What is the role of Fresubin (oral nutritional supplement) in nutritional support for patients at risk of malnutrition?

Fresubin for Nutritional Support in Malnutrition

Fresubin oral nutritional supplements should be offered to patients who are malnourished or at risk of malnutrition when dietary counseling and food fortification alone cannot meet nutritional requirements, providing at least 400 kcal/day with 30g of protein to improve body weight, nutritional status, and reduce hospital readmissions. 1

When to Initiate Fresubin

Start Fresubin when patients cannot achieve 75% of their energy and protein requirements through regular diet alone, even with dietary counseling and food fortification. 1 This threshold is critical because achieving at least 75% of nutritional goals significantly reduces mortality and adverse events. 1

Specific Indications:

• Hospitalized patients: Initiate within 48 hours of admission for malnourished or at-risk patients to reduce mortality, adverse events, and lean body mass loss 1
• Cancer patients: Use when oral intake is inadequate despite dietary counseling, as nutritional therapy improves body weight and energy intake 1
• Geriatric patients: Offer to older adults (≥65 years) who are malnourished or at risk, as it increases dietary intake and body weight 1
• Kidney disease patients: Provide to non-critically ill hospitalized patients with acute or chronic kidney disease who cannot meet requirements with regular diet 1
• Polymorbid medical inpatients: Use as a cost-effective intervention to improve nutritional status, quality of life, and overall survival 1

Optimal Dosing and Composition

Fresubin should provide at least 400 kcal/day with 30g or more of protein (approximately 30% of energy from protein). 1 This translates to roughly 2 servings per day of standard formulations. 2

High-Protein Formulations:

Prioritize high-protein Fresubin products (>20% energy from protein) as they demonstrate superior outcomes including reduced complications, reduced hospital readmissions, improved grip strength, and better preservation of lean body mass. 1

Evidence for Clinical Outcomes

Proven Benefits:

• Body weight and nutritional status: Fresubin significantly increases body weight, BMI, mid-arm circumference, and overall nutritional parameters 1, 2
• Hospital readmissions: Reduces non-elective readmissions in malnourished hospitalized patients 1
• Energy and protein intake: Increases daily intake by 10-12 kcal/kg and 0.3-0.5 g protein/kg without significantly suppressing normal food consumption 1
• Functional outcomes: Some studies show improvements in grip strength and activities of daily living 1

Important Caveats:

Meta-analyses show mixed results on mortality and length of hospital stay, with some individual trials showing mortality benefits while pooled analyses often show no effect. 1 One recent large trial in 652 malnourished older hospitalized patients found significantly lower 90-day mortality with high-protein ONS, contradicting earlier meta-analyses. 1

Duration of Treatment

Continue Fresubin for at least one month (35 days or more) to achieve meaningful clinical benefits. 1 Subgroup analyses demonstrate that supplementation for 35 days or longer shows consistently better outcomes compared to shorter durations. 1

Nutritional support must be continued after hospital discharge to maintain or improve body weight and nutritional status and to lower mortality. 1 Post-discharge continuation prevents weight loss and improves functional outcomes. 1

Practical Implementation

Timing and Administration:

• Provide at least 1 hour after meals to minimize suppression of normal food intake 1
• Adapt flavor, texture, and timing to patient preferences to maximize adherence 3
• Initiate early (within 48 hours of hospital admission) rather than waiting for severe malnutrition to develop 1

Monitoring:

• Assess nutritional status weekly including weight, appetite, and dietary intake 3
• Monitor for refeeding syndrome in severely malnourished patients by checking phosphate, magnesium, potassium, and thiamine during the first 3 days 4
• Evaluate drug-nutrient interactions with pharmacist assistance, particularly in polymorbid patients 1

When Fresubin is Insufficient

If oral nutritional supplements cannot meet requirements, escalate to enteral nutrition via feeding tube before considering parenteral nutrition. 1 Enteral nutrition is superior to parenteral nutrition due to lower risk of infectious and non-infectious complications and maintenance of gut integrity. 1

Common Pitfalls to Avoid

• Do not delay until severe malnutrition develops; early intervention is more effective 4
• Do not use restrictive diets that limit energy intake in malnourished patients, even those with obesity 1, 4
• Do not rely on hypoalbuminemia alone as a marker for protein malnutrition, as it is affected by inflammation 4, 5
• Do not stop supplementation at hospital discharge; continuation is essential for sustained benefits 1

Evidence Quality Note

The strongest evidence comes from recent ESPEN guidelines (2024) for polymorbid medical inpatients, which provide Grade A recommendations with 100% consensus for offering ONS to malnourished patients. 1 A 2022 randomized controlled trial specifically using Fresubin powder demonstrated significant improvements in body weight (mean increase 1.381 kg), BMI, and nutritional parameters over 12 weeks in Chinese adults at risk of malnutrition. 2