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Oral Nutritional Supplements (ONS) to Tackle M alnutrition

Oral Nutritional Supplements (ONS) to Tackle M alnutrition. A summary of the evidence base Medical Nutrition International Industry (MNI). Content . What is malnutrition? Identifying malnutrition Prevalence of malnutrition Causes and consequences of malnutrition

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Oral Nutritional Supplements (ONS) to Tackle M alnutrition

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  1. Oral Nutritional Supplements (ONS)to Tackle Malnutrition A summary of the evidence base Medical Nutrition International Industry (MNI)

  2. Content • What is malnutrition? • Identifying malnutrition • Prevalence of malnutrition • Causes and consequences of malnutrition • Economic consequences of malnutrition • Benefits of oral nutritional supplements (ONS) • Nutritional • Functional • Clinical • Economic benefits • Benefits of screening for malnutrition • Recommendations 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”1 Management of malnutrition Oral Nutritional Supplements (ONS) are an important strategy in nutritional care but there is often poor awareness of the value of nutritional care, especially ONS Ljungqvist O & de Man F. NutrHosp 2009; 24(3):368-370.

  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-nutrition • Here ‘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. 2000 2. Lochs H et al. ClinNutr 2006; 25(2):180-186.

  5. Identifying malnutrition risk • Nutritional screening identifies individuals who: • are ‘at-risk’ across the spectrum of nutritional status • are at risk of adverse outcome and who • may benefit clinically from nutritional support Patients 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 malnutrition • Specifically designed for different patient groups and care settings Examples include: ‘MUST’ For hospital and community patients For older people For adult hospital patients For children NRS 2002 Strongkids However, they are not routinely used, meaning that malnutrition is often missed

  7. Malnutrition goes undetected and untreated • Lack of routine screening for malnutrition and itsrisk factors has meant that the opportunity for early intervention, and prevention, is often missed • Even when found, malnutrition is not always appropriately treated:Often less than 50% of patients identified as malnourished receive nutritional intervention1-4 Lamb CA et al. Br J Nutr 2009; 102(4):571-575 2. Meijers JM et al. Nutrition 2009; 25(5):512-519 3. van Nie-Visser NC et al. ClinNutr 2009; 4 Supplement 2:45. 4. Meijers JM et al. Nutr 2009; 25(5): 512-519.

  8. Mandatory screening shown to lower malnutrition (NL) Decreased prevalence of malnutrition in hospitals and home following introduction of mandatory screening 1 • Increasing awareness and actively working toward improvementcould lower the rate of malnutrition1 • Screening allows early identification and management with an appropriate care plan Malnutrition prevalence rates in hospitals, nursing homes and home care institutions (NL) Meijers JM et al. J Nutr 2009; 139(7):1381-1386.

  9. Screening for malnutrition risk - Conclusions • Reliable and validated tools for screening are available BUT screening is still not routinely used Malnutrition continues to go unidentified The opportunity for early intervention is often missed Screening 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 untreated Population of Europe: > 800 million An estimated 33 million people in Europe are at risk of malnutrition1 1. Ljungqvist O, de Man F. NutrHosp 2009; 24:368-70.

  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 come More than 1 in 3 people in care homes at risk1,6,8-10 Around 1 in 3 older people living independently at risk6 An estimated 93% of malnourished people live in the community11 About 1 in 3 older people in hospital at risk1-7 1. Russell C & Elia M. Redditch, BAPEN. 2008. 2. Russell C & Elia M. Redditch, BAPEN. 2009. 3. Russell C & Elia M. Redditch, BAPEN. 2011. 4. Russell C & Elia M. Redditch, BAPEN. 2012. 5. Imoberdorf R et al. ClinNutr 2010; 29(1):38-41. 6. Kaiser MJ et al. J Am Geriatr Soc 2010; 58(9):1734-1738. 7. Vanderweek et al. J Adv Nurs 2011; 67(4):736-746. 8. Suominen MH et al. Eur J ClinNutr 2009; 63(2):292-296. 9. Lelovics Z et al. Arch GerontolGeriatr 2009; 49(1):190-196. 10. Parsons EL et al. Proc Nutr Soc 2010; 69:E197. 11. 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 malnutrition1-7 1. Russell C & Elia M. Redditch, BAPEN. 2008. 2. Russell C & Elia M. Redditch, BAPEN. 2009. 3. Russell C & Elia M. Redditch, BAPEN. 2011. 4. Russell C & Elia M. Redditch, BAPEN. 2012. 5. Meijers JM et al. Br J Nutr 2009; 101(3):417-423. 6. Imoberdorf R et al. ClinNutr 2010; 29(1):38-41. 7. Schindler K et al. ClinNutr 2010; 29(5):552-559.

