A Guide to Prescribing Nutritional Supplements

Joint Area Nutrition Prescribing Committee Oral Nutrition Support Guidelines for Adults 2011

1. Aim To ensure effective patient centred oral nutrition support throughout Barnsley.

2. Nutritional Screening NICE guidelines (Nutrition Support in Adults 2006) recommends that all adults in the community are screened for nutritional risk:  Within primary care on initial registration and where there is clinical concern  On admission into care homes and where there is a clinical concern  On a monthly basis when identified at risk.

A validated screening tool should be used. However, currently in Barnsley community nutritional screening is not routinely provided as this service has not been commissioned due to a lack of funding. As such, this document has been devised to aid the appropriate prescribing of oral nutritional supplements (ONS). When using this guide, please consider whether your patient is already under the care of a Dietitian, or whether they would benefit from a dietetic referral.

Appendix 1 is a summary of the following guidance for your convenience.

3. Initial Assessment Your initial assessment should always establish whether the patient is malnourished or at risk of malnutrition using the following criteria:  BMI <18.5kg/m2  Unintentional weight loss >10% in the past 3-6 months  BMI<20kg/m2 and unintentional weight loss >5% in the past 3-6 months

Before prescribing any nutritional supplements, please consider the following points: o Is there any underlying cause of weight loss? o Are there any swallowing/chewing problems (including poor fitting dentures and poor dentition)? o Does the patient have any existing dietary restrictions e.g. coeliac disease, lactose intolerance, diabetes? o Are there any GI symptoms such as nausea, vomiting, constipation and/or diarrhoea? o Does your patient have poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as metabolism o Is the patient experiencing any social/financial difficulties which might contribute to a poor diet?

If you answered ‘yes’ to any of the above points, consider referring to, treating or providing information on, the following: o Further investigations into cause of weight loss o Speech and language therapy assessment for dysphagia o Dentist o Age UK, Social Services, Care Agencies

o Treatment for symptoms such as constipation, nausea, vomiting, diarrhoea

4. Referral to Dietitian Please consider dietetic referral in any of the following circumstances:  to advise on nutritional supplementation strategies and the appropriateness of initiating ONS  to assist in appropriate goal setting for individual patients  when there is deterioration in nutritional status despite supplementation after excluding other contributory pathology  when there is apparent requirement for ONS beyond three months  where there are cultural, social, religious or financial influences affecting dietary intake  when the patient has co existing medical conditions e.g. diabetes, renal failure, coeliac disease or high cardiovascular risk  where there are swallowing difficulties and a modified texture diet has been advised by a Speech and Language Therapist  where there is unexplained weight loss and/or poor wound healing/skin integrity  where there has been no improvement in nutritional intake despite advice about food fortification and ONS

5. ‘Food first’ Prior to prescribing ONS first line treatment should be the use of fortified appropriate normal food. This includes advice on the following:  3 regular meals and 2-3 snacks daily that are high in calories and protein  Include nourishing drinks e.g. milky coffee, malted milk drinks, hot chocolate, smoothies  Discuss the following point with your patient o Add extra fat and sugar to foods where possible o Add 2-4 tablespoons of skimmed milk powder to 1pint full fat milk and use throughout the day o Buy full fat versions of food, avoiding ‘diet’, ‘light’ and ‘low fat’ products  Provide your patient with written information regarding the above such as ‘A Nourishing Diet’ patient information leaflet (enclosed with this guidance, please note this can be printed as a booklet).

Please make the current dietary priority clear to your patient i.e. it is more important to treat the acute malnutrition; blood glucose and cholesterol levels can be considered separately.

6. Review of progress A review of compliance, aims and general condition should be carried out in no more than 4 weeks. An improvement could be defined as:  halting weight loss  improvement in appetite  improvement in general well being  improvement in wound healing/skin condition

7. Over the counter ONS If, on review, ‘food first’ advice has been followed without the desired result, it may be appropriate to consider recommending an over the counter ONS:

Name Manufacturer Presentation Approximate Instructions Available Flavours Cost (RRP) from Original, Reconstitute Community Chocolate, Complan Complan 4 sachets per £3.32 with milk or Pharmacy Strawberry, Foods box (83p per unit) water Banana, Chicken, Supermarkets Vegetable, Oats, Vanilla Banana, Community Chocolate, Build Up 4 sachets per £2.99 Mix with milk Pharmacy Strawberry, Shake Nestle box (75p per unit) Vanilla, Supermarkets Community Tomato, Build Up 4 sachets per Reconstitute Pharmacy Chicken, Soup Nestle box £3.44 with hot Potato & (86p per unit) water leek, Supermarkets Vegetable

8. Use of ONS on prescription If, after a further 4 weeks using over the counter ONS, there has been no improvement, consider prescribing a 1.5kcal/ml ONS for up to a four week trial period (usually 1-2 supplements per day). Please refer to Appendix 2 for guidance, and consider the following points:  Whether your patient may prefer a milk, juice or yoghurt style supplement drink  The volume of fluid your patient is able to tolerate  Which flavours your patient may prefer  Whether they have the financial and social support to purchase and store the milk needed should you choose a supplement which requires reconstituting. (Complan Shake may be a cost effective first line supplement in these circumstances)  A ‘nutritionally complete’ supplement is not always necessary if it is being used to supplement the diet as your patient should obtain the majority of nutrients from normal food

ONS should only be prescribed for the following approved standard ACBS indications (BNF, 2011):  disease related malnutrition  intractable malabsorption  pre operative preparation of malnourished patients  dysphagia  proven inflammatory bowel disease  following total gastrectomy  short bowel syndrome  bowel fistula 3

ONS should be prescribed as an acute prescription where possible as long term use is seldom indicated. Sip feeds should not automatically be added to a repeat prescription. The direction should be specified on the prescription e.g. sip the contents between meals. Do not use ‘as directed’ or ‘as required’.

Substance misuse patients – please note that prescription of ONS for this patient group does not meet ACBS criteria

Patients with dementia – please note that prescription of ONS for this patient group does not meet ACBS criteria. Other strategies such as food fortification, finger foods and the inclusion of regular non-prescribable nourishing drinks should be the treatment of choice in this patient group.

Advice to patients:

 Patients should still be encouraged to eat regular meals and snacks, and continue food fortification methods as outlined above  ONS should not be used as meal replacements and should be sipped between meals  ONS should only be used for a short period of time until goals are achieved

9. Review of ONS on prescription Following the 4 week trial period on ONS on prescription, progress and compliance should be reviewed (see point 6, above). Consider stopping prescription if targets have been achieved. Use clinical judgement to determine whether repeat prescription is necessary. Review prescription on a 4 weekly basis. Please refer to a Dietitian as outlined in point 6.

10.Guidance for prescription of alternatives to standard infant formulas Formula-fed infants under the age of 6 months with suspected cows’ milk allergy or intolerance should be prescribed an extensively hydrolysed or amino acid infant formula as a first line treatment, and referred to a paediatrician and/or paediatric dietitian.

Soya formula is not recommended for infants under 6 months of age due to it’s high phyto- oestrogen content and the risk of sensitisation to soya protein.

References NICE (2006) Clinical Guideline 32, Nutrition Support in Adults (http://www.nice.org.uk/CG32)

British National Formulary 61 (2011) (www.bnf.org)

Further information British Association of Parenteral and Enteral Nutrition (BAPEN) (http://www.bapen.org.uk/) British Dietetic Association (www.bda.uk.com)

Ratified by Barnsley Area Prescribing Committee: December 2011 Next Review Due: December 2013

Appendix 1 – Nutrition Support Guidelines for Adults

Initial Assessment Always establish whether the patient is malnourished or at risk of malnutrition using the following criteria: BMI <18.5kg/m2 Unintentional weight loss >10% in the past 3-6 months BMI<20kg/m2 and unintentional weight loss >5% in the past 3-6 months

Consider referral to a Dietitian - see point 4 (page 2) for further guidance

Food First Prior to prescribing ONS first line treatment should be the use of fortified appropriate normal food. This includes advice on the following: 3 regular meals and 2-3 snacks daily that are high in calories and protein Include nourishing drinks e.g. milky coffee, malted milk drinks, hot chocolate, smoothies Discuss the following point with your patient Add extra fat and sugar to foods where possible Add 2-4 tablespoons of skimmed milk powder to 1pint full fat milk and use throughout the day Buy full fat versions of food, avoiding ‘diet’, ‘light’ and ‘low fat’ products Provide your patient with written information (‘A Nourishing Diet patient information leaflet) regarding the above.

First review of progress A review of compliance, aims and general condition should be carried out in no more than 4 weeks. An improvement could be defined as: halting weight loss improvement in appetite improvement in general well being improvement in wound healing/skin condition

Consider the use of over the counter ONS If, on review, ‘food first’ advice has been followed without the desired result, it may be appropriate to consider recommending an over the counter ONS – see table (page 3)

Second review of progress – use of ONS on prescription If, after a further 4 weeks using over the counter ONS, there has been no improvement, consider prescribing a 1.5kcal/ml ONS for up to a four week trial period (usually 1-2 supplements per day). See page 3 for further guidance and ACBS indications

Review of ONS on prescription Following the 4 week trial period on ONS on prescription, progress and compliance should be reviewed (as above). Consider stopping prescription if targets have been achieved. Use clinical judgement to determine whether repeat prescription is necessary. Review prescription on a 4 weekly basis. Please refer to a Dietitian for specialist intervention if targets have not been achieved

Appendix 2 – ONS first line choices

Ready to drink milkshake style first line supplement choices

Product Volume Energy Protein Fibre Nutritionally Gluten Free = GF ACBS Indications Cost per unit (MIMS December 2011), (kcal) (g) (g) Complete? Lactose Free = LF presentation & flavour

