Bad medicine: medical nutrition
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e451 (Published 18 January 2012) Cite this as: BMJ 2012;344:e451
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Spence's article, his opinions and his response will resonate with many GPs. He made it clear that calories are not the only things that matter; balance is almost everything.
Criticism of GPs' failure to recognise (and correct) inadequate nutrition in the community reflects a lack of understanding about the real world inhabited by GPs and patients. GPs are rather good at recognising the unpalatable aspects of our patients' lives, but can do almost nothing to alter them or the social and economic poverty which often lies behind them.
A recent Bulletin of the President of the RCP (6 Dec 2011) suggested exchange days between hospital consultants and GPs so that each gets a better idea of what the other does. Out in the community a surprise awaits the specialist.
Competing interests: No competing interests
Firstly this is clearly an opinion piece , for debate and to question current practice. Consider, the cost of supplements in the community alone is likely this year to be of the order of quarter of a billion pounds and rising. Clearly the total cost to the NHS is much higher, if we were to include hospital care. I am not suggesting that supplements have no place but merely question if these are being used appropriately. The “opportunity costs” are enormous: 12 500 additional full time carers could be provided to aid in feeding alone with this money.
I never suggested that a Mars bar was the same as Sip Feed, just that they are as calorie dense. And surely in a community setting, like a nursing home, the real issue is total calorie intake ? This should of course be balanced with carbohydrates, proteins , fats and nutrients. Small adjustments in daily intake would increase weight , or are my calculations incorrect ?
As for the evidence, the last NICE update was in 2006 and data came from very mixed sources.[ 1] As I was unable to find the Conflict of Interest statements from the NICE GDG on the website, I relied mainly on a more recent Cochrane review on Supplements from 2009. This states “There was no significant reduction in mortality in the supplemented compare with control groups from 42 trials.” And in conclusion it says: “additional data from large-scale mulit-centre trials are still required.”[2] As for the reputation of BAPEN. Is the funding as I suggest ? I thought I merely set out the facts. I do find it regrettable that many medical charities take money from corporations with large vested financial interests. I never stated that BAPEN endorsed any products. But for the sake of transparency please would BAPEN publish full payments made to them and by which corporation , and all payments made to committee members.
I repeat, “nutrition is very important in health care and is a key health care priority. ” The question is , could these resources be better spent on feeding , especially in the community? Last a damning report into NHS care from The Care Quality Commission concluded: “people not being given the assistance they needed to eat – meaning they struggled to eat and in some cases were physically unable to eat meals……. people not being given enough to drink – water left out of reach or no fluids given for long periods of time”. [3 ] Prescribing supplements can distract us from the most important issue , improving general nursing care.
[1] Nutritional support in Adults NICE 2006 http://guidance.nice.org.uk/CG32/Guidance/pdf/English
[2 ] http://summaries.cochrane.org/CD003288/protein-and-energy-supplementatio...
[3] http://www.cqc.org.uk/media/cqc-publish-first-detailed-reports-dignity-a...
Competing interests: No competing interests
There is a marvelous service set up in parts of Cardiff to rehabilitate very ill people as much as possible to continue living at home. One of the most admirable is the CERT (Cardiff East Rehabilitation Team).Without them many people would undoubtedly languish in hospital as no hospital can provide the level of compassionate, skillful individual care frail and very ill people need. The team responds to changing circumstances immediately, before things deteriorate by liasing with the relevant team member. This includes expert nurses, nurse practitioners, receptionists, GPs physiotherapists, and importantly dieticians. When very frail people are unable to eat their help in prescribing food supplements and other advice is absolutely invaluable and plays a huge part in the rehabilitation. If only this service could be replicated and offered to many more people instead of sending them into a hospital where relatives and friends cannot help or advocate on their behalf and where the psychological damage of being admitted can be irreversible Importantly friends and relatives cannot make sure they receive proper tailored nourishment. I know several people who will be eternally grateful that the need for proper nourishment in the form of supplements when just about all else could not be stomached was taken seriously,
Competing interests: No competing interests
I respond to the startlingly ill-informed views reported in Des Spence's 'From the Frontline - 'Bad medicine: medical nutrition' speaking as chair of the NICE Guideline Development Group on Nutrition Support (published 2006).
