Split Doses and Compliance

Oral nutritional supplements (ONS) are a clinically and cost-effective way to manage disease-related malnutrition (1, 2, 3). In adults with or at risk of malnutrition, clinical benefits are often seen with 300-900kcal/day (e.g. 1-3 ONS servings per day) (4). However, ONS are only effective when they are consumed. The volume of ONS served is one important factor which has been found to have an influence on compliance. This article explores the evidence base for split doses of ONS and patient compliance.

Patient Compliance

Patient compliance has been described as when “patients consume a high percentage of what is prescribed in order to meet their nutritional requirements and keep wastage to a minimum” (5). Many factors influence ONS compliance. These include volume, variety (flavour and form of ONS) and energy density of ONS as well as the patient’s age (5, 6). 

Compliance can also be altered by:

• Reduced taste/smell function (7)
• Dysphagia (5)
• Functional capacity (8)
• Health status (9)
• Gastrointestinal symptoms (10) 
• Taste fatigue; which tends to occur when ONS are consumed regularly over a prolonged period (11)

Volume Matters

A systematic review of 46 studies across a range of settings reported greater compliance with high-energy, low volume ONS (> 2 kcal/ml), compared to standard ONS (5). Furthermore, an observational study of 108 patients showed that high energy, low volume ONS resulted in higher rates of compliance in acutely ill older inpatients (12). 

It is important to offer flexible serving sizes for patients struggling with ONS volume or compliance. Evidence has shown that when high energy ONS are taken in smaller doses (62ml) compliance may improve, especially in patients with reduced appetite (13). This randomised controlled trial (RCT) examined the effects of offering ONS with medication rounds, in varying volumes. A total of 234 malnourished inpatients were randomised into three groups; 

1. Usual care: offered 125ml of ONS twice a day, between meals
2. Intervention 1: offered 125ml ONS twice a day, an hour before meals, together with prescribed medication (if any)
3. Intervention 2: offered 62ml ONS four times a day together with prescribed medication (if any). 

No differences in compliance were seen between the “usual care” group and “intervention 1” (i.e. there was no difference whether patients received higher volumes of ONS in between meals or during medication rounds). However, more patients consumed their ONS when offered smaller volumes (62ml), four times a day together with prescribed medication (13).

Flexible ONS Serving Options

As mentioned above, the evidence suggests that patients are more likely to consume high energy, low volume ONS.AYMES ActaGain 2.4 Complete Maxi is an innovative, one-a-day ONS that allows for flexible serving options, especially for patients who struggle with volume or compliance due to reduced appetite. 

It provides 480 calories and 19.2g protein per 200ml bottle and is available in a range of flavours including strawberry and vanilla, as well as the new banana flavour; launched this month. 

To support patients with measuring their AYMES ActaGain 2.4 Complete Maxi into smaller servings, AYMES have introduced a new dosage cup which is contained in all Starter Packs from November onwards. 

Practical Tips to Improve Compliance

Here are some helpful tips to help improve ONS compliance:

Summary

ONS are a clinically and cost-effective way to manage disease-related malnutrition. ONS are only effective, however, when they are consumed. There are a number of factors that affect compliance to ONS, including taste fatigue, health status, functional capacity and ONS volume.

Evidence suggests that patients are more likely to consume high energy, low volume ONS. Furthermore, an RCT has shown that when high energy ONS are taken in smaller doses (62ml) compliance may improve, especially in patients with reduced appetite.

In conclusion, high energy, low volume ONS can be useful for improving compliance. It is important to offer flexible serving sizes for patients struggling with ONS volume or compliance. Using a dosage cup to split ONS dosages into smaller servings throughout the day may help to further improve compliance.  

References 

1. Seguy D, Hubert H, Robert J, Meunier JP, Guérin O, Raynaud-Simon A. Compliance to oral nutritional supplementation decreases the risk of hospitalisation in malnourished older adults without extra health care cost: Prospective observational cohort study. Clin Nutr. 2020;39(6):1900–7.
2. Elia M, Normand C, Laviano A, Norman K. A systematic review of the cost and cost effectiveness of using standard oral nutritional supplements in community and care home settings. Clin Nutr [Internet]. 2016;35(1):125–37. Available from: http://dx.doi.org/10.1016/j.clnu.2015.07.012
3. Parsons EL, Stratton RJ, Cawood AL, Smith TR, Elia M. Oral nutritional supplements in a randomised trial are more effective than dietary advice at improving quality of life in malnourished care home residents. Clin Nutr [Internet]. 2017;36(1):134–42. Available from: http://dx.doi.org/10.1016/j.clnu.2016.01.002
4. Malnutrition Pathway (2017). Managing Malnutrition: Including a Pathway for Appropriate Use of ONS. Accessed online:www.malnutritionpathway.co.uk/library/managing_malnutrition.pdf (Accessed Oct 2020)
5. Hubbard GP, Elia M, Holdoway A, Stratton RJ. A systematic review of compliance to oral nutritional supplements. Clin Nutr [Internet]. 2012;31(3):293–312. Available from: http://dx.doi.org/10.1016/j.clnu.2011.11.020
6. Regan E, O’Neill GJ, Hutchings SC, O’Riordan D. Exploring how age influences sensory perception, thirst and hunger during the consumption of oral nutritional supplements using the check-all-that-apply methodology. Food Qual Prefer [Internet]. 2019;78(July):103736. Available from: https://doi.org/10.1016/j.foodqual.2019.103736
7. Darmon P, Karsegard VL, Nardo P, Dupertuis YM, Pichard C. Oral nutritional supplements and taste preferences: 545 days of clinical testing in malnourished in-patients. Clin Nutr. 2008;27(4):660–5.
8. Ginzburg Y, Shmilovitz I, Monastyrsky N, Endevelt R, Shahar DR. Barriers for nutritional care in the transition from hospital to the community among older patients. Clin Nutr ESPEN [Internet]. 2018;25:56–62. Available from: https://doi.org/10.1016/j.clnesp.2018.04.004
9. Hogan SE, Solomon MJ, Carey SK. Exploring reasons behind patient compliance with nutrition supplements before pelvic exenteration surgery. Support Care Cancer. 2019;27(5):1853–60.
10. Lidoriki I, Schizas D, Mylonas K, Frountzas M, Mastoraki A, Pikoulis E, et al. Oral Nutritional Supplementation Following Upper Gastrointestinal Cancer Surgery: A Prospective Analysis Exploring Potential Barriers to Compliance. J Am Coll Nutr [Internet]. 2020;0(0):1–7. Available from: https://doi.org/10.1080/07315724.2020.1723453
11. Galaniha LT, McClements DJ, Nolden A. Opportunities to improve oral nutritional supplements for managing malnutrition in cancer patients: A food design approach. Trends Food Sci Technol. 2020;102(May):254–60.
12. Lombard K, van Steijn J, Schuur T, Kuhn M, Rouws C, Huinink EL, et al. Compliance of energy-dense, small volume oral nutritional supplements in the daily clinical practice on a geriatric ward — An observational study. J Nutr Heal Aging. 2014;18(7):649–53.
13. van den Berg GH, Lindeboom R, van der Zwet WC. The effects of the administration of oral nutritional supplementation with medication rounds on the achievement of nutritional goals: A randomized controlled trial. Clin Nutr [Internet]. 2015;34(1):15–9. Available from: http://dx.doi.org/10.1016/j.clnu.2014.04.011