Tackling undernutrition through appropriate supplement prescribing

Reasons for and against Nutritional Interventions. An Exploration in the Nursing Home Setting

Malnutrition (MN) is widespread in nursing homes. Sometimes, but not always, nutritional interventions (NIs) are made, and the reasons for or against NIs are unknown. The aim of this cross-sectional study was to describe these reasons for residents with and without MN according to nurses’ subjective judgement and according to objective signs of MN. The nutritional status of 246 nursing home residents was subjectively judged by nurses (MN, at risk of MN, no MN) and objectively assessed by body mass index (BMI), weight loss (WL), and low food intake. NIs (enriched meals and/or oral nutritional supplements) were recorded using a standardized questionnaire, and nurses’ main reasons for (not) giving NIs were obtained in an open question. Of the residents, 11.0% were subjectively malnourished, and 25.6% were at risk of MN; 32.9% were malnourished according to objective criteria. Overall, 29.7% of the residents received NIs, 70.4% of those with MN as assessed by the nurses, 53.0% of those with objective MN, and 11.0% and 18.0% of non-malnourished residents, respectively. Reasons for NIs most often stated were low intake (47.9%), WL (23.3%), and low BMI (13.7%). Reasons against NIs mostly mentioned were adequate BMI (32.9%) and sufficient intake (24.3%). The lack of NIs for residents with MN was partially—but not always—explained by valid reasons. As residents without MN frequently received NIs, criteria for both MN rating and providing NIs, require closer scrutiny.

Use of Oral Nutrition Supplements In Long-term Care Facilities

Purpose: Practices related to oral nutrition supplement (ONS) use were examined in elderly people living in longterm care (LTC) facilities.

Methods: Thirteen LTC facilities within a large regional health authority participated, and 17 people responsible for prescribing ONS in their facilities were interviewed, using a key informant telephone survey. A survey on ONS practice wasmodified, pilot tested, and used.

Results:Oral nutrition supplements were primarily prescribed by nursing staff (59%), followed by physicians, registered dietitians, or other staff; ONS use was prescribed for decreased intake, unintentional weight loss, or wound healing. Various ONS products (e.g., Ensure, Boost, or Resource 2.0) were prescribed. Only 18% of respondents reported using alternative food options first to supplement nutritional intake, before introducing ONS. In terms of follow-up and evaluation, the measures of improvement included weight gain, wound healing, or improved well-being; reasons for discontinuation included weight gain, increased intake, or death.

Conclusions: Within LTC settings, the prescription and monitoring of ONS vary considerably. Evidence-based guidelines for the prescription and monitoring of ONS and for the use of a food-first strategy should be developed, implemented, and evaluated to optimize the nutritional health of the elderly in LTC facilities.

Enteral Formulary Management: A Cost-effective Approach

Although enteral formularies emerged over 30 years ago, their effectiveness remains to be clearly demonstrated. Enteral formulary (EF) development has occurred over 17 years at the Toronto Rehabilitation Institute (Toronto Rehab), and a historical account is available in the literature. At Toronto Rehab, the creative process begins with a review of specific nutrition support requirements for each patient population, which is coupled with a clinical decision-making algorithm to promote standardized clinical nutrition practices and selection of products. The requirements are translated into detailed product specifications for a streamlined array of oral and tube-feeding formulae. Despite outsourced food service systems, the feasibility of simple in-house production should be considered to help curtail overall costs. The promotion of consistent practices requires nutrition support guidelines, including indications and contraindications for each EF product. Competitive bidding practices and policies that scrutinize non-formulary requests and encourage automatic substitution for non-formulary products promote formulary adherence and contain costs. Ongoing evaluation is intended to capture changes in patient populations and product availability to target opportunities for future EF revisions.

Evidence-based strategies for the use of oral nutritional supplements

Prescribable oral nutritional supplements are commonly used as a method of nutritional support in the prevention and treatment of malnutrition in adults. There is growing evidence to suggest that when used appropriately in treatment plans, individuals receiving them will benefit from functional and clinical improvements. The use of supplements in the community has increased over the last decade and questions about the increasing costs and efficacy of the products are often raised within health-care communities. The development of guidelines and protocols for the use of supplements in the community that are based on evidence of need and indicate a clear pathway of care, together with intended benefit, should help to address the issues of costly, inappropriate prescribing.