NHD CPD eArticle Vol 7.15 by NH Publishing Ltd

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Volume 7.15 - 21st September 2017

ORAL NUTRITIONAL SUPPLEMENTS IN NUTRITION SUPPORT Emma Coates Registered Dietitian Emma has been a registered dietitian for 10 years, with experience of adult and paediatric dietetics. She specialised in clinical paediatrics for six years, working in the NHS. She has recently moved into industry and currently works as Metabolic Dietitian for Dr Schar UK.

Malnutrition, found commonly in association with disease, can affect all age groups. Older people are more at risk, with hospital patients over the age of 65 at particular risk of becoming malnourished. Nutrition support is a necessary part of patient care which can include the use of oral nutritional supplements (ONS). Nutrition support ensures that patients have access to nutritional food to meet their needs either in hospital or in the community. Good nutritional care includes nutritional screening to identify a patient’s risk of malnutrition, care planning to ensure that a patient receives the appropriate nutrition at the right time and monitoring by healthcare professionals with the relevant skills and training in nutritional monitoring. ONS can complement (or possibly even replace), a normal diet to provide patients with the essential nutrients required when food alone is insufficient to meet their daily nutritional needs. GUIDELINES AND RECOMMENDATIONS

In the UK, NICE Quality Statement 241 states, ‘It is important that nutrition support goes beyond just providing sufficient calories and looks to

provide all the relevant nutrients that should be contained in a nutritionally complete diet. A management care plan aims to provide this and identifies condition specific circumstances and associated needs linked to nutrition support requirements.’ NICE QS24 recommends that all patients in a care setting should have regular nutritional screening using a validated tool, such as the most commonly used Malnutrition Universal Screening Tool (MUST).2 BAPEN3 recommends that nutritional screening ‘should alert health and social care staff to the need for more detailed nutritional assessment by a dietitian. Decisions about the appropriateness and effectiveness of nutritional support should then be made by the multidisciplinary team.’ NHS England Commissioning Excellent Nutrition and Hydration (2015-2018)4 document recommends

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Table 1: Types of ONS available3 Type

Notes

Juice type

Volume ranges from 200-220ml with an energy density of 1.25-1.5kcal/ml. They are fat free

Milkshake type

Volume ranges from 125-220ml, energy density ranges from 1-2.4kcal/ml. Also available with added fibre.

High-energy powders

Volume ranges from ~125-350ml, ideally made up with full cream milk to give an energy density of 1.5-2.5kcal/ml.

Soup type

Volume ranges from 200-330ml. Some are ready mixed and others are a powder and can be made up with water or milk to give an energy density of 1–1.5kcal/ml.

Semi-solid/dysphagia ranges

Range of presentations from thickened liquids (stage 1 and 2) to smooth pudding styles (stage 3), with an energy density of ~1.4-2.5kcal/ml.

High protein

Range of presentations; jellies, shots, milkshake style containing 11-20g of protein in volumes ranging from 30-220ml.

Low volume high concentration (shots)

These are fat and protein based products that are taken in small quantities (shots), typically 30-40ml as a dose taken 3-4 times daily.

the ‘development of service specifications and management structures to ensure high standards of nutrition and hydration care using food and drink, oral nutritional supplements, enteral tube feeding provision or intravenous support as necessary ensuring appropriateness and safe standards of practice in line with NICE Clinical Guidance CG325 and associated QS241 and CG1746.’ INDICATIONS FOR USE

Oral Nutritional Supplements in the form of sterile liquids, semi-solids or powders (see Table 1 overleaf), provide macro and micro nutrients and their use must be approved by the Advisory Committee on Borderline Substances (ACBS). ONS cannot be used as a sole source of nutrition as they are not all nutritionally complete, as they contain varying concentrations

of macronutrients and micronutrients. Dietitians are essential in making individual dietetic assessments to ensure that ONS prescriptions are appropriately advised. Indications for use of ONS include the following conditions and diseases:3 • Short bowel syndrome • Dysphagia • Intractable malabsorption • Pre-operative preparation of undernourished patients • Inflammatory bowel disease • Total gastrectomy • Bowel fistulae • Disease related malnutrition (chronic/acute) MONITORING

