Dietitians are the only nutrition specialists who are regulated by a professional body, using evidence-based research to support patients in a variety of health settings. They are registered under the Health and Care Professions Council (HCPC), along with other allied health professions (AHPs), which ensures their practice is regulated by law, is ethical and to appropriate high standards. With pressures across the NHS, including in community nursing, multidisciplinary team (MDT) working and shared care between professions is becoming increasingly important.
Following direction from policies such as the NHS Long Term Plan (2019), there has been an increase in funding for AHPs who can support patients in managing their disease and monitor their wellbeing in the community setting. Areas including malnutrition, obesity, diabetes and gastrointestinal disorders have been identified by Health Education England (HEE) (2021) as areas of interest for dietitians, in addition to community patient groups such as home enteral tube feeding (HETF), palliative care, complex conditions and wound healing. These areas will be discussed in further detail, with reference to research papers and national guidance, to demonstrate the roles of dietitians in community patient care.
It can be easy to overlook the ‘pandemic’ of malnutrition in the UK. With the abundance of shops, restaurants and fast-food outlets in the country, and with the media focusing often on obesity-the number of patients living with malnutrition can come as a surprise to some. The British Association of Parenteral and Enteral Nutrition (BAPEN) estimated that in 2018, malnutrition affected over 3 million adults in the UK, with 1.3 million being over the age of 65, with a staggering 93% of malnourished patients being found in the community setting (BAPEN, 2018). We know that malnutrition can lead to sarcopenia (muscle wastage), which causes an accelerating decline in muscle mass, and ultimately contributing to frailty (Boulos et al, 2016). However, it is important to note that malnutrition does not always mean a patient is underweight. A patient with an overweight or obese body mass index (BMI) may be malnourished through poor dietary intake or a large, unintentional weight loss.
A 2015 report from BAPEN estimated that the cost of malnutrition in adults and children in England is over £19 billion per year (Elia, 2015), with similar research suggesting that malnourished patients in the UK see their GP twice as often, have three times the number of hospital admissions and stay in hospital three days longer than those who are well–nourished (Guest et al, 2011).
The Malnutrition Universal Screening Tool (MUST) may be used to identify malnourished patients. This tool looks at several factors, including weight, BMI, weight loss and disease state to determine if a patient is at risk of malnutrition and can be used in all adult care settings. It has been found to be reliable, easy to use and promotes MDT working (Elia, 2003). Screening for malnutrition can be undertaken by any healthcare professional at opportunistic moments (for example, upon new registration at a GP practice) or upon clinical concern (for example, visible weight loss, pressure sores, muscle wastage) (Holdoway et al, 2021). The MUST screening tool suggests that a referral to dietitians should be considered for patients scoring 2 or above—in essence, these are patients at high risk of malnutrition. National Institute for Health and Care Excellence (NICE) guidance on nutrition support (2017) advises that healthcare professionals who are trained in nutritional requirements and methods of nutrition support should be involved in malnourished patients' care and indicates that they are often a mix of nurses and dietitians.
Considering a patient's clinical condition, their eating habits, social circumstances, limitations and anthropometry all falls within a dietitian's assessment. They may suggest ‘food first’ measures to increase calorie and protein intake – such as fortifying meals, including nourishing drinks or suggesting additional energy–dense snacks. Some patients may require support in the form of oral nutritional supplements (ONS)—usually high calorie, high protein and vitamin dense drinks—in the form of powder or ready–made bottled drinks. Dietitians have the appropriate skills and training to estimate a patient's energy, protein and vitamin needs, and act appropriately to ensure the patient meets these. They can play an essential role in the care of those patients who are at high risk of malnutrition, have increased nutritional requirements as a result of clinical diagnosis (for example, wound healing, cancer, liver disease) or for supportive care in palliative patients.
Obesity and diabetes
Many patients in the community can have multiple diagnoses, and these secondary diagnoses are often long–term conditions that dietitians can provide input on, such as obesity and type 2 diabetes.
The NHS statistics report for 2019/2020 found that much of the population was overweight (67% of males and 60% of females) and that there was a 4% increase in the number of hospital admissions directly attributed to obesity when compared to 2018/2019 data (NHS England, 2020). Navigating the past 2 years through COVID–19 has also emphasised the risks of poor diet, lifestyle and ultimately, being overweight, with evidence linking obesity as being a risk factor for severe symptoms in COVID–19, and even death (Senthilingam, 2021).
The rise in obesity also carries an increased risk of developing chronic conditions such as type 2 diabetes. The number of people with diabetes has doubled in the last 20 years, mainly due to the rapid increase in type 2 diabetes, currently estimated to be 4.7 million (Diabetes UK, 2019).
