Area Prescribing Committee
Oral Nutrition Support Guidelines for Adults 2014
1. Aim
To support prescribers in providing effective patient centred oral nutrition support
throughout Barnsley. When using this guide, please consider whether the patient is
already under the care of a Dietician, or whether they would benefit from a dietetic referral.
A flow chart summarising the guidance can be found in appendix 1.
2. Nutritional Screening
NICE Clinical Guideline 32 (Nutrition Support in Adults, 2006) recommends that all adults
in the community are screened for nutritional risk:
 Within primary care on initial registration and where there is clinical concern.
Screening should also be considered at other opportunities (for example, health
checks, flu injections)
 On admission into care homes and where there is a clinical concern
 On a monthly basis when identified at risk.
A validated screening tool should be used. The Malnutrition Universal Screening Tool
(MUST) is a validated screening tool to identify adults who are malnourished or at risk of
malnutrition. The tool has been developed by the Malnutrition Advisory Group of The
British Association for Parenteral and Enteral Nutrition (BAPEN) and can be accessed
online at http://www.bapen.org.uk/screening-for-malnutrition/must/introducing-must.
An
online calculator is also available http://www.bapen.org.uk/screening-for-malnutrition/mustcalculator. The MUST tool uses various nutritional measurements (weight, body mass
index, weight loss) and also takes into consideration the effect of acute disease to
determine an overall malnutrition risk score (0=low risk, 1=medium risk, 2 or more=high
risk).
NICE recommend that nutrition support should be considered in people who are
malnourished or at risk of malnutrition:
 BMI <18.5kg/m2
 Unintentional weight loss >10% in the past 3-6 months
 BMI<20kg/m2 and unintentional weight loss >5% in the past 3-6 months
3. Assess underlying causes, treat and refer
The following points should be considered before nutritional supplements are prescribed:
o Is there any underlying cause of weight loss?
o Are there any swallowing/chewing problems (including poor fitting dentures and
poor dentition)?
o Does the patient have any existing dietary restrictions e.g. coeliac disease, lactose
intolerance, diabetes?
o Are there any GI symptoms such as nausea, vomiting, constipation and/or
diarrhoea?
o Does the patient have poor absorptive capacity and/or high nutrient losses and/or
increased nutritional needs from causes such as metabolism?
o Is the patient experiencing any social/financial difficulties which might contribute to
a poor diet?
1
If answering ‘yes’ to any of the above points, consider referring to, treating or providing
information on, the following as appropriate:
o Further investigations into cause of weight loss
o Speech and language therapy assessment for dysphagia
o Dentist
o Age UK, Social Services, Care Agencies
o Treatment for symptoms such as constipation, nausea, vomiting, diarrhoea
4. Referral to Dietitian
Consider dietetic referral in any of the following circumstances:
 to advise on nutritional supplementation strategies and the appropriateness of
initiating oral nutritional supplements
 to assist in appropriate goal setting for individual patients
 when there is deterioration in nutritional status despite supplementation after
excluding other contributory pathology
 when there is apparent requirement for oral nutritional supplements beyond three
months
 where there are cultural, social, religious or financial influences affecting dietary
intake
 when the patient has co existing medical conditions e.g. diabetes, renal failure,
coeliac disease or high cardiovascular risk
 where there are swallowing difficulties and a modified texture diet has been advised
by a Speech and Language Therapist
 where there is unexplained weight loss and/or poor wound healing/skin integrity
 where there has been no improvement in nutritional intake despite advice about
food fortification and oral nutritional supplements
5. Dietary Advice – ‘Food First’
Prior to prescribing oral nutritional supplements, first line treatment should be the use of
fortified appropriate normal food. The current dietary priority should be made clear to the
patient i.e. it is more important to treat the acute malnutrition; blood glucose and
cholesterol levels can be considered separately.
Advise the patient to:
- eat three regular meals and two to three snacks daily that are high in calories and
protein.
Each meal or snack should be as nourishing as possible by
enriching/fortifying foods with extra fat and sugar. For example:
o Add extra butter or cheese to potatoes and vegetables
o Add cream to sauces and milk puddings
o Add sugar, honey, syrup or jam to cereals and puddings
o Full fat milk can be fortified by adding 2-4 tablespoons of skimmed milk powder
to 1 pint full fat milk for use throughout the day
-
buy full fat products e.g. full cream milk, thick and creamy yoghurts etc. and to avoid
diet, ‘light’ and ‘low fat’ products
-
introduce nourishing drinks e.g. milky coffee, malted milk drinks, hot chocolate,
smoothies and milk shakes. Homemade fortified drinks can be easily prepared (a
patient recipe sheet is available).
