Split Doses and Compliance

November 16, 2020 5 min read

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:

●     Serve ONS chilled or add ice cubes. 

●     Offer a variety of flavours. New flavours such as AYMES ActaGain 2.4 Complete Maxi offer patients more variety and choice to help overcome taste fatigue.

●     Offer ONS between meals, rather than at mealtimes.

●     Use high energy, low volume ONS (for patients with low appetite/struggling with compliance).

●     Offer high energy, low volume ONS in smaller amounts, more frequently. Consider using our new AYMES dosage cup to help patients to split their ONS into smaller servings.

●     Involve the patient in decision making.


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.  


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