Prescription Of Oral Nutritional Supplements Research Articles

2023 Oral nutritional supplement prescribing in care homes: The benefit of dietetic review

Abstract Introduction Prevalence of malnutrition in care homes is high and oral nutritional supplements (ONS) often prescribed. Prescription and monitoring of ONS use varies considerably within residential settings. Locally dietetics are not funded to visit care homes and input is limited. This project explored dietetic ONS prescribing within care homes in one primary care network within Devon, recording the potential impact on costs. Methods All patients prescribed ONS (n=50) across 16 care homes were reviewed, alongside referrals to dietetics (n=39) from November 2022-March 2023. Supplements were switched to first-line formulary supplements where possible, stopped where unnecessary according to dietetic assessment, and a “food first” approach encouraged within homes. Cost of supplements prescribed pre-dietetic assessment, cost of new prescriptions, dietetic staff time and mileage costs were recorded. Supplement cost was calculated from the local formulary and staff cost from NHS oncosts. Results Patients seen represented 20% of all residents 20% (89/436) within the 16 care homes, suggesting high suspected clinical need. Mean age was 90 years, ranging from 73-103 years. Female patients accounted for the majority (n=68). Addressing inappropriate prescribing saved £57.62 per day in prescriptions through stopping or changing ONS. Cost of dietetic staff time and milage totalled £3105.80 over the five-month period meaning that after 54 days the dietetic review service was saving money. Patients often preferred first line powder-based supplements, and these were either similar or more appropriate in nutrient content than initially prescribed ONS. For example, one patient affected by pressure ulcers was prescribed a fat emulsion supplement. It contained no protein or micronutrients to promote skin healing (cost £3.15) whilst first--line supplements provided macronutrient and micronutrient needs (cost 52p each and £1.04 total prescription). Discussion Dedicated dietetic input for care home residents appears to save costs on ONS prescribing whilst providing specialist nutritional expertise.

Oral Nutritional Supplement Prescription and Patient-Reported Symptom Burden Among Patients With Late-Stage Non-Dialysis Chronic Kidney Disease.

Malnutrition and protein-energy wasting (PEW) are nutritional complications of advanced chronic kidney disease (CKD) that contribute to morbidity, mortality, and decreased quality of life. No previous studies have assessed the effect of oral nutritional supplements (ONSs) on patient-reported symptom burden among patients with non-dialysis CKD (CKD-ND) who have or are at risk of malnutrition/PEW. The objective of this study was (1) to quantify the associations between baseline nutritional parameters and patient-reported symptom scores for wellbeing, tiredness, nausea, and appetite and (2) to compare the change in symptom scores among patients prescribed ONS with patients who did not receive ONS in a propensity-score-matched analysis. This study conducted observational cohort analysis using provincial registry data. This study was done in multidisciplinary CKD clinics in British Columbia. Adult patients >18 years of age with CKD-ND entering multidisciplinary CKD clinics between January 1, 2010-July 31, 2019 who had at least 2 Edmonton Symptom Assessment System Revised: Renal (ESASr:Renal) assessments. The measurements include nutrition-related parameters such as body mass index (BMI), serum albumin, serum phosphate, serum bicarbonate, neutrophil-to-lymphocyte ratio (NLR), and ESASr:Renal scores (overall and subscores for wellbeing, tiredness, nausea, and appetite). Multivariable linear regression was applied to assess associations between nutritional parameters and ESASr:Renal scores. Propensity-score matching using the greedy method was used to match patients prescribed ONS with those not prescribed ONS using multiple demographic, comorbidity, health care utilization, and temporal factors. Linear regression was used to assess the association between first ONS prescription and change in ESASr:Renal overall score and subscores for wellbeing, tiredness, nausea, and appetite. Of total, 2076 patients were included. Higher baseline serum albumin was associated with lower overall ESASr:Renal score (-0.20, 95% confidence interval [CI] = -0.40 to -0.01 per 1 g/L increase in albumin), lower subscores for tiredness (-0.04, 95% CI = -0.07 to -0.01), nausea (-0.03, 95% CI = -0.04 to -0.01), and appetite (-0.03, 95% CI = -0.06 to -0.01). Higher BMI was associated with higher overall ESASr:Renal score (0.32, 95% CI = 0.16 to 0.48 per 1 kg/m2 increase in BMI), higher symptom subscores for wellbeing (0.02, 95% CI = 0.00 to 0.04) and tiredness (0.05, 95% CI = 0.02 to 0.07). Higher baseline NLR was associated with higher overall score (0.21, 95% CI = 0.03 to 0.39 per 1 unit increase in NLR), higher symptom subscores for wellbeing (0.03, 95% CI = 0.01 to 0.05) and nausea (0.03, 95% CI = 0.02 to 0.05). In the propensity-score-matched analysis, there were no statistically significant associations between ONS prescription and change in overall ESASr:Renal (beta coefficient for change in ESASr:Renal = 0.17, 95% CI = -2.64 to 2.99) or for subscores for appetite, tiredness, nausea, and wellbeing. Possible residual confounding. The ESASr:Renal assessments were obtained routinely only in patients with G5 CKD-ND and/or experiencing significant CKD-related symptoms. This exploratory observational analysis of patients with advanced non-dialysis CKD demonstrated BMI, serum albumin, and NLR were modestly associated with patient-reported symptoms, but we did not observe an association between ONS use and change in ESASr:Renal scores.

Trends in the characteristics of patients treated with nutritional supplements in the Northern Area of Gran Canaria in the period 2016 -2021

assess the prescription of oral nutritional supplements (ONS) in the Northern Area of Gran Canaria in the period 2016-2021. based on electronic prescription data, the first ONS prescription during 2016-2021 was analyzed considering age, gender, nutritional requirements (NR), body mass index (BMI), percentage of weight loss (%WL), albumin and number of prescribed ONS per patient. 10,595 prescriptions were identified corresponding to 6661 patients with the following characteristics: 46.3 % men, mean age 72.84 ± 15.93 years, BMI 20.60 ± 3.98 kg/m2, %WL 11.89 ± 8.32 %; albumin 3.08 ± 0.63 g/dl. The most frequent etiologies of DRE were: neoplasms 42.6 %; degenerative processes of the CNS 28.9 %; stroke 3.9 %; short intestine 6.9 %, and inflammatory bowel disease (IBD) 5.5 %. The percentages of NR covered by the prescribed ONS were: 100 % in 8.9 % of cases, 50 % in 36.9 %, and 25 % in 54.2 %; 40.4 % of patients received 1 unit of ONS daily, 36.3 % took 2 units of ONS, and 23 % received > 3 units of ONS per day. Greater NR were associated with a greater number of ONS (p < 0.001), but 40.8 % of patients who needed to cover > 50 % of NR received only one unit of ONS. a significant percentage of patients with DRM do not receive a number of ONS according to their NR.

Exploring treatment burden of Oral Nutritional Supplements (ONS) and impact on antibiotics using a data linkage approach

Abstract Introduction Treatment burden associated with thickeners is significant1. Understanding of potential treatment burden associated with ONS is lacking, however wastage due to ONS partial or full nonconsumption, and stock piling are recognised2. Wastage is evidence of over prescribing. Improving fluid intake by increasing variety is evidence based3 - ONS reduces opportunity. Whether thickener or ONS is prescribed, patients can withdraw consent by not drinking (verbally/silently). We investigated a potential correlation between ONS and low intake dehydration, and if detectable using a proxy measure: antibiotic prescribing for urinary tract infection (UTI). We explored using ePACT2 data to investigate co-prescribing of interventions that inter-relate, a type of data linkage study. Improved fluid intake can decrease laxative use, but did not reduce antibiotic use3. We hypothesized that with a large data set, it may be possible to detect associations of treatment burden and antibiotic use. Aim To explore the relationship between prescribing of ONS with antibiotics for UTIs in older adults in Primary Care (England). Methods We investigated co-prescribing of antibiotics prescribed for UTI (nitrofurantoin, trimethoprim) and ONS in older adults (&amp;gt; 65 years) in Primary Care. Data was obtained from the NHS Business Services Authority Data Services Support as bespoke analysis of prescribing ePACT2 data linked by NHS number. Retrospective analysis was performed on anonymised data for 3 years (January 2019 to December 2022). Ethical approval was not required. Data unattributable to a specific region was excluded. Results Initial analysis suggested that prescribing of UTI antibiotics was 3 times more common in older adults prescribed ONS compared with controls (an average 2.86% of the patients on GP list were prescribed an antibiotic for a UTI, increasing to 8.59% for those co-prescribed ONS). This correlation appeared consistent, however, due to high volume and level of detail of UTI antibiotic prescribing, this interpretation is incorrect. On further analysis, the population rate of UTI antibiotic and ONS was plotted to show trend over time, demonstrating no correlation. Prescription of UTI antibiotic over time is consistent, reflecting that acute lower UTI is not very reducible, and antibiotic prophylaxis use is common and repeated monthly. Additionally, from this data set you cannot ascertain if frequency of antibiotic prescription(s) pre-dates initiation of ONS. We did not investigate confounding factors such as co-prescribing of catheter use, gender, frailty and advancing age. Our oldest patients with decreased thirst, reduced appetite cues and ability to eat and drink will also be those most likely to get an UTI. Discussion/Conclusion Future data linkage work in this area should include a wider range of data e.g. detailed demographics, medical and prescribing history over time and all adverse events from low intake dehydration. Exploration of the impact of ONS and thickener prescription on patient experience, perceived treatment burden and the impact on fluid intake would be useful. Audit of shared decision making at initiation and review would also be beneficial in obtaining baseline data on consent at start and throughout duration of prescription.

Factors Associated with Significant Weight Loss in Hospitalised Patients with COVID-19: A Retrospective Cohort Study in a Large Teaching Hospital.

SARS-CoV-2 infection (COVID-19) is associated with malnutrition risk in hospitalised individuals. COVID-19 and malnutrition studies in large European cohorts are limited, and post-discharge dietary characteristics are understudied. This study aimed to assess the rates of and risk factors for ≥10% weight loss in inpatients with COVID-19, and the need for post-discharge dietetic support and the General Practitioner (GP) prescription of oral nutritional supplements, during the first COVID-19 wave in a large teaching hospital in the UK. Hospitalised adult patients admitted between March and June 2020 with a confirmed COVID-19 diagnosis were included in this retrospective cohort study. Demographic, anthropometric, clinical, biochemical, and nutritional parameters associated with ≥10% weight loss and post-discharge characteristics were described. Logistic regression models were used to identify risk factors for ≥10% weight loss and post-discharge requirements for ongoing dietetic input and oral nutritional supplement prescription. From the total 288 patients analysed (40% females, 72 years median age), 19% lost ≥ 10% of their admission weight. The length of hospital stay was a significant risk factor for ≥10% weight loss in multivariable analysis (OR 1.22; 95% CI 1.08–1.38; p = 0.001). In addition, ≥10% weight loss was positively associated with higher admission weight and malnutrition screening scores, dysphagia, ICU admission, and artificial nutrition needs. The need for more than one dietetic input after discharge was associated with older age and ≥10% weight loss during admission. A large proportion of patients admitted to the hospital with COVID-19 experienced significant weight loss during admission. Longer hospital stay is a risk factor for ≥10% weight loss, independent of disease severity, reinforcing the importance of repeated malnutrition screening and timely referral to dietetics.

Malnutrition risk screening: New insights in a new era

Twenty years ago, ESPEN published its "Guidelines for nutritional screening 2002", with the note that these guidelines were based on the evidence available until 2002, and that they needed to be updated and adapted to current state of knowledge in the future. Twenty years have passed, and tremendous progress has been made in the field of malnutrition risk screening. Many screening tools have been developed and validated for different patient groups and different health care settings. Some countries even have introduced mandatory screening for malnutrition at admission to hospital. Yet, changes in society and healthcare require a reflection on current practice and policies regarding malnutrition risk screening. In this opinion paper, we share our perspectives on malnutrition risk screening in the twenty-twenties, addressing the changing and varying profile of the malnourished individual, the goals of screening and screening tools (i.e., preventive or reactive), the construct of malnutrition risk (i.e., screening for risk factors or screening for existing malnutrition), and screening alongside a patient's journey.

Reflections on recruiting healthcare professionals as research participants: Learning from the ONSPres Study.

The involvement of healthcare professionals (HCPs) as research participants is essential to generate high quality evidence for enhancing health services and practice. Research teams face many challenges in recruiting HCPs for research, and barriers and enablers for interdisciplinary research are not well described in the literature. The Oral Nutritional Supplement Prescribing Malnutrition Research Study (ONSPres Study) examined malnutrition identification, management, and appropriate oral nutritional supplement prescribing in primary care in Ireland. The ONSPres Study offers a unique view of recruiting HCPs for research because a range of disciplines were sought for participation in a mixed methods study. The purpose of this open letter is to describe the experiences of recruitment and participation. Sixteen general practitioners (GPs) were recruited to participate in one-to-one interviews, eighty health and social care professionals working in community care (including nurses, pharmacists, dietitians, physiotherapists, speech and language therapists, and occupational therapists) were recruited to take part in 12 focus groups, and 31 GPs and trainee GPs were recruited to participate in an education programme developed by the study team. Strategies required to gain access and reach HCPs differed between disciplines. Professional networks enhanced access to HCPs working in practice and recruitment was slower and more tailored when those networks were less available to the team. An interest in malnutrition, to assist in research, to advance patient care, and the opportunity for learning were incentives for the participating HCPs. Limitations in the diversity of the sample arose, with a bias towards female participants and GPs motivated by an interest in the topic. It is recommended that study teams collaborate early with relevant HCP disciplines so they can contribute to recruitment planning at project concept and design stages. To enhance and incentivise HCP participation in research, dedicated time and acknowledgement of participation as continuous professional development is proposed.

MO931: Serum Uric Acid—A Marker of Malnutrition and Mortality in Patients Undergoing Maintenance Haemodialysis

