PowerPoint Presentation

Nutrition in Care Homes for People with DiabetesKurt Maloney, Specialist Dietitian Bradford Nutrition & Dietetic Department St Lukes Hospital

(10)1Objectives Identify the CQC regulation for nutrition & hydration Discuss the dietary management of diabetes Introduction to dietary advice for overweight & malnourished patientsOutline the importance of screening for malnutrition with examples

Try to keep it discussion based, case studies, questions encourage questions and interaction during presentation 2Regulation 14: Meeting nutritional & hydration needs (2014)People must have enough to eat & drink to meet their needs People must have nutritional needs assessed & food provided to meet their individual needsMust receive support with nutrition & hydration if needed

Provide a variety of nutritious & appetising foodAppropriate temperature Culturally appropriate Preference & choice Prompts, encouragement, eating aidsFollow prescribing plan for supplements Regular assessment of needsStaff should know when specialist nutritional advice is needed & how to refer

Regulation 14: Meeting nutritional & hydration needs (2014)When avoidable harm or exposure to significant risk of harm is identified.CQC can prosecute for breach of regulation 14 without serving a warning noticeCQC will refuse registration if providers cannot provide evidence of compliance

Dietary Advice for Diabetes

6Points to considerPriority of the persons diabetes management Individualised assessment & treatment No one size fits all approach Diagnosis, prognosis & quality of life Social aspects of eatingPleasure from eating Respect individuals choices

1) Tight control? NH 2) symptom management Res ** some will need healthy eating, some wont7Which Nutrient Affects Blood Glucose?

All affect blood glucose!

Food is chewed to start breaking it downFood is broken down further in the stomachCarbohydrate is broken down into glucose Shortly after eating carbohydrate blood glucose starts to riseBody cells use the glucose for fuel or store it for laterWhich Nutrient Affects Blood Glucose?

Why is Diet Important? Major influence on diabetes management & health

Blood glucose control Long & short term complications Body fat and insulin resistanceRisk of other diet related diseasesVitamins, Minerals, Protein & Fats are essential for good health

10Diet Myths True or FalsePeople with diabetes shouldn't have:Bananas, grapes, melon & mangoSweet foods and puddingsLots of sugary drinks

People with diabetes should: Use diabetic products Always snack between meals Follow a special or diabetic diet

What is the dietary advice for diabetes?Healthy Eating

Relevant to care homes12Healthy Eating in Care HomesRegular & Balanced MealsPortion control Healthy menu planning & cookingAppetising meals & variety Healthier snack & pudding optionsLimit processed or junk foodsAvoid sugary drinks & added sugars Occasional treat foods are fine

Points more relevant to nursing homes13Healthy Eating

Doesnt show fats/junk14How much is important Regular meals spreads carbs outAvoid added sugars & sugary food/drinks Fruit & fruit juices Dont double up on starches Smaller portions of puddings The type is also importantPorridge, basmati rice, new potatoes, seeded bread, whole grain starches & cereals

CHO affects blood glucose so is important in diabetes management. Too much can lead to high glucose, also the type of carb can have an effect .so some simple things which can help with blood glucose control are: 15Weight Management Simple Tips for weight management in care settingsRegular Meals Portion Control even healthy food can affect weight!Healthy, tasty menu choices and healthy snack options Healthier puddings & desserts or small portions Avoid added sugars (drinks & foods) Non restrictive approach with occasional treat foods

Simple swaps and small changesSwap Chocolate pudding for chocolate Muller light Swap Shortcake biscuits for rich teaChange drinks to diet, sugar free, no added sugarSwap sugar for sweeteners

16Weight Management What would you change?

Breakfast: Large bowl of cereal with milk, 2 Toast with butter, 1 glass of fruit juiceMid morning: 3 plain digestives with cup of teaLunch: Tuna mayo sandwich, 2 slices granary bread with 5 teaspoons mayonnaise and packet of crisps Evening Meal: Beef casserole with large portion of mashed potato (made with butter) and full portion sponge pudding with custardSupper: 3 plain digestives with cup of tea

Weight Management What would you change?

Breakfast: Large bowl of cereal with milk, 2 Toast with butter, 1 glass of fruit juiceMid morning: 3 plain digestives with cup of teaLunch: Tuna mayo sandwich, 2 slices granary bread with 5 teaspoons mayonnaise and packet of crisps Evening Meal: Beef casserole with large portion of mashed potato (made with butter) and full portion sponge pudding with custardSupper: 3 plain digestives with cup of tea

Change to either or half with BF might save ~ 200 kcal, portion control at EM rough estimate ~ 300kcal 18Weight Management What would you change?

Breakfast: Large bowl of cereal with milk, 2 Toast with butter, 1 glass of fruit juiceMid morning: 3 plain digestives with cup of teaLunch: Tuna mayo sandwich, 2 slices granary bread with 5 teaspoons mayonnaise and packet of crisps Evening Meal: Beef casserole with large portion of mashed potato (made with butter) and full portion sponge pudding with custardSupper: 3 plain digestives with cup of tea

Digestive = 500kcal for 6, mayo = 250kcal = 750kcal Swap to rich tea and light mayo ~ 6 rich tea = 180kc 5 tsp light mayo = 100kc (300 rich tea saving) (mayo = 150) saving) = total of 450kcal saved = a small meal Change would also improve blood glucose 19Weight Management What would you change?

