Understanding the NICE Guideline for Malnutrition
The National Institute for Health and Care Excellence (NICE) is a UK-based organisation that provides evidence-based guidance for healthcare professionals. Its guideline, 'Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition' (CG32), offers a systematic approach to identifying and managing malnutrition in adults aged 18 and over. The guideline aims to ensure that individuals at risk of, or already suffering from, malnutrition receive appropriate and effective nutritional care, whether they are in a hospital, care home, or their own home.
Core Principles of the NICE Guideline
The NICE guideline is built on several core principles to address the high prevalence of malnutrition and its significant impact on health outcomes. By standardising care, it seeks to improve patient recovery, reduce complications, and decrease healthcare costs associated with malnourishment. A central aspect is the role of a multidisciplinary team, which includes dietitians, nurses, and other specialists, to coordinate effective nutritional care.
The NICE Screening Protocol
Early identification is critical for managing malnutrition effectively. The NICE guideline mandates routine screening for adults in various settings.
- Hospital Inpatients: All inpatients should be screened for malnutrition risk upon admission and weekly thereafter.
- Outpatients: Screening should occur at their first clinic appointment, and subsequently whenever clinical concern arises.
- Care Homes: Residents should be screened upon admission and when there is clinical concern, such as unplanned weight loss or a change in health.
- General Practice: Screening is recommended upon initial registration and when there is a specific clinical concern.
The Malnutrition Universal Screening Tool (MUST) is often used to assess malnutrition risk, considering factors like Body Mass Index (BMI), unintentional weight loss, and reduced food intake. The results of this screening inform the next steps in a patient's nutritional care plan.
How NICE Defines Malnutrition
NICE identifies a person as malnourished based on specific criteria. These definitions help healthcare professionals accurately diagnose and intervene. A person is considered malnourished if they meet any of the following conditions:
- A BMI of less than 18.5 kg/m$^2$.
- Unintentional weight loss greater than 10% within the last 3 to 6 months.
- A BMI of less than 20 kg/m$^2$ and unintentional weight loss greater than 5% within the last 3 to 6 months.
Additionally, nutrition support should be considered for those at risk of malnutrition, such as individuals who have had little to no food intake for more than five days or have a poor absorptive capacity.
Types of Nutrition Support and Management
The NICE guideline recommends a tiered approach to nutrition support, starting with less invasive methods and progressing to more intensive interventions if necessary. The choice of support depends on the patient's condition, ability to eat, and risk level.
- Oral Nutrition Support (ONS): This involves enhancing the nutrient intake of individuals who can still eat and swallow safely. ONS can include dietary advice, food fortification (adding protein, energy, or vitamins to food), nutritional snacks, or oral nutritional supplements (sip feeds).
- Enteral Tube Feeding: For patients who cannot eat or swallow safely but have a functional gut, nutrition can be delivered directly into the stomach or small intestine via a feeding tube. This method is used when ONS is insufficient or inappropriate.
- Parenteral Nutrition (PN): This is the delivery of nutritional substances directly into a person's vein, bypassing the digestive system entirely. PN is reserved for patients whose gastrointestinal tract is not functioning and requires careful management to avoid complications.
Comparison of Nutrition Support Methods
| Feature | Oral Nutrition Support (ONS) | Enteral Tube Feeding | Parenteral Nutrition (PN) |
|---|---|---|---|
| Route of Delivery | Oral intake (food, supplements) | Tube into the gut (e.g., nasogastric, gastrostomy) | Directly into the bloodstream via a vein |
| Patient Condition | Can swallow safely; mild-moderate malnutrition or at risk | Functional gut, but unable to eat or swallow sufficient amounts | Non-functional or inaccessible gut; severe malnutrition |
| Complexity | Least complex; often involves dietary changes and supplements | Moderate complexity; requires tube insertion and monitoring | Most complex; requires intensive medical and nursing care |
| Risk of Infection | Low risk | Increased risk (tube site) | Highest risk (catheter-related bloodstream infection) |
| Examples | Fortified meals, sip feeds, high-protein snacks | Liquid formula via tube (NG, PEG) | IV nutrient bags containing glucose, amino acids, and lipids |
Managing Refeeding Syndrome
One of the most critical aspects of the NICE guideline is the prevention and management of refeeding syndrome. This potentially fatal condition can occur when severely malnourished individuals are fed too aggressively. The guideline outlines specific criteria for identifying high-risk patients, including those with:
- A BMI below 16 kg/m$^2$
- Significant unintentional weight loss
- Little or no nutritional intake for prolonged periods
- Pre-existing low levels of phosphate, potassium, or magnesium
Management for high-risk individuals involves carefully introducing nutrition slowly and providing additional supplements of thiamin, B vitamins, and electrolytes like potassium, phosphate, and magnesium.
Monitoring and Review
Regular monitoring is essential to ensure that nutrition support is effective and well-tolerated. The NICE guideline recommends that healthcare professionals regularly review the patient's nutritional status and treatment goals. Monitoring involves tracking nutrient intake, weight, and fluid balance, and checking for tolerance issues like nausea or diarrhoea. For those receiving long-term support, monitoring frequency can be adjusted once stable, but should increase if there is a change in the patient's clinical condition. Family and carers are also trained to recognise adverse changes and manage the nutritional delivery system.
Conclusion
In conclusion, the NICE guideline for malnutrition provides a robust, evidence-based framework for the effective identification, assessment, and management of malnutrition in adults. By prioritising routine screening, defining clear diagnostic criteria, and outlining a tiered approach to nutritional support, the guideline helps standardise care and improve patient outcomes. Its specific recommendations for preventing refeeding syndrome and conducting consistent monitoring are vital for safe and effective nutritional management across various healthcare settings. Adherence to these guidelines is crucial for all healthcare professionals involved in patient care to ensure malnourished individuals receive the high-quality, coordinated care they need. For additional information, the complete guideline can be accessed on the NICE website [https://www.nice.org.uk/guidance/cg32].
Summary of Malnutrition Management
NICE emphasizes a proactive, comprehensive approach to malnutrition care, from initial screening to ongoing management.
The Malnutrition Care Pathway
- Screening: Use a validated tool like MUST to screen all adults on admission to hospital, care homes, and at GP registration.
- Assessment: If medium or high risk is identified, a full nutritional assessment is carried out by trained professionals, often involving a dietitian.
- Nutrition Support: The appropriate level of support (oral, enteral, or parenteral) is selected based on patient need, ability to swallow, and gastrointestinal function.
- Refeeding Syndrome Risk: Identify patients at high risk of refeeding syndrome and start nutrition support cautiously, providing necessary electrolyte and vitamin supplementation.
- Monitoring: Regularly monitor patients' nutritional intake, weight, fluid balance, and clinical status to evaluate the effectiveness of the support and adjust as needed.
- Coordination: Ensure seamless coordination of nutritional care between hospital and community settings to prevent gaps in treatment.