Abstract BACKGROUND AND AIMS Malnutrition in patients on maintenance haemodialysis (HD) develops along different pathways, and factors contributing to the development of malnutrition may be categorized as of iatrogenic and non-iatrogenic origins. Iatrogenic factors are an inadvertent consequence of dialysis for HD patients (e.g. removal of uremic solutes), whereas non-iatrogenic factors develop spontaneously from different factors accompanying the progression of kidney disease but are not related to the primary treatment (e.g. low dietary energy and protein intake). Malnutrition is prevalent in 28%–54% HD patients and is an important risk factor for mortality. The aim of our study was to investigate the impact of serum uric acid (SUA) and other non-invasive markers of malnutrition on the survival of maintenance HD patients. METHOD We performed a study on 77 HD patients without malignant disease who were observed from January 2016 until their death or January 2021. Their median age was 63.0 (IQR 19) years, and their dialysis vintage was 1449 (IQR 1848) days. We recorded past medical history, laboratory tests and basic demographic data and performed bioelectrical impedance analysis with BodyStat (BodyStat Ltd). Patients who were at risk for malnutrition, based on nutrition screening tools, received oral nutritional supplements (ONS). SUA was measured every 2 months and the mean value was used for analysis. Kaplan–Meier survival analysis and Cox's regression were performed. RESULTS Included patients (51.9% males) had diabetes mellitus (33.8%), arterial hypertension (87.0%), ischemic heart disease (24.7%), chronic obstructive lung disease (3.9%), liver disease (3.9%) and were smokers (14.3%). They received an ONS in 63.6%. During the observation period, 50.6% of them died. We created tertile groups (low, medium and high) based on mean SUA &amp;lt; 294 μmol/L, 294–337 μmol/L and &amp;gt; 337 μmol/L, respectively. The low group had significantly lower body mass index (BMI) (P = 0.044), total iron binding capacity (TIBC) (P = 0.001), phase angle (P = 0.003) and dry lean mass (DLM) (P = 0.048), however there were no significant differences in prescription of ONS (P = 0.092). Kaplan–Meier survival analysis showed significantly higher mortality for patients in the low tertile group (P = 0.004). In Cox's regression model, SUA remained significant when adjusted for age, sex, BMI and comorbidities (P = 0.026). However, when adjusting for other markers of malnutrition and receiving ONS, only phase angle, albumin, DLM, fat free mass index and TIBC remained statistically significant. CONCLUSION Low SUA levels in chronic HD patients are associated with lower survival and can help identify individuals who are at risk for malnutrition. Further studies should be done to guide possible interventions.

Protein intake in hospitalized older patients after hip fracture: Pilot feasibility study evaluating ESPEN guidelines for geriatrics

Background & AimOlder patients with hip fracture are often malnourished or at risk of developing malnutrition. Poor oral food intake and difficulties reaching the recommended protein intake have been reported in this population. Recently published ESPEN guidelines for geriatrics recommend oral nutritional supplements (ONS) providing at least 30 g protein/day. The aim of the study was to assess the feasibility of implementing these ESPEN recommendations in a real-world setting.MethodsPatients ≥65 years with a hip fracture admitted to the orthopaedic ward at Herlev-Gentofte University Hospital, Copenhagen, Denmark were included in a single-arm study. Patients received standard care and were offered two servings ONS daily (Nutridrink Compact Protein, 18 g protein/125 ml serving), at breakfast and pre-bedtime, from first postoperative day until hospital discharge. Protein and energy intake from hospital food, beverages, and study ONS were recorded during hospitalization. Achievement of target ONS (30 g protein/day from ONS) and adherence to ONS prescription by serving time were calculated. Further total protein intake was compared to 1.0, 1.2 and 1.5 g/kg BW/day and specifically at postoperative day 4 to 1.2 g/kg BW/day. Data are presented as median [IQR].ResultsForty patients (70% women) with a median age of 86.5 years were included. Only five patients met the recommended 30 g protein/day from ONS during hospitalization. Overall adherence to ONS during hospitalization was 58.2% [33.3–75.0]; highest at breakfast (66.7% [44.9–100]) compared to pre-bedtime (48.8% [5.0–66.7]). Total daily protein intake was 48.7 g [34.9–56.1], of which 18.5 g [11.7–27.0] came from ONS, 23.2 g [14.6–29.0] from food and 6.2 g [1.5–10.00] from beverages. At postoperative day 4, 17 of the 40 patients were still in the hospital. The median total protein intake on day 4 was 0.5 g/kg BW/day [0.4–0.8], representing 42.2% [29.2–64.4] of 1.2 g/kg BW/day. Only three of the 17 patients achieved 100% of the protein reference level.ConclusionThe recommended intake of 30 g protein/day from ONS during hospital stay was met in a minority of this population of older patients with hip fracture, with low adherence to ONS prescription as an important barrier. However, ONS substantially contributed to the daily protein intake since protein intake from food was also very low. These insights should be used to inform further research aiming to discover ways to improve dietary intake with multiple dietary strategies, tailored to individual needs. Older patients with hip fracture are often malnourished or at risk of developing malnutrition. Poor oral food intake and difficulties reaching the recommended protein intake have been reported in this population. Recently published ESPEN guidelines for geriatrics recommend oral nutritional supplements (ONS) providing at least 30 g protein/day. The aim of the study was to assess the feasibility of implementing these ESPEN recommendations in a real-world setting. Patients ≥65 years with a hip fracture admitted to the orthopaedic ward at Herlev-Gentofte University Hospital, Copenhagen, Denmark were included in a single-arm study. Patients received standard care and were offered two servings ONS daily (Nutridrink Compact Protein, 18 g protein/125 ml serving), at breakfast and pre-bedtime, from first postoperative day until hospital discharge. Protein and energy intake from hospital food, beverages, and study ONS were recorded during hospitalization. Achievement of target ONS (30 g protein/day from ONS) and adherence to ONS prescription by serving time were calculated. Further total protein intake was compared to 1.0, 1.2 and 1.5 g/kg BW/day and specifically at postoperative day 4 to 1.2 g/kg BW/day. Data are presented as median [IQR]. Forty patients (70% women) with a median age of 86.5 years were included. Only five patients met the recommended 30 g protein/day from ONS during hospitalization. Overall adherence to ONS during hospitalization was 58.2% [33.3–75.0]; highest at breakfast (66.7% [44.9–100]) compared to pre-bedtime (48.8% [5.0–66.7]). Total daily protein intake was 48.7 g [34.9–56.1], of which 18.5 g [11.7–27.0] came from ONS, 23.2 g [14.6–29.0] from food and 6.2 g [1.5–10.00] from beverages. At postoperative day 4, 17 of the 40 patients were still in the hospital. The median total protein intake on day 4 was 0.5 g/kg BW/day [0.4–0.8], representing 42.2% [29.2–64.4] of 1.2 g/kg BW/day. Only three of the 17 patients achieved 100% of the protein reference level. The recommended intake of 30 g protein/day from ONS during hospital stay was met in a minority of this population of older patients with hip fracture, with low adherence to ONS prescription as an important barrier. However, ONS substantially contributed to the daily protein intake since protein intake from food was also very low. These insights should be used to inform further research aiming to discover ways to improve dietary intake with multiple dietary strategies, tailored to individual needs.