2
-
avoid drinking liquids just before a meal as this can lead to early satiety.
The patient should also be provided with written advice:
‘A Nourishing Diet’ patient information leaflet (this can be printed as a booklet).
Nourishing drinks.
.
6. Review of progress
A review of compliance, aims and general condition should be carried out in no more than
four weeks. An improvement could be defined as:
 halting weight loss
 improvement in appetite
 improvement in general well being
 improvement in wound healing/skin condition
The following should be checked and recorded:
 patient’s weight and weight change
 body mass index
 dietary changes
 change in appetite
 symptoms which might affect food intake e.g. nausea, diarrhoea
 wound healing if appropriate
7. Over the counter nutritional supplements
If, on review, ‘food first’ advice has been followed without the desired result, it may be
appropriate to consider recommending an over the counter oral nutritional supplement.
The patient should be advised to take the supplements between meals.
Name
Complan
Manufacturer
Complan
Foods
Presentation
4 sachets per
box
Approximate
Cost (RRP)
£3.32
(83p per unit)
Instructions
Available
from
Reconstitute
with milk or
water
Community
Pharmacy
Supermarkets
Build Up
Shake
Build Up
Soup
Nestle
Nestle
4 sachets per
box
4 sachets per
box
£2.99
(75p per unit)
£3.44
(86p per unit)
Mix with milk
Reconstitute
with hot
water
Community
Pharmacy
Supermarkets
Community
Pharmacy
Supermarkets
Flavours
Original,
Chocolate,
Strawberry,
Banana,
Chicken,
Vegetable,
Oats,
Vanilla
Banana,
Chocolate,
Strawberry,
Vanilla,
Tomato,
Chicken,
Potato &
leek,
Vegetable
8. Use of oral nutritional supplements on prescription
If, after a further four weeks of using an over the counter nutritional supplement, there has
been no improvement, consider prescribing a 1.5kcal/ml oral nutritional supplement for up
3
to a four week trial period (usually 1-2 supplements per day) if the patient meets the ACBS
criteria detailed below. Please refer to Appendix 2 for guidance, and consider the
following points:
 Patient preference; milk, juice or yoghurt style supplement drink and choice of
flavours
 Powdered supplements or ready to drink. Aymes Shake® or Complan Shake®
are cost effective first line options when a powdered supplement for
reconstitution with milk is considered appropriate.
 The volume of fluid the patient is able to tolerate
 A ‘nutritionally complete’ supplement is not always necessary if it is being used
to supplement the diet as the patient should obtain the majority of nutrients from
normal food
Oral nutritional supplements should only be prescribed for the following approved standard
ACBS indications (Drug Tariff June 2014):
 disease related malnutrition
 intractable malabsorption
 pre operative preparation of malnourished patients
 dysphagia
 proven inflammatory bowel disease
 following total gastrectomy
 short bowel syndrome
 bowel fistulae
Clear goals should be set and patients should be monitored frequently (see point 6).
Substance misuse patients – please note that prescription of oral nutritional
supplements for this patient group does not meet ACBS criteria. There are reports of
supplements being traded as street currency.
Patients with dementia – please note that prescription of oral nutritional supplements for
this patient group does not meet ACBS criteria. Other strategies such as food fortification,
finger foods and the inclusion of regular non-prescribable nourishing drinks should be the
treatment of choice in this patient group.
Prescribing Advice
 Prescribe oral nutritional supplements as an acute prescription where possible as
long term use is seldom indicated.
 Do not automatically add oral nutritional supplements to a repeat prescription.
 Specify the directions e.g. sip the contents of one carton between meals.
 Do not use ‘as directed’ or ‘when required’.
 Prescribe a two week supply initially or prescribe starter packs to enable the
suitability of the supplement to be reviewed before further prescriptions are issued.
Patient Advice:
 Patients should still be encouraged to eat regular meals and snacks, and
continue food fortification methods as outlined above
 Oral nutritional supplements should not be used as meal replacements and
should be sipped between meals
 Oral nutritional supplements should only be used for a short period of time until
goals are achieved
4
9. Review of oral nutritional supplements on prescription
Following the four week trial period of oral nutritional supplements on prescription,
progress and compliance should be reviewed (see point 6, above). Consider stopping
prescription if targets have been achieved. Use clinical judgement to determine whether
repeat prescription is necessary. Review prescription on a four weekly basis. Please
refer to a Dietitian as outlined in point 4.
