Optimising recovery through good nutrition

For patients who have a hospital admission looming, a fast and uncomplicated recovery is every patient’s wish. Thankfully, hospital stays have become shorter, driven by hospital targets to increase the throughput of patients and the improvement of community services. On the downside this means many discharged patients are still in the recovery phase when they arrive home and need to understand actions they can put in place to achieve optimal health and fitness. Good nutrition and hydration is vital for optimal recovery as poor nutritional status relates to poor clinical outcome and can complicate recovery. This means patients stay in hospital for longer, succumb to infections and require more home support after illness. Long term deficiencies can lead to serious illness.
    
The launch of the NICE guideline number 32 in 2006 ‘Nutrition Support in Adults’ put nutrition on the medical agenda and promotes acute and primary care trusts, nursing homes and carers to take an active role in the management of malnutrition. Four years on from this guideline, despite improvements, it is alarming to see that malnutrition continues to be present, under-recognised and under-treated. This need for further improvement highlights that nutrition still needs to be higher on everyone’s agenda.

High-risk groups
Prevalence of malnutrition on admission to hospital, care homes and mental health units affects up to one in three of all adults of all ages1 who are mostly in the high-risk category. Much of the malnutrition present on admission originates in the community. Knowing this, it is imperative to correct nutritional depletion by providing a diet that will ensure optimal nutritional status, prevent/minimise weight loss and increase weight if necessary prior to or on admission. This will enable the patient to obtain maximum benefit from any medical intervention.
    
Well nourished patients should also be aware, increased metabolic stress brought on by injury, illness, high temperature, surgery coupled with pre and post operative fasting, and reduced appetite can reduce nutritional stores quickly resulting in a rapid change in nutritional status putting patients at risk of complications, infections and increased length of hospital stay.
    
Body mass index (BMI) which is weight in kilos divided by height in metres squared (BMI= wt/h²) results should not be considered in isolation as patients with a normal or high BMI may have experienced significant weight loss yet remain within the normal BMI range, and just taking into account the patients weight is not sufficient. Body weight and BMI should be used in conjunction with other objective and subjective markers (subjective – loose fitting clothes and rings, visual appearance, poor appetite, recent unintentional weight loss) when classifying patient’s nutritional status. There are a variety of screening tools to make screening simple and they are in use in both the community and acute hospitals throughout the UK. The Malnutrition Universal Screening tool (MUST) is validated and promoted by the NICE guideline for Nutritional Support in Adults. It was developed by the British Association of Parenteral and Enteral Nutrition (BAPEN) with the support of the British Dietetic Association, The Royal College of Nursing and the Registered Nursing home association. The tool is available in downloadable form at www.bapen.org.uk/must_tool.html
    
MUST is widely used but some trusts have their own adapted version. This screening process quickly identifies those at risk and those patients who require a referral to a dietitian. The dietitian will then tailor an appropriate individual dietetic intervention with clear nutritional aims to improve their nutritional status e.g. to encourage the patient to select high protein/calorie snack and menu items, establish a food record to monitor nutritional intake, discuss ways of improving their eating – does the patient require assistance with feeding, to prescribe fortified nutritional supplements – high calorie/protein powders, drinks, puddings.

Metabolic stress
Metabolic stress caused by injury or disease may impair nutritional status so it’s important to strive towards good nutrition
The key features of the response to metabolic stress are

• Body rapidly uses glycogen stores to supply glucose
• Increase in metabolic rate (hypermetabolic – which increases energy needs)
• Increased energy requirements
• Increased reliance on protein to supply energy and manufacture stress hormones (i.e. glucagon and cytokines) 
• Depletion of muscle store
• During the stress response the presence of hyper metabolism sends nutrients reserves on a downhill course. As adaption occurs and/or there is a resolution of disease, nutrient balance is gradually restored. If however, a patient is undernourished, he or she may be unable to make the uphill journey to recovery.

A metabolic response is normally accompanied by a reduction of food consumption and depletion of the body’s stores of vitamins, minerals and trace elements.
    
In the presence of any metabolically active disease (i.e. cancer, inflammatory bowel disease, Parkinson’s disease) or injury/surgery, the body mounts an immune response (characterised by the release of cytokines) and hormonal response (release of glycogen, cortisol, and catecholamines) that result in the ‘melting down’ of both lean and adipose tissue. This differs from long term starvation where there is a preservation of lean tissue.
    
The clinical benefits of nutritional sip feeds2 are well accepted and this, in combination with an increased awareness of under nutrition and improved products, has led to an increased use of sip feeds in recent decades.
    
Studies3 looking at post operative nutritional supplementation in surgical patients (give more detail about subjects and treatment) showed that when they consumed more than 700kcals more than the control group they

• maintained pre-operative weight status
• voluntary dietary intake significantly greater than control group
• muscle function significantly greater than the control group 
• significantly lower incidence of serious infections (pneumonia, wound infection) compared with control group.

The patients in the study were not malnourished but would be at risk of becoming so due to their surgery and periods of nil by mouth pre and post operatively.
    
Sip feeds are advantageous in their convenience and are promoted widely in the community through prescription for relevant patients. However, it is emphasised that assessment of clinical status should precede the prescription of sip feeds. The simplest and safest dietary measure to improve nutritional intake is veer away slightly from the healthy eating advice of low fat, high fibre and encourage patients to eat more high calorie, nutrition dense foods such as full fat milk and yogurts, ready to eat desserts, adding cheese to food and for example by encouraging patients to consume small quantities of higher energy foods at regular intervals throughout the day, or by enriching ordinary foods with other energy and/or nutrient dense foods that do not alter the volume of the meal.
    
A prospective randomised controlled trial (ref Ravasco et al 2005; ) compared individual nutritional counselling based on ordinary foods versus giving supplements or usual diet in colorectal patients undergoing radiotherapy. Results after three months showed that the nutritional counselling group had the highest consumption of energy and protein and concluded that concurrent individualised dietary counselling based on everyday foods is the most effective means of improving patients’ nutritional status and quality of life, thereby lessening radiotherapy induced morbidity. What is often seen in the clinical setting is taste fatigue with supplements or a reduction in the patient’s motivation to keep taking them. What about lack of carer involvement so the partner feels de-motivated and that they are not doing anything to help. This was also seen in the study but patients who received dietary advice about normal foods were able to continue with the advice. Those who had maintained a better dietary intake experienced fewer symptoms from radiotherapy.
    
A dietitian would be able to advise on an appropriate eating plan, energy dense foods and fortification.
    
There are many factors that can affect nutritional intake for example; eating in isolation, depression, anorexia, reduced appetite, swallowing difficulties, physical ability, ill-fitting dentures. Friends and family can help patients improve their nutritional intake by simple activities to help patients improve their eating. For example:

• Check position of patient at meal times – ensure they are able to get to the food, sitting up
• Offer snacks between meal times 
• Bring around ready made/cooked meals for them 
• Help with feeding patient if required
• Offer adequate time to eat
• Offer suitable utensils, i.e. special cutlery if required
• Check dentures and bite
• Offer drinks 
• Make eating area attractive – take any offending items away.

Healthy Eating Principles
For patients whose nutritional status is not compromised and their metabolic response related to the hospital admission is stable then eating a healthy diet is still a vital consideration coupled with sound dietary principles to minimise the risk of chronic disease (obesity, hypertension, high cholesterol, cardiovascular disease, diabetes, arthritis, respiratory disease and various cancers).
    
A healthy diet is one that provides sufficient energy and nutrients to prevent deficiency but which also helps to optimise health and reduce the risk of disease. The diet should:

• have an energy (kcal) content that achieves and maintains normal body weight (being underweight or overweight increases mortality and morbidity)
• provide an appropriately low intake of saturated fats. Most dietary fats should be monounsaturated fats, together with sufficient polyunsaturated fats to provide the essential omega-6 and omega-3 that cannot be made in the body
• provide a relatively high proportion of energy in the form of starchy, fibre containing carbohydrates and a low intake of refined sugar
• be low in sodium, rich in fruit and vegetables 
• be balanced in overall terms with respect to the variety, quantity and frequency that different types of food and drink are consumed.

The most important food tip is to choose a wide range of foods. This is essential. No one food or food group can supply all the nutrients that our bodies need. The overall evidence from numerous studies point towards following healthy eating guidelines, which ensures an optimal intake of all the vital nutrients for health and recovery. Moreover, a healthy balanced diet provides a rich supply of nutrients including vitamins, minerals and phyto-chemicals which can help to protect and repair the body.
    
Enjoying a healthy balanced diet means choosing a variety of foods from each food group in appropriate amounts and eating some foods more often than others. The FSA Eatwell Plate is a great place to start for information on food balance and portion sizes. Take a look at www.eatwell.gov.uk/healthydiet/eatwellplate
    
For most a balanced and varied diet provides all the nutrients we need for good health and to reduce the risk of disease. However, if you do choose to take a supplement, as an “insurance policy” to ensure you are getting all the nutrients you need, choose a general multi-vitamin/mineral supplement that provides at least 15 nutrients at levels at or below 150 per cent EC Recommended Daily Amount. You should avoid taking several single dose supplements alongside a multivitamin/mineral complex as you may be at risk of excessive intakes.

Notes
1. BAPEN Nutrition Screening survey in
the UK 2008 ISBN 978 1 899467 41 9
2. NICE 32 Nutritional Support for Adults; Milne et al: Meta-Analysis.: protein and energy supplementation in older people. Annuals of internal medicine 2006; 144: 37-48; Potter et al; Routine protein energy supplementation in adults: systematic review. British Medical Journal 1998; 317: 495-501
3. Ravesco et al: dietary counselling improves patient outcomes: A prospective, randomised controlled trial in colorectal cancer patients undergoing radiotherapy: J Clin.Oncol. 23:1431-1438