The evidence for the use of oral nutritional supplements (ONS) in the treatment of disease related malnutrition is overwhelming (Grade A according to the independent NICE assessments) and there are many probable reasons why they are effective in treating malnutrition when simple dietary manipulation is not. These include their protein and micronutrient content and anyone who knows anything about malnourishment, would realise that the benefits of treatment are likely to have little to do with 'total calories' as Des Spence seems to think . It is therefore absolute nonsense to suggest that they can be replaced with a chocolate bar or biscuit to the same effect. GPs have repeatedly failed to recognise the importance of nutritional screening, despite 93% of malnourished individuals or those at risk of malnutrition living in the community and as a consequence they often fail to ensure adequate intakes of protein and micronutrients in addition to calories. This is actually very difficult to achieve with foodstuffs in those who are at nutritional risk from the decreased appetite seen so often with disease or injury, whilst study after study has shown that it can be at least partly achieved using ONS which probably explains why Cochrane meta-analyses demonstrate little or no effect from trying to manipulate food intake whilst they do confirm outcome benefits from ONS usage in line with the Grade A findings from NICE.
Finally, Des Spence has no right to impugn the integrity of the many health professionals in BAPEN who are trying to translate the Grade A evidence to improve clinical practice related to all aspects of nutritional care.
Yours sincerely
Dr Mike Stroud FRCP Consultant Gastroenterologist and Senior Lecturer in Medicine and Nutrition, Southampton
Chair of the NICE GDG on Nutrition Support
Competing interests: No competing interests
Des Spence makes one very important and accurate point in the opening of his article which is that Nutrition is a key priority in healthcare. The remainder of his article is factually inaccurate and demonstrates a total lack of understanding of disease related malnutrition, which is not simply about calorie intake and achieving weight gain.
The cost of nutritional products is just 2% of the estimated £13b cost of malnutrition in the UK. The real issues lie with the delivery of good nutritional care which is dependent upon nutritional screening to detect malnutrition / risk of malnutrition. The importance of this is something that traditionally GPs have failed to recognise, or to ensure adequate intakes of protein and micronutrients in addition to calories for patients. It is also vital to have nutritional care pathways in place for those at risk and to provide education for frontline staff.
BAPEN is the UK’s leading multidisciplinary charity tackling malnutrition with a broad membership of health care professionals (doctors, nutrition nurses, dietitians, pharmacists and patients). Like most other research-led charities it also has some industry sponsorship which provide funds for the vital work of the charity. However, all work is conducted independent of commercial influence. BAPEN does not endorse the use of any nutritional supplement products. It has led the work to develop and launch the UK’s leading screening tool for malnutrition (‘MUST’) and has undertaken national nutrition surveys to identify the prevalence of malnutrition in the UK. BAPEN has also produced many leading reports on combating malnutrition and developed nutrition action plans, clinical guidance and commissioning guides. Its work is undertaken independently by the UK’s leading researchers in clinical nutrition and focuses on implementing sound research and science into clinical practice, with the sole aim of improving nutritional care for patients. The NICE Guidance for nutrition support in adults contains grade A evidence both for oral nutritional supplements and more invasive means of support and the inclusion of nutrition in the NICE Quality standards for 2012 clearly indicate the importance of this work in driving quality improvements in patient care.
Competing interests: No competing interests
Re: Bad medicine: medical nutrition
I was dismayed by the emphasis in this article on the costs of oral nutritional supplements, which I felt detracted from the very significant problem of disease related malnutrition in both the community and hospital setting. BAPEN’s nutrition screening weeks1 have consistently identified that 1/3 of patients on admission to care homes and hospitals are at risk of malnutrition and also that there are problems with the continuity of nutritional care between different care settings. To try and address some of these issues BAPEN published a Nutrition Toolkit for Commissioners and Providers in England2 and I would draw attention to the section on the Development of nutritional screening, assessment and care pathways. This states “Pathways should incorporate a logical approach to identification of the malnourished using screening and assessments steps, followed by treatment of those found to be malnourished or at risk starting with food intake where possible, and moving on to oral nutritional supplements or artificial nutrition support where indicated.” The more detailed guidance also advises inquiry about factors preventing adequate intake and advocates the adoption of a “food first” approach with appropriate social help and dietary advice to ensure adequate and balanced intakes.
BAPEN members are passionate about ensuring high quality appropriate nutritional care in both community and hospital settings. This should be based on the available evidence, but there will always be a need for more high quality evidence and BAPEN will continue to support this. However, in the absence of the required support to enable frail elderly patients to maintain their weight and in the specific situations where the use of oral nutritional supplements is supported by the evidence, then we should not stand back and do nothing.
1. BAPEN’s Nutrition Screening Week – 12th to 14th Jan 2010. Available from: http://www.bapen.org.uk/nsw10.html
2. Brotherton A, Simmonds N, Stroud M on behalf of BAPEN quality group. Malnutrition Matters. Meeting Quality Standards in Nutritional Care. A toolkit for commissioners. Launched May 2010. Executive summary available from: http://www.bapen.org.uk/pdfs/bapen_pubs/mm-toolkit-exec-summary.pdf
Competing interests: Honorary Secretary BAPEN Medical, Treasurer elect BAPEN