Although there is limited research into this area, studies have shown that increasing the energy density of meals through food enrichment can increase an individual’s overall caloric intakes up to 30% (Odlunds et al 2003). Other studies have indicated that dietary counselling gave comparable increases in weight to oral nutritional supplement use (Baldwin and Weekes, 2012). 

If a patient has a poor appetite, problems with eating, or has lost weight recently, it is important that the food and drinks taken contain as much energy and protein as possible.

Dietary advice could include:

  1. Little & often: aim to have three small meals plus two to three nourishing snacks in between (eating every 2-3 hours) as trying larger meals may over-face the patient (see table 1 for snack ideas)

  2. Choosing full fat and sugar products rather than ‘low fat/sugar’ as they contain more calories. e.g. Choose full cream milk instead of skimmed/semi skimmed milk and normal butter/spread rather than low fat spread.

  3. Nourishing drinks can be a simple way of increasing calories intake. Options include malt drinks, milk based coffee, hot chocolate, fresh fruit juices, milkshakes, smoothies or enriched soups. 

  4. Food Enrichment: Involves using every day food items to enrich the diet with energy and protein such as using adding butter, cream, cheese, full fat milk, skimmed milk powder, oils, crème fraiche to foods to boost their energy and protein content (see Table 3). Please note that some foods only add energy to food while others also provide protein which is required for tissue growth and repair (see Table 4).

  5. Consider a multivitamin & mineral supplement as those eating small amounts or a limited variety of foods may not have adequate micronutrient intake.

Savoury and sweet snacks ideas

Savoury
Crisps Flavoured rice cakes Cheese biscuits
Bread sticks Crackers / crisp breads Cheese twists
Handful of nuts Mini sausage rolls Mini pork pies
Scotch egg Cheese and crackers Build up/ Complan packet soups
Sweet (may not be suitable for patients with diabetes)
Jelly sweets Snack / full size chocolate bars Jaffa cakes
Biscuits Flapjacks Pastries
Cakes Teacake Scones
Dried fruit Popcorn Ice cream
Full fat yoghurts or mousses Custard pots Tinned fruit in syrup
Rice pudding Chocolate spread
Puddings
Angel Delight Fruit and custard / cream Crème caramel
Crème brulée pots Trifle pots Panna cotta
Mini apple pies Cream cakes Fruit Fool
Milk jelly Semolina Sponge Pudding

Recipe for homemade milkshakes

Ingredients Per portion
Double Cream 40ml
Whole milk 80ml
Sugar 4g (1 tsp)
Vanilla Ice Cream 80ml
Skimmed milk powder 24g
Total (approx. -more if whisked and frothy) 180ml
Calorie content (estimated) 400kcal
Protein content (estimated) 13g
Combine all ingredients with a whisk or in a blender.
Milkshake powder/chocolate spread/fruit can be added to vary flavour if desired.

Examples of the increases in energy possible through food enrichment

Food enrichment ideas Energy before (kcal) Energy After (kcal) and % added
Whole Milk (1 Pint) Add 4 tablespoons of dried skimmed milk powder. 375 583 (55% extra)
Custard (125ml) Add 1 tablespoon of dried skimmed milk powder and 2 tablespoons of double cream. 148 349 (135% extra)
Milk based Soup (125ml) Add 1 tablespoon of dried skimmed milk powder and 2 tablespoons of double cream. 80
280 (250% extra)
Porridge made with whole milk (200g) Add 1 tablespoon dried skimmed milk powder and 2 tablespoons of double cream. 226
426 (88% extra)
Mash potato (1 scoop) Add 1 tablespoon of butter and 1 tablespoon double cream. 70 183 (160% extra)
Vegetables (2 tablespoons)
Add 1 teaspoon of butter. 15
52 (246% extra)
Rice Pudding (125g) Add 1 tablespoon of dried skimmed milk powder and 2 tablespoons double cream and 2 teaspoons of jam. 106
332 (213% Extra)

Energy and Protein in common food enrichers

Food Enricher Energy Protein
Butter
Cream
Full Fat Milk
Skim Milk Powder
Oil
Crème fraiche
Cheese
Cream cheese ✔ Low
Sugar

References

Baldwin, C. and Weekes, C. E. (2012), Dietary counselling with or without oral nutritional supplements in the management of malnourished patients: a systematic review and meta-analysis of randomised controlled trials. Journal of Human Nutrition and Dietetics, 25: 411–426.

