Managing Malnutrition

A helpful guide for nursing home staff to make every mouthful matter.

Section 1 - Before you refer to a dietitian.

Is your resident losing weight or currently underweight (BMI less than 20kg/m²) or do they have a MUST score of 2 or more?

Before you refer to your dietitian have you:

1. Changed to full fat milk?

2. Offered milky drinks (between or after meals) 2 or 3 times a day? Examples include: Horlicks, Ovaltine, hot chocolate, milkshakes, fortified cold milk, milky coffee

3. Fortified any milky foods and drinks with skimmed milk powder? Examples include: custard, yoghurt, milk puddings, breakfast cereals, mashed potatoes, porridge

4. Offered extra snacks? Examples include: sausage rolls, crisps, cheese and biscuits, mini sandwiches, toast, crumpets, sweets, chocolate, biscuits, cakes, scones, yoghurt, mousse, trifle

5. Offered at least one per day of the homemade supplements from this information pack?

Section 2 - Fortified Milk

Full fat milk is high in calories and protein and easy to fortify without altering the taste or texture. Each resident should aim for at least one 200ml glass of milk per day.

Recipe

• Add 3-4 heaped tablespoons of milk powder to every 1 pint of milk used.
• Pour 1 pint of full fat milk in to a jug, whisk in the skimmed milk powder until all powder has dissolved and store in the fridge.

To ensure your patient/resident is getting the maximum benefit from using fortified milk why not make up a jug in the morning and use it throughout the day where possible. Use in cups of tea or coffee, cereal or porridge, mash potatoes, any milk puddings or custards, any homemade sauces or homemade milkshakes.

Nutritional Information

Made with full fat milk 568mls/1 pint is 559 kcals and 38.4g protein

Cost per pint

1 pint of fortified milk = 80p

Section 3 - Home-made supplements

Section 4 - Fortified desserts

Section 5: Eating with a small appetite 

Having a small appetite can have a large effect on someone’s nutritional status and can result in malnutrition if not well managed.

This can result in fatigue, poor/delayed wound healing, reduction in activity, low mood and frequent hospital admissions.

Tips for managing a small appetite:

• Eating little and often - offer snacks or a small meal every 2-3 hours, even if it is as small as a biscuit or a cup of milk, ensuring the frequency is key.
• Avoid filling up on fluids which have no nutritional value - instead offer nourishing drinks and ensure drinks aren’t taken right before a meal as this can fill someone up.
• Getting some fresh air and exercise - this can stimulate the appetite and, if the weather is good, sitting out in the garden can help as well as walking small distances.
• Ensure a relaxing dining atmosphere - try and get people to eat in the dining room rather than staying in their rooms to eat where possible.
• If your resident is a night owl ensure they have snacks and finger foods available through the night.

Section 6 - Fortifying your diet

Adding extra fat or sugar to meals, snacks and drinks can increase the amount of calories and protein in the food without increasing the portion size.

Fortified Milk:

Fortified milk can be used in foods and drinks such as:

• Porridge.
• Cereals.
• Tea and coffee or as a milky drink.
• Mash potatoes.
• Custard.

Butter/Oils:

Butter and oil are both fats which can be added into food where appropriate. Full fat butter should be used rather than margarine/other lower fat alternatives.

• Fry food where possible in plenty of oil.
• When making sandwiches/toast/crumpets etc. always put plenty of butter on them.
• Add a knob of butter into things like mash potato and scrambled egg.

Cheese:

Cheese can be enjoyed on its own as a snack or added to meals to increase the calorie and protein content. Try adding cheese to:

• Scrambled eggs/omelettes.
• Sandwiches.
• Toast/crumpets.
• Mixed into soup.
• Mixed into mashed potato.
• Plenty of cheese on top of pasta dishes.
• Make butter based sauces for fish/meat.

Sugar based fortification:

Adding extra sugars can also help to increase the calorie content. If a resident has diabetes these shouldn’t be added to their food, stick to the other methods of fortification.

Jams & syrups, can be added to:

• Porridge.
• Rice pudding.
• Crumpets and toast – ensure a thick spread.

Table sugar can be added to:

• Tea/Coffee.
• Hot chocolate.
• Milkshakes.
• Porridge.
• Breakfast cereals.
• Fruit juice.