ONS should not be prescribed without being monitored to ensure that they remain

FROM HOLDING BACK.. . .TO HOLDING JACK

. .In a shot SOMETIMES PATIENTS CAN’T MEET THE ENERGY REQUIREMENTS THEY NEED THROUGH NORMAL DIET AND ONS ALONE.1

IT’s BEEN SHOWN TO:

Little wonder it helps so much

55% 92% 67%

Increase calorie intake by 55% IN ADDITION TO NORMAL diet2 HAVE 92% COMPLIANCE OF THE PRESCRIBED DAILY AMOUNT3 Reduce ‘MUST’ scoreS IN 67% OF PATIENTS*3,4

Pro-Cal shot is a food for special medical purposes and should be used under strict medical supervision. ® Reg. Trademarks of Société des Produits Nestlé S.A.

Vitaflo International Ltd, Suite 1.11, South Harrington Building, 182 Sefton Street, Brunswick Business Park, Liverpool L3 4BQ, UK. Tel: 0151 709 9020 vitaflo.co.uk abbottnutrition.co.uk A Nestlé Health Science Company

References 1. Wright C. CN Focus 2012;4(3):17-19. 2. Sharma M et al. Colorectal Disease 2013;15: 885-891. 3. Data on file. 4. Malnutrition Advisory Group (MAG) 2011.Malnutrition Universal Screening Tool. www.bapen.org.uk/pdfs/must/must_full.pdf. Accessed September 2016. *Of those who were at medium or high risk of malnutrition at baseline, 67% were at low risk of malnutrition on study completion.

All information correct at the time of print. December 2016

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appropriate and are being taken as prescribed. The prescription should be reviewed according to the person’s progress, and care should be taken when: • using food fortification which tends to supplement energy and/or protein without adequate micronutrients and minerals; • using feeds and supplements that meet full energy and nitrogen needs, as they may not provide adequate micronutrients and minerals when only used in a supplementary role. Oral nutrition support should be stopped when the patient is established on adequate oral intake from normal food and dietary intake is meeting nutritional requirements, or when a patient can no longer tolerate them due to taste fatigue.

RESPONSIBLE PRESCRIBING

As the financial limitations of the NHS are ever more prominent, it is typical for ONS and other prescribed products such as gluten-free foods to be limited or completely restricted. The rationale for this practice is to ensure valuable resources are not wasted. However, malnutrition affects up to 40% of patients being admitted to hospital.7 This can increase the risk of complications, length of stay by 25-75% and the risk of readmission.7 In the community, malnourished patients may present to the GP 25-35% more than well-nourished patients, with a greater risk of hospital admission.7 In 2015, a systematic review with meta-analysis by Elia et al suggested that there are cost savings and it is cost effective to use ONS in the hospital and community settings when used appropriately.7