Ensure Plus 220ml 330 13.8 0 GF, LF Standard criteria £1.89. Banana, blackcurrant, caramel, milkshake Yes in 5 units (also CAPD & chocolate, coffee, fruits of the forest, orange, style haemodialysis) peach, raspberry, strawberry, vanilla, neutral Fortisip Bottle 200ml 300 12 0 GF, LF Standard criteria. £1.89. Banana, chocolate, neutral, orange, Yes in 4-4.5 Not suitable for strawberry, toffee, tropical fruits, vanilla units child under 3 years; use with caution in child 3–5 years Ensure Plus 200ml 310 13 5 GF, LF Standard criteria; £1.89. Banana, chocolate, fruits of the forest, Fibre Yes in 5 units also CAPD, raspberry, strawberry, vanilla haemodialysis Fortisip 200ml 300 12 4.6 GF, LF Standard criteria. £1.91. Banana, chocolate, orange, Multifibre Yes in 4-4.5 Not suitable for strawberry, vanilla units child under 3 years; use with caution in child 3–5 years

Milkshake style first line supplement choices – require reconstituting with full cream milk

Product Volume Energy Protein Fibre Nutritionally Gluten Free = GF ACBS Indications Cost per unit (MIMS December 2011), of milk (kcal) (g) (g) Complete? Lactose Free = LF presentation & flavour required Enshake 240ml 600 16.01 Nil No GF Standard. Not Sachet: 96.5 g = £2.01. Banana, chocolate, (96.5g) suitable for child strawberry, vanilla under 1 year; use with caution in child 1–6 years Complan 200ml 387 15.6 0.2 No GF Standard Sachet: 57g = £0.90. 4 × 57 g = £3.60. Shake (57g) Banana, chocolate, original, strawberry, vanilla. Starter pack: 5 × 57 g = £5.07

Juice style first line supplement choices

Product Volume Energy Protein Fibre Nutritionally Gluten Free = GF ACBS Cost per unit (MIMS December 2011), (kcal) (g) (g) Complete? Lactose Free = LF Indications presentation & flavour

Ensure 220ml 330 10.6 0 No GF, LF Standard £1.84. Apple, fruit punch, lemon-lime, orange, Plus Juce peach, strawberry Fortijuce 200ml 300 8 0 No GF, LF Standard. Not Bottle: 200 mL = £1.85. Apple, black currant, suitable for child forest fruits, lemon, orange, strawberry, tropical. under 3 years; Starter pack (mixed): 4 × 200 mL = £7.40 use with caution in child 3–5 years

Yoghurt Style first line supplement choices

Product Volume Energy Protein Fibre (g) Nutritionally Gluten Free = GF ACBS Indications Cost per unit (MIMS December 2011), (kcal) (g) Complete? Lactose Free = LF presentation & flavour

Ensure Plus 220ml 330 13.8 0 Yes in 5 units GF, LF Standard; also £1.89. Orange, peach, pineapple, strawberry Yoghurt Style CAPD, haemodialysis Fortisip Yoghurt 200ml 300 12 0.4 Yes in 3.5-5 GF Standard. Not £1.85. Peach-orange, raspberry, vanilla-lemon Style units suitable for child under 3 years; use with caution in child 3–5 years Fresubin 125g 187 9.3 0 No GF Standard Pot 125g = £1.84 apricot-peach, biscuit, lemon, YoCreme neutral, raspberry

Savoury style first line supplement choices

Product Volume Energy Protein Fibre (g) Nutritionally Gluten Free = GF ACBS Indications Cost per unit (MIMS December 2011), (kcal) (g) Complete? Lactose Free = LF presentation & flavour

Ensure Plus 220ml 330 14.0 0 Yes in 4 units GF, LF Standard £1.89 chicken, mushroom Savoury Fortisip Savoury 200ml 300 15.0 4.6 Yes in 4-7.5 GF, LF Standard. Not £1.91 cream of chicken, cream of tomato Multifibre units suitable for children under 3 years, or as a sole source of nutrition for children under 6 years

Low volume first line supplement choices

Product Volume Energy Protein Fibre Nutritionally Gluten Free = GF ACBS Indications Cost per unit (MIMS December 2011), (kcal) (g) (g) Complete? Lactose Free = LF presentation & flavour

Ensure 200ml 399 16.8 2.0 Yes in 5 units GF, LF Standard; also £2.18. Banana, neutral, strawberry, vanilla TwoCal haemodialysis, CAPD Fortisip 125ml 300 12 0 Yes in 3.5- GF Standard. Not £1.85. Apricot, banana, forest fruits, mocha, Compact 4.5 units suitable for child strawberry, vanilla. Starter pack: 4 × 125 mL = £7.40 under 3 years; use with caution in child 3–5 years