Managing Adult Malnutrition
Including a pathway for the appropriate use of
oral nutritional supplements (ONS)
Oral nutritional supplements (ONS) to optimise oral intake
- ONS are typically used to supplement the diet when diet alone is insufficient to meet daily nutritional requirements. They are not intended as a food replacement but rather to increase overall nutritional intake without displacing normal food consumption40
- Patient education, combined with early assertive nutrition support and advice on resistance activity may achieve the best outcomes in those with limited intake, poor appetite and disease-related malnutrition41
- ONS should be given in accordance with an evidence-based PATHWAY Their use should be regularly reviewed
- Serving method and timing can influence adherence - ONS are best consumed at a time when the patient feels most comfortable, such as between meals, as split doses e.g. 40ml doses regularly across the day, first thing in the morning, or before bed. Serving ONS chilled or blending it with flavouring agents such as coffee, mixing into jellies, soups, or sauces can be considered to enhance acceptability42
- Multimorbidity is a key driver of malnutrition. Advice to adapt food intake might represent a significant burden to people who are ill and their carers. ONS may therefore be needed to help such individuals meet their nutritional needs40,43
- NICE CG32 recommends considering oral nutrition support to improve nutritional intake for people who can swallow safely and are malnourished or at risk of malnutrition (based on high quality/A-grade evidence)29
- NICE QS24 emphasises the need for all care services to take responsibility for the identification of people at risk of malnutrition, to provide nutritional support for everyone who needs it and to take an integrated approach to the provision of services30
The Evidence
Clinical studies, systematic reviews and meta-analysis in malnourished patients, demonstrate that ONS:
- - Increase energy, protein, and micronutrient intake, contributing to improved nutritional status29,40,44
- - Do not suppress voluntary food intake when timed appropriately13,44
- - Improve weight and functional benefits (e.g. improved hand grip strength and quality of life)13,29, 44-48
- - Are a clinically and cost-effective way to manage malnutrition in the community particularly amongst those with a low body mass index (BMI) (BMI<20 kg/m 2) and those with a ‘MUST’ score of 2 or more 29,46-51
- - Contribute to reducing healthcare costs through reductions in pressure ulcers, poor wound healing, infections 43,46 hospital admissions and readmissions 46,48,50
- - Clinical benefits in the community are achieved with 300-900kcal/day (1-3 ONS servings per day) typically with 2-3 months’ supplementation 29,44,46. Supplementation periods may be shorter, or longer (up to 1 year) according to clinical need
- Clinical benefits of ONS are presumed due to the increased multi-nutrient intake. If a similar increase in nutrient intake can be achieved by dietary means alone, it is reasonable to expect similar clinical benefits. In those who are unwell, at high risk of malnutrition and with eating difficulties, it should be born in mind that it may not be possible nor feasible to modify and rely on food intake alone to achieve the desired nutrient increases and hence a multimodal approach utilising ONS in combination with support and dietary counselling from a suitably skilled professional e.g. Dietitian, to optimise intake may be needed 16,32,40,43
NB: Most clinical studies used ready-to-drink ONS. Currently there is limited evidence to confirm whether powered ONS yield comparable outcomes to those listed in the evidence section above.
Management of malnutrition according to risk category
A screening and management pathway using 'MUST' that can be used across care settings to identify adults who are malnourished or at risk of malnutrition.
A Guide to Managing Adult Malnutrition in the Community: the complete document is available.
Resources
A selection of publications for use by healthcare professionals, patients and carers are available in the resources section of the website.
Support for Patients & Carers
A number of resources are available that have been developed to support patients and carers.
Further Information
We can be contacted regarding the malnutrition pathway materials and website
No part of this site may be reproduced in whole or in part in any manner without the permission of the copyright owner.