use of oral nutritional supplements (ONS) Supported by the Supported by the Endorsed by the Royal College Supported by the Endorsed by the Primary Care

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SLIDE 1

Managing adult malnutrition in the community

Including a pathway for the appropriate use of oral nutritional supplements (ONS)

www.malnutritionpathway.co.uk

Endorsed by the British Association for Parenteral and Enteral Nutrition Supported by the British Dietetic Association Endorsed by the British Pharmaceutical Nutrition Group Endorsed by the Pharmaceutical Services Negotiating Committee Endorsed by the Primary Care Society for Gastroenterology Endorsed by the Royal Pharmaceutical Society Supported by the National Nurses Nutrition Group Endorsed by the Royal College

  • f General Practitioners

Supported by the Royal College of Nursing Endorsed by the Primary Care Pharmacists Association

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SLIDE 2

www.malnutritionpathway.co.uk

Managing adult malnutrition in the community

  • A practical guide to support

General Practitioners and community healthcare professionals to identify and manage individuals at risk of disease-related malnutrition

  • Includes a pathway for the

appropriate use of oral nutritional supplements (ONS)

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SLIDE 3

www.malnutritionpathway.co.uk

Managing adult malnutrition in the community

Developed by a multi-professional panel with expertise and an interest in malnutrition. Based on evidence, clinical experience and accepted best practice Contents:

  • Malnutrition overview
  • Identification of malnutrition using nutrition screening
  • Managing malnutrition according to risk category
  • Pathway for using ONS in the management of

malnutrition (high risk)

  • Optimising oral intake

Including a pathway for the appropriate use of oral nutritional supplements (ONS)

Produced by a multi-professional consensus panel

M a n a g i n g A d u l t M a l n u t r i t i

  • n

i n t h e C

  • m

m u n i t y

www.malnutritionpathway.co.uk

Endorsed by the British Association for Parenteral and Enteral Nutrition Supported by the British Dietetic Association Endorsed by the British Pharmaceutical Nutrition Group Endorsed by the Pharmaceutical Services Negotiating Committee Endorsed by the Primary Care Society for Gastroenterology Endorsed by the Royal Pharmaceutical Society Supported by the National Nurses Nutrition Group Endorsed by the Royal College
  • f General Practitioners
Supported by the Royal College of Nursing Endorsed by the Primary Care Pharmacists Association
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SLIDE 4

www.malnutritionpathway.co.uk

Panel members

Dr Ailsa Brotherton

  • Senior Research Fellow,

Honorary Secretary of the British Association for Parenteral and Enteral Nutrition Anne Holdoway (chair)

  • Specialist Dietitian and

Independent Practitioner. Chair

  • f the England Board of the

British Dietetic Association. Chair of the Parenteral and Enteral Nutrition (PEN) Group of the British Dietetic Association Pamela Mason

  • Community pharmacy

and Nutrition Consultant. Member of the British Pharmaceutical Nutrition Group Iain McGregor

  • Former chair of the Royal

College of Nursing Older People’s Forum. Training Manager (Scotland and North East England), Four Seasons Health Care Barbara Parsons

  • Head of Pharmacy Practice at

the Pharmaceutical Services Negotiating Committee Dr Rachel Pryke

  • General Practitioner.

Royal College of General Practitioners Clinical Champion for Nutrition and Health

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SLIDE 5

www.malnutritionpathway.co.uk

Professional groups supporting ‘Managing Adult Malnutrition in the Community’

Endorsed by the British Association for Parenteral and Enteral Nutrition Supported by the British Dietetic Association Endorsed by the British Pharmaceutical Nutrition Group Endorsed by the Pharmaceutical Services Negotiating Committee Endorsed by the Primary Care Society for Gastroenterology Endorsed by the Royal Pharmaceutical Society Supported by the National Nurses Nutrition Group Endorsed by the Royal College

  • f General Practitioners

Supported by the Royal College of Nursing Endorsed by the Primary Care Pharmacists Association

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SLIDE 6

www.malnutritionpathway.co.uk

Introduction

  • Malnutrition (under-nutrition) is a common and

costly problem

1

  • Public health expenditure in excess of £13 billion per year
  • Malnutrition prevalence:
  • 10% of people in GP surgeries

