Register for updates

Pathway For Using ONS In The Management of Malnutrition

Oral Nutritional Supplements (ONS)

Oral Nutritional Supplements (ONS) are multi-nutrient products designed to provide additional calories, protein and micronutrients. There are a wide range of ONS styles (milk, juice, yoghurt, savoury), formats (liquid, powder, pudding, pre-thickened), types (high protein, fibre containing, low volume) energy densities (1-2.4kcal/ml) and flavours available to suit a wide range of needs.

Most ONS provide ~300kcal, 12g of protein and a full range of vitamins and minerals for serving16.

Visit www.bnf.org (Registration Required) Visit www.mims.co.uk

Malnutrition Overview

The term malnutrition can refer to both over and under nutrition. In this guide, malnutrition refers to under nutrition; a deficiency of energy, protein and other nutrients that causes adverse effects on the body (shape, size and composition), the way it functions and clinical outcomes1. Most malnutrition is disease related, although some social and mechanical (e.g. dentition) factors can also have an impact2.

Individual identified as high risk

High Risk

Individual identified as high risk of malnutrition according to MUST.

Identification of Malnutrition

Malnutrition can be identified using a validated screening tool such as the ‘Malnutrition Universal Screening Tool’ (‘MUST’)1. For ‘MUST’ see BAPEN or e-Guidelines Website.

‘MUST’ is a 5 step screening tool that can be used across care settings to identify adults who are malnourished or at risk of malnutrition. ‘MUST’ includes management guidelines and alternative measures when BMI cannot be obtained by measuring weight and height1.

Dietary advice to maximise nutritional intake. Record intake for 3 days, encourage small frequent meals and snacks, with high energy and protein food and fluids13.

Prescribe oral nutritional supplements (ONS) and monitor.

On improvement, consider managing as medium risk.

If no improvement or more specialist support is required, refer to Dietitian.

Step 2

Record details of malnutrition risk.

Record Details of Malnutrition Risk

Include; details of screening (weight, previous weight, BMI), screening result, risk category or clinical judgement. Record actions taken to manage malnutrition risk.

Agree goals of intervention.

Goal Setting

Agree goals of intervention with individual/carer

Goal Setting

Set goals to assess the effectiveness of intervention e.g. prevent further weight loss, maintain nutritional status, optimise nutrient intake during acute illness, healing of wounds or pressure ulcers, improved mobility

Consider disease stage and treatment; adjust goals of intervention accordingly. 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.

Consider underlying symptoms and cause of malnutrition

Underlying Symptoms and Cause

Symptoms of disease or side effects treatment which may affect appetite and oral intake e.g. nausea, constipation, pain, diarrhoea. Treat or aim to alleviate symptoms where possible e.g. anti-emetics, pain control.

Consider social requirements

Social Requirements

For example: ability to collect prescriptions, storage at home if large volumes prescribed (may need to provide shorter repeat prescriptions).

Some individuals with a low income may need signposting on where to receive benefits advice to ensure food can be purchased.

Reinforce advice to optimise oral intake*.

Optimise Food Intake

Confirm individual is able to eat and drink; address any physical issues e.g. dysphagia, dentures.

Optimise Oral Intake

Dietary advice to optimise oral intake (also known as ‘food first’)

Everyday foods (e.g. cheese, full fat milk) added to the diet to increase energy and protein content without increasing volume of food consumed. Check with local Dietitians or primary care commissioning group for local policy and guidance. For more information refer to Manual of Dietetic Practice13.

Small frequent meals and snacks, with food and fluids high in energy and protein.

Powdered nutritional supplements are available.

Overcome potential barriers to oral intake: physical (e.g. dentition, illness related loss of appetite), mechanical (e.g. need for modified texture diet/thickened fluids) and environmental (e.g. unable to prepare food)2. Consider referral to other healthcare professionals such as Dietitian, Occupational Therapist, Speech and Language Therapist.

There is some evidence for managing malnutrition with dietary advice (food first) alone. However, data on clinical outcomes or cost is limited19.

Care should be taken when using food fortification to ensure that requirements for all nutrients including protein and micronutrients are met7. Consider a multivitamin and mineral supplement

Acute and chronic disease may adversely affect appetite and the ability to source and prepare meals and drinks. Dietary advice can only be effective if acceptable and feasible to the individual.

Step 3

Acute illness/recent hospital discharge:

Short-term nutritional support

Confirm need for ONS

Need for ONS

Is individual able to manage adequate nutritional intake from food alone? e.g. how much of their meals are they usually eating and how does this compare to their normal intake?

Where intake remains inadequate, ONS prescription for 4-6 weeks (1-3 ONS per day)** in addition to oral intake15.

1-3 ONS per day

Most ONS provide ~300kcal, 12g of protein and a full range of vitamins and minerals per serving16.

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 7,17,20, however supplementation periods maybe shorter, or longer (up to 1 year) according to clinical need

If a continuation from hospital prescription, confirm need using screening tool1.

