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The Prescribing of Oral Nutritional

Supplements

This document has been produced to support the appropriate use and Prescribing of Oral Nutritional Supplements (ONS)

Developed by the Medicines Management team in Collaboration with the Homerton University Hospital

Dietitians

Date Implemented: August 2016 Version: 2.0 Date of Review: August 2018

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Contents

INTRODUCTION.............................................................................. 3

IDENTIFICATION OF MALNUTRITION………………………………………. 4

PATHWAY FOR THE MANAGEMENT OF UNDERNUTRITION……………….. 5

GOAL SETTING……………………………………………………………… 6

PRESCRIBING OF ONS……………………………………………………… 6

SPECIAL GROUP PATIENTS………………………………………………… 7

DIETITIAN REFERRAL FORM………………………………………………. 8

PATIENT INFORMATION LEAFLET ON FOOD FORTIFICATION…………… 9-10

LINK WEBSITES……………………………………………………………. 11

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INTRODUCTION

This document is a practical guide to support General Practitioners and other health professionals in the

community to identify and manage individuals at risk of disease related malnutrition including the

appropriate use of oral nutritional supplements (ONS).

The economic impact of malnutrition is substantial; a malnourished patient visiting their GP incurs an

additional health care cost of £1449 in the year following diagnosis (Guest et al, 2011; Malnutrition Task

Force, 2013). Data from 2011 suggested malnutrition and its consequences were estimated to cost in

excess of £19.6billion in the UK (Elia & Russell for BAPEN 2015).

ONS products should be prescribed for patients that have been identified as being at HIGH RISK for

malnutrition and or if a valid ACBS indication is documented. Use of ONS requires regular monitoring of

the patient’s progress and tolerance. In cases of MEDIUM RISK for malnutrition this is a treatable

condition using first line FOOD FIRST dietary advice to maximize food intake and advising over the

counter supplements where necessary.

ONS are relatively expensive for the NHS and audits and project work in recent years by the community

dietitians and medicines management team in City and Hackney have shown ONS are often initiated

inappropriately and or continued unnecessarily, without adequate reviews.

Management of malnutrition should be linked to the level of malnutrition risk. For all individuals:

RECORD RISK

AGREE GOAL OF INTERVENTION

MONITOR

Advisory Committee on Borderline Substances Criteria for ONS

The Advisory Committee on Borderline Substances (ACBS) advises that ONS may be regarded as drugs for prescribing for the following approved indications:

Short bowel syndrome

Intractable malabsorption

Pre-operative preparation of patients who are undernourished

Proven inflammatory bowel

Following total gastrectomy

Dysphagia

Bowel fistulas

Disease-related malnutrition

Continuous ambulatory peritoneal dialysis (CAPD)

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Identification of Malnutrition

Supplements should only be prescribed to patients who

1) meet the Advisory Committee on Borderline Substance (ACBS) prescribing criteria AND

2) have been screened using the local malnutrition screening tool e.g. Malnutrition Universal

Screening Tool (MUST) and deemed to be at nutritional risk (MUST score 2)

MUST Screening for the Management of Undernutrition in Adults

SCREENING GUIDELINE: For further information on Malnutrition Universal Screening Tool (MUST) see

www.bapen.org.uk.

If unable to obtain height and weight see the ‘MUST’ Explanatory Booklet for alternative measurements

and use of subjective criteria http://www.bapen.org.uk/pdfs/must/must_page6.pdf

STEP 1 BMI Score

BMI kg/m2 Score >20 = 0 18.5-20 = 1 < 18.5 = 2

STEP 2 Weight Loss Score

Unplanned weight loss in past 3-6 months % Score

< 5 % = 0 5-10% = 1 > 10% = 2

STEP 3 Acute Disease Effect Score

If patient is acutely ill and there has been or is likely to be little or no nutritional intake for 5 days or more.

Score = 2

STEP 4 Overall Risk of Malnutrition -Add scores together to calculate overall risk of malnutrition

Low Risk – (0) Routine Clinical Care

- Routine clinical care - Review / repeat

screening MONTHLY in care homes ANNUALLY in

community

Medium Risk – (1) Observe

- Dietary advice to maximise nutritional intake. Record intake for 3 days, encourage small frequent meals and snacks, with high energy and protein foods and fluids

- Powdered nutritional supplements to be made up with water or milk are available OTC

- Review progress/ repeat screening after 1 – 3 months according to clinical condition or sooner if the condition requires

- If improving continue until ‘low risk’

- If deteriorating, consider treating as ‘high risk’

High Risk – (2 or more)

Treat* - Dietary advice to maximise

nutritional intake. Record intake for 3 days, encourage small frequent meals and snacks, with high energy and protein foods and fluids

- Refer to Homerton Dietetics and prescribe ONS (if ACBS criteria fulfilled) to cover for one month whilst awaiting diettitian consultation.

- For patients who do not fulfil the ACBS criteria, advise OTC nutritional supplements.

*unless detrimental or no benefit is expected from nutritional support

- If BMI<16kg/m2 there can be a high risk of re-feeding syndrome or relying solely on ONS then refer

urgently to dietetic services (please e-mail, fax referral form, or contact via telephone) - For all individuals consider underlying symptoms and cause of malnutrition and treat if

appropriate.

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Pathway for the Management of Undernutrition

Individual identified as high risk (MUST score of 2 or more)

The clinician should:

consider underlying symptoms and cause of malnutrition and treat if appropriate e.g. nausea, infection

document details of malnutrition risk (screening result / risk category, or clinical judgment)

refer to Homerton Community Dietetics Department, using the standard referral form (which should be filled in with as much detail as possible to avoid delay in patient being seen, this can be faxed or e-mailed to the department)

if ACBS criteria met, provide ONE week supply of ONS initially (on acute prescription) to establish patient preference, followed by a further 3 weeks supply to cover period until Dietetic consultation

Following Dietitian consultation, the Dietitian should communicate via letter:

Details of malnutrition risk

If ONS advised, name, dosage and duration of therapy and ACBS criteria Treatment goals agreed with patient / carer

Monitoring requirements

Next review date

The Clinician Should Monitor Compliance and Progress Monthly*

Check compliance to ONS and amend type / flavour if necessary to maximise intake Review goals set by Dietitian

Goals Met / Good Progress

Encourage oral intake and dietary advice

Consider reducing to ONE ONS per day for 2 weeks before stopping Monitor progress; continue to treat as ‘medium risk’

Goals Not Met / Limited Progress

Check ONS compliance; amend prescription as necessary, increase

volume of ONS. Re-assess clinical condition, re-refer back to dietitian

When to Stop ONS Prescription Goals of intervention have been met and the individual is no longer at risk of malnutrition

Individual is clinically stable

Individual is back to their normal eating and drinking pattern If no further clinical input would be appropriate

*If the patient fails to attend ONE GP review without a reasonable explanation then the supply of ONS should be

suspended until the prescriber has seen the patient.

Should the patient fail to attend a dietitian review the dietetic service should inform the GP immediately. ONS

should not be supplied until the patient has been followed up for monitoring.

Community Dietitians

St Leonard’s Hospital London, D Block, 2nd Floor, Nuttal

Street, N1 5LZ. Tel: 020 7683 4267 Fax: 020 7014 7261

Email: nutritionanddietetics@homerton.nhs.uk

Goal Setting

Realistic and measurable goals should be set to assess the effectiveness of intervention e.g.

o Prevent further weight loss

o Maintain nutritional status

o Optimise nutrient intake during acute illness

o Healing of wounds or pressure ulcers

o Improved mobility

They can also be set to biochemical, functional, psychological or behavioural symptoms e.g. improvement in strength, physical appearance, appetite,

ability to perform activities of daily living.

Goals of intervention may need to be adjusted by the Dietitian accordingly depending on the disease stage. For example nutritional interventions in

some groups such as palliative care, patients undergoing cancer treatment, patients with progressive neurological conditions and those in advanced

stages of illness may not result in improvements in nutritional status, but may provide a valuable support to slow decline in weight and function.

Prescribing of ONS

Two supplements per day are usually recommended. Instruct to take’ between meals’. If more are required check compliance first. Exceptions are

those on liquid only diet.

Avoid prescribing less than the clinically beneficial dose of 2 bottles a day which will provide an extra 600-800kcals/day. 25-40g protein in 400mls.

Once daily prescriptions only provide 300- 400kcals 12-20g protein in 200mls which can easily be met with food fortification e.g. Fortified milk (1 pint

full fat milk with 4 tablespoons of skimmed milk powder added) contains up to 470kcal and 27g protein in 600mls. DO NOT prescribe 1kcal / ml

preparations unless advised by a Dietitian in writing.

Some powdered products such as Scandishake®, Enshake® and Calshake® are higher in calories so

only 1 sachet is required to provide 500-600kcals. These need to be made with 240ml full fat milk (blue top)

• Not all supplements are Kosher approved, Halal certified, vegetarian, gluten-free and lactose-free. Check the current BNF or company’s website for

product details.

If patients wish to continue taking ONS that are no longer indicated by ACBS criteria, OTC powdered supplements (ie M e r i t e n e E n g e r i s ™

( f o r m e r l y B u i l d U p ™ ) , C o m p l a n ™ , A y m e s R e t a i l ™ , s h o u l d b e m a d e w i t h f u l l f a t m i l k . R e a d y t o d r i n k

s u p p l e m e n t s Nutriment™, and Nurishment™ should be recommended rather than prescribing ONS.

Table of Recommended Cost Effective ONS Products First line products

Powdered Supplements Ready to drink (only for patients who have an intolerance to lactose)

Aymes Shake: 1st Line Fresubin Powder: 2nd Line (kosher)

Aymes Complete: 1st l ine Fresubin 2kcal: 2nd Line

Type of Oral Nutritional Supplement Product Name

Cost (£) April 16 MIMS

Nutrient per presentation Energy; protein

Quantity Replacing Unless dietician recommended

1st Line Complete milk-based powdered supplement Aim for 2 per day to be effective

Aymes ® Shake

(made up with 200mls full fat milk)

0.70 per 57g sachet

388 kcal; 15.8g

7x57g sachets per box 3192g for 28 days

Altraplen, Altraplen protein, Fresubin 2kcal drink, Ensure compact, Ensure Twocal, Fortisip, Fortisip Compact Ensure plus, Fresubin energy drink, Resource Energy

2nd Line (for pts who require Kosher products) Complete milk-based powdered supplement Aim for 2per day to be effective

Fresubin® Powder Extra

(made up with 200mls full fat milk)

0.76 per 62g sachet

397 kcal; 17.7g

7x 62g sachets per box 3742g for 28 days

Ready to drink supplements should only be prescribed for patients who are lactose intolerant or have other intolerances to powdered supplements. 1st Line Ready to drink supplement Aim for 2 per day to be effective

Aymes® Complete 1.26 per 200mls

300 kcal; 12g 200 ml bottles 11200 mls for 28 days

Ensure plus, Altraplen protein, Fresubin energy drink, Resource Energy, Fortisip

2nd line ready to drink supplement Aim for 1- 2 per day to be effective

Fresubin® 2kcal Drink*

1.98 per 200ml

400 kcal; 20g

200 ml bottles 5600 mls-11200 mls for 28 days

Aymes Shake 1st l ine choice for lactose tolerant patients that don’t require kosher approved supplements Fresubin powder extra 2nd line choice: for patients requiring a kosher approved product who don’t have lactose intolerance Aymes Complete 1st l ine product for lactose intolerant patients Fresubin 2kal 2nd l ine product for lactose intolerant and when a Kosher approved product is needed.

