derbyshire joint area prescribing committee (japc) · powdered alternatives to ready-made, liquid...

Management of undernutrition in adults Frist Produced: August 2010

Reviewed: June 2018 Next review date: May 2020 (Extended to November 2020)

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Management of undernutrition in adults

Patients should be screened for nutritional risk using the Malnutrition Universal Screening Tool (MUST) (See http://www.bapen.org.uk/pdfs/must/must_full.pdf and Appendix 1)

Record baseline weight, height and Body Mass Index (BMI) and agree outcomes of treatment

First line treatment is the fortification of normal diet (See Appendix 2)

Use of over the counter supplements is the next intervention (See table, page 4)

Prescribed oral nutritional supplements (ONS) should only be used if other interventions have been unsuccessful alongside fortified foods. (See Appendix 3 for information about standard ONS products).

Powdered ONS products are the most cost effective, if patients/carers have adequate manual dexterity to make them up

Weight and BMI should be monitored at regular intervals as outlined in the adult nutritional management algorithm (page 2)

ONS should not be prescribed under the NHS for other indications e.g. for substance misusers who do not meet an additional approved ACBS criterion

Specialist products (Appendix 4) should be prescribed ONLY on the advice of a Dietician.

DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC)

http://www.bapen.org.uk/pdfs/must/must_full.pdf%20and%20Appendix%201

http://www.bapen.org.uk/pdfs/must/must_full.pdf%20and%20Appendix%201



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NO IMPROVEMENT

NO IMPROVEMENT

NO IMPROVEMENT

NO

Adult Nutritional Management Algorithm for GPs and Community Nurses

Moderate risk of malnutrition if MUST score = 1

BMI between 18.5 - 20 kg/m2 Or

Unintentional weight loss between 5-10% in the last 3-6 months

Identify and treat underlying medical conditions e.g. malignancy, nausea, vomiting, diarrhoea, dysphagia, pain, depression, poor dentition (see appendix 1 Step 5 for action)

High risk of malnutrition if MUST score ≥ 2 Patient is malnourished if:

BMI < 18.5kg/m2

Or

Unintentional weight loss >10% in the previous 3-6 months Or

BMI 18.5-20kg/m2 and unintentional weight loss >5% in the

previous 3-6 months. Identify and treat underlying medical conditions e.g. malignancy, nausea, vomiting, diarrhoea, dysphagia, pain, depression, poor dentition. IF MUST SCORE ≥2 CONSIDER REFERRAL TO DIETICIAN,(undertaking actions below whilst referral is accepted)

Measure & record weight & height/ulna length, calculate & record BMI & MUST score

Continue to monitor at 3m, 6m then annually until goals met and maintained (for approx. 1 month)

Consider referral to Dietician.

NO IMPROVEMENT

NO IMPROVEMENT

IMPROVEMENT

IMPROVEMENT

Review patient progress in no more than 4 weeks. Review aim and goals of nutritional intervention

Try different ONS product / flavours

Consider prescribing powdered ONS twice daily for 4 weeks. (See section 7 below)

Agree realistic aim and goals of nutritional intervention. Give advice regarding food fortification and snacks (continued throughout) and ‘Big Nutrition for

Small Appetites’ patient information leaflet. (See Appendix 2)

Prescribe nutritionally complete ONS for 4 week trial

Give advice regarding the use of over the counter ONS (See section 6 below)

Review patient progress in no more than 4 weeks. Review aims and goals of nutritional intervention. Monitor compliance, weight and general condition.

Review patient progress in no more than 4 weeks. Review aim and goals of nutritional intervention.

Monitor compliance, weight and general condition.

Review patient progress in no more than 4 weeks. Review aim and goals of nutritional intervention.

Monitor compliance, weight and general condition.

Gradually reduce

usage and stop

YES

GOALS MET & MAINTAINED?



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1. Aim The aim of the guidelines is to ensure effective patient centred oral nutrition support in Derbyshire by promoting appropriate and effective ONS use. 2. Importance Of Nutrition Risk Screening The importance of nutrition and the consequences of malnutrition especially in vulnerable groups are well recognised.