CASE STUDY Charlie, a 10-year-old boy, was referred for a dietetic review by his community paediatrician due to concerns regarding his static weight and the limited variety of foods in his diet. Charlie required an operation on his hip; however, the surgical team and paediatrician were concerned that he had not gained weight in the last six months and this would increase the risks of complications post operatively. They had hoped for dietetic intervention to improve his weight before the surgery. The referral stated that he was born at 39 plus four weeks gestation on the 2nd centile with a head circumference on the 9th centile, his length was between the 2nd and 9th centile. 1 Assessment A diagnosis of mild cerebral palsy was given at 12 months of age, as milestones, such as sitting, crawling and babbling, were delayed and inconsistent. He had a developmental delay of around six to eight months. He started walking at the age of two years and required physiotherapy and orthotic input to support the development and stability of his mobility. His speech developed well once he started to attend school full time and there were no concerns here. Cognitively he was now well matched to his peers and he was attending a main stream school. He still required specialist footwear and leg splints to support his mobility. He was generally well. At the initial assessment Charlie’s weight and height had remained static and matched that on the referral. Weight 22kg (0.4th centile), Height 131cm (9th centile) and BMI 12.8kg/m2 (0.4th centile). Mum explained that Charlie had been a ‘poor eater’ since weaning. He didn’t take to mixed textured foods well. He continued with a smooth pureed diet until he was well over 12 months. They saw a dietitian at that time and they were prescribed a 1kcal/ml oral supplement to support his low calorie diet of pureed fruits and yoghurts. He took this well and preferred the strawberry flavour only. When he did progress to more textured foods, he was approximately two years old. He would accept bite and melt textures and fork mashed foods. He disliked any mixed textured foods such as baked beans, spaghetti Bolognese or stew. However, his intake improved enough to discontinue the oral supplement. Mum couldn’t remember a time when she didn’t have concerns about Charlie’s food intake, but she felt he always took fluids well. They had intermittently revisited the 1-1.5kcal/ml oral supplements throughout Charlie’s life, particularly when he had several bouts of tonsillitis between the age of five and seven, where he would stop eating altogether. Currently, she relied heavily on milk and dairy products such as yoghurt, ice cream and soft cheese to maximise his energy intake. He was not at all keen on fruits or vegetables. Mum reported mealtime tensions, as Charlie was reluctant to come to the table to eat. He would avoid sitting at the table and had been known to hide food in the plant pots in the dining room. Continued . . . Copyright © 2017 NH Publishing Ltd - All rights reserved. Available for printing and sharing for the use of CPD activities for personal use. Not for reproduction for publishing purposes without written permission from NH Publishing Ltd.

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2 Identification of and plan nutrition and dietetic diagnosis Table 2 overleaf shows an outline of Charlie’s oral intake of food and fluids. This was not consistent and this would be described as a ‘good day’. Some days his packed lunch would return untouched and half or less of the intake reported at evening meal time would taken. His estimated requirements would be around 1970kcal and 28.3g protein per day.8 He was not meeting his requirements for energy and his intake of many micronutrients as well as fibre was poor. Mum was worried about Charlie’s bowel movements, she explained he was often constipated. The community paediatrician had prescribed Movicol (one to two sachets per day); however, these were taken sporadically as Charlie disliked the taste. In light of Charlie’s energy and micronutrient deficits, we discussed the options for increasing his food and fluid intake and variety. Charlie didn’t feel he could eat or drink more, saying he didn’t want to take more. He didn’t feel hungry and disliked food most of the time. He told me that, ‘food was his enemy’. When I discussed this further with him, he explained that he didn’t enjoy eating and mealtimes spoiled his time for play at home and school. He wanted everyone to stop telling him to eat more. We then discussed using oral nutritional supplements. Charlie spoke about how he felt about taking them, saying he liked oral supplements as long as they were strawberry flavour. We also talked about how and when he would take them. He agreed to have 3 x 125ml, 2.4.kcal plus fibre milkshake style supplement drinks per day, providing 900kcal and 17.1g protein, with much greater support for micronutrient intake. Whilst he would need additional calories to support catch up growth, Mum didn’t feel he would consume these at this time. We planned to review after three months. Table 2: A typical day’s intake for Charlie Estimated calorie intake

Estimated protein intake

Time

Food/drinks taken

Breakfast (7.30-8am)

1-2 full fat soft cheese triangles 100ml full fat milk Mouthful of toast (sometimes nil)

Snack at school (10.15am)

Nil or very occasionally a small banana (100g) 103kcal 150ml full fat milk 96kcal

1.2g 4.8g

Lunch (12.15am)

Packed lunch as won’t take the school meals 2 full fat cheese triangles 1 full fat yoghurt (125g pot) 1-2 cocktail sausage rolls (30g)

70kcal 123kcal 91-182kcal

4.2g 4.3g 2.9-5.8g

Snack after school (4pm)

Full fat yogurt (125g pot) 150ml full fat milk

123kcal 96kcal

4.3g 4.8g

Evening meal (5.30pm)

Various options but generally: 1-2 fish fingers or skinless sausages (grilled) 1 tablespoon of tomato ketchup Offered peas or baked beans - not eaten ½ -1 potato waffle Offered no added sugar squash - may take 100ml at best