All other products should be initiated only by Dietitians Once patients have been started on ONS prescribers should review for tolerance and wei ght changes at every month where possible. Prescribers should notify the Dietitian of any changes and request a dietetic review where needed. Please check before re-prescribing ONS that patients have not been discharged by the Hospital and or Community Dietitian’s due to DNA Patients discharged will need a new written referral before they can be seen. Due to vitamin D3 content (animal source) none of the supplements are vegetarian

All other products should be started by a Dietitian ONLY and reviewed for tolerance and weight changes at least every three months by the practice. Notify the Dietitian of any changes and request a Dietetic review where needed. Patients may have been discharged by the Hospital and or Community Dietitian’s due to DNA and will therefore need a new written referral before they can be seen. NB The above guidance is for oral ( via the mouth) intake of supplements and not for enteral feeding tube intake. Powdered supplements products if not mixed correctly risk blocking the feeding tube. They are not sterile which increases the RISK of infection.

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SPECIAL GROUP PATIENTS Patients with diabetes can be given milk based or savoury supplements but blood glucose levels will

need careful monitoring and Diabetic medication may need to be altered. Juice type supplements

should be avoided due to their high sugar content, unless advised by dietitian. Sipping supplements

over an hour rather than taking all in one go improves blood sugar control.

Palliative care patients- in the final weeks of life the benefit from ONS supplement is more

complex (please confer with the dietetics department for advice). OTC supplements such as

Meritene Engeris™, Complan™, Nutriment™ and Nurishment™ may be a better option due to

palatability.

Care homes should provide adequate quantities of good quality food so the use of unnecessary

nutrition support is avoided (Standards for Care Home 2003). ONS should not be used as a

substitute for the provision of food. Suitable snacks, food fortification (see ‘food fact sheets for

patients’) as well as OTC products can be used to improve the nutritional intake of those at risk of

malnutrition and can be discussed with a dietitian. Nursing staff in care homes requesting

supplements should have referred the patient to the HUH Community Dietitians first.

Post hospital discharge . Many patients experience a loss of appetite in hospital due to change in

environment and stress and are supplemented with ONS without nutritional assessments. This may be

due to lack of nutritional snacks, knowledge, reduced capacity of dietetic support and extremely low

cost of ONS in the hospital setting.

This loss of appetite usually resolves on returning home, and does not warrant continuation of ONS.

Patients discharged on ONS, who previously were not on ONS, or has not been specifically

requested to continue ONS by the hospital dietitian, should have their nutritional status

assessed, ONS reviewed and stopped accordingly.

Patients who have been prescribed ONS on a dietitian request will usually have provided

additional information on the discharge summary.

Substance misusers. Care should be taken when prescribing supplements as once started, ONS

can be difficult to stop.

Supplements are often used to replace meals and therefore can be of negligible clinical

benefit

Often sold and used as a source of income

Can be poor clinic attendees therefore making it difficult to weigh them and re-assess need for

ONS

Clear goals should be set for patients who meet prescribing criteria

ONS should NOT be prescribed in substance misusers unless ALL the following criteria are met:

Assessed as high risk of malnutrition (MUST score of 2 or more)

there is a co-existing medical condition which could affect weight or food intake and meets the ACBS

criteria

once nutritional advice has been advised and tried

the patient is in a rehabilitation programme e.g. methadone or alcohol programme or on the waiting list to

enter a programme

If ONS is initiated:

•And the patient fails one appointment for monitoring then ONS should be discontinued

•If there is no change in weight (or other agreed treatment goals) after three months, ONS will be reduced and

discontinued

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Referral to the C Community Dietitians

PA

TIE

NT

D

ET

AILS

Male

Female

Patient’s Surname:

Forename:

Date of Birth:

Patient’s address: Telephone number:

Mobile number:

Any communication difficulties? Yes/No What?

Patient’s postcode:

Patient NHS number:

Reason for referral: Weight: Height: BMI:

Weight history:

MUST score:

Social information: Is the patient Housebound/immobile? YES / NO

On Child Protection Register or a vulnerable adult?: YES/NO

Medical details: (please include diagnosis, treatment and prognosis)

Relevant Medication: GP EMIS summary attached: YES / NO Relevant blood results (please state: cholesterol/HDL ratio, etc):

Ethnicity:

Advocate required: YES/NO – if YES, state language/dialect required:

Has the patient consented to this referral? Yes/No

Risk/health and safety issues for staff?

RE

FE

RR

ER

DE

TA

ILS

Referrer’s full name: Position:

Organisation and address with full postcode: Telephone number (and fax no. if available):

GP details (if referred by other member of the healthcare team):

Signature: Date referred:

Community Dietitians

St Leonard’s Hospital London, D Block, 2nd Floor, Nuttal Street, N1 5LZ.

Tel: 020 7683 4267 Fax: 020 7014 7261

Email: nutritionanddietetics@homerton.nhs.uk

NOTE: Referrals will be returned if details are in complete

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Produced by HUH Community Dietitians TEL 02076834267 Email:nutritionanddietetics@homerton.nhs.uk July 2016

FOOD FIRST - INSTRUCTIONS FOR PATIENTS

Patient Name: …………………………………….…………………… Date: …………………

Your Doctor/Health Care Professional is concerned about your dietary intake.

It is recommended you follow the instructions below for 4 weeks. Your Doctor/Health Care Professional will then review your progress.

If you live in a Care Home, these instructions are for your carers to follow.

INSTRUCTIONS:

TRY TO EAT EVERY THREE HOURS (three meals and three snacks every day)

FORTIFY AT LEAST TWO FOODS AT EACH MEAL *

HAVE AN ENRICHED MILKSHAKE ONCE A DAY *

CHECK YOUR WEIGHT ONCE A MONTH WITH YOUR GP, PRACTICE NURSE or DISTRICT NURSE

* PLEASE SEE BACK OF LEAFLET FOR RECIPES AND SNACK IDEAS

Health Care Professional: ………………………………………………………………………….

Contact Details: ………………………………………………………………………………………

Date Review Due:……………………………………………………………………………………..

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RECIPES FOR FORTIFYING FOODS

WHOLE MILK To make fortified milk, add 4 heaped tablespoons milk powder

to 1 pint whole milk, mix well. Use 1 pint of this per day.

FULL FAT SOYA MILK To make fortified soya milk, add 4 heaped tablespoon of soya protein powder to 1 pint calcium enriched soya milk, mix well. Use 1 pint of this per day.

BREAKFAST CEREAL Use fortified milk & add 2 teaspoon sugar or 1 tablespoon of dried fruit.

PORRIDGE To make up porridge use fortified milk; add cream & sugar / honey or dried fruit.

SOUP Use fortified milk & add grated cheese & 2 tablespoons cream or 1 tablespoon of vegetable oil.

MASHED POTATO Add grated cheese & 1 teaspoon margarine or 1 teaspoon

mayonnaise.

VEGETABLES Add 1 teaspoon margarine when serving or 1 teaspoon of vegetable oil.

CUSTARD / MILKY PUDDINGS Use fortified milk to make up or buy full fat variety. Add 1

tablespoon of cream & syrup or jam.

FRESH / TINNED FRUIT Serve with 2 tablespoon cream or evaporated/ condensed milk or fortified custard.

SPONGE PUDDING Add an extra 2 teaspoon jam/syrup over pudding when serving & serve with fortified custard / ice cream / cream.

FULL FAT YOGHURT Add 1 tablespoon cream and 2 tablespoons glucose powder or honey.

BREAD / TOAST / PITTA Serve with peanut butter / cheese / egg / tinned sardines / sliced chicken / hummus / mayonnaise / margarine

/ guacamole / vegetable oil.