As part of an MDT, AHPs including dietitians, have been found to have a measurable impact on patients with long–term conditions and comorbidities (Jackson et al, 2010; Walker et al, 2018) such as diabetes and obesity. Dietitians are known for using a holistic approach to healthcare (Grace et al, 2018) and have a skill set that enables them to deliver therapeutic support for patients with conditions requiring dietary manipulation (Hickson et al, 2019). For instance, supporting patients with diet and lifestyle changes or using more specific diets such as a very low-calorie diet (VLCD), as seen in the Diabetes Remission Clinical Trial (DiRECT) study (Lean et al, 2019). The DiRECT study looked at patients with type 2 diabetes who undertook an intensive weight loss regime for 12-20 weeks, involving meal replacements and calorie restrictions of around 800 calories per day. The study showed improvements in BMI and diabetes control, with some even showing remission of diabetes (Lean et al, 2019).
Dietitian's involvement in patients with obesity and diabetes can therefore have a significantly positive impact on patient outcomes. Reductions in obesity/diabetes prevalence can lead to improved mobility, reduced numbers of cardiovascular disease (CVD) and diabetic complications commonly seen in the district nurse (DN) setting.
Dietitians are also often involved in the management of gastrointestinal (GI) diseases, for example, symptom management of irritable bowel syndrome (IBS), support during remission and active inflammatory bowel disease (IBD) and management of high output ileostomies (HOS).
There is thought to be a global prevalence of 4–9% of people experiencing symptoms of IBS (Oka et al, 2020) using around 8–10 GP appointments per patient per year in the UK (Canavan, 2016). Diet and lifestyle measures are an essential part of the treatment process for IBS (NICE, 2017), with specialised diets often being used, such as a low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) diet. The Low FODMAP diet is a well–established treatment for managing IBS symptoms, with research suggesting 75% of patients see an improvement in symptoms (Halmos et al, 2014). However, this diet isn't suitable for all patients and should therefore only be recommended by healthcare professionals with expertise in dietary management (NICE, 2017). Recent research has shown that dietitians providing this service have demonstrated good outcomes on patient satisfaction and reducing pressures in the community (Seamark et al, 2021).
For patients with IBD, The European Society for Clinical Nutrition and Metabolism (ESPEN, 2020) guidelines advise that all patients in remission should undergo counselling by a dietitian as part of an MDT approach to avoid malnutrition and vitamin deficiencies and should be screened for malnutrition at diagnosis and thereafter. Dietitians can support with the identification and correction of these, as well as using specific diets such as liquid only diet for 6–8 weeks (using whole protein oral nutritional supplements) to aid remission of Crohn's disease (ESPEN, 2020).
For post-surgical patients, dietitians can play an important role in the management of nutrition and hydration, particularly in patients with HOS. For these patients, absorption of nutrients and fluids is often significantly reduced (Nightingale, 2006). Dietary advice such as fibre manipulation, fluid restriction (contrary to popular belief), rehydration solutions and the addition of salt are just some examples of care that needs to be considered. In addition to this, dietitians may advise on medications and monitoring/replacing vitamins such as B12 and fat–soluble vitamins A, D, E and K. Therefore, dietitians play an important part in the MDT to support this relatively small but often complex patient group.
Patients with a functioning gut who are unable to take any or sufficient nutrition orally, may be fed enterally (NICE 2017; BAPEN, 2018). Enteral feeding provides nutrition to patients via a tube—often via a nasogastric (NG) route, a percutaneous endoscopic gastrostomy (PEG) tube, or bypassing the stomach and feeding directly into the jejunum. Enteral feeding is often needed as a result of underlying diseases such as neurological conditions, malignancies (particularly head and neck cancers), surgeries and diseases affecting the oesophagus.
NICE guidance (2017) states that all people in the community having enteral tube feeding should be supported by a coordinated MDT, which includes dietitians and district nurses. This is also endorsed by the ESPEN guidelines on home enteral nutrition, which describes ongoing monitoring from a dietitian (ESPEN, 2020).
Dietitians can advise on feed type, timings and fluids, with consideration to the patient's clinical picture and nutritional assessment, which are indicated as important in the ESPEN guidelines for supporting HETF patients (ESPEN 2020).
Adequate nutrition to support wound healing is an important part of an MDT approach to managing wounds in community, in conjunction with considering immunological response, physiology, physical activity and social factors (Quain & Khardori, 2015). Nutrition has been shown to be important in both post–operative surgery wounds and aiding pressure ulcer healing (National Pressure Ulcer Advisory Panel, 2009; Quain & Khardori, 2015; Weimann et al, 2017). Nutrition for wound healing often focuses on three aspects: ensuring adequate energy intake, protein and fluids.