2

  • 46% of nursing home residents

3

  • 41% of residential home residents

3 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

Residential Home Nursing Home GPs Surgery

5 10 15

Malnutrition Prevalence %

20 25 30 40 50

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SLIDE 7

www.malnutritionpathway.co.uk

Introduction

  • Groups at risk of malnutrition include

4:

  • Malnourished individuals have poorer clinical
  • utcomes and greater healthcare use,

impacting on the health economy

5,6 Chronic disease COPD, cancer, inflammatory bowel disease, gastrointestinal disease, renal or liver disease Chronic progressive Dementia, neurological conditions (Parkinson’s disease, MND) disease Acute illness Where food is not being consumed for more than 5 days (this is often seen in the acute setting and is rare in the community) Debility Frailty, immobility, old age, depression, recent discharge from hospital Social issues Poor support, housebound, inability to cook and shop, poverty Clinical

  • utcomes

Healthcare use

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www.malnutritionpathway.co.uk

Consequences of Malnutrition

4,5,6

  • Impaired immune system, wound healing and recovery
  • Reduced muscle strength and poorer clinical outcomes
  • More hospital admissions/re-admissions
  • Longer hospital stay
  • Greater healthcare needs in the community
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SLIDE 9

www.malnutritionpathway.co.uk

UK Guidance

National Institute for Health and Clinical Excellence (NICE)

NICE CG32: Nutrition support in adults

7

  • Nutritional screening to identify malnutrition
  • action should be taken to manage risk (A-grade evidence)
  • 2 common oral nutrition support strategies are:
  • dietary advice to increase nutrient content of diet
  • oral nutritional supplements (ONS)
  • Despite available guidance, malnutrition

remains under-detected and under-treated

1.

  • UK GPs acknowledge that a clear evidence based pathway

for identifying and managing malnutrition is required

8

Issue date: February 2006

Nutrition support in adults

Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition Clinical Guideline 32

Developed by the National Collaborating Centre for Acute Care
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SLIDE 10

www.malnutritionpathway.co.uk

Key UK Guidance around managing malnutrition

Essence of care: Benchmarks for food and Drink. Department of Health 2010

  • 10 factors are outlined in the Food and Drink section, including Screening and assessment, planning

implementation, evaluating implementation of care and monitoring. Each section provides guidance and some best practice examples. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_119969 National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 32: Nutrition support in adults. NICE 2006

  • Set of guidelines, based on evidence. Includes specific guidance on screening for malnutrition in all care

settings, provision of nutrition support and monitoring. Note: full guidance contains a costing report and a systematic review. http://guidance.nice.org.uk/CG32 Essential standards of quality and safety. Reg. 14 of the Health and Social Care Act 2008. Meeting Nutritional Needs, outcome 5. Care Quality Commission 2009

  • Where food and hydration are provided to service users the registered person must ensure that service

users are protected from the risk of inadequate nutrition and dehydration.

  • Nutritional screening is carried out to identify those at risk of poor nutrition or dehydration, action is

taken where any risk of poor nutrition of dehydration is identified http://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_March_2010_FINAL.pdf

Issue date: February 2006 Nutrition support in adults Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition Clinical Guideline 32 Developed by the National Collaborating Centre for Acute Care Guidance about compliance

Essential standards

  • f quality and safety
What providers should do to comply with the section 20 regulations of the Health and Social Care Act 2008 March 2010

Essence of Care

2010

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www.malnutritionpathway.co.uk

Managing malnutrition – cost implications

  • Tackling malnutrition can improve nutritional status, clinical outcomes and healthcare use

7

  • NICE have shown substantial cost savings can result from identifying and managing malnutrition

9

  • NICE CG32 is ranked the 3rd top clinical guideline to produce savings

9

Clinical Guidance Short title Why does this guidance save money? Estimated saving per £100,000 CG34 Hypertension (partial update of CG18) Revised recommendations cost more in drugs, outweighed by predicted number of cardiovascular events avoided through hypertension control

  • 446,627

CG30 Long-acting reversible contraception

Nutrition support in adults

Hypertension (update) The additional cost of providing these methods is offset by the costs

  • f unplanned pregnancies (reduced terminations or reduced births).
  • 214,681

CG32 Costs arising from improving screening, assessment and treatment of malnourished patients are offset by reduced complications, reduced GP and outpatient appointments, reduced admissions and reduced length

  • f hospital stay.
  • 28,472

CG127 Accurate detection of high blood pressure will reduce the inappropriate use of antihypertensive drugs, which will outweigh the additional costs of diagnoses.

