Recommendation Report

SELECTING ORAL
NUTRITIONAL
SUPPLELEMTS
FOR NEW HAVEN
HOSPITAL

Holland, Emily E
Tech Writing and Presentation
 Table of Contents

Abstract……………………….2
Executive Summary…………..3
Introduction…………………...4
Research Methods…………….4
Results………………………...5
Conclusion…………………….8
Recommendation……………...8
Resources……………………..10
Appendices……………………11

1
Abstract
A small city hospital in New Haven, Connecticut contacted me to help with their decision
making process on whether or not to supply their patients with oral nutritional supplements, and
if so which supplements to use. As a dietician, I consulted a fellow future dietician for their
recommendations as well as their perception of what is most important when it comes to
choosing a supplier for oral nutritional supplements. Several different approaches were taken
when considering which supplements to choose, beginning with understanding the population of
New Haven CT better. New haven was found to be a food desert indicating that its residents are
likely to struggle with getting the proper nutrition at home, making it even more important that
the hospital provide adequate nutrition to all of its patients. An analysis of Carnation, Boost,
Ensure, and any Nutricia was conducted. The nutritional facts of each brand as well as the
products available were compared in order to determine which brand met the needs of the
hospital the best. Nutricia was recommended as the best choice for the hospital because of the
wide variety of products that can be used for all different types of patients including products
that are specially formulated for dementia care, wound care, pediatrics, allergies, and many other
specialty products that will suit patients of the hospital. It is recommended that although
nutritional supplements have many benefits, that they are used alongside a balanced diet rather
than as the sole source of nutrition. This is because of the possible side effects which include
muscle cramps, diarrhea, constipation, and other mild gastrointestinal symptoms. I want to
highlight the importance of proper use in the healthcare setting as well as proper education about
the oral nutritional supplements prior to discharge as there are more severe side effects that can
occur including seizures, heart rate issues and trouble breathing. That being said, the benefits
short term use of oral nutritional supplements while in a healthcare setting far outweigh the
possible negative effects. Some positive effects of the nutritional supplements that are beneficial
to the hospital include shorter length of stays, and decreased readmission.

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Executive Summary
Oral nutritional supplements are liquids or powders which supply both macro and
micronutrients to people and are an integral part of the care plan for a variety of different patients
within a healthcare setting. This is especially true for those patients which are critically ill who
are unable to meet their nutritional needs with diet alone, or are not able to consume a real meal.
Choosing the best oral nutritional supplement brand to provide throughout the hospital is
especially important in this hospital because of the economic factors that impact the citizens of
New Haven, including a 25% poverty rate. This means that 1 in 4 patients that comes into the
hospital is likely to be struggling financially or is considered poor. Factors like the lack of
grocery stores in a short distance make New Haven a food desert, and anyone without adequate
transportation is not likely to be able to get access to proper produce and fresh groceries. Rather,
they are left to purchase whatever is in an accessible distance, likely a convenience store or fast
food restaurant for their nutritional needs.
Analysis of several major brands of oral nutritional supplements was conducted. The
costs, variety available, flavor, nutritional value, and specialty products offered were all
considered in the decision making process. The brands that were considered were 4 popular
brands most used in hospitals. This includes Carnation, Boost, Ensure, and Nutricia. An
interview with a future registered dietican was also conducted to get their view on the
importance of oral nutritional supplements as well as what aspects of the supplementation is
most important. Secondary research was also conducted on the positive effects that oral
nutritional supplements can have on patients. These include a shorter length of stay, increased
patient strength, and decreased patient readmission.
A recommendation to use the brand Nutricia was made because of the similar cost to
other products but the increase in variety and specialty products that the brand can bring to the
hospital. Not only does Nutricia offer products with increased calorie count for the
malnourished, but also offers products for patients from birth until geriatrics with all different
needs including allergies, metabolic disease, and Alzheimer’s.
Not only would the decision to use Nutricia be beneficial to the patients that are taking it,
but the hospital would benefit from its effects as well. A decreased length of stay means that the
hospital will be able to intake more patients on an annual basis, in turn increasing revenue for the
hospital and creating a healthier community since a decrease in readmission rates has also been
proven with correct supplement use. When increased patient strength and rehabilitation is paired
with the other benefits, it is likely that patient satisfaction would also increase. This would lead
to patients choosing this hospital again over other options in the area, as well as recommending it
to friends and family.
Although the nutritional supplements can be costly, especially the specialized versions,
Nutricia’s website disclosed that many of their products can only be used under medical
supervision and can then be considered a medical intervention. It is likely that insurance would
play a part in the payment for these types of medical interventions and the hospital would not be
responsible for the bill for some of the products that are being used.
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Introduction
This recommendation report is being conducted to address the need of nutritional supplements
in a hospital setting in New Haven, Connecticut. The hospital will be seeing a large variety of
patients, and with a poverty rate of 25% in New Haven, it is likely that at least 1 in 4 patients
will be struggling financially. New Haven is also known as a food desert, meaning that there are
not enough options for it’s citizens to get adequate nutrition because grocery stores are not
located in areas that the people of the city are. Through an interview with a future registered
dietician, the importance of oral nutritional supplements was emphasized, especially considering
the area of New Haven and the likelihood that many are not able to get the proper nutrition at
home. Research done on the demographics of the New Haven area were conducted, as well as
different options for these nutritional supplements. It was found that one brand in particular,
Nutricia, offered not only the best oral nutritional supplement for adults, but also offered a whole
line of products that would be especially beneficial to the hospital. Partnering with a company
like Nutricia and having them be the sole provider of products to the hospital would be highly
recommended as there could likely be a financial advantage for both sides.

Research Methods
The first part of research that was done was to figure out the demographic of the region in New
Haven, CT. Knowing what types of patients the hospital will be servicing will make it easier to
identify the likelihood of what their nutritional needs would be. Knowing the poverty rate and
what sources of food are available is an important step in identifying what the nutritional intake
of the people who live in the city is like. Other important data that was researched was about the
nutrition and the people of New Haven. I was able to research the food supply in the city. What
was not included in the research was different services of transportation that could get patients to
and from these grocery stores and if the stores are really as accessible to the citizens as they
appear to be. I have conducted an interview with a student who is currently in school to become
a registered dietician. The purpose of the interview was to receive input on the importance of
nutrition to sick patients and make suggestions on nutritional supplements that are affordable for
the hospital, can be given to a wide variety of patients, and can give insight as to what is most
important in the eyes of a true dietician. I was most concerned with getting information about
what is most important to a general hospital patients health in order to determine which types of
nutritional supplements the hospital would be using. A final piece of research that was done was
regarding different types