ONS | Hot Topic


way to improve compliance in community healthcare settings, e.g. if a patient has a daily district nurse visit to administer ONS at this time, if there is focused clinical research to support such approaches. Within the hospital setting, interventions such


as a specific supplement ward round or signage above a patient’s bed have been indicated to improve compliance with ONS.24


an outcome of the mappmal project, is a prototype food provision system that records preferences and nutrient intake.25


The ‘hospitalfoodie’ concept, Whilst the researchers focus on


the prototype is currently on oral food intake, such a system could be adapted to also record this data for ONS. The model can be applied across other care settings, e.g. nursing homes, and could be an inventive way of ensuring ONS compliance.


The role of commercial companies


in improving compliance Companies which produce oral nutritional supplements for prescription in accordance with ACBS guidance have advanced efforts in recent years to impede concordance with ONS prescriptions. One factor healthcare professionals list as a contributor to poor compliance is the taste of ONS.20


Abbott Nutrition undertook research


which indicated that taste, mouthfeel, aroma, appearance and aftertaste were amongst the most important factors in compliance with ONS, when subjects consumed ONS for a period of five days.26 ‘Taste fatigue’ can also occur if patients have the same flavour for a period of time. Ravasco27 recommends a regular review of patient’s preferences and that offering a variety of flavours is important to ensure compliance. Simple measures, such as prescribable sample packs which allow patients to trial different flavours, may assist compliance, and are set within guidance for prescribers by some community health organisations in England28


– e.g. Complan Shake


Starter Pack, Ensure Plus Commence, Fortisip Compact/Extra/Range Starter Pack, Pro-Cal Shot Starter Pack.29


Further to this, some companies


have reformulated products, offering a greater range of flavours, including increasing savoury options (e.g. Ensure Plus Savoury [Abbott Nutrition], Fortisip Savoury Multifibre [Nutricia], Vitasavoury [Vitaflo]),29


or suggesting recipes to


incorporate ONS within habitually eaten foods. Whilst it has been cited that flavour enhancement may be beneficial,30


measure the clinical effect. Harper et al.’s31


more research is required to data


argues that taste alone is unlikely to be the only factor affecting compliance. With regards to product development, another


area which commercial companies have focused on is increasing the concentration and reducing the volume of supplements. There is evidence that volume, independent of energy density, can influence satiety.32


There is an increase in the range


of 2kcal/ml ONS (e.g. Ensure TwoCal [Abbott], Fresubin 2Kcal/Fibre [Fresenius Kabi], Resource 2.0 Fibre [Nestle]), which in a 200ml presentation


offers greater energy, protein and micronutrients than the same volume of standard 1.5kcal/ml ONS. More recently a 2.4kcal/ml sip feed has become available (Fortisip Compact/Fibre [Nutricia]), providing in 125ml presentations, the equivocal nutrition of 1.5kcal/ml feeds in a 200ml bottle. For non-nutritionally complete ONS there has also been an increase in the availability of low volume supplements (e.g. Calogen/Calogen Extra [Nutricia], Fresubin 5kcal [Fresenius Kabi], Pro-Cal Shot [Vitaflo], ProSource [Nutrinovo]). There is also an increasing range of supplements with fibre, and a study involving 66 Spanish Nursing Homes produced very high levels of compliance (96%), which may be linked to a reported improvement in intestinal function by 50 per cent of subjects.33


Other aspects of the


presentation or packaging of an oral nutritional supplement drink may also factor in compliance,34 and warrant further investigation to consider as an aid to compliance.


