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Printable Malnutrition 'Food First' Pathway

What’s New? – March 2019

The previous guidance has been updated and is now in an easy-to-read and printable format.  The ‘Food First’ dietary information for patients has also been re-designed as one booklet and is available to print here.


GCCG Oral Nutritional Supplement (ONS) or ‘Sip Feed’ Prescribing Guidance

Ensure Food First approach has been followed.

Review goals and check if still appropriate (see condition specific guidance below)


Ensure patient meets Advisory Committee on Borderline Substances (ACBS) criteria and document which approved category is relevant. Consider presence of renal disease, malabsorption and dysphagia. Some ONS may not be appropriate in these conditions. Refer to the BNF or consider not prescribing ONS and seek dietetic advice. Consider risk of refeeding syndrome.

Advisory Committee on Borderline Substance (ACBS) Criteria

Patient’s clinical condition should fall within the Advisory Committee on Borderline Substances (ACBS) approved categories for prescribing nutritional supplements (Short bowel syndrome, intractable malabsorption, pre-operative preparation of undernourished patients, proven inflammatory bowel disease, following total gastrectomy, bowel fistulas, disease related malnutrition)

Please note, not all oral nutritional supplements are approved for use in all ACBS categories. Refer to BNF for the more specific indications which apply to individual products (such as dysphagia and age related restrictions).

  • Follow flow chart to issue prescription for a SAMPLE PACK ONLY of the most appropriate first-line ONS.
  • Inform patient that these should not replace meals or snacks but be taken in between.



Follow ONS review guidelines in 1 month.

Guidelines for ONS review

Review continuing need for ONS prescription after 28 days of ONS.


Prescribing other Health Care Professional ONS Requests

All prescription requests for oral nutritional supplements (ONS) should be dietitian led. If a request is received from another healthcare professional including specialist community nurisng teams, then please contact the GCCG Prescribing Support Dietitian for further advice.

A prescription request should be sent by the dietitian indicating:

  • MUST score
  • Cause of malnutrition
  • ACBS criteria
  • What Food First advice has been issued
  • Goal(s) of nutritional support
  • Whether the dietitian intends to review the patient and timeframe for this. 

Patient will have been trialled with ONS and sent home with 1-2 weeks supply.

Issue prescription to bring total amount to 28 days supply.

If patient has been receiving sip feeds in hospital and/or discharged with a supply but NO dietitian letter has been sent to request further prescription then DO NOT issue and encourage Food First instead.

Patient will have been trialled with ONS.

Issue prescription for amount requested by dietitian.

Do not issue further prescription until request from dietitian is received.

If patient’s supply has ended they should contact their dietitian for a review.

Review patient after 28 days following ONS review guidelines

Assessment of Risk of Refeeding Syndrome

Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients on refeeding following a period of starvation (NICE, 2006). This is particularly common in patients receiving artificial refeeding, but is possible with oral refeeding (particularly if oral nutritional supplements are prescribed). The patient should be considered at risk of refeeding syndrome if they meet the following criteria (NICE 2006).

  • Body mass index less than 16 kg/m2
  • Unintentional weight loss more than 15% in the past three to six months
  • Little or no nutritional intake for more than 10 days
  • Low levels of potassium, phosphate, or magnesium before feeding

  • Body mass index less than 18.5 kg/m2
  • Unintentional weight loss more than 10% in the past three to six months
  • Little or no nutritional intake for more than 5 days
  • History of alcohol misuse or drugs, including insulin, chemotherapy, antacids, or diuretics

  • Start nutrition support at a maximum of 10 kcal/kg/day, increasing levels slowly to meet or exceed full needs by 4–7 days
  • Restore circulatory volume and monitoring fluid balance and overall clinical status closely
  • Provide immediately before and during the first 10 days of feeding: oral thiamine 200–300 mg daily, vitamin B compound strong 1 or 2 tablets, three times a day (or full dose daily intravenous vitamin B preparation, if necessary) and a balanced multivitamin/ trace element supplement once daily. See the CCG Live Specialist Drug Traffic Light List for further information.
  • Provide oral, enteral or intravenous supplements of potassium (likely requirement 2–4 mmol/kg/day), phosphate (likely requirement 0.3–0.6 mmol/kg/day) and magnesium (likely requirement 0.2 mmol/kg/day intravenous, 0.4 mmol/kg/day oral) unless pre-feeding plasma levels are high. Pre-feeding correction of low plasma levels is unnecessary
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