Dietetics │Self-help for nursing homes

Watch our video tutorial to learn more about the MUAC and ULNA measurements:

Alternatively, follow this link to download the BAPEN document which explains how to measure MUAC and ulna length

Across nursing homes in East Lancashire, the Malnutrition Universal Screening Tool (MUST) is in place to identify individuals who are at risk of malnutrition.

This tool takes into account a number of factors which generate a score ranging from 1 to 4 which grade an individual’s malnutrition risk.

Here are some useful links to BAPEN pages which explain how to implement and understand MUST:

• BAPEN MUST score calculator
• BAPEN MUST guide

Some other useful equations that should be used and understood across nursing homes are Body Mass Index (BMI) and percentage weight loss. The points below show the equations that should be used to calculate both BMI and percentage weight loss. There are also some example case studies which can be used to better understand the process of the equations. Please see below:

• BMI calculation- Current Weight (kg) ÷ Height (m)²  or Current Weight (kg) ÷ (Height (m) x Height (m))
• Percentage Weight Loss= Weight when weight loss started (kg) – Current Weight (kg) = A
  A ÷ Weight when weight loss started (kg)= B
  B x 100 = % weight loss

Case study example:

Brenda is a new resident at a nursing home and has been weighed as 50kg on arrival, she also has a standing height of 1.54m. In order to be screened for malnutrition the nursing home requires a BMI calculation. Brenda’s BMI can be calculated as below:

BMI = 50kg ÷ (1.54m x 1.54m)

BMI = 21.1kg/m2

Brenda has now been living at the nursing home for 3 months. Staff have noticed that she has been losing weight over the past 3 months. When she moved to the nursing home Brenda was 50kg, in the 2 months following she has weighed 48kg and most recently 46kg.

Brenda’s weight loss in the last 3 months can be calculated as below:

First calculate the difference between the weight from when Brenda moved into the nursing home and her most recent weight, as follows:

50kg – 46kg = 4kg

This value now needs to be divided by Brenda’s weight when she moved to the nursing home (start of weight loss).

4kg ÷ 50kg = 0.08

This value now needs to be multiplied by 100 to give the value of percentage weight loss.

0.08 x 100 = 8

Percentage weight loss = 8%

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Assessing the necessary application of food first approaches

The chart below can be used to identify if an individual required food fortification and the use of food first approaches.

Baseline food first advice for malnourished nursing home residents

The approaches below show the food first approaches that can be used should be used as standard for individuals who are at a significant risk of malnutrition/individuals experiencing significant weight loss:

• Fortify all relevant meals and fluids with everyday foods like cheese, full fat milk, cream, dried milk powder, full fat sauces, spreads, dressings, honey, jams. This increases the calorie and protein content of food without increasing the volume
• Little and often approach. Aim to have a small meal, snack, or nourishing drink every 2-3 hours
• Offer energy dense sweet and savoury snacks in between meals. These can be used as an alternative if refusing main meals. E.g., toast with butter, scones, cheese and crackers, mini pork pies, scotch eggs, sausage rolls, fruit loaf, nuts, cakes and pastries, thick and creamy yoghurts, ice-cream, fortified rice pudding.
• Aim to have at least 2-3 nourishing drinks per day. E.g., milk powder and cream added to glasses of milk, homemade milkshakes, milky coffees, milky hot chocolates, Horlicks, fruit smoothies. This will improve calorie and protein intake as well as help meet daily fluid needs.​​​​

Poor Appetite

KEY: Small frequent energy dense meals/snacks

Taste changes, illnesses, loose fitting dentures, nausea, constipation and side effects of medication can contribute to poor appetite. Methods for making the most of a small appetite to ensure adequate nutritional intake are as follows:

1. Encouragement and assistance at mealtimes can be crucial.
2. Eat little and often – three small meals with nourishing drinks/energy dense snacks in between.
3. Serve smaller portions on smaller plates to avoid being overwhelmed at mealtimes.
4. Have one fortified dish with each meal.
5. Choose full fat and full sugar products.
6. Make the most of times of day where appetite is greatest.
7. Provide easy access to ready-to-eat snacks throughout the day.
8. Discourage drinking fluids directly before or during meals to avoid compromising food intake.

