Guidelines

The Malnutrition and Oral Nutritional Supplement (ONS) Prescribing guidelines are supported by the following summary documents:

This guideline aims to support all health and social care staff in South West London (SWL) who work with patients who are at risk of malnutrition, including those involved in prescribing or recommending a prescription of ONS.

Identification of Malnutrition

To assess their risk of malnutrition, patients should be screened using a validated nutritional screening tool such as the Malnutrition Universal Screening Tool (MUST) or Patients Association Nutrition Checklist. Screening should take place on initial registration at GP practices and when there is clinical concern. Screening should also be considered at other opportunities (for example health check or flu vaccine appointments). Anthropometry such as weight, height and BMI (Body Mass Index) and MUST score should be documented in the patient record.

Assess Underlying Causes of Malnutrition

Once nutritional risk has been established, the underlying cause of malnutrition should be assessed, and the treatment options identified. In addition to medical and pathological reasons, including disease related malnutrition; social and psychological reasons for increased malnutrition risk should be considered. Advice should be provided for relevant services including social services, drug and alcohol groups, community social groups and social prescribing services.

Below is a list of potential underlying causes of malnutrition and suggested actions:

Chronic or acute medical condition

  • May include cancer, Chronic Obstructive Pulmonary Disease (COPD), gastrointestinal conditions, liver or kidney disease or dementia and other neurological conditions.
  • Can cause poor appetite, nausea, disrupt ability to digest food or absorb nutrients, increase nutritional requirements or increase energy expenditure.
  • Suggest GP to review management of condition.

Constipation

  • Can cause abdominal discomfort and poor appetite.
  • Check hydration is adequate, encourage fibre-rich foods and undertake a medication review.

Difficulty swallowing

  • Can cause coughing on eating and drinking or food ‘sticking’ in the throat.
  • Refer to Speech and Language Therapy (SLT) for assessment.

Low mood and anxiety

  • Loneliness, depression, bereavement or isolation can result in poor appetite.
  • Consider GP or mental health review, review social needs, refer to befriending or social prescribing services if available.

Issues with teeth or mouth

  • Poor dentition, badly fitting dentures or a sore or dry mouth can make eating difficult or painful.
  • Check oral hygiene needs are met and consider dentist referral.

Unable to shop, cook or feed self

  • Physical disability or lack of equipment or skills can make it difficult cook or shop for food.
  • Suggest food deliveries, meals-on-wheels or help from friends or relatives. Consider referral to social services or community therapy team.

Financial difficulties

  • Refer to social services, signpost to local charities or food banks if patient unable to purchase sufficient food.

Excess alcohol intake or substance abuse

  • Can lead to reduced food intake, poor food choices, increased nutrient loss through vomiting or diarrhoea, and increased nutrient requirements.
  • Refer to community drug and alcohol services.

Once a patient has been identified as malnourished or at risk of malnutrition, a Food-Based approach should be used as the first-line treatment. This should be trialled for at least 4 weeks prior to considering a prescription for ONS. See Food-Based Resources which can be provided to patients as required.

ONS should only be prescribed for patients who meet all the below criteria:

  • Screened using a validated screening tool e.g. MUST and found to be at high risk of malnutrition or malnourished.
  • Assessed regarding the underlying cause of malnutrition, with appropriate advice and support given to address this.
  • Meets the Advisory Committee on Borderline Substances (ACBS) criteria (listed below).
  • Food-Based approach trialled for at least 4 weeks and not successful in meeting treatment goals.

ACBS Criteria

  • Disease-related malnutrition
  • Short bowel syndrome
  • Pre-operative preparation of patients who are undernourished
  • Continuous ambulatory peritoneal dialysis
  • Haemodialysis
  • Proven inflammatory bowel disease
  • Following total gastrectomy
  • Dysphagia
  • Bowel fistulas

Initially, a sample or starter pack should be provided aiming to establish tolerance and taste preference, to avoid unnecessary medicines waste. Samples can be provided in 2 ways, please select an appropriate method based on local policy:

  • GP practices are encouraged to supply a ‘sample’ via prescription. A starter pack or one week supply of the ONS can be prescribed.
  • Dietitians have the option of utilising free ‘direct-to-patient’ ONS sample services. These are available to order online via the nutritional company websites and can be delivered directly to the patient’s home or care home.