Odlunds Olin A., Armyr I., Soop M., et al. (2003) Energy dense meals improve energy intake in elderly residents in a nursing home. Clin Nutr, 22:125-131

Further reading

Silver, H.J. (2009) Food modification versus Oral Liquid Nutrition Supplementation. Nestle Nutrition institute workshop service clinical performance program, 12:79-93

Stratton, R. (2005) Should food or supplements be used in the community for the treatment of disease-related malnutrition?. Proceedings of the Nutrition Society, 64: 325–333.

Oral Nutritional Supplements (ONS) are sterile liquids, semi-solids or powders, which provide macro and micro nutrients. They are widely used within the acute and community health settings for individuals who are unable to meet their nutritional requirements through oral diet alone. ONS use must be approved by the Advisory Committee on Borderline Substances (ACBS). Indications for use include:

  • Short bowel syndrome
  • Dysphagia
  • Intractable malabsorption
  • Pre-operative preparation of undernourished patients
  • Inflammatory bowel disease
  • Total gastrectomy
  • Bowel fistulae
  • Disease related malnutrition (chronic/acute)

ONS may be prescribed in the short term during acute illness, but also for individuals with long term chronic conditions. The role of ONS is to complement nutritional intake, and simultaneous information around improving oral intake should be provided.

Some ONS are available to buy over the counter in supermarkets or pharmacies (usually in powder form which are mixed with milk or water) but the majority of ONS are only available on prescription ideally following advice from a registered dietitian. ONS often contain macronutrients (protein and/or energy) and micronutrients (vitamins and minerals) at varying levels of concentrations. Therefore, not all ONS are nutritionally complete, meaning that they cannot be used as a sole source of nutrition. Individual dietetic assessment will take into account nutritional requirements and taste and texture preferences to ensure a tailored prescription is advised.

The following table shows the most common types of ONS available:

Type Notes
Juice type Volume ranges from 200-220ml with an energy density of 1.25-1.5kcal/ml. They are fat free
Milkshake type Volume ranges from 125-220ml, energy density ranges from 1-2.4kcal/ml. Also available with added fibre.
High-energy powders Volume ranges from ~125-350ml, ideally made up with full cream milk to give an energy density of 1.5-2.5kcal/ml.
Soup type Volume ranges from 200-330ml. Some are ready mixed and others are a powder and can be made up with water or milk to give an energy density of 1–1.5kcal/ml.
Semi-solid/dysphagia ranges Range of presentations from thickened liquids (stage 1 and 2) to smooth pudding styles (stage 3), with an energy density of ~1.4-2.5kcal/ml.
High protein Range of presentations; jellies, shots, milkshake style containing 11-20g of protein in volumes ranging from 30–220ml.
Low volume high concentration (shots) These are fat and protein based products that are taken in small quantities (shots), typically 30-40ml as a dose taken 3-4 times daily.

What else should be considered?

  • Further information regarding suitability of ONS should be checked with individual manufacturers for example, gluten or lactose free, halal or kosher.
  • ONS should be used with caution in those with dysphagia to ensure the correct consistency is provided. Thickeners can be added to obtained the recommended consistency.
  • A range of flavours should be offered to avoid taste fatigue.
  • There is an emerging group of ONS which are designed for individuals over the age of 65 years who can be at risk of vitamin D deficiency.
  • Other products may be useful in patients with specific medical conditions where fluid and electrolyte balance is important. Patients with short gut may not tolerate heyperosmolar ONS as they may increase stoma losses.

Monitoring

ONS should not be prescribed without being monitored to ensure that they remain appropriate and are being taken as prescribed. ONS may be stopped when:

  • Dietary intake is meeting nutritional requirements.
  • Weight has increased to target.
  • BMI is within healthy range.
  • The individual’s medical condition has changed, e.g. an individual with a swallowing difficulty recovers some/all of their functionality.
  • The individual can no longer tolerate them due to taste fatigue.

A number of strategies can be used to aid those with inadequate food intakes. These may include food enrichment, regular snacks and nourishing drinks. These strategies can be used alone or in combination with other methods such as oral nutritional supplements and enteral nutrition.

Malnutrition Pathway

One of the most recent resources in this area is found at www.malnutritionpathway.co.uk'Managing Adult Malnutrition in the Community’ is a practical guide to help identify, treat and prevent malnutrition in community settings. Developed by a multi-professional team it is supported/endorsed by ten key professional organisations including BAPEN. The document is based on clinical experience and evidence alongside accepted best practice and includes a pathway to assist in the appropriate use of oral nutritional supplements. Patient materials, a poster for use in general practice, care plans and an app as well as specific information for dietitians, GPs, nurses, speech and language therapists, patients and carers are also available via the website.

Other Resources

Carers UK have teamed up with Nutricia to produce information for carers and to help provide better support for carers around nutritional problems and eating difficulties. Please click here for information on Eating well for carers, Improving nutritional intake for the person you care for, Signs of a problem and Dementia and nutrition.

“Eating Better, Feeling Better” is a leaflet produced by the British Dietetic Association (BDA) as part of their “Mind the Hunger Gap campaign” for people who need simple advice to add more energy to their diet.

“Eating well for older people and older people with dementia: Practical Guide.” Helen Crawley and Erica Hocking. Caroline Walker Trust. This report includes a report and materials that can be used by those caring for older people to support them to eat well.

“Dementia Gateway: Eating well for people with dementia”. This web resource from the Social Care Institute for Excellence (SCIE) includes practical advice and a video on nutritional care for older people.

“Food First” Project Advice Leaflets These leaflets have been made available by the kind permission of Cathy Forbes, Advanced Specialist Dietitian - Food First Project Lead, SEPT Community Health Services, Bedfordshire.

“Focus on Undernutrition” is a project implementing a service to identify and treat undernutrition in health and social care settings across County Durham and Darlington. Although primarily addressed at healthcare professionals, it does also have resources for the public available on the website including information on “Food as Treatment for Undernutrition” and “Nutritional Supplements.”

The “Nutritional COPD Guideline” was created a working group of the Respiratory Healthcare Professionals and includes information leaflets on nutrition for patients with COPD:

“Eating well for Your Lungs” for patients at low risk of malnutrition

“Improving Your Nutrition” for patients at medium risk of malnutrition

“Nutrition Support in COPD” for patients at high risk of malnutrition

“Solihull Nutrition Support Project” Advice Leaflets These leaflets have been made available by the kind permission of Ruth Stow and the Soihull Nutrition Project Support Team

‘A Practical Guide for Lung Cancer Nutritional Care’, has been developed to assist the multidisciplinary team in delivering high quality nutritional care to patients with lung cancer.


Thanks are due to many healthcare professionals who provided copy for this area of the BAPEN website. Among them are...

  • Nicki Simmonds
  • Clare Thompson
  • Lisa Waldron
  • Laura Jones
  • Katrina Evans

With thanks also to the PENG committee of 2016 who reviewed content.

These leaflets have been made available by the kind permission of Cathy Forbes, Advanced Specialist Dietitian - Food First Project Lead, SEPT Community Health Services, Bedfordshire. They may be used with acknowledgement, but should not be modified or used without acknowledgement.

100 Calorie Boosters

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Fortified Diet Plan

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Getting the Balance Right: Following a Fortified Diet Longer Term

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Keeping Hydrated

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Nourishing Drinks

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Supplement Drinks

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