NICE (2006) recommends all adults in the community are screened for nutritional risk:

Within primary care on initial registration and where there is clinical concern On admission into care homes and when there is a clinical concern On a monthly basis when identified at risk

Screening should be done using the Malnutrition Universal Screening Tool (MUST). The Malnutrition Universal Screening Tool (MUST) developed locally for use in Derby and Derbyshire has been included in Appendix 1.

Alternatively, a web based tool may be used: http://www.bapen.org.uk/screening-for-malnutrition/must-calculator

3. Improving Nutritional Intake Clear treatment goals and a care plan should be agreed with patients. Treatment goals should be documented on the patient record and should include the aim of the nutritional support, timescale, and be realistic and measurable. This could include: Target weight or target weight gain or target BMI over a period of time. Wound healing if relevant. Weight maintenance where weight gain is unrealistic or undesirable. Improved activities of daily living. Falls prevention. Reduced infections. Prevention/healing of pressure ulcers. Reduced anxiety associated with ‘having to force feed’ oneself in the absence of appetite for

patients and/or their carers. A halt in weight loss, increased appetite, improved general wellbeing or better wound healing would generally be regarded as improvements. 4. Food fortification First line treatment should be the use of fortified diet, using every day foods. In most cases this will not include the use of ONS. Patients should be advised to have small frequent meals and snacks that are high in calories and protein. Advice can also be given on ways to fortify food. The information leaflet entitled ‘Big Nutrition For Small Appetites - Getting A Lot Out Of A Little’ in Appendix 2 has been developed as supporting information for patients.

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



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5. Referral To Dietician For Nutrition Support Advice Dietetic referral may be appropriate in any of the following circumstances: To advise on nutritional supplementation strategies and the appropriateness of initiating ONS. To assist in appropriate planning and goal setting for nutritional support for individual patients. When there is deterioration in nutritional status despite supplementation after excluding other

contributory pathology. When there is apparent requirement for ONS longer than three months. Where there are cultural, social or religious influences affecting dietary intake. When the patient has co-existing medical conditions such as diabetes, renal failure, coeliac

disease or high cardiovascular risk. Where swallowing difficulties or other indications for modified food texture exist. Where there is unexplained weight loss and / or poor wound healing. Where there has been no improvement in nutritional intake despite advice about food fortification

and oral nutrition support. When patient rely on ONS as their sole source of nutrition Patients at risk of re-feeding syndrome. See criteria below

NICE Criteria for determining people at high risk of developing refeeding problems

Patient has one or more of the following:

BMI less than 16 kg/m2

unintentional weight loss greater than 15% within the last 3–6 months

little or no nutritional intake for more than 10 days

low levels of potassium, phosphate or magnesium prior to feeding.

Or patient has two or more of the following:

BMI less than 18.5 kg/m2

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

little or no nutritional intake for more than 5 days

a history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics.

6. Use of over the counter ONS Over the counter ONS could be recommended if, on review, the advice has been followed but the goals have not been achieved. The table below lists the ONS available to buy over the counter from community pharmacies and some supermarkets:

Over the Counter ONS NAME MADE BY PRESENTATION INSTRUCTIONS FLAVOURS

Aymes Retail Aymes 4 sachets per box Mix with full fat milk Banana, Chocolate, Strawberry, Vanilla

Complan (not to be confused with complan shake)

Complan Foods

4 or 7 sachets per box

Mix with full fat milk

Banana, Chicken, Chocolate, Original, Strawberry. and

Vanilla

Meritene Energis (formally Build Up)

Nestle 4 sachets per box Mix sweet flavours with full fat milk and savoury with water

Chicken, Chocolate, , Strawberry, Vegetable,

Vanilla.

Meritene ready to Drink

Nestle 200ml bottle N/A Chocolate and Strawberry

These should not be prescribed but can be bought from pharmacies and some supermarkets. As with any form of ONS they should not be used to replace meals and patients will generally require two supplements per day sipped between meals.



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7. Use Of ONS Available On Prescription (See Appendix 3 for information about products) After further review, it may be that the patient would benefit from an ONS available on prescription if they have followed the advice but have not met their treatment goals. Advisory Committee on Borderline Substances (ACBS) criteria for NHS prescriptions of ONS are:

Short bowel syndrome Intractable malabsorption Pre-operative preparation of patients who

are malnourished Proven inflammatory bowel disease

Total gastrectomy Dysphagia Bowel fistulae Disease related malnutrition.