Nourishing drinks

Drinks can be fortified as an easy way of providing additional energy and protein in the diet.

Those with poor appetites often find drinks easier to consume. Aim for at least two of these drinks daily. These drinks also contribute to the overall daily fluid intake and have the advantage of containing protein and calories when compared to water.

Examples of these drinks are shown below: ​​​​​

A useful method that can be used in increase energy intake is by making fortified milk using full fat milk and skimmed milk powder. This can be incorporated into various foods and fluids such as tea, coffee, hot chocolate, mash potato, cereal, rice pudding, jellies or any other food where normal milk would be used.

Fortified Milk Recipe (recipe per pint of milk)

• Mix four tablespoons (60g) of milk powder in a small amount of full-fat milk to make a paste
• Make up to 568ml/one pint using full-fat milk
• Store in the refrigerator and consume within 24 hours

High Energy High Protein Snacks

High energy high protein (HEHP) snacks are a quick and effective way to provide additional energy and protein into an individual’s diet. These snacks should be used in between meals and as part of a little and often approach.

Examples of snacks and easy to make foods are shown below:

Food Fortification

What is food fortification?

Food fortification is the enrichment of meals and drinks with small amounts of everyday ingredients to improve the nutritional content, without altering portion size. Most common fortification steps lead to increases in the energy and/or protein content of a meal.

It is recommended that at least one dish with each meal is fortified.

Why should food be fortified?

Fortifying food means that the food consumed is more nutrient dense. This means that every mouthful of food consumed is more nourishing. Those with small appetites and who are only managing small quantities of food benefit greatly from food fortification. Individuals struggling to maintain their weight can also benefit from food fortification.

When is food fortification not suitable?

The methods of food fortification described in this resource may not be suitable for those who require a restricted or low potassium diet, or for those with lactose or milk protein intolerance, or diabetes.

How can food be fortified?

Meals and fluids can be fortified by incorporating everyday foods like cheese, butter, full fat milk, cream, dried milk powder, full fat sauces, spreads, dressings, honey, jams.

What types of food can be fortified?

Examples of foods that can be easily fortified and how they are fortified is shown below:

You may find that some residents living in a nursing home require specific dietary adjustments based on their tolerance to certain foods or fluids. This may be due to previous episodes of coughing, choking or aspiration and related to certain medical conditions such as dementia which can see an individual develop issues with swallowing (dysphagia).

The guidelines for an individual with an adjusted diet are set by SLT (Speech & Language Therapists) and are advised after an assessment by themselves. Advice in the sections below shows ways an individual’s diet can be fortified whilst on a adjusted diet. 

Emphasis is placed on eating in-line with SLT recommendations: Please note meal, snack and fluid examples provided are just a guide. Speech and language recommendations and allergy requirements must be followed at all times if required.

Please note: For individuals requiring a high energy high protein diet the food first advice mentioned in ‘Food First Advice and Approaches for Malnourished Individuals’ section can be used.

Level 6 - Soft and Bite-Sized Diet

The foods listed in this section are a guide. Extra care should be taken to ensure these foods are prepared to resemble a texture which is soft, tender and cut into bite-sized pieces. Foods should match the criteria as show below:

Food should be...

• Food is soft, tender and moist
• Soft lumps should be no bigger than 1.5cm by 1.5cm
• Chewing is required before swallowing
• Can be easily broken down with gentle pressure from a fork
• Can be eaten with a spoon or a fork
• A thick sauce may be required

There should be no...

