W10 Oral nutrition supplements (ONS) and Gluten Free Foods (GFF)

Question 1

ONS Vs GFF?

Answer 1

• 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)

Question 2

Diagnosis & Criteria for the prescribing/provision of GFF:
What tests? (3)

Answer 2

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

Question 3

Recommended Monthly Unit Allowance
What is this?

Answer 3

Different monthly unit allowance for
* Men
* Women ( +pregnancy)
* Children
+ 4 units for high physical activity levels

Question 4

Current supply mechanisms to access
gluten free foods in Wales:
What schemes to access this? (2)

Answer 4

1. WP10 Prescription
2. Gluten Free Subsidy Card Scheme

Question 5

What are the Gluten Free Foods available on
Prescription via Community Pharmacy?

Answer 5

• 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)

Question 6

Gluten Free Food Provision via Subsidy Card Scheme

Answer 6

• 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

Question 7

How does the GFF Subsidy Card Scheme work in practice?

Answer 7

• 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

Question 8

What should & shouldn’t be purchased with the subsidy card

Answer 8

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

Question 9

Oral Nutritional Supplements (ONS) –
What are they?

Answer 9

• ‘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

Question 10

Malnutrition - Diagnosis & Treatment

Answer 10

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

Question 11

Definition of Malnutrition?

Answer 11

“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)”

Question 12

Community Setting- What tool is used to assess malnutrition?

Answer 12

• 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

Question 13

Care Planning & Treatment:
MUST Score 0 = LOW Risk
MUST Score 1 = MEDIUM Risk

Answer 13

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

Question 14

Care Planning & Treatment:
MUST Score of 2 or more = HIGH RISK

Answer 14

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

Question 15

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?

Answer 15

• 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).

Question 16

Are ONS the only answer?

Answer 16

• 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.”

Question 17

ONS – What does the Evidence
Say about their effect on malnutrition?

Answer 17

Overall, the review found little
evidence of oral nutritional supplements having significant effects on reducing malnutrition or its adverse outcomes in frail older adults

Question 18

‘Food Based Treatment or ‘Food First’

Answer 18

• 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…….

Question 19

Homemade Fortified Drinks
Examples?

Answer 19

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

Question 21

Oral Nutritional Supplements:
Examples?

Answer 21

Nutricrem, Foodlink complete, Ensure, Fortisip Impact, Cologne, Fresubin, Fortijuice, ActaGain, Fresubin

Question 22

Secondary V’s Primary Care
& Cost Implications?

Answer 22

• 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

Question 23

1st Line – Powder Based ONS

Answer 23

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

Question 24

2nd Line Products
Ready To Drink (RTD) Milkshake Style

Answer 24

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

Question 25

3rd Line - Juice Style Products
for patients who dislike are unable to tolerate milk

Answer 25

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

Question 26

When to prescribe ONS?

Answer 26

Only prescribe ONS to treat patients;
* Classified as ‘high’ risk of malnutrition/assessed as being malnourished using a validated nutritional
screening tool i.e. MUST in community (score 2 or more) or alternative validated measures, or WAASP in hospital setting (Exclusions apply)
* Where a prescription request has been received from a Dietitian/Dietetic Support Worker (countersigned by Dietitian) with documentation of clear treatment goals/outcomes and date for F/U and review.

Question 27

What to prescribe?

Answer 27

• Follow the local Health Board prescribing
  guidance and Formulary recommendations
• NB: Recommended ONS products may vary
  between care settings & patients may be
  switched to alternative products at the point of discharge from Secondary to Primary Care
• Dietitians & Dietetic Support Workers may
  request alternative more specialist products to meet the patients individual clinical need