Cream:

Cream is another high calorie food which can be added in small amounts to increase the calorie content of food. Double cream is a very versatile addition, and can be added to things like:

• Porridge.
• Soups (such as cream of tomato, mushroom, pea and ham, cream of chicken).
• Mashed potato.
• Scrambled eggs.
• Sauces to accompany meat/fish should be cream/butter based.
• Added into drinks (both hot drinks like coffee and hot chocolate and cold drinks like milkshakes).
• Custard, milky puddings, and mixed with ice cream.
• Food like cakes should always be served with custard, ice cream or cream.

Section 7 - Nourishing snacks

For your residents who prefer snacks or foods on the go encouraging high calorie high protein snacks and finger foods would be optimal.

Sweet snacks:

• Cakes or pastries e.g. mini muffins, croissants, iced buns, jam tarts.
• Chocolate – mini chocolate bars or out of a box.
• Biscuits – try adding chocolate spread/peanut butter to add extra calories.
• Mini rice pudding/custard.
• Full fat yoghurt.
• Ice cream.
• Mini sponge and cream/ custard.
• Toast/crumpets/fruit loaf with butter and jam/chocolate spread.

Savoury snacks:

• Scotch eggs, mini pork pies or sausage rolls.
• Toast/crumpets with butter and cheese.
• Crisps.
• Nuts.
• Spring rolls.
• Pakoras, samosas, bhajis.
• Small sandwiches with a meat, cheese or fish filling.
• Small portion of scrambled egg on toast/crumpets.
• Mini omelette with cheese.
• Small slice of pizza.
• Potato wedges with dip.
• Hummus on toast/with pitta bread.
• Fish fingers/chicken goujons/ cocktail sausages.
• Cheese cubes.

Starchy carbohydrates:

• Toast/bread fingers.
• Potato wedges.
• Mini roast potatoes.
• Mini naan breads/chapattis.
• New potatoes.
• Mini bread rolls.
• Crumpets.
• Chips.

Section 8 - Nourishing Finger Foods

Some residents may prefer finger foods in place of a main meal, just because someone prefers to eat this way, shouldn’t mean they miss out on essential food groups. Try and make a meal for residents using a starchy carbohydrate, a protein source and some vegetables/salad but in finger food form.

Puddings:

• Mini cakes/muffins.
• Iced buns.
• Crumpets with jam.
• Toast with jam/chocolate spread.
• Flapjacks made with plenty of butter.
• Chocolate.
• Malt loaf with butter.

Protein sources:

• Cooked meat rolls e.g. ham/chicken.
• Chicken/fish goujons.
• Boiled eggs cut in half.
• Cocktail sausages.
• Cheese cubes.
• Nuts.

Vegetables/Fruits:

• Cucumber/carrot/pepper/celery sticks.
• Cherry tomatoes.
• Baby corns.
• Sugar snap peas.
• Chopped and cooked broccoli/ cauliflower/green beans.
• Sliced fruit like, banana, apple, pear, melon, mango.
• Nectarines and peaches.
• Grapes and berries.

Section 9 - Eating and drinking with Constipation

When a person’s appetite is poor they can miss out on the foods that help their bowels work normally.

Fibre is needed to keep your bowels working smoothly. As it passes through the bowel it absorbs water that makes the stools soft and easy to pass. Fibre is found in plant and cereal foods such as fruit, vegetables, breakfast cereals and bread.

How can fibre be increased in the diet?

• Cereals – choose whole wheat cereals e.g. porridge, bran flakes, shredded wheat, Weetabix or muesli  Bread, crispbreads and cereal bars – choose wholemeal, wholegrain or high fibre white options.
• Fruit and vegetables – all kinds including fresh, frozen, dried or tinned are good sources of fibre. To make them easier to manage try stewing fruit or use sauces with vegetables e.g. cauliflower cheese or vegetable ragu.
• Cakes and snacks – choose cakes that contain dried fruit e.g. fruit cake, Eccles cake, mince pies etc.
• Choose biscuits such as digestives, oat biscuits, muesli bars, wholemeal crackers or Ryvita.
• Dried fruit and nuts – dried fruit is a good source of fibre e.g. prunes, sultanas, apricots, figs etc.
• Peas, beans lentils etc. – all pulses are a good source of fibre and can be added to soups and stews. Try marrowfat peas or baked beans with meals.
• Rice, pasta and potatoes – try wholemeal or brown rice and pasta, also cook potatoes in their skins.
• Fluid - as well as increasing fibre it is essential to have plenty of fluid during a day. Try to aim for at least 8 cups of fluid a day and all fluids will do e.g. coffee, tea, water, squash etc.

