Hot Topic | ONS ‘


ONS have been demonstrated to improve many clinical outcomes, such as improved weight, energy and protein intake...


Defining compliance Historically, poor compliance has been associated with the taste,4


sweetness4 or palatability5 of


supplements. Systematic reviews across acute and community settings demonstrate that compliance with oral nutritional supplements (ONS) increases energy and nutrient intake with little or no effect on oral intake.6


’ Who is at a greater risk of Clearly, all clinicians will be striving to


achieve compliance with any prescribed treatment, but the question of a patient complying or not with ONS is not as clear cut as other clinical treatments, such as taking a tablet or insulin injection. Many peer-reviewed studies define compliance with ONS as the patient reporting to consume 75 per cent of the amount prescribed,7


amount of ONS that has been consumed in a set time period or measuring residual volumes,8 the clinician’s own judgement.9


by a clinician counting the or even


Thus ‘compliance’


may not necessarily be considered as consuming 100 per cent of the total volume of ONS prescribed. This may put forward the importance of having a clear treatment aim, e.g. to prevent further weight loss, as a marker that the patient has complied adequately with ONS treatment to achieve a clinically significant benefit, in order to warrant continuation of ONS.


Benefits of ONS compliance ONS have been demonstrated to improve many clinical outcomes, such as improved weight, energy and protein intake, improved pressure sore healing, and a reduction in infections and other medical complications.6, 10


ONS may also reduce overall mortality.11 There is also some evidence to support a


financial benefit to the NHS in that a reduced length of stay may be associated with ONS compliance. In some clinical specialities, there is a greater strength of evidence to support these arguments, such as in the field of oncology,


pathologies, such as pancreatic cancer has shown a statistically significant increase in energy, protein intake and weight when there is conformity with prescribed ONS.12


For renal patients undergoing


dialysis, a large body of evidence indicates that compliance with ONS is of importance in treating malnutrition associated with renal function decline.13-14 The benefits of ONS compliance are also


applicable to a wider health economy, especially as non-compliance may raise a financial cost to the NHS. In 2010, over £210 million was spent nationally on ONS,15


has raised concerns about the appropriate level of prescribing.16


ONS by 33 per cent in the last three years.15 BAPEN highlight that properly thought Appropriate


in part due to an increase in the use of This


out nutritional care will reduce costs of inappropriate use and wastage.17


prescribing does include screening for malnutrition and assessment to ensure that patients meet the necessary criteria for ONS upon initiation. Of equal importance, is the monitoring of compliance when reviewing prescriptions, by ensuring that the patient continues to meet prescribing criteria and is achieving the aims of treatment.


22 | CN Focus Vol.4 No.1 April 2012


non-compliance? Some patient groups may be at greater risk of non- compliance, and warrant closer nutritional monitoring. One study amongst cystic fibrosis patients indicated adults, and those with more severe disease, were less compliant with oral nutritional supplements;9


amongst a renal population receiving peritoneal dialysis.18


a result which has been mirrored There is a suggestion in the literature that


when patients have a perception that a treatment is important, or that it will affect their quality of life, they may be more likely to comply.9


A recent survey,


conducted in 2011 by the Patient’s Association, amongst members of the UK public, including those who had been inpatients or were carers, indicated that many have a poor understanding of malnutrition.19


A fifth of respondents did not know of


any treatment for malnutrition. Of those respondents who were aware of treatments for malnutrition, just over 30 per cent had heard of ONS.19


community healthcare professionals, including dietitians, cited patient or carer’s poor understanding of the importance as a common hindrance to compliance with ONS.20


Highlighting to patients the


possible implications to their health, if they are non- compliant with oral nutritional supplements, is vital for the best patient outcomes.


What healthcare professionals research amongst specific


are doing to aid compliance Specific directions of administering ONS, such as timing, may aid healthcare professionals in promoting compliance amongst their patients. For optimal compliance, some authors have not favoured ONS being given mid-morning or afternoon, as this may imply it is optional.21


Indeed,


Roberts et al.’s research demonstrated 75 per cent of subjects had moderate compliance when ONS were administered as a medicine during specific drug rounds.21


Since then, Australian research into


a ‘nutrition as medication’ approach, where the intervention group of the study had 60ml of a 2kcal/ml feed four times a day, demonstrated a compliance of 95 per cent versus 48 per cent compliance with the current practice of ONS administration.22


In fact, the Dietitians Association


of Australia consider the evidence in this area to be strong enough to include in their guidelines on the management of malnutrition.10 There is also evidence to consider ONS


administration during medical treatment. For example, when ONS are administered during dialysis sessions, this has shown a greater compliance,7


with


some studies demonstrating up to 80 per cent compliance.23


care settings, e.g. for cancer patients undergoing radiation or chemotherapy, where administrating ONS at the same time may cause patients to associate the side effects of cancer treatment with ONS. However, this could prove to be an innovative


This may not be applicable to other In addition, qualitative investigations amongst


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