  13. Prevalence of malnutrition in hospital patients Malnutrition affects people of all ages Almost 1 in 5 children admitted to hospital at risk1 1. Joosten KF et al. Arch Dis Child 2010; 95(2):141-145.

  14. Malnutrition is prevalent across a wide variety of diseases Prevalence of malnutrition risk in hospital by diagnosis Republic of Ireland n = 1102 (‘MUST’ medium + high risk), UKn = 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. 2012. 2. Meijers JM et al. Br J Nutr 2009; 101(3):417-423.

  15. Prevalence of malnutrition - Conclusions • Studies across the developed world show that malnutrition is common in patients • in hospital • in care homes and • in people who live at home • Malnutrition affects all age groups, including children • Malnutrition is particularly common in older people

  16. Causes of malnutrition • Insufficient dietary intake • disability and disease are at the heart of the problem • Effects of disease and its treatment • leading to low food intake e.g. poor appetite, swallowing problems and side effects of drugs1 • Lack of clear responsibilities for health authorities and healthcare staff • inadequate training and equipment for screening exacerbates the problem of malnutrition2-3 • More 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 needs Stratton RJ et al. Wallingford: CABI Publishing; 2003. 2. Elia M & Russell C. Redditch, BAPEN. 2009. 3. Elia M. Redditch, BAPEN. 2003. 4. Hiesmayr M et al. ClinNutr2009; 28(5):484-491. 5. Valentini L et al. ClinNutr2009; 28(2):109-116.

  17. Factors causing poor food and nutrient intake1 • Individuals • Physical e.g. chewingorswallowingproblems, difficultyself-feeding • Physiological e.g. anorexia, feelingfullrapidly, nausea, taste changes, pain • Psychological e.g. confusion, lowmood, anxiety • Healthcareworkers • Lack ofrecognitionofimportanceofnutrition • Lack ofknowledgeandskills • Poor documentationofnutritioninformation • Lack ofscreening, actionandmonitoring • Institutions • Lack ofnutritionpolicyorguidance • Poor organisationofnutritionservices • Limitations in cateringprovision • Lack ofspecialistposts Insufficient energy and nutrient intake* DiseaseRelated Malnutrition *Requirements for some nutrients may be increased due to malabsorption, altered metabolism and excess losses. Adapted from Stratton RJ et al. Wallingford: CABI Publishing; 2003.

  18. Causes of malnutrition - Conclusions • The causes of malnutrition are multi-factorial • Patient-related factors resulting from disease and disability contribute to low food intake • Organisational and institutional factors are also involved • A multi-stakeholder approach is needed to identify and implement effective solutions

  19. Consequences of malnutrition for individuals • Markedly increased morbidity and mortality rates1-2 • Malnourished patients experience more complications than well nourished patients; the risk of infection is more than three times greater in hospitalised malnourished patients2-3 • Associated with poorer quality of life1 • Malnutrition has a particularly high adverse impact in the older person4 impairing function, mobility and independence5 • Malnutrition has an adverse impact on growth and development in children 1,5 Stratton RJ et al. Wallingford: CABI Publishing; 2003. 2. Sorensen J et al. ClinNutr2008; 27(3):340-349. 3. Schneider SM et al. Br J Nutr 2004; 92(1):105-111. 4. Stratton RJ et al. Br J Nutr 2006; 95(2):325-330. 5. Elia M & Russell C. Redditch, BAPEN. 2009.

  20. Malnutrition is associated with increased morbidity • Malnutrition is associated with increased morbidity in acute and chronic disease including: • Development of pressure ulcers1 • Poor wound healing1 • Post-operative complications such as acute renal failure, pneumonia and respiratory failure1 • Increased risk of infection2 • Norman K et al. ClinNutr 2008; 27(1):5-15. 2. Schneider SM et al. Br J Nutr 2004; 92(1):105-111.

  21. Economicconsequencesofmalnutrition • Malnutrition increasesuseofhealthcareresources • Hospital patients • Increase in lengthofhospital stay1-5 • Increase in readmission rates4,6 • Delays in returning home7 • Community patients • Increasednumberofvisitstofamily doctors8,9 • Increases in hospitaladmissionsand readmissions10,11 • Increases in lengthofhospital stay8,9,11 • Also in childrenmalnutritionisassociatedwith an increasedlengthofhospital stay12-14 Leandro-Merhi VA et al. J ParenterEnteralNutr2011; 35(2):241-248. 2. Pressoir Met al. Br J Cancer 2010; 102(6):966-971. 3. Pirlich M et al. ClinNutr2006; 25(4):563-572. 4. Lim SL et al.ClinNutr2011; 31(3):345-350. 5. Marco J et al. ClinNutr2011; 30(4):450-454. 6. Planas M etal. ClinNutr2004; 23(5):1016-1024. 7. Nitenberg GM et al. ClinNutr2011; 6(Suppl 1):149. 8. Feldblum I et al. Nutrition 2009; 25(4):415-420. 9. Guest JF et al. ClinNutr2011; 30(4):422-429. 10. Collins PF et al. Proc Nutr Soc 2010; 69:E148. 11. Cawood AL et al.ProcNutr Soc 2010; 69:E149. 12. Secker DJ & Jeejeebhoy KN. Am J ClinNutr 2007; 85(4):1083-1089. 13. Hulst JM et al. ClinNutr2010; 29(1):106-111. 14. Joosten KF et al. Arch Dis Child 2010; 95(2):141-145.

  22. Economic consequences of malnutrition Costsofmalnutrition 1. Elia M & Russell C. Redditch, BAPEN. 2009 2. House of Commons Health Committee. 2004. 3. Cepton. Munich. 2007. 4. Freyer K et al. ClinNutr 2012.. 5. Rice N & Normand C. Pub Health Nur. 2011.

  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*)1 • These 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 community * Calculated based on an exchange rate of £ to € of 1.17993 Source: Interbank 29.02.12). • Elia M & Russell C. Redditch, BAPEN. 2005.

  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 stays • Greater need for long term care The UK alone spends in excess of €15 billion annually onmanaging 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 1.17993 Source: Interbank 29.02.12). † 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. 2005.

  25. Estimated cost of malnutrition across the EU Malnutrition in Europe costs healthcare systems an estimated €170 billion per year1 Ljungqvist O, de Man F. NutrHosp 2009; 24:368-70.

  26. Costs of malnutrition vs. obesity in the UK Estimated UK public expenditure (health and social care): 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 1.17993 Source: Interbank 29.02.12) • Elia M & Russell C. Redditch, BAPEN. 2009. 2. House of Commons Health Committee. London, The Stationery Office. 2004.

  27. Consequences of malnutrition - Conclusions • The adverse consequences of malnutrition are far-reaching • Malnutrition is associated with: • Increased complications • Greater risk of infections • Poor quality of life • Increased mortality • Suboptimal growth and development in children Malnutrition is associated with increased healthcare resource use and higher costs

  28. Management of malnutrition • Early identification is key to effective management of malnutrition • Screening using validated tools should be routine practice • A 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. ClinNutr 2006; 25(2):180-186.

  29. Benefits of Oral Nutritional Supplements (ONS) • ONS are an effective and non-invasive solution to tackling malnutrition • National and international reviews of the evidence, for example NICE, cite ONS as having significant clinical benefits for malnourished patients when compared to standard care1-5 1. National Institute for Health and Clinical Excellence (NICE). London. 2006. 2. Milne AC et al. Cochrane Database Syst Rev 2009;(2):CD003288. 3. Milne AC et al. Cochrane Database Syst Rev 2005;(2):CD003288. 4. Milne AC et al. Ann Intern Med 2006; 144(1):37-48. 5. Avenell A & Handoll HH. Cochrane Database Syst Rev 2010;(1):CD001880.

  30. Benefits of Oral Nutritional Supplements (ONS) • Proven nutritional benefits • ONS 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 settings1-4 • Proven functional benefits • ONS have proven functional benefits such as improvements in activity, quality of life and independence measures, particularly in older malnourished patients in the community5-11 1. Stratton RJ et al. Wallingford: CABI Publishing; 2003. 2. National Institute for Health and Clinical Excellence (NICE). 2006. London, National Institute for Health and Clinical Excellence (NICE). 3. Milne AC et al. Cochrane Database Syst Rev 2009;(2):CD003288. 4. Cawood A et al.Ageing Res Rev 2012; 11(2):278-296 5. McMurdo ME et al.J Am Geriatr Soc 2009; 57(12):2239-2245. 6. Norman K et al.ClinNutr 2008; 27(1):48-56. 7. Rabadi MH et al.Neurology 2008; 71(23):1856-1861. 8. Gariballa S et al. J Am Geriatr Soc 2007; 55(12):2030-2034. 9. Persson M et al. ClinNutr 2007; 26(2):216-224. 10. Parsons EL et al. ClinNutr 2011; 6(Suppl 1):31. 11. Stange I et al. ClinNutr 2011; 6(Suppl 1):128.