Review the sample pack within one week, identify flavour preference and prescribe an initial 4-week acute prescription of the ONS.

Notes for prescribing:

  • Starter packs of powdered ONS contain a shaker for patient use.
  • Ensure any ongoing prescription is not for a starter pack as these have a higher cost.
  • Choose a maximum of two flavours for ongoing prescribing to reduce dispensing costs.
  • The suggested therapeutic dose for most ONS products is twice daily. Once daily prescriptions should be avoided where possible; these provide 300 to 380 calories per day which can be easily achieved using a Food-Based approach. Exceptions may be made for frail patients with very poor food intake, where a once daily powdered ONS may significantly increase overall nutritional intake; clinical judgement should be utilised.
  • It is rarely necessary to provide more than two bottles of nutritionally complete ONS per day. Any patient who is reliant on ONS as their sole source of nutrition or to provide the majority of their nutrition, should be under the care of a dietitian.
  • To maximise their effectiveness, patients should be advised to take ONS between meals and not before meals or as a meal replacement.
  • Patients should continue to implement a Food-Based approach alongside their ONS prescription.
  • Ensure all anthropometry including weight, height, BMI and MUST score is documented in the patient record to aid reviews.
  • Following initial prescription, ONS should ideally be reviewed after 4 weeks. However, if this is not feasible, a review should take place at least every 3 to 6 months, or more frequently if there is a change in clinical condition. The following areas should be considered during reviews:
    • Weight and MUST score
    • Goals of ONS intervention
    • Tolerance and compliance with the prescribed ONS
    • Progress of care plans to address underlying causes of malnutrition
    • Reinforcement of Food-Based advice
  • During reviews, anthropometry such as weight, BMI and MUST score should be documented in the patient record.
  • If no improvement, a further 4-week acute prescription should be provided. GP Practices should consider referral to local dietetic team if available or seek advice from local Prescribing Support Dietitian if required.
  • Further information for GP Practices on reviewing ONS prescriptions is available in the ‘SWL ONS Prescribing Top Tips’ document which is hosted on GP Teamnet (free registration may be required).
  • When the agreed treatment goals are achieved, ONS should be discontinued. ONS may be reviewed and discontinued by the GP, pharmacist or dietitian. Discontinuation or changes to ONS prescriptions should be communicated clearly by the clinician to the patient, GP and any other healthcare professional involved in the patients’ nutritional care. A dietetic treatment summary should be completed following dietetic assessment and shared with appropriate persons as above.
  • On discontinuing ONS, a review of nutritional risk screening should ideally be provided within one month to ensure there is no recurring problem. Arrangements for review should be detailed by the healthcare professional who discontinued the ONS.
  • If the patient wishes to continue taking ONS although they do not meet prescribing criteria, they can be advised to purchase the ONS over the counter or follow a Food-Based approach.
  • If ONS has not been issued in the last 3 months, it should be removed from the patient’s current prescription screen to help prevent it being re-issued without any reassessment of appropriateness. 
  • Patients can be given ONS Transition from Hospital to Home leaflet for information on what to expect when they are discharged.
  • ONS are often prescribed while in hospital and may be included in the transfer of care document (e.g. discharge drug summary or ‘to take home’ medications); however, ONS is not always required post-discharge. As such, ONS for patients discharged into primary care should be clearly communicated to GP Practices. If no clear communication, the need for ONS prescription should be reviewed in line with local guidance. The patient’s nutritional status should also be reviewed to ensure an appropriate treatment and management plan is in place.
  • Supplements requested to continue in primary care on FP10 prescription should meet the SWL ONS Prescribing Criteria. If the patient does not meet defined criteria, a Food-Based approach should be recommended instead.
  • If the patient meets ONS prescribing criteria, the ONS product prescribed should be in line with the SWL ONS product guidance. ONS should ideally be prescribed on an acute 4-week prescription and reviewed prior to continuation.
  • Non-preferred products should only continue post-discharge if the patient remains under dietetic review or if preferred ONS products are contraindicated or not suitable. This information should be included in discharge communication. Rationale for continuation should be documented in the patient’s consultation notes in the GP Practice.
  • Ideally, the patient will receive a trial of the ONS prior to changing the prescription. If unable to provide the trial in secondary care, advising the GP on a suitable clinically and cost-effective ONS to trial in primary care will support the GP to prescribe in line with SWL Guidelines. It is helpful to advise the patient that their ONS product may change once they are discharged into Primary Care.
  • ONS prescription requests may be received from other healthcare professionals such as District Nurses, Tissue Viability Nurses or Consultants.
  • As outlined above, clear communication must be provided to the GP for all ONS prescription requests.
  • If the patient meets ONS prescribing criteria, the ONS product prescribed should be in line with the SWL primary care ONS product guidance. ONS should ideally be prescribed on an acute 4-week prescription and reviewed prior to continuation. If the patient does not meet the prescribing criteria, a Food-Based approach should be recommended instead.
  • If the request is for a product on the ‘dietitian-only’ list, a suitable product from the preferred list must be prescribed instead.
  • Patients in care homes should be screened for malnutrition on admission and monthly thereafter using a validated screening tool such as MUST. Care Homes have a responsibility to meet CQC regulation 14 ‘Meeting Nutrition and Hydration Needs’.
  • A Food-Based approach should be utilised for all residents at risk of malnutrition. ONS should only be prescribed where there is clear clinical justification.
  • An ONS Prescription Request Form is available for use by care homes. This form can be used to support care homes and GPs in ensuring that patients meet the SWL ONS Prescribing Criteria, and an appropriate product and quantity is prescribed.
  • If ONS is required, powdered ONS should be prescribed unless contraindicated. Inability to prepare powdered ONS should not be used as a contraindication for care home patients as nursing or care staff are able to do this.
  • ONS should be prescribed, like other medications, on an individual patient-named basis and documented in the patients’ drug chart/medications card or electronic record. Care Home staff should be advised ONS must not be provided to a patient if they have not been prescribed the product.

Dysphagia

Patients presenting with dysphagia should be referred to a Speech and Language Therapist (SLT) for specialist assessment, monitoring, intervention and advice. Patients at risk of malnutrition may also be referred to local dietetic teams for specialist advice on a Food-Based approach for texture-modified diets and thickened fluids, and advice on appropriate ONS to prescribe if SWL ONS Prescribing Criteria are met. ONS prescribed should follow recommendations as per the SLT assessment. The International Dysphagia Diet Standardisation Initiative (IDDSI) framework provides a common terminology for describing food textures and fluid thicknesses to improve safety for patients with swallowing difficulties. Adding thickener to powdered or ready-to-drink ONS can be problematic; therefore, it is advised to choose a pre-thickened ONS or a product which is ‘naturally’ the correct IDDSI level. Always follow SLT advice.

Palliative Care

  • Before prescribing ONS in palliative care, consider the patient’s prognosis, treatment plan, and quality of life. Address barriers to intake such as pain, nausea, and constipation.
  • In early palliative care, where patients may live months or years, nutritional screening and support can improve outcomes and reduce complications. If ONS is used, agree on clear goals and review its necessity regularly.
  • In end-of-life care, ONS rarely improves nutrition or extends life; the focus should be on comfort and enjoyment. Focus on ONS can cause distress, so nutritional support should prioritise favoured foods and drinks to maximise quality of life.
  • An information leaflet is available to share with carers or relatives as required: Carer Information: Eating and Drinking at End of Life.

Diabetes

Malnutrition risk should be reviewed with dietary advice aiming to optimise both nutritional status and diabetic control; however treatment of malnutrition may take priority over optimising blood glucose control depending on the diagnosis, prognosis and degree of malnutrition. ‘Juice’-based ONS should not routinely be prescribed for patients with diabetes. Instead, milk-based or savoury ONS are preferable due to their lower Glycaemic Index. Following prescription of ONS or a significant change in oral intake, blood glucose levels may need to be monitored more closely, and diabetes medications reviewed to accommodate changes in nutrition.

Renal Patients

Dependant on Chronic Kidney Disease (CKD) stage and treatment, malnutrition can be a significant problem for renal patients. When treating malnutrition, consideration needs to be given to the stage of CKD and the presence of any fluid or electrolyte imbalances. Muscle atrophy is a significant consequence at CKD stage 5 on dialysis and nutrition support often focuses on high-energy, high-protein interventions. However, in CKD stage 4 the focus is on high-energy and protein intake may need to be restricted. Due to the above complications, a Food-Based approach is not always appropriate. Similarly, preferred ONS may not meet patients’ nutritional needs and specialist ONS products may be required. Renal patients may be under the care of a specialist dietitian; check recent correspondence and liaise with dietitian as required prior to making any changes to a patient’s ONS prescription.

Vitamin K and Warfarin

For patients on Warfarin therapy, inconsistent intakes of Vitamin K can affect INR (International Normalised Ratio) levels and the way that Warfarin works. Therefore, it is important to aim to have a consistent intake of Vitamin K on a daily basis. ONS contain varying levels of Vitamin K and nutritional companies will be able to provide details of this if necessary. Patients who commence, change or stop ONS whilst on Warfarin therapy should be advised to discuss this with their GP or appropriate healthcare professional. INR levels may need to be checked more often or Warfarin dose adjusted.

Substance Misuse

  • This patient group may have a range of nutrition-related problems such as poor appetite, weight loss, nutritionally inadequate diet, constipation and dental decay. Therefore, advice on diet and nutrition should be given, especially if drinking heavily.
  • Substance misuse (alcohol and drug abuse) is not a specified ACBS indication for ONS prescription. The Department of Health recommends that this patient group should only receive ONS if there are clear medical reasons.
  • Prescribing ONS in this patient group can be problematic. ONS may be difficult to stop as the following issues can occur:
    • ONS may be taken instead of meals, therefore providing no benefit.
    • They may be sold on as a source of income.
    • Prescriptions can be difficult to review due to poor appointment attendance.
  • ONS should not be prescribed for substance misuse unless all the following criteria are met:
    • BMI less than 18.5kg/m2
    • and there is evidence of significant weight loss (more than 10%)
    • and there is a co-existing medical condition which could affect weight or food intake
    • and a Food-Based approach has been trialled
    • and the patient is in a rehabilitation programme (e.g. methadone or alcohol programme) or on the waiting list to enter a programme
  • If ONS is initiated:
    • The patient should be assessed by a dietitian. If they fail to attend on two consecutive occasions, ONS should be discontinued.
    • The dose prescribed should be no more than twice daily.
    • Do not put on repeat prescription.
    • Prescribed on a short-term basis only (i.e. 1 to 3 months).
    • If there is no change in weight after three months, ONS should be reduced and discontinued.
    • If goals of treatment are achieved, reduction and discontinuation of ONS will be negotiated.
  • If the patient does not meet the criteria, recommend a Food-Based approach instead.

First-Line Treatment

Food-Based Approach

A Food-Based approach should be trialled for at least 4 weeks prior to considering a prescription of ONS. A Food-Based approach can include the following strategies:

  • Homemade Nutritious Drinks such as fortified milk or milkshakes.  
  • High-Energy High-Protein products available at supermarkets. 
  • Food Fortification (using nutrient-dense ingredients to add extra calories, protein, vitamins and minerals to your food).
  • Nutritious Snacks. 

Please see Food-Based Resources for further information. The resources can be shared with patients and carers as required, including via AccuRx. Contact your local ICB Dietitian or Pharmacist for an example AccuRx message that can be uploaded in GP Practices.

Second-Line Treatment

Prescription of Powdered ONS

Powdered ONS is the preferred choice unless contraindicated. Contraindications include:

  • Limited dexterity and inability to prepare
  • Poor home hygiene or no facilities to prepare
  • Under 6 years of age
  • Galactosaemia
  • Enteral feeding tubes
  • Long-term use as a sole source of nutrition.
  • Patients with advanced renal disease or those who require texture-modified fluids due to dysphagia should be assessed by a dietitian prior to prescribing ONS. Seek dietetic advice if unsure.
Preferred Powder ONS
Foodlink Complete Powder®:
  • Available as 57g sachets (7 sachets per pack) or 1596g tub.
  • Provides 383kcal and 19g of protein per serving (57g mixed with 200ml full-fat milk).
  • Suggested dose: 57g twice daily.
  • Total volume to prescribe for 28 days: 56 sachets (8 packs) or 3,192g.
  • Flavours: banana, chocolate, natural, strawberry and vanilla
  • IDDSI level 0*.
  • Suitable for vegetarian diets. Not suitable for vegan diets. Halal certified. Not Kosher certified however does not contain any ingredients forbidden in the Kosher diet. Contains soya and lactose; does not contain gluten or nuts.
Aymes Shake Powder®:
  • Available as 57g sachets (7 sachets per pack) or 1600g tub
  • Provides 383kcal and 19g protein per serving (57g mixed with 200ml full-fat milk).
  • Suggested dose: 57g twice daily.
  • Total volume to prescribe for 28 days: 56 sachets (8 packs) or 3,200g.
  • Flavours: banana, chocolate, ginger, natural, strawberry and vanilla.
  • IDDSI level 0*.
  • Suitable for vegetarian diets. Not suitable for vegan diets. Not Halal or Kosher certified however does not contain any ingredients forbidden in the Halal or Kosher diet. Contains soya and lactose; does not contain gluten or nuts.
Milk-Free Powder ONS

‘Juice’-style option for patients who cannot tolerate or dislike milk or follow a vegan diet.

Aymes ActaSolve Smoothie®:
  • Provides 297kcal and 11g protein per serving (66g sachet mixed with 150ml water).
  • Suggested dose: 66g sachet twice daily.
  • Total volume to prescribe for 28 days: 56 sachets or 3,696g (8 packs).
  • Available in mango, peach, pineapple, and strawberry & cranberry flavours.
  • IDDSI level 2*.
  • Suitable for vegan and vegetarian diets. Not Halal or Kosher certified however does not contain any ingredients forbidden in the Halal or Kosher diet. Contains soya; does not contain lactose, gluten or nuts.
Foodlink Smoothie®:
  • Provides 287kcal and 10g protein (66g sachet mixed with 150ml water).
  • Suggested dose: 66g sachet twice daily.
  • Total volume to prescribe for 28 days: 56 sachets or 3696g (8 packs).
  • Flavours: orange & mango, red berry, peach and tropical.
  • IDDSI level 1 to 2*.
  • Suitable for vegan and vegetarian diets. Halal certified. Not Kosher certified however does not contain any ingredients forbidden in the Kosher diet. Contains soya; does not contain lactose, gluten or nuts.

Third-Line Treatment

Prescription of Ready-to-Drink ONS

To be prescribed only if powdered ONS are contraindicated or not tolerated.

Preferred Ready-to-Drink ONS
Altraplen Energy®:
  • Provides 300kcal and 12g of protein per serving (200ml carton).
  • Suggested dose: 200ml carton twice daily.
  • Total volume to prescribe for 28 days: 56 cartons or 11,200ml.
  • Flavours: banana, chocolate, strawberry and vanilla.
  • IDDSI level 0 to 1*.
  • Suitable for vegetarian diets. Not suitable for vegan diets. Not Halal or Kosher certified however does not contain any ingredients forbidden in the Halal or Kosher diet. Contains soya; does not contain gluten, lactose or nuts.
Aymes Actagain 1.5 Complete®:
  • Provides 300kcal and 14g of protein per serving (200ml carton).
  • Suggested dose: 200ml carton twice daily.
  • Total volume to prescribe for 28 days: 56 cartons or 11,200ml.
  • Flavours: banana, chocolate, strawberry and vanilla.
  • IDDSI level 0 to 1*.
  • Suitable for vegetarian diets (except strawberry flavour). Not suitable for vegan diets. Not Halal or Kosher certified however does not contain any ingredients forbidden in the Halal or Kosher diet (except strawberry flavour which is not suitable). Does not contain soya, gluten, lactose or nuts.
Juice-Style Ready-to-Drink ONS:

For patients who cannot tolerate or dislike milk. Should not routinely be prescribed for patients with diabetes.

Aymes Actagain Juce®:
  • Provides 300kcal and 10g protein per serving (200ml carton).
  • Suggested dose: 200ml carton twice daily.
  • Total volume to prescribe for 28 days: 56 cartons or 11,200ml.
  • Flavours: apple, berry, exotic fruit, orange, peach.
  • IDDSI level 0*.
  • Suitable for vegetarian diets. Not suitable for vegan diets. Not Halal or Kosher certified however does not contain any ingredients forbidden in the Halal or Kosher diet (except strawberry and blackcurrant flavours which are not suitable). Does not contain soya, gluten, lactose or nuts.
Fortijuce®:
  • Provides 300kcal and 8g protein per serving (200ml bottle).
  • Suggested dose: 200ml bottle twice daily.
  • Total volume to prescribe for 28 days: 56 bottles or 11,200ml.
  • Flavours: apple, orange, strawberry and tropical.
  • IDDSI level not known.
  • Suitable for vegetarian diets. Not suitable for vegan diets. Halal and Kosher certified. Does not contain soya, gluten, lactose or nuts.

*International Dysphagia Diet Standardisation Initiative (IDDSI) levels are reported by manufacturers and correct at time of publication. For the most up to date information and details on how flow testing was completed, please see manufacturers’ websites.

The below products should be prescribed on recommendation of a Dietitian only, and clear clinical justification should be given in the prescription request communication. Dietitians are uniquely skilled to be able to complete a thorough nutritional assessment and identify when these specialist products are needed to meet nutritional requirements. Dietitians should ensure their product choice is both clinically and cost-effective.

Powdered ONS:

Note for dietitians: preferred powdered products from the ‘second-line treatment’ section should be used where possible.

Aymes ActaSolve® High Energy

Calshake®

Complan® Shake

Enshake®

Ensure® Shake

Foodlink® Extra

Fresubin® Powder Extra

Scandishake® Mix

Milkshake-Style Ready-to-drink ONS:

Note for dietitians: preferred ready-to-drink products from the ‘third-line treatment’ section should be used where possible.

Ensure® Plus Milkshake

Ensure® TwoCal

Fortisip® Bottle

Fresubin® Energy

‘Juice’-Style ONS:

Note for dietitians: preferred juice/smoothie style products from the ‘second-line treatment’ and ‘third-line treatment’ sections should be used where possible.

Altrajuce®

Ensure® Plus Juce

Fresubin® Jucy

Savoury-Style ONS:

Aymes ActaSolve® Savoury

Compact-Style ONS:

Note for dietitians: patients’ hydration status should be considered when recommending a prescription of a compact ONS. Clinical rationale for a low volume and nutritionally dense product should be provided in the prescription request letter, e.g. patient is on a fluid restriction.

If recommending two compact products per day, it should be considered whether one ‘once-a-day’ ONS can be used instead as a more cost-effective option.

Altraplen Compact®

Aymes® Shake Compact Powder

Ensure® Compact

Foodlink® Complete Compact Powder

Fortisip® Compact

‘Once-A-Day’ ONS:

Altraplen Compact Daily®

Aymes Actagain® 2.4 Daily

Plant-Based ONS:

Aymes Actagain® 1.5 Plant Power

Fortisip® PlantBased 1.5kcal

Higher Protein ONS:

Note for dietitians: consider using preferred powder ONS from the ‘second-line treatment’ section which contain 19g protein per sachet.

Altraplen Protein®

Aymes ActaGain® 2.0

Aymes ActaGain® 2.4

Aymes ActaSolve® Protein Compact Powder

Ensure® Plus Advance

Fortisip® 2kcal

Fortisip® Compact Protein

Fortisip® Extra

Fresubin® Pro Compact

Yogurt-Style ONS:

Fresubin® YoDrink

Fibre-Containing ONS:

Note for dietitians: consider providing dietary advice using fibre-rich foods instead of prescribing fibre-containing ONS.

Aymes Actagain® 2.0 Fibre

Aymes® Shake Fibre

Ensure® Plus Fibre®

Foodlink Complete with Fibre®

Fortisip® Compact Fibre

Fresubin  2kcal Fibre Drink

Fresubin® Energy Fibre

Resource® 2.0 Fibre

Pre-Thickened ONS for Dysphagia:

Note for dietitians: consider using preferred powder ONS or other cost-effective alternatives when manufacturers specify the appropriate ONS IDDSI level.

Fresubin® Thickened Level 2

Fresubin® Thickened Level 3

Nutilis Complete Crème Level 3®

Nutilis Complete Drink Level 3®

Nutilis Fruit Level 4®

Pudding Style ONS:

Note for dietitians: should only be used for patients with dysphagia.

Aymes® ActaCal Crème

Aymes ActaSolve® Delight

Fresubin® 2kcal Crème

Fresubin® YoCreme

Nutricrem®

Specialist ONS:

Elemental 028 Extra Liquid®

Elemental 028 Extra Powder®

Modulen® IBD

Peptamen Vanilla Bottle®

Peptisip Energy HP®

Survimed OPD 1.5kcal Drink®

Vital® 1.5

Modular ONS:

Note for dietitians: consider whether food fortification using energy, protein or fibre rich foods can be utilised instead of prescribed modular ONS.

SWL ICB does not support prescribing of Calogen® for the routine management of malnutrition. See SWL Position Statement on the Prescribing of Calogen for details.

Energy and Protein Fortifiers:

Altrashot®

Calogen Extra®

Calogen Extra Shot®

Pro-Cal Shot®

High Protein Fortifiers:

Aymes Actagain Protein Shot®

ProSource Jelly®

ProSource Liquid®

ProSource Plus®

Renapro Shot®

Energy Fortifiers:

Calogen® (see position statement for further information)

Fresubin 5kcal Shot®

Fibre Fortifiers:

HyFiber® Liquid

Optifibre® Powder

In line with the NHS’s commitment to deliver net zero healthcare, prescribers should consider the environmental impact of ONS and involve patients in discussions to raise awareness in the population.

ONS will have environmental impact through:

  • The carbon cost of production.
  • The carbon cost of transportation (many products are manufactured overseas).
  • Disposal: packaging and the challenge of recycling.
  • Disposal: wastage of nutrient dense product and impact on sewage system and water quality.

The most environmentally sustainable way to address issues of poor appetite and weight loss is a Food-Based approach.

Overall recommendations are therefore as follows:

  • Where clinically appropriate, avoid prescribing ONS and instead issue Food-Based advice.
  • If a prescription is issued, it is considered that preferred powdered ONS have a lower environmental impact overall through lower carbon costs in transportation and the use of UK milk in reconstituting.
  • Patients should be encouraged to recycle in line with guidance from the manufacturers and local authorities.
  • There is likely over-prescribing of ONS, review prescriptions and stop when no longer clinically indicated.

References

Guideline approved by Integrated Medicines Optimisation Committee (IMOC) October 2025.