Encouraging appropriate, evidence-based use of oral nutritional supplements

Abstract

With the considerable cost of disease-related malnutrition to individuals and to society (estimated to be > £13 · 10 9 for the UK, 2007 prices), there is a need for effective and evidence-based ways of preventing and treating this condition. The wide range of oral nutritional supplements that may be prescribed for the dietary management of malnutrition and other conditions account for only about 1 % (about £99 · 10 6 , 2007 data) of the prescribing budget in England. Systematic reviews and meta-analyses consistently suggest that ready-made, multinutrient liquids which may be prescribed can improve energy and nutritional intake, body weight and have a variety of clinical and functional benefits in a number of patient groups. Meta-analyses have repeatedly shown that oral nutritional supplements produce significant reductions in complications (e.g. infections) and mortality, and a recent meta-analysis shows a reduction in hospital admissions (OR 0 . 56 (95% CI 0 . 41, 0 . 77), six randomised controlled trials). Such benefits suggest that the appropriate use of oral nutritional supplements should form an integral part of the management of malnutrition, particularly as there is currently a lack of evidence for alternative oral nutrition strategies (e.g. food fortification and counselling). As with all therapies, compliance to oral nutritional supplements needs to be maximised and the use monitored. To make sure that those at risk of malnutrition are identified and treated appropriately, there is a need to embed national and local policies into routine clinical practice. In doing so, the economic burden of this costly condition can be curtailed. As recently suggested by the National Institute for Health and Clinical Excellence, substantial cost savings could be made if screening and treatment of malnourished patients was undertaken.

Response of appetite and potential appetite regulators following intake of high energy nutritional supplements

“…Despite this overfeeding, subjective appetite measures during prelunch period and energy intake during ad libitum lunch did not differ between the HENSD and PLACEBO trials. Thus, HENSD may improve energy and nutritional intake in individuals with an increased risk of becoming malnourished (Cawood et al, 2012; R.J. Stratton & Elia, 2010;Rebecca J. Stratton et al, 2013) as the suppressive response of appetite and energy compensation following consumption of such supplements is short lived.…”

“…Systematic reviews and meta-analyses consistently suggest that oral, ready to drink high energy liquid supplements (HENSD) improve body weight and energy and nutritional intake, and thus may have various clinical and functional benefits in patients with an increased risk of becoming malnourished (Cawood, Elia, & Stratton, 2012;Stratton & Elia, 2010;Stratton, Hebuterne, & Elia, 2013). HENSD typically contain a mixture of macro and micronutrients, providing between 6$3 kJ/ml to 10$1 kJ/ml per typical serving of 125e220 ml (Stratton & Elia, 2010).…”

“…HENSD typically contain a mixture of macro and micronutrients, providing between 6$3 kJ/ml to 10$1 kJ/ml per typical serving of 125e220 ml (Stratton & Elia, 2010). Although HENSD should increase daily energy intake by an average of 1569 kJ/d, their net benefit is lower than anticipated (Milne, Avenell, & Potter, 2005;Poustie, Russell, Watling, Ashby, & Smyth, 2006), implying that HENSD consumption partially displaces food and energy intake during habitual meals.…”

Preoperative immunonutrition in patients at nutritional risk: results of a double-blinded randomized clinical trial

“…Of note, powder supplements that need to be reconstituted before consumption may have a negative impact and its use is not generally recommended. 10,32 An impaired compliance was also found in the study of Hiesmayr et al 33 who showed that X50% of their patients had an insufficient nutritional intake. In fact, despite a 100% compliance is always implied, no randomized trial on IN reported the real nutritional intake.…”

“…The observed impaired compliance also inherits an aspect of 'nontolerance'. As described by Stratton et al, 32 psychosocial factors such as anxiety and depression rather impair compliance; other disease-related factors, for example, anorexia, nausea or changes in taste and smell related to chemotherapy mainly contribute to non-tolerance. Of note, powder supplements that need to be reconstituted before consumption may have a negative impact and its use is not generally recommended.…”