  • 20,464
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www.malnutritionpathway.co.uk

Identifying malnutrition – ‘MUST’

  • Nutrition screening tool e.g. ‘Malnutrition Universal Screening Tool’ (‘MUST’)10 www.bapen.org.uk
  • Validated for use across healthcare settings by healthcare professionals10
  • 5 step tool assesses risk based on BMI, unintentional weight loss and nutrition intake in the

presence of acute disease10

  • Recommended actions and screening frequency

BMI score >20kg/m2 Score 0 18.5 – 20kg/m2 Score 1 <18.5kg/m2 Score 2 Weight loss score Unplanned weight loss score in past 3-6 months <5% Score 0 5 – 10% Score 1 >10% Score 2 Acute disease effect score (unlikely to apply outside hospital) If patient is acutely ill & there has been or is likely to be no nutritional intake for more than 5 days Score 2 Total score 0-6 Low risk - score 0 Routine clinical care Medium risk - score 1 Observe High risk - score 2 or more Treat*

*Treat, unless detrimental or no benefit is expected from nutritional support.

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SLIDE 13

Identifying malnutrition

  • In the absence of height and weight subjective indicators can be used:
  • Physical appearance e.g. thin or very thin10
  • History of recent unplanned weight loss
  • Loose fitting clothing/jewellery, need for assistance with feeding, changes in appetite and problems

with dentition

  • Risk of undernutrition due to current illness
  • Increased nutritional needs as a result of disease
  • Presence of swallowing difficulties which could impact on ability to eat and drink
  • The individual’s ability to eat and drink; how does current intake compare with 'normal' intake?
  • If only using clinical judgement the following can act as a guide

Physical appearance Unlikely to be at risk of Not thin, weight stable or gaining weight (no unplanned weight loss), no change malnutrition (low) to appetite Possible risk of Thin as a result of disease/condition or history of unplanned weight loss in previous malnutrition (medium) 3-6 months, reduced appetite/ability to eat Likely malnourished (high) Thin/very thin and/or substantial unplanned weight loss in previous 3-6 months, No oral intake for 5 days in the presence of acute disease (unlikely to be seen in the community)

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Managing malnutrition according to degree of risk

7,10,11

  • Routine clinical care
  • Review/repeat screening

Monthly in care homes Annually in community

  • If BMI>30kg/m2 (obese) treat

according to local policy/national guidelines.

  • Dietary advice to maximise nutritional
  • intake. Record intake for 3 days,

encourage small frequent meals and snacks, with high energy and protein food and fluids13

  • Powdered nutritional supplements

to be made up with water or milk are available13

  • Review progress/repeat screening after

1-3 months according to clinical condition

  • r sooner if the condition requires
  • If improving continue until ‘low risk’
  • If deteriorating, consider treating as

‘high risk’.

  • Dietary advice to maximise nutritional
  • intake. Record intake for 3 days,

encourage small frequent meals and snacks, with high energy and protein food and fluids13

  • Prescribe oral nutritional supplements

(ONS) and monitor: See pathway, page 7 on appropriate use

  • f ONS
  • On improvement, consider managing

as ‘medium risk’

  • If no improvement or more specialist

support is required, refer to Dietitian. Low risk - score 0 Routine clinical care Medium risk - score 1 Observe High risk - score 2 or more Treat*

For all individuals:

  • Consider whether dietetic assessment is indicated due to underlying illness e.g. diabetes, COPD
  • Consider underlying symptoms and cause of malnutrition (e.g. nausea, infections) and treat if appropriate
  • Agree goals of intervention with individual/carer and record details of the malnutrition risk
  • Reassess individuals identified at risk as they move through care settings

* Treat, unless detrimental or no benefit is expected from nutritional support

For all interventions, goals of intervention should be set and monitoring undertaken

For more information and references please go to www.malnutritionpathway.co.uk

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SLIDE 15

www.malnutritionpathway.co.uk

Managing Malnutrition: Optimising Nutritional Intake

  • ‘Dietary advice’, ‘food first’, ‘food fortification’
  • Everyday foods (e.g. cheese, full fat milk) added to the diet to increase energy and

protein content without increasing volume of food consumed

  • This can include

12:

