When to use oral nutrition supplements (ONS) in primary care

Nutrition support should be considered in people who are malnourished, as defined by any of the following:

• a body mass index (BMI) of less than 18.5 kg/m2
• unintentional weight loss greater than 10% within the last 3-6 months
• a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3-6 months.

Nutrition support should be considered in people at risk of malnutrition who, as defined by any of the following:

• have eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for the next 5 days or longer
• have a poor absorptive capacity, and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism

Healthcare professionals should consider using oral, enteral or parenteral nutrition support, alone or in combination, for people who are either malnourished or at risk of malnutrition, as defined above. Potential swallowing problems should be taken into account.

Screening for malnutrition and the risk of malnutrition in hospital and the community

• screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training
  • all hospital inpatients on admission and all outpatients at their first clinic appointment should be screened. Screening should be repeated weekly for inpatients and when there is clinical concern for outpatients
    • hospital departments who identify groups of patients with low risk of malnutrition may opt out of screening these groups. Opt-out decisions should follow an explicit process via the local clinical governance structure involving experts in nutrition support
  • people in care homes should be screened on admission and when there is clinical concern
  • screening should take place on initial registration at general practice surgeries and when there is clinical concern. Screening should also be considered at other opportunities (for example, health checks, flu injections)
  • screening should assess body mass index (BMI) and percentage unintentional weight loss and should also consider the time over which nutrient intake has been unintentionally reduced and/or the likelihood of future impaired nutrient intake.The Malnutrition Universal Screening Tool (MUST), for example, may be used to do this

Indications for oral nutrition supplementation

• healthcare professionals should consider oral nutrition support to improve nutritional intake for people who can swallow safely and are malnourished or at risk of malnutrition as defined above
• healthcare professionals should ensure that the overall nutrient intake of oral nutrition support offered contains a balanced mixture of protein, energy, fibre, electrolytes, vitamins and minerals
• if there is concern about the adequacy of micronutrient intake, a complete oral multivitamin and mineral supplement providing the reference nutrient intake for all vitamins and trace elements should be considered by healthcare professionals with the relevant skills and training in nutrition support who are able to determine the nutritional adequacy of a patient's dietary intake
• oral nutrition support should be stopped when the patient is established on adequate oral intake from normal food

Monitoring and Stopping Supplementation for Malnutrition

• people having oral nutrition support and/or enteral tube feeding in the community should be monitored by healthcare professionals with the relevant skills and training in nutritional monitoring
  • people should be monitored every 3-6 months or more frequently if there is any change in their clinical condition
  • some of the clinical observations may be checked by patients or carers. If clinical progress is satisfactory, laboratory tests are rarely needed

Notes:

• oral nutritional supplements (ONS) are typically used in addition to the normal diet, when diet alone is insufficient to meet daily nutritional requirements
• ONS
  • not only increase total energy and protein intake, but also the intake of micronutrients
  • do not reduce intake of normal food
  • are a clinically and cost effective way to manage malnutrition particularly amongst those with a low BMI (BMI < 20kg/m2)
  • increase energy and protein intakes, can improve weight and have functional benefits (e.g. improved hand grip strength)
  • benefits of ONS include reductions in complications (e.g. pressure ulcers, poor wound healing, infections) and mortality (in acutely ill older people)
  • clinical benefits of ONS are often seen with: 300-900kcal/day (e.g. 1-3 ONS servings per day) with benefits seen in the community typically with 2-3 month's supplementation
    • however, supplementation periods maybe shorter, or longer (up to 1 year), according to clinical need.

Reference:

1. NICE. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical guideline [CG32]. Published: February 2006 Last updated: August 2017