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        Malnutrition and oral nutritional supplements – a 360° approach to understanding management and compliance
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Malnutrition is often the cause or the consequence of ill health(1). BAPEN (2009) reports that care pathways for the identification and treatment of malnutrition are complex and often knowledge of the condition is poor among health-care professionals (HCP)(2), many of whom have not received training in nutrition. Oral nutritional supplements (ONS) can play a key role in the management of malnutrition, and yet compliance is often perceived as poor.

Two complementary studies that examine different aspects of compliance with ONS were conducted. The first study set out to establish factors affecting compliance in the United Kingdom from both a HCP and a patient/caregiver perspective. The second study examined the effects of sensory attributes of ONS on preference and compliance.

In study 1, qualitative interviews were conducted with HCP (n 9, 6 dietitians, 2 district nurses and 1 GP). Subsequent 360° focus group sessions involving patients (n 7), caregivers (n 8) and HCP (n 4) gave insights on ONS compliance from the patient/caregiver perspective, with HCP providing interpretation and feedback. Six further one-to-one interviews were conducted with 2 patients, 3 carers and 1 pharmacist.

In study 2, 174 individuals (85 men, 89 women, aged ≥50 years) living independently and not receiving ONS took part in a blinded study in which they received two full units each day of an ONS drink. A different product was tasted each day over a consecutive 5-d period. Evaluation of sensory attributes was by daily self-administered questionnaires and a face-to-face interview at the end of the study period.

In study 1, factors that HCP cited as affecting compliance were (1) the duration and frequency of ONS, (2) the HCP's view of the palatability of the ONS, (3) patients/carers' poor understanding of the role of ONS in improving health outcomes and (4) inconsistent follow-up. The patient/caregiver focus groups also cited reasons (3) and (4) in addition to lack of patient/caregiver awareness of the need for, or willingness to, arrange a follow-up ONS prescription.

In study 2, taste, mouthfeel, aftertaste, aroma and appearance were all identified as key sensory factors for determining ONS preference (P<0.05). In terms of compliance, participants claimed they could consume more units of the supplement rated highest for sensory attributes (2.2 units/d).

A 360° approach (i.e. involving patients, caregivers and HCP) identified the importance of training, education, goal setting, follow-up and the sensory attributes of ONS in improving patient motivation and compliance. These factors are key for both the duration and frequency of ONS consumption. Tailored education for both patients/carers and HCP could help to improve understanding of the clinical value of ONS.

1.NICE Clinical Guideline 32. Nutrition support in adults: Oral nutrition support, enteral tube feeding and parenteral nutrition. February 2006.
2.Advisory Group on Malnutrition, led by BAPEN (2009) Combating Malnutrition: Recommendations for Action [M Eliaand CA Russell editors]. Worc, UK: BAPEN.