Breakfast: Small bowl of cereal with milk, 1 Toast with butter, 1 glass of fruit juiceMid morning: 3 rich tea biscuits with cup of teaLunch: Tuna mayo sandwich, 2 slices granary bread with 5 teaspoons light mayonnaise and packet of crisps Evening Meal: Beef casserole, extra veg with medium portion of mashed potato (made with butter) and small portion sponge pudding with custardSupper: 3 rich tea biscuits with cup of tea

These simple changes might save ~ 1000kcal per day CONSIDER MEDICATIONS BEFOERE MAKING CHANGES AS POSSIBLE HYPO RISK MAY NEED TO LIAISE WITH DSN20Weight Management Reducing the portions with some simple swaps saves approximately 900 - 1000 calories per day!

These simple changes might save ~ 1000kcal per day CONSIDER MEDICATIONS BEFOERE MAKING CHANGES AS POSSIBLE HYPO RISK MAY NEED TO LIAISE WITH DSN21Balance the Plate

Malnutrition

The nutritional intake does not meet the persons needs(10)23MalnutritionThe priority is getting the patient to eatAt this stage healthy eating is not a priorityAim to provide nutritious foods which are high in calories & protein Control Blood glucose with medications during this period

Consequences of malnutritionPoor wound healing and higher risk of infections

Frequent hospital admissions

Muscle wasting, Lack of energy/Depression

Dehydration

Vitamin and mineral deficiencies

Its expensive to the NHS25Recognising MalnutritionMobility: weakness, impaired movement

Mood: apathy, lethargy, poor concentration

Current intake: reduced appetite, changes in meal pattern and food choice

Physical appearance: loose clothing, rings or dentures, sunken eyes, dry mouth, emaciation, pale complexion, hair loss

Screening tools: e.g. MUST

Flip chart26Nutritional Screening

(10)27Why Screen for malnutrition?Early identification of patients at risk

Early intervention

When repeated weekly allows monitoring where nutritional care plans in place

Audit practice

MUST

Benefits of using MUSTEasy to use, rapid and reproducible

Any care worker can be trained to use MUST

Can be used with patients who cant be weighed and measured

Available on line from www.bapen.org, as well as paper format in a variety of sizes

31MUST Toolkit is freely available to use for non-commercial purposes and available for download from the BAPEN website: http://www.bapen.org.uk/screening-for-malnutrition/must/must-toolkit/the-must-itself

Discuss other measurements if no weight available.

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Discuss other measurements if no weight available if you cannot move a patient use ulna to estimate height, MUAC to estimate weight. Clearly explained on MUST toolkit with pictures

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The chart is available for higher body weights35Acute Disease is unlikely to apply outside hospital

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Discuss other measurements if no weight available.

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Case Study: Jane 75 years oldType 2 diabetes: Diet controlled5 4 or 1.62m 7st 12lb or 50kg Resident for 2 weeksNot eating well, managing small amounts of meals, no snacks but says Ive always had a small appetite No previous weights available despite checking with family and available medical documentation

BMI = 19 overall simply observe, monitor weights and intake 39Case Study: Steve80 years oldType 2 diabetes: Gliclazide & Metformin 5 9 or 1.76m 13st 5lb or 85kg Long term resident, normally has a good appetite but slowly lost his appetite, staff are concernedEating one small meal per day and struggling with snacks despite being encouragedGliclazide was stopped by the DSN due to hyposConcerned staff check his weight history and discover he weight 98kg only 2 months ago = 13kg weight loss

BMI = 27 weight loss = 2 refer to dietitian 40Treating Malnutrition

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What to do If you feel a resident is at risk of malnutrition:

Food charts need to be completed properly, weight monitoring important how do you assess changes if not monitoring? 42Food Fortification

Adds calories & protein without increasing volumeLittle & often, high calorieCheaper than supplements, more palatable, more compliance, simple to do, normal foodsRaise the question what do we do for people with diabetes who are malnourished or at risk what is priority? 43Ideas for Food fortificationSprinkle 2-3 tablespoons of dried milk powder into a pint of full fat milk

Full fat yoghurts, full fat milk, milky drinks, ice creams, milkshakes

Add margarine or butter to vegetables, potatoes, bread and chapattis. Dont use a low fat spread!

Sprinkle grated cheese onto savoury dishes such as soup & potatoes

Add sugar, honey or syrup to puddings, cereals, drinks and milkshakes

Double cream can be added to a variety of savoury and sweet foods such as casseroles, curries, soup, mashed potato, sauces, custard, milky puddings and drinks.

Fortified menuMenu 1BreakfastPorridge (made with water), bread + butter, cup of tea

LunchCup a soup, banana

Evening mealPoached cod, jacket potato, yoghurt

ExtrasTea between meals, Horlicks at supper

Menu 2 Fortified menuBreakfastPorridge (whole milk, syrup) bread + butter (+ jam), cup of tea (+ orange juice)LunchSoup (creamy + bread), banana (+ custard)Evening mealPoached cod (+cheese sauce) jacket potato (+ butter), yoghurt (trifle)ExtrasTea between meals, Horlicks at supper(made with milk (+ 2 biscuits, cake)

What do you think about this for a person with diabetes?

45Comparison Menu 1

Energy 980 kcalsProtein 48g

Menu 2

2070 kcals

75 g

46HydrationGood hydration can help withMental performance Headaches Urinary tract infectionsFalls Pressure sores and woundsConstipation Concentration Kidney stones Gall stones TirednessLethargy Oral health

Oral Nutritional SupplementsPrescribed supplements Ensure Plus, Pro Cal ShotHigh energy, high protein in small volume Expensive to use & compliance is poor Quick & Easy to use Follow prescribing information TimingFlavours

Referring to the DietitianCommunity Matron ( Nursing Homes) District Nurses (Residential Homes)GP

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