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Recommendations Summary

MiOA: Oral Nutrition Supplements (2023)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    MiOA: Oral Nutrion Supplements in Long-Term Care

    Healthcare practitioners should recommend oral nutrition supplements (ONS) for older adults with malnutrition or at risk for malnutrition living in long-term care. ONS intake 1–2 times per day to meet caloric, and protein deficit is associated with increased calorie and protein intake, weight gain, and improved nutrition status.

    Rating: Level 1(B)
    Imperative

    MiOA: Oral Nutrion Supplements in the Community

    Healthcare practitioners should consider oral nutrition supplements (ONS) as part of an individualized and comprehensive nutrition intervention for older adults with malnutrition or at risk for malnutrition living in the community. ONS intake of 1–2 servings per day is likely to increase calorie and protein intake.

    Rating: Level 1(B)
    Imperative

    MiOA: Oral Nutrion Supplements when Discharged From Acute Care to the Community

    Healthcare practitioners should consider oral nutrition supplements (ONS) as part of an individualized and comprehensive nutrition intervention for older adults with malnutrition or at risk for malnutrition discharged from acute care to the community. ONS intake of 1–2 servings per day is likely to increase calorie and protein intake and improve nutrition status.

    Rating: Level 1(C)
    Imperative

    • Risks/Harms of Implementing This Recommendation

      Side effects from ONS may include feelings of fullness or gastrointestinal upset. These conditions are likely to be transitory and can be addressed by stopping the ONS or serving a different form or volume/quantity and/or adjusting the time the ONS if provided. For other individuals, allergies to a component of a specific ONS (e.g., casein or whey) may exist and therefore the selection of an appropriate ONS may benefit from the advice of a dietitian. 

      Concerns have been raised about ONS being an ultra-processed food item. For example, over-reliance on ONS may result in insufficient fiber intake as ONS generally contains little or no fiber. Individuals may not benefit from the additional calories, protein, and micronutrients if ONS displaces the intake of nutritious meals. Dependence on ONS may also prevent individuals from pursuing the nutritional and social benefits of eating healthy meals, especially meals eaten with others, as eating alone and loneliness are risk factors for malnutrition.  

      There are concerns about reduced health equity with ONS interventions. Individuals with lower income, persons with disabilities, lack of transportation and other barriers may limit an individual’s ability to purchase and transport ONS to their residences. Long term use of ONS may cause economic burden, potentially requiring individuals to choose between continued purchase of ONS, healthy foods, or purchasing medications, etc.

      The benefit of daily consumption of ONS likely outweighs the harms in older adults considered malnourished or at risk of malnutrition. Older adults, caregivers and practitioners would likely value this intervention if it may prevent the negative consequences of malnutrition such as decreased physical function and quality of life, and increased risk for mortality. 

    • Conditions of Application

      ONS may be an effective nutrition intervention for older adults living in LTC or in the community with symptoms or conditions such as cancer, dementia, depression, or inflammatory disease, or reduced ability to cook or prepare meals, which may limit their ability to consume sufficient nutrients through everyday food. ONS may also assist with recovery during post-acute care, as rates of malnutrition in the acute care setting are higher than in the community, and older adults are likely to become deconditioned and have poor food intake during a hospital stay. 

      ONS should be incorporated into individualized comprehensive nutrition care plans that are monitored and evaluated by healthcare professionals. ONS are best used as a supplement rather than a meal replacement. The amount, form, viscosity, flavor, temperature, and time of intake should be individualized.  

      Acceptability

      Residents, if cognitively able, should be involved with the decision to add ONS to their diet prescription. A qualitative study conducted in the Netherlands (den Uijl LC, Kremer S, Jager G, et al. 2015) evaluated the personal factors of older adults living in LTC that led to ONS consumption. Approximately 45% of the participants found ONS satiating, 40% took ONS to maintain or gain weight, 35% considered ONS intake important and related to good health, and 25% took ONS for increased energy and greater enjoyment in life (35%). If not cognitively able, care team family members and authorized health care proxies should be consulted.  

      den Uijl LC, Kremer S, Jager G, 2015 also evaluated the personal factors of older adults living in the community that led to ONS consumption. The majority of participants considered ONS a snack (65%) and ate regular food at mealtimes. Most consumed ONS using a straw because it was considered easier. 60% of participants preferred ONS at a fridge temperature, and 25% preferred room temperature. Approximately half of the participants reported ONS to be. However, 60% found fullness unpleasant. Only 35% of participants drank the whole bottle at once, and 30% drank ONS at set times. 30-40% drank ONS to improve strength, maintain or gain weight, and prolong independence.  

      Implementation

      Table. Barriers and Facilitators for Implementation of Oral Nutrition Supplement Intake in Older Adults Living in Long-Term Care and Community Settings

      Barriers Facilitators
      Adverse physical side effects such as stomach pain and nausea
      • Practitioners should use individualized strategies to prevent adverse effects. 
      • Strategies may include drinking from a glass or changing the temperature of the ONS.
      • Practitioners may also consider stopping the ONS or serving a different type or level of viscosity, e.g., puddings, instead of shakes or adjusting the volume/quantity at one time. Also, consider adjusting volume provided at one time. 
      • Practitioners and supporting healthcare staff should ensure that ONS are properly stored out of sunlight. Once opened, they should be refrigerated. The label should be checked on how long it can be stored. 
      Allergies to a component of ONS
      • Food allergy information should be obtained from older adults to guide nutrition care.
      Poor consumption of ONS
      • Consumption of ONS should be monitored by dietitians and the healthcare team and individualized within a comprehensive nutrition intervention.
      • A variety of flavors, viscosities, and forms should be offered if feasible.
      • Further individualization should include consideration of temperature, using a glass and/or straw, amount (resealable containers), and time of intake.
      Gaps in primary care or management
      • The Malnutrition in Older Adults Evidence Based Nutrition Practice Guideline should be disseminated to healthcare practitioners, administrators, and policymakers to increase the knowledge base on the use of ONS.
      • Individuals that may benefit from ONS interventions should also be referred to a dietitian to ensure appropriate ONS use within an individualized and comprehensive nutrition care plan.
      • Dietitians should monitor for tolerance of the ONS prescription and whether the ONS is placing undue economic pressure or decreasing the older adults’ interest in, or ability, to consume a healthy diet.
      Perception by older adults that ONS are recommended to financially benefit ONS companies.
      • As part of a comprehensive nutrition assessment, the dietitian works collaboratively with the patient to discuss identified nutritional deficits and options, including ONS, for addressing them.
      • The patient is empowered to determine whether ONS is an option they wish to pursue. Provide patients with scientific evidence that supports ONS use when indicated.   
      Lack of monitoring of ONS intake goals
      • Provide patients with a log form to record intake and education on why consumption is important with subsequent communication with a healthcare practitioner. 
      A limited number of dietitians to prescribe and monitor intake in older adults living in the community.
      • The Malnutrition in Older Adults Evidence Based Nutrition Practice Guideline should be disseminated to healthcare practitioners, administrators, and policymakers to increase the knowledge base on the use of ONS.
      • Community-based organizations utilize staff and paraprofessionals to perform malnutrition screening and initiate primary interventions such as participation in meals programs, nutrition education, chronic disease self-management, etc. as well as programs to address social determinants.
      • If scheduled re-screening indicates continued risk for malnutrition, dietitian referrals are made at that time.
      ONS are processed with limited fiber. ONS may lead to a decrease in everyday food intake
      • Dietitians should provide guidance on how to add fiber to patients’ diets as well as considerations for timing of ONS, increasing nutrient density of foods and beverages, and adjustments to meal patterns to reduce the risk of insufficient nutrient intake.

    • Potential Costs Associated with Application

      There is a financial cost to purchasing ONS and that cost may be a limiting factor in its continued use of LTC facilities. LTC facilities that accept Medicare and Medicaid payments are subject to annual site inspections to assure adherence to the Conditions of Participation. Surveyors review the number of residents receiving ONS and over usage (eg,  > 30% of a facility’s population) may suggest a problem with meal service. In addition, surveyors examine the timing of ONS versus the timing of meals to identify whether meal intake is being replaced by ONS, which would be considered undesirable from a nutrition and quality of life standpoint. 

    • Recommendation Narrative

      Oral Nutrition Supplements in Long-Term Care

      A study conducted in the United Kingdom (Russell et al. 2010) found that disease related malnutrition is higher in older adults living in LTC than older adults in hospitals, outpatients and sheltered housing. Furthermore, most older adults living in LTC consume insufficient calorie and protein intake according to a cross-sectional study conducted in the Netherlands. ONS is a non-invasive nutrition intervention commonly used in LTC facilities to improve calorie and protein intake in older adults. Evaluation of available evidence on the effectiveness of ONS intake is necessary for the guidance of evidence-based nutrition practice. 

      Twenty-one randomized controlled trials were included in the Evidence Analysis Center systematic review that evaluated the effect of ONS intake on identified outcomes in older adults living in LTC (Abe et al. 2016, Beck et al. 2002, Beck et al. 2010, Fiatarone et al. 2000, Kwok et al. 2001, Lauque et al. 2000, Manders et al. 2009, Parsons et al. 2017, Rondanelli et al. 2016, Simmons et al. 2010, Simmons et al. 2015, Stow et al. 2015, Tylner et al. 2016, Van Wymelbeke et al. 2016, Bonnefoy et al. 2003, Fiatarone et al. 1994, Lee et al. 2013, Pouyssegur et al. 2015, Stange et al. 2013, Lee et al. 2015, Elia et al. 2018).  All studies provided ONS 1–2 times per day except for Tylner et al. 2016 who provided ONS 3 times per day. ONS intake was prescribed in addition to regular meals.

      Fourteen studies (Fiatarone et al. 2000, Kwok et al 2001, Lauque et al 2000, Manders et al 2009, Parsons et al 2017, Rondanelli et al 2016, Simmons et al 2010, Simmons, et al 2015, Stow et al 2015, Tylner, et al 2016, Fiatarone et al. 1994, Lee et al. 2013, Pouysseguar et al. 2015, Stange et al. 2013) evaluated the effect of ONS on body weight or BMI, and a significant increase was found in kilograms of body weight and BMI (moderate certainty). Fourteen studies (Beck et al. 202, Beck et al 2010, Fiatarone et al. 2000, Kwok et al. 2001, Lauque et al. 2000, Manders et al. 2009, Parsons et al. 2017, Rondanelli et al. 2016, Simmons et al. 2010, Semmons et al. 2015, Stow et al. 2015, Tylner et al. 2016, Van Wymelbeke et al. 2016, Bonnefoy et al, Fiatarone et al, Lee et al, Pouyssegur et al, Stange et al)  evaluated the effect of ONS on protein and energy intake, and significant increases were found (moderate certainty). Three studies (Lauque et al. 2000, Rondanelli et al. 2016, Van Wymelbeke et al. 2016) evaluated the effect of ONS on nutrition status, and found a significant increase (low certainty). Nine studies (Abe et al.2016, Fiatarone et al 2000, Kwok et al. 2001, Lauque et al. 2000, Manders et al. 2009, Rondanelli et al. 2016, Stow et al. 2015, Tylner et al. 2016, Van Wymelbeke et al 2016,   Bonnefoy et al 2003, Fiatarone et al. 1994, Stange et al.2013,  Lee et al. 2015) evaluated the effect of ONS on physical function (ADLs, handgrip strength, and gait speed) with no significant effect found (low certainty). Three studies (Simmons et al. 2010, Simmons et al. 2015, Elia et al. 2018) evaluated the cost-effectiveness of ONS, and limited research indicates that ONS may be a cost-effective intervention (very low certainty). No studies were found that evaluated the effect of ONS on mortality. 

      Oral Nutrition Supplements in the Community

      Older adults living in the community are at higher risk for malnutrition and unintended weight loss, especially those recently discharged from acute care. Malnutrition is associated with increased morbidity and mortality and impaired activities for daily living and quality of life. Older adults are susceptible to malnutrition through a variety of mechanisms, including but not limited to their increased risk for chronic disease. Chronic disease can lead to inadequate intake, unintended weight loss and decreased physical function. Furthermore, the aging process and multifactorial social and economic factors result in an increased risk for decline in nutritional status. Oral nutrition supplements are concentrated forms of nutrition that are primarily provided in ready-to-drink bottles or packets of powder. Bottles are typically 237 ml, and the quantities of energy, protein and micronutrients vary. ONS can offer convenient macronutrient assistance that may prevent or treat aspects of malnutrition and improve nutrition status. Therefore, evaluation of available evidence on the effectiveness of ONS intake is necessary for the guidance of evidence-based nutrition practice. 

      Two systematic reviews were conducted to evaluate the effect of ONS on the following outcomes: mortality, weight, BMI, calorie and protein intake, physical function (ADL, gait speed, hand grip strength), nutrition status (measured by a valid nutrition assessment), hospital readmissions, and cost-effectiveness. One systematic review evaluated older adults living in the community, the other evaluated older adults discharged from acute care to the community. The expert panel conducted two separate systematic reviews due to the heterogeneity between populations living at home, and those recently discharged from acute care.  

      Twenty-three studies were included in the community review (Bauer et al. 2015, Bisek et al. 2021, Bo et al. 2019, Gray-Donald et al. 1995, Kim et al. 2021, Kim et al. 2013, Nabuco et al. 2019, Ottestad et al. 2017, Tieland et al. 2012, Payette et al. 2002, deCarvlho et al. 2020, Bjorkman et al. 2012, Chapman et al. 2009, Peng et al. 2022, Smith et al. 2020, Zdzieblik et al. 2015, Assantachai et al. 2020, Fielding et al. 2017, Zhu et al. 2019, Kim et al. 2021, Park et al. 2018, Bjorkman et al. 2020, Roschel et al. 2021). All studies were conducted outside the United States (U.S.) except for Fielding 2017, which was conducted in the U.S. and Sweden. Oral nutrition supplement interventions included a variety of commercial drinks and powders and were primarily provided by research staff within an approved nutrition intervention protocol. ONS intake was compared to placebos or standard care. Older adults consuming ONS had significantly greater calorie intake and protein intake compared to those receiving placebos or standard care, with low and moderate certainty evidence (moderate certainty) (Bauer 2015, Bisek 2021, Bo 2019, Gray-Donald 1995, Kim 2021, Kim 2013, Nabuco 2019, Ottestad 2017, Payette 2002, Smith 2020, Park 2018). Little to no statistically significant effect was found on weight or body mass index (moderate certainty) (Bisek 2021, Bo 2019, Gray-Donald 1995, Kim 2013, Ottestad 2017, Tieland 2012, Payette 2002, Bjorkman 2012, Chapman 2009, Peng 2022, Smith 2020, Zdzieblik 2015); physical function (moderate certainty) (Bauer 2015, Bisek 2021, Bo 2019, Gray-Donald 1995, Kim 2021, Kim 2013, Nabuco 2019, Ottestad 2017, Tieland 2012, Payette 2002, deCarvalho 2020, Bjorkman 2012, Chapman 2009, Peng 2022, Assantachai 2020, Fielding 2017, Zhu 2019, Bjorkman 2020, Roschel 2021) or hospital readmission (low certainty) (Edington 2004, Gade 2019, McMurdo 2009) No evidence was found for mortality, and evidence for nutrition status measured by valid nutrition assessment was limited (Chapman 2009).

      Fourteen studies were included in the systematic review that evaluated the effect of ONS on identified outcomes in older adults discharged from acute care to the community (Edington 2004, Gade 2019, Loman 2019,  McMurdo 2009, Price 2005, Amasene 2019, Deer 2019, Feldblum 2011, Neelemaat 2011, Persson 2007, Volkert 1996, Deutz 2016, Neelemaat 2017, Soderstrom 2020). ONS intake improved calorie and protein intake (moderate certainty)(Edington 2004, Gade 2019, Loman 2019, McMurdo 2009, Price 2005, Neelemaat 2011) and nutrition status measured by valid nutrition assessment (low certainty) (Amasene 2019, Deutz 2016). However, little to no difference in weight or BMI (moderate certainty) (Edington 2004, McMurdo 2009, Price 2005, Amasene 2019, Deer 2019, Feldblum 2011, Neelemaat 2011, Persson 2007)  functional status (low certainty) (Gade 2019, McMurdo 2009, Amasene 2019, Deer 2019, Neelemaat 2011, Persson 2007, Volkert 1996, Deutz 2016), hospital readmission (low certainty) (Chapman 2009, Smith 2020),  or mortality was found (moderate certainty) (Edington 2004, Gade 2019, Deutz 2016, Neelemaat 2017, Soderstrom 2020).   

    • Recommendation Strength Rationale

      The evidence supporting the recommendations is based on Grades B (Moderate),  C (Low) and D (Very Low).

    • Minority Opinions

      None.