Summary and future perspectives The measures which can be taken by healthcare professionals, as indicated by peer-reviewed research, alongside the product developmental work of commercial companies, are working together to improve compliance. Concepts, such as ‘hospitalfoodie’,25


both measured and self-enforcing may assist compliance in the future.


measures, further research is warranted as to how best to achieve compliance, especially with an increased pressure on healthcare professionals to justify ONS prescriptions. A recent opinion piece in the BMJ criticises the quality of evidence behind ONS,35


refuted in a response by BAPEN,36 it highlights that


some clinicians may benefit from a more robust evidence base to both enhance and measure compliance with ONS. Further qualitative research, especially amongst patients who may be taking ONS for extended periods, may guide the direction of multi-centre trials with a greater number of subjects. In particular, there is less evidence in community-based healthcare settings and, therefore, investment in this field may help strengthen the data. As aforementioned, there are differing definitions to compliance, and a universal definition may help practitioners when reflecting on evidence to modify their healthcare practices. Whilst obtaining funding to carry out research remains a barrier, particularly in a time of austerity, there has been promise that riboflavin may be used as an accurate chemical marker of compliance with ONS, thus providing an exact measure of compliance.37


In the interim, measuring


nutritional outcomes, such as with a framework, e.g. British Dietetic Association Model for Dietetic Outcomes,38


may facilitate practitioners in measuring compliance with ONS treatment.


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NOW TEST YOUR KNOWLEDGE Visit CPD section at: www.nutrition2me.com


where compliance could be Despite these


treatment for malnutrition being considered as ‘Grade A’ by NICE.3


despite the evidence of ONS as Whilst this opinion has been


References: 1. BAPEN (2011). Results of Nutrition Screening Week 2010. Accessed online: http://www.bapen.org.uk/nsw10.html (February 2012). 2. ESPEN Guidelines Group (2006). ESPEN Guidelines on adult enteral nutrition. Journal of Clinical Nutrition; 25(2). 3. NICE (2006). NICE Clinical Guideline for Nutrition Support. Accessed online at: http://guidance.nice.org.uk/CG32/NICEGuidance/pdf/English (February 2012). 4. Methven L, et al (2010). The effect of consumption volume and liking of oral nutritional supplements of varied sweetness: sequential profiling and boredom tests. Food Quality and Preference; 21(8): 948- 955. 5. Gosney M (2003). Are we wasting our money on food supplements on elder care wards? Journal of Advanced Nursing; 43(3): 275-280. 6. Stratton RJ, et al (2005). Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Research Reviews; 4: 422–450. 7. Caglar K, et al (2002). Theraputic effects of oral nutritional supplements in haemodialysis Kidney International; 62: 1054-1059. 8. Keele AM, et al (1997). Two phase randomised controlled clinical trial of postoperative oral dietary supplements in surgical patients. Gut; 40: 293-399. 9. Arias Lorente RP, Garcia CB, Martin JJD (2008). Treatment compliance in children and adults with Cystic Fibrosis. Journal of Cystic Fibrosis; 7(5): 359-368. 10. Tapsall L, et al (2009). Evidence Based Practice Guidelines for the Nutritional Management of Malnutrition in Adult Patients Across the Continuum of Care. Nutrition and Dietetics; 66(3): S1-S24. 11. Koretz R, et al (2007). Does Enteral Nutrition affect clinical outcome? A systematic review of the randomized trials. Am J Gastroenterol.; 102: 412–429. 12. Bauer J, et al (2005). Compliance with nutrition prescription improves outcomes in patients with unresectable pancreatic cancer. Clinical Nutrition; 24(6): 998-1004. 13. Kalantar- Zadeh, et al (2011). Diets and enteral supplements for improving outcomes in chronic kidney disease. Nature Reviews; 7: 369-384. 14. Boudville N, Rangan A, Moody H (2003). Oral nutritional supplementation increases caloric and protein intake in peritoneal dialysis patients. American Journal of Kidney Disease; 41: 658–663. 15. The Information Centre Prescription Cost Analysis England (2010). Accessed online: http://www.ic.nhs.uk/statistics-and-data-collections/ primary-care/prescriptions/prescription-cost-analysis-england--2010 (February 2012). 16. Todorovic V (2005). Evidence-based strategies for the use of oral nutritional supplements British Journal of Community Nursing; 10(4):158,160,162-4. 17. Ailsa Brotherton, Nicola Simmonds and Mike Stroud on behalf of the BAPEN Quality Group (2010). A Toolkit for Commissioners and Providers in England: Malnutrition Matters Meeting Quality Standards in Nutritional Care. Accessed online: http://www.bapen.org.uk/pdfs/bapen_pubs/mm-toolkit-exec-summary.pdf (February 2012). 18. Teixido-Planas J, et al (2005). Oral protein-energy supplements in peritoneal dialysis: a multicenter study. Peritonial Dialysis International; 25(2): 163-172. 19. The Patients Association. Malnutrition in the Hospital and the Community. Accessed online at: http://www.patientsassociation.com/Portals/0/Public/Files/Advice Publications/Malnutrition%20in%20the%20community%20and%20ho sptial%20settting.pdf (February 2012). 20. Glencorse C, Edington J, Stelling J (2010). Malnutrition and oral nutritional supplements – a 360° approach to understanding management and compliance. Proceedings of the Nutrition Society; 69 (OCE7): E582. 21. Roberts M, et al (2003). Can prescription of sip-feed supplements increase energy intake in hospitalised older people with medical problems? British Journal of Nutrition; 90: 425–9. 22. Jukkola K, MacLennan P (2005). Improving the efficacy of nutritional supplementation in the hospitalised elderly. Australasian Journal on Ageing; 24: 119–124. 23. Scott MK, et al (2009). Effects of peridialytic oral supplements on nutritional status and quality of life in chronic hemodialysis patients. Journal of Renal Nutrition; 19: 145–152. 24. McCormick SE, et al (2007). Compliance of acute and long stay geriatric patients with oral nutritional supplementation Irish Medical Journal; 100(5): 473-5. 25. Hospitalfoodie. Accessed online at: http://www.hospitalfoodie.com/ (February 2012) 26. Glencorse C, Stanford J, Stelling J (2010). Study to improve Understanding of Sensory factors and Taste And their Impact on compliance with Nutritional drinks (SUSTAIN, Stage 2) Accessed online at: https://www.abbott.ch/fileadmin/docs/nutrition/SUSTAIN2 __ClinicalNutrition_2010.pdf (February 2012). 27. Ravasco, P (2005). Aspects of taste and compliance in patients with cancer European Journal of Oncology Nursing; 9(2): S84-S91. 28. Salisbury NHS Foundation Trust. Prescribing ONS in the Community Accessed online: http://www.icid.salisbury.nhs.uk/ClinicalManagement/DieteticsAndNu trition/Pages/PrescribingONSforAdultsintheCommunity.aspx (February 2012). 29. British National Formulary Nutritional Supplements Non Disease Specific. Accessed Online at: http://bnf.org/bnf/bnf/ current/202300.htm (February 2012). 30. Lambert MA, Potter JM, McMurdo MET (2010). Nutritional Supplementation for Older People. Reviews in Clinical Gerontology; 20: 317-326. 31. Harper JR, et al (2001). Preferences for Different High-Energy Foods in Elderly Medical in?Patients. Scott Med J; 46(6): 171-2. 32. Rolls, B.J., Bell, E.A., Waugh, B.A. (2000) Increasing the volume of a food by incorporating air affects satiety in men American Journal of Clinical Nutrition 2:361–8 33. Cruz- Jentoff AJ, et al (2006). Compliance with a hyperproteic supplement with fibre in nursing home residents The Journal of Nutrition, Health and Aging; 12(9): 669-673. 34. Cohen J, et al (2011). Paediatric oncology patient preference for oral nutritional supplements in a clinical setting. Supportive Care in Cancer; 19(9): 1289-1296. 35. Spence D (2012). Bad medicine: medical nutrition. British Medical Journal; 344 :e451. 36. Bowling T, et al (2012). Tim Bowling and colleagues reply to Des Spence. BMJ.; 344 :e811 37. Ramanujam VMS, et al (2011). Riboflavin as an oral tracer for monitoring compliance in clinical research. The Open Biomarkers Journal; 4: 1-7. 38. British Dietetic Association (2011). Model for Dietetic Outcomes. Available online via: http://www.knowledge.scot.nhs.uk/ media/CLT/ResourceUploads/1011509/BDA%20Model%20for%20dietet ic%20outcomes%20document%20April%202011.pdf .


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