RECIPE FOR ENRICHED MILKSHAKE 200mls fortified milk

Milkshake syrup / powder

add 1 scoop ice cream or

add 1 tablespoon double cream or evaporated/ condensed milk

EXAMPLES OF NOURISHING SNACKS

Cereal & full fat milk Cheese and biscuits Crème caramel *

Crumpet / hot cross bun / Teacake with margarine

Dried fruit and nuts Fruit cake / pie Ice cream *

Instant Whip/Delight *

Malt loaf with butter and cheese spread Scone with margarine & jam

Trifle * * Soft choices

EXAMPLES OF NOURISHING DRINKS AVAILABLE TO BUY Ready to Drink

NurishmentTM

NutramentTM

Powdered (use ⅓ pint of full fat milk) Meritene Engeris™ (formerly Build Up) Aymes Retail™

ComplanTM * Sweet & savoury flavours

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LINKS/ WEBSITES BAPEN British Association for Parenteral and Enteral Nutrition www.bapen.org.uk

Key documents and reports ‘MUST’ toolkit, including ‘MUST’, explanatory booklet, e-learning and ‘MUST’ calculator

NICE National Institute for Health and Clinical Excellence www.nice.org.uk

NICE CG32: Nutrition Support in Adults

E-Guidelines Clinical guidelines summaries for primary care www.eguidelines.co.uk

BDA British Dietetic Association www.bda.uk.com Information on food first approach, dietetic profession

NPC National Prescribing Centre www.npc.nhs.uk/quality/ONS/index.php

Prescribing of adult oral nutritional supplements (ONS). Guiding principles on improving the systems and processes for ONS use

References and recommended reading. Brotherton, A., Stroud, M. & Simmonds, N. (2010) ‘Malnutrition Matters: Meeting quality standards in nutrition care’ BAPEN Quality Group, BAPEN. Campbell, N. (2011) ‘ Dehydration: why is it still a problem? Nursing Times, Vol 107, No 22, pp 12-15. Cawood, A.L., Green, C. & Stratton, R. (2010) ‘The budget impact of oral nutritional supplements on older community patients at high risk of malnutrition in England’, Proceedings of the Nutrition Society, Volume, 69, OCE7, E544. Cawood A.L., Elia, M. & Stratton, R (2012). ‘Systematic review and meta -analysis of the effects of high protein oral nutritional supplements’ Ageing Res Rev 2012; 11:278-296. Elia, M. & Russell, C.A. (Eds) (2009) ‘Combating Malnutrition: recommendations for action: Report from the advisory group on malnutrition, led by BAPEN’, BAPEN. Elia M & Stratton RJ. (2009) ‘Calculating the cost of disease-related malnutrition in the UK in 2007 (public expenditure only’) in: Combating Malnutrition: Recommendations for Action. Report from the advisory group on malnutrition, led by BAPEN. Ferreira IM, Brooks D, White J, Goldstein R. Nutritional supplements for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Dec 12;12:CD000998. doi10.1002/14651858 CD000998.pub3. Review Gomes F et al. Risk of Malnutrition On Admission Predicts Mortality, length of Hospital Stay and Hospitalisation Costs at 6 months post Stroke. 2014; 45;A63 Guest, J. F., Panca, M., Baeyens, J.P., de Man, F., Ljungqvist, O., Pichard, C.,Wait, S & Wilson, L. (2011) ‘Health economic impact of managing patients following a community-based diagnosis of malnutrition in the UK’, Clinical Nutrition, Volume 30, Issue 4 , Pages 422-429, August 2011 Malnutrition Task Force (2013) ‘Cost of Malnutrition: Methods, Estimation and Projection, Jose Iparraguirre for the Malnutrition Task Force. National Institute for Health and Clinical Excellence (NICE). Clinical guideline 32. London: NICE, 2006. NICE (2012) ‘Quality Standard for Nutrition Support in Adults, NICE Quality Standard 24, guidance.nice.org.uk/qs24 NICE (2012b) ‘Implementation Programme - NICE support for commissioners and others using the quality standard on nutrition support in adults, November 2012. Parsons, E.L., Stratton, R.J., Jackson, J.M. & Elia, M. (2012) ‘ Oral Nutritional Supplements are cost effective in improving quality adjusted life years in malnourished care home residents’, Gut, Vol 61, Suppl 2, pp A17. Russell, C. A. & Elia, M. (2011) ‘Nutrition Screening Survey in the UK and Republic of Ireland in 2010; A report by the British Association of Parenteral and Enteral Nutrition (BAPEN) Hospital Care Homes and mental Health units’ BAPEN.