Consider ACBS indications.

Prescribable Indications

For more information

Prescribable indications - ACBS (Advisory Committee for Borderline Substances) indications for prescribing standard oral nutritional supplements (ONS)15.

Disease related malnutrition

Short bowel syndrome

Intractable malabsorption

Pre-operative preparation of undernourished patients

Inflammatory bowel disease

Total gastrectomy

Dysphagia

Bowel fistulae

Step 2
Step 3

Chronic conditions

Chronic Conditions

For Example: COPD, cancer, frail elderly.

Longer term nutritional support when food approaches alone are insufficient

2 ONS per day (range 1-3) in addition to oral intake, 12 week duration according to clinical condition/ nutritional needs7,17,18.

2 ONS Per Day

Most ONS provide ~300kcal, 12g of protein and a full range of vitamins and minerals per serving16.

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 7,17,20, however supplementation periods maybe shorter, or longer (up to 1 year) according to clinical need

Prescribe 1 'starter pack', then 60 preferred ONS per month

Commencing Oral Nutrition Supplements (ONS)

Aim to establish preferred flavours, likes and dislikes e.g. milk or juice, sweet or savoury.

Test preferences and compliance with a prescribable ‘starter pack’ (offers a range of products/flavours).

Prescribe preferred product or range of products/flavours; 2 ONS per day (1-3 per day), initially for up to 3 months (see flow chart for guidance)7,17,18,20,21.

For those that require ONS as a sole source of nutrition and those with complex nutritional needs referral to a Dietitian is recommended.

Modular ONS that provide only one or two nutrients should be used under dietetic supervision.

Consider ACBS indications

Prescribable Indications

For more information

Prescribable indications - ACBS (Advisory Committee for Borderline Substances) indications for prescribing standard oral nutritional supplements (ONS)15.

Disease related malnutrition

Short bowel syndrome

Intractable malabsorption

Pre-operative preparation of undernourished patients

Inflammatory bowel disease

Total gastrectomy

Dysphagia

Bowel fistulae

Step 2

Monitor compliance after 6 weeks

Compliance

Check compliance to ONS; is the individual taking the recommended volume, finishing bottles/units, do they like or dislike the taste/texture. Amend type/flavour if necessary to maximise intake.

Step 2

Monitor progress after 4 - 6 weeks

Progress

Review progress against goals set before intervention. Consider weight change, physical appearance, appetite, ability to perform activities of daily living.

Monitor progress as recommended depending on malnutrition risk or reason for ONS (e.g. acute/chronic), or sooner if there is clinical concern e.g. unintentional weight loss, appears thin, fragile skin, poor wound healing, pressure ulcers, apathy, wasted muscles, poor appetite, altered taste sensation, impaired swallowing, altered bowel habit, loose fitting clothes or prolonged intercurrent illness.

Step 3

Monitor progress after 12 weeks

Progress

Review progress against goals set before intervention. Consider weight change, physical appearance, appetite, ability to perform activities of daily living.

Monitor progress as recommended depending on malnutrition risk or reason for ONS (e.g. acute/chronic), or sooner if there is clinical concern e.g. unintentional weight loss, appears thin, fragile skin, poor wound healing, pressure ulcers, apathy, wasted muscles, poor appetite, altered taste sensation, impaired swallowing, altered bowel habit, loose fitting clothes or prolonged intercurrent illness.

Step 3

Goals met/Good progress:

Goals Met/Good Progress

Goals of intervention have been met e.g. weight loss attenuated, nutritional status maintained throughout acute episode which has passed or where progress has been made against goals e.g. pressure ulcer/wound healing, mobility improving.

Encourage oral intake and dietary advice

Consider reducing to 1 ONS per day for 2 weeks before stopping

Maximise nutritional intake

Monitor progress, consider treating as medium risk

Monitor Progress

Review progress against goals set before intervention. Consider weight change, physical appearance, appetite, ability to perform activities of daily living.

Monitor progress as recommended depending on malnutrition risk or reason for ONS (e.g. acute/chronic), or sooner if there is clinical concern e.g. unintentional weight loss, appears thin, fragile skin, poor wound healing, pressure ulcers, apathy, wasted muscles, poor appetite, altered taste sensation, impaired swallowing, altered bowel habit, loose fitting clothes or prolonged intercurrent illness.

Medium Risk

Dietary advice to maximise nutritional intake. Record intake for 3 days, encourage small frequent meals and snacks, with high energy and protein food and fluids13.

Powdered nutritional supplements to be made up with water or milk are available13.

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'.

Goals not met/Limited progress:

Goals Not Met/Limited Progress

Goals of intervention have not been met e.g. weight loss is on-going or there has been limited progress e.g wound healing slowly or not improving.

