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Volume 9.11 12th Sep 2019

ORAL NUTRITIONAL SUPPLEMENTS: THE RANGE AVAILABLE AND HOW TO USE THEM As dietitians, we follow the mantra of 'food first', aiming to meet our patients’ nutritional requirements using real, easily accessible, affordable and appetising food. However, while we have many tools in our box to elevate the nutritional density of our patients’ food (for example, high energy/high protein snacks, food fortification and optimised menu planning), unfortunately, this is not always sufficient, and there is still a shortfall between nutritional intake and requirements. This puts patients at risk of developing malnutrition. Malnutrition (a dirty word to a dietitian) instantly pricks our ears up and sets the wheels in motion to get to work to rectify the situation! But what is ‘malnutrition’? NICE defines it as, ‘a state in which a deficiency of nutrients such as energy, protein, vitamins and minerals causes measurable adverse effects on body composition, function or clinical outcome”.1 Unfortunately, malnutrition is a prevalent problem in the UK with approximately 1 in 10 people over the age of 65 either malnourished or at risk of malnutrition.2 However, it is suggested that the majority of people at risk of malnutrition are actually younger than this, with more than three million UK citizens suffering from malnutrition at any one time.3 This

places a huge financial burden on our already stretched health and social care system, with malnourished patients costing two to three times more to treat than a comparable well-nourished patient.4 More importantly, and aside from the financial burden, malnutrition causes further health complications in an already vulnerable patient; for example, impaired immune response, compromised muscle strength, delayed wound healing, longer hospital stays and an escalation of medical care.

Evelyn Toner RD Freelance Dietitian Evelyn’s specialist areas include sports nutrition and gastroenterology, especially IBS and health and wellbeing. She enjoys media work and running her social media persona ‘The Active Dietitian’ (on Instagram as @the_active_ dietitian).

THE NEXT STEP FROM FOOD FIRST

Oral nutrition support is the first tool in the dietitian’s repertoire for tackling malnutrition and when the food-first approach fails to achieve the desired results, we will opt for oral nutrition supplements (ONS) as the next step. If possible oral nutrition support, using such supplements, is preferential to enteral or parenteral feeding, as it has less risk of complications or side effects, is less invasive and is more cost effective.5 ONS are generally calorie dense preparations that come in the form

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NHD CPD eArticle

Volume 9.11 - 12th September 2019

Table 1: The most common types of ONS available (adapted from BAPEN 2016)11 Type

Examples

Notes

Juice type

Fortijuce, Ensure Plus Juce, Fresubin Jucy

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

Milkshake type

Fortisip, Fortisip Compact (protein/fibre), Fortisip 2kcal, Fortisip Extra, Ensure Plus, Ensure Compact, Ensure Twocal, Altraplen Compact, Resource Energy, Resource 2.0 Fibre, Fresubin Energy, Fresubin 3.2kcal Drink, Fresubin 2kcal Drink

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

High-energy powders

Complan Shake, Scandishake Mix, Ensure Shake, Enshake, Foodlink Complete (+/- fibre), Aymes Shake

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

Vitasavoury, Aymes Savoury, Ensure Plus Savoury

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/

Forticreme Complete, Nutilis (Complete Creme Level 3, Fruit Level 4), Ensure Plus Crème, Nutricrem, Aymes Creme, Fresubin Dessert Fruit, Fresubin YoCreme

Smooth semi solid style products (often IDDSI level 3 or 4) with an energy density of ~1.4-2.5kcal/ml.

High protein

Fortisip Compact Protein, Fortisip Extra, Protifar (powder), Ensure Plus Advance, ProSource range (Liquid, Plus, Jelly), Altraplen Protein, Fresubin Protein Energy

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

Low volume high modules (shots)

Calogen, Calogen Extra, ProCal Shot/ Powder, Altrashot, Fresubin 5kcal Shot Drink

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

of liquids, semi-solids or powders. Some are available to purchase over the counter; however, the majority are prescribable. These products provide macronutrients and micronutrients in varying quantities and are intended to supplement the patient’s diet, not usually to be the sole source of nutrition and, as such, they are not nutritionally complete. The use of ONS has been exten-sively studied with convincing findings as to their benefits in terms of improving nutritional status, reducing mortality, complications and length of hospital stay.1,6,7,8

Table 1 above shows a summary of the most common types of ONS available on the market today. As we can see, there is a wide variety of nutritional supplements for dietitians to choose from and this needs to be done with careful consideration of the patients’ individual requirements and preferences in order to increase compliance, as they will only do their job if they are actually consumed! Studies have suggested that taste is the most important factor in ensuring compliance, and having a variety of different flavours available will prevent taste fatigue.9,10 But choosing

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NHD CPD eArticle

Volume 9.11 - 12th September 2019

Table 2: ONS for specific clinical indications/disease states Supplement name/range

