1.10/ Malnutrition and the Canadian Malnutrition Task Force

INTRO: Hello, and welcome to Clinical Nutrition Notes, a podcast where we speak with guest experts and opinion leaders about the art and science of clinical nutrition. Brought to you by Nestlé Health Science Canada. This podcast is intended for healthcare professionals for education purposes. I’m your host Monica Beck, medical affairs manager with Nestlé Health Science.

Beck: Today we’ll be talking with Heather Keller, about the Canadian Malnutrition Task Force and new initiatives from this group. Dr. Keller is the Schlagel Research Chair in nutrition and aging at the University of Waterloo. Her research programs are focused on improving the nutritional status and food intake of older adults. Professor Keller has published widely and translates research into practice with practitioner tools and resources. As a founding member and past chair of the Canadian Malnutrition Task Force she is involved in advocating for improvements in nutrition care. Dr. Keller is currently chair of the Primary Care Working Group for the task force and involved in several national and international expert groups advancing the prevention, detection and treatment of malnutrition. Thank you for joining us Heather. You’ve been an instrumental part of the Canadian Malnutrition Task Force or CMTF for short. Today we will be talking about malnutrition in Canada, and more specifically key initiatives and the direction of CMTF. Heather, to begin, can you briefly describe what the CMTF is and why this group started in Canada?

Keller: Well, the CMTF is basically a group of researchers and clinician who are really interested in making improvements in nutrition care in Canada, and specifically we wanted to cover all sectors of healthcare, but start with the hospital sector. We were really concerned about the fact that we were seeing malnutrition, people coming into hospital and leaving the hospital malnourished and we weren’t doing our best quality care for those folks in terms of nutrition. We recognized that a study would actually be a way to demonstrate that this was actually happening, and that it was important to help Canadians. So we decided to start to start the CMTF, actually as a research group, not as a knowledge translation or advocacy group as it is today, but more the group that would lead a study called Nutrition Care in Canadian Hospitals study and to lead it and demonstrate the importance of malnutrition to healthcare.

Beck: That’s great Heather and I think that really sets the stage for what we can continue to talk about here. I wanted to move on and maybe ask you for a little bit more detail about the study you referred to, the Nutrition Care in Canadian Hospitals study. I know it gave us an understanding and an appreciation of malnutrition and nutrition care in Canadian hospitals. There’s one statement that I’ve seen you make and that’s that you’ve indicated that hospital malnutrition starts in the community. Can you elaborate a little bit on this statement?

Keller: Sure. So when people come from the community, retirement homes, long term care homes, into hospital for acute care of a condition, whatever that may be. So if within the first day or so of admission, we notice that they’re malnourished, apparently then the malnutrition is happening in the community. And so unless there’s been a recent admission, like in the last week or so, it’s very likely that malnutrition is happening/starting in the community sector.

Beck: Right, and you had said where the initial focus was on acute care and in-hospital, so it’s exciting that out of that work that focused on an acute care setting, new directions for the CMTF have emerged. One of those new directions, I know, is focusing on primary care. Can you give us a sense of what clinicians can expect to see related to this community focused initiative?

Keller: Sure. Maybe I’ll just back up a little bit to say that when we did the hospital work we identified gaps in care and that led us to, what we consider, better practices. So that pathway we’re trying to follow with a primary care community sector to 1) establish what the prevalence of the issue is, if it’s a gap in care as well, that are happening, and then to develop better practices, and resources to then support primary care. Last year we actually had a knowledge exchange where we brought people from across Canada interested in primary care. We basically used our network to find people that were working in that sector, whether they be dietitians, nurses or physicians. Brought them together and said: ok, what’s going on in your region of the country with respect to primary care nutrition, and basically recognized that with no one model that was working across all regions. There were some areas that had very little going on because they didn’t have outpatient dietitians, so they didn’t have a real interest in the primary care sector yet with respect to nutrition. And other sectors, that are in other regions of the country where there actually is quite a bit of work already going on. So there was, compared to hospitals, this diversity in what was going on in community sectors. That was our first key takeaway, and we realized that if we were going to do the same sort of thing we did in acute care, we had to perhaps move towards a pathway of care in looking at how that could happen, to realize it’s needs to be very flexible, regional differences could be seen within it, and still something improving nutrition care of community patients in some shape or form. It’s still evolving, but what we’re hoping to see is basically a pathway that can help us with patients moving from hospital into home, going home, what should happen to them to make sure they’re doing well. And for those folks that are coming into a primary care sector, older adults is our focus, because we know that that group tends to be highly vulnerable, and what we would be doing with respect to care of those folks to detect and treat malnutrition that’s happening, so before they come into hospital. One of the things I forgot to mention was that when we did our first study with that hospital study, we actually asked a variety of things of people when they came into hospital, and it demonstrated basically that the most vulnerable group coming into hospital are older adults. Those who have been in hospital a few times in the last 5 years, those who were frail in terms of requiring other people or supports to get food into the home. And so we recognized that as a vulnerable group, and that’s why we’re using the primary care sector to try and focus in on that group again. They’re the most vulnerable group to malnutrition, more likely to end up in the hospital, and more likely then, a group that we can then perhaps prevent or delay that admission to hospital with care in the community.

Beck: That’s great, thanks for providing a really good snapshot of what we can look forward to and I love that you used the word adapting, specifically regionally across the country, where there are such difference in the way community care is delivered. One thing I wanted to ask you about was that Canadian clinicians frequently turn to the CMTF as a resource. I’m wondering if you could share what sorts of information and tools they’re most often looking for?

Keller: Great question. After we finished that first Nutrition Care in Canadian Hospitals study we realized that it actually raised a lot of interest and awareness about this issue. We thought we’re a research group. We’re a standing committee of the Canadian Nutrition Society, we’re just going to do this study, and then walk away and hopefully things will take care of themselves. Well, that’s not the way things happened of course. And so, we realized very early on, after we finished that study, Dr. Jeejeboy said to me “Heather, we basically made a lion of the community, in the sense of the hospital sector, and now we have to feed the lion, and now we have to actually support the lion to do what it wants to do, which is actually change practice for the betterment of patients.”

And so, the best resource is our website, where all of these resources are held, and are all freely available to the healthcare sector for use. There is no charge for any of the materials we create. They’re all often created collaboratively, through stakeholders, often with a research process. Some are also created/shown to be worthwhile and working well. I guess the things that are the most relevant to people are the practical things. One of the key follow up projects of our first knowledge translation was developing a pathway for acute care. Unlike the community sector, they’ll have in every region of the country, there’s a dietician in every hospital, at least there is that resource, and we could build around a pathway of what would be the best care that could happen to a patient in a hospital. We call that the Integrated Nutrition Pathway for Acute Care. That resource is hugely important to clinicians and frequently downloaded and people talk about implementing the INPAC, which is the short term for it. And if I did it, we could do strategic activities during admission for a patient and it leads to their better outcomes with respect to length of stay. So we have shown that in a couple of studies now that it does make improvements in care processes and in a current state, we’re actually trying to change some of the health outcomes for patients. That’s one key thing, this pathway of care. Secondly, we’ve got resources around screening tools, resources around how to do assessments, resources with respect to if you’re looking for all those better activities/things you might be able to do. For example, one of the key issues we found in the hospital sector in terms of gaps in care, we weren’t always providing food in a way that people could eat it. There were lots of barriers in the environment, in the hospital that affected their access to food. We created, as a research process, a graduate student of mine and I, created a tool called the MealTime Audit Tool, which can then be used by hospitals to say: “Ok, if we’re going to audit our units, our wards, to see how we’re doing in terms of barriers to food intake, how are we doing?”

So we created that tool. It can be used in research and it can be used in practice. So I think that’s a key thing, that we created tools that have a research basis, but are practical and can be used in a clinical perspective. So I’m hoping with our primary care work will do the same thing, create a pathway that is evidence informed, based on stakeholders knowledge and what we think can work regionally, and then start testing it out, and building in the resources to support people across the country with doing the key activities which we think are important to prevent, detect and treat malnutrition in the community sector.

Beck: I think that’s a great explanation and to see how a research-based tool can end up having such practical applications and probably turned up some really, surprisingly simple barriers that could be corrected.

Keller: Another key resource that I think that I should mention is that we’ve been holding the Canadian Malnutrition Week for the last 4-5 years, as part of that campaign we do webinars around a focused topic area and we do infographics and we know that colleagues across the country then use those webinars as ‘lunch & learns’ with their colleagues, or they use infographics in their hospital settings or other settings to raise awareness basically of the issue of malnutrition in the community or in the hospital sector. This year we’re doing it all on the community, and we have 2 wonderful new infographics focused in the area.

Beck: Something to look forward to. Heather, what would you suggest to someone just starting to tackle the issue of malnutrition within his or her facility or practice setting?

Keller: That’s a great question as well. So I think often clinicians who are, I’ll call them champions for lack of a better word, that know there’s an issue and want to make change, they have to get their colleagues around them to also realize this is a priority and so regardless of being in a community setting or in a hospital setting or long term care setting, it’s demonstrating to your colleagues that this is an issue. So we recommend that folks actually collect their own data to show that in our hospitals, in our community, in our long term care homes, this is the state of the issue. It’s not some other homes, not in some of community, not in some other hospitals. It is happening here. That’s the first step, having valid and reliable tools available for people to screen and assess and demonstrate the level of malnutrition. That’s the first step. The second would be then also think about how we can start actually doing that as part of practice routinely, because the literature and our evidence suggests that when you identify nutrition risks and malnutrition it then leads to the treatment pathway. So then figuring out how you change towards that better practice of detection is key. What we recommend is gathering together a small group of people within whatever sector you’re in, and working in, and talk about how can we start creating screening for malnutrition in this setting, and what would we do with those people that identify that nutrition risks lead to the next step for their care. Building a small team collectively, rather than one person trying to do it on their own, builds that capacity. We suggest that that be a multi-disciplinary or inter-professional team rather than a single clinical group or discipline group, because that way they’re going to build that support for making change across the board. Nutrition isn’t one discipline, it’s many disciplines, and so we have to involve a broad group of people.

Beck: For sure, and the other advantage is picking up more champions along the way as you’re involving more people in the process.

Keller: Exactly. So we found that the More-To-Eat phase 1 study where we were putting the Integrated Nutrition Pathway for Acute Care into five hospitals, we found there were some, I wouldn’t say ‘nay-sayers’, but there were people who were skeptical at the beginning, saying “Oh yeah, we’ve tried this, but it’s not really going to change anything.”

By the end of the year and half of that study, they were ‘gungho’. They were believers, and they saw the benefit to their patients. I think that’s key, when people see this helps my patients, and it helps me then, as a provider, to provide the best quality care. They’re then hooked. And so that’s essential so that if you start that process even in a small way and people can see that ‘hey, that person might have missed, might have stayed longer in hospital because we missed that malnutrition, now is getting out sooner with a better quality of life and better health.’

So that’s the hook that we have.

Beck: That’s great, and what a great motivator for somebody just starting off, wanting to look at this and also having the tools to go and access so that they don’t have to feel like they’re starting from square one completely on their own.

Heather, I’d like to thank you so much for your insights and providing us with a glimpse of what to expect from the CMTF as time goes on. As we know malnutrition is a serious issue across care settings and so it’s really helpful to know that there’s resources out there to assist in the detection, prevention and management of malnutrition in Canada.

Before we sign off, I’d love to take just a minute to ask you one last question, just so our listeners can get to know you a little bit better. Can you tell us how you first became interested in the field of nutrition?

Keller: It was sort of by default quite frankly. I was planning to go to university on a music scholarship, and I failed my grade 8 piano exam. You needed to have 2 instruments at that time and I realized I probably don’t want to teach violin to children for the rest of my life, so my mother said “Well, healthcare is a good option Heather. [This was the 80’s] Healthcare is a good option or being a teacher.”

Well, I thought, and I didn’t want to be a teacher, I’ll go into healthcare, and I didn’t want to be a nurse, so I thought well, food. I like food. I’ve worked in restaurants. I’ve done 4H as a kid with my Mom. We grew food at home. I thought, food is interesting. I had no idea what I’ll do with that, but I’m sure it’ll be helpful, and I haven’t looked back since those days.

Beck: Isn’t that great! So, what started out as a second choice quickly became a passion. On that note, we will conclude this podcast. I’d like to thank you Heather for joining us and thank all of our listeners.