Check ONS compliance

Compliance

Check compliance to ONS; is the individual taking the recommended volume, finishing bottles/units, do they like or dislike the taste/texture. Amend type./flavour if necessary to maximise intake

Oral nutritional supplements (ONS) – range and selection of products

There are a wide range of ONS styles (milk, juice, yoghurt, savoury), formats (liquid, powder, pudding, pre-thickened), types (high protein, fibre containing, low volume) energy densities (1-2.4kcal/ml) and flavours available to suit a wide range of needs.

Most ONS provide ~300kcal, 12g of protein and a full range of vitamins and minerals per serving16.

The majority of people requiring ONS can be managed using standard ONS (1.5-2.4kcal/ml); these are often used for people who are frail, elderly or with diagnoses of dementia, COPD and cancer.

High protein ONS are suitable for individuals with wounds, post-operative patients, some types of cancer, and the elderly

Fibre-containing ONS are useful for those with constipation (not suitable for those requiring a fibre-free diet)

Pre-thickened ONS and puddings are available for individuals with neurological conditions that affect their swallow

Small volume high energy dense ONS may aid compliance22,23, and may be better tolerated by patients who cannot consume larger volumes

Reassess clinical condition, consider more intensive nutrition support or seek advice from a registered Dietitian

Clinical Condition

Consider whether clinical condition has changed. If there has been a deterioration or complications, more intensive nutrition support e.g. enteral tube feeding, or specialist advice from a Dietitian e.g. disease specific ONS may be required.

Consider goals of intervention

Goals Of Intervention

Consider original goals of intervention set and whether clinical condition has changed e.g. disease progression. ONS may be provided as support for individuals with deteriorating conditions.

If no improvement, seek advice from a Dietitian.

Review individuals on ONS every 3-6 months or upon change in clinical condition7.

Review

Review goals set before intervention. Consider weight change, physical appearance, appetite, ability to perform activities of daily living.

Change In Clinical Condition

An individual who is clinically stable or improving may only require review every 3-6 months, however if there is a change in condition or acute event, more frequent review may be required and ONS dose adjusted accordingly.

When to stop ONS prescription

Goals of intervention have been met and individual is no longer at risk of malnutrition.

Goal Setting

Agree goals of intervention with individual/carer

Goal Setting

Set goals to assess the effectiveness of intervention e.g. prevent further weight loss, maintain nutritional status, optimise nutrient intake during acute illness, healing of wounds or pressure ulcers, improved mobility

Consider disease stage and treatment; adjust goals of intervention accordingly. 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.

Individual is clinically stable/acute episode has abated.

Individual is back to their normal eating and drinking pattern7

If no further clinical input would be appropriate

Appropriate

Continuing a prescription may not be appropriate if there is no benefit to the individual e.g. end of life care.

ONS – oral nutritional supplements/sip feeds/nutrition drinks (BNF section 9.4.2)16.

Oral Nutritional Supplements (ONS)

There are a wide range of ONS styles (milk, juice, yoghurt, savoury), formats (liquid, powder, pudding, pre-thickened), types (high protein, fibre containing, low volume) energy densities (1-2.4kcal/ml) and flavours available to suit a wide range of needs.

Most ONS provide ~300kcal, 12g of protein and a full range of vitamins and minerals for serving16.

Visit www.bnf.org Visit www.mims.co.uk Continue to Oral Nutritional Supplements (ONS)

Advice on ONS prescription according to consensus clinical opinion. ONS prescription-units to prescribe per day e.g. 2 ONS = 2 bottles/units of ONS per day.

2 ONS = 2 bottles/units of ONS per day

Most ONS provide ~300kcal, 12g of protein and a full range of vitamins and minerals per serving16.

* For more detailed support or complex conditions seek advice from a Dietitian

**Some individuals may require more than 3 ONS per day – seek dietetic advice

NOTE: ONS requirement will vary depending on nutritional requirements, patient condition and ability to consume adequate nutrients, ONS dose and duration should be considered

Nutritional Requirements

Nutritional requirements can be altered in disease, increasing requirements for nutrients such as protein.

ONS Dose And Duration

Most ONS provide ~300kcal, 12g of protein and a full range of vitamins and minerals per serving16.

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 7,17,20, however supplementation periods maybe shorter, or longer (up to 1 year) according to clinical need.

Download full document Survey What the experts say
Download The Pathway For Using ONS In The Management Of Malnutrition

Contact us

If you would like to contact us regarding the malnutrition pathway materials and website please email: hilary@franklincoms.co.uk

Open Popup

This information is for healthcare professionals only:

Please confirm if you are a professional patient or carer below

General Practitioner
Dietitian
Nurse
Pharmacist
Speech & Language Therapist
Student
Patient
Carer
Other:

* = required

Would you like to request an A4 or A3 printed poster (UK only)?

Please contact hilary@franklincoms.co.uk if you would like multiple copies of the poster.


The information you have provided will be used to notify you of future initiatives and developments related to 'Managing Adult Malnutrition in the Community' (www.malnutritionpathway.co.uk).
If you would prefer not to be contacted in the future please tick here: