W10 Oral nutrition supplements (ONS) and Gluten Free Foods (GFF) Flashcards
ONS Vs GFF?
- Oral Nutritional Supplements (ONS) – for
the treatment & management of malnutrition
(undernutrition) - Gluten Free Foods – to support the clinical
management of Coeliac disease (CD), Dermatitis Herpetiformis (DH) and other
gluten sensitive enteropathies (NICE NG20)
Diagnosis & Criteria for the prescribing/provision of GFF:
What tests? (3)
Diagnosis via blood tests/biopsy
* Total immunoglobulin A (IgA)
* IgA Tissue transglutaminase antibody
(shortened to tTG)
* Biopsy of intestine - Marsh Scale used to classify severity of intestinal damage
(NB: post covid 19 some adults can be diagnosed without biopsy based on blood results and symptoms
- Gluten-free products should be prescribed for patients diagnosed with gluten-sensitive
enteropathies, including steatorrhoea due to
gluten sensitivity, coeliac disease and dermatitis herpetiformis. - Monthly unit allowance is determined based on age, gender and physical activity/status
Recommended Monthly Unit Allowance
What is this?
Different monthly unit allowance for
* Men
* Women ( +pregnancy)
* Children
+ 4 units for high physical activity levels
Current supply mechanisms to access
gluten free foods in Wales:
What schemes to access this? (2)
- WP10 Prescription
- Gluten Free Subsidy Card Scheme
What are the Gluten Free Foods available on
Prescription via Community Pharmacy?
- All types of bread products
- Flour mixes (except cake mixes)
- Breakfast cereals (with fibre) & oats
- Pasta
- Crackers & crispbreads
- Pizza bases
(England – only bread and flour mixes permitted)
These are ACBS approved (advisory commitee on borderline substances)
Gluten Free Food Provision via Subsidy Card Scheme
- Aim of introduction of the scheme, is to provide consistent approach in the provision of GF products
- ‘Mixed model’ approach - includes an ‘opt in’ subsidy card scheme (as piloted in Hywel Dda), whilst maintaining the availability of GF products via pharmacy where appropriate
- Scheme aims to meet the joint community pharmacy services/NHS/WG policy and transformation agenda (A New Prescription, December 2021)
- Focus on reducing the dispensing of products where CP provides no added clinical value or efficiency
How does the GFF Subsidy Card Scheme work in practice?
- Monthly monetary allowance uploaded onto pre-paid card
- Currently £1 per unit (under review)
- Can be used to purchase GFF foods in retail
outlets, including supermarkets, pharmacies,
online) - Well received by patients
- Positive feedback from GPs and Community
Pharmacies
What should & shouldn’t be purchased with the subsidy card
Should:
* GF flour and pastry mixes
* GF bread
* GF rolls, ciabatta, baguettes, wraps, pitta bread, crumpets
* GF breakfast cereals/oats
* GF noodles
* GF crackers, oatcakes
* GF savoury products e.g. pizza, lasagne, fajita kits, bean burgers, chicken goujons, pies, breaded fish, ready meals
* GF sauces, gravy, stock, stockpots
Shouldn’t:
* Food that is naturally gluten free such as fresh vegetables, fruit, meat, fish and milk
* GF cakes
* GF biscuits
* GF chocolate
* GF alcohol
Oral Nutritional Supplements (ONS) –
What are they?
- ‘Foods for Special Medical Purposes’ (FSMPs)
are specially designed foods to meet the
nutritional/dietary needs of patients living with a disease, disorder or medical condition who are temporarily or permanently unable to achieve an adequate nutritional intake from normal foods and are at risk of malnutrition - Approved by Advisory Committee Borderline
Substances (ACBS) and are listed in the Drug
Tariff
Malnutrition - Diagnosis & Treatment
Provide a basic understanding of the
management of patients classified as
malnourished/at risk, including;
* Defining malnutrition
* Nutritional screening – identifying nutritional risk using validated screening tools
* 1st line management strategies – ‘Food based treatment’
* Oral Nutritional Supplements (ONS) prescribing across the different healthcare
settings
Definition of Malnutrition?
“Malnutrition is a state of nutrition in which a
deficiency or excess (or imbalance) of energy,
protein and other nutrients causes measurable adverse effects on tissue / body form (body shape, size and composition) and function and clinical outcome. (BAPEN 2018)”
Community Setting- What tool is used to assess malnutrition?
- Malnutrition Universal Screening Tool (MUST) - 5 Step
- An online MUST toolkit/calculator is available via BAPEN ‘MUST’ Calculator
|or via app store - Categorises nutritional risk as Low, Medium, High
- Guidance on management of risk, including
patient/carer information sheets
Care Planning & Treatment:
MUST Score 0 = LOW Risk
MUST Score 1 = MEDIUM Risk
MUST Score 0 = LOW Risk
* Routine Care
* Review
Offer first line dietary advice, including food fortification, & encouraging regular meals, 2 x snacks and 2 x nourishing drinks per day for 1 month, and review.
* ONS should not routinely be prescribed first line for these patients
Care Planning & Treatment:
MUST Score of 2 or more = HIGH RISK
Treatment with ONS indicated (exclusions apply)
OR
* Where dietary advice alone is unlikely to achieve an improvement in intake (e.g. in those with a disease-related severely limited appetite)
OR
* Dietary advice & food fortification have been tried for 1 month and there has been no progress towards the goal/s
Appropriate Prescribing of Oral Nutritional Supplements (ONS):
ONS are only eligible to be prescribed where which of the ACBS criteria are met??
What about patients that dont meet the criteria?
To be clinically effective, a daily increase in
how many calories is required?
- Appropriate identification, treatment and
monitoring of nutritional risk is key to ensuring the appropriate initiation/ongoing prescribing. - Short bowel syndrome, Dysphagia, Intractable malabsorption, Pre-operative preparation of undernourished patients, Inflammatory bowel disease, Total gastrectomy, Bowel fistulae Disease Related Malnutrition (DRM)
- Patients who do not meet the criteria should be advised on alternative homemade options or purchase OTC alternatives
- ONS are typically used in addition/to supplement the diet, not as a food/meal
replacement.. - ~ 500-600 kcals per day is required
(Typically 1-2 ONS depending on the nutritional profile of the supplement).
Are ONS the only answer?
- Baldwin & Weekes, Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults (Cochrane Review, 2021)
- States “it is reasonable to presume that any
benefits from ONS reflect their functional
contribution to an increased nutrient intake (or balance of nutrients). - It follows that if a similar increase in nutrient
intake can be achieved by dietary means rather than using ONS, it is reasonable to expect similar clinical benefits.”
ONS – What does the Evidence
Say about their effect on malnutrition?
Overall, the review found little
evidence of oral nutritional supplements having significant effects on reducing malnutrition or its adverse outcomes in frail older adults
‘Food Based Treatment or ‘Food First’
- 1st line treatment to manage patients nutritional risk is referred to as Food Based Treatment or ‘Food First’
- Strategies should be implemented when a
patient scores Medium or High nutritional risk - Food fortification strategies i.e. taking everyday foods, snacks or drinks and making them more nutrient dense without increasing the quantity of food/fluid having to be consumed, alongside a ‘little & often’ approach.
- Challenges in Secondary Care…….
Homemade Fortified Drinks
Examples?
Fortified Milkshake (220ml)
(300kcal & 17g protein)
Ingredients
* 180ml whole milk
* 2 heaped tablespoons (30g)
skimmed milk powder**
* 4 heaped teaspoons (20g)
vitamin fortified milkshake
powder
* Or 5 heaped teaspoon Ovaltine or Horlicks
* Recommended Dose - BD
Fortified Fruit Juice (220ml )
(180 – 250kcal & ~9g protein)
Ingredients
* 180ml pure fruit juice (with
added vitamins) OR
* 40ml undiluted premium
cordial (not sugar
free/diet/NAS)
* 10grams (2 x 5gram sachets)
egg white powder or 80gram
liquid egg white
* Recommended Dose - BD
Oral Nutritional Supplements:
Examples?
Nutricrem, Foodlink complete, Ensure, Fortisip Impact, Cologne, Fresubin, Fortijuice, ActaGain, Fresubin
Secondary V’s Primary Care
& Cost Implications?
- Secondary Care – All Wales Framework
(zero/minimal cost)
DoH England assessing the potential the impact of zero pricing in Secondary Care on NHS budgets –potential for changes to this contracting model - Primary Care – Drug Tariff Prices (WP10)
- Significant cost variation can be seen within and between ONS products with equivalent/similar nutritional profiles
1st Line – Powder Based ONS
Nutritional profile
* ~ 385kcals & ~17g protein when made up
with whole milk
* Recommended dose – BD (One 57g sachet
mixed with 200ml full cream milk).
* Powder based products rely on an individual on the patient having access to milk and the ability (or carer) to make up the shake.
* Cost £0.55p per sachet
* Not typically used in Secondary Care setting
2nd Line Products
Ready To Drink (RTD) Milkshake Style
Nutritional profile
* 300kcals & 12g protein (1.5-2.4 kcal per ml)
* 125ml & 200ml bottles
* Recommended dose – BD
* Cost ~£1.56
OR
* 600kcal & 24g protein (2.4 kcal per ml)
* 250ml bottle
* Recommended dose OD
* Cost £1.60
3rd Line - Juice Style Products
for patients who dislike are unable to tolerate milk
Nutritional Profile
* 300 – 330kcals & 8-12g protein
* 200ml – 220ml bottles/Tetra Pak
* Cost £1.80 - £2.67
* Recommended dose - BD
NB: Juice style supplements should be used with caution for patients with diabetes
