Guidelines for the use of  
                    Prescribable Oral Nutritional 
                         Supplements in Adults. 
                    For GPs and Community Healthcare Staff 
           
           
           
           
           
           
           
           
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                               Contents                                             
             
            
                1.  Aim and Background                                                Page 3 
                2.  Seven Steps to appropriate prescribing (Summary)                  Page 4 
                3.  Malnutrition Screening & Care Pathway  - Summary                        Page  5 
                4.  Seven steps to appropriate prescribing                            Page 6  
                5.  Prescribing of ONS following discharge from hospital              Page 10         
                     
                6.  Prescribing of ONS for Nursing or Care Home residents             Page 11 
                     
                     
                    Appendices: 
                    Malnutrition Universal Screening Tool (MUST) flowchart            Page 12 
                    Guide to assessing underlying causes of malnutrition              Page 13 
                    Making the Most of Your Food – Food First Advice                  Page 14 
                    Oral Nutritional Supplements (ONS) to prescribe                   Page 15 
                    Prescribing of ONS in Substance Misusers                          Page 17 
                    Prescribing of ONS in Palliative Care                             Page 18 
                     
                                           
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             Aim 
             These guidelines aim to (ensure cost efficiency) and standardise the management of adult 
             patients requiring oral nutrition support (ONS) in the local health economy.  The guidelines 
             advise on: 
                Identifying adult patients at risk of malnutrition (step 1) 
                Assessing underlying causes of malnutrition (step 2) 
                Setting treatment goals (step 3) 
                Offering ‘food first’ advice (step 4) 
                Monitoring and assessing progress (step 5) 
                Initiating prescribing of ONS (step 6) 
                Reviewing and discontinuing prescriptions for ONS (step 7). 
              
             The guidelines also offer advice on prescribing ONS for those with substance misuse and 
             prescribing in palliative care. 
              
             Adherence to these pathways will optimise the nutritional status of patients at risk of 
             malnutrition and ensure the appropriate use of oral nutritional supplements (ONS). 
              
             Background 
             Malnutrition can have serious negative health consequences amongst which include poor 
             recovery from illness and surgery; impaired immune function; reduced muscle strength; 
             impaired psychosocial function; increased susceptibility to pressure ulcers.  Malnutrition results 
             in longer hospital stays, increased visits to GP surgeries, and ultimately increased mortality. 
             Malnutrition also has significant financial costs, estimated at £19 billion in 2015 (BAPEN).    
             Therefore it is important to promptly identify and treat those who are malnourished or at risk 
             of becoming malnourished.  Effective treatment of such patients involves providing adequate 
             oral nutrition support. 
             Oral nutrition support is defined in the NICE clinical guideline CG32 as ‘the modification of food 
             and fluid by fortifying food with protein, carbohydrate and/or fat plus minerals and vitamins; 
             the provision of snacks and/or oral nutritional supplements as extra nutrition to regular meals, 
             changing meal patterns or the provision of dietary advice to patients on how to increase overall 
             nutrition intake by the above’. 
             Oral nutritional supplements are a medical intervention and should only be provided to 
             patients who are classed as malnourished or at risk of malnutrition where dietary intervention 
             has not led to an improvement in nutritional status.  In order to ensure the clinically and cost 
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             effective use of ONS, they can only be prescribed for specific ACBS indications           and should be 
             prescribed appropriately in line with relevant guidelines.   
              
              
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                                                                                                                       Seven steps to Appropriate Prescribing of Oral Nutritional Supplements (ONS) in Adults (Summary) 
                                                                                                                       This summary page should be read in conjunction with the full guidance and relevant pathways. 
                                                Step 1: Identify adults at risk of malnutrition. 
                                                NICE Clinical Guideline 32, Nutrition Support in Adults, suggests the following criteria are used to identify people who are 
                                                malnourished: 
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                                                                                               Malnutrition Universal Scoring Tool (MUST) score of 2 or more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             BMI of less than 20 kg/m  and unintentional weight 
                                                                                               Unintentional weight loss greater than 10% within the last 3–6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             loss greater than 5% within the last 3–6 months.  
                                                                                                months.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Those who have poor absorptive capacity and/or 
                                                                                               Those who have eaten little or nothing for more than 5 days                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                high nutrient losses and/or increased nutritional 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       2                                                                                                                                                                                                                   needs from causes such as catabolism. 
                                                                                               Body Mass Index (BMI) of less than 18.5 kg/m  
                                                The ‘MUST’ screening tool should be used to identify adults, who are malnourished, at risk of malnutrition (undernutrition), 
                                                or obese.  Link to Online MUST calculator.    Link to MUST charts 
                                                Step 2: Assess underlying causes of malnutrition 
                                                Consider underlying causes for weight loss as listed below.  Investigate/ treat /refer to local services as appropriate. 
                                                                                               Medical conditions                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Psychological issues – poor emotional or mental health 
                                                                                               Physical, chewing and swallowing difficulties                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             Environmental and social issues 
                                                                                               Substance or alcohol misuse                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
                                                                                      
                                                Step 3: Set treatment goals (aim of nutrition support) 
                                                Set and document clear, realistic, measurable treatment goals within set timescales in agreement with patients.  For example: 
                                                                                    Target weight / target weight gain / target BMI / target MUST over a set period of time 
                                                                                    Wound healing if relevant 
                                                                                    Weight maintenance where weight gain is unrealistic or undesirable. 
                                                Step 4: Offer ‘Food First’ advice 
                                                To ensure patients get the most nutrition from the food they are eating, promote and encourage intake of: 
                                                                                    Fortified foods Link to Patients' Guide to Making the Most of your Food Leaflet 
                                                                                    Over the counter (OTC) products (Complan® milkshakes or soups, Build-Up® milkshakes or soups, Nurishment® milkshakes)   
                                                Step 5: Monitor & assess prgress 
                                                                                    Monitor patient’s progress. Re-weigh after 2-4 weeks to assess weight gain and success of food first intervention. 
                                                Step 6: IF required, Prescribe Oral Nutritional Supplements (ONS) 
                                                                                    If a ‘food first’ approach has failed to achieve a positive change towards meeting goals in specified time periods, consider 
                                                                                     prescribing of ONS in addition to the food first changes.   
                                                                                    If MUST is ≥2, and food first has not been successful, refer to Dietitians. Dietitians referral 
                                                                                    ONS should only be prescribed to patients who meet at least one of the Advisory Committee on Borderline Substances 
                                                                                     (ACBS) criteria. See page 8 for list of ACBS criteria. 
                                                                                    Prescribe first line Powdered ONS – Food Link Complete®, Aymes® Shake, Complan® Shake 
                                                                                    Prescribe second Liquid ONS (only if patient is likely to have difficulty preparing powdered ONS or has lactose intolerance). 
                                                                                                                           o  Liquid ONS (Milkshake Style) – Ensure Plus®, Aymes Complete® (not lactose-free) 
                                                                                                                           o  Liquid ONS (Juice Style, only if patient dislikes milky drinks) – Nutricia Fortijuice® , Fresubin Jucy® 
                                                                                    Prescribe ONS twice daily on acute prescriptions.  A one week prescription or starter pack should always be prescribed 
                                                                                     initially to avoid wastage in case products are not well tolerated. Some of the companies provide trial samples via their 
                                                                                     websites that can be delivered directly to the patient.    
                                                Step 7: Review and discontinue ONS. 
                                                                                    Patients on ONS should be reviewed regularly, ideally at least every 3 months. Patients referred to the dietitians will be 
                                                                                     reviewed regularly. When conducting general medication reviews, ONS should be included.  Reviews should assess: 
                                                                                                                           o  Progress towards goals – weight/BMI/wound healing, changes in food intake 
                                                                                                                           o  Compliance with ONS and stock levels at home/care home  
                                                                                    When treatment goals are met, discontinue perscriptions.  Ideally, review one month after discontinuation of ONS to 
                                                                                     ensure that there is no recurrence of the precipitating problem.   
                                                                                    If the patient no longer meets ACBS criteria, or goals are met, but still wishes to take ONS, OTC products as in Step 4. 
                                                                                    ONS prescriptions for patients discharged from Medway Maritime Hospital are reviewed by dietitians, and are also subject 
                                                                                     to these guidelines.  
                                                                                                                        
                                                                                                                        
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                                                                                                                       Approved by: 
                                                                                                                       Date approved: 
                                                                                                                       Review date: