Based on the results of the MNA, Mr Tanner was found to be at risk of malnutrition, but not malnourished at this stage. The adequacy of his dietary intake needs to be assessed during admission (may become inadequate due to physical or psychological reasons).
Mr Tanner has essentially maintained his weight throughout his acute hospital admission (pre-rehabilitation admission). His energy requirements have decreased due to his restricted mobility and he has had assistance with eating which has enabled him to maintain an adequate intake. However a soft diet should enable him to eat with minimal assistance.
I spoke with Mr and Mrs Tanner together, with Mrs Tanner supplying most of the information, but Mr Tanner being given the opportunity to speak and provide advice about preferred food choices in hospital, etc. Mrs Tanner reports that Mr Tanner eats well in hospital (all meals) when assisted by staff members/herself. Mr Tanner would benefit from food/fluid charts being kept for the first 3-7 days of his rehabilitation and thereafter as needed to allow assessment of the adequacy of his intake.
Mrs Tanner’s recall of Mr Tanner’s dietary intake at home shows he consumed a nutritionally adequate diet pre-admission except for an inadequate intake of vegetables on some days. However his intake of total and saturated fat was too high for effective lipid management and he was not meeting lipid targets despite the statin therapy. Mr Tanner also consumed a high sodium diet and a reduction in salt intake to <4g/day (65mmol sodium) will assist with long term blood pressure management, reduction in recurrence of stroke/TIAs, reduced risk of other cardiovascular events and maintenance of normal renal function.
As previously mentioned, Mr Tanner’s intake of vegetables at home was often inadequate, although he does consume 2 serves of fruit daily. An increase in vegetable intake to > 5 serves daily and maintenance of his fruit intake will increase intake of vitamins, minerals, fibre and potassium. An increase in potassium will also help with long term blood pressure management and reduction in recurrence of stroke/TIAs and other cardiovascular events.
At home Mr Tanner's intake of carbohydrate (CHO) was sometimes excessive and a reduction in CHO intake at some meals (e.g. dinner) and consumption of regular low GI CHO portions over the day will assist with blood glucose level (BGL) management (Mx). Currently Mr Tanner's BGL are satisfactory (but not ideal). Improvements in dietary intake and weight will assist with long term BGL Mx however he will need ongoing monitoring of these by his doctor.
At home Mr Tanner’s alcohol intake was above recommendations and would have caused raised BGL, contributed to hypertension and excess body weight. Mr Tanner would benefit from reducing his intake as per his doctors instructions (already provided) or national recommendations (≤2 standard drinks per day and to include 2 alcohol free days per week).
Mr Tanner is obese with central adiposity and in the future weight loss will assist with lipid/BP/BGL management. He will also need to reduce his energy intake if his mobility continues to be reduced to prevent further weight gain. Reduced mobility may also result in raised BGL unless CHO/energy intake is restricted.
Mr Tanner’s biochemistry results show adequate nutritional status, fluid status, renal and liver function, however his lipids remain above target. His BGL collected 4x daily on the ward show satisfactory BGL control (e.g. 6-7mol/L fasting/premeal and ≤10mmol/L 2 hours post prandial), however these could be improved to good or ideal control (e.g. 4-6mol/L fasting/premeal and ≤8mmol/L 2 hours post prandial), with lifestyle change.
The aim of nutrition intervention is to provide a nutritionally adequate intake of appropriate texture (soft) foods/fluids, which prevent recurrence of stroke/TIAs and manages his co-morbidities while in hospital. Education will also be provided so this diet may be continued at home. As he is obese, weight and waist circumference loss would also be of benefit providing this occurs via a nutritionally adequate intake.
Requirements:
Energy for weight maintenance = (Harris Benedict, Activity Factor=1.2, Injury Factor=1.0) = 8473.2kJ
Energy for weight loss = 6000kJ (2500kJ below estimated requirements to allow >0.5kg loss/week).
Protein= 0.8-1.0g ptn/kg = 73.3g
Fluid 35-45ml/kg = 3200-4120ml/day
Sodium = <65mmol/day
Recommended diet for Mr Tanner: A soft, nutritionally adequate diet, low in energy/kilojoules, total and saturated fat, salt and sugar and high in fibre with low GI foods provided where possible. CHO portions must be controlled and spaced regularly over the day.
The above diet was ordered from the hospital kitchen and the menu ordering system was explained to Mrs and Mr Tanner. It was decided that Mrs Tanner would assist her husband in completing the daily menu.
The reasons for implementing the recommended diet were explained to Mr and Mrs Tanner who were willing to keep to the prescribed diet. This discussion was kept brief as they have received a lot of information from other health professionals since being admitted to the ward.
