FAQ Nutrition Supports

Healthcare professionals working in the community are well-placed to provide first-line nutrition support for people who are malnourished or at risk of malnutrition and this toolkit aims to assist them in providing that support. It is intended primarily for prescribers (GPs, registered nurse prescribers (RNPs)) and may also be helpful for community dietitians, community nurses, and nurses working in social care residential settings.

Included in the resources are a Prescribing Pathway and Prescribing List to aid initiation and renewal of oral nutritional supplements (ONS), patient information leaflets, and a 222-page cookbook called 'Making the most of every bite', which was developed by dietitians at UCC. The patient resources are available to view or print from the ‘Public’ section of the webpage; healthcare professionals can order copies of the cookbook free of charge for patients who might benefit at www.healthpromotion.ie

This guidance is intended for use with adult patients who are malnourished or at risk of malnutrition, under the supervision of their healthcare professional. It is important to note that, as the guidance recommends, patients with complex nutritional needs (e.g. renal disease, diabetes, coeliac disease), should always be referred to a dietitian for specific advice in relation to their dietary needs and the prescribing of ONS if required.

The following patient groups are particularly at risk of malnutrition:

• those with chronic disease such as respiratory disease, inflammatory conditions of the gut, or malignancy,
• those with progressive conditions that affect bodily function, such as dementia and neurological conditions,
• those who are going through, or are recovering from, a period of acute illness (especially where hospital admission was required), or those who are experiencing side effects of treatments, such as medication or anti-cancer therapy,
• those who have some level of impairment with bodily function including frailty, loss of mobility, lack of dexterity, dental problems or swallowing problems (dysphagia),
• those with psychological difficulties such as poor mental health, bereavement, addiction or substance abuse, and,
• those in isolated social situations such as living alone, lacking support with cooking, shopping or preparing food.

A multi-professional strategic and clinical advisory group developed the nutrition supports toolkit and ONS prescribing guidance. Members of the advisory group included representatives from the Primary Care Service Improvement Programme Nutrition Working Group, the Medicines Management Programme (MMP), Social Care, Public Health Nursing, Primary Care Reimbursement Scheme (PCRS), Health Business Services (HBS) Procurement, and Community Health Care Organisation Management. A number of sub-groups including representation from the acute hospital division and voluntary locations worked on individual resources developed as part of the overall nutrition supports toolkit.

Risk of malnutrition can only be identified using a validated nutrition screening tool that is age and population appropriate. Nutrition screening is the first step that all healthcare professionals can perform in order to identify patients who are at risk and may benefit from more detailed nutrition assessment and intervention led by a registered dietitian.

The Malnutrition Universal Screening Tool (MUST) & Mini-Nutritional Assessment (MNA) are two common nutritional screening tools in use in the Irish setting. More information on MUST can be found at www.bapen.org.uk and two e-based learning models related to the MUST are available for HSE staff on www.hseland.ie.

The ONS Prescribing Pathway, which is part of this nutrition supports toolkit, provides a pathway to support prescribers in providing quality care for their patients, while awaiting dietetic referral, or in the absence of a dietetic service.

While nutritional screening can be carried out by all healthcare professionals, a comprehensive nutrition assessment leading to diagnosis should be carried out by a registered dietitian. The dietitian collects and documents information such as food or nutrition-related history; biochemical data, medical tests and procedures; anthropometric measurements; nutrition-focused physical findings, and client history. The dietitian uses this information to make a nutrition diagnosis and then selects the appropriate intervention and care plan for the patient.

The Prescribing Pathway provides a stepwise approach to the first-line management of malnutrition and healthcare professionals can use these steps as a guide. The pathway also provides guidance on the appropriate initiation and renewal of ONS. Please refer to the full documents provided in the toolkit for more information.

Community-based healthcare professionals can contact the community dietitian manager in the local area; they will be able to direct you to the most appropriate location to forward referrals.

A food-based approach is recommended for all patients who are malnourished or at risk of malnutrition. The resources provided in this toolkit highlight basic high calorie high protein dietary advice. Suggestions that can be incorporated include:

• increasing frequency of food intake through additional snacks between meals;
• increasing the consumption of energy and nutrient-dense foods at meal times;
• using fortified foods to increase the nutrient density of food, e.g. adding skimmed milk powder to full cream milk in order to increase the protein content.

More ideas are available in Making the most of every bite patient information leaflet and 222-page cookbook.

Dietary advice should always be given in conjunction with a prescription for ONS.

It is important that patients are given information on how to improve their diet; it is also recommended that residential care settings provide fortified food and suitable snacks for patients.

ONS should not normally be used as a long-term substitute for normal meals or snacks.

Evidence shows that nutrition support, including dietary advice and the appropriate use of ONS, can lead to improved health and wellbeing. This in turn can aid improved response to some medical treatments. Other benefits of nutrition support include:

• weight gain or weight maintenance for patients who are malnourished,
• increased nutritional intake,
• improved functional status, and
• improved wound healing.

Decreased admission rates to hospital are also seen when nutrition support is targeted at high-risk patient groups, and studies of ONS have found that benefits in the community are typically seen within 2-3 months of use.

The purpose of the guidance is to assist in improving the quality of care provided to people who are malnourished or at risk of malnutrition by providing prescribers with a best practice ONS Prescribing Pathway for the appropriate initiation and renewal of ONS prescriptions. Information on first line standard ONS is also provided to aid prescribing decisions.

It is intended for prescribers, i.e. GPs and RNPs. It is also intended for healthcare professionals who influence ONS prescribing decisions, i.e. dietitians, nurses, pharmacists, and speech & language therapists.

The Prescribing List applies only to HSE and Section 38 care locations where ONS is reimbursed through the Community Drug Schemes i.e. GMS, DPS. If your care location purchases ONS through a site-specific contract with a medical nutrition company, please consult with the location pharmacist or dietitian for guidance on local product costs.

The HSE has developed this guidance to promote the appropriate prescribing of standard ONS for adults living in the community. While ONS are useful in treating and preventing malnutrition, they should not be used alone as first-line treatment for malnutrition. Irish and international evidence suggests that at a minimum 30% of ONS are inappropriately prescribed to patients who are unlikely to receive any clinical benefits from them.

The 2019 Prescribing Pathway and List is an update of previous ONS prescribing guidance issued by the HSE in 2009, 2017 and 2018.  Best practice indicates that ONS should not be considered an alternative to or replacement for food, and patients who require nutrition support should always be given dietary advice in conjunction with an ONS prescription. A range of prescriber and patient resources have been developed as part of the nutrition supports toolkit.

The 2017 HSE guidance was piloted in a small number of general practices during 2017, in advance of publication. Changes were made to the content as a result, incorporating the feedback from GPs and practice nurses who were consulted.

Oral nutritional supplements (ONS) are legally defined as food for special medical purposes (FSMPs) to be used under medical supervision. They are commercially manufactured liquid, powdered and semi-solid food products with varying nutritional content.

The main indication for prescribing ONS is the treatment of disease-related malnutrition. ONS are typically used to increase energy and protein intake in addition to a normal diet, when diet alone is insufficient to meet patients’ daily nutritional requirements.

ONS are an evidence-based treatment for disease-related malnutrition when targeted at appropriate patient groups. There is evidence that when ONS are prescribed for patients who are malnourished or at risk of malnutrition they can improve health outcomes and reduce overall healthcare costs.

The guidance relates to standard ONS only. For the purpose of this prescribing guidance the term ‘standard ONS’ is defined as either powdered or readymade multi-nutrient (complete or incomplete) products providing a mix of macronutrients and micronutrients produced by specialist medical nutrition manufacturers. Disease-specific ONS e.g. renal-, diabetic-, and oncology-specific ONS should ideally only be prescribed under the supervision of a dietitian and are not included in this guidance.

The guidance is not suitable in cases where a patient requires ONS as a sole source of nutrition.

Some patients are prescribed ONS as part of a specific care plan under the supervision of other healthcare professionals. This new guidance recommends that ONS prescriptions should not be adjusted without prior consultation with the relevant healthcare professional, where a patient is:

• under the care of a community dietitian or acute hospital dietetic/medical team
• using ONS via enteral feeding tubes e.g. naso-gastric, naso-jejunal, gastrostomy or jejunostomy tubes
• under the care of speech and language therapist, as swallow status may have changed.

An information leaflet called ‘How to use oral nutritional supplements’ – a guide for patients, their carers and families is available to view, or download at www.hse.ie/nutritionsupports. The website also offers dietary resources for patients, including a high protein high energy diet sheet and cookbook.

Only standard ONS were included in this guidance. Factors considered in developing the Prescribing List included, but were not limited to, nutritional content (energy and protein content), clinical evidence, unit cost, range of flavours available, factors affecting compliance and current national ONS prescribing trends.

Current evidence suggests that compliance is positively associated with higher density ONS (~2kcals/ ml). This may be due to patients being able to achieve desired increases in protein and energy intake, with less volume. Therefore first line standard ONS were selected on the basis that they were multi-nutrient products that contained approximately 2kcal/ml and had a relatively lower kcal/ml cost.

Patient taste preference has also been shown to be a key factor in compliance. Therefore in addition to the recommended first line standard ONS ‘juice-style’ sip feeds are included as an option under the heading 'Options if the patient cannot tolerate milk-based drinks'. The list aims to give variety in product preparation types and flavours for patients.

Over 25 flavours are available between first line and 'juice-style' sip feed products.

This list will be reviewed regularly and updated as and when new ONS products are added to the HSE-PCRS reimbursable list.

Evidence suggests that patients who benefit most from ONS are those who are either malnourished or at risk of malnutrition. There are no clinical benefits to prescribing ONS for a well-nourished person who can consume a normal balanced diet.

National and international research has shown that ONS are sometimes prescribed for ‘non-clinical’ reasons such as to address social issues such as difficulty cooking or shopping, particularly in older persons and other vulnerable patient groups. While this type of ONS prescribing may be helpful in the short term, this guidance recommends that food-based advice should be provided to all patients and ONS should not be considered a long-term ‘alternative to food’ solution for patients.

ONS are available from local pharmacies; they are available on the community drug schemes. In the case of the GMS scheme, community pharmacists will only be reimbursed for ONS which are written on a monthly standard prescription form. This is to facilitate closer monitoring of the patient’s response to the nutrition support.

The guidance documents and supporting resources for both healthcare professionals and patients are available on www.hse.ie/nutritionsupports

For prescribers

• Prescribing Pathway for the Initiation and Renewal of Standard ONS for Adults Living in the Community
• Standard ONS Prescribing List for Adults Living in the Community
• Guidance for Prescribing ONS in Late Stages of Palliative Care in the Community Setting

For patients

• Making the most of every bite - A high protein, high calorie diet sheet
• Making the most of every bite - A high protein, high calorie cookbook (©UCC provided under special licence agreement to the HSE)
• How to use oral nutritional supplements - A guide for adult patients, their carers and families
• When illness reduces your appetite - Informaion and guidance for patients in palliative care, their families and carers

The guidance states that if a patient (or a carer) has the functional ability to mix a powder with milk AND has access to fresh milk, AND can tolerate a 200ml volume, the following powdered ONS should be considered as the initial ONS prescription:

• Complan® Shake
• Ensure® Shake
• Foodlink Complete®
• Foodlink Complete® with Fibre
• Fresubin® Powder Extra
• Nutriplete® Shake

Reconstituted with 200mls of whole milk, these first line products provide 380-840 kcal and 15-39g protein.  The products are available in a variety of flavours.

This product requires some preparation, which can be done with or without a shaker; shakers are available free of charge from manufacturers' websites and/or pharmacies.

Foodlink Complete® with Fibre may be a useful ONS for patients who are at risk of malnutrition or are malnourished and who also require additional fibre in their diet.

Powdered ONS are unsuitable for:

• patients using ONS via enteral feeding tubes e.g. naso-gastric, naso-jejunal, gastrostomy or jejunostomy tubes
• patients using ONS as a sole source of nutrition

Powdered ONS should not be prescribed for the following patients (unless under the clinical supervision of a dietitian)

• patients with diabetes: due to carbohydrate content
• patients with renal impairment: due to potassium content

Powdered ONS is not suitable if the patient (or carer) does not have:

• the functional ability to mix a powder with milk and/or
• access to fresh milk and/or
• cannot tolerate an approximate 200ml volume.

If powdered ONS are not suitable for patients because they do not have the functional ability to mix a powder with milk or access to fresh milk or they cannot tolerate a 200ml volume* consider the compact and mini-drink first line standard ONS

• Altraplen® Compact
• Ensure® Compact
• Fortisip® Compact
• Fortisip® Compact Fibre
• Fresubin® 2kcal Mini Drink 
• Fresubin® 2kcal Fibre Mini Drink

Compact or mini-drink ONS (125mls) should not be prescribed for the following patients (unless under the supervision of a dietitian):

• patients with diabetes: due to carbohydrate content
• patients with renal impairment: due to potassium content

Juice-style ONS (Ensure® Plus Juce, Fortijuce® & Fresubin® Jucy) should be considered when first and second choice ONS are unacceptable to the patient due to dislike of the taste of milk or to address taste fatigue for patients. While they are referred to as ‘juice-style’ it should be noted that these products are not milk free (they contain milk protein). They have a slightly lower protein content than the milk-based first choice and second choice products. These juices provide approximately 300-330kcal and 8-10.6g protein per bottle.

Semi-solid style ONS are clinically indicated where a patient has a diagnosed swallowing difficulty i.e. dysphagia (as determined by a speech and language therapist), and is either at risk of malnutrition, or is malnourished.

This guidance recommends that for patients who are malnourished but do not have a diagnosed swallowing difficulty, prescribers should consider the use of first line ONS as listed in this guidance, as alternatives to prescribing semi-solid style ONS.

The guidance rationale is that first-line products are in most cases, nutritionally superior and less costly than semi-solid style ONS. (as Aymes Crème is less costly than compacts)