• No hard, tough, chewy, stringy, dry, crispy food items
• Foods with skins, husks or outer shells e.g. peas, grapes, sweetcorn
• Crunchy foods such as cucumber or lettuce
• Bread

Mealtime Suggestions for a Level 6 Diet

Breakfast:

• Cereal (softened if soaked in milk and drained) e.g. cornflakes, branflakes, cheerios. Avoid nuts, dried fruits, seeds etc
• Porridge/ready brek/weetabix
• Soft fruit and yoghurt, e.g banana, stewed fruit
• Eggs: scrambled, boiled or egg mayonnaise
• Level 6 full English: skinless sausages or hot dog sausages, hash browns, poached or scrambled eggs, baked beans, skinless tomatoes (all cut into 1.5cm pieces)

Main Meals:

• Risotto
• Curries, e.g. chickpea/veg/meat/fish curry
• Pies: remove pastry and top with mashed potato
• Cottage pie, fish pie
• Flaked fish or fish cake in a sauce
• Plain crustless quiche
• Plain or cheese omelette
• Soft pasta / rice and sauce
• Potatoes: remove skin, boiled (and diced), creamed, mashed
• Steamed/boiled vegetables, e.g. carrots, swede, beetroot, broccoli, cauliflower, mushy peas (into 1.5cm cubed chunks)
• Avoid mushrooms, green beans, stir fry veg

Desserts and snack ideas:

• Diced soft tinned or fresh fruit
• Swiss roll diced and served with custard
• Fruit crumble soaked with custard
• Dunked plain digestive/shortcake biscuits in a hot drink (avoid fruit or nut biscuits)
• Diced/ mashed down sticky toffee pudding
• Diced/ mashed down Jam roly poly pudding
• Inside of custard tart
• Fruit smoothies 
• Houmous

Level 5 – Minced and moist diet

The foods listed in this section are a guide. Extra care should be taken to ensure these foods are prepared to resemble a texture which is mashed and/or minced in 4mm pieces. Foods should match the criteria below:

Mashed:

• Foods should have been mashed, or minced finely
• Food pieces should not be bigger than 4mm by 4mm and should fit between the prongs of a fork
• If the texture cannot be finely minced it should be pureed

Minimal chewing:

• Food is soft and moist, it needs very little chewing

• Can be eaten with a spoon or a fork

• Lumps are easy to squash

• Add extra sauces: sauces should be thick and smooth: gravy

How to prepare minced and moist foods

• Remove all skin, bones and gristle, pips, excess juice

• Meat must be finely minced

• Sausages should be skinless and minced

• Cook until soft then mash or chop to 4mm

• Rice should not be sticky—if it is, separate into individual grains when cooked. Add sauce

• Cut up pasta/noodles no bigger than 4mm by 4mm

Mealtime suggestions for a Level 5 diet

Breakfast:

• Weetabix well soaked in milk with no excess milk (should be a cohesive texture)
• Porridge/ReadyBrek (texture should have movement and not be claggy) with or without mashed banana
• Smooth yoghurt or fromage frais
• Egg (scrambled, poached, boiled), mashed and sauce added
• Stewed fruit with yoghurt
• Fruit smoothies
• Level 5 Full English: scrambled eggs, mashed corned beef (or pureed meats), tomato passata sauce, mashed hash brown (not crispy, with a sauce)

Main Meals:

• Flaked fish in thick sauce
• Puréed meats with gravy
• Well mashed skinless sausages
• Dahl
• Eggs (see breakfast ideas)
• Cottage pie / shepherd’s pie
• Corned beef hash
• Risotto
• Potato, sweet potato with soft filling e.g. well mashed tuna mayonnaise, cream cheese, blended sauce (chilli, curry)
• Soft root vegetables e.g. broccoli or cauliflower
• Mushy peas (no skins)
• Cauliflower in a cheese sauce and mashed

Desserts and snack ideas:

• Stewed fruit with thick custard or cream
• Soft mashed tinned or fresh fruit
• Milk pudding, e.g; rice pudding, semolina, kheer (made with pudding rice, no nuts)
• Trifle (no hard bits of fruit)
• Jelly or milk jelly
• Egg custard (remove pastry)
• Crème caramel
• Smooth yoghurt, fromage frais, mousse
• Angel Delight, Instant Whip or blancmange
• Cake with custard or cream
• Mashed avocado
• White or wholemeal bread (no crusts) soaked in thick soup and broken down within the soup

