Ministry of Health Malaysia

MODULE NO. 5

NUTRITION & FALL

LET’S FIND THE BALANCE

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NATIONAL FALL PREVENTION AND NATIONAL FALL PREVENTION AND

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INTERVENTION STEERING COMMITTEE INTERVENTION STEERING COMMITTEE

MinistryMINISTRY OF HEALTH
of Health Malaysia MALAYSIA MINISTRY OF HEALTH MALAYSIA
 Learning Objective (1) POPULATION
IN-PATIENT
POPULATION
COMMUNITY / PRIMARY CARE SETTING /
OUT-PATIENT

NUTRITION SCREENING
BY HEALTHCARE TEAM MEMBERS
TOOL: MNA-SF

MNA-SF MNA-SF MNA-SF

SCORE 12 - 14 SCORE 8 - 11 SCORE 0 - 7

NUTRITION SCREENING
NORMAL AT RISK MALNOURISHED

PERIODICAL SCREENING
SCREEN SARC-F
AFTER 6 MONTH/1 YEAR

perform standardized NORMAL

AT RISK
≥4

nutritional screening MALNUTRITION PATHWAY DIAGNOSIS SARCOPENIA

+ MUSCLE HEALTH
(Tool: MNA-SF) •DIAGNOSE AND GRADE SEVERITY
•BIA
•HANDGRIP
MALNUTRITION (GLIM CRITERIA) •5-TIMES CHAIR STAND TEST
•NUTRITION ASSESSMENT
•NUTRITION DIAGNOSIS
•NUTRITION INTERVENTION RE-ASSESSMENT
•NUTRITION MANITORING AND EVALUATION According to follow-up visit

Figure 1. NUTRITION CARE PROCESS FLOW

CHART
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NATIONAL FALL PREVENTION AND

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Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
 Learning Objective (2)

TEXTURE MODIFICATION

prescribe suitable texture

modified diet prior to
referral to dietitian

IDDSI is ultimate
recommendation

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NATIONAL FALL PREVENTION AND

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INTERVENTION STEERING COMMITTEE

Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
 Learning Objective (3) POPULATION
IN-PATIENT
POPULATION
COMMUNITY / PRIMARY CARE SETTING /
OUT-PATIENT

NUTRITION SCREENING
BY HEALTHCARE TEAM MEMBERS
TOOL: MNA-SF

MNA-SF MNA-SF MNA-SF

SCORE 12 - 14 SCORE 8 - 11 SCORE 0 - 7

NUTRITION INTERVENTION
NORMAL AT RISK MALNOURISHED

PERIODICAL SCREENING
SCREEN SARC-F
AFTER 6 MONTH/1 YEAR

Understand the importance NORMAL

AT RISK
≥4

to carry out the nutrition MALNUTRITION PATHWAY DIAGNOSIS SARCOPENIA

+ MUSCLE HEALTH
intervention/s prescribed •DIAGNOSE AND GRADE SEVERITY
•BIA
•HANDGRIP
MALNUTRITION (GLIM CRITERIA) •5-TIMES CHAIR STAND TEST
by dietitian •NUTRITION ASSESSMENT
•NUTRITION DIAGNOSIS
•NUTRITION INTERVENTION RE-ASSESSMENT
•NUTRITION MANITORING AND EVALUATION According to follow-up visit

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NATIONAL FALL PREVENTION AND

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Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
 ENERGY
R E C O M M E N D AT I O N R AT I O N A L E
This value should be individually adjusted with regards to nutritional status,
30 kcal/kgBW/day
physical activity level, disease status and tolerance
32 – 38 kcal/kgBW/day For older persons with underweight, BMI ≤ 21 kg/m2
27 – 3 0 k c a l / k g BW /d ay Minimal requirements of ill older persons
ESPEN, 2021 & 2022

PROTEIN Distribute throughout the day

~having 20-25g Protein each meal
HOSPITALIZED PATIENT WITH KIDNEY DISEASE
RECOMMENDATION RATIONALE
RECOMMENDATION ( g / kg BW / day)
RATIONALE
( g / kg BW / day) 0.6 – 0.8 without acute / critical illness
1.0 – 1.2 healthy older adults ≥ 1.2 on RRT without / critical illness
active, exercising healthy older AKI, AKI on CKD without acute /
≥ 1.2 0.8 – 1.0
adults critical illness
elderly with acute chronic AKI, AKI on CKD with acute /
1.2 – 1.5 1.0 – 1.3
illness, malnourished critical illness
in critical or severe illness, Critically ill patients with AKI or
up to 2.0 1.3 – 1.5
injury or marked malnutrition AKI on CKD or CKD on RRT

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NATIONAL FALL PREVENTION AND

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Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
 CALCIUM REQUIREMENT (RNI 2017):
Calcium intake are recognised are significant
19 – 65 years : 1000mg/day
contributors to bone health ≥ 65 years : 1000mg/day
BEST SOURCE:
Milk and dairy products, and calcium fortified milk alternatives.
ALTERNATIVE SOURCE: 19 – 65 years : 1000mg/day
Fish with edible soft bones (sardines and anchovies), green leafy > 65 years : 1200mg/day
vegetables (spinach, kailan, chye sim), legumes (dhal, soy and
its products).

VITAMIN D REQUIREMENT (RNI 2017):

Enhance calcium absorption and maintain bone
19 – 65 years : 15 µg/day
health. > 65 years : 20 µg/day
Deficiencies/low vitamin D status should be corrected with
vitamin D supplementation to reduce falls risk 5
Salmon, tuna, mackerel, food enriched with vitamin D (milk, 19 – 65 years : 15 µg/day
yogurt, margarine, breakfast cereal), liver, egg yolk and fish oil. > 65 years : 20 µg/day

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NATIONAL FALL PREVENTION AND

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Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
 IRON REQUIREMENT (RNI 2017):
Reduce the risk of anemia 14 - >65 years : 14mg/day
Red meat, cockles, egg yolk, liver and spinach.
Vitamin C is a powerful enhancer of iron absorption
Cocoa, tea, milk and soy inhibit iron absorption
19 – 50 years : 29mg/day

FLUID 51 - >65 years : 11mg/day

Dehydration can lower blood pressure and cause weakness and REQUIREMENT (ESPEN 2012):
dizziness6 thus increasing the likelihood of falling
All older person should be considered to be at risk of low-intake At least 2 L/day
dehydration and encourage to consume adequate amount of
drinks.
Interventions shall be individualized if patient requires fluid At least 1.6 L/day
restriction.

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Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
 Oral Nutritional Supplements, ONS
ONS are energy and nutrient-dense products designed to increase dietary intake when diet
alone is insufficient to meet daily requirements7
R E C O M M E N D AT I O N S
ESPEN Practical Guideline: Clinical Nutrition and Hydration in Geriatric, 2022

ONS shall provide at least 400 kcal/day including 30 gram or more of protein/day
shall be continued for at least one month
compliance in ONS consumption shall be regularly assessed
type, flavor, texture and time of consumption shall be adapted to the patient’s taste and eating
capacity

ONS containing beta-hydroxyl-beta-methylbutyrate (HMB) may be considered and should be

taken according to the specific prescribing information8

7. ESPEN, 2022
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NATIONAL FALL PREVENTION AND
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INTERVENTION STEERING COMMITTEE

Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
 Enteral Nutrition, EN
R E C O M M E N D AT I O N S
ESPEN Practical Guideline: Clinical Nutrition and Hydration in Geriatric, 2022
Older persons with reasonable prognosis
shall be offered EN if oral intake is expected to be impossible for more than 3 days or expected
to be below half of energy requirements for more than one week, despite intervention to ensure
adequate oral intake, in order to meet the nutritional requirements and maintain or improve
nutritional status
If EN is indicated, it shall be started without delay
fibre-containing products should be used
EN presumably for less than four weeks should receive a NG tube
EN for more than four weeks should receive a PEG

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NATIONAL FALL PREVENTION AND

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Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
 OTHER CONSIDERATIONS
SUPPORTIVE INTERVENTIONS
R E C O M M E N D AT I O N S
ESPEN Practical Guideline: Clinical Nutrition and Hydration in Geriatric, 2022
Older persons with malnutrition or at risk of malnutrition shall be offered / supported
mealtime assistance
home-like, pleasant dining environment (institutional setting)
share their mealtime with others
meals on wheels
nutritional information and education
where the nutritional counselling should be individualized.

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NATIONAL FALL PREVENTION AND

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Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA