Nutrition 411: Best Practices, Tips, and Techniques for Preventing Unintended Weight Loss and Healing Wounds

     Obesity in the US has reached epidemic proportions. Each day, the media features at least one article on the health consequences of extra weight. But another epidemic is occurring much more quietly in our nation’s hospitals, nursing homes, wound care clinics, and patients’ private homes: Medical teams and caregivers are struggling to keep the pounds on patients who have lost interest in eating, endure taste abnormalities, are too fatigued to shop and prepare meals, get a feeling of fullness quickly, and suffer many other impediments to consuming a proper diet.

     Ultimately, many diseases alter the normal metabolic machinery, rendering patients in need of more calories and protein just when their intake dwindles. In response, registered dietitians from across the country have shared best practices, tips, and techniques for dealing with unintended weight loss and wounds.

     Heather Schwartz, MS, RD, Stanford, CA: I work with patients who are chronically ill and often struggle to keep their weight on. To deal with this problem, I frequently encourage the use of liquid oils as a calorie booster. They are heart-healthy, reasonably priced, familiar to most people, and accessible at nearly all markets. Some oils such as flaxseed or walnut oil even may help reduce inflammation. The oils blend in well with most foods and are easily added to dishes such as salads, soups, pasta, rice, shakes, or hot cereals. Oils spread easily on breads or crackers, or you can give the oil by the spoonful or add it to a tube feeding. An added bonus is that these oils are calorie-dense — for example, 1 tablespoon of oil provides 120 calories. That’s a lot of bang for your buck!

     Jan Patenaude, RD, Carbondale, CO: Over the years, I noticed that certain residents only would eat foods with a sweet flavor, such as desserts, juices, fruits, and sweetened medical nutrition supplements. When I sprinkled a small amount of sugar (1 to 2 teaspoons) over meat, potatoes, and vegetables, the residents began to eat 100% of their meals, their body weight stabilized, and we could eliminate many high-calorie supplements. A similar trick is to use more fruit sauces and fruit glazes to add a sweeter flavor to foods.

     Alyson Z. Mar, RD, San Francisco, CA: During my internship, my preceptor, Sandy Von Bieberstein, said, “Eating is like going to work; sometimes you don’t mind it and sometimes you really don’t feel like going, but you do because it’s your job and you have to.” That little talk helps motivate people to eat their meals, even when they don’t want to.

     Janice Baker, MBA, RD, CDE, San Diego, CA: I work with many senior citizens who are dealing with diabetes. Over time, because of changes in dentition, social circumstances, and a general lack of nutrition and diabetes education, they often become afraid to eat certain foods. This puts them at risk for unintended weight loss and failure to thrive. Nutrition counseling that teaches them to relax unnecessary dietary restrictions is very helpful to them, both nutritionally and emotionally. I also include counseling about easy-to-prepare, nutrient-dense meals. When patients understand the facts and the priorities for their health and well being, they can enjoy meals with less stress.

     Sonal R. Patel, MS, RD, LDN, Sparks, MD: At weekly nutrition/skin meetings, we review all of the residents with unintended weight loss, poor meal intake, skin integrity problems, or swallowing issues. We have a team comprised of the unit nurse, the assistant director of nursing, the speech therapist, the food service director, and the registered dietitian. We follow all the residents who have nutrition/skin issues, incorporating the team approach and using root cause analysis to find individualized solutions. If the plan we set up is not working, the nursing staff completes a special form and interventions are changed. The key to our success is communicating among all disciplines.

     Andrea Maher, RD, LD, Huxley, IA: I include my residents and/or family members in the decision-making process, whether it is about changing the meal tray, individualizing a snack between meals, or adding a medical nutrition supplement. I often bring “test trays” to my residents and let them try different snacks or supplements so they can choose what will work best for them. They appreciate the concern and the one-on-one time provided. Although it takes extra time initially, it saves time on unsuccessful approaches that weren’t tailored to the individual.

     Linda S. Eck Mills, MBA, RD, LDN, FADA, Bernville, PA: The best way I’ve found to increase protein and calories in home care patients is to provide recipes for shakes that offer variety, good taste, and affordability. The most popular recipes are:

Chocolate Cocoa Drink

      (600 calories and 24 g protein/serving)
     1¼ cup (C) ice cream
     ½ C whole milk
     1 package hot chocolate mix
     2 teaspoons sugar

Yogurt Frost

      (400 calories and 19 g protein/serving)
     1 envelope vanilla instant breakfast mix
     1 C whole milk
     ½ C flavored yogurt
     6 to 10 crushed ice cubes

     Vary the flavor of ice cream or yogurt to expand the options. Make fortified milk by mixing 1 quart whole milk plus 1 C nonfat dry milk — it contains 211 calories and 14 g protein/1 C. This will boost the nutritional levels even more.

     Lindsey Guerriero, RD, Dearborn, MI: I assess the patient before the weight loss begins. If I identify nutritional risk factors for weight loss, I immediately address them so they do not become a bigger problem later. I include frequent snacks that pair a protein source with a carbohydrate source, such as graham crackers and peanut butter, making sure to include enough calories, protein, and healthy fat in each snack. I also encourage beverages such as milk with added milk powder to double the calories and protein in the same volume of milk. I encourage a heartier meal at the time of day when the patient is likely to eat best.

     Cheryl Havens, RD, Mt. Angel, OR: We offer an extensive room service menu, along with a fully functioning restaurant-style dining program. Our four-page menu is designed to encourage high-calorie and high-protein food choices. Since we implemented these programs, incidence of unintended weight loss has decreased among our nonhospice residents and we were able to eliminate our routine medical-nutrition-supplement program, although we still use it for residents who are anorexic or who prefer supplements.

     Our dining room program has had the unexpected additional benefit of getting residents out of their rooms. This means they spend less time sitting in one position and increase their daily exercise by walking the distance to the dining room or propelling themselves there and back. We also have observed the positive effects of the increased socialization. This approach follows the resident-directed care model in which residents make decisions for themselves, rather than the old approach of combating weight loss with the same supplements for everyone. While this model involves more dietitian time, we find it worthwhile.

     Susan Olfert, RD, Visalia, CA: Wound healing is expedited by having stepwise wound-care-intervention guidelines posted at all the nursing stations. This avoids any delays in implementing interventions and avoids questions as to where to start. The process begins with a skin-risk assessment tool that is completed by the admitting nurse on all new admissions. Baseline interventions can begin immediately if deemed necessary. The process works best with good interdisciplinary communication and follow-through.

     Jamie McGinn, RD, LDN, Wake Forest, NC: We obtain food preferences upon admission and update them as dietary needs change. If residents receive foods they dislike, it can ruin an entire meal. The dietary managers are instructed to stay in contact with new residents within 24 hours of admission, if possible. If the resident is unable to participate in the interview because of lack of cognition, the dietary manager contacts the family within 3 days. Nursing assistants are made aware of all weight loss problems or residents at risk for weight loss; in turn, they report any problems they see and any tips that were helpful in increasing meal intake. This information is shared with all key staff members. Empowering nursing assistants and dietary staff is the key to improving nutritional status.

     Shaun K. Riebl, MS, RD, LDN, Deerfield Beach, FL: I recommend that a patient incorporate one hard-boiled egg each day (after reviewing cholesterol and other health conditions) in the morning in addition to their normal breakfast or as a mid-morning or mid-afternoon snack. Albumin levels have improved from this intervention alone. We also use protein powders and mix them with oatmeal, grits, cereal, casseroles, juices, eggs, melted ice cream, sorbet, and yogurt. One to two scoops/day tends to work wonders for albumin levels.

     Colleen Gill, MS, RD, CSO, Aurora, CO: Patients are encouraged to keep a meal or snack next to them while watching television and take a bite or sip of a beverage each time a commercial is played. This helps pace the intake and divert attention from the work of eating. It also prevents patients from becoming overwhelmed.

     I also suggest that we separate the role of the caregiver from the person losing weight. Caregivers can remind the patient when it is time to eat, assist with meal choices, and fix the snack and present it to the person. Then the caregivers must step back and realize that they cannot make another person eat. It is important to return control to the patients, which is why we have to start with them understanding why it is important for them eat, even when they have few, if any, incentives to do so.

     Dawn Simpson-Foster, MSA, RD, LDN, Raleigh, NC: We have establish standards so physicians and physician assistants can easily identify patients at nutritional risk. This early identification helps us provide timely nutritional intervention from day 1. First, we check prealbumin levels. If prealbumin is abnormal and the patient has a history of eating poorly, we begin a liquid protein supplement and obtain an order for a nutrition consultation. Next, a medication pass supplement is given three to four times daily with medications. By using a calorically dense product instead of water with medications, we provide between 450 and 560 calories and an additional 30 g protein/day. Lastly, a high-calorie, high-protein cereal (eg, super cereal — recipes available at www.RD411.com) is given, which provides approximately 300 calories and 9 g protein/serving.

Coming next month: Nutrition Considerations at End of Life

Nancy Collins, PhD, RD, LD/N, FAPWCA, is founder and executive director of RD411.com and Wounds411.com. For the past 20 years, she has served as a consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation. Correspondence may be sent to Dr. Collins at NCtheRD@aol.com.

This article was not subject to the Ostomy Wound Management peer-review process.