N.B. ONS should not be prescribed under the NHS for other indications e.g. for substance misusers who do not meet an additional approved ACBS criterion When providing ONS on prescription the following should be noted:

ONS should not be used to replace meals (unless an individual requires a liquid diet) ONS should usually be sipped between fortified meals Trying to eat at mealtimes should always be encouraged ONS should only be used for a short period of time while food intake is inadequate or until weight

gain is achieved. Fortified food approach should be recommended alongside prescribed ONS. To derive benefit from ONS patients should be having at least 2 -3 each day (powdered ONS

only twice daily). In situations where patients are relying totally on ONS for their nutrition these must be complete

with respect to all nutrients and they will generally require between 5 and 7 units a day however these patients should be under the care of a dietician.

Powdered alternatives to ready-made, liquid products are available (use most cost effective choices) and should be considered before ready-made, liquid products.

8. If ONS Is Initiated: The patient should be weighed and measured, and nutritional goals set and monitored e.g. goal

to improve food intake and prevent further weight loss or attain an acceptable weight* (* = a target BMI of over 20kg/m² depending upon what is a realistic goal for the individual).

If the patient fails to attend on two consecutive occasions, ONS should be discontinued. Maximum prescription should be for 600-800kcal/day (i.e. a 300-400kcal supplement twice daily) Prescriptions should be on acute, not repeat prescriptions, to facilitate monitoring and review

unless otherwise stated by a dietician. Prescribe on a short term basis only (i.e. 1-3 months). If there is no change in weight after three months, ONS should be reduced and discontinued. If weight gain occurs, continue until usual weight or acceptable weight is reached, and commence

a withdrawal plan by reducing one supplement per day initially for one month, then discontinue ONS.

A powdered supplement should be offered initially (see Appendix3). These are cost effective products, which the patient mixes with whole milk (consider patient’s ability to prepare it). These are not however suitable for all; see table below for exclusion criteria of powdered shakes:

Diagnosis of Chronic Kidney Disease stages 3 with the presence of hyperphosphatemia and/or hyperkalaemia, stage 4 or 5

ONS are administered via an artificial feeding tube (enteral feeding patients)

Diagnosis of cow’s milk protein allergy or lactose intolerance

Patients who require ONS as the sole source of nutrition

Follow speech and language therapist advice in patients with dysphagia. Do NOT use standard powdered supplement if thickened fluid is recommend.



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9. Patient Preference Is Paramount To Ensure Maximum Compliance ONS should not routinely be added to a repeat prescription to ensure regular review both in terms of nutritional status and compliance with products and flavours. Review flavour choice regularly to reduce flavour fatigue.

Factors for consideration

Flavour Milk, juice or yoghurt style, sweet or savoury

Volume 200mls or 125mls

Dexterity Ability to make up powdered ONS

Cost Consider unit cost

Specialist products listed in Appendix 4 have limited application. Many provide energy ONLY (as fat and/or carbohydrate). Patients need comprehensive nutritional assessment by a dietician before they are used, to ensure the adequacy of provision of other nutrients. 10. Discharge From Hospital When patients have been commenced on a prescribable ONS by a Dietician a letter will be sent to the patient’s General Practitioner informing them of the aims of nutrition support with a request to: provide further ONS monitor the patient’s progress If the patient is to be reviewed by the Dietician the letter will state this and the General practitioner will be informed of the patient’s progress. If no further dietetic review is planned, arrange to review the patient and discontinue when appropriate. Some patients may require ONS product during hospital stay (food fortification may not be possible in all acute hospital settings) but NOT once discharged, as ‘food first’ approach is more appropriate. No patients should be discharged on ONS products for repeat prescriptions without a nutritional care plan from a dietician, without this care plan ONS products should not be entered onto GP prescribing clinical systems. 11. Care homes Care homes should provide residents with an appropriate diet. ONS should NOT be used as a substitute for the provision of fortified food. Suitable snacks, food fortification as well as homemade milkshakes/ smoothies, and over the counter products can be used to improve the nutritional intake of those at risk of undernutrition. Do not automatically prescribe an ONS on carer’s request without appropriate assessment. Follow treatment flowchart and ensure regular re-assessment carried out. Advice and resources can be found on care home companion website including information for

food fortification/ snack and tips for dementia patients. https://carehomecompanion.uk/eating Consider giving fortified homemade milkshake between meals. Consider assisted feeding when appropriate especially with dementia patients as they often

forget to finish a meal.

https://carehomecompanion.uk/eating



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12. Palliative care and ONS prescribing

The use of ONS in palliative care should be assessed on an individual basis. The aim of nutritional care changes as patients progress through the stages (see table below). Emphasis should always be on the enjoyment of nourishing food and drinks and maximising quality of life.

Nutritional management in different stages of palliative care: Early palliative care

Patient is diagnosed with a terminal disease but death is not imminent. Patients may have months or years to live and maybe undergoing palliative treatment to improve quality of life.

Following treatment flowchart and pay particular attention to assessment of causes of malnutrition.

Nutrition screening and assessment in this patient group is a priority and appropriate early intervention could improve the patient’s response to treatment and potentially reduce complications.

However, if a patient is unlikely to consistently manage 2 servings of ONS per day, they are unlikely to derive any significant benefit to well-being or nutritional status from the prescription.

Over the counter products can be recommended if required as per treatment flowchart.

Late palliative care

The patient’s condition is deteriorating and they may be experiencing increased symptoms such as pain, nausea and reduced appetite.

Nutrition screening, weighing and initiating prescribing of ONS at this stage is NOT recommended.

The goal of nutritional management should NOT be weight gain, but quality of life.

Patients should be encouraged to eat and drink the foods they enjoy in amounts they are able to comfortably manage.

Avoid prescribing ONS for the sake of ‘doing something’ when other dietary advice has failed – be aware that family or carers may request. It is important to gently discuss with these individuals the need for comfort and enjoyment of food during remaining life rather than causing anxiety with aggressive feeding.

Last days of life

The patient is likely to be bed-bound, very weak and drowsy with little desire for food or fluid.

The aim should be to provide comfort for the patient and offer mouth care and sips of fluid or mouthfuls of food as desired.

Patient unlikely to benefit from ONS

Avoid prescribing ONS for the sake of ‘doing something’ when other dietary advice has failed – be aware that family or carers may request. It is important to gently discuss with these individuals that it is much more appropriate for the patient to have mouthfuls of food or sips of fluid as desired for comfort.

References 1. Nutrition Support for Adults. Oral Nutrition Support, Enteral Tube Feeding and Parenteral

Nutrition. NICE CG32. February 2006 2. PrescQIPP bulletin 145 Guidelines for the appropriate prescribing of oral nutritional supplements

(ONS) for adults in primary care. April 2017

Document updates Date Appendix 3 price updated (Fortisip compact / resource energy) October 2018

Appendix 4 discontinued products deleted (Polycose, resource dessert energy/ fruit, resource protein)

December 2018

p.14 Nutilis completed stage 1/2/3 product name updated to Level 3/4 March 2019

Ensure Plus Juce added to Appendix 3 March 2019

Energie shake added to Appendix 3 October 2019



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Appendix 1. Calculating MUST score



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MUST record (add name of patient and date of birth, NHS number, etc)

Date

Weight

Height

BMI Step 1 0 BMI score 1 2

Step 2 0 % Weight 1 loss score 2

Step 3 0 Acute disease effect score 2

Step 4 Enter score Low(L)/Med(M)/High(H)

L / M / H

L / M / H

L / M / H

L / M / H

L / M / H

Signature

Date

Weight

Height





L / M / H

L / M / H

L / M / H

L / M / H

L / M / H

Signature

Date

Weight

Height





L / M / H

L / M / H

L / M / H

L / M / H

L / M / H

Signature

Document action taken within patient healthcare / nursing records



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Fortified milk 1. Take one pint of full cream/whole milk. 2. Add 4 tablespoons of skimmed milk powder to a small

amount of milk and mix to a paste. 3. Top up with the remaining milk from the 1 pint.

Store in the fridge and use throughout the day

AAppppeennddiixx 22

BBiigg NNuuttrriittiioonn ffoorr SSmmaallll AAppppeettiitteess GGeettttiinngg aa lloott oouutt ooff aa lliittttllee

If you are not eating very much and losing weight it is important to increase the calorie and protein content of your diet. Fortifying foods will do this without increasing the amount you eat. You may need to fortify your diet if: You have a poor appetite, eating less food and losing weight. You have a good appetite but are still losing weight

Healthy eating guidelines of a low fat diet are not appropriate for you.

Choose full fat products

Remember to try to have 8 cups of fluid per day

A glass of fresh fruit juice is a rich source of vitamin C and can be helpful for healing wounds and sores

Here are 5 easy ways to help you to add more calories and protein to your food. 1) Make up a pint of fortified milk (see recipe below) and use it for all your drinks, on cereals, to

make puddings, sauces, soups, milk jellies and in other recipes that require milk. (A pint of this milk per day will significantly increase your calorie intake)

2) Fortify other foods – here are some suggestions:

Food item Adapting the recipe

Cereals e.g. porridge

In porridge use fortified milk and add 2 tablespoons of double cream per portion (1 portion is equal to a ladle full) Use fortified milk on all breakfast cereals

Toast, bread, sandwich Add extra butter, preserves, mayonnaise

Soup – tinned, dried or home made

Add 1 heaped tablespoon of milk powder and 2 tablespoons of cream to soup per portion (1 ladle full)



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Potatoes Add an extra knob of butter/margarine; also add 1 tablespoon of cream to mashed potatoes Grated cheese can also be added

Vegetables Add 1 teaspoon of margarine / butter to 2 tablespoons of vegetable, allow to melt

Custard Use fortified milk then add 2 tablespoons of cream per portion (1 ladle full)

Puddings Add extra cream, custard made with fortified milk, evaporated milk, jam, syrup, chocolate or fruit sauces

Ice Cream Pour 2 tablespoons of cream over 1 scoop of ice cream

Preserves Use plenty of sugar, syrup, jam, peanut butter, lemon curd, chocolate spread, honey, mayonnaise

3) Choose high calorie drinks – milky coffee, malted milk or hot chocolate using the fortified milk Hot Chocolate drink 150mls (¼ pint) full cream milk 1 heaped tablespoon milk powder 4 tablespoons of cream 3 teaspoons of hot chocolate powder (or to taste) Beat the ingredients together. Heat all the ingredients together in a saucepan or microwave

Milkshake 200mls Full Cream Milk 2 heaped tablespoons milk powder Milkshake powder (Nesquick, Crusha) Whisk milk and milk powder together. Add flavourings to taste. Serve chilled. 4) Aim for 3 small meals a day and snacks in between. Little and often is more appealing for a

small appetite Examples of Snacks Biscuits, scone, cake, crisps, nuts, dried fruit, mini cheese biscuits, mini pasties, cheese and biscuits, hummus, samosas, chocolate bar, small trifle, dessert pot, creamy yoghurt, flapjack, mousse, toast spread with sweet toppings (lemon curd, jam, chocolate spread), toast spread with savoury toppings (pate, cream cheese, paste, peanut butter), crumpets, teacakes, scotch eggs, pork pie, sausage roll, cereals, milkshakes, squash, cocoa, lassi. 5) You can buy Meritene Energis Soups or Shakes or Complan from your supermarket or

chemist If you have any specific dietary concerns about diabetes, Coeliac Disease or renal disease, ask for further guidance from your G.P or Dietician.



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Appendix 3. Standard ONS products for adults

POWDERED products Vits K and A, and phosphate may exceed Dietary Reference Values. Use with caution in pregnancy & patients with

renal disease or on warfarin**. Gluten free, NOT Lactose Free

NAME COST

per unit

PRESENTATION

FLAVOURS Energy per unit with 200ml full

fat milk

Protein per unit with 200mls of

full fat milk

ADDITIONAL INFORMATION

Energie shake 54p 4 x 57g sachets

Banana, neutral, vanilla, chocolate,

strawberry 381 kcal 15.8g

Aymes shake 60p 7 x 57g sachets

Banana, strawberry, chocolate, vanilla,

neutral 384 - 389 kcal 15.6 - 16.0g

Gluten free

Not lactose free

Ensure shake 60p 7 x 57g sachets

Strawberry, vanilla and banana

389 kcal 17g Gluten free

Not lactose free

Foodlink complete

60p 7 x 57g sachets

Banana, chocolate, natural, strawberry,

vanilla* 378 - 386 kcal 18.3 - 18.7g

Gluten free

Not lactose free * contains fibre

Foodlink complete fibre

67p 7 x 63g sachets


vanilla 399 kcal 18.6g

Fresubin Powder Extra

76p 7 x 62g sachets

Chocolate, neutral, strawberry, vanilla

420 kcal 17.5g Gluten free

Not lactose free

Aymes shake Chicken

78p 7 x 57g sachets

Chicken Made with water

251 kcal 9.2g

Complan shake

78p 4 x 57g sachets

Original, vanilla, strawberry,

chocolate, banana

387 kcal

15.8g Gluten free

Not lactose free

Vitasavoury 300

£1.28 10x50g sachets

Chicken, golden vegetable, leek and potato, mushroom

Made with water 309 kcal

Full fat milk = 375 kcal

Made with:Water

= 6g Milk = 9g

Not lactose free

STARTER PACK products. Starter Packs should only be issued for and acute 1-2 week prescription to determine flavour preference. These usually give a shaker to aid with mixing

Energy Shake 58p 5x 57g sachets

Banana, neutral, vanilla, chocolate,

strawberry 381 kcal 15.8g

Foodlink Complete Start

Pack 60p

4x 57g 1 x 63g (fibre)


vanilla 378 - 386 kcal 18.3 - 18.7g

Complan Shak Starter Pack

88p 5 x 57g sachets

Original, vanilla, strawberry,

chocolate, banana 387 kcal 15.8g

Gluten free Not lactose free

Aymes Shake Starter Pack

96p 5 x 57g sachets

Banana, strawberry, chocolate, vanilla,

neutral 384 - 389 kcal 15.6 - 16.0g

** Powdered ONS have relatively higher phosphate, potassium and vitamins K and A content. Care is needed if transferring a patient on warfarin due to differing vitamin K content (monitor INR at start and end of treatment and if changing from an alternative supplement) and with some renal patients. See section 8 for exclusion criteria of powdered shakes. Maximum of two daily due to higher vitamin A content. Patients need to be able to shake the container. Not nutritionally complete



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READY-MADE products. Suitable as a sole source of nutrition if recommended by dietician

NAME COST PER UNIT

VOLUME FLAVOURS Energy per

unit Protein per

unit ADDITIONAL

INFORMATION

Aymes Complete

£1.11 200ml Banana, chocolate*, strawberry, vanilla

300 kcal 12g

Not lactose free

Gluten free *chocolate flavour contains fibre

Ensure plus milkshake

style £1.11 200ml

Banana, chocolate, coffee, fruits of the

forest, neutral, orange, peach, raspberry, strawberry, vanilla

300 kcal 12.5g

Residual lactose

Gluten free

Fortisip bottle £1.12 200ml

Neutral, vanilla, toffee, chocolate, banana, orange, strawberry,

tropical fruits, apricot, forest fruit

300 kcal 12g Lactose free

Gluten free

Nutricomp drink plus

£1.12 200ml

Vanilla, strawberry, chocolate, banana

300 kcal 12g

Strictly low in lactose

Gluten free

Fresubin energy

£1.40 200ml

Banana, blackcurrant, cappuccino, chocolate,

lemon, strawberry, tropical fruit, vanilla

300 kcal

11.2g Gluten free

Residual lactose

Resource Energy

£2.06 200ml Apricot, chocolate,

banana, coffee, vanilla, strawberry/ raspberry

300 kcal 11.2g

Lactose free

Gluten free

READY MADE products – compact volume of 125mls

Altraplen compact

£1.33 125ml Hazel chocolate,

vanilla, strawberry, banana

300 kcal 12g Gluten free

Ensure Compact

£1.33 125ml Banana, strawberry,

vanilla 300 kcal 13g

Not lactose free

Gluten free

Fortisip Compact

£1.33 125ml Vanilla, strawberry,

banana, mocha, chocolate

300 kcal 12g

Not lactose free

Gluten free

READY MADE products – Savoury flavour

Ensure plus savoury

£1.11 200ml Chicken, mushroom 300 kcal 14g Residual lactose

Gluten free

READY MADE products – yoghurt style (Suitable for Level 1 Slightly Thick IDDSI)

Ensure plus yoghurt style

£1.11 200ml Orchard peach, strawberry swirl

300 kcal

13g Lactose free

Gluten free

READY MADE products – juice (consider for diary intolerance/ allergy only)

Ensure plus JUCE

£1.97 220ml Orange, apple, lemon and lime, strawberry,

peach, fruit punch 330 kcal 10.6g

For diary intolerance/ allergy only

Prices correct October 2018.



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Appendix 4. Specialist Products

It is recommended that other products, such as those listed below, should be prescribed ONLY on the advice of a Dietician. Pre thickened supplements should be prescribed only after a formal dysphagia assessment. Examples of specialist products:

Altraplen Protein Altrashot

Aymes Creme Calogen

Calogen Extra Caloreen Powder

Calshake Duocal super soluble Elemental 028 Extra

Enshake Ensure cans

Ensure Plus Advance Ensure Plus Crème

Ensure Plus Fibre Ensure TwoCal

Forticare Forticreme complete

Fortisip 2kcal Fortisip Compact Fibre

Fortisip Compact Protein Fresubin 2 kcal +/- fibre Fresubin 2kcal Crème

Fresubin 5kcal shot Fresubin Energy Fibre

Fresubin Original Drink

Fresubin Protein Fresubin Thickened Fresubin YoCreme

Liquigen Maxijul powder Modulen IBD

Nutilis Complete Stage 1+2

Nutricrem

Peptamen Polycal Liquid

Polycal Powder Procal powder

Procal shot Pro-sure

Resource 2.0 fibre Scandishake Mix

Examples of specialist dysphagia products: (for information only, please follow speech and language therapist and dietician recommendations.

DYSPHAGIA PRODUCTS Please follow recommendations for consistency as per speech and language therapy

NAME COST /unit

PRESENTATION FLAVOURS IDDSI / Previous

Consistency Descriptor Energy per unit

Protein per unit

Slõ® Milkshake +1

84p 7 x 50g sachets

Strawberry, Chocolate Level 2 Mildly Thick /

Stage 1 Syrup 327-333

kcal 23.8-24.2g

Slõ® Milkshake +2

84p 7 x 50g sachets

Strawberry, Chocolate Level 3 Moderately

Thick/ Stage 2 Custard 327-333

kcal 23.8-24.2g

Nutricrem £1.40 125g pot Chocolate, strawberry,

vanilla Level 4 Extremely Thick/

Stage 3 Pudding 225 kcal 12.5g

Resource Dessert Energy

£1.63 125g pot Vanilla, Chocolate,

Caramel Level 4 Extremely Thick/

Stage 3 Pudding 200 kcal

6g

Ensure Plus Crème

£1.89 125g pot Banana, Chocolate,

Vanilla, Neutral Level 4 Extremely Thick/


Fresubin 2kcal Crème

£1.93 125g pot Vanilla, Strawberry, Praline, Chocolate,

Cappuccino

Level 4 Extremely Thick/ Stage 3 Pudding

231 kcal 12.5

Forticreme £1.96 125g pot Strawberry, Vanilla,

Chocolate Level 4 Extremely Thick/


Nutilis Complete Drink level 3

£2.21 125ml bottle Strawberry, Chocolate,

Vanilla Level 2 Mildly Thick/

Stage 1 Syrup 306 kcal 12.4g

Nutilis Complete Creme level 3

£2.21 125g pot Strawberry, Chocolate,

Vanilla Level 3 Moderately

Thick/ Stage 2 Custard 306 kcal

12.4g

Fresubin Thickened

Stage 1 £2.35 200ml bottle

Wild Strawberry, Vanilla

Level 2 Mildly Thick/ Stage 1 Syrup

300 kcal 20g

Fresubin Thickened

Stage 2 £2.35 200ml bottle

Wild Strawberry, Vanilla

Level 3 Moderately Thick/ Stage 2 Custard

300 kcal 20g

Nutilis fruit level 4

£2.36 150g Apple, Strawberry Level 4 Extremely Thick/


derbyshire joint area prescribing committee (japc) · powdered alternatives to ready-made, liquid...

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