Disease state/notes

Liquigen

Epilepsy/MCT ketogenic diet

Lophlex/Anamix ranges

Inborn errors of metabolism

Nutilis Complete/Fruit range

Dysphagia specific products, which include prethickened drinks and semi-solid products

Souvenaid

For the dietary management of early Alzheimer’s disease

Renilon 7.5

Fluid or electrolyte restriction,in renal disease patients

Forticare

Cachexia in oncology patients contains n-3 fatty acids and fibre

Respifor

COPD/respiratory patients

Prosure

Weight loss in oncology patients – contains n-3 fatty acids and antioxidants

Nepro HP

High-energy, low electrolyte, low volume for use in renal disease patients

Vital 1.5kcal

Peptide based for use in dsease-related malnutrition and malabsorption or for those who experience symptoms of poor feed tolerance

Modulen IBD

Crohn’s disease

Oral Impact

For the dietary management of major elective surgery patients

MCT Procal

MCT supplement/fat malabsorption

PKU, MSUD, TYR, MMA/ PA specialist products (Gel, Express, Cooler)

Specialist amino acid-based products for use in inborn errors of metabolism

Keyo, Betaquik, Carbzero

For use as part of ketogenic diet therapy for drug resistant epilepsy and neurometastic disease, e,g. GLUT-1 deficiency syndrome

the best flavour is only one element in the decision making process; factors such as texture preferences, disease state, medical restrictions, fluid restrictions, electrolyte disturbances, swallowing ability (dysphagia), independence and cultural and religious beliefs, all need to be considered when designing an effective ONS regime. For this reason, medical nutrition companies have devised specialist ONS to cater for specific disease states. Table 2 shows some examples of these specialist supplements for use in adults. Please note that this is not an exhaustive

Manufacturer

Nutricia

Abbott

Nestle Health Science

Nestle Health Science/ Vitaflo

list and individual research should always be done into the most appropriate supplements for your patient’s medical status. ASSESSMENT

Hospitals and care homes should screen all patients on admission for malnutrition using a validated nutritional screening tool, eg, ‘MUST’, and repeat screening at regular intervals or when there is clinical concern.1 If there is a concern around the existence or development of malnutrition (ie, if a certain threshold score in

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NHD CPD eArticle

Volume 9.11 - 12th September 2019

Any patient on ONS should be monitored and reviewed by the appropriate healthcare professional at regular intervals to ensure the ongoing appropriateness of their prescription.

the tool is reached), an onward referral should be made to the dietitian for a full assessment. As discussed, there are many complex factors to be considered when designing an effective ONS regime, therefore, the patient should be fully assessed by a healthcare professional/ dietitian trained in evaluating nutritional requirements before being started on ONS.1 Nutritional requirements for energy, protein, fluid, electrolytes, minerals and fibre need to be calculated, alongside considerations such as activity levels, underlying disease states and their consequences, eg, pyrexia, or taste changes, gastrointestinal tolerance, risk of refeeding syndrome and monitoring plans.1 A thorough knowledge of the patient and their circumstances is essential before prescribing any supplements, to ensure they are suitable for any restrictions they may have, eg, dietary restrictions: gluten/ lactose free, fluid restrictions, religious or cultural beliefs including Halal, Kosher, etc. Furthermore, it is important to consider swallow ability. If there is a history of any difficulties, or the patient/relatives express any concern, a swallow assessment may be appropriate and an onward referral made to a speech and language therapist. Supplements of an appropriate consistency can then be prescribed, or a thickener added as necessary. A patient should also be educated on how to improve their nutritional intake from food alongside any ONS prescription.11

According to NICE (2006), the initiation of nutrition support should be considered when any of the following are evident:1 • a body mass index (BMI) of less than 18.5kg/m2; • unintentional weight loss greater than 10% within the last three to six months; • a BMI of less than 20kg/m2 and unintentional weight loss greater than 5% within the last three to six months; • little or no nutritional intake for more than five days and/or are likely to eat little or nothing for five days or longer; • poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism. MONITORING

Any patient on ONS should be monitored and reviewed by the appropriate healthcare professional at regular intervals to ensure the ongoing appropriateness of their prescription. The frequency of monitoring will depend on a number of factors, one of which being the care setting; for example, a hospital patient on ONS may be reviewed every couple of days, whereas for a patient in the community, it may be every few months. As a patient becomes more established on their regimen, the intervals may extend. When monitoring a patient on ONS, the following factors should be assessed:1

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NHD CPD eArticle

Volume 9.11 - 12th September 2019

• Total nutritional intake from all sources – daily, then twice weekly. • Weight, BMI – weekly, then monthly. • Other anthropometric measures as available, or if weight cannot be obtained, eg, mid-arm circumference, tricep skinfold thickness – monthly. • GI function and tolerance, ie, nausea/ vomiting, bowel function, eg, diarrhoea, constipation, abdominal distension – daily, then twice weekly. • Clinical condition and changes in management, eg, changes to medications, planned investigations (requiring fasting). • Laboratory blood tests as appropriate depending on the patient’s setting and clinical condition, eg, sodium, potassium, glucose, full blood count. The initial goals should be continually reviewed to gauge progress and, depending on the clinical indication for starting a patient on ONS in the first place, there should be a plan

to get them off the supplements in a timely manner. Targets that may be set for stopping the supplements include:11 • dietary intake sufficient to meet nutritional requirements; • target weight achieved; • healthy BMI; • change/improvement in medical condition; • non-compliance due for example to taste fatigue. CONCLUSION

Nutrient dense (but not necessarily nutritionally complete) ONS are often required when a patient is unable to meet their nutritional requirements from food alone. There is a wide variety of ONS available, therefore, the prescription of a successful ONS regime should be led by a suitably skilled dietitian, include a thorough assessment of the individual patient and a plan for the ongoing monitoring of its effectiveness, with an end goal in sight.

References 1 National Institute for Clinical Excellence (NICE) (2006). Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition CG 32. Accessed 03.05.19 www.nice.org.uk/guidance/cg32 2 Wilson L (2017). Malnutrition Task Force: State of the Nation, Older people and malnutrition in the UK Today. Accessed 03/05/19 www. malnutritiontaskforce.org.uk/wp-content/uploads/2017/10/AW-5625-Age-UK-MTF_Report.pdf 3 Elia M and Russell C (2009). Combating malnutrition; Recommendations for Action. Accessed 03/05/19 www.bapen.org.uk/pdfs/reports/advisory_ group_report.pdf 4 Elia M (2015). The cost of malnutrition in England and potential cost savings from nutritional interventions. A report on the cost of disease-related malnutrition in England and a budget impact analysis of implementing the NICE clinical guidelines/quality standard on nutritional support in adults. Accessed 03/05/19 www.bapen.org.uk/pdfs/economic-report-short.pdf 5 Ruxton C (2015). ONS and the power of taste. Dietetics Today. Accessed 07/05/19 www.bda.uk.com/dt/articles/ons_the_power_taste 6 Stratton RJ and Elia M (2007). A review of reviews: A new look at the evidence for oral nutritional supplements in clinical practice. Clinical Nutrition Supplements 2:5-23 7 Philipson TJ et al (2013). Impact of oral nutritional supplementation on hospital outcomes. Am J Manag Care 19: 121-128 8 Elia M et al (2009). The cost of disease-related malnutrition in the UK and economic considerations for the use of oral nutritional supplements (ONS) in adults. BAPEN. Accessed 03/05/19 www.bapen.org.uk/pdfs/health_econ_exec_sum.pdf 9 Lad H et al (2005). Elderly patients’ compliance and elderly patients’ and health professionals’ views, and attitudes towards prescribed sip-feed supplements. J Nutr Health Aging 9: 310-314 10 Ozcagli TG et al (2013). A study in four European countries to examine the importance of sensory attributes of oral nutritional supplements on preference and likelihood of compliance. Turk J Gastroenterol 24: 266-272 11 BAPEN (2016). Oral Nutritional Supplements (ONS). www.bapen.org.uk/nutrition-support/nutrition-by-mouth/oral-nutritional-supplements. Accessed 03/05/19

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NHD CPD eArticle Volume 9.11 - 12th September 2019

Questions relating to: Oral nutritional supplements: the range available and how to use them Type your answers below, download and save or print for your records, or print and complete by hand. Q.1

When considering ‘food first’, give examples of how you can elevate the nutritional density of a patient’s food.

A

Q.2

Explain the impact of malnutrition on vulnerable patients, as well as on the NHS.

A

Q.3

What are ONS and what do they offer a patient when ‘food first’ fails?

A

Q.4

What are the factors to consider when designing an effective ONS regime?

A

Q.5

Describe the process for testing for malnutrition in hospital.

A

Q.6

Explain what calculations are involved in a patient assessment.

A

Q.7

Give three reasons for the initiation of nutritional support, according to NICE.

A

Q.8

When monitoring a patient, what measures need to be taken?

A

Q.9

What targets need to be set for stopping a patient’s ONS regime?

A

Please type additional notes here . . .

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NHD CPD eArticle Vol 9.11: ORAL NUTRITIONAL SUPPLEMENTS: THE RANGE AVAILABLE AND HOW TO USE THEM  

As dietitians, we follow the mantra of 'food first', aiming to meet our patients’ nutritional requirements using real, easily accessible, af...

NHD CPD eArticle Vol 9.11: ORAL NUTRITIONAL SUPPLEMENTS: THE RANGE AVAILABLE AND HOW TO USE THEM  

As dietitians, we follow the mantra of 'food first', aiming to meet our patients’ nutritional requirements using real, easily accessible, af...

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