Nutrition Supplements and Sip Feeds: When Food Is Not Enough

When "food first" is not enough

The sequence usually followed by clinical guidelines, such as those of the European Society for Clinical Nutrition and Metabolism (ESPEN), is:

1. Find and treat causes of poor intake: teeth, swallowing, mood, constipation, pain, medicines; see loss of appetite in older adults: causes and practical fixes. 2. Fortify ordinary food and offer small frequent meals and snacks; see malnutrition in older adults: signs and prevention and high-protein Indian meals for seniors. 3. Add oral nutritional supplements if weight loss or low intake continues. 4. Consider tube feeding if the person cannot safely eat or drink enough, even with supplements, and it fits their wishes and prognosis.

Supplements are most often used for people who are malnourished or at risk, recovering from illness, surgery or a pressure sore, with a poor appetite from chronic disease, with dysphagia, or with dementia and low intake.

Types of oral nutritional supplements

• Ready-to-drink milk-style or juice-style supplements: sealed bottles or cartons, usually 200 to 250 ml, supplying roughly 200 to 400 kilocalories and 8 to 20 grams of protein, plus vitamins and minerals. Available in many flavours, and in "high-protein" and "high-calorie" versions.
• Powdered formulas: to be mixed with water or milk; often cheaper per serving; must be mixed carefully for hygiene and consistency.
• Thickened or pudding-style supplements for people with swallowing problems, as the speech therapist advises.
• Diabetes-specific formulas: with slower-digesting carbohydrates, designed to limit rises in blood sugar; see eating for diabetes after 60.
• Renal formulas for kidney disease, lower in potassium, phosphorus and fluid volume; use only on the nephrologist's or dietician's advice; see eating with chronic kidney disease: a family guide.
• Protein-only powders or liquids to add to food; see protein powder for older adults: who needs it and how to choose.
• Multivitamin and mineral products; see multivitamins for older adults: helpful or wasteful?.

Ready-made supplements are classed as "foods for special medical purposes" in many countries, including India, and should be used under medical supervision.

How to use sip feeds

• Follow the doctor's or dietician's prescription: how many a day, which flavour, and for how long, often one to three servings a day.
• Use between meals, not instead of them, usually mid-morning, mid-afternoon and at bedtime, so as not to spoil the appetite for meals. Some people take them with or after meals if they are very frail, as advised.
• Sip slowly over 20 to 30 minutes if large, or in small amounts through the day.
• Serve chilled (often better tolerated), or at room temperature; warm in some cases, such as milk-based types as the label allows; do not microwave unevenly.
• Use in cooking: powder or liquid supplements can be added to porridge, kheer, soups, milkshakes and custards to disguise taste, as the dietician allows.
• Vary flavours to avoid taste fatigue, but do not alter diabetes or kidney formulas.
• Check expiry and storage: keep unopened packs cool and dry; refrigerate opened bottles and use within the time on the label (often 24 hours); wash cups and straws; mix powders with safe boiled and cooled water and consume promptly.
• Swallowing difficulty: use only a texture approved by the speech and language therapist; do not thicken on your own; see soft and pureed diets and swallowing problems (dysphagia) in older adults.
• Monitor weight weekly, appetite, intake and side effects; see weighing scales and unplanned weight loss in older adults; the doctor or dietician reviews at about two to four weeks and stops the supplement when no longer needed.

Possible side effects

Fullness that reduces meals, nausea, bloating, loose stools or constipation, taste fatigue, high blood sugar with standard formulas in diabetes, and allergic reactions (milk and soy are common allergens) can occur. Tell the dietician. Seek urgent help for severe vomiting, difficulty breathing or swelling; call 112 if severe.

Homemade alternatives

Fortified home foods are often cheaper, familiar and culturally acceptable, and may be tried before or alongside commercial supplements. Examples (amounts approximate, adjusted by the dietician):

• Fortified milk: a glass of full-fat milk with two to three tablespoons of skimmed milk powder, a teaspoon of ghee or nut powder, and flavouring (cardamom, saffron, almond, dates, banana or mango).
• Banana, date or mango milkshake with milk powder and ground nuts.
• Sattu or ragi drink made with milk, jaggery and nut butter.
• Dal or lentil soup blended with ghee and paneer.
• Kheer, custard, halwa, ragi malt, dalia with milk, powder and ghee.
• Khichdi with ghee, mashed paneer or egg.
• Egg flip, scrambled egg or mashed egg in curries.
• Peanut butter or nut paste stirred into porridge and sauces.

Cautions: avoid excess sugar in diabetes; avoid unsterilised raw eggs; keep hygiene; calculate calories and protein with a dietician; and for kidney disease, potassium and phosphorus matter. Homemade mixtures do not contain a balanced set of micronutrients unless supplemented.

Tube feeding: what it is

Tube feeding (enteral nutrition) delivers a liquid feed directly into the stomach or intestine through a tube, when a person cannot take enough food by mouth safely. It does not mean a person can never eat again; in some cases, tube and oral feeding are combined.

Types of tubes - Nasogastric (NG) tube: a thin tube passed through the nose into the stomach, used short term (usually up to a few weeks) in hospital or at home. - Gastrostomy (PEG or similar): a tube placed through the abdominal wall into the stomach, by a small procedure, for longer-term use.

When it is considered - Severe swallowing difficulty after stroke, in neurological disease or head and neck cancer, with a reasonable expectation of benefit. - Prolonged inadequate intake despite supplements. - Recovery from major illness or surgery. - Some digestive conditions.

Not always helpful: evidence shows that in advanced dementia, tube feeding generally does not prolong life, prevent aspiration pneumonia or improve comfort compared with careful hand feeding, and many guidelines advise against starting tube feeding in this situation; careful hand feeding and comfort-focused care are usually recommended; see dementia, eating and weight loss and palliative care at home: what it is and how to arrange it. Decisions should involve the person's wishes (advance wishes), the family, the doctor, the dietician and the therapist, and consider benefits, burdens and values.

Types of feeds - Special formulas for diabetes, kidney disease, high protein, fibre-enriched or semi-elemental. - Blenderised (homemade) feeds: some families prepare blended food for tubes. These carry risks: inconsistent nutrition, blocked tubes, contamination and infection; they should only be used with a dietician's recipe and training, hygiene and the right tube size.

Basic safety for tube feeding at home

This is nursing care; a trained nurse and dietician must teach the family before discharge and review regularly.

• Hand hygiene before any contact.
• Position: upright at 30 to 45 degrees or more during feeds and for at least 30 to 60 minutes afterwards, to reduce reflux and aspiration.
• Check the tube position and securing as taught; never push or pull the tube; report if it has moved or fallen out (a gastrostomy tube that falls out within weeks can close quickly, so seek help at once).
• Use the right feed, at the right rate and volume, and at room temperature; do not mix feeds with medicines.
• Flush the tube with the prescribed amount of water before and after feeds and medicines, to avoid blockage.
• Medicines: give each separately, using liquid or crushable forms as the pharmacist advises; never crush slow-release or coated tablets; see giving medicines safely at home.
• Feed hygiene: clean equipment and discard unused feed per label.
• Mouth care continues; see oral care for frail older adults and denture hygiene.
• Monitor weight, bowel habit, hydration and blood sugar if diabetic.
• Watch for complications: blocked tube, diarrhoea, constipation, nausea, vomiting, aspiration, infection at the site, bleeding, leakage; see diarrhoea and dehydration in older adults and constipation in older adults: fibre, fluids and movement.

Seek urgent help (call 112) for choking, severe breathlessness, vomiting with a swollen abdomen, a tube that has come out with bleeding or severe pain, or signs of sepsis such as high fever with confusion and low blood pressure.

Questions to ask the doctor and dietician

Ask why the supplement or tube is needed and what the goal is; which product, how much and for how long; how success will be judged and when it will be reviewed; whether there are interactions with medicines or conditions; and, if tube feeding is suggested, what the benefits, burdens and alternatives are, what the person would want, and who to call in an emergency.

When to ask a professional

Ask the doctor and a dietician to assess nutrition and decide on supplements or tube feeding, and a speech and language therapist to assess swallowing. Ask a nurse to teach tube care. Ask a pharmacist about medicine administration and interactions. Seek help promptly for weight loss, poor intake, choking, vomiting, diarrhoea or tube problems.