Level 4 – Puree diet

The listed foods in this section are a guide. All foods provided with this dietary adjustment should be prepared to a puree consistency and meet the criteria below:

• Smooth, thick and moist consistency with no lumps

• Can be eaten with a spoon/fork

• Falls off a spoon in a single spoonful when tilted

• Continues to hold shape on a plate

• Can be piped layered or moulded

• No chewing or biting required

• It’s not sticky

• Not too thick/claggy

• Cannot be poured, drunk from a cup or   sucked through a straw

• Ice cream is not suitable for people having thickened fluids

How to prepare puree foods

• Use a blender/liquidiser/food processor
• Remove tough skins and large seeds
• Cut food into small chunks
• Some foods may need sieving after pureeing to remove lumps and bits e.g. stringy meats, fruit with pips, vegetables with shells
• Avoid all nuts or seeds, string foods (e.g. celery, onions )and foods with a tough skin (e.g. dried beans, peas or corn) - these foods do not puree well

To thicken: try adding  cornflour, instant mash, custard powder or thickener. Keep adding a little until desired consistency is reached.

To thin down: try adding extra milk, fruit juice, single cream, gravy, thin soup or stock. Water should not be used as it is not nutritious.

Mealtime suggestions for a Level 4 diet

Breakfast:

• Pureed porridges, Ready Brek or Ready Oats, Weetabix made with milk
• Pureed creamy scrambled egg with extra cheese
• Smooth yoghurt or fromage frais
• Milkshake - may need to modify consistency

Main meals:

• Pureed meat and gravy (no bones or skin)
• Pureed cooked fish and sauce (e.g. cheese and white)
• Pureed pasta with sauce
• Pureed boiled white rice with sauce (e.g. pureed curry)
• Pureed meat or vegetable casserole
• Potatoes and vegetables (cook until soft and tender, drain and puree)
• Thick smooth soups (may need thickener/ pureed lentils adding to modify consistency)

Dessert and snack ideas:

• Pureed rice or other milk pudding
• Angel Delight, mousse, custard, instant whip
• Puree stewed fruit and custard 
• Smooth yoghurt—thick and creamy varieties, Greek yoghurt
• Crème caramel

For residents who are already prescribed Oral Nutritional Supplements (ONS) there are many ways that these products can be incorporated into an individual’s diet. It is important to note that these products are meant to supplement an individual’s diet so eating regular meals and following Dietitian’s advice on food fortification is key. These supplements are usually only used short term. The Dietitian will review usage when appropriate.

Tips on how to use supplements

• Unopened bottles of drinks and desserts should be stored in a cool, dry place
• Once opened store in the fridge and throw away if not used after 24 hours
• If not refrigerated, often supplements must be consumed within 4 hours
• Before opening check the best before date
• Once powder supplements are made up, store in the fridge and throw away if has not been drunk within 24 hours
• Most supplements are best served chilled/cold so keep a small supply in the fridge
• Some flavours you may enjoy warmed but be careful not to boil them as this can affect the taste and nutrient content.

Nutritional supplements come in a variety of styles including milkshakes, juice, yoghurts and powders. They are available in a range of sweet and neutral flavours which are very versatile, meaning they can be incorporated into many different foods/fluids, some examples are as follows:

Recipes for fruit based supplements

Fruit jellies (serves 2)

• 1 bottle of fruit-based supplement (any flavour)
• 1 pack of fruit jelly (same flavour as the supplement)
• 275ml of boiling water.

