Presentation on theme: "Oral Nutritional Supplements (ONS) to Tackle Malnutrition"— Presentation transcript:
1 Oral Nutritional Supplements (ONS) to Tackle Malnutrition A summary of the evidence baseMedical Nutrition International Industry (MNI)
2 Content What is malnutrition? Identifying malnutrition Prevalence of malnutritionCauses and consequences of malnutritionEconomic consequences of malnutritionBenefits of oral nutritional supplements (ONS)NutritionalFunctionalClinicalEconomic benefitsBenefits of screening for malnutritionRecommendations for action
3 The ‘hidden’ problem of malnutrition “Malnutrition does not show up in the streets in Europe. Instead malnutrition is a hidden health problem residing at home or in care homes”1Management of malnutritionOral Nutritional Supplements (ONS) are an important strategy in nutritional care but there is often poor awareness of the value of nutritional care, especially ONSLjungqvist O & de Man F. Nutr Hosp 2009; 24(3):
4 What is malnutrition?No universally accepted definition of malnutrition, but following definition widely acknowledged (also by ESPEN)1-2:‘Malnutrition’ includes both over-nutrition (overweight and obesity) as well as under-nutritionHere ‘malnutrition’ is used synonymously with under-nutrition and nutritional risk“A state of nutrition in which a deficiency, 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.”Elia M. Maidenhead, BAPEN Lochs H et al. Clin Nutr 2006; 25(2):
5 Identifying malnutrition risk Nutritional screening identifies individuals who:are ‘at-risk’ across the spectrum of nutritional statusare at risk of adverse outcome and whomay benefit clinically from nutritional supportPatients will only benefit from nutritional screening if it results in action* to improve their nutritional care*Unless detrimental or no benefit expected from nutritional support e.g. imminent death.
6 Tools to identify malnutrition risk Practical, validated tools available to screen for risk of malnutritionSpecifically designed for different patient groups and care settingsExamples include:For hospital and community patientsFor older peopleFor adult hospital patientsFor children‘MUST’NRS 2002StrongkidsHowever, they are not routinely used, meaning that malnutrition is often missed
7 Malnutrition goes undetected and untreated Lack of routine screening for malnutrition and its risk factors has meant that the opportunity for early intervention, and prevention, is often missedEven when found, malnutrition is not always appropriately treated : Often less than 50% of patients identified as malnourished receive nutritional intervention1-4Lamb CA et al. Br J Nutr 2009; 102(4): Meijers JM et al. Nutrition 2009; 25(5): van Nie-Visser NC et al. Clin Nutr 2009; 4 Supplement 2: Meijers JM et al. Nutr 2009; 25(5):
8 Mandatory screening shown to lower malnutrition (NL) Decreased prevalence of malnutrition in hospitals and home following introduction of mandatory screening 1Increasing awareness and actively working toward improvement could lower the rate of malnutrition1Screening allows early identification and management with an appropriate care planMalnutrition prevalence rates in hospitals, nursing homes and home care institutions (NL)Meijers JM et al. J Nutr 2009; 139(7):
9 Screening for malnutrition risk - Conclusions Reliable and validated tools for screening are availableBUT screening is still not routinely usedMalnutrition continues to go unidentifiedThe opportunity for early intervention is often missedScreening must result in action if patients are to benefit
10 Prevalence of malnutrition Malnutrition is a major public health concern that frequently goes unrecognised and untreatedPopulation of Europe: > 800 millionAn estimated 33 million people in Europe are at risk of malnutrition11. Ljungqvist O, de Man F. Nutr Hosp 2009; 24:
11 Prevalence of malnutrition in older people Malnutrition is significantly more common in older people1-4; an ageing population will only exacerbate the problem in years to comeAbout 1 in 3 older people in hospital at risk1-7More than 1 in 3 people in care homes atrisk1,6,8-10Around 1 in 3 older people living independently at risk6An estimated 93% of malnourished people live in the community111. Russell C & Elia M. Redditch, BAPEN Russell C & Elia M. Redditch, BAPEN Russell C & Elia M. Redditch, BAPEN Russell C & Elia M. Redditch, BAPEN5. Imoberdorf R et al. Clin Nutr 2010; 29(1): Kaiser MJ et al. J Am Geriatr Soc 2010; 58(9): Vanderweek et al. J Adv Nurs 2011; 67(4): Suominen MH et al. Eur J Clin Nutr 2009; 63(2):9. Lelovics Z et al. Arch Gerontol Geriatr 2009; 49(1): Parsons EL et al. Proc Nutr Soc 2010; 69:E Elia M. & Russell C. Redditch: BAPEN, 2009.
12 Malnutrition is prevalent in hospitals worldwide About 1 in 4 patients in hospital are at risk of malnutrition1-71. Russell C & Elia M. Redditch, BAPEN Russell C & Elia M. Redditch, BAPEN Russell C & Elia M. Redditch, BAPEN Russell C & Elia M. Redditch, BAPEN5. Meijers JM et al. Br J Nutr 2009; 101(3): Imoberdorf R et al. Clin Nutr 2010; 29(1): Schindler K et al. Clin Nutr 2010; 29(5):
13 Prevalence of malnutrition in hospital patients Malnutrition affects people of all agesAlmost 1 in 5 children admitted to hospital at risk11. Joosten KF et al. Arch Dis Child 2010; 95(2):
14 Malnutrition is prevalent across a wide variety of diseases Prevalence of malnutrition risk in hospital by diagnosisRepublic of Ireland n = 1102 (‘MUST’ medium + high risk), UK n = 7521 (‘MUST’ medium + high risk)1, The Netherlands n = 8028 (defined by BMI, undesired weight loss, nutritional intake)2.1. Russell C & Elia M. Redditch, BAPEN Meijers JM et al. Br J Nutr 2009; 101(3):
15 Prevalence of malnutrition - Conclusions Studies across the developed world show that malnutrition is common in patientsin hospitalin care homes andin people who live at homeMalnutrition affects all age groups, including childrenMalnutrition is particularly common in older people
16 Causes of malnutrition Insufficient dietary intakedisability and disease are at the heart of the problemEffects of disease and its treatmentleading to low food intake e.g. poor appetite, swallowing problems and side effects of drugs1Lack of clear responsibilities for health authorities and healthcare staffinadequate training and equipment for screening exacerbates the problem of malnutrition2-3More than 50% of patients in hospital don’t eat the full meal they are given4, and 30% of nursing home residents eat less than half their lunch5, often failing to meet their nutritional needsStratton RJ et al. Wallingford: CABI Publishing; Elia M & Russell C. Redditch, BAPEN Elia M. Redditch, BAPEN Hiesmayr M et al. Clin Nutr 2009; 28(5):5. Valentini L et al. Clin Nutr 2009; 28(2):
17 Factors causing poor food and nutrient intake1 IndividualsPhysical e.g. chewing or swallowing problems, difficulty self-feedingPhysiological e.g. anorexia, feeling full rapidly, nausea, taste changes, painPsychological e.g. confusion, low mood, anxietyInstitutionsLack of nutrition policy or guidancePoor organisation of nutrition servicesLimitations in catering provisionLack of specialist postsHealth care workersLack of recognition of importance of nutritionLack of knowledge and skillsPoor documentation of nutrition informationLack of screening, action and monitoringInsufficient energy and nutrient intake*Disease Related MalnutritionAdapted from Stratton RJ et al. Wallingford: CABI Publishing; 2003.*Requirements for some nutrients may be increased due to malabsorption, altered metabolism and excess losses.
18 Causes of malnutrition - Conclusions The causes of malnutrition are multi-factorialPatient-related factors resulting from disease and disability contribute to low food intakeOrganisational and institutional factors are also involvedA multi-stakeholder approach is needed to identify and implement effective solutions
19 Consequences of malnutrition for individuals Markedly increased morbidity and mortality rates1-2Malnourished patients experience more complications than well nourished patients; the risk of infection is more than three times greater in hospitalised malnourished patients2-3Associated with poorer quality of life1Malnutrition has a particularly high adverse impact in the older person4 impairing function, mobility and independence5Malnutrition has an adverse impact on growth and development in children 1,5Stratton RJ et al. Wallingford: CABI Publishing; Sorensen J et al. Clin Nutr 2008; 27(3): Schneider SM et al. Br J Nutr 2004; 92(1): Stratton RJ et al. Br J Nutr 2006; 95(2):5. Elia M & Russell C. Redditch, BAPEN
20 Malnutrition is associated with increased morbidity Malnutrition is associated with increased morbidity in acute and chronic disease including:Development of pressure ulcers1Poor wound healing1Post-operative complications such as acute renal failure, pneumonia and respiratory failure1Increased risk of infection2Norman K et al. Clin Nutr 2008; 27(1): Schneider SM et al. Br J Nutr 2004; 92(1):
21 Economic consequences of malnutrition Malnutrition increases use of healthcare resourcesHospital patientsIncrease in length of hospital stay1-5Increase in readmission rates4,6Delays in returning home7Community patientsIncreased number of visits to family doctors8,9Increases in hospital admissions and readmissions10,11Increases in length of hospital stay8,9,11Also in children malnutrition is associated with an increased length of hospital stay12-14Leandro-Merhi VA et al. J Parenter Enteral Nutr 2011; 35(2): Pressoir Met al. Br J Cancer 2010; 102(6): Pirlich M et al. Clin Nutr 2006; 25(4): Lim SL et al.Clin Nutr 2011; 31(3): Marco J et al. Clin Nutr 2011; 30(4): Planas M etal. Clin Nutr 2004; 23(5): Nitenberg GM et al. Clin Nutr 2011; 6(Suppl 1): Feldblum I et al. Nutrition 2009; 25(4): Guest JF et al. Clin Nutr 2011; 30(4): Collins PF et al. Proc Nutr Soc 2010; 69:E Cawood AL et al.Proc Nutr Soc 2010; 69:E Secker DJ & Jeejeebhoy KN. Am J Clin Nutr 2007; 85(4): Hulst JM et al. Clin Nutr 2010; 29(1): Joosten KF et al. Arch Dis Child 2010; 95(2):
22 Economic consequences of malnutrition Costs of malnutritionCountryCosts of malnutritionNoteUK1€15 billionPublic expenditure on malnutrition in 2007Germany3€9 billionAdditional costs due to malnutrition across all care sectors in 2003The Netherlands4€1.9 billionAdditional costs due to malnutrition in 2011Republic of Ireland5€1.4 billion1. Elia M & Russell C. Redditch, BAPEN House of Commons Health Committee Cepton. Munich4. Freyer K et al. Clin Nutr Rice N & Normand C. Pub Health Nur
23 Malnutrition and associated diseases increase healthcare costs in the UK In 2003, the estimated UK annual healthcare cost of malnutrition and any associated disease was over €8.4 billion (£7.3 billion*)1These costs can be further broken down:€4.5 billion (£3.8 billion*) due to the treatment of malnourished patients in hospital€3.1 billion (£2.6 billion*) due to the treatment of malnourished patients in long-term care facilities€0.58 billion (£0.49 billion*) from GP visits€0.21 billion (£0.18 billion*) from outpatient visits and€0.18 billion (£0.15 billion*) from nutrition support in the communityElia M & Russell C. Redditch, BAPEN* Calculated based on an exchange rate of £ to € of Source: Interbank ).
24 Malnutrition and associated diseases increase healthcare costs in the UK A further estimated incremental cost of over €6.3 billion (£5.3 billion*), is largely due to1†:More frequent and expensive hospital staysGreater need for long term careThe UK alone spends in excess of €15 billion annually on managing malnourished patients, corresponding to more than 10% of the total spend on health and social care1* Calculated based on an exchange rate of £ to € of Source: Interbank ). † The extra cost of treating all patients in the general population with medium and high risk of malnutrition and associated disease compared with treating the same number of patients with low risk of malnutrition and associated disease.Elia M & Russell C. Redditch, BAPEN
25 Estimated cost of malnutrition across the EU Malnutrition in Europe costs healthcare systemsan estimated €170 billion per year1Ljungqvist O, de Man F. Nutr Hosp 2009; 24:
26 Costs of malnutrition vs. obesity in the UK Estimated UK public expenditure (health and social care):Annual Cost in 2007Disease-related malnutrition€ 15 billion (£13 billion)Obesity€ billion (£ billion)Overweight and obesity€ billion (£ billion)The economic costs of malnutrition are double the economic costs of overweight and obesity1-2*Public expenditure includes social and health care costs. Calculated based on an exchange rate of £ to € of Source: Interbank )Elia M & Russell C. Redditch, BAPEN House of Commons Health Committee. London, The Stationery Office
27 Consequences of malnutrition - Conclusions The adverse consequences of malnutrition are far-reachingMalnutrition is associated with:Increased complicationsGreater risk of infectionsPoor quality of lifeIncreased mortalitySuboptimal growth and development in childrenMalnutrition is associated with increased healthcare resource use and higher costs
28 Management of malnutrition Early identification is key to effective management of malnutritionScreening using validated tools should be routine practiceA range of strategies can be used to manage malnutrition, e.g. dietary advice, oral nutritional supplements, tube feeding or parenteral nutrition (intravenous nutrition)*Based on the ESPEN definition.Lochs H et al. Clin Nutr 2006; 25(2):
29 Benefits of Oral Nutritional Supplements (ONS) ONS are an effective and non-invasive solution to tackling malnutritionNational and international reviews of the evidence, for example NICE, cite ONS as having significant clinical benefits for malnourished patients when compared to standard care1-51. National Institute for Health and Clinical Excellence (NICE). London Milne AC et al. Cochrane Database Syst Rev 2009;(2):CD Milne AC et al. Cochrane Database Syst Rev 2005;(2):CD4. Milne AC et al. Ann Intern Med 2006; 144(1): Avenell A & Handoll HH. Cochrane Database Syst Rev 2010;(1):CD
30 Benefits of Oral Nutritional Supplements (ONS) Proven nutritional benefitsONS increase total energy intake without decreasing food intake and lead to weight gain and prevention of weight loss in patients who are malnourished or ‘at-risk’ of malnutrition in hospital and in community settings1-4Proven functional benefitsONS have proven functional benefits such as improvements in activity, quality of life and independence measures, particularly in older malnourished patients in the community5-111. Stratton RJ et al. Wallingford: CABI Publishing; National Institute for Health and Clinical Excellence (NICE) London, National Institute for Health and Clinical Excellence (NICE). 3. Milne AC et al. Cochrane Database Syst Rev 2009;(2):CD Cawood A et al.Ageing Res Rev 2012; 11(2): McMurdo ME et al.J Am Geriatr Soc 2009; 57(12): Norman K et al.Clin Nutr 2008; 27(1): Rabadi MH et al.Neurology 2008; 71(23): Gariballa S et al. J Am Geriatr Soc 2007; 55(12): Persson M et al. Clin Nutr 2007; 26(2): Parsons EL et al. Clin Nutr 2011; 6(Suppl 1): Stange I et al. Clin Nutr 2011; 6(Suppl 1):128.
31 Benefits of Oral Nutritional Supplements (ONS) Proven clinical benefitsONS have proven clinical benefits; ONS use is consistently linked to lower mortality and complication rates for malnourished patients when compared to standard care1-4, 5, 6Lower complication rates in supplemented vs control patients in hospital11. Stratton RJ et al. Wallingford: CABI Publishing; National Institute for Health and Clinical Excellence (NICE) London, National Institute for Health and Clinical Excellence (NICE). 3. Milne AC et al. Cochrane Database Syst Rev 2009;(2):CD Cawood A et al.Ageing Res Rev 2012; 11(2): Avenell A & Handoll HH. Cochrane Database Syst Rev 2006;(4):CD Stratton RJ et al. Ageing Res Rev 2005; 4(3):
32 Benefits of Oral Nutritional Supplements (ONS) Data on the benefits of dietary counselling and food fortification in the management of malnutrition are lacking; ONS have been shown to be more effective1-5Greater nutrient intakes and fewer complications are seen in patients with hip fractures given ONS compared with food snacks4-6Compliance to ONS is good. Compliance to other methods of oral nutritional intervention need investigation71. National Institute for Health and Clinical Excellence (NICE). London Baldwin C & Weekes CE. Cochrane Database Syst Rev 2011;(9):CD Weekes CE et al. J Hum Nutr Diet 2009; 22: Stratton RJ et al. Proc Nutr Soc 2006;10A. 5. Stratton RJ et al. Proc Nutr Soc 2006; 65:4A. 6. Stratton RJ et al. Clin Nutr 2007; 2 Supplement 2:9. 7. Hubbard GP et al. Clin Nutr 2012; 31(3):
33 ONS reduce mortality in hospital patients Significantly lower mortality rates found in supplemented hospitalised liver disease, orthopaedic, and surgical patients, and hospitalised older people1Represents a 24% reduction in mortalityLower mortality in supplemented versus control patientsp < 0.001; odds ratio 0.61 (95% CI, 0.48 to 0.78), meta-analysis of 11 trials, n = 1965; no significant heterogeneity between individual studiesStratton RJ et al. Wallingford: CABI Publishing; 2003.