Section 10 - Eating and drinking with Dementia

Dementia can affect a persons appetite, ability to eat and interest in food and drink.

Common eating and drinking problems in dementia:

• Changes in dietary behaviour.
• Tastes can change and therefore food choices also change.
• People can sometimes forget to eat and can lose the ability to eat independently.
• Dementia may affect mood and therefore appetite can decrease.
• Food refusal can occur with advancing dementia.
• Energy requirements may be higher.
• People who are mobile and have dementia may pace around and burn a lot of calories. This may lead to weight loss if their energy requirements are not met.

Dehydration

Dehydration is very common in people with dementia due to the person forgetting to drink. This can lead to problems such as constipation, urinary tract infections (UTI’s), pressure ulcers and falls.

Medication

Side-effects from medications such as stomach cramps, constipation and sedation may occur which can affect appetite.

Difficulty Swallowing

As dementia progresses, some people find chewing or swallowing difficult They may forget to swallow and hold food in their mouth, this is known as ‘pouching’.

Communication

Dementia can affect a person’s communication so they may not be able to indicate whether they are hungry or thirsty.

Practical tips for a successful meal time:

• Offer foods the person likes and provide variety, try different foods as likes and dislikes can change.
• Try different flavours, colours and smells, the aroma of cooking can stimulate appetite.
• Sweeter and/or stronger foods may be preferred, experiment with sugar/honey, seasoning, spices, chutneys and sauces.
• Avoid making food and drinks too hot.
• Presentation should be attractive and colourful.
• Avoid serving white food on a white plate and don’t overload the plate.
• Use recognisable plates, cups and glass - avoid any with detailed patterns.
• Try regular snacks and small meals.
• Always allow the person to eat independently; they may not always need assistance.
• Offer meals that can be eaten with a spoon rather than a knife and fork to help maintain independence.
• Make the most of good times during the day and maximise food and fluid intake.
• Offer finger foods if preferred.
• Allow plenty of time for a meal and do not rush the person.
• Softer, single textured foods may be more acceptable as people can become sensitive to mixed textures.
• If a person walks away from the table and does not finish their meal, encourage and prompt them to finish their meal.
• Don’t withhold dessert if savoury meal hasn’t been eaten.
• Consider specialist aides e.g. deep lipped plates, non-slip place mats, adapted cutlery, wide necked mugs.
• Explain to the person what food or drink is being served and serving one familiar food at a time can reduce confusion.

Section 11 - Soft diet

Speech and Language Therapy will sometimes advise that patients will require a different/modified consistency diet. Any resident, for a variety of reasons, may find a soft diet easier to manage than a normal consistency diet.

To prepare food to a soft consistency it should be:

Soft, tender and moist but needs some chewing.

Mixed with a sauce or gravy.

Meat

Meat should be soft and tender and be finely chopped or minced.

Casserole or stew to make meat softer and easier to eat.

Served with a thick smooth sauce or gravy.

Fish

Fish should be soft enough to break up into small pieces with a fork.

Served with thick smooth sauce or gravy.

Eggs

Eggs can be scrambled, poached or made into an omelette.

Extra butter, margarine or milk can be used to make them softer Boiled eggs can be grated or mashed with butter or mayonnaise.

Cheese

Add grated cheese to mashed potatoes, sauces and soups.

Bread

Be cautious of bread, only serve if the resident can manage and ensure to cut off the crust. If offering a sandwich ensure to use soft fillings such as tuna, egg mayo or jam.

Pasta and potatoes

Serve potatoes mashed with milk, butter, margarine or grated cheese.

Pasta dishes which contain well cooked pasta and sauce are appropriate such as macaroni cheese, spaghetti bolognaise or lasagne.

Fruit and vegetables

Fresh, frozen or tinned fruit can be mashed or stewed with added sugar.

Remove any skins or seeds and serve with custard, yoghurt, ice cream, fromage frais, condensed or evaporated milk

Fresh, frozen or tinned vegetables can be cooked until soft with butter, margarine or served with sauce.

Breakfast cereals

Porridge or fine oatmeal made with milk.

Cereals such as Weetabix, cornflakes or bran flakes need to be left to soak in milk or served with hot milk to soften.

Section 12 - Referral to a Dietitian

If you have tried all the advice above and your resident is still losing weight and has a MUST of 2 or more then please refer to the Dietitian.

Please ensure you have included the weight, height, BMI, MUST score and any weight loss. The referral will not be accepted without this information.

Our new electronic referral form can be accessed at: https://www.elht.nhs.uk/services/dietetics