What is an appropriate Oral Nutritional Supplement (ONS) for a patient with severe malnutrition and hypoalbuminemia?

Appropriate Oral Nutritional Supplement for Severe Malnutrition with Hypoalbuminemia

For a patient with severe malnutrition and hypoalbuminemia, prescribe a high-protein ONS providing at least 400 kcal/day with 30g or more of protein daily, continued for a minimum of one month with monthly efficacy assessments. 1

Specific ONS Characteristics Required

Energy and Protein Content

• The ONS must deliver ≥400 kcal/day with ≥30g protein/day (representing approximately 30% of energy from protein). 1
• High-protein formulations are defined as providing >20% of energy from protein. 1
• This threshold of 400 kcal/day was consistently associated with statistically significant mortality benefits in subgroup analyses of 62 randomized trials. 1

Format and Texture Options

• ONS are available in multiple formats: liquid, powder, pudding, or pre-thickened preparations. 1
• Style options include milk-based, juice-based, yogurt-style, or savory formulations. 1
• For patients with dysphagia or chewing problems, texture-modified ONS should be selected. 1
• Energy density ranges from 1.0 to 3.0 kcal/mL, with high energy-dense formulations (≥1.5 kcal/mL) classified as "high energy." 1

Implementation Strategy

Duration and Monitoring

• Continue ONS for at least one month (≥35 days), as shorter durations have not demonstrated mortality benefits. 1
• Assess efficacy monthly by monitoring body weight, appetite, and clinical status. 1
• Older malnourished patients require longer intervention periods because they need higher energy supply than younger adults to gain weight, and their increase in body weight and fat-free mass occurs more slowly. 1

Compliance Optimization

• Regularly assess compliance and adapt the type, flavor, texture, and timing of ONS consumption to patient preferences. 1
• Offer variety to prevent taste fatigue, as patients may tire of consuming the same product daily. 1
• Recent evidence suggests that higher energy-dense formulations (2.4 kcal/mL) may have non-inferior compliance with less product waste compared to standard formulations. 2

Hierarchical Approach to Nutritional Support

When to Initiate ONS

• ONS should be offered when dietary counseling and food fortification fail to achieve nutritional goals. 1
• For hospitalized patients with malnutrition, ONS should be offered to improve dietary intake, body weight, and lower risk of complications and readmission. 1
• After hospital discharge, continue ONS to improve intake and body weight while lowering risk of functional decline. 1

Complementary Interventions

• ONS should not be viewed as mutually exclusive with other strategies but as complementing dietary counseling, food fortification, and additional snacks. 1
• Combine nutritional interventions with physical activity to maintain or improve muscle mass and function. 3

Special Considerations for Hypoalbuminemia

Important Caveats About Albumin

• Hypoalbuminemia reflects disease-associated catabolism and inflammation rather than pure nutritional status. 1, 4, 3
• While hypoalbuminemia is a clear surgical risk factor, it should not be used as the sole marker for protein malnutrition. 1, 4, 3
• Correction of albumin alone for a short time is unlikely to lead to major clinical benefits without addressing overall nutritional status. 5

Specialized Formulations for Severe Hypoalbuminemia

• In patients with severe hypoalbuminemia (<2.5 g/dL) experiencing diarrhea with standard enteral formulations, peptide-based formulas may be better tolerated. 6
• For post-bariatric patients with severe hypoalbuminemia, continuous 24-hour nasal-jejunal MCT formulations combined with pancreatic enzyme supplementation have demonstrated efficacy. 7
• Anti-inflammatory and antioxidant nutritional supplements containing omega-3 fatty acids, gamma-linolenic acid, and antioxidants have shown promise in hypoalbuminemic hemodialysis patients. 8

Protein Requirements

Target Protein Intake

• Malnourished patients require 1.2-1.5 g/kg/day of protein from all sources combined (diet plus ONS). 4, 3
• For cancer patients, protein intake should ideally reach 1.5 g/kg/day to promote muscle protein anabolism. 4
• For cirrhosis patients, 1.2-1.5 g/kg/day is safe and does not worsen hepatic encephalopathy. 4

Common Pitfalls to Avoid

• Do not delay ONS initiation until severe malnutrition develops; early intervention is more effective. 3
• Do not restrict energy intake even in malnourished patients with obesity, as this worsens nutritional status. 3
• Avoid using restrictive diets that limit dietary intake, as they are potentially harmful. 3
• Do not rely solely on albumin correction without addressing overall protein-calorie malnutrition. 5
• In severely malnourished patients, start nutritional support early but increase gradually over the first three days to prevent refeeding syndrome, with monitoring of phosphate, magnesium, potassium, and thiamine. 3