International expert consensus: Here are the answers to 22 clinical questions about oral nutritional supplements

Malnutrition is a common challenge faced by the global healthcare industry, especially among chronic disease patients and the elderly population, which is closely related to prolonged hospitalization, increased complications, functional decline, and increased mortality. **Oral nutritional supplements (ONS) are an important component of medical nutrition therapy, but there has been a lack of internationally unified guidance on how to use them in a standardized manner in clinical practice. Recently, an international Delphi consensus study led by the Türkiye Society of Clinical Parenteral and Enteral Nutrition gave the answer – * * 22 multidisciplinary experts from 13 countries * *, reached consensus on 22 key issues of ONS clinical application through two rounds of Delphi method, and formed * * the first internationally recognized practice guide * *.

Research Background: From National Consensus to International Validation

In 2023, the Clinical Parenteral and Enteral Nutrition Society of Türkiye released an ONS national consensus report covering 22 issues. To further improve its international applicability, the research team invited 22 experts from Brazil, Canada, China, France, Germany, Italy, Japan, the Netherlands, Poland, Portugal, Spain, Sweden, Taiwan, China and other places to participate in the international validation. These experts cover multiple disciplines such as geriatrics, internal medicine, gastroenterology, surgery, family medicine, physical medicine, clinical nutrition, and nutrition, ensuring a consensus based multidisciplinary perspective.

Core Consensus: Answers to 22 Clinical Questions

After two rounds of Delphi method, consensus was reached on all 22 recommended opinions. The following is a summary of some core content:

1. Start timing

When patients are able to take it orally but cannot meet their nutritional needs through regular diet, or have been diagnosed with malnutrition and are at risk of malnutrition, ONS should be considered (recommendation 1).

2. Storage and use

Liquid ONS should be stored in a cool and dark place. After opening, it can be refrigerated at 4 ° C for 24 hours. It should be consumed within 4 hours at room temperature. Powder products should be used up within 4 weeks after opening (recommendation 2).

3. Dose and Time

Suggest * * 1-3 times a day * * as an additional meal * * after meals. Be careful not to use it before meals or as a substitute for regular meals to avoid affecting appetite. It is best to drink slowly and in small sips, at least 2 hours after or between meals, and before the next meal (recommendation 3).

4. Taste and Tolerance

When choosing ONS, consideration should be given to the patient’s taste preferences. If the intake is insufficient, you can try switching to products with different flavors. If necessary, banana, strawberry, lemon juice, cocoa powder, ginger, cinnamon and other seasonings can be added. It should be noted that patients with oral mucositis caused by radiotherapy and chemotherapy should use fruit puree and other seasonings with caution (recommendation 4).

5. Monitoring frequency

Assess compliance within * * 1 week after starting use * *. Monitor every 2-4 weeks for the first 3 months, and every 3-6 months for long-term users. The evaluation includes compliance, compliance with energy and protein intake standards, nutritional status, functional abilities, etc. (Recommendation 5).

6. Suspension timing

When the goal of nutritional therapy is achieved and the cause of malnutrition is eliminated, discontinuation may be considered. If the problem persists, it should not be easily discontinued. If ONS still cannot meet the needs, enteral or parenteral nutrition should be considered (recommendation 6).

7. Vitamins and Trace Elements

When optimizing diet combined with ONS to provide at least 1500 kcal of energy per day, there is no need for routine supplementation of vitamins and trace elements. Individualized assessment is required for special circumstances (Recommendation 7).

8. Continued use upon discharge

If the indications for ONS use persist, * * should continue to be used and closely followed up after discharge. Individualized dietary guidance should be provided by nutritionists or medical personnel upon discharge (recommendation 8).