App. 110-130kcal 15kcal

5-7g 0.2g

44-88kcal

0.5-1g

Supper (7.30pm)

Offered food such as crumpet or toast - nil taken Occasionally takes another 150ml full fat milk

96kcal

4.8g

Total intake

847-1037kcal

44.3-51.8g

35-70kcal 64kcal

2.1-4.2g 3.2g

Values taken from www.tesco.com/groceries/ <accessed 15/03/17> Copyright © 2017 NH Publishing Ltd - All rights reserved. Available for printing and sharing for the use of CPD activities for personal use. Not for reproduction for publishing purposes without written permission from NH Publishing Ltd.

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3 Monitor and review At his review appointment, Charlie explained that he was enjoying the oral supplements and he had gained a small amount of weight and grown enough to continue along his centiles. Mum had noticed some improvement in his bowel movements. He was opening them every other day since taking the supplements with fibre. He still wouldn’t take the Movicol. Mum updated me with some progress regarding interactions with other health teams. Charlie had been referred to CAMHS for an autism assessment. His school support and teaching staff has expressed some concerns regarding his behaviour and his community paediatric agreed that he was displaying some traits of autism. Mum felt that this explained some of Charlie’s feeding history and current behaviours. As a result, the family had placed less pressure on him to eat and drink more. She felt this was also due to the support from the ONS and the ‘goodness’ they were providing. Continued . . . Overall she felt the nutrition support and CAMHS assessment had helped to improve their relationship and Charlie seemed more relaxed. He was happy to continue to take the 3 x 125ml, 2.4kcal oral supplements; however, he was not willing to increase this volume or take any additional food. We agreed to continue with the current amount and to review again in three months’ time. He would be monitored for weight and height in between dietetic appointments at the next paediatrician appointment, which was a comfort to Mum. 4 Evaluation Charlie continues to take the oral supplements as an ongoing intervention. He has not showed any indication of increasing his food intake, but has agreed to increase the volume of oral supplements to 4 x 125ml per day, which continues to help and support some additional weight gain and growth. References 1 NICE Quality Standard [QS24]: Nutrition support in adults. www.nice.org.uk/guidance/qs24 2 The ‘Malnutrition Universal Screening Tool’ (‘MUST’) developed by the Malnutrition Advisory Group, a standing committee of BAPEN. www.bapen.org. uk/screening-and-must/must/introducing-must 3 The British Association for Parenteral and Enteral Nutrition (BAPEN). Oral Nutritional Supplements (ONS). www.bapen.org.uk/nutrition-support/ nutrition-by-mouth/oral-nutritional-supplements 4 NHS England Guidance: Commissioning Excellent Nutrition and Hydration (2015-2018). www.england.nhs.uk/wp-content/uploads/2015/10/nut-hydguid.pdf 5 NICE Clinical Guidance CG32: Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition www.nice.org.uk/ guidance/cg32/ 6 NICE Clinical Guidance CG174: Intravenous fluid therapy in adults in hospital https://www.nice.org.uk/guidance/cg174 7 Based on Elia et al, Stratton et al (various publications). www.nutriciacongresses.com/congresses/presentation/62/ new-evidence-on-the-costs-of-malnutrition-and-the-benefits-of-nutritional-support/ 8 HM Stationery Office (1991). Dietary Reference Values for Food Energy and Nutrients for the United Kingdom: Report of the Panel on Dietary Reference Values of the Committee on Medical Aspects of Food Policy.

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Questions relating to: Oral nutritional supplements in nutrition support. Type your answers below, download and save or print for your records, or print and complete by hand. Q.1

Explain what is involved in nutrition support.

Q.2

Why are oral nutritional supplements (ONS) used in nutrition support?

Q.3

What does a management care plan provide?

Q.4

What are the recommendations for nutritional screening in the UK?

Q.5

Outline the types of ONS available to patients.

Q.6

Explain why ONS cannot be used as a sole source of nutrition.

Q.7

Why is monitoring a patient who has been prescribed ONS, so important?

Q.8

When should ONS be stopped?

Please type additional notes here . . .

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