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Dietetics

Dietetics Guidelines

Main referral email: rch-tr.DietitansCornwallReferrals@nhs.net

Dietetics Referral Form

Home Enteral Feeding

All patients discharged with a PEG or PEJ from a hospital in Cornwall will be known to the Home Enteral Feeding Service and will be regularly reviewed.

Refer any patient who does not have regular contact  ( at least every 6mths ) with the home enteral feeding team or who has symptoms potentially related to their feed e.g.

                                - unintentional weight loss

                                - unintentional weight gain

                                - nausea, vomiting, bloating 

                                 - persistent diarrhoea

For problems relating to the PEG tube or stoma contact the gastrostomy nurse on cornwallstrokeservice@nhs.net

Renal

All patients who are on dialysis are known and reviewed by the Renal  Dietitians. Other patients with CKD 4/5  are referred by the  Renal Consultants/Renal Team.  Refer to the Renal Dietician if you have any dietary concerns with a renal patient under your care:

-with CKD 4/5,

-patient is on dialysis

 

Oncology

Most patients will already be known and referred to the dietitian via the Oncology Team and consultant but consider referral if:

•       The patient is losing weight or is at risk of malnutrition

•       Their swallow is effected by the disease or treatment

Good advice can be found on

http://www.macmillan.org.uk/information-and-support/coping/maintaining-a-healthy-lifestyle/healthy-eating/healthy-diet-benefit.html#13743

 

Gastroenterology

Patients may already be known to the dietitian via gastroenterology consultant but consider referral if :

•       The patient has newly diagnosed coeliac disease (and not already referred)

•       The patient has symptoms of irritable bowel syndrome that do not respond to first line advice. https://www.bda.uk.com/foodfacts/IBSfoodfacts.pdf

•       The patient has a difficult to manage allergic response to foods that potentially results in exclusion of main food groups, nutritional deficiencies and/or weight loss

•       Decompensated liver disease with significant muscle loss.

•       Fatty liver linked with obesity

 

Diabetes (adults)

The most recent Nutritional Guideline from Diabetes UK 1 recommends that:

  • Everyone with diabetes should receive individual, ongoing nutritional advice from a Registered Dietitian.
  • All people with diabetes and/or their carer should be offered structured education at the time of diagnosis with an annual follow-up.

 

The Referral Pathway can be accessed here

Type 1 Diabetes

All patients newly diagnosed with Type 1 Diabetes should be referred for an individual appointment with a Registered Dietitian for personalised nutritional advice. This forms part of a structured diabetes education programme that is jointly delivered with the Diabetes Specialist Nurse (DSN) Service.

Carbohydrate awareness course

Alongside this individualised education all adults with newly diagnosed Type 1 Diabetes are offered a half day carbohydrate awareness course.

This is jointly delivered by a Diabetes Specialist Dietitian and Diabetes Specialist Nurse and has been developed to meet the recently published NICE guidance Type 1 Diabetes in adults: diagnosis and management https://www.nice.org.uk/guidance/ng17 which recommends referral to a structured education programme 6-12 months after diagnosis. Referral to this course is via the Diabetes Specialist Nurses.

 

Carbohydrate Counting Course

Those who wish or for whom it is appropriate are offered the opportunity to progress to a longer carbohydrate counting course. Carbohydrate counting involves matching insulin dose with the amount of carbohydrate that is eaten.

These courses are locally delivered by Diabetes Specialist Dietitians and Diabetes Specialist Nurses over 2 half days and are evidence-based.

Referral to the course is via the Secondary Care Diabetes Team (Diabetes Dietitians / Diabetes Specialist Nurses / Diabetes Consultants).

 

Type 2 Diabetes

NICE recommends that all patients newly diagnosed with Type 2 Diabetes should be provided with individualised and ongoing nutritional advice from a healthcare professional with specific expertise and competencies in nutrition. https://www.nice.org.uk/guidance/ng28

All people newly diagnosed with Type 2 Diabetes should be given a copy of the Cornwall Diabetes Centre yellow book “Understanding Diabetes” at diagnosis and understanding checked at each subsequent review.

Registered Dietitians deliver group education sessions for people newly diagnosed with Type 2 Diabetes at various locations throughout the county - Refer via rch-tr.DietitansCornwallReferrals@nhs.net

Consider an individual referral to the dietitian if:

  • The patient is unable / unwilling to attend group education
  • Following group education additional advice / support is required
  • The patient is struggling with implementing advice/ motivation
  • The patient has an additional medical condition / nutritional concern

 

Obesity

Many patients can be directed to Cornwall healthy weight groups  https://www.cornwallhealthyweight.org.uk

The referred adult must be:

·         18 years and above

·         Have a BMI between 26-39.9

·         Give their consent for referral to Cornwall Healthy Weight

·         Motivated and ready to change

·         Can commit to 12 week programme and is ready to make healthier lifestyle choices.

Self help information or commercial groups such as ‘weight watchers’ or ‘slimming world’ may be appropriate.      

 

Consider referral to a dietician if:

·         patient has BMI >30 that has not responded to a Cornwall Healthy Weight Programme

Bariatric services – link to RMS bariatric section 

Unintentional Weight loss

An individual is Malnourished if there is:

•       a body mass index (BMI) of less than 18.5 kg/m2

•       unintentional weight loss greater than 10% within the last 3–6 months

•       a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months.

An individual is at Risk of being Malnourished if :

•       Someone who  has eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for 5 days or longer

•       a poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism.

Prior to referral undertake  MUST ( malnutrition Universal Screening Tool) 

http://www.bapen.org.uk/screening-and-must/must-calculator

Provide first line advice Making the most of your food // Homemade fortified drinks   

Refer to dietitian if:

·         patient has not responded to first line advice over a 2 month period

 

Learning Disabilities

Please refer to the dietitian working with the learning disability service using the referral form if: 

•       The patient has complex needs requiring input from a number of specialists within the learning disability service, eg Speech and language therapist, learning disability nurse .

•       The patient will struggle to access main stream services due to challenges with communication , behaviour etc.

•       The patients’ dietary needs are closely associated with their learning disability, eg limited food selection, weight loss associated with swallowing problems.

•       The patient’s family and/or care team need additional support and advice that cannot be delivered via a routine clinic appointment.   

Eating Disorders

Specialist dietitians can be accessed via the CAMHS and Adult Eating Disorders Services. 

 

<18 years - refer to the CAMHS Eating Disorders Service - a specialist dietitian will conduct a dietetic assessment as part the Eating Disorders Assessment.

 

>18 years - refer to the ICMHT who after initial assessment will refer to the Adult Eating Disorders Service. Once the person has been assessed and meets service criteria specialist dietetics will be offered as part of their treatment.  

 

Further information can be found here: LINK to Adults- Eating Disorders page

 

 

Paediatric Dietetics

Please see attached pathway – referrals can be made using standard referral form at the top of this page.

 

References:

1.       https://www.diabetes.org.uk/Documents/Reports/nutritional-guidelines-2013-amendment-0413.pdf