9. Patients with special illnesses

-* * diabetes * *: diabetes patients * * at risk of malnutrition should consider using ONS * *. The special formula for diabetes is similar to the standard product in improving the nutritional status, but it may be more effective in controlling postprandial blood glucose (9 recommended).
-Chronic Kidney Disease: It is recommended to use ONS for nutritional supplementation. Dialysis patients should use it regularly instead of just on dialysis days. For patients at high risk of electrolyte imbalance and fluid overload, a kidney specific formula with low phosphorus, low potassium, low sodium, and low volume can be chosen (recommendation 11).
-Cirrhosis: ONS is recommended. The energy target for non obese patients is * * 30-35 kcal/kg/day * * and protein * * 1.2-1.5 g/kg/day * *. **Eating extra meals at night or before bedtime with ONS * * can help prevent morning hypoglycemia and catabolism (recommendation 12).
-Chronic heart failure: ONS is recommended, but there is insufficient evidence to support the use of disease-specific formulas (recommendation 13).
-Chronic obstructive pulmonary disease: ONS is recommended, but there is insufficient evidence to support the use of disease specific formulas (recommendation 14).
-Pressure ulcers: All patients with pressure ulcers or high-risk conditions should undergo nutritional assessment. Energy target * * 30-35 kcal/kg/day * *, protein * * 1.25-1.5 g/kg/day * *. Products containing arginine, glutamine, β – hydroxy – β – methylbutyric acid, zinc, vitamins A, C, and E can be selected (recommendation 16).
-Swallowing disorders: Patients suspected of swallowing disorders must undergo evaluation before receiving ONS. It is recommended that a speech therapist conduct a bedside swallowing assessment. Determine the dosage form (liquid or thickened) of ONS or whether tube feeding is necessary based on the evaluation results (recommendation 17).
-Elderly patients: It is recommended to supplement at least 400 kcal of energy and 30 g of protein daily. The energy requirement of elderly patients is about 30 kcal/kg/day, while the protein requirement of healthy elderly people is 1.0-1.2 g/kg/day, and 1.2-1.5 g/kg/day when sick. You can choose products with low capacity, high energy, high protein, and dietary fiber content. Once activated, it is recommended to use it continuously for at least 1 month (Recommendation 19).
-Tumor patients: Due to symptoms such as decreased appetite, nausea, and early satiety, they can choose products with low volume, high energy, and high protein. Patients with upper gastrointestinal and head and neck tumors during the perioperative period may consider * * immunonutrition * * (omega-3 fatty acids, arginine, ribonucleotides). When advanced cancer patients receive chemotherapy and are at risk of malnutrition, omega-3 fatty acids may help maintain appetite, weight, and lean body mass (recommendation 20).
-Elderly patients undergoing hip fracture surgery: Regardless of their nutritional status, ONS is recommended to reduce the risk of postoperative complications. Considering that most of these patients are elderly and have multiple comorbidities, it is recommended to use a specialized formula with high protein and HMB content (recommendation 21).

10. Common problem handling

Common issues include improper use, non-compliance, unpleasant taste, gastrointestinal reactions (nausea, vomiting, bloating, diarrhea). The response measures include adjusting the dosage, changing flavors or products, and evaluating storage conditions. For patients with nausea/early satiety, the use of prokinetic drugs may be considered. Diarrhea patients should reduce their single dose, prolong their drinking time, and switch to products containing dietary fiber or low osmotic pressure after ruling out other causes. Constipation patients should first consider the effects of reduced activity, sedatives, or opioid drugs, such as increasing fluid intake, reducing concentration, or switching to a formula containing dietary fiber (recommendation 22).

Clinical Implications: Moving from Experience to Standardization

This international consensus study not only verified the scientificity of the original national consensus, but also made many optimizations based on the feedback of international experts, such as replacing “compliance” with “compliance” to reflect the initiative of patients, changing “diabetes patients” to “diabetes patients” to reflect the people-oriented language, and emphasizing the important role of * * nutritionists and speech therapists * * in the evaluation.

The study specifically pointed out that the application of ONS should follow the principle of “food first” and be activated when regular diet cannot meet the needs. Simultaneously emphasizing individualized decision-making and multidisciplinary collaboration to achieve patient-centered nutrition management.

Conclusion

This * * world’s first ONS international Delphi consensus study * * provides a systematic, practical, and actionable guidance framework for clinical nutrition practice. The answers to 22 questions cover the entire process of ONS clinical application, from the timing of initiation to the point of discontinuation, from the general population to specific diseases, from dosage selection to problem handling.