Evidence Corner For ONS

The benefits of oral nutrition support (ONS) have been consistently documented across different studies. We provide below a quick review of the benefits of ONS and the evidence supporting their use in patients. For the purposes of the cited literature evidence, “high protein ONS” refers to ONS that has at least 20% of its calories from protein.

  • High Protein Oral Nutritional Supplements have proven nutritional, functional, clinical and economic benefits in both the hospital and community setting in a wide variety of patient groups1.
  • High Protein ONS leads to weight gain and prevention of weight loss in adult hospital patients2,3,4,6,7,11,14
  • High-Protein ONS lead to significant functional and quality of life benefits in adult hospital patients as well as in adult patients and older people in the community2,12,14,15,20,21,22,23,24,25
  • Significantly higher rate of remission in pediatric patients undergoing intensive chemotherapy for malignant disease who are supplemented with protein- and calorie-dense ONS compared with the group who received usual care19
  • High-protein ONS reduce length of hospital stay2,4
  • Protein-rich ONS prevent development of pressure ulcer32,33
  • High Protein ONS increase total energy intake in adult hospital patients2,4,5,7,8,9,10
  • High-Protein ONS lead to improvement in body mass in older people, adults and children2,4,6,8,13,17,18,19
  • Meta-analyses consistently show a reduction in mortality in patients given high-protein ONS versus standard care or control2,6,11,16,27,28
  • Meta-analyses consistently show a reduction in a variety of complications (nosocomial infections, pressure ulcer, GI complications, surgical site infection, anemia, cardiac complications), in patients given high-protein ONS compared with standard care2,4,6,11,26,29,30,31,32,33,39
  • Improve energy intake and reduction in weight loss in cancer patients2,29,34,35,36,37,38
  • High-protein ONS reduce hospital readmissions by 30%4,38,39 through reduction in complications and post-discharge relapse


1. Oral Nutritional Supplements to Tackle Malnutrition: A summary of Evidence Base: Medical Nutrition International Industry (MNI)

2. Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: An evidence based approach to treatment. Wallingford: CABI Publishing; 2003.

3. Parsons EL, Stratton RJ, Elia M. Systematic review of the effects of oral nutritional interventions in care homes. Proc Nutr Soc 2010; 69:E547. Ref Type: Abstract

4. Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Res Rev 2012; 11(2):278-296.

5. Duncan DG, Beck SJ, Hood K, Johansen A.Using dietetic assistants to improve the outcome of hip fracture: a randomised controlled trial of nutritional support in an acute trauma ward. Age Ageing 2006; 35(2):148-153.

6. Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev 2009;(2):CD003288.

7. Gazzotti C, Arnaud-Battandier F, Parello M, Farine S, Seidel L, Albert A et al. Prevention of malnutrition in older people during and after hospitalisation: results from a randomised controlled clinical trial. Age Ageing 2003; 32(3):321-325.

8. Lauque S, Arnaud-Battandier F, Gillette S, Plaze JM, Andrieu S, Cantet C et al.Improvement of weight and fat-free mass with oral nutritional supplementation in patients with Alzheimer’s disease at risk of malnutrition: a prospective randomized study. J Am Geriatr Soc 2004; 52(10):1702-1707.

9. Price R, Daly F, Pennington CR, McMurdo ME. Nutritional supplementation of very old people at hospital discharge increases muscle strength: a randomised controlled trial. Gerontol 2005; 51(3):179-185.

10. Parsons EL, Elia M, Cawood AL, Smith TR, Warwick H, Stratton RJ.Randomized controlled trial shows greater total nutritional intakes with liquid supplements than dietary advice in care home residents. Clin Nutr Suppl 2011; 6(1):31. Ref Type: Abstract

11. National Institute for Health and Clinical Excellence (NICE).Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition (clinical guidelines 32). London, National Institute for Health and Clinical Excellence (NICE). 2006. Ref Type: Report

12. Norman K, Kirchner H, Freudenreich M, Ockenga J, Lochs H, Pirlich M.Three month intervention with protein and energy rich supplements improve muscle function and quality of life in malnourished patients with non-neoplastic gastrointestinal disease-a randomized controlled trial. Clin Nutr 2008; 27(1):48-56.

13. Bos C, Benamouzig R, Bruhat A, Roux C, Valensi P, Ferriere F et al.Nutritional status after short-term dietary supplementation in hospitalized malnourished geriatric patients. Clin Nutr 2001; 20(3):225-233.

14. Persson M, Hytter-Landahl A, Brismar K, Cederholm T.Nutritional supplementation and dietary advice in geriatric patients at risk of malnutrition. Clin Nutr 2007; 26(2):216-224.

15. McMurdo ME, Price RJ, Shields M, Potter J, Stott DJ. Should oral nutritional supplementation be given to undernourished older people upon hospital discharge? A controlled trial. J Am Geriatr Soc 2009; 57(12):2239-2245.

16. Feldblum I, German L, Castel H, Harman-Boehm I, Shahar DR. Individualized nutritional intervention during and after hospitalization: the nutrition intervention study clinical trial. J Am Geriatr Soc 2011; 59(1):10-17.

17. Alarcon PA, Lin LH, Noche M, Jr., Hernandez VC, Cimafranca L, Lam W et al. Effect of oral supplementation on catch-up growth in picky eaters. Clin Pediatr (Phila) 2003; 42(3):209-217.

18. Soylu OB, Unalp A, Uran N, Dizdarer G, Ozgonul FO, Conku A et al. Effect of nutritional support in children with spastic quadriplegia. Pediatr Neurol 2008; 39(5):330-334.

20. Rabadi MH, Coar PL, Lukin M, Lesser M Blass JP. Intensive nutritional supplements can improve outcomes in stroke rehabilitation. Neurology 2008; 71(23):1856-1861.

21. Gariballa S, Forster S. Dietary supplementation and quality of life of older patients: a randomized, double-blind, placebo-controlled trial. Clin Nutr 2007; 25(6)545-551.

22. Gariballa S, Forster S. Dietary supplementation and quality of life of older patients: a randomized, double-blind, placebo-controlled trial. J Am Geriatr Soc 2007; 55(12)2030-2034.

23. Edington J, Barnes R, Bryan F, Dupree E, Frost G, Hickson M et al. A prospective randomised controlled trial of nutritional supplementation in malnourished elderly in the community: clinical and health economic outcomes. Clin Nutr 2004; 23(2):195-204.

24. Bunout D, Barrera G, de la Maza P, Avendano M, Gattas V, Petermann M et al. The impact of nutritional supplementation and resistance training on the health functioning of free-living Chilean elders: results of 18 months of follow-up. J Nutr 2001; 131(9):2441S-2446S.

25. Bonnefoy M, Cornu C, Normand S, Boutitie F, Bugnard F, Rahmani A et al. The effects of exercise and protein-energy supplements on body composition and muscle function in frail elderly individuals: a long-term controlled randomised study. Br J Nutr 2003; 89(5):731-739.

26. Avenell A, Handoll HH.Nutritional supplementation for hip fracture aftercare in older people. Cochrane Database Syst Rev 2010;(1):CD001880.

27. Milne AC, Potter J, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev 2005;(2):CD003288.

28. Milne AC, Avenell A, Potter J. Meta-analysis: protein and energy supplementation in older people. Ann Intern Med 2006; 144(1):37-48.

29. Burden ST, Hill J, Shaffer JL, Campbell M, Todd C. An unblinded randomised controlled trial of preoperative oral supplements in colorectal cancer patients. J Hum Nutr Diet 2011; 24(5):441-448.

30. Stratton RJ, Elia M. Who benefits from nutritional support: what is the evidence? Eur J Gastroenterol Hepatol 2007; 19(5):353-358

31. Lidder P, Lewis S, Duxbury M, Thomas S. Systematic review of postdischarge oral nutritional supplementation in patients undergoing GI surgery. Nutr Clin Pract 2009; 24(3):388-394.

32. Langer G, Schloemer G, Knerr A, Kuss O, Behrens J. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev 2003;(4):CD003216.

33. Stratton RJ, Ek AC, Engfer M, Moore Z, Rigby P, Wolfe R et al. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Res Rev 2005; 4(3):422-450

34. Bozetti F. Nutritional support in patients with oesophageal cancer. Support Care Cancer 2010; 18(Suppl 2):S41-S50.

35. Elia M, van Bokhorst-de van der Schueren MA, Garvey J, Goedhart A, Lundholm K, Nitenberg G et al. Enteral (oral or tube administration) nutritional support and eicosapentaenoic acid in patients with cancer: a systematic review. Int J Oncol 2006; 28(1):5-23.

36. Lee H, Havrila C, Bravo V, Shantz K, Diaz K, Larner J et al.Effect of oral nutritional supplementation on weight loss and percutaneous endoscopic gastrostomy tube rates in patients treated with radiotherapy for oropharyngeal carcinoma. Support Care Cancer 2008; 16(3):285-289.

37. Garg S, Yoo J, Winquist E. Nutritional support for head and neck cancer patients receiving radiotherapy: a systematic review. Support Care Cancer 2010; 18(6):667-677.

38. Stratton RJ, van Binsbergen J, Volkert D. Systematic review and meta-analysis of the effects of oral nutritional supplements on hospital admissions. Clin Nutr 2011; 6(Suppl 1):16. Ref Type: Abstract

39. de Aguilar-Nascimento JE, Bicudo AS, Caporossi C, Dintz BN, Silva RM, Santos TP. Clinical benefits after the implementation of a multimodal perioperative protocol in elderly patients. Clin Nutr 2008; 3(Suppl 1):22. Ref type: Abstract

40. Hiesmayr M, Schindler K, Pernicka E, et al. Decreased food intake is a risk factor for mortality in hospitalised patients: The NutritionDay survey 2006. Clin Nutr. 2009; 28(5):484-491.

41. Valentini L, Schindler K, Schlaffer R, et al.The first nutrition Day in nursing homes: Participation may improve malnutrition awareness. Clin. Nutr. 2009; 28(2):109-116.

42. Andreyev HJ, Norman AR, Oates J, Cunningham D.Why do patients with weight loss have a worse outcome when undergoing chemotherapy for gastrointestinal malignancies? Eur J Cancer 1998; 34(4):503-509.

43. Argiles JM. TCancer-associated malnutrition Eur J Oncol Nurs 2005; 0 (Suppl2):S39-S50.