34 ONS reduce complications in hospital patients Significantly lower complication rates in supplemented surgical, orthopaedic, elderly and neurology hospital patients1Represents a 56% reduction in complication ratesLower complication rates in supplemented versus control patients in hospitalp < 0.001; odds ratio 0.31 (95% CI, 0.17 to 0.56), meta-analysis of 7 trials, n = 384; no significant heterogeneity between studiesStratton RJ et al. Wallingford: CABI Publishing; 2003.
35 ONS reduce length of hospital stay Reduced length of hospital stay found in patients who received ONS compared with control patients (meta-analysis of 9 trials)Average reductions ranged from 2 days (in surgical patients) to 33 days (in orthopaedic patients)1Stratton RJ et al. Wallingford: CABI Publishing; 2003.
36 ONS reduce hospital readmissions High protein ONS have been shown to reduce hospital readmissions by 30%1Significant reductions in readmissions with ONSCawood AL et al. Ageing Res Rev 2012; 11(2):
37 Financial Benefits of Oral Nutritional Supplements (ONS) in hospital COUNTRYAUTHOR (year)PATIENT GROUPCOST-SAVING* PER PATIENTCOST-SAVING* PER ANNUMHOSPITALDenmarkLassen et al. (2006) 1Medical-€16.4 million (USD 22 million)**The NetherlandsFreijer & Nuijten (2010) 2Abdominal surgery patients€252€40.4 millionUKElia et al. (2005) 3Pooled results from analysis in surgical, elderly and stroke patients€1002 (£849) (bed day costs)€352 (£298) (complication costs)Elia & Stratton (2005) 4Older patients at risk of developing pressure uclers (Stage IV)€543 (£460)Stratton et al. (2003) 5Surgical, orthopaedic, elderly and cerebrovascular accident patients€415-€9651 (£352-£8179)* Calculated based on an exchange rate of £ to € of (Source: Interbank 29/02/2012. ** Calculated based on an exchange rate of USD to € of (Source: Interbank 29/02/2012); based on medical inpatient days.1. Lassen KO et al. BMC Health Serv Res 2006; 6:7. 2. Freijer K, Nuijten MJ. Eur J Clin Nutr 2010; 64(10): Elia M et al. Redditch, BAPEN Elia M, Stratton RJ. Clin Nutr 2005; 24: Stratton RJ et al. Wallingford: CABI Publishing; 2003
38 ONS can reduce medical care costs in community patients - France Evaluation of the economic impact of using ONS among malnourished older people in the community found that intervention with ONS supported clinical and economic advantages including1:Reduction in healthcare utilisationFewer home nursing visitsLess GP and physiotherapist visitsFewer hospital admissionsShorter length of hospital stay with admissionAfter considering the investment required for ONS, the average reduction in medical care costs was €195 per patientArnaud-Battandier F et al. Clin Nutr 2004; 23(5):
39 COST-SAVING* PER PATIENT COST-SAVING* PER ANNUM Financial Benefits of Oral Nutritional Supplements (ONS) in the communityCOUNTRYAUTHOR (year)PATIENT GROUPCOST-SAVING* PER PATIENTCOST-SAVING* PER ANNUMCommunityFranceArnaud-Battandier et al. (2004) 1Malnourished older people (>70 years of age)€195-GermanyNuijten (2010) 2Eligible for ONS due to risk of DRM€234-€257€604-€662 millionThe NetherlandsFreijer & Nuijten (2010) 3Older people (>65 years of age) eligible for ONS due ro DRM€173Nuijten & Freyer (2010) 4€13.3 millionUKCawood et al. (2010) 5Older people (>65 years of age) at high risk of malnutrition€19 million (£16 million)Elia et al. (2005) 6Pre-surgery (elective)*€812 (£688) (hospital bed-day costs)€424 (£359) (excess bed-day costs)* Short-term ONS (about 2 weeks)1. Arnaud-Battandier F et al. Clin Nutr 2004; 23(5): Nuijten M, Mittendorf T. Aktuel Ernahrungsmed 2012; 37: Freyer K, Nuijten M. Value in Health 2010; 13(3):A101 (PH106). 4. Freijer K et al. Front Pharmacol 2012; 3: Cawood AL et al. Proc Nutr Soc 2010; 69:E Elia M et al. Redditch, BAPEN
40 ONS are cost-effective (UK) Cost per quality adjusted life year (QALY) of the use of ONS within the context of a screening program undertaken in older hospital patients: €8,024* (£6,800) based on NICE economic modelling 1This is well below the NICE threshold of €23,599-35,398/QALY (£20-30,000*/QALY) for treatments deemed to be good value for money*Public expenditure includes social and health care costs. Calculated based on an exchange rate of £ to € of Source: Interbank )National Institute for Health and Clinical Excellence (NICE). London
41 Recommendations for action Fundamental prerequisites for successThere must be multi-stakeholder involvement at all levelsAwareness, training and education are central to successAudit and quality improvement activities should be included in any initiative that strives to tackle malnutritionGood practice should be routinely shared
42 Recommendations for action IdentifyingMalnutritionNational nutrition policy addressing under-nutrition as well as obesity/overweightRoutine screening for vulnerable groups built into national nutrition policiesValidated screening tools routinely usedAppropriate equipment (weighing scales, stadiometers) availableAgreement about who is responsible for performing screeningEvidence-based guidance (including nutritional care plans) used to take action following screening and for monitoringPrevalenceCommitment made to systematically measure the prevalence of malnutritionA common approach taken to measuring and documenting malnutrition and risk of malnutrition, enabling comparisons to be madeCausesEvidence based approaches for nutritional care plans should be used taking account of causesConsequencesAwareness raised about the negative consequences of malnutrition for patients, healthcare providers and for societyEvidence based screening programmes used to ensure malnutrition is identified early and appropriate action taken
43 Recommendations for action Benefits of ONSA wealth of evidence is available that demonstrates the benefits of ONS. This should be translated into practice to ensure that patients who need nutritional intervention receive it in a timely and appropriate mannerGuidanceGuidance on managing malnourished patients or patients at risk of malnutrition should reflect current evidence and should provide clear and practical advice about how and when to use different forms of nutritional intervention, including ONSGood PracticeExamples of good practice should be shared widely to facilitate the implementation of nutritional guidelines and ensure best use of resources.
44 NoteThis presentation is based on a report synthesising relevant information on the rationale for and value of ONS to provide stakeholders with an up-to-date and practical summary of the evidence base:This document is an updated version of previous reports prepared in 2009 and A pragmatic approach was used to identify relevant publications and material for inclusion. This document draws on the key elements of a comprehensive systematic review of the evidence base for the management of disease related malnutrition published in It builds on it by adding recent data on the prevalence, causes and consequences of malnutrition as well as the nutritional, functional, clinical and economic benefits of ONS. It now includes new data from outside Europe, as well as data examining the paediatric area.This document includes a unique collation of relevant guidelines relating to ONS, as well as examples of implementation of guidelines and good practice. We recognize there are gaps - either real gaps or due to difficult accessibility of documentation. We hope this will be the starting point to encourage further documentation and sharing of informationTherefore, this report represents work in progress as unpublished data may not be included, trials are ongoing and further guidelines and good practice may be in developmentThe full report is available to download at
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