I am interested in hearing views on the use of oral nutritional supplements (ONS) as part of client treatment plans. Recent work locally and across London have indicated that these products (fortisip, ensure plus, fresubin etc) are often prescribed to clients for low weight and poor appetite. I have met with many healthcare professionals and note practice and opinion varies greatly. As a dietitian, my colleagues and I are seeing more clients on ONS and often find ONS is not prescribed/used/monitored appropriately. It is also a big challenge to stop the prescription once commenced. I would appreciate any comments and/or direction to guidance that may be available in this area. Many thanks

This issue has been contentious over the years. ONS products have been discovered on market stalls and in children's lunch boxes. The first is clearly as sign of misuse and poor prescribinbg, the second is likely to be a parent's prioritising their children's need over their own.

Locally a protocol requires that a BMI less than 18 or other objective signs of poor nutrition are present and that attempts to promote weight gain by healthy eating of normal foods have not been effective. ONS use is then part of the overall review process regarding treatment.

I still encounter the occasional client who uses ONS instead of buying food, but this is rare if it is part of an invididual care package that is understood b the client. ONS prescribing is now quite a rare event in this patch.

Hope this helps

I expect Judith will be charging into this debate soon I think you'll find she's not a fan. The evidence for their usefulness does seem to be extremely limited and their use seems only to be ever justified as part of a tight package such as Jim prescribes.

The rules in the BNF are quite strict but many people don't seem to read them.

I always think that prescribing is medicalising what is either a motivational or a social issue, and that it's more effective to do whatever you can to help someone to eat properly/have the tools to prepare food rather than to prescribe.

Having said that, there are always some patients who may benefit, and there is NICE guidance on the subject. This is a link to the quick guidance, but there is the full guideline too http://www.nice.org.uk/nicemed...032quickrefguide.pdf

I ran this query by the NTA policy team who directs us to the 2007 Clinical Guidelines which say 'Drug misusers may suffer from poor nutrition but should only receive oral nutrition support if there are clear medical reasons to do so' ... which may be helpful if only the 'clear medical reasons' were made explicit!

As Simon says, the instructions are clear in the BNF (which is accessible to all on-line ) The only "clear medical reasons" which the Advisory Committee for Borderline Substances (ACBS) accepts for prescribing of enteral foods and food supplements are : "short-bowel syndrome, intractable malabsorption, pre-operative preparation of undernourished patients, proven inflammatory bowel disease, following total gastrectomy, bowel fistulas, or disease-related malnutrition."


The vast majority (added on 11.7.09.. see Jez thompson post further down) of our patients do not have any of these diseases. I explain to people who ask, that these chemical foods are "plastic food" and not as good as fresh fruit and vegetables. (people are sometimes astonished to hear this as they have believed some kind of marketing hype) They are to be eaten only by people who cannot digest real food. Where people have experience of prison life, I remind them that they weighed 2 stone heavier when they came out of prison, and ask them how this was acheived. Not by eating plastic food, but by having a regular timetable of eating. (and also often regular exercise) They all agree that when they first came out of prison they had a hearty appetite for the first week or so, as the pavolovian reflex of regularity of eating leads to regularity of hunger within a week. (same happens for more fortunate people who have a week in an all inclusive hotel on holiday.. they feel hungry at lunchtime for a good week after returning home as their stomach has quickly learned to expect food at this time)

Many of our patients need to be reminded of their biological rythms, which given half a chance (as within the prison regular regime) will keep them fit and healthy, eating and sleeping at the right times. So they don't need sleeping tablets (usually)(just a large alarm clock to get up each morning) and they don't need food supplements.. just a regular regime of eating at predictable times which their stomach can learn to expect, causing the sensation of hunger.

I do occasionally prescribe these horrible drinks for people who have fallen foul of the many gaps in the welfare state, and have no benefits for several weeks or months. It is either that or hand out 5 pound notes myself. i also of course direct them to whatever local free food sources i can think of. As this is not within the "ACBS" guidelines above, the Prescription Pricing Authority would be within their rights to refuse to pay for the prescriptions, and to send me a personal bill to refund the NHS for them. I am hoping you will all write in my support if this occurs.

This message has been edited. Last edited by: judith yates,

Many thanks for all the responses!

I am aware of ACBS & NICE guidance and was recently involved in the London Procurement Programmes Oral Nutritional Support Project (LPPCONSP) which assessed ONS demand management initiatives across London (dietetic departments) and developed clinical guidelines for the use of ONS. As part of these we gave the Grampian Joint Formulary guidance as an example of good practice. However we are finding it difficult to take this or any local guidance forward to HCPs involved in this client group because of many of the reasons you have all mentioned. If anyone has some tips on how to engage interest in appropriate ONS prescribing please let me know. And how to maintain that interest!

It is interesting to note that along with these products being inappropriately used with many clients, which can be detrimental to their health and recovery, they also have a significant cost to the NHS. The LPPCONSP estimated that nationally it is over £80million pa.

I appreciate the examples given Judith! And I believe your discussions with clients in prison will be very useful for us practically.

I feel like Delia Smith sometimes with the dietary advice. I guess many people get used to not eating and find it hard to re-start. I give lots of advice, little and often, start with soups with bread in, cheap tinned rice puddings,scrambled eggs, build up to mash potato and mince. Add in cheese to mash for few extra calories and calcium. Move on to more solid type food with clear advice that liquid NHS drinks will pass through the stomach and wll not make it easier to eat.
I think many young people just don't know how to cook. In time when I discuss my home-made burger recipe I know I'm on to a winner.

Either Ripple in Bradford or Project 7 in Keighley ran cookery classes a couple of years ago.

Hi Jeff, that is more useful and a long term solution. We did a similar thing in a prison I used to work at. A local college used to send a home economics teacher, we only had a microwave but it was amazing what meals she could make with one. It was the best attended class that was run.

Judith, I'd like to offer a gentle challenge to your rather blanket statement that 'our patients don't have any of these diseases' when it comes to ACBS guidance, and would suggest qualfying it with 'the vast majority of...'.

Our patients often have comorbidities that are associated with anorexia and resultant poor nutrition, such as HCV and HIV infection. As time goes on and the 'boomers' of the 1980s get cancers and other illnesses we are likely to see increasing amounts of malnutrition associated with these conditions in the patients we see. Alcohol and/or opioid dependence (with or without the effects of social deprivation) are easily arguable as causes of 'disease-related' malnutrition in those with low BMI requiring food supplement prescribing in adherence to NICE guidance.

I'm not in favour of widespread prescribing of sip feeds, but believe we have to keep all options open when we manage the complex multifaceted situations associated with dependence, and should manage our patients' needs as individuals (as long as it's within national guidance). That way we can achieve the dual goals of helping our patients with appropriate prescribing, even if it is 'those horrible drinks' while avoiding footing the bill to the PPA

Jez, its a good job I have people like you to keep me off my high horses. I have the moderator's privilege of being able to edit late in the day, so have added your suggested "vast majority of" for future readers. However I do feel strongly that where there is no "intractable malabsorption " ordinary food is more effective than these artificial concoctions .

I have seen the physical transformation that a few weeks in prison can bring too many times to be able to avoid the conclusion that access to regular food is what most people are missing, rather than inability to absorb food which is offered.

I have also of course seen the weight fall off again immediately, when the person comes out of prison, sometimes without a discharge grant, and with no money for several weeks because of benefit confusions. last month a patient told me that he had been taken back to prison while on licence then released again without charge because he had done no wrong He got no discharge grant because he had already had one for that crime number when released in the past (can that be right?) and he had lost his flat because everyone had assumed he would be in for the remainder of his sentence. He is now very thin again.

So I think I can say that the majority of people who ask me for SIP feeds are in need of access to proper food,and also to the money needed to purchase and prepare real ingredients not plastic predigested food. They also need the kind of advice Simon Greasley is giving. Cookery classes and access to kitchens and pans and things are of course essential and often beyond reach.

This discussion has reminded me to find a way to set up more cooking lessons....