Implications of inappropriate prescription of oral nutritional supplements on the quality of life of cancer outpatients: a cross-sectional comparative study

Background and aimsOral nutritional supplements (ONS) are considered a cornerstone in the treatment plan of malnutrition in cancer patients. However, the prevalence of inappropriate prescription of ONS is high. In this study, we aim to investigate the effect of inappropriate oral nutritional supplementation (consisting of prescription of ONS without evident clinical indication, or the absence of ONS when at risk of malnutrition) on the quality of life of cancer outpatients.MethodsA cross-sectional comparative study was conducted in 104 cancer outpatients, receiving ONS without prior malnutrition risk screening (n = 51), and patients not receiving ONS (n = 53). Nutritional risk screening was performed using the abridged patient-generated subjective global assessment (ab-PG-SGA). The quality of life was assessed using EORTC QLQ-C30 version 3.0 questionnaire. Multivariate analysis was conducted to determine the predictors of quality-of-life scales. Age (years), malnutrition (ab-PG-SGA scores), BMI (kg/m2), TSF (mm), MUAC (cm), ONS (yes, no) were entered into the linear regression analysis as predictors (backward stepwise linear regression analysis).ResultsThe prevalence of malnutrition risk (ab-PG-SGA ≥ 6) was 74%. The median score of the ab-PG-SGA for ONS receiving group was significantly higher (p = 0.045). Furthermore, univariate analysis showed that the scores of the global health status (QoL) and the role functioning (RF) scales were significantly lower for the ONS receiving group (p = 0.020 and p = 0.016, respectively). Multivariately, malnutrition, inappropriate ONS prescription, and triceps skin fold were found to be predictors of the RF scale, while malnutrition was the only predictor for the QoL.ConclusionThe inappropriate ONS prescription does not improve nutritional status or quality of life of cancer outpatients.

Trajectories of Nutritional Parameters Before and After Prescribed Oral Nutritional Supplements: A Longitudinal Cohort Study of Patients With Chronic Kidney Disease Not Requiring Dialysis

Background:The association between oral nutritional supplement use and nutritional parameters among patients with nondialysis chronic kidney disease (CKD-ND) with or at high risk of undernutrition/protein-energy wasting has not been previously studied. The definition of patient subgroups most likely to benefit from oral nutritional supplementation (ONS) is also an area where more research is needed.Objective:To assess nutritional parameter trajectories among patients with CKD-ND prescribed oral nutritional supplements in British Columbia, and to compare trajectories by nutritional phenotype.Design:Longitudinal cohort study, pre-post design.Setting:Multidisciplinary CKD clinics across British Columbia.Patients:A total of 3957 adult patients with CKD-ND, who entered multidisciplinary CKD clinics during 2010 to 2019, met criteria for oral nutritional supplement prescription based on dietitian assessment, and received ≥1 oral nutritional supplement prescription.Measurements:Longitudinal nutritional parameters, including body mass index (BMI), serum albumin, serum bicarbonate, serum phosphate, and neutrophil-to-lymphocyte ratio (NLR).Methods:Using linear mixed models, slopes for nutritional and inflammation parameters were assessed in the 2-year periods before and after the first oral nutritional supplement prescription. Hierarchical cluster analysis was applied to identify nutritional phenotypes using baseline data, and slope analysis was repeated by cluster.Results:In the pre-oral-nutritional-supplement period, declines in BMI (−0.87 kg/m2/year, 95% confidence interval [CI]: −0.99 to −0.75), albumin (−1.11 g/L/year, 95% CI: −1.27 to −0.95), and bicarbonate (−0.49 mmol/L/year; 95% CI: −0.59 to −0.39), and increases in NLR (+0.79/year; 95% CI: 0.60 to 0.98) and phosphate (+0.05 mmol/L/year; 95% CI: 0.04 to 0.06) were observed. Following oral nutritional supplement prescription, there were statistically significant increases in BMI slope (+0.91 kg/m2/year, P < .0001), albumin slope (+0.82 g/L/year, P < .0001), and phosphate slope (+0.02 mmol/L/year, P = .005), as well as a decline in NLR slope of −0.55/year (P < .0001). There was no significant change in bicarbonate slope. Cluster analysis identified 5 distinct phenotypes. The cluster with the highest mean baseline NLR and lowest mean BMI demonstrated the greatest number of improvements in nutritional parameter slopes in the post-oral-nutritional-supplement period.Limitations:Possibility of residual confounding. Data on dietary intake, muscle mass, and nutritional scoring systems were not available in the registry.Conclusions:Among patients with CKD-ND prescribed oral nutritional supplements, there were improvements in nutrition/inflammation parameters over time following the first ONS prescription. The heterogeneity in response to ONS by cluster subgroup suggests an individualized approach to nutritional management may be beneficial.

