4.1 Recommendations from international, national, and professional guidelines: ONS
Table 4.1, Table 4.2, Table 4.3, Table 4.4 and Table 4.5 include the results of efforts made to identify evidence-based national and professional guidelines referring to ONS as an integral part of patient and disease management across the world. Relevant professional and national organisations were contacted or searches of websites were undertaken, including the US Department of Health and Human Sciences National Guideline Clearinghouse (www.guideline.gov), searches of the published literature from 2002 to 2016 were completed, and approaches were made to contacts in relevant areas. Other guidelines may exist but are not included as they were not identified using the above strategies, or we were unable to obtain information in the English language for inclusion. We would welcome information about other guidelines that could be included in future editions of this report.
In addition, guidelines for nutrition support exist in the following countries and are, to our knowledge, based on the guidelines developed by ESPEN:
- China (www.cspen.org);
- Czech Republic
Note: Terminology referring to ONS is not consistent within the various guidelines; therefore, the term [ONS] has been inserted inplace of these terms to avoid confusion.
The tables that follow include the recommendations relating to ONS only as they appear in the guidelines or documents from various organisations. Please refer to the full documents for other information relating to nutritional management, e.g., screening, assessment, and use of other forms of nutritional support.
GENERAL
Table 4.1
Summary of some examples of evidence-based national and professional guidelines referring to ONS as an integral part of patient and disease management - General (parts of guidelines relevant to ONS are presented here, standard ONS formulae only)
| Country | Body | Patient Group | Title | Recommendation, guideline, or standard [grade of evidence, where available] |
|---|---|---|---|---|
| Denmark | The National Board of Health (2008) | Patients in hospitals | Screening and treatment of patients at nutritional risk. A guide for doctors, nurses, healthcare assistants, auxiliary nurses and clinical dietitians1 | There is a positive effect of ONS in patients where there is an indication for intensive nutritional therapy according to NRS-2002 ONS recommended for: • Patients who need an energy-dense diet • Patients with low food intake • Patients with chewing and swallowing difficulties, such as patients with dysphagia, patients with painful mouth and throat, patients with paralysis, and generally impaired condition because of dementia or amyotrophic lateral sclerosis |
| Denmark | Danish Health Authority (2022) | Patients in institutions | Malnutrition: Detection, treatment and follow-up of citizens and patients at nutritional risk. Guidance for municipalities, hospitals and general practice 2 | ONS recommended for: • Patients with chewing and swallowing difficulties, such as patients with dysphagia, patients with painful mouth and throat, patients with paralysis and generally impaired condition because of dementia or amyotrophic lateral sclerosis • Patients with chronic disease, patients with general low energy and protein intake, for recovery after surgery – before considering enteral nutrition |
| England and Wales | National Institute for Health and Care Excellence (NICE) (2006) | All patients in hospital and in the community | Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition3 | Indications for oral nutrition support: • Healthcare professionals should consider oral nutrition support to improve nutritional intake for people who can swallow safely and are malnourished or at risk of malnutrition** [A] • Healthcare professionals should ensure that the overall nutrient intake of oral nutrition support offered contains a balanced mixture of protein, energy, fibre, electrolytes, vitamins, and minerals [D (GPP)] • Oral nutrition support should be stopped when the patient is established on adequate oral intake from normal food [D (GPP)] Note: see Table 4.6 for summary of grading of recommendations NICE has published a Quality Standard on Nutrition Support in Adults which has been developed from this guideline. https://www.nice.org.uk/guidance/qs24 |
| Finland | Finnish Institute for Health and Welfare (2023) | All patients in hospital, community, care/elderly homes and rehabilitation centres | Guidelines for nutritional care 4 | A patient found to be at risk of malnutrition during screening or who is diagnosed with malnutrition as a result of nutritional status assessment requires enhanced nutritional care. Methods for enhancing nutritional care include enriched diet, preferred foods, extra snacks, oral nutritional supplements, enteral nutrition, and intravenous nutrition A high-protein diet is needed in situations where the patient’s need for protein has increased but their energy requirement is moderate. These cases can involve overweight or obese patients, wound patients with a low level of physical activity, or older patients recovering from major surgery. The diet is not suitable for people with advanced renal failure. Oral nutritional supplements effectively increase the amount of protein in the diet.. |
| Norway | Norwegian Directorate for Health (2022) | All patients in hospital and in the community | The National Guideline for Prevention and Treatment of Malnutrition 5 | • Malnutrition Screening: The use of the Malnutrition Screening Tool (MST) is now recommended for all adults (≥18 years) across all healthcare settings, including hospitals, community care, and primary care, regardless of diagnosis or condition. • Nutritional Treatment: For patients identified as malnourished or at risk of malnutrition, a high-energy and nutrient-dense diet is advised, potentially in combination with ONS. |
| Sweden | The Swedish National Board of Health and Welfare (2017) | All patients within healthcare | The Handbook for Healthcare 6 | • Malnutrition Screening: The use of validated screening tools to identify individuals at risk of malnutrition. • Nutritional Support: The provision of tailored nutritional interventions, including ONS, to meet individual needs. • Indications for ONS Use: ONS are recommended for individuals who are at risk of or are experiencing malnutrition, particularly when their nutritional needs cannot be met through regular food intake alone. • Types of ONS: Protein-rich ONS are recommended to address specific nutritional deficiencies and to support recovery in various patient populations. • Monitoring and Evaluation: Regular assessment of the patient's nutritional status is advised to determine the effectiveness of ONS and to make necessary adjustments to the nutrition plan. • Integration into Care Plans: ONS should be incorporated into individualised care plans, considering the patient's overall health condition, preferences, and specific nutritional requirements. |
| The Netherlands | Steering Committee Malnutrition (Stuurgroep Ondervoeding, 2011) | Malnutrition in general, all lines of healthcare) (including children) | Guidelines Malnutrition: screening and treatment7 | • When 75–100% of nutritional requirements are met: Utilise protein- and energy-rich foods and consider supplementing them with ONS if necessary. • When 50–75% of nutritional requirements are met: Combine protein- and energy-rich foods with ONS. When less than 50% of nutritional requirements are met: Continue ONS if possible and consider initiating tube feeding. |
| The Netherlands | Dutch malnutrition center of expertise (Stuurgroep Ondervoeding, 2022) | Malnutrition in general, all lines of healthcare) (including children) | Guidelines Malnutrition: treatment and evaluation8 | • Dietary foods for medical use The dietitian will optimize the diet taking into account the patient’s preferences and habits. If the treatment goals cannot be achieved with normal nutrition, the use of diet foods for medical use is indicated, for example protein supplements, medical nutrition, tube feeding, parenteral nutrition. The general rule used is: • At an intake of 75 – 100% of the established needs, the treatment plan consists of protein- and energy-rich food in the form of fortified main meals, interim provisions and possibly additional medical nutrition or protein supplements. • At an intake of 50% – 75% of the established needs, the advice is medical nutrition and/or tube feeding in addition to protein and energy-rich food. • If the intake is less than 50% of the needs and there is no chance of a rapid improvement in intake, full tube feeding is recommended, supplemented with what is possible per os. • TPN is indicated when sufficient nutrition cannot be provided via the gastrointestinal tract for more than seven days because enteral nutrition is not or insufficiently possible or is contraindicated. Deviations from the above can be made on the basis of the specific characteristics and individual situation and wishes of the patient. |
| UK | Malnutrition Advisory Group of BAPEN (2003) | All | The ‘MUST’ Report Nutritional screening of adults: a multidisciplinary responsibility9 | There is substantial evidence of the beneficial clinical effects of [ONS] containing a mixture of macro- and micronutrients in particular groups of patients in hospital and the community, and of greater benefit in individuals with a BMI of < 20 kg/ m2 than > 20 kg/m2, particularly patients in the community. [A – at least 1 RCT as part of the body of literature of overall good quality and consistency addressing the specific recommendation] |
| UK | BAPEN (2000) | Patients in the community | Guidelines for the detection and management of malnutrition 10 | • Treatment typically begins with food but may progress to the use of [ONS]. In some patients it may begin with food and [ONS] • If ordinary food is ineffective in improving nutritional status and ineffective in achieving the goals set at the beginning of treatment, [ONS] (mixed micro- and macronutrient supplements in solid or liquid form) can be of value. This is because they are readily available, easy to consume between meals, require little or no preparation, and are largely additive to food intake in undernourished subjects [A – at least 1 RCT as part of the body of literature of overall good quality and consistency addressing the specific recommendation] |
| USA | Council for Nutritional Strategies in Long-Term Care (2000) | With or at risk of malnutrition | Nutritional management in long-term care: development of a clinical guideline11 | • [ONS] can increase dietary intake and produce weight gain • [ONS] must be given between meals in order not to substitute for calorie intake at meals |
| USA | American Society for Parenteral & Enteral Nutrition (2016) | Adults | Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patients12 | • Nutrition Support Initiation: The guideline recommends initiating nutrition support therapy within 24–48 hours in critically ill patients who are unable to maintain volitional intake. 12 |
| USA | American Society for Parenteral & Enteral Nutrition (2010) | Adults | Assessment and Intervention in Adults13 | • Nutrition support intervention is recommended for patients identified by screening and assessment as at risk for malnutrition or malnourished [C] |
| Australia | Dietitians Association of Australia Malnutrition Guideline Steering Group (2009) | Malnutrition in adult patients across care settings | Practice guidelines for the nutritional management of malnutrition in adult patients across the continuum of care14 | • [ONS] (high energy and/or protein) may improve outcomes See full guidelines for details of evidence base for outcomes in specific settings (across settings, acute care, rehabilitation, residential aged care and community) Note: see Table 4.7 for summary of grading of recommendations Nutrition goals, intervention, monitoring practice tips: When providing [ONS], consider the following (see full guidelines for individual references):
|
*Oral nutrition support includes any of the following methods to improve nutritional intake: fortified food with protein, carbohydrate and/or fat, plus minerals and vitamins; snacks; ONS; altered meal patterns; the provision of dietary advice (DA)
**Malnourished: BMI < 18.5 kg/m2, unintentional weight loss > 10% within the last 3–6 months, a BMI < 20 kg/m2 and unintentional weight loss > 5% within the last 3–6 months Textbox 6990,
***At risk of malnutrition: eaten little or nothing for more than 5 days and/or likely to eat little or nothing for the next 5 days or longer or poor absorptive capacity, and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism
OLDER PEOPLE
Table 4.2
Summary of examples of evidence-based national and professional guidelines referring to ONS as an integral part of patient and disease management – Older People(parts of the guidelines relevant to ONS are presented here, standard ONS formulae only)
| Country/Region | Body | Title | Recommendation, guideline, or standard [grade of evidence] |
|---|---|---|---|
| Europe | European Society for Clinical Nutrition and Metabolism (2018) | ESPEN guideline on clinical nutrition and hydration in geriatrics 15 | •Hospitalised older persons with malnutrition or at risk of malnutrition shall be offered ONS, in order to improve dietary intake and body weight, and to lower the risk of complications and readmission. [A] •Oral nutritional supplements offered to an older person with malnutrition or at risk of malnutrition shall provide at least 400 kcal/day, including 30 g or more of protein/day. [A] •After discharge from the hospital, older persons with malnutrition or at risk of malnutrition shall be offered ONS in order to improve dietary intake and body weight, and to lower the risk of functional decline. [A] •When offered to an older person with malnutrition or at risk of malnutrition, ONS shall be continued for at least one month. The efficacy and expected benefit of ONS shall be assessed once a month. [Strong consensus] When offered to an older person with malnutrition or at risk of malnutrition, ONS compliance consumption shall be regularly assessed. Type, flavour, texture, and time of consumption shall be adapted to the patient's taste and eating capacities. [Strong consensus] |
| Europe | European Society for Clinical Nutrition and Metabolism (2006) | ESPEN Guidelines on Enteral Nutrition: Geriatrics 16 | •In patients who are undernourished or at risk of under-nutrition, use ONS to increase energy, protein, and micronutrient intake, maintain or improve nutritional status, and improve survival [A] •In frail elderly, use ONS to improve or maintain nutritional status [A] •In geriatric patients after hip fracture and orthopaedic surgery, use ONS to reduce complications [A] •In early and moderate dementia, consider ONS – and occasionally tube feeding – to ensure adequate energy and nutrient supply and to prevent under-nutrition [C] •ONS, particularly with high protein content, can reduce the risk of developing pressure ulcers [A] •In the case of nutritional risk (e.g., insufficient nutritional intake, unintended weight loss > 5% in 3 months or > 10% in 6 months, BMI < 20 kg/m2), initiate ONS and/or tube feeding early [B] Note: see Table 4.8 for summary of grading of recommendations |
| Denmark | Danish Health Authority (2022) | Malnutrition: Detection, treatment and follow-up of citizens and patients at nutritional risk. Guidance for municipalities, hospitals and general practice 2 | ONS recommended for: •Dietary management of malnutrition, decreased appetite and weight loss •Older people with low energy and protein intake to prevent underweight and loss of function and strength because of malnutrition |
| Finland | Finnish National Nutrition Council & Finnish Institute for Health and Welfare (2020) | Vireyttä seniorivuosiin 17 | Indications for ONS: •ONS are recommended for elderly individuals who: •Have acute illnesses or are recovering from surgery. •Experience significant weight loss (e.g., >3 kg over 3 months). •Have a low body weight (e.g., BMI <23 kg/m²). •Suffer from conditions such as cancer, COPD, heart failure, or dysphagia. •Exhibit poor appetite or inadequate food intake. Implementation Strategies: •Regularly assess nutritional status and monitor weight changes. •Incorporate ONS into individualised care plans based on specific nutritional needs. •Ensure that ONS are used to complement meals, not replace them. •Promote social dining experiences to enhance appetite and food intake. |
| France | Haute Autorité de Santé (2011) | Clinical practice guidelines from the French Health High Authority: Nutritional support strategy in protein-energy malnutrition in the elderly18 | Methods of nutritional support: Oral nutritional support. This comprises nutritional guidance, assistance during eating, provision of enriched food and oral nutritional supplements, some of which are reimbursed Choice of method of nutritional support: The choice of a nutritional support strategy is based on the patient’s nutritional status and on spontaneous food, energy and protein intake (see Table 4.8). It also takes into account the nature and severity of any underlying disease(s) and associated disabilities as well as their foreseeable outcome (swallowing disorders, for example). Nutritional support strategy must also take into account the opinion of patients and their close relatives as well as ethical considerations. Apart from situations contra-indicating oral feeding, nutritional support should, as a priority, be initiated by providing DA and/or fortified foods, [C] if possible in collaboration with a dietitian. Oral nutritional supplements (ONS) may be given if these supportive measures are ineffective or from the onset in patients with severe malnutrition [C] Practical measures: Oral nutritional support: Studies on malnourished elderly patients have shown an improvement in body weight and survival and a reduction in the incidence of complications after oral nutritional support [A] ONS: High energy and/or high-protein ONS come in different flavours, with or without lactose, and in a variety of forms (liquid, cream, etc.). Several types of products are available, including dairy desserts, soups, complete meals, fruit juices, etc. Preference should be given to high energy (> 1.5 kcal/ml or/g) and/or high-protein products (proteins > 7.0 g/100 ml or 100 g or proteins > 20% of total energy intake) ONS are prescribed as follows: • ONS may be eaten as a snack or during meals. When they are provided during meals, they must be eaten in addition to meals and not as a meal replacement. As a snack, they should be given about 2 h before or after a meal in order not to spoil the appetite • The prescription of an ONS should supply an additional food intake of 400 kcal/day and/or 30 g protein/day; this generally requires 2 units per day • Patients should be told that ONS are a treatment for malnutrition to encourage consumption • The taste of the prescribed ONS should be suited to patient preferences in terms of being salty or sweet, creamy or not, and in terms of flavour. A vanilla or plain product may be modified by adding flavours (fruit syrup, caramel, coffee, chocolate powder, etc.). Consumption may be encouraged by varying products and flavours and respecting patient preferences • ONS should be adapted to any disabilities (difficulties in swallowing or in gripping objects, etc.). The texture of drinks may be modified with a thickening powder (not included on the list of reimbursed products) • ONS intake may be encouraged by serving them at the correct temperature. Sweet products are often preferred cold. ONS that should be served hot may often be heated up in a double boiler or microwave oven. Once opened, the supplement may be kept for 2 h at room temperature and for up to 24 h in the refrigerator • A regular check should be performed to ensure that the prescribed ONS are actually consumed • When patients live at home, the first prescription is made for a maximum period of 1 month. After medical reassessment, subsequent prescriptions may be made for a maximum period of 3 months. Medical reassessment should be based on the following:
|
| USA | Academy of Nutrition and Dietetics (2024) | Prevention and Treatment of Malnutrition in Older Adults Living in Long-Term Care or the Community: an evidence-based nutrition practice guideline. 19 | •Indications for ONS: ONS are recommended for older adults who are undernourished or at risk of under-nutrition, including those who are frail, have infections, impaired wound healing, pressure ulcers, depression, early to moderate dementia, and/or have undergone hip fracture or orthopaedic surgery. •Effectiveness: Studies support ONS as a method to provide energy and nutrient intake, promote weight gain, maintain or improve nutritional status, or prevent under-nutrition. •Implementation Strategies: •Timing: ONS should be provided between meals to minimize appetite suppression and compensatory decreased intake of food at mealtimes. •Variety and Presentation: Encourage patients to sample a variety of ONS to find acceptable options. Presentation of the supplement should also be varied to enhance acceptance. Composition: A liquid supplement in which the energy is supplied by glucose instead of fat is less likely to cause satiation 19 |
| USA | Academy of Nutrition and Dietetics (2009) | Unintended Weight Loss (UWL) in Older Adults Evidence-based Nutrition Practice Guideline (login required) 20 | Indications for [ONS] The Registered Dietitian (RD) should recommend [ONS] for older adults who are undernourished or at risk of under-nutrition (i.e., those who are frail, those who have infection, impaired wound healing, pressure ulcers, depression, early to moderate dementia and/or after hip fracture and orthopaedic surgery). Studies support [ONS] as a method to provide energy and nutrient intake, promote weight gain and maintain or improve nutritional status or prevent under-nutrition [Strong] *Note that the guidance uses the term ‘medical food supplements’ but to avoid confusion with vitamin and mineral food supplements, the term ONS has been inserted in its place |
CHILDREN
Table 4.3
Summary of examples of evidence-based national and professional guidelines referring to ONS as an integral part of patient and disease management – Children (parts of the guidelines relevant to ONS are presented here, standard ONS formulae only)
| Country/Region | Body | Title | Recommendation, guideline, or standard [grade of evidence] |
|---|---|---|---|
| Europe | European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition (2010) | Practical approach to paediatric enteral nutrition: A comment by the ESPGHAN Committee on Nutrition 21 | •[ONS]* should be given only as an addition to other foods when enhancement of oral energy and substrate intake is necessary *Note: The term ‘supplement feeds’ (sip feeds) is used in the original paper, but it has been replaced here with ‘ONS’ to avoid confusion |
| Europe | ESPEN- ESPGHAN-ECFS (2023) | ESPEN-ESPGHAN-ECFS Guideline on Nutrition Care for Cystic Fibrosis (2023) 22 | •ONS are recommended for individuals with cystic fibrosis who fail to achieve optimal growth rates and nutritional status through oral dietary intake and PERT alone. (Grade of evidence: GPP; strong consensus 100% agreement). •Clinicians should regularly review and re-evaluate patients on ONS to determine the necessity of continued supplementation. (Grade of evidence: GPP; strong consensus 100% agreement). |
| Europe | ESPEN- ESPGHAN-ECFS (2016) | ESPEN- ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with cystic fibrosis 23 | Guideline: oral nutritional supplements •We recommend clinicians consider the use of oral nutritional supplements for treating children and adults who fail to achieve optimal growth rates and nutritional status with oral dietary intake and pancreatic enzyme replacement therapy (PERT) alone. (Grade of evidence: low) •We recommend clinicians regularly review and re-evaluate patients who are taking oral nutritional supplements to determine whether the patient should continue taking them. (Grade of evidence: high) |
| UK | British Society of Paediatric Gastroenterology Hepatology and Nutrition (BSPGHAN) (2010) | Guidelines for the Management of Inflammatory Bowel Disease (IBD) in Children in the United Kingdom 24 | •Exclusive enteral nutrition (given either orally or enterally) is effective first line therapy for small and large bowel disease, inducing remission in 60–80% of cases (EL +1 -1) •Supplementary therapy may reduce the risk of relapse and may improve growth and nutritional status (EL 2-) •Nutritional support should be considered as adjunctive therapy for any patient with CD or UC who has malnutrition. •Nasogastric/gastrostomy tube feeding can be considered Supplemental enteral feeding or cyclical enteral nutrition for children with CD in remission may improve growth and help to maintain remission |
| England | NICE (2014) | Pressure Ulcers: Prevention and Management 25 | Prevention: Nutritional supplements and hydration Do not offer nutritional supplements specifically to prevent a pressure ulcer in neonates, infants, children and young people with adequate nutritional status for their developmental stage and clinical condition. Management: Nutritional supplements and hydration Offer an age-related nutritional assessment to neonates, infants, children and young people with a pressure ulcer. This should be performed by a paediatric dietitian or other healthcare professional with the necessary skills and competencies. Discuss with a paediatric dietitian (or other healthcare professional with the necessary skills and competencies) whether to offer nutritional supplements specifically to treat a pressure ulcer in neonates, infants, children and young people whose nutritional intake is adequate. Offer advice on a diet that provides adequate nutrition for growth and healing in neonates, infants, children and young people with a pressure ulcer. Discuss with a paediatric dietitian whether to offer nutritional supplements to correct nutritional deficiency in neonates, infants, children and young people with a pressure ulcer. Assess fluid balance in neonates, infants, children and young people with a pressure ulcer. Ensure there is adequate hydration for age, growth and healing in neonates, infants, children and young people. If there is any doubt, seek further medical advice. |
SPECIFIC DISEASES
Table 4.4
Summary of examples of evidence-based national and professional guidelines referring to ONS as an integral part of patient and disease management – Specific Diseases and Conditions (parts of guidelines relevant to ONS are presented here, standard ONS formulae only)
| Patient Group | Country | Body | Title | Recommendation, guideline, or standard [grade of evidence] |
|---|---|---|---|---|
| Patients with hip fracture | Europe | European Society for Clinical Nutrition and Metabolism (2022) | ESPEN practical guideline: Clinical nutrition and hydration in geriatrics 26 | Older patients with hip fractures shall be offered ONS postoperatively in order to improve dietary intake and reduce the risk of complications. (R43, Grade A, strong consensus 100%) |
| Patients with hip fracture | Europe | European Society for Clinical Nutrition and Metabolism (2006) | ESPEN Guidelines on Enteral Nutrition: Geriatrics 16 | In geriatric patients after hip fracture and orthopaedic surgery, use ONS to reduce complications [A] Note: see Table 4.8 for summary of grading of recommendations |
| Patients with hip fracture | USA | American Academy of Orthopaedic Surgeons (AAOS) (2015) | American Academy of Orthopaedic Surgeons clinical practice guideline on management of hip fractures in the elderly. 27 | Nutrition Moderate evidence supports that postoperative nutritional supplementation reduces mortality and improves nutritional status in hip fracture patients. (Strength of Recommendation: Moderate ***) |
| Patients with dementia | Europe | European Society for Clinical Nutrition and Metabolism (2024) | ESPEN guideline on nutrition and hydration in dementia – Update 2024 28 | •Use of ONS: ESPEN recommends offering ONS to individuals with dementia who are at risk of malnutrition or are already malnourished. The goal is to improve energy and protein intake and to enhance or maintain nutritional status. This recommendation carries a Grade A level of evidence with strong consensus (100% agreement). •Limitations of ONS: While ONS are beneficial for improving nutritional status, they are not recommended for correcting cognitive impairment or preventing cognitive decline. •Routine Use of Dementia-Specific ONS: The guideline advises against the routine use of dementia-specific ONS (Grade B), ketogenic diets (Grade B), omega-3 fatty acid (Grade A) supplementation, and appetite-stimulating agents (GPP; consensus 89% agreement) due to insufficient evidence supporting their efficacy in this population (Grade A). |
| Patients with dementia | Europe | European Society for Clinical Nutrition and Metabolism (2015) | ESPEN Guidelines on Nutrition in Dementia 29 | We recommend the use of ONS to improve nutritional status. (Grade of evidence: High; Strength of recommendation: Strong) |
| Patients with pressure ulcers (pressure injury) | Europe | European Society for Clinical Nutrition and Metabolism (2022) | ESPEN practical guideline: Clinical nutrition and hydration in geriatrics 26 | Nutritional interventions should be offered to older patients at risk of pressure ulcers in order to prevent the development of pressure ulcers. (R52, Grade B, strong consensus 100%) |
| Patients with pressure ulcers (pressure injury) | Europe | European Society for Clinical Nutrition and Metabolism (2006) | ESPEN Guidelines on Enteral Nutrition: Geriatrics 16 | • ONS, particularly with high protein content, can reduce the risk of developing pressure ulcers (A) • Based on positive clinical experience, enteral nutrition (by means of ONS or tube feeding) is also recommended in order to improve healing of pressure ulcers [C] Note: see Table 4.8 for summary of grading of recommendations |
| Patients with pressure ulcers (pressure injury) | International | European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Injury Advisory Panel (NPIAP), and Pan Pacific Pressure Injury Alliance (PPPIA) (2019) | The Role of Nutrition for Pressure Injury Prevention and Healing: The 2019 International Clinical Practice Guideline Recommendations 30 | •Offer high-calorie, high-protein nutritional supplements for adults at risk or who have pressure ulcers if oral intake is not enough. •Offer high-calorie, high-protein, arginine, zinc, and antioxidants nutritional supplements for adults with stage II pressure injury. |
| Patients with pressure ulcers (pressure injury) | International | European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Ulcer Advisory Panel (NPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA) | Prevention and treatment of pressure ulcers 31 | •Energy intake: Offer fortified foods and/or high calorie, high protein oral nutritional supplements between meals if nutritional requirements cannot be achieved by dietary intake. (Strength of Evidence = B; Strength of Recommendation = CC) Consider enteral or parenteral nutritional support when oral intake is inadequate. This must be consistent with the individual’s goals. (Strength of Evidence = C; Strength of Recommendation = C) •Protein intake: Offer high calorie, high protein nutritional supplements in addition to the usual diet to adults with nutritional risk and pressure ulcer risk, if nutritional requirements cannot be achieved by dietary intake. (Strength of Evidence = A; Strength of Recommendation = C) Supplement with high protein, arginine, and micronutrients for adults with a pressure ulcer Category/ Stage III or IV or multiple pressure ulcers when nutritional requirements cannot be met with traditional high-calorie and protein supplements. (Strength of Evidence = B; Strength of Recommendation = 👍🏼) * The strength of recommendation in this document is indicated by multiples of a thumbs-up symbol |
| Patients with pressure ulcers (pressure injury) | USA | Academy of Nutrition and Dietetics | Spinal Cord Injury (SCI) Evidence-Based Nutrition Practice Guideline 32 (login required) | Nutrition Intervention to Prevent Development of Pressure Ulcers If a patient with SCI is at risk of pressure ulcer development as indicated by biochemical, anthropometric and lifestyle factors, the RD should implement aggressive nutrition support measures. The range of options may include [ONS]† and enteral and parenteral nutrition. Research suggests that improved nutrition intake, body weight and biochemical parameters may be associated with reduced risk of pressure ulcer development [Strong Conditional] Nutrition Prescription for SCI Patients with Pressure Ulcers A nutrition prescription should be formulated as part of the nutrition intervention for patients with SCI and pressure ulcers which includes the energy, protein, fluid and micronutrient requirements. Evidence suggests that additional energy and protein is needed for optimal healing of pressure ulcers. Fluid and micronutrient needs will vary depending on the patient’s status. See the Assessment of Nutritional Needs for Pressure Ulcers for determining levels of each of these [Consensus Imperative] *Note that the guidance uses the term ‘Medical food supplements’ but to avoid confusion with vitamin and mineral food supplements, the term ONS has been inserted in its place |
| Patients with pressure ulcers (pressure injury) | Australia | Trans-Tasman Dietetic Wound Care Group (2011) Endorsed by Dietitians Association of Australia & Dietitians New | Evidence-based practice guidelines for the dietetic management of adults with pressure injuries 33 | • Nutritional interventions should start with modification of current dietary intake and progress to the use of [ONS] before considering enteral support [III–3; Grade C] Note: see Table 4.7 for summary of grading of recommendations |
| Patients with pressure ulcers (pressure injury) | England | National Institute for Health and Care Excellence (NICE) (2014) | Pressure Ulcers: Prevention and Management 25 | Prevention: Nutritional supplements and hydration 1.1.11 Do not offer nutritional supplements specifically to prevent a pressure ulcer in adults whose nutritional intake is adequate. Management: Nutritional supplements and hydration 1.4.4 Offer adults with a pressure ulcer a nutritional assessment by a dietitian or other healthcare professional with the necessary skills and competencies. 1.4.5 Offer nutritional supplements to adults with a pressure ulcer who have a nutritional deficiency. 1.4.6 Provide information and advice to adults with a pressure ulcer and, where appropriate, their family or carers, on how to follow a balanced diet to maintain an adequate nutritional status, taking into account energy, protein, and micronutrient requirements. 1.4.7 Do not offer nutritional supplements to treat a pressure ulcer in adults whose nutritional intake is adequate. |
| Patients with pressure ulcers (pressure injury) | Finland | Finnish National Nutrition Council & Finnish Institute for Health and Welfare (2020) | Vitality in later years: food recommendation for older adults.12 | Pressure ulcers and chronic wounds: Intensive nutrition treatment and at least 1 protein-rich ONS/day |
| Patients with pressure ulcers (pressure injury) | Finland | National Nutrition Council (2010) | Nutrition treatment recommendation "Ravitsemushoito – Suositus sairaaloihin, terveyskeskuksiin, palvelu- ja hoitokoteihin sekä kuntoutuskeskuksiin" 34 | Pressure ulcers and chronic wounds: Intensive nutrition treatment and at least 1 protein-rich ONS/day |
| Patients with COPD | Europe | European Society for Clinical Nutrition and Metabolism (2006) | ESPEN Guidelines on Enteral Nutrition: Cardiology and Pulmonology 35 | Frequent small amounts of ONS are preferred to avoid postprandial dyspnoea and satiety and to improve compliance [B] Note: see Table 4.8 for summary of grading of recommendations |
| Patients with COPD | Europe | European Respiratory Society (2014) | [Nutritional assessment and therapy in COPD: a European Respiratory Society statement}(http://www.ers-education.org/guidelines.aspx) 36 | Treatment of weight loss in COPD Oral nutritional supplements (as powders, puddings, or liquids) can be used to supplement the diet when nutrient requirements cannot be satisfied through normal food and drink. Conclusions: 5) Nutritional intervention is likely to be effective in undernourished patients (based on the Cochrane review) and is probably most effective if combined |
| Patients with COPD | England and Wales | National Institute for Health and Care Excellence (NICE) (2010) | Chronic Obstructive Pulmonary Disease: In over 16s: Diagnosis and Management 37 | If the BMI is low, patients should also be given [ONS] to increase their total calorific intake and be encouraged to take exercise to augment the effects of nutritional supplementation |
| Patients with COPD | International | Global Initiative for Chronic Obstructive Lung Disease (2023) | Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 38 | Support nutritional interventions for malnourished COPD patients, citing evidence that nutritional support can lead to significant gains in weight, fat-free mass, and improvements in exercise capacity and quality of life. 38 |
| Patients with COPD | International | Global Initiative for Chronic Obstructive Lung Disease (2017) | [Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease] 39 | Nutritional support: Low-to-moderate quality evidence suggests that nutritional support promotes significant gain in weight and fat-free mass among patients with COPD, especially if malnourished. In addition, significantly greater changes from baseline have been observed in supplemented patients for six-minute walk test, respiratory muscle strength, and (only in malnourished patients) overall HRQoL as measured by SGRQ. Positive effects have been observed when nutritional supplementation is proposed alone or as an adjunct to exercise training. The optimal amount and duration of supplementation are not clearly established. |
| Patients with COPD | USA | Academy of Nutrition and Dietetics (2008) | Chronic Obstructive Pulmonary Disease (COPD) Evidence-based Nutrition Practice Guideline (login required) 40 | Macronutrient Composition of [ONS]* RDs should advise that the selection of [ONS] for individuals with COPD should be influenced more by patient preference than the percentage of fat or carbohydrate. There is limited evidence to support consumption of a particular macronutrient composition of [ONS] [Fair] COPD: Frequent Small Amounts of [ONS] RDs should recommend frequent small amounts of [ONS] for individuals with COPD. Studies report that frequent small amounts of [ONS] are preferred to avoid postprandial dyspnoea and satiety and to improve compliance [Fair] COPD: [ONS] for Inpatients For inpatients with COPD who have low BMI (less than 20 kg/m²), unintentional weight loss, reduced oral intake, or who are at nutritional risk, registered dietitians should initiate provision of [ONS]. Studies report that [ONS] for 7–12 days results in increased energy intake in the inpatient setting [Fair] COPD: [ONS] for Outpatients* For outpatients with COPD who have low BMI (less than 20 kg/m2), unintentional weight loss, reduced oral intake, or who are at nutritional risk, RDs should recommend consumption of [ONS]. In the outpatient setting, studies report that [ONS] results in increased energy intake, with weight gain more likely when combined with exercise [Fair] Note that the guidance uses the term ‘Medical food supplements’, but to avoid confusion with vitamin and mineral food supplements, the term ONS has been inserted in its place |
| Patients with cystic fibrosis | Europe | ESPEN-ESPGHAN- ECFS (2024) | ESPEN- ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with cystic fibrosis 22 | Clinicians may consider the use of ONS for children and adults who fail to achieve optimal growth rates and nutritional status with oral dietary intake and PERT alone. •Grade of recommendation: GPP (Good Practice Point) Consensus: Strong consensus (100% agreement) Clinicians should regularly review and re-evaluate patients who are taking ONS to determine the impact and consideration of continued use. •Grade of recommendation: GPP •Consensus: Strong consensus (100% agreement). 22 |
| Patients with cystic fibrosis | Europe | ESPEN-ESPGHAN- ECFS (2016) | ESPEN- ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with cystic fibrosis 23 | Guideline: oral nutritional supplements •We recommend clinicians consider the use of oral nutritional supplements for treating children and adults who fail to achieve optimal growth rates and nutritional status with oral dietary intake and pancreatic enzyme replacement therapy (PERT) alone. (Grade of evidence: low) •We recommend clinicians regularly review and re-evaluate patients who are taking oral nutritional supplements to determine whether the patient should continue taking them. (Grade of evidence: high) |
| Patients with acute or chronic pancreatitis | Europe | European Society for Clinical Nutrition and Metabolism (2020) | ESPEN Guidelines on Clinical Nutrition: Pancreas 41 | ONS should be prescribed to undernourished patients only if oral nutrition is insufficient for reaching the calorie and protein goals. Grade of Recommendation GPP Strong consensus (100% agreement). 41 |
| Patients with acute or chronic pancreatitis | Europe | European Society for Clinical Nutrition and Metabolism (2006) | ESPEN Guidelines on Enteral Nutrition: Pancreas 42 | Acute pancreatitis •Oral feeding (normal food and/or ONS) can be progressively attempted once gastric and outlet obstruction has resolved, provided it does not result in pain, and complications are under control [C] Chronic pancreatitis •10–15% of all patients require ONS [C] Note: see Table 4.8 for summary of grading of recommendations |
| Patients with liver disease | Europe | European Society for Clinical Nutrition and Metabolism (2020) | ESPEN Guidelines on Clinical Nutrition: Liver disease 43 | Alcoholic Steatohepatitis (ASH): •Nutrition therapy should be offered to all patients with severe ASH who cannot meet requirements by spontaneous food intake in order to improve survival, infection rate, liver function, and resolution of encephalopathy. (Grade B, strong consensus 100%) •ONS should be used when patients with severe ASH cannot meet their caloric requirements through normal food in order to improve survival. (Grade B, strong consensus 100%) •ONS shall be used as first-line therapy when feeding goals cannot be attained by oral nutrition alone and should be given as a late evening or nocturnal supplement. (Grade GPP, strong consensus 100%) Liver Cirrhosis: •In cirrhotic patients, nutritional intervention (either oral, EN or PN) shall be implemented according to current guidelines for non-cirrhotic patients. (Grade A, consensus 89%) Acute liver failure (ALF): Patients suffering from only mild hepatic encephalopathy can be fed orally as long as cough and swallow reflexes are intact. (Grade GPP, strong consensus 100%) In patients with mild hepatic encephalopathy oral nutritional supplements (ONS) should be used when feeding goals cannot be attained by oral nutrition alone. (Grade GPP, consensus 85%) Alcoholic Steatohepatitis (ASH): ONS should be used when patients with severe ASH cannot meet their caloric requirements through normal food in order to improve survival. (Grade B, strong consensus 100%) ONS shall be used as first line therapy when feeding goals cannot be attained by oral nutrition alone and should be given as a late evening or nocturnal supplement. (Grade GPP, strong consensus 100%) For ONS or EN in patients with severe ASH standard formulas should be used, preferably formulas with high energy density (≥1.5 kcal/ml). (Grade GPP, strong consensus 92%) |
| Patients with liver disease | Europe | European Society for Clinical Nutrition and Metabolism (2006) | ESPEN Guidelines on Enteral Nutrition: Liver Disease 44 | Alcoholic steatohepatitis •In general, ONS are recommended [B] Liver cirrhosis •If patients are not able to maintain adequate oral intake from normal food, use ONS [C] Note: see Table 4.8 for summary of grading of recommendations |
| Patients with HIV and chronic infectious diseases | Europe | European Society for Clinical Nutrition and Metabolism (2006) | ESPEN Guidelines on Enteral Nutrition: Wasting in HIV and Other Chronic Infectious Diseases 45 | HIV •Diarrhoea does not prevent a positive effect of ONS on nutritional status [A] •Nutritional counselling with ONS or counselling alone are equally effective at the beginning of nutritional support and/or for preserving nutritional status [B] •In settings where qualified nutritional counselling cannot be provided, ONS may be indicated in addition to normal food, but this should be limited in time [C] Chronic infectious diseases •Nutritional support should be given to patients with under-nutrition resulting from infectious diseases – prefer ONS [B] Note: see Table 4.8 for summary of grading of recommendations |
| Patients with renal disease | Europe | European Society for Clinical Nutrition and Metabolism (2023) | [ESPEN guideline on clinical nutrition in hospitalised patients with acute or chronic kidney disease] 46 | Early nutritional support (i.e., provided in less than 48 h from hospital admission) compared to later nutritional support should be performed in polymorbid medical inpatients, as sarcopenia could be decreased and self-sufficiency could be improved. Grade of recommendation B – strong consensus (95% agreement) In malnourished non-critically ill hospitalised patients with AKI/AKD or CKD with or without KF and those patients at risk for malnutrition who can safely feed orally but cannot reach their nutritional requirements with a regular diet alone, ONS shall be offered. Grade of recommendation A – Strong consensus (100% agreement) |
| Patients with renal disease | Europe | European Society for Clinical Nutrition and Metabolism (2006) | ESPEN Guidelines on Enteral Nutrition: Adult Renal Failure 47 | Acute Renal Failure (ARF) •In uncomplicated ARF, when spontaneous alimentation is insufficient, ONS may be useful to meet estimated requirements [C] Patients on maintenance haemodialysis (HD) therapy •Use ONS to improve nutritional status [A] •ONS should be the preferred route in conscious HD patients Note: see Table 4.8 for summary of grading of recommendations |
| Patients with renal disease | Canada | Canadian Society of Nephrology (2011) | Clinical practice guidelines and recommendations on peritoneal dialysis adequacy 48 | [ONS] should be considered for patients with mild-to-severe malnutrition [B]. However, certain supplements may be poorly tolerated by individual patients, and thus close monitoring is required [A] |
| Patients with GI disease | Europe | European Society for Clinical Nutrition and Metabolism (2006) | ESPEN Guidelines on Enteral Nutrition: Gastroenterology 49 | CD •In the case of persistent intestinal inflammation (e.g., steroid-dependent patients) use ONS [B] •Use ONS in addition to normal food to improve nutritional status and to eliminate consequences of under-nutrition such as growth retardation [A] •Using ONS, a supplementary intake of up to 600 kcal/day can be achieved in addition to normal food [A] Short bowel syndrome •Use ONS or tube feeding if normal nutritional status cannot be maintained by normal food alone [C] Note: see Table 4.8 for summary of grading of recommendations |
| Patients with intestinal failure | Europe | European Society for Clinical Nutrition and Metabolism (2016) | Management of acute intestinal failure: A position paper from the European Society for Clinical Nutrition and Metabolism (ESPEN) Special Interest Group 50 | Enteral nutrition: Disease-specific formulae are probably not required; many different standard oral nutritional supplements or enteral feeds may be helpful in intestinal failure, selected according to their energy density and convenience Oral feeding: Except in situations where fasting is believed to help promote fistula healing or control (e.g., acute phase, very proximal, high output fistula), patients will be advised to eat ad libitum. Regular meals, as well as the use of oral nutritional supplements, should be considered. The supervision of an experienced dietician is essential for best results, not least because of the problems with the net secretory state of many of these patients and the consequent need to restrict salt-free fluids. |
| Patients with intestinal failure | Europe | European Society for Clinical Nutrition and Metabolism | ESPEN guideline on Clinical Nutrition in Inflammatory Bowel Disease 51 | ONS is the first step when medical nutrition is indicated in IBD, as supportive therapy in addition to normal food. Grade of recommendation 0 – Strong consensus 92% agreement. |
| Patients with intestinal failure | Europe | European Society for Clinical Nutrition and Metabolism (2021) | ESPEN guidelines on chronic intestinal failure in adults 52 | Intestinal rehabilitation strategy - medical We suggest the addition of oral isotonic nutritional supplements in borderline (i.e., B1 category of clinical classification) Short Bowel Syndrome intestinal failure patients at risk of malnutrition. (Grade of evidence: low) |
| Surgical patients | Europe | European Society for Clinical Nutrition and Metabolism (2017) | ESPEN Guideline: Clinical Nutrition in Surgery 53 | •Perioperative nutritional therapy is indicated in patients with malnutrition and those at nutritional risk. Perioperative nutritional therapy should also be initiated, if it is anticipated that the patient will be unable to eat for more than five days perioperatively. It is also indicated in patients expected to have low oral intake and who cannot maintain above 50% recommended intake for more than seven days. In these situations, it is recommended to initiate nutritional therapy (preferably by the enteral route - ONS-TF) without delay. (GPP, strong consensus) •When patients do not meet their energy needs from normal food it is recommended to encourage these patients to take oral nutritional supplements during the preoperative period unrelated to their nutritional status. (GPP, consensus) •Preoperatively, oral nutritional supplements shall be given to all malnourished cancer and high-risk patients undergoing major abdominal surgery. A special group of high-risk patients are the elderly people with sarcopenia (A, strong consensus) •Immune modulating oral nutritional supplements including arginine, omega-3 fatty acids and nucleotides can be preferred and administered for five to seven days pre-operatively. (0/GPP, majority agreement) Pre-operative enteral nutrition/oral nutritional supplements should preferably be administered prior to hospital admission to avoid unnecessary hospitalisation and to lower the risk of nosocomial infections (GPP, strong, consensus) •Regular reassessment of nutritional status during the stay in hospital and, if necessary, continuation of nutrition therapy including qualified dietary counselling after discharge, is advised for patients who have received nutrition therapy perioperatively and still do not cover appropriately their energy requirements via the oral route (GPP, strong, consensus) Note: see Table 4.10 for summary of grading of recommendations |
| Surgical patients | Europe | European Society for Clinical Nutrition and Metabolism (2021) | ESPEN practical guideline: Clinical nutrition in surgery 54 | •Perioperative nutritional support therapy is indicated in patients with malnutrition and those at nutritional risk. Perioperative nutritional therapy should also be initiated if it is anticipated that the patient will be unable to eat for more than five days perioperatively. It is also indicated in patients expected to have low oral intake and who cannot maintain above 50% of the recommended intake for more than seven days. In these situations, it is recommended to initiate nutritional support therapy (preferably by the enteral route – oral nutritional supplements – tube feeding) without delay. Grade of recommendation GPP – strong consensus (92% agreement) •Peri-operative, or at least postoperative, administration of a specific formula enriched with (arginine, omega-3-fatty acids, ribonucleotides) should be given in malnourished patients undergoing major cancer surgery (B). There is currently no clear evidence for the sole use of these formulas enriched with immuno-nutrients vs. Standard ONS in the preoperative period (0). Grade of recommendation B/0 – consensus (89% agreement) •Whenever feasible, the oral/enteral route shall be preferred (A). Grade of recommendation A – strong consensus (100% agreement) •When patients do not meet their energy needs from normal food, it is recommended to encourage these patients to take ONS during the preoperative period, unrelated to their nutritional status. Grade of recommendation GPP – consensus (86% agreement) Preoperatively, ONS shall be given to all malnourished cancer and high-risk patients undergoing major abdominal surgery. A special group of high-risk patients is elderly people with sarcopenia. Grade of recommendation A – strong consensus (97% agreement) •Immune modulating ONS, including (arginine, omega-3 fatty acids, and nucleotides) can be preferred (0) and administered for five to seven days preoperatively (GPP). Grade of recommendation 0/GPP – majority agreement, 64% agreement. •Preoperative EN/ONS should preferably be administered prior to hospital admission to avoid unnecessary hospitalisation and to lower the risk of nosocomial infections. Grade of recommendation GPP – strong consensus (91% agreement). |
| Surgical patients | Europe | European Society for Clinical Nutrition and Metabolism (2017) | ESPEN Guideline: Clinical Nutrition in Surgery 53 | •Perioperative nutritional therapy is indicated in patients with malnutrition and those at nutritional risk. Perioperative nutritional therapy should also be initiated if it is anticipated that the patient will be unable to eat for more than five days perioperatively. It is also indicated in patients expected to have low oral intake and who cannot maintain above 50% recommended intake for more than seven days. In these situations, it is recommended to initiate nutritional therapy (preferably by the enteral route - ONS-TF) without delay. (GPP, strong consensus) •When patients do not meet their energy needs from normal food, it is recommended to encourage these patients to take oral nutritional supplements during the preoperative period, unrelated to their nutritional status. (GPP, consensus) •Preoperatively, oral nutritional supplements shall be given to all malnourished cancer and high-risk patients undergoing major abdominal surgery. A special group of high-risk patients is elderly people with sarcopenia (A, strong consensus) •Immune modulating oral nutritional supplements, including arginine, omega-3 fatty acids, and nucleotides, can be preferred and administered for five to seven days pre-operatively. (0/GPP, majority agreement) •Pre-operative enteral nutrition/oral nutritional supplements should preferably be administered prior to hospital admission to avoid unnecessary hospitalisation and to lower the risk of nosocomial infections (GPP, strong, consensus) Regular reassessment of nutritional status during the stay in hospital and, if necessary, continuation of nutrition therapy including qualified dietary counselling after discharge, is advised for patients who have received nutrition therapy perioperatively and still do not cover appropriately their energy requirements via the oral route (GPP, strong, consensus) Note: see Table 4.10 for summary of grading of recommendations |
| Surgical patients | Europe | European Society for Clinical Nutrition and Metabolism (2012) | Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations 55 | Postoperative nutritional care •Patients should be screened for nutritional status and, if deemed to be at risk of undernutrition, given active nutritional support. For the standard ERAS patient, preoperative fasting should be minimised, and postoperatively, patients should be encouraged to take normal food as soon as possible after surgery. ONS can be used to supplement total intake. See also Guidelines for perioperative care in elective rectal/pelvic surgery 56 and Guidelines for perioperative care for pancreaticoduodenectomy 57 |
| Surgical patients | England and Wales | National Institute for Health and Care Excellence (NICE) (2017) | Nutrition Support for Adults Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition 3 | •Healthcare professionals should consider oral nutrition support to improve nutritional intake for people who can swallow safely and are malnourished or at risk of malnutrition [A] •Healthcare professionals should ensure that the overall nutrient intake of oral nutrition support offered contains a balanced mixture of protein, energy, fibre, electrolytes, vitamins, and minerals. [D(GPP)] •Oral nutrition support should be stopped when the patient is established on adequate oral intake from normal food. [D(GPP)] •Oral nutrition support for surgical patients peri-operative oral nutrition support should be considered for surgical patients who can swallow safely and are malnourished. [B] •Healthcare professionals should consider giving post-caesarean or gynaecological surgical patients who can swallow safely, some oral intake within 24 hours of surgery. [A] Healthcare professionals should consider giving post-abdominal surgery patients who can swallow safely, and in whom there are no specific concerns about gut function or integrity, some oral intake within 24 hours of surgery. The patient should be monitored carefully for any signs of nausea or vomiting. [A] 3 |
| Surgical patients | England and Wales | National Institute for Health and Care Excellence (NICE) (2006) | Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition 3 | Oral nutrition support for surgical patients •Patients should be encouraged to commence oral food intake 4 hours after surgery. can swallow safely and are malnourished [B] Note: see Table 4.6 for summary of grading of recommendations |
| Patients with SCI | USA | Academy of Nutrition and Dietetics (2009) | Spinal Cord Injury (SCI) Evidence-based Nutrition Practice Guideline (login required) 32 | Nutrition Intervention to Prevent Development of Pressure Ulcers If a patient with spinal cord injury is at risk of pressure ulcer development as indicated by biochemical, anthropometric and lifestyle factors, the RD should implement aggressive nutrition support measures. The range of options may include [ONS] and enteral and parenteral nutrition. Research suggests that improved nutrition intake, body weight and biochemical parameters may be associated with reduced risk of pressure ulcer development [Strong Conditional] Nutrition Prescription for SCI Patients with Pressure Ulcers* A nutrition prescription should be formulated as part of the nutrition intervention for patients with SCI and pressure ulcers which includes the energy, protein, fluid and micronutrient requirements. Evidence suggests that additional energy and protein is needed for optimal healing of pressure ulcers. Fluid and micronutrient needs will vary depending on the person’s status. See the Assessment of Nutritional Needs for Pressure Ulcers for determining levels of each of these [Consensus Imperative] |
| Stroke patients | England and Wales | National Institute for Health & Care Excellence (NICE) (2008) | Stroke: National Clinical Guideline for Diagnosis and Initial Management of Acute Stroke and Transient Ischaemic Attack (TIA) 58 | Nutritional support should be initiated for people with stroke who are at risk of malnutrition. This may include ONS, specialist DA and/or tube feeding |
| Stroke patients | Scotland | Scottish Intercollegiate Guidelines Network (SIGN) (2010) | Management of Patients with Stroke: identification and management of dysphagia Management of patients with stroke: Rehabilitation, prevention and management of complications, and discharge planning 59 | Following nutritional screening, those identified as undernourished and those at risk of becoming undernourished should be referred to a dietitian and considered for prescription of [ONS] as part of their overall nutritional care plan [C] Note: see Table 4.6 for summary of grading of recommendations (Grade C similar to NICE) |
| Stroke patients | Australia | Stroke Association | Clinical Guidelines for Stroke Management 2017 60 | For stroke patients whose nutrition status is poor or deteriorating, nutrition supplementation should be offered. |
| Stroke patients | UK | Intercollegiate Stroke Working Party | National Clinical Guideline for Stroke for the UK and Ireland 61 | Patients with acute stroke who are at low risk of malnutrition on admission and are able to meet their nutritional needs orally should not routinely receive oral nutritional supplements. Patients with stroke who are at risk of malnutrition should be offered nutritional support. This may include oral nutritional supplements, specialist dietary advice and/or tube feeding in accordance with their expressed wishes or, if the patient lacks mental capacity, in their best interests. |
ONCOLOGY
Table 4.5
Summary of examples of evidence-based national and professional guidelines referring to ONS as an integral part of patient and disease management in Oncology (parts of guidelines relevant to ONS are presented here)
| Patient Group | Country | Body | Title | Recommendation, guideline, or standard [grade of evidence] |
|---|---|---|---|---|
| Patients with cancer | Europe | European Society for Clinical Nutrition and Metabolism (2021) | ESPEN guidelines on nutrition in cancer patients 62 | We recommend nutritional intervention to increase oral intake in cancer patients who are able to eat but are malnourished or at risk of malnutrition. This includes dietary advice, the treatment of symptoms and derangements impairing food intake (nutrition impact symptoms) and offering ONS. (Recommendation B3-1; strength of recommendation strong – Level of evidence moderate – consensus) |
| Patients with cancer | Europe | European Society for Clinical Nutrition and Metabolism. Officially endorsed by the European Society of Surgical Oncology (ESSO), the European Association for Palliative Care (EAPC) and the Chinese Society of Clinical Oncology (CSCO) (2016) | ESPEN guidelines on nutrition in cancer patients 63 | Nutrition interventions: Efficacy of nutritional intervention: We recommend nutritional intervention to increase oral intake in cancer patients who are able to eat but are malnourished or at risk of malnutrition. This includes dietary advice, the treatment of symptoms and derangements impairing food intake (nutrition impact symptoms) and offering oral nutritional supplements. (Strength of recommendation STRONG; Level of evidence Moderate) |
| Patients undergoing anti-cancer therapy | Australia | Dietitians Association of Australia (2013) | Updated evidence-based Practice Guidelines for the Nutritional Management of Patients Receiving Radiation Therapy and/or Chemotherapy 64 | In chemotherapy patients, simple nutrition intervention (simple dietary counselling and/or supplements without medical nutrition therapy) is effective at improving dietary intake and weight, but does not improve patient-centred outcomes. [Grade A] |
| Patients undergoing anti-cancer therapy | Australia | Clinical Oncology Society of Australia (2014, last modified 2024) | COSA guidelines for the nutritional management of adult patients with head and neck cancer (Version 1.2) 65 | •Nutrition intervention (dietary counselling and/or ONS) for 3 months post-treatment improves or maintains nutritional status. (A) •Nutrition intervention for 3 months post-treatment improves or maintains quality of life. (A) •Nutrition interventions (dietary counselling and/or ONS and/or tube feeding) improve or maintain nutritional status. (A) •Nutrition interventions improve patient-centred outcomes, such as quality of life, physical function, and patient satisfaction. (B) •Immunonutrition is a form of oral nutritional supplement or enteral feeding formula which has added nutrients for a proposed immune modulating effect which can then impact upon patients' clinical outcomes, such as reduced infections. The most common types of formula have conditionally essential amino acids, arginine and/or glutamine, n-3 fatty acids, and/or ribonucleic acids added. The feeds used in the studies have been polymeric formulas (with or without fibre) with the addition of arginine at varying doses. •Standard polymeric fibre feed should be used post-operatively. (B) •If immunonutrition is to be used post-operatively, this should be given for a minimum of 7 days. (C) Aim for energy intakes of at least 125kJ/kg/day (30kcal/kg/day). As energy requirements may be elevated post-operatively, monitor weight and adjust intake as required. (C) |
| Patients undergoing anti-cancer therapy | Australia | Clinical Oncology Society of Australia (2011, last modified June 2014) | Evidence-based practice guidelines for the nutritional management of adult patients with head and neck cancer 66 | Surgery: Preoperative nutrition intervention in malnourished patients may lead to improved outcomes, such as quality of life, and reduce adverse related consequences of malnutrition [Recommendation Grade: B]. Peri-operative n-3 fatty acid-enriched nutrition support may improve nutritional outcomes such as weight, lean body mass and fat mass.[Grade C]. Radiotherapy and chemotherapy: Nutrition intervention (dietary counselling and/or [ONS] and/or tube feeding) improves/ maintains nutritional status [Recommendation Grade: A]. Nutrition intervention (dietary counselling and/or [ONS] and/or tube feeding) improves patient-centred outcomes (QOL, physical function, and patient satisfaction) [Recommendation Grade: B]. Post treatment: Nutrition intervention (dietary counselling and/or [ONS]) for 3 months post treatment improves/maintains nutritional status [Recommendation Grade: A]. Nutrition intervention (dietary counselling and/or [ONS]) for 3 months post treatment improves/maintains QOL [Recommendation Grade: A]. Note: see Table 4.6 for summary of grading of recommendations |
| Patients with head and neck cancer | Scotland | Scottish Intercollegiate Guidelines Network (SIGN) (2011, revised 2016) | Diagnosis and Management of Colorectal Cancer 67 | Nutrition and weight loss: Patients and families understandably focus on what patients are able to eat. Although there is no evidence that nutritional supplements, parenteral or enteral feeding are of benefit in preventing cancer cachexia when the disease is advanced, evidence is emerging that it may be of value at an earlier stage. Referral to a specialist state-registered dietitian or advice from a nutrition support team should be sought where appropriate. As anorexia and weight loss are so distressing for the patient and their family, the issue of nutrition must be addressed. |
| Patients with head and neck cancer | Spain | (2008) | Consensus document on Nutrition in Cancer (Nutr Hosp Suplementos. 2008;1(1):13) 68 | •Nutritional care should be provided early, and it should be part of the overall treatment plan for oncology patients. •The cancer patient's diet should be in line with healthy nutrition guidelines (balanced, varied, desirable, and sufficient to meet needs). •When DA is not enough, nutritional support should be given. Symptoms such as anorexia, nausea, and vomiting as a result of the cancer or its treatment make it difficult for patients to meet their nutritional needs. •Cancer patients may need artificial nutrition (same indications as non-cancer patients) with an appropriate formula to meet their particular needs. •The effectiveness of nutritional support must be balanced with the risk of its use. (Summary in English of section on Nutritional Intervention Criteria: goals, directions, and evidence) |
| Patients with head and neck cancer | USA | Academy of Nutrition and Dietetics (2013) | Oncology Evidence-Based Nutrition Practice Guideline 69 | ONC: Nutrition Intervention of Adult Oncology Patients with Cancer Cachexia: In adult oncology patients who have been identified to have pre-cachexia or cancer cachexia, prompt and aggressive intervention to address nutrition impact symptoms and preserve or prevent loss of lean body mass (LBM) and weight should be initiated by the RDN. Early rather than later intervention to prevent weight loss in this population is more likely to be effective. The metabolic derangements in cancer cachexia that promote wasting can lead to loss of weight and LBM and poor outcomes. [Consensus]. ONC: [ONS] Containing Fish Oil for the Adult Oncology Patient: If sub-optimal symptom control or inadequate dietary intake has been addressed and the adult oncology patient is still experiencing loss of weight and LBM, the RDN may consider use of a [ONS] containing EPA as a component of nutrition intervention. Research indicates that [ONS] containing fish oil (actual consumption, 1.1 g to 2.2 g of EPA per day) resulted in significant weight stabilisation or weight gain and preservation or improvement of LBM in adult oncology patients with weight loss. [Grade I and II] |
| Patients with head and neck cancer | USA | Academy of Nutrition and Dietetics (2013) | Oncology Evidence-based Nutrition Practice Guideline 69 | Head and neck cancer: [ONS]* and radiation. Dietitians should consider use of [ONS] to improve protein and calorie intake for patients with head and neck cancer undergoing radiation therapy. Use of [ONS] may be associated with fewer treatment interruptions and a reduction of mucosal damage, and it may minimise weight loss. |
| Patients with lung cancer | USA | American College of Chest Physicians (ACCO) (2013) | Complementary Therapies and Integrative Medicine in Lung Cancer - Evidence-Based Clinical Practice Guidelines 70 | •In patients undergoing treatment of lung cancer who have experienced weight loss, the addition of high-calorie and protein supplements (1.5 kcal/mL) as a nutritional adjunct is suggested to achieve weight stabilisation (Grade 2C). •In patients with lung cancer who have sarcopenia, oral nutritional supplementation with n-3 fatty acids is suggested in order to improve the nutritional status (Grade 2C). |
Table 4.6
NICE Guidelines: Grading of recommendations (adapted from NICE 2006)3
| Grade | Evidence |
|---|---|
| A | •At least one meta-analysis, systematic review, or RCT rated as 1++ (i.e., high-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias), directly applicable to the target population, or •A systematic review of RCTs or a body of evidence consisting principally of studies rated as 1+ (i.e., well-conducted meta-analyses, systematic reviews of RCTs or RCTs with a low risk of bias), directly applicable to the target population and demonstrating overall consistency of results, or •Evidence drawn from a NICE technology appraisal |
| B | •A body of evidence including studies rated as 2++ (i.e., high-quality systematic reviews of case-control or cohort studies, high-quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal), directly applicable to the target population and demonstrating overall consistency of results, or •Extrapolated evidence from studies rated as 1++ or 1+ |
| C | •A body of evidence including studies rated as 2+ (i.e., well-conducted case-control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal), directly applicable to the target population and demonstrating overall consistency of results, or •Extrapolated evidence from studies rated as 2++ |
| D | •Evidence level 3 (i.e., non-analytic studies, e.g., case reports, case series) or 4 (i.e., expert opinion), or •Extrapolated evidence from studies rated as 2+, or •Formal consensus |
| D (GPP) | •A good practice point (GPP) is a recommendation for best practice based on the experience of the Guideline Development Group |
Table 4.7
Dietitians Association of Australia Guidelines: Grading of recommendations
| Grade | Description* |
|---|---|
| A | Body of evidence can be trusted to guide practice |
| B | Body of evidence can be trusted to guide practice in most situations |
| C | Body of evidence provides some support for recommendation(s) but care should be taken in its (their) application |
| D | Body of evidence is weak and recommendation(s) must be applied with caution |
*Full details of level of evidence according to type of research question available from NHMRC71
Table 4.8
ESPEN Guidelines: Levels of evidence used in guidelines pre- 2015 (adapted from Schutz 2006)72
| Grade | Level of evidence | Requirement |
|---|---|---|
| A | Ia Ib |
Meta-analysis of randomised controlled trials (RCTs) At least one RCT |
| B | IIa IIb III |
At least one well-designed controlled trial without randomisation At least one other type of well-designed quasi-experimental study Well-designed non-experimental descriptive studies such as comparative studies, correlation studies, case-control studies |
| C | IV | Expert opinions and/or clinical experience of respected authorities |
Table 4.9
ESPEN Guidelines: Levels of evidence used in guidelines from 2015 onwards adapted from Bischoff et al. 201573
| Levels of evidence | |
|---|---|
| 1++ | High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias |
| 1+ | Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias |
| 1- | Meta-analyses, systematic reviews, or RCTs with a high risk of bias |
| 2++ | High-quality systematic reviews of case-control or cohort, studies. High-quality case-control or cohort studies with a very low risk of confounding or bias and a high prob- ability that the relationship is causal |
| 2+ | Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal |
| 2- | Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is causal |
| 3 | Non-analytic studies, e.g., case reports, case series |
| 4 | Expert opinion |
According to the Scottish Intercollegiate Guidelines Network (SIGN) grading system. Source: SIGN 50; A guideline developer’s handbook. Quick reference guide October 2014
Table 4.10
ESPEN Guidelines: Grades of evidence used in guidelines from 2015 onwards adapted from Bischoff et al. 201573
| Grades of recommendation | |
|---|---|
| A | At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results |
| B | A body of evidence including studies rated as 2++, directly applicable to the target population; or A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 1++ or 1+ |
| O | Evidence level 3 or 4; or extrapolated evidence from studies rated as 2++ or 2+ |
| GPP | Good practice points/expert consensus: Recommended best practice based on the clinical experience of the guideline development group |
Table 4.11