10. Hospital Discharge
Oral Nutritional Supplements can often be prescribed for patients during hospital
admission. Oral nutritional supplements may be included on the discharge summary and a
small supply provided for the patients to take home. In the absence of written
correspondence from a dietician, patients should be assessed prior to continuing to
prescribe oral nutritional supplements commenced by secondary care.
References
NICE (2006) Clinical Guideline 32, Nutrition Support in Adults
(http://www.nice.org.uk/CG32)
Drug Tariff June 2014
MIMS June to August 2014
British Association of Parenteral and Enteral Nutrition (BAPEN) (http://www.bapen.org.uk/)
Further Information
British Dietetic Association (www.bda.uk.com)
Originally produced December 2011
Reviewed June 2014
Ratified by Barnsley Area Prescribing Committee: November 2014
Next Review Due: November 2016
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Appendix 1 – Nutrition Support Flow Chart for Adults
Establish whether the patient is malnourished or at risk of malnutrition taking into
consideration the NICE criteria/ MUST score
 BMI <18.5kg/m2
 Unintentional weight loss >10% in the past 3-6 months
 BMI<20kg/m2 and unintentional weight loss >5% in the past 3-6 months
 MUST score (0 = low risk, 1 = moderate risk, 2 = high risk)
Consider referral to a Dietician - see point 4 (page 2) for further guidance
Food First
Prior to prescribing oral nutritional supplements first line treatment should be the use of fortified
appropriate normal food. This includes advice on the following:
 3 regular meals and 2-3 snacks daily that are high in calories and protein
 Include nourishing drinks e.g. milky coffee, malted milk drinks, hot chocolate, smoothies
 Fortify normal food with extra fat and sugar where possible
o Add 2-4 tablespoons of skimmed milk powder to 1 pint full fat milk and use throughout
the day
o Buy full fat versions of food, avoiding ‘diet’, ‘light’ and ‘low fat’ products
 Provide written information (‘A Nourishing Diet patient information leaflet and
nourishing drinks recipes)
≤ 4 weeks
First review of progress
A review of compliance, aims and general condition should be carried out in no more than 4 weeks.
An improvement could be defined as:
 halting weight loss
 improvement in appetite
 improvement in general well being
 improvement in wound healing/skin condition
ACBS criteria met)
If, after a further 4 weeks using over the counter ONS, there has been no improvement, consider
prescribing a 1.5kcal/ml ONS for up to a four week trial period (usually 1-2 supplements per day).
Consider
the useShake®
of overorthe
counter
nutritional
supplements
Consider Aymes
Complan
Shake®
as cost
effective first line options where appropriate
If,
on review,
‘food first’with
advice
has
been
followed
withoutguidance
the desired
may be appropriate to
(require
reconstitution
milk).
.See
page
3 for further
andresult,
ACBSit indications
consider recommending an over the counter nutritional supplement – see table (page 3)
4 weeks
Second review– use of oral nutritional supplement on prescription (if ACBS criteria met)
If, after a further 4 weeks of using over the counter supplement, there has been no improvement,
consider prescribing a 1.5kcal/ml ONS for up to a four week trial period (usually 1-2 supplements per
day). Consider Aymes Shake® or Complan Shake® as cost effective first line options where
appropriate (require reconstitution with milk). See page 3 for further guidance and ACBS indications
4 weeks
Review of oral nutritional supplement on prescription
Following the 4 week trial period on ONS on prescription, progress and compliance should be
reviewed (as above). Consider stopping prescription if targets have been achieved. Use clinical
judgement to determine whether repeat prescription is necessary. Review prescription on a 4 weekly
basis. Please refer to a Dietician for specialist intervention if targets have not been achieved
6
Appendix 2 – Oral Nutritional Supplements First Line Choices
Milkshake style first line supplement choices – require reconstituting with full cream milk
Product
Volume
of milk
required
Energy
(kcal)
Protein
(g)
Fibre
(g)
Aymes Shake
(57g)
200ml
388
15.6
0.1
Complan
Shake (57g)
200ml
387
15.6
0.2
Gluten Free = GF
Lactose Free = LF
ACBS Indications
Cost per unit (MIMS June-August 2014),
presentation & flavour
No
GF
Standard
Sachet: 57g = £0.78. Neutral, vanilla,
strawberry, chocolate or banana
No
GF
Standard
Sachet: 57g = £0.90. 4 × 57 g = £3.60.
Banana, chocolate, original, strawberry,
vanilla. Starter pack: 5 × 57 g = £5.07
Nutritionally
Complete?
Ready to drink milkshake style first line supplement choices
Product
Volume
Energy
(kcal)
Protein
(g)
Fibre
(g)
Ensure Plus
milkshake
style
Fortisip Bottle
220ml
330
13.8
0
Nutritionally
Complete?
Gluten Free = GF
Lactose Free = LF
ACBS Indications
Cost per unit (MIMS June – August 2014),
presentation & flavour
GF, LF
Standard criteria
(also CAPD &
haemodialysis)
Standard criteria.
Not suitable for
child under 3 years;
use with caution in
child 3–5 years
Standard criteria;
also CAPD,
haemodialysis
Standard criteria.
Not suitable for
child under 3 years;
use with caution in
child 3–5 years
£2.02. Banana, , chocolate, coffee, fruits of
the forest, orange, peach, raspberry,
strawberry, vanilla, neutral
£2.06. Banana, chocolate, neutral, orange,
strawberry, caramel/coffee, tropical fruits,
vanilla,
Yes in 5 units
200ml
300
12
0
GF, LF
Yes in 4-4.5
units
Ensure Plus
Fibre
200ml
Fortisip
Multifibre
200ml
310
13
5
GF, LF
Yes in 5 units
300
12
4.6
GF, LF
Yes in 4-4.5
units
£2.02. Banana, chocolate, fruits of the
forest, raspberry, strawberry, vanilla,
chocolate
£2.09. Vanilla
7
Juice style first line supplement choices
Product
Volume
Energy
(kcal)
Protein
(g)
Fibre
(g)
Ensure
Plus Juce
Fortijuce
220ml
330
10.6
0
200ml
300
8
0
Nutritionally
Complete?
No
No
Gluten Free = GF
Lactose Free = LF
ACBS
Indications
Cost per unit (MIMS June-August 2014),
presentation & flavour
GF, LF
Standard
GF, LF
Standard. Not
suitable for child
under 3 years;
use with caution
in child 3–5 years
£1.97. Apple, fruit punch, lemon-lime, orange,
peach, strawberry
Bottle: 200 mL = £1.85. Apple, black currant,
forest fruits, lemon, orange, strawberry, tropical.
Starter pack (mixed): 200 mL = £2.02
Yoghurt Style first line supplement choices
Product
Volume
Energy
(kcal)
Protein (g) Fibre
(g)
Ensure Plus 220ml
Yoghurt
Style
Fortisip
200ml
Yoghurt
Style
330
13.8
0
300
12
0.4
Fresubin
YoCreme
187
9.3
0
125g
Nutritionally
Complete?
Gluten Free = GF
Lactose Free = LF
Yes in 5 units GF, LF
Yes in 3.5-5
units
No
GF
GF
ACBS Indications Cost per unit (MIMS June-August 2014),
presentation & flavour
Standard; also
CAPD,
haemodialysis
Standard. Not
suitable for child
under 3 years; use
with caution in child
3–5 years
Standard
£2.02. Peach, strawberry
£2.02. Peach-orange, raspberry, vanilla-lemon,
peach-orange
Pot 125g = £1.93 apricot-peach, biscuit, lemon,
neutral, raspberry
Savoury style first line supplement choices
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Product
Volume
Ensure Plus
220ml
Savoury
Fortisip Savoury 200ml
Multifibre
Energy
(kcal)
Protein
(g)
Fibre (g) Nutritionally
Complete?
Gluten Free = GF
Lactose Free = LF
ACBS Indications Cost per unit (MIMS June-August 2014),
presentation & flavour
330
14.0
0
Yes in 4 units
GF, LF
Standard
300
15.0
4.6
Yes in 4-7.5
units
GF, LF
£2.16 cream of chicken
Standard. Not
suitable for
children under 3
years, or as a sole
source of nutrition
for children under
6 years
£2.02 chicken, mushroom
Low volume supplement choices – should only be prescribed on the advice of a dietician
Product
Volume
Energy
(kcal)
Protein
(g)
Fibre
(g)
Nutritionally
Complete?
Gluten Free = GF
Lactose Free = LF
ACBS Indications
Cost per unit (MIMS June-August 2014),
presentation & flavour
Ensure
TwoCal
200ml
399
16.8
2.0
Yes in 5 units
GF, LF
£2.22. Banana, neutral, strawberry, vanilla
Fortisip
Compact
125ml
300
12
0
Yes in 4-5
units
GF
Ensure
Compact
125ml
300
12.75
0
Yes in 4-5
units
GF
Standard; also
haemodialysis,
CAPD
Standard. Not
suitable for child
under 3 years; use
with caution in child
3–5 years
Disease related
malnutrition
£2.02. Apricot, banana, chocolate, forest fruits,
mocha, strawberry, vanilla.
£2.02 Vanilla, strawberry, banana
9