  31. Benefits of Oral Nutritional Supplements (ONS) • Proven clinical benefits • ONS 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, 6 Lower complication rates in supplemented vs control patients in hospital1 1. Stratton RJ et al. Wallingford: CABI Publishing; 2003. 2. National Institute for Health and Clinical Excellence (NICE). 2006. London, National Institute for Health and Clinical Excellence (NICE). 3. Milne AC et al. Cochrane Database Syst Rev 2009;(2):CD003288. 4. Cawood A et al.Ageing Res Rev 2012; 11(2):278-296. 5. Avenell A & Handoll HH. Cochrane Database Syst Rev 2006;(4):CD001880. 6. Stratton RJ et al. Ageing Res Rev 2005; 4(3):422-450.

  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 effective1-5 • Greater nutrient intakes and fewer complications are seen in patients with hip fractures given ONS compared with food snacks4-6 • Compliance to ONS is good. Compliance to other methods of oral nutritional intervention need investigation7 1. National Institute for Health and Clinical Excellence (NICE). London. 2006. 2. Baldwin C & Weekes CE. Cochrane Database Syst Rev 2011;(9):CD002008. 3. Weekes CE et al. J Hum Nutr Diet 2009; 22:324-335. 4. Stratton RJ et al. ProcNutrSoc 2006;10A. 5.Stratton RJ et al. ProcNutrSoc 2006; 65:4A. 6. Stratton RJ et al. ClinNutr 2007; 2 Supplement 2:9. 7. Hubbard GP et al. ClinNutr 2012; 31(3):293-312.

  33. ONS reduce mortality in hospital patients • Significantly lower mortality rates found in supplemented hospitalised liver disease, orthopaedic, and surgical patients, and hospitalised older people1 • Represents a 24% reduction in mortality Lower mortality in supplemented versus control patients p < 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 studies Stratton 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 patients1 • Represents a 56% reduction in complication rates Lower complication rates in supplemented versus control patients in hospital p < 0.001; odds ratio 0.31 (95% CI, 0.17 to 0.56), meta-analysis of 7 trials, n = 384; no significant heterogeneity between studies Stratton 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)1 Stratton RJ et al. Wallingford: CABI Publishing; 2003.

  36. ONS reduce hospital readmissions • High protein ONS have been shown to reduce hospital readmissions by 30%1 Significant reductions in readmissions with ONS Cawood AL et al. Ageing Res Rev 2012; 11(2):278-296.

  37. Financial Benefits of Oral Nutritional Supplements (ONS) in hospital * Calculated based on an exchange rate of £ to € of 1.17993 (Source: Interbank 29/02/2012. ** Calculated based on an exchange rate of USD to € of 0.74448 (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 ClinNutr 2010; 64(10):1229-1234. 3. EliaM et al. Redditch, BAPEN. 2005.4. Elia M, Stratton RJ. ClinNutr 2005; 24:640-641. 5. 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 utilisation • Fewer home nursing visits • Less GP and physiotherapist visits • Fewer hospital admissions • Shorter length of hospital stay with admission • After considering the investment required for ONS, the average reduction in medical care costs was €195 per patient Arnaud-Battandier F et al. ClinNutr 2004; 23(5):1096-1103.

  39. Financial Benefits of Oral Nutritional Supplements (ONS) in the community * Short-term ONS (about 2 weeks) 1. Arnaud-BattandierF et al. ClinNutr 2004; 23(5):1096-1103. 2. Nuijten M, Mittendorf T. AktuelErnahrungsmed 2012; 37:126-133. 3. FreyerK, Nuijten M. Value in Health 2010; 13(3):A101 (PH106). 4. FreijerK et al. Front Pharmacol 2012; 3:78.5. CawoodAL et al. ProcNutrSoc 2010; 69:E544. 6. EliaM et al. Redditch, BAPEN. 2005.

  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 modelling1 • This 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 1.17993 Source: Interbank 29.02.12) National Institute for Health and Clinical Excellence (NICE). London. 2006.

  41. Recommendations for action Fundamental prerequisites for success • There must be multi-stakeholder involvement at all levels • Awareness, training and education are central to success • Audit and quality improvement activities should be included in any initiative that strives to tackle malnutrition • Good practice should be routinely shared

  42. Recommendations for action

  43. Recommendations for action

  44. Note • This 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:http://www.medicalnutritionindustry.com/mni-publications/ • This document is an updated version of previous reports prepared in 2009 and 2010. 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 20031. 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 information • Therefore, 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 development • The full report is available to download at www.medicalnutritionindustry.com

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