  • Altered meal patterns (small meals and snacks)
  • Powdered nutritional supplements
  • Fortifying foods to increase calorie and protein intake
  • Overcome potential barriers
  • Evidence for dietary advice show improvements in muscle mass and

hand grip strength with dietary advice

13

  • Data on clinical outcomes or cost effectiveness is limited

13

  • Care should be taken to ensure a balance of nutrients is provided

7

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Managing malnutrition: Oral nutritional supplements (ONS)

  • ONS contain energy, protein and

micronutrients, in addition to oral diet

  • Evidence demonstrates a range of

clinical and health economic benefits

7,14

  • Increase in nutritional intakes
  • Improve weight and function (e.g. strength)
  • Reduce complications, mortality, hospital

admissions/re-admissions

  • Benefits seen with 1-3 ONS per day,

2-3 months duration

7,14

Individual identified as high risk (page 6)

Record details of malnutrition risk (screening result/risk category, or clinical judgement) Agree goals of intervention with individual/carer14 Consider underlying symptoms and cause of malnutrition e.g. nausea, infections and treat if appropriate Consider social requirements e.g. ability to collect prescription Reinforce advice to optimise food intake*, confirm individual is able to eat and drink and address any physical issues e.g. dysphagia, dentures12 Goals met/Good progress: Encourage oral intake and dietary advice Consider reducing to 1 ONS per day for 2 weeks before stopping Maximise nutritional intake, consider powdered nutritional supplements to be made up with water or milk Monitor progress, consider treating as ‘medium risk’ (see page 6) Goals not met/Limited progress Check ONS compliance; amend prescription as necessary, increase volume of ONS Reassess clinical condition, consider more intensive nutrition support or seek advice from a Dietitian Consider goals of intervention, ONS may be provided as support for individuals with deteriorating conditions If no improvement, seek advice from a Dietitian Review individuals on ONS every 3-6 months or upon change in clinical condition7 When to stop ONS prescription Goals of intervention have been met and individual is no longer at risk of malnutrition Individual is clinically stable/acute episode has abated Individual is back to their normal eating and drinking pattern7 If no further clinical input would be appropriate Acute illness/Recent hospital discharge: Short-term nutritional support Confirm need for ONS - is individual able to manage adequate nutritional intake from food alone? Where intake remains inadequate, ONS prescription for 4-6 weeks (1-3 ONS per day)** in addition to oral intake15 If a continuation from hospital prescription, confirm need using screening tool1 (page 4 and Appendix 1), verify compliance Consider ACBS (Advisory Committee for Borderline Substances) indications (see page 9)14/16 Monitor compliance after 6 weeks Check compliance to ONS and amend type/flavour if necessary to maximise intake Monitor progress after 4 - 6 weeks Review goals set before intervention Consider weight change, strength, physical appearance, appetite, ability to perform activities of daily living Monitor monthly or sooner if clinical concern Monitor progress after 12 weeks Review goals set before intervention Consider weight change, strength, physical appearance, appetite, ability to perform activities of daily living Monitor every 3 months or sooner if clinical concern Chronic conditions e.g. COPD, cancer, frail elderly: Longer term nutritional support when food approaches alone are insufficient 2 ONS per day (range 1-3) in addition to oral intake, 12 week duration according to clinical condition/ nutritional needs7,17,18 Prescribe 1 ‘starter pack’, then 60 preferred ONS per month Consider ACBS (Advisory Committee for Borderline Substances) indications (see page 9)14/16

Advice on ONS prescription according to consensus clinical opinion. ONS prescription-units to prescribe per day e.g. 2 ONS = 2 bottles/units of ONS per day * For more detailed support or complex conditions seek advice from a Dietitian **Some individuals may require more than 3 ONS per day – seek dietetic advice NOTE: ONS requirement will vary depending on nutritional requirements, patient condition and ability to consume adequate nutrients, ONS dose and duration should be considered ONS – oral nutritional supplements/sip feeds/nutrition drinks (BNF section 9.4.2)16 (see pages 8-9)
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www.malnutritionpathway.co.uk

Managing malnutrition: Oral nutritional supplements (ONS)