Protein plays an essential role in wound healing, as it supports mechanisms such as immune function, collagen synthesis and supplying skin structural proteins (Harris et al, 2004). It is thought that protein may be lost through wound extrudate (Russell, 2001) and that loss is increased during wound infection or if a patient has a poor nutritional status (Lizaka et al, 2010). For these reasons, it is recommended that patients with wounds such as pressure ulcers aim to consume 1.25-1.5g of protein per kg body weight (National Pressure Ulcer Advisory Panel, 2009).
A diet with adequate energy from carbohydrate sources is also important in wound healing, as without this, the body uses its protein stores for energy, impairing its ability to heal (Quain & Khardori, 2015).
Fluids help to promote wound healing as they help to maintain skin turgor and promote blood flow/oxygenation to the site (Stechmiller, 2012). There are several factors that may contribute to dehydration: including a raised temperature, losses via vomiting or diarrhoea, losses via the wound and poor fluid intake (Quian & Khadori, 2015).
NICE guidance on wound healing advises that adults with pressure ulcers should be offered an assessment by a dietitian or other healthcare professional with the necessary skills and competencies, and recognises nutrition deficiencies as a risk for developing pressure ulcers (NICE, 2014). ONS may be used for patients unable to meet their energy and protein needs (NICE, 2014), and research has suggested that standard ONS may be more effective than specialised wound ONS (Bauer et al, 2013). A dietitian can provide thorough nutritional screening, assessment and dietary advice, individualised to patients with wounds in community.
End of life care
Community nurses have a measurable impact on patients in palliative or end of life care, and dietitians can also support patients and their families in this challenging time. Nutrition continues to play an important role in caring for patients. However, several factors may differ as a patient reaches end of life.
NICE guidance (2019) recognises that patients approaching their end of life should have support from healthcare practitioners with symptom management, nutrition and hydration. Contrary to the use of the MUST screening tool for the general population, it is still encouraged to be used in end of life care, but more so to help identify early stages of risk of malnutrition, so a plan may be implemented to slow nutritional deterioration (Porter et al, 2021). Nutrition support for patients in the final stage of life can be a difficult subject for patients and family, and care is needed when discussing supportive dietary plans and weight monitoring, so as not to cause distress (Porter et al, 2021). This is perhaps where a dietitian's skill set could be utilised. Dietitians may work as part of an MDT and help family members understand how nutrition, intake and weight may change during end of life care and set expectations that nutritional plans may need to be altered. However, a qualitative study by Pinto et al (2016) suggested that there is a lack of dietetic input in palliative care. The study highlights that dietitians may be involved in family discussions around nutrition, nutritional screening and diet modification for symptom control in both oral and enteral diet patients. More importantly, it is noted that some patients stated how food helped them find comfort in having some element of control (Pinto, 2016), which is a significant take on how dietitians may help care for this patient group.
Towards the end of disease progression, patients' interest in food and drink often reduces. Nourishing drinks or ONS may be used to encourage some intake when their appetite is poor, but it is also important that good mouth care is provided, as this can prove more comforting for patients when food and drink become less of a priority (Porter et al, 2021).
Cost-saving and extended roles
Dietitians may also support HETF patients in extended roles, such as unblocking or placing feeding tubes. This enables dietitians and DNs to work collaboratively and can reduce pressures in teams with vacant positions (Stanley and Borthwick, 2013).
In November 2021, Health Education England (HEE, 2021) released the ‘First contact practitioners and advanced practitioners in primary care: (dietitian) a roadmap to practice’. This is a clear pathway for dietitians who want to work in Primary Care and progress to first contact practitioners (FCPs) and advanced practice dietitians – allowing them to use advanced skills such as prescribing, clinical examinations and diagnosis for patients with certain conditions. Dietitians have only fairly recently gained the rights to become supplementary prescribers, following additional training in 2016. HEE has also identified that dietitians can assist with significant cost-saving strategies across PCNs when reviewing prescriptions of oral nutritional supplements (ONS) (HEE, n.d).
Dietitians can have a positive impact on a variety of patient groups, as demonstrated in this summative article. A dietitian not only focuses on ‘diets’, but looks at a mix of holistic, medical and evidence-based practices to enhance patient care. Referring to local dietitian services to support patients in the community should be considered, not only for those patients who are at risk of malnutrition, and requiring support in palliative care or wound healing, but also for secondary conditions seen in community nursing case loads such as diabetes or gastrointestinal diseases. As the dietetic profession progresses, their roles in the community MDTs will likely accelerate to help support the ever-growing pressures of the NHS and its long-term goals.