In the Home Setting

M Elia and R J Stratton, University of Southampton, Southampton, UK

© 2005 Elsevier Ltd. All rights reserved.

The prevalence of nutritional problems in developed societies is a cause of growing concern. At one end of the nutritional spectrum, the obesity 'epidemic' is spreading at an alarming rate. At the other end of the spectrum, protein-energy malnutrition and nutrient deficiencies are also common, especially in the elderly and in those with disease. Table 1 shows the frequency of specific vitamin deficiencies and underweight (body mass index <20 kg/m2) in people aged 65 years or older resident in the United Kingdom. Complimentary information on protein-energy status can be obtained by considering simple criteria, such as those used by the 'Malnutrition Universal Screening Tool' (MUST) (Figure 1). This tool, which depends on weight loss and body mass index (and an acute disease effect, which does not normally apply to community patients), has been used to estimate that 10-15% of older people in the United Kingdom are at medium to high risk of malnutrition. The prevalence of malnutrition increases with age, and it is more common in the presence of disease and in institutions, where about one in five people are at risk. With the growing number of older people, especially those living in nursing homes and alternative care facilities, the overall prevalence of malnutrition may increase. It is disturbing that malnutrition is underrecognized and undertreated, despite its adverse effects on the individual and society.

The first important step in the management of malnutrition is identifying it using one of a number of validated nutritional screening tools. MUST was developed specifically for all types of patients in all health care settings. The potentially broad application of the same tool encourages consistency of thought and continuity of care through different health care settings. The care plan linked to this tool varies from dietary restriction in the case of obesity to supplementation and other forms of nutritional support in the case of malnutrition. For special situations, enteral tube feeding (e.g., in some patients with swallowing problems) and parenteral (intravenous) nutrition are required.

This article focuses on the treatment of malnutrition (rather than obesity) in the home setting. This treatment includes dietary counselling and fortification, oral nutritional supplementation (mixed macro- and micronutrient supplements), and artificial nutritional support (enteral tube feeding (ETF) and parenteral

Table 1 Proportion of subjects 65years or older with selected vitamin deficiencies and body mass index <20 kg/m2

Free living (%) Institutions (%)a Criteria

Table 1 Proportion of subjects 65years or older with selected vitamin deficiencies and body mass index <20 kg/m2

Free living (%) Institutions (%)a Criteria

Vitamin deficiencies

Folate deficiency

29

35

Red blood cell concentration

<345 mmol/l

- Severe deficiency

8

16

<230 mmol/l

Thiamine deficiency

9

14

Erythrocyte transketolase activation coefficient (ratio)

>1.25

Vitamin B12 deficiency

6

9

Plasma concentration

<118pmol/l

Vitamin D deficiency

1-2

1-5

<12 mmol/l

Vitamin C deficiency

14

40

Plasma concentration

<11 mmol/l

- Severe deficiency

5

16

<5 mmol/l

Underweight

3

16

Body mass index

<20 kg/m2

aRegistered residential homes (57%), nursing homes (30%), dual-registration homes (9%), and other facilities (4%) Based on the National Dietary and Nutrition Survey (1998) in the United Kingdom.

aRegistered residential homes (57%), nursing homes (30%), dual-registration homes (9%), and other facilities (4%) Based on the National Dietary and Nutrition Survey (1998) in the United Kingdom.

Weight Loss Score

(unplanned wt loss in 3-6 mo) Wt loss <5% = 0 Wt loss 5-10% = 1 Wt loss >10% = 2

Add all scores

Weight Loss Score

(unplanned wt loss in 3-6 mo) Wt loss <5% = 0 Wt loss 5-10% = 1 Wt loss >10% = 2

Add all scores

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