  • ONS varieties available to meet individual needs and preferences
  • Styles (milk, juice, yoghurt, savoury),
  • Formats(liquid, powder, pudding, pre-thickened)
  • Types (high protein, fibre containing, low volume)
  • Energy densities (1-2.4kcal/ml) and
  • Flavours
  • Most ONS provide ~300kcal, 12g protein and a full range of vitamins

and minerals per serving

  • High protein ONS are suitable for individuals with wounds, post-operative patients, some types of cancer, and the elderly
  • Fibre-containing ONS are useful for those with constipation (not suitable for those requiring a fibre-free diet)
  • Pre-thickened ONS and puddings are available for individuals with neurological conditions that affect their swallow
  • Small volume high energy dense ONS may aid compliance22,23, and may be better tolerated by patients who cannot

consume larger volumes

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SLIDE 18

Pathway for using ONS in the management of malnutrition

  • For individuals at high risk of malnutrition
  • Outlines considerations prior to initiating a

prescription

  • Goal setting and monitoring
  • 2 routes;
  • Recent hospital discharge/require ONS short term
  • Use of ONS in chronic conditions or longer term
  • Monitoring progress and adapting management
  • Advice on when and how to discontinue

ONS prescription

Individual identified as high risk (page 6)

Record details of malnutrition risk (screening result/risk category, or clinical judgement) Agree goals of intervention with individual/carer14 Consider underlying symptoms and cause of malnutrition e.g. nausea, infections and treat if appropriate Consider social requirements e.g. ability to collect prescription Reinforce advice to optimise food intake*, confirm individual is able to eat and drink and address any physical issues e.g. dysphagia, dentures12 Goals met/Good progress: Encourage oral intake and dietary advice Consider reducing to 1 ONS per day for 2 weeks before stopping Maximise nutritional intake, consider powdered nutritional supplements to be made up with water or milk Monitor progress, consider treating as ‘medium risk’ (see page 6) Goals not met/Limited progress Check ONS compliance; amend prescription as necessary, increase volume of ONS Reassess clinical condition, consider more intensive nutrition support or seek advice from a Dietitian Consider goals of intervention, ONS may be provided as support for individuals with deteriorating conditions If no improvement, seek advice from a Dietitian Review individuals on ONS every 3-6 months or upon change in clinical condition7 When to stop ONS prescription Goals of intervention have been met and individual is no longer at risk of malnutrition Individual is clinically stable/acute episode has abated Individual is back to their normal eating and drinking pattern7 If no further clinical input would be appropriate Acute illness/Recent hospital discharge: Short-term nutritional support Confirm need for ONS - is individual able to manage adequate nutritional intake from food alone? Where intake remains inadequate, ONS prescription for 4-6 weeks (1-3 ONS per day)** in addition to oral intake15 If a continuation from hospital prescription, confirm need using screening tool1 (page 4 and Appendix 1), verify compliance Consider ACBS (Advisory Committee for Borderline Substances) indications (see page 9)14/16 Monitor compliance after 6 weeks Check compliance to ONS and amend type/flavour if necessary to maximise intake Monitor progress after 4 - 6 weeks Review goals set before intervention Consider weight change, strength, physical appearance, appetite, ability to perform activities of daily living Monitor monthly or sooner if clinical concern Monitor progress after 12 weeks Review goals set before intervention Consider weight change, strength, physical appearance, appetite, ability to perform activities of daily living Monitor every 3 months or sooner if clinical concern Chronic conditions e.g. COPD, cancer, frail elderly: Longer term nutritional support when food approaches alone are insufficient 2 ONS per day (range 1-3) in addition to oral intake, 12 week duration according to clinical condition/ nutritional needs7,17,18 Prescribe 1 ‘starter pack’, then 60 preferred ONS per month Consider ACBS (Advisory Committee for Borderline Substances) indications (see page 9)14/16

Advice on ONS prescription according to consensus clinical opinion. ONS prescription-units to prescribe per day e.g. 2 ONS = 2 bottles/units of ONS per day * For more detailed support or complex conditions seek advice from a Dietitian **Some individuals may require more than 3 ONS per day – seek dietetic advice NOTE: ONS requirement will vary depending on nutritional requirements, patient condition and ability to consume adequate nutrients, ONS dose and duration should be considered ONS – oral nutritional supplements/sip feeds/nutrition drinks (BNF section 9.4.2)16 (see pages 8-9)
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SLIDE 19

www.malnutritionpathway.co.uk

Summary

  • Malnutrition is a common and costly problem in the UK

1,2

  • The majority of malnutrition occurs in the community

1

  • Tackling malnutrition can improve nutritional status, clinical
  • utcomes and reduce healthcare use