Nutritional Status, Nutritional Phenotypes, and Oral Nutritional Supplement Prescription Patterns Among Patients With Non-Dialysis Chronic Kidney Disease in British Columbia

Management of protein-energy wasting and undernutrition with oral nutritional supplements (ONS) has not been systematically studied in the non-dialysis chronic kidney disease (CKD-ND) population. We aimed to describe nutritional status, identify phenotypes of patients prescribed ONS, and evaluate ONS prescription patterns among CKD-ND patients in British Columbia. This observational study assessed adult CKD-ND patients who entered multidisciplinary CKD clinics during 2013-2018 in British Columbia. Descriptive statistics were used to describe baseline nutrition and inflammation parameters among patients prescribed ONS versus patients not prescribed ONS within 1year of clinic entry. Hierarchical clustering method with consensus clustering was applied to identify phenotypes of patients prescribed ONS. Multivariable logistic regression was used to assess the associations between ONS prescription and health region/dietitian full-time equivalents per 1,000 CKD patients. Of 15,859 CKD-ND patients, 9% of patients entering CKD clinics were prescribed ONS within 1year of clinic entry, and these patients demonstrated lower baseline estimated glomerular filtration rate, body mass index (BMI), serum albumin, bicarbonate, as well as greater age, serum phosphate, and neutrophil-to-lymphocyte ratio compared with those not receiving ONS. Cluster analysis revealed 5 phenotypes of ONS users: cluster 1 had the highest mean neutrophil-to-lymphocyte ratio; cluster 2 had the lowest mean albumin; cluster 3 had the lowest mean BMI; cluster 4 had the highest mean BMI; and cluster 5 had the lowest mean bicarbonate. There was regional variability in ONS prescription, and an odds ratio for ONS prescription of 1.32 (95% confidence interval 1.16-1.50) for every 1-unit increase in dietitian full-time equivalents per 1,000 patients. Over 3years of follow-up, overall ONS use among CKD-ND patients remained stable. This study demonstrates appropriate prescribing of ONS to patients with suboptimal nutritional status, although regional variation exists. Patients receiving ONS represent a heterogenous group with phenotypes reflecting several clinical and biochemical features of the protein-energy wasting syndrome. These findings will assist with updating ONS policy, planning quality improvement initiatives, and informing dietitian resource allocation.

Advances in knowledge of screening practices and their use in clinical practice to prevent malnutrition

Malnutrition is common among older adults and is associated with a progressive decline in overall health and increased mortality. With a rapidly ageing population, the detection, prevention and management of malnutrition require urgent attention within health service planning and delivery. Routine screening for malnutrition among older adults in community settings, which addresses aetiological as well as phenotypic factors, is considered an important step for prevention and early intervention. The aim of this review is to summarise current malnutrition screening literature and highlight research that seeks to understand and address community-based approaches to malnutrition screening and management. Key healthcare professionals (HCPs) that encounter community-dwelling older adults include general practitioners (GPs), community-based nurses, community pharmacists and a range of other health and social care professionals including dietitians, physiotherapists, speech and language therapists, and occupational therapists. The key barriers to implementing screening in primary care include lack of knowledge about malnutrition among non-dietetic HCPs, lack of resources allocated to managing malnutrition, lack of access to dietetic services, and poor GP knowledge about oral nutritional supplement prescribing. In addition, older adults have poor insight into the clinical condition and the associated negative health implications. Investment in education among HCPs and public awareness is required, as well as accompanying resources to successfully implement malnutrition screening programmes for community-dwelling older adults.

OA04.03 Feasibility of Prospective Dietetic Assessment and Intervention of Patients Receiving Chemo-Radiotherapy for Lung Cancer

Chemo-radiotherapy for lung cancer can be a morbid treatment, often in an older and co-morbid population. Our patients are not routinely seen by a dietitian. As a pilot project, all patients receiving either sequential or concurrent chemo-radiotherapy for lung cancer between May and November 2020, were identified by the lead lung radiographer and bookings team and referred to a specialist oncology dietitian. These patients were offered up to 3 routine fortnightly assessments on treatment. We recorded their symptoms (based on a standardised tool, PG-SGA) and weight during treatment. 15 patients were referred to the dietitian: 7 male, 8 female. All patients accepted dietetic review. The median age was 64 years old; mean age 63 years old (range 50-79). The mean average number of cycles of chemotherapy was 3.4. Concurrent chemo-radiotherapy was given to 11 patients, with the remaining 4 having sequential treatment. Of all patients, 1 had small cell lung cancer, 1 had a mixed adenocarcinoma and small cell. The remaining 13 were non-small cell lung cancers, and of these 6 were adenocarcinomas and 6 were squamous cell carcinomas and 1 mixed histology. All patients were reviewed at least twice whilst on treatment. The most complete data was for the review in weeks 3/4 of radiotherapy. All 15 patients had scores for this time point. Mean number of symptoms was 5.5 (range 3-9). The commonest symptoms were fatigue (100%), loss of appetite (67%), pain (67%) and dysphagia (60%). For 12 patients receiving 6 weeks of radiotherapy median symptom number increased from 5 in 1st 2 weeks, to 5.5 in weeks 2nd 2 weeks, to 6.5 in final 2 weeks. All patients in this group lost weight. Median weight loss during treatment was 6.6% (range 1.8-15.9%). All patients received food fortification advice throughout their treatment and advice on symptom management. The symptom management advice for 12 of the 15 patients either reinforced advice, or, made adjustments to the timing of medications prescribed by medical or nursing staff. The other 3 patients did not have an existing prescription, and so recommendations were made of medications to manage symptoms, e.g. oxcetacaine, anti-emetics and laxatives. Oral nutritional supplements (ONS) were recommended if patients were not meeting their estimated nutritional requirements from dietary assessment. Seven patients received ONS prescription in addition to the food fortification advice. One patient declined an ONS prescription. 1. Routine dietetic review during radical chemo-radiotherapy is feasible and occurred successfully during the COVID-19 pandemic. It led to some simple, but vital changes in practice such as weekly weighing of patients on treatment 2. Patients undergoing chemo-radiotherapy have a high symptom burden. 3. All patients receiving 6 weeks of radiotherapy lost weight during treatment. 4. We received positive feedback from patients.

Adherence to Oral Nutritional Supplements in Patients With Gastrointestinal Cancer: A Mixed-Method Study.

Oral nutritional supplements (ONS) is a cost-effective nutritional therapy in patients with gastrointestinal cancer. However, information is lacking about adherence to ONS in general clinical settings. Figuring out adherence to ONS and related factors will provide evidence for the improvement of ONS usage practice. The aim of this study was to survey adherence to ONS in gastrointestinal cancer patients with an ONS prescription and the factors associated with it. A mixed-method prospective study was conducted. Multivariate analysis and semistructured interviews were performed to identify factors that affected patient adherence to ONS. Of 111 gastrointestinal cancer patients provided with an ONS prescription, the median of adherence to ONS was 50.00% (interquartile range, 28.57%-91.67%). Multivariate analysis indicated that participants with low weight showed higher adherence to ONS than those with normal weight (β = -2.61, P = .011) or overweight (β = -3.25, P = .002). Semistructured interviews on 14 participants suggested that factors related to adherence to ONS were needs perception and benefits, clarity of the target daily ONS intake, tolerance to ONS, the impact of disease or treatment, personal preference, and professional support. This study reveals poor adherence to ONS in patients with gastrointestinal cancer and factors related to it in current clinical settings. Our findings could provide evidence for the development of strategies to improve ONS usage practice. It suggests that the practice in ONS should be improved from aspects of nutritional assessment, education, tolerance, and symptom management, as well as follow-up and monitoring of patients.

Impact of a Geriatric Intervention to Improve Screening and Management of Undernutrition in Older Patients Undergoing Surgery for Colorectal Cancer: Results of the ANC Stepped-Wedge Trial

Almost two in three patients who are aged 75 years and older and scheduled for surgery for colorectal cancer (CRC) are undernourished. Despite evidence that perioperative nutritional management can improve patients outcomes, international guidelines are still insufficiently applied in current practice. In this stepped-wedge cluster-randomized study of five surgical hospitals, we included 147 patients aged 70 years or older with scheduled abdominal surgery for CRC between October 2013 and December 2016. In the intervention condition, an outreach team comprising a geriatrician and a dietician visited patients and staff in surgical wards to assist with the correct application of guidelines. Evaluation, diagnosis, and prescription (according to nutritional status) were considered appropriate and strictly consistent with guidelines in 39.2% of patients in the intervention group compared to only 1.4% in the control group (p = 0.0002). Prescription of oral nutritional supplements during the perioperative period was significantly improved (41.9% vs. 4.1%; p < 0.0001). However, there were no benefits of the intervention on surgical complications or adverse events. A possible benefit of hospital stay reduction will need to be confirmed in further studies. This study highlights the importance of the implementation of quality improvement interventions into current practice for the perioperative nutritional management of older patients with CRC.

Healthcare professionals' perceptions of malnutrition management and oral nutritional supplement prescribing in the community: A qualitative study.

Protein-energy malnutrition is under-recognised in the community despite being common in older adults due to physiological and social changes which are often compounded by chronic disease. This qualitative study aimed to explore the opinions of healthcare professionals (HCPs) working in the primary care and community settings about the management of malnutrition and the prescription of oral nutritional supplements (ONS), often included in the treatment of malnutrition. Twelve healthcare professional (HCP) focus groups with 75 participants were conducted: community dietitians (n=17), registered dietitians working in industry (n=5), community and residential care nurses (n=22), physiotherapists (n=12), pharmacists (n=9), occupational therapists (n=6) and speech and language therapists (n=4). Focus group discussions were audio-recorded and transcribed verbatim. The data were coded and analysed using thematic analysis and key themes with illustrative quotes extracted are presented. Similar views on malnutrition management existed across professions. 'Gaps in Primary Care Management' was the first key theme wherein HCPs identified limitations in malnutrition management in the community. Barriers included limited or no dietetic services available in primary care and poor communication between general practitioners and wider primary care team members which resulted in inappropriate or delayed treatment. The second key theme, 'Challenges with ONS use in the Community', encapsulated several issues HCPs experienced with ONS usage including inappropriate prescribing and lack of monitoring of treatment goals. Conflicts of interest regarding dietitians working in industry assessing and treating older adults in residential care settings was highlighted by participants. This study highlights that more emphasis is needed to identify patients when they are at risk of malnutrition to avoid advanced or severe malnutrition presentations currently seen. Community dietitians for older people are required to address many of the issues raised including the need for awareness, education and training, resources, and malnutrition care pathway structures.

A qualitative exploration of dietitians’ experiences of prescribing oral nutritional supplements to patients with malnutrition: A focus on shared tailoring and behaviour change support

Oral nutritional supplements (ONS) are commonly prescribed to patients with malnutrition. Dietitians have been suggested as preferred prescribers but generally lack ONS prescribing rights. How dietitians with prescribing rights experience their professional practice of prescribing ONS remains understudied. Thus, by exploring dietitians' experiences of prescribing ONS, the present study aimed to obtain a deeper understanding of specific aspects that are of importance for dietitians when providing a nutrition therapy including ONS. Qualitative individual interviews were conducted with 13 dietitians prescribing ONS to free-living adult outpatients with malnutrition or at nutritional risk in the hospital or primary care setting. Systematic text condensation was used for data analysis. Two main categories signifying important aspects were identified and labelled: 'Shared tailoring of the ONS prescription' and 'Supporting and facilitating ONS use'. First, the dietitians described tailoring the ONS prescription together with the patient, having their acceptance as a prerequisite, and being flexible regarding products and amounts prescribed. Second, they described performing different communication strategies and organising of practical issues (e.g., ONS delivery and support from others) to support and facilitate patients' ONS usage. The present study identifies patient involvement and the role of dietitians as behaviour change facilitators as two important aspects when dietitians prescribe ONS. These findings allow for dietitians' ideals and strategies on how to prescribe ONS to be made more visible, which can inform both clinical practice and clinical trials for future improvements in nutrition therapy to address malnutrition.

Healthcare professionals’ perceptions of malnutrition management and oral nutritional supplement prescribing in the community: a qualitative study

Healthcare professionals’ perceptions of malnutrition management and oral nutritional supplement prescribing in the community: a qualitative study

Adherence to Oral Nutritional Supplements After Being Discharged from the Hospital is Low but Improves Outcome in Patients with Advanced Chronic Liver Disease.

PurposePatients with advanced chronic liver disease (ACLD) often have a poor nutritional status. In the management, current guidelines recommend dietary counseling and oral nutritional supplements (ONS). Nutritional goals and adherence to ONS are difficult to achieve while studies addressing adherence are scarce. We aimed to evaluate adherence to ONS, the associated factors, and its impact on outcome among ALCD patients who are discharged from the hospital.Patients and MethodsWe identified consecutive hospitalized patients with ACLD from the cirrhosis registry and ONS prescription at discharge. Baseline demographics, anthropometrics, hand-grip strength (HGS), nutritional, and laboratory parameters were recorded. Adherence was assessed at 30, 90, and 180 days, but not in patients who did not survive or in those who underwent liver transplantation (LT) before the time-point.ResultsFrom the registry containing 1004 patients, we included 450 cases, the median age was 56.3 (IQR 47–62), 60% were males, 63.8% had alcoholic etiology, and the median model for end-stage liver disease score (MELD) was 16 (11–21). During follow-up, 13.6%, 23.6%, and 31.1% of patients have died within 30, 90, and 180 days, respectively, and 21 underwent LT. Adherence to ONS in surviving patients was observed in 46%, 26.1%, and 16.9% within 30, 90, and 180 days, respectively. Baseline refractory ascites (HR=0.43, 0.24–0.76), HGS (HR=1.03, 1.01–1.06), and mid-arm circumference (HR=0.93, 0.88–0.99) were independently associated with 30-day adherence. Among patients who survived beyond 30 days, adherents for >30 days had improved synthetic liver function, HGS, a higher probability of LT (HR=1.7, 1.03–2.8) and lower risk of death (HR=0.65, 0.45–0.89), particularly those with MELD>16 (OR=0.55, 0.36–0.85) and low HGS (OR=0.61, 0.39–0.93).ConclusionIn ACLD patients after discharge, adherence to ONS steeply declined and was associated with baseline refractory ascites and low muscle strength. Adherence to ONS also improved liver function, muscle strength, and survival.