Red flags & evidence for dietetic input - Specialist Nutrition Rehab

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10 Jul 2024

Red flags & evidence for dietetic input

When is dietetic input “essential” and what is the evidence for this?  While most people would benefit from improving their eating habits and seeing a dietitian, there are certain situations when case managers, solicitors and insurance companies, need to consider dietetic input and medical nutrition therapy as a “must have” part of someone’s rehab after a major trauma.

 

Top 7 red flags for dietetic input

 

1. Malnutrition (1, 2, 3, 4)

Have you screened all of your clients for malnutrition?  Malnutrition, especially in overweight clients, can go undetected unless case managers are specifically looking for it.

Inadequate levels of protein, vitamins and minerals, particularly over long periods of time, will affect every organ system in the body – from muscle mass, to gut function, skin integrity and immunity.  In severely injured patients, the prevalence of malnutrition can be up to 76%, while other studies have found that trauma and/or major surgery results in 59% of people being malnourished.  The longer someone stays in hospital, the worse the malnutrition tends to become.  All case managers should therefore be screening all of their clients for malnutrition at the initial assessment.  There are several different screening tools that can be used, but the Malnutrition Universal Screening Tool (MUST) is the tool most commonly used in the UK.  Clients who score “high risk,” meaning a MUST score of 2 or higher, should be referred to a dietitian for a comprehensive dietetic assessment and treatment plan.

 

2. Elective surgery (5, 6, 7, 8)

NICE guideline NG180 on Perioperative Care in Adults (section 1.3.10), recommends that all clients be screened for malnutrition if they are going in for intermediate or complex surgery.  Case managers can either use the Malnutrition Universal Screening Tool or the Perioperative Nutrition Screen to complete this.  Poor nutrition before or after surgery results in a longer length of hospital stay, higher rates of postoperative morbidity and mortality and increased rates of postoperative infections and complications.  Malnutrition is an independent and readily-modifiable risk factor associated with poor surgical outcomes, so it makes sense to screen for it and take appropriate action.

 

3. Gut-related issues (9, 10, 11, 12, 13, 14)

Clients experiencing chronic constipation, diarrhoea, vomiting and/or abdominal pain should be referred to a dietitian, especially if symptoms are not sufficiently managed with medication.  Dietitians can request certain screening tests from the GP, provide first-line dietetic and lifestyle advice for managing these conditions and support clients with referrals to gastroenterology as required.  Once an accurate diagnosis is made, dietary changes are often the cornerstone to effective long-term management of gut-related issues anyways (in combination with prescribed medication) and dietitians can provide ongoing follow up to ensure symptoms are being effectively managed.

Dietitians can also support clients who have ileostomies and colostomies to manage symptoms of excess stoma output and/or poor nutrient absorption.

 

4. Diabetes (15, 16, 17, 18, 19)

If someone is newly diagnosed with diabetes or has poor glycaemic control (defined as having an HbA1c >53mmol/mol), then there is strong evidence that a dietitian needs to be involved to help clients manage their blood glucose levels.  Dietitians can support clients with:

  • accessing and using continuous blood glucose monitoring devices (privately or via the NHS);
  • educating clients on how to change diet and lifestyle factors to optimise blood glucose levels;
  • educating clients on how to adjust the type, amount and timing of their food intake to match their current insulin or medication regime; and/or
  • liaising with the GP or endocrinologist when diet and lifestyle changes aren’t sufficient and changes to insulin or medication need to be made.

 

5. Weight Management (20, 21)

Not everyone who wants to lose a few pounds needs to see a dietitian.  However, after a major trauma, up to 59% of clients with a brain injury and 66% of clients after a spinal cord injury, will struggle with being overweight or obese. The metabolic changes that occur as a result of the trauma means these clients often have very low calorie requirements (commonly under 1500 calories per day), which makes weight gain much more likely.  To complicate matters further, these clients are often prescribed medication(s) following their trauma that contribute to weight gain as well (see our article on medication-induced weight gain for more information).

Dietitians can request blood tests to rule out metabolic factors contributing to weight gain (e.g. thyroid issues) and check for common consequences of weight gain (e.g. diabetes and high cholesterol).  They can also liaise with the GP or psychiatrist if certain medications are likely to be contributing to someone’s weight problem and/or highlight if weight loss injections or bariatric surgery need to be considered.  Dietitians can then advise clients (and their family and support team) on sustainable dietary changes that will support weight loss and liaise with their physiotherapist or personal trainer as required to support muscle building as well.

The following weight-related situations have the greatest evidence for dietetic input:

NICE guidelines on Weight Management: lifestyle services for overweight or obese clients, state that input from a multidisciplinary team (consisting of a dietitian, psychologist and physical activity instructor), may be of particular benefit to clients with a BMI over 30kg/m2 (or a BMI of 25-30kg/m2 for those from black and minority ethnic groups or those with other comorbidities such as type 2 diabetes).  Losing 3-10% of someone’s body weight is a realistic expectation for diet and lifestyle intervention in these situations. Preventing future weight gain is also a goal to be considered, as there are health benefits to that as well. To achieve long-term success and to prevent weight regain, research has found that clients will need to receive ongoing input for at least 1 year after their target weight has been achieved.

 

  • Waist circumference >102cm in men or >88cm in women (even if BMI is under 30kg/m2) (25, 26, 27)

Waist circumference is an independent predictor of morbidity and risk of death.  Many clients after a major trauma have reduced levels of muscle mass, which means that waist circumference can be a better predictor of excess body fat (and health risk) compared to BMI alone.  For example, one study of people with spinal cord injuries found that a waist circumference over 94cm (in men) increased cardiovascular risk.

 

  • Bariatric surgery – being considered or already completed (23, 28, 29)

Bariatric surgery should be considered in clients with a BMI >40kg/m2, or those with a BMI >35kg/m2 if the person also has an obesity-related comorbidity such as type 2 diabetes.  Dietetic and psychological assessments are critical in deciding whether surgery is an appropriate intervention or not, as extreme changes to diet and other lifestyle factors will be required long-term to promote and sustain the weight loss.  Following the procedure, dietitians will need to advise clients on vitamin and mineral supplement use and dietary changes necessary to promote weight loss while maintaining nutritional adequacy.  Annual monitoring of these clients by a dietitian is also recommended.

 

6. Grade 3 or 4 pressure sore OR slow healing wound (30, 31, 32)

Undernutrition is an independent risk factor for the development of pressure injuries and is linked to pressure sore severity and delayed healing according to the 2019 International Clinical Practice Guidelines on Pressure Injuries.  Clients with pressure sores (or assessed as being at high risk of malnutrition as outlined above), should therefore be referred to a dietitian for an in-depth nutrition assessment and nutrition care plan.  While the Malnutrition Universal Screening Tool is an acceptable screening tool in these instances, the Mini Nutritional Assessment (MNA) does specifically ask about pressure sores and has more evidence for identifying someone’s pressure injury risk status. Dietitians can arrange for blood tests and then calculate and help clients achieve the calorie, protein, vitamin and mineral requirements that are needed to heal these wounds (using a combination of food, fluid and supplements).

 

7. Nonunion OR slow bone healing (33, 34, 35)

Nutritional status has a major influence on bone healing and yet traumatic injuries and fractures often depress appetite and can result in malnutrition.  Dietitians can work with GP’s to screen for and correct nutrient deficiencies and metabolic factors, such as hypothyroidism, hypogonadism and/or vitamin D deficiency, all of which can interfere with bone healing and result in nonunion.  Dietitians can also advocate for referrals to endocrinology when required.  Dietitians can then help clients improve their intake of protein, calcium, vitamin D and other micronutrients to promote fracture healing, and help clients manage their blood glucose levels to promote bone healing as well.

 

How to refer

Clients assessed as needing dietetic input based on the the criteria listed above, can be referred to either an NHS dietitian (usually through the GP and depending on local referral criteria) or a private dietitian (via their case manager).  To refer to Specialist Nutrition Rehab for a comprehensive dietetic assessment, report and private blood tests (if required), get in touch at info@specialistnutritionrehab.co.uk or 0121 384 7087.

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