7

  • Practical, evidence-based guide to complement existing UK

guidance is required

8

  • ‘Identifying and managing adult malnutrition in the community’ is a new

document, developed by a multi professional panel to for General Practitioners and healthcare professionals working in the community

  • Endorsed by key professional bodies
  • Provides a practical, evidence based approach to tackle malnutrition
  • Includes a pathway for the appropriate use of ONS
Including a pathway for the appropriate use of oral nutritional supplements (ONS) Produced by a multi-professional consensus panel

Managing Adult Malnutrition in the Community

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References

1. Elia M, Russell C. Combating Malnutrition: Recommendations for Action. Report from the advisory group on malnutrition, led by

  • BAPEN. 2009.

2. Elia M and Stratton RJ. Calculating the cost of disease-related malnutrition in the UK in 2007 (public expenditure only) in: Combating Malnutrition: Recommendations for Action. Report from the advisory group on malnutrition, led by BAPEN. 2009. 3. Russell CA and Elia M. Nutrition Screening Survey in the UK and Republic of Ireland in 2011. A report by BAPEN. 2012 4. Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: an evidence-based approach to treatment. Oxford: CABI publishing; 2003. 5. Elia M. Nutrition and health economics. Nutrition 2006; 22(5):576-578. 6. Guest JF et al. Health Economic impact of managing patients following a community-based diagnosis of malnutrition in the UK. Clin Nutr 2011; 30(4): 422-429 7. National Institute for Health and Clinical Excellence (NICE). Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical Guideline 32. 2006. 8. Ashman K et al Are the NICE clinical guidelines for nutrition support implemented in GP practices? CN Focus (2011) Vol.3 No.4 9. National Institute for Health and Clinical Excellence (NICE). Cost saving guidance: http://www.nice.org.uk/usingguidance/benefitsofimplementation/costsavingguidance.jsp Accessed 17.01.2012 10. The "MUST" report. Nutritional screening for adults: a multidisciplinary responsibility. Elia M, editor. 2003. Redditch, UK, BAPEN. www.bapen.org.uk/musttoolkit 11. National Prescribing Centre. Prescribing of adult oral nutritional supplements (ONS). Guiding principles on improving the systems and processes for ONS use. http://www.npc.nhs.uk/quality/ONS/resources/borderline_substances_final.pdf. Accessed 24.4.12 12. Manual of Dietetic Practice. 4th ed. Blackwell Publishing Ltd; 2007 13. Baldwin C, Weekes CE. Dietary advice with or without oral nutritional supplements for disease related malnutrition in adults (review). Cochrane Database of Systematic Reviews. 2011. 14. Stratton RJ, Elia M. A review of reviews: a look at the evidence for oral nutritional supplements. Clin Nutr Supp 2007; 2, 5-23

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www.malnutritionpathway.co.uk

Development of the malnutrition pathway

Need for evidence based pathway identified Multi professional panel drawn together Panel meeting: content developed and agreed Electronic version developed based on document Endorsement from professional bodies Launch

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SLIDE 22

www.malnutritionpathway.co.uk

www.malnutritionpathway.co.uk

  • Interactive website based on content of the document

‘Managing adult malnutrition in the community’

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SLIDE 23

Managing adult malnutrition in the community

Including a pathway for the appropriate use of oral nutritional supplements (ONS)

www.malnutritionpathway.co.uk

Endorsed by the British Association for Parenteral and Enteral Nutrition Supported by the British Dietetic Association Endorsed by the British Pharmaceutical Nutrition Group Endorsed by the Pharmaceutical Services Negotiating Committee Endorsed by the Primary Care Society for Gastroenterology Endorsed by the Royal Pharmaceutical Society Supported by the National Nurses Nutrition Group Endorsed by the Royal College

  • f General Practitioners

Supported by the Royal College of Nursing Endorsed by the Primary Care Pharmacists Association