Method:

1. Dissolve jelly in ½ pint boiling water
2. Add fruit-based supplement to make up to 1 pint
3. Spoon into bowls and place in fridge until set
4. Serve with cream or ice-cream

Kiwi cooler (serves 1)

• 1 kiwi fruit peeled and chopped
• 4 tablespoons full-fat Greek yoghurt
• 200ml fruit flavour supplement

Method:

1. Blend all ingredients together for 1 minute
2. Serve immediately whilst frothy

Fruit sparkler (Serves 1)

• 1 bottle of fruit-based supplement
• 100ml chilled ginger ale
• Squeeze of lime

Method:

1. Add the supplement drink to the ginger ale and squeeze in a dash of lime to taste
2. Decorate with a slice of fruit

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Recipes for milk based supplements

Hot chocolate delight (serves 1)

• 1 bottle of chocolate flavour supplement
• 2-3 tablespoons whipped cream
• 2 teaspoons of instant hot chocolate
• 2 teaspoons milk powder
• A few drops of vanilla essence

Method:

1. Heat the supplement drink in a pan but do not boil
2. Mix in instant hot chocolate powder
3. Pour warm drink into a mug and add a few drops of vanilla essence and then top with whipped cream
4. Decorate with pieces of chocolate flake and serve immediately

​​​​​​Vanilla rice pudding (serves 1)

• 25g of pudding rice
• 1 bottle of vanilla flavour supplement
• Pinch of cinnamon

Method:

1. Preheat oven to 160oC/325oF/Gas Mark 3
2. Lightly grease a 300ml (1/2 pint) individual ovenproof baking dish
3. Place rice into dish. Pour in the vanilla supplement, stir in the ground cinnamon and bake for 1-1 ½ hours or until the rice is tender. Serve with fruit/jam

Yoghurt supreme (serves 2)

• 1 bottle of milk-based supplement – fruit flavour to match yoghurt
• 125g thick and creamy yoghurt

Method:

1. Blend ingredients together and serve immediately with fresh fruit to decorate. Alternatively freeze and serve as an ice-cream ​

Strawberry whip (serves 1)

• 1 bottle of strawberry flavour milk-based supplement
• 1 packet of instant whip
• 1-2 scoops ice-cream – strawberry or vanilla flavour

Method:

1. Whisk ingredients together in a bowl
2. Place in a fridge until set

​​​​​Iced latte (serve 1)

• 2 teaspoons of coffee granules
• 50ml hot water
• 2 teaspoons sugar
• 1 bottle neutral supplement
• 2 tablespoons of milk powder.

Method:

1. Mix hot water, coffee, sugar together
2. Add neutral supplement and stir
3. Stir in milk powder
4. Chill until required

Usage of neutral flavoured supplements

Neutral flavour drinks can be used to replace milk in foods and drinks.

• Over cereal or porridge
• To make up packet soups
• To make milk puddings, instant whips, blancmanges and rice pudding
• Use a base to make a sauce e.g. cheese sauce
• To add to coffee or hot chocolate powder instead of milk.

They can also be used in recipes as shown below: ​​​​​

Scrambled egg (serves 1)

• 100ml (1/2) bottle of neutral supplement
• 2 eggs
• Knob of butter or margarine
• Salt or pepper to taste

Method:

1. Beat together the eggs, supplement drink and seasoning
2. Melt the butter/margarine in pan
3. Add the egg mixture and cook until soft and creamy, stirring occasionally

Creamy tomato soup (serves 2)

• 1 tin of cream of tomato soup
• 1 bottle of neutral supplement

Method:

1. Heat the tinned soup in a saucepan and stir well
2. When heated, take off the heat and stir in the neutral supplement
3. Return to the heat and warm gently, without boiling
4. Season to taste with salt and pepper

For additional information on oral nutritional supplements, their function and more recipes please see the Fresubin Recipe Booklet following this link.

In the final stages of a life-limiting illness, when someone is approaching the end of his or her life the focus of care for the person may change and tends to be centred on helping them to be as comfortable as possible. Individuals often experience a decrease in appetite and a loss of interest in food and drink.

At this stage of life, meeting nutritional needs becomes less important than providing comfort, and even very small amounts of the person’s favourite food and drink can provide comfort.

For information on the end of life pathway and how this affects an individual’s diet please follow this link to ‘Eating and Drinking at End of Life’  by the BDA (British Dietetic Association).

Further to the information on this page, we also have an online malnutrition training portal to aid the learning and understanding of the impact of malnutrition and managing this in a nursing home.

If you would like access to this training for your members of staff please contact us at 01282 804 700 or by email at dietitians@elht.nhs.uk