9.4.3 Formulary choice oral nutritional supplements

There are two leaflets available to help patients and carers.

A guide to making the most of your food and

Advice for patients and carers who are prescribed nutrition drinks (oral nutritional supplements)

Please refer to guidance on Adult Malnutrition

Oral Nutritional Supplements (ONS) must not be prescribed at NHS expense for nursing home patients who do not meet ACBS criteria as rules state that food items are not prescribable.

ONS should only be prescribed if indicated by their MUST score (Malnutrition Universal Screening Tool) or if they have been assessed by a Dietitian. See Adult malnutrition, screening for malnutrition.

Further specialist oral nutritional supplements are available, that are not included in the formulary, but are suitable to be prescribed at a specialist dietitian's request.

Please contact the Department of Nutrition and Dietetics for further advice on appropriate nutritional supplements and severe / end stage kidney failure.

Contact Details:

Department of Nutrition and Dietetics, Hengrave House, Torbay Hospital, TQ2 7AA, 01803 654380

Department of Nutrition and Dietetics, Derriford Hospital, Plymouth, PL6 8DH, 01752 432243

South Devon and Torbay support videos

Nutritional supplements (non-disease specific)

Powder supplements to be reconstituted with fresh milk

Powder milk shakes are not suitable for patients with severe or end stage kidney failure (CKD Stage 4-5), or for patients with Stage 3B CKD who are hyperkalemic or have hyperphosphatemia.

Foodlink Complete
  • Banana, strawberry, chocolate, neutral, vanilla (£0.61 = 57g sachet)
  • One sachet reconstituted with 200ml full fat milk provides approximately 386kcal and protein 18.3g

Notes

  1. May not be suitable for patients with poor manual dexterity
  2. Gluten-free powder
  3. Not suitable for patients with galactoseamia or an intolerance to soya or milk protein

Complete ready to drink milkshake style sip feeds

AYMES® Complete
  • Liquid; banana, chocolate, strawberry, vanilla (£1.11 = 200ml bottle)
  • 300kcal, protein 12g, fat 12g, carbohydrate 36g per 200ml
  • Patients discharged on Fresubin Energy can be prescribed Aymes Complete
Fresubin® Energy
  • Liquid; vanilla, strawberry, chocolate, cappuccino, tropical fruit, blackcurrant, neutral, banana, lemon (£1.40 = 200ml bottle)
  • 300kcal, protein 11.2g, fat 11.6g, carbohydrate 37.6g per 200ml

High Energy low volume sip feed

Contact the Department of Nutrition and Dietetics for advice if dexterity problems, poor renal function.

Foodlink Complete
  • Banana, strawberry, chocolate, neutral, vanilla (£0.61 = 57g sachet)
  • One sachet reconstituted with 125ml full fat milk provides approximately 335kcal and protein 15.8g

Notes

  1. May not be suitable for patients with poor manual dexterity
  2. Gluten-free powder
  3. Not suitable for patients with galactoseamia or an intolerance to soya or milk protein
Ensure® Compact
  • Liquid; vanilla, strawberry, café latte, banana (£1.33 = 125ml bottle)
  • 300kcal, protein 13g, carbohydrate 36g, fat 11.6g per 125ml
Fortisip® Compact
  • Liquid; neutral, strawberry, vanilla, banana, mocha, apricot, forest fruit, chocolate (£1.33 = 125ml bottle)
  • 300kcal, protein 12g, carbohydrate 37.1g, fat 11.6g per 125ml

Juice style sip feeds 1.5kcal/ml

Ready to drink sip feed appropriate for patients who dislike milky drinks or for those with fat malabsorption.

Fresubin® Jucy Drink
  • Liquid; orange, apple, pineapple, cherry, blackcurrant (£1.99 = 200ml)
  • 300kcal, protein 8g, carbohydrate 67g per 200ml

For other considerations please see below:

Dislike of sweet flavours:

Ensure® Plus Savoury
  • Liquid; chicken flavour (£1.11 = 220ml bottle)
  • 300kcal, protein 12.5g, carbohydrate 40.4g, fat 9.84g per 200ml
AYMES® Savoury
  • Powder chicken, vegetable (£0.70 = 57g sachet)
  • 251kcal, protein 9.2g, carbohydrate 34.3g, fat 8.5g, fibre 0.23g per 57g
Vitasavoury®
  • Powder, chicken, golden vegetable (£2.08 = 50g sachet)
  • 310kcal, protein 6g, carbohydrate 11.25g, fat 26g, fibre 3.2g per 50g
  • One sachet reconstituted with 100ml of warm water provides approximately 300kcal and protein 6g

Constipation and Low fibre intake

Dietitian input is required before patients begin these supplements

Foodlink® Complete with Fibre
  • Powder (with added fibre) banana, strawberry, chocolate, vanilla, natural (£0.71 = 63g sachet)
  • One sachet reconstituted with 200ml full fat milk provides approximately 386kcal, protein 18.3g and fibre 4.5g
Fresubin® Energy Fibre
  • Liquid; strawberry, chocolate, caramel, cherry, vanilla, banana (£2.20 = 200ml bottle)
  • 300kcal, protein 11.2g, fat 11.6g, carbohydrate 37.6g, fibre 3g per 200ml

Taste Fatigue

Ensure® Plus Yogurt
  • Liquid; orchard peach, strawberry (£1.12 = 220ml bottle)
  • 300kcal, protein 13.75g, carbohydrate 44.44g, fat 11.07g per 220ml

Swallowing Problems

The following products have been considered based on The International Dysphagia Diet Standardisation Initiative (IDDSI) Framework. The new standards for Texture Modified Foods and Thickened Liquids can be found here.

Feed thickeners

Indicated for patients with dysphagia, as identified by a Speech and Language Therapist (SALT), who have advised on the stage of thickened fluids.

Clear (gum based) thickeners retain the clarity of clear liquids; they are amylase resistant when in contact with saliva and maintain stable viscosity over time. They are shown to improve the safety of swallowing without increasing oropharyngeal residue over their starch based counterparts.

Starch based thickeners are often not well accepted by patients however if an individual is tolerating starch thickener with no hydration concerns, this may continue.

Thick and Easy® Clear
  • Powder (126g tin = £6.50)
Nutilis® Clear
  • Powder (175g tin = £8.46)

If a patient is prescribed thickener whilst in hospital, it is important to continue the same product into primary care for clinical continuity and to reduce errors in mixing.

Clear (gum based) products have very specific mixing instructions which must be adhered to, to ensure the product is the correct thickness for patient safety. Please refer to mixing instructions on the tins or seek appropriate advice.

Sachets are significantly more expensive than tins. Sachets do not display mixing instructions and can be cumbersome to use. Routine use of sachets is not recommended.

The following tables provide guidance on approximate quantities of feed thickeners to prescribe per month (28 days):

Thick and Easy ® Clear (126g tin)

Volume per day Level 1 - Slightly Thick Level 2 - Mildly Thick Level 3 - Moderately Thick Level 4 - Extremely Thick
1500ml 3 x 126g tins 5 x 126g tins 7 x 126g tins 14 x 126g tins
2000ml 4 x 126g tins 7 x 126g tins 10 x 126g tins 17 x 136g tins

Nutilis ® Clear (175g tin)

Volume per day Level 1 - Slightly Thick Level 2 - Mildly Thick Level 3 - Moderately Thick Level 4 - Extremely Thick
1500ml 2 x 175g tins 3 x 175g tins 5 x 175g tins 11 x 175g tins
2000ml 2 x 175g tins 4 x 175g tins 6 x 175g tins 14 x 175g tins

The Speech and Language Therapist will inform GPs of the required consistency in terms of IDDSI descriptors after an assessment. If a different quantity is required a clinical reason should be stated.

Pre-thickened drinks

Indicated for patients with dysphagia and disease related malnutrition (see ACBS indicators above)

Only to be given if patient is malnourished (identified by a high Malnutrition Universal Screening Tool (MUST) score or by a Dietitian) with swallowing problems (identified by a Speech and Language Therapist).

Powder milk shakes are not suitable for patients with severe or end stage kidney failure (CKD Stage 4-5), or for patients with Stage 3B CKD who have hyperkalaemia or have hyperphosphatemia.

Changes in temperature of pre-thickened drinks could affect consistency

IDDSI Level 2
Slõ® Drinks Milkshake Stage 1 (IDDSI Level 2, Mildly Thick)
  • May not be suitable for patients with poor manual dexterity
  • Milkshakes containing thickener in chocolate and strawberry (£5.88 = 7 sachets)
  • One sachet reconstituted with 200ml full fat milk provides approximately 333kcal and protein 24g
  • Follow instructions on the packet exactly to achieve the correct consistencies
  • Leave for 10 minutes before drinking and consume within 3 hours
Fresubin® Thickened Stage 1 (IDDSI Level 2, Mildly Thick)
  • Lactose free, vanilla, wild strawberry (£2.35 = 200ml)
  • 300kcal, protein 20g, carbohydrate 24.4g, fat 13.4g per 200ml
IDDSI Level 3
Slõ® Drinks Milkshake Stage 2 (IDDSI Level 3, Moderately Thick)
  • May not be suitable for patients with poor manual dexterity
  • Milkshakes containing thickener in chocolate and strawberry (£5.88 = 7 sachets)
  • One sachet reconstituted with 200ml full fat milk provides approximately 333kcal and protein 24g
  • Follow instructions on the packet exactly to achieve the correct consistencies
  • Leave for 10 minutes before drinking and consume within 3 hours
Fresubin® Thickened Stage 2 (IDDSI Level 3, Moderately Thick)
  • Lactose free, vanilla, wild strawberry (£2.35 = 200ml)
  • 300kcal, protein 20g, carbohydrate 24g, fat 13.4g per 200ml

Semi-solid Dessert

IDDSI Level 4
Nutricrem® (IDDSI Level 4, Extremely Thick)
  • Gluten and lactose free dessert, strawberry, vanilla, chocolate orange, mint chocolate (£1.65 = 125g)
  • Starter pack, strawberry, vanilla, chocolate orange (3 x 125g = £4.46)
  • 225kcal, protein 12.5g, carbohydrate 23.5g, fat 9g per 125g
Fresubin® 2 kcal Creme (IDDSI Level 4, Extremely Thick)
  • Gluten and lactose free dessert, vanilla, wild strawberry, cappuccino, chocolate, praline (£2.04 = 125g)
  • 250kcal, 12.5 g protein, 28g carbohydrate, 9.57g fat per 125g

High energy requirement and poor compliance with ready to drink supplements

High energy milk shake powder
Calshake®
  • Powder, 600kcals, 12g protein/ serving (£2.43 = per sachet)

Notes

  1. For disease related malnutrition
  2. For hypoproteinaemia
  3. Needs to be reconstituted with 240ml full cream milk and is not nutritionally complete

Specialist products for specific clinical conditions

There are further specialist ONS available not listed here however the recommendation is that these should

only be prescribed on the advice and recommendation of a dietitian. Patient compliance should be paramount in the product choice.

High energy and High protein milkshake style sip feeds
Fresubin® 2kcal
  • Liquid neutral, vanilla, apricot-peach, toffee, cappuccino, fruits of the forest (£2.02 = 200ml bottle)
  • 400kcal, protein 20g, carbohydrate 45g, fat 15.6g per 200ml
Fresubin® 2kcal fibre
  • Liquid chocolate, lemon, cappuccino, apricot-peach, neutral vanilla (£2.02 = 200ml bottle)
  • 400kcal, protein 20g, carbohydrate 45g, fat 15.6g, fibre 3g (3.2g for chocolate flavour) per 200ml
Higher Protein milkshake style sip feeds
Fresubin® Protein Energy
  • Liquid vanilla, chocolate, tropical fruits, cappuccino, wild strawberry (£2.08 = 200ml)
  • 300kcal, protein 20g, carbohydrate 24.8g, fat 13.4g per 200ml
Fortisip® Compact Protein
  • Liquid neutral, vanilla, strawberry, banana, peach, mango, mocha, berries, and hot tropical ginger (£2.00 = 125ml bottle)
  • 300kcal, protein 18g, carbohydrate 30.5g, fat 11.75g per 125ml

Single Nutrient supplements

Fat based liquid supplement

For conditions requiring fortification with a high fat supplement

  • Not to be used as a sole source of nutrition
  • Recommended dose: 30ml three-four times daily
  • Lactose free, cow's milk protein free
Fresubin® 5kcal Shot
  • Neutral, lemon (£2.85 = 120ml)
  • 600kcal, carbohydrate 4.8g, fat 64.56g, fibre 0.48g per 120ml
Calogen®
  • Unflavoured, strawberry (£4.44 = 200ml)
  • 900kcal, fat 100g per 200ml

Notes

  1. Dose required is dependent on dietitian recommendation

MCT based fat supplement

For patients with fat malabsorption e.g. pancreatic insufficiency, cystic fibrosis,

Liquigen®
  • 4.5kcal/ml unflavoured (£9.39 = 250ml)
  • 1,125kcal, fat 125g per 250ml

Notes

  1. Quantity required is dependent on dietitian recommendation

Carbohydrate based powder supplement

  • Use as an energy enhancer in disease related malnutrition, not to be used as a sole source of nutrition
  • Lactose free, fat free
  • Care when used in diabetics
Maxijul® Super Soluble
  • Powder 3.8kcal/g (£2.64 = 200g)
  • Carbohydrate 0.95g/g

Notes

  1. Dose required is dependent on dietitian recommendation

Liquid Protein supplement

  • For hypoproteinaemia
  • Contains residual lactose
ProSource®
  • Liquid supplement providing 3.3kcal and 0.3g protein/ml (£1.01 = 30ml sachet)
  • Typical dose 2 sachets / day provides 198kcals, 18g protein

Fat and protein liquid supplements

  • Disease related malnutrition, conditions requiring fortification with fat
  • For hypoproteinaemia
Calogen® Extra
  • Emulsion, strawberry, unflavoured (£4.98 = 200ml bottle)

Notes

  1. Dose required is dependent on dietitian recommendation, typically 120ml daily in divided doses. 120ml gives 480kcal and 6g protein.

Disease specific supplements

Anti-inflammatory (Crohn's disease)

Modulen® IBD
  • Powder 100kcals, 3.6g protein/ 100ml reconstituted powder (£15.06 = 400g)
  • Protein 18g, carbohydrate 54g, fat 23g per 100g

Notes

  1. Modulen IBD is a nutritionally complete powdered feed, designed to meet the specific needs of patients with Crohn's disease. It is a palatable whole protein liquid feed which contains a naturally occurring anti-inflammatory factor. A dietitian will need to assess the quantity of Modulen IBD required based on weight, age and activity levels.
  2. Use of exclusive enteral nutrition for the treatment of Crohn's disease should be discussed in conjunction with secondary care specialist teams.

Peptide based ready to drink supplement

Vital 1.5kcal
  • Liquid (£2.98 = 200ml)
  • 300kcal, protein 13.5g, carbohydrate 37.2g, fat 11g per 200ml

Notes

  1. For malabsorption

Amino acid formula

Elemental 028® Extra
  • Liquid, orange and pineapple, grapefruit, summer fruits (£3.68 = 250ml)
  • 215kcal, protein 6.25g, carbohydrate 27.5g, fat 8.75 g per 250ml

 

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