Recommended Oral Nutritional Supplement
For patients requiring high-protein, multivitamin support, prescribe a high-protein oral nutritional supplement (ONS) providing 2-3 bottles daily, with each bottle delivering approximately 300-400 kcal and 15-20g protein, alongside multivitamin/multimineral supplementation.
Specific Product Recommendations
Based on the most recent guideline evidence, appropriate polymeric oral supplements include 1:
- Ensure Plus (Abbott Nutrition)
- Kate Farms
- Jevity (Abbott Nutrition) - consumed orally
- Other polymeric oral supplements with similar nutritional density
Nutritional Targets to Achieve
Your prescription should aim for 2:
- Energy: 25-30 kcal/kg/day
- Protein: 1.2-2 g/kg/day (critical care) or 1.3 g/kg/day (general medical patients)
- Multivitamins: 50-100% of recommended daily intake per supplement bottle
When to Prescribe ONS
Initiate ONS immediately if 3:
- Patient is malnourished or at high nutritional risk
- Oral intake is inadequate (<75% of calculated requirements)
- Patient can safely swallow but cannot meet needs through regular food alone
Early initiation (within 48 hours) is critical - delays worsen outcomes including mortality, complications, and lean body mass loss 3.
High-Protein Formulations Are Superior
Prioritize high-protein ONS (≥20% energy from protein) because they 4, 3:
- Reduce complications by 101 per 1,000 patients (Number Needed to Treat = 12)
- Decrease hospital length of stay by 0.26 days
- Maintain functional status and muscle mass better than standard formulations
- Improve quality of life and overall survival
The most recent meta-analysis (2025) demonstrates that high-protein ONS providing approximately 580 kcal and 34g protein daily significantly reduces infectious, non-infectious, and post-operative complications 4.
Practical Prescribing Algorithm
Step 1: Calculate patient's requirements (25-30 kcal/kg, 1.2-2g protein/kg)
Step 2: Prescribe 2-3 bottles daily of high-protein ONS to supplement regular meals
- Timing: Between meals (2-3 hours after) or late evening to avoid meal replacement 5
- During dialysis sessions if applicable (improves compliance) 5
Step 3: Add multivitamin/multimineral supplementation
- Intravenous multivitamin/multimineral trace element solutions at admission for acute illness 6
- Oral multivitamin if stable outpatient
- Check and correct vitamin D, selenium, zinc, magnesium deficiencies 7
Step 4: Monitor consumption daily
- If patient consumes <2 bottles/day for 2 consecutive days, escalate to enteral tube feeding or parenteral nutrition 6
- Target achieving >75% of calculated requirements 3
Critical Caveats
Do NOT use disease-specific renal formulas in dialysis patients - they contain inadequate protein. Use standard high-protein ONS instead 5.
Avoid meal replacement - ONS must be additional to regular food intake, not substituting for meals 8. This is a common prescribing error that undermines nutritional goals.
Monitor for refeeding syndrome in malnourished patients during the first 3 days - supplement phosphate, magnesium, potassium, and thiamine even with mild deficiency 9, 3.
Continue post-discharge - nutritional support must extend beyond hospitalization to maintain improvements in body weight, nutritional status, and reduce mortality 3.
Special Populations
Surgical patients (including IBD, cancer): Start ONS preoperatively if malnourished, continue perioperatively to reduce complications and hospital stay 10, 11.
Geriatric hip fracture: Offer ONS regardless of baseline nutritional status - reduces postoperative complications 9.
Cancer patients undergoing chemoradiation: Provide ONS early to prevent esophagitis-related malnutrition, targeting 30 kcal/kg and 1.0-1.5g protein/kg 12.
The evidence consistently demonstrates that systematic, early use of high-protein ONS with multivitamin support improves clinical outcomes across diverse patient populations when prescribed at adequate doses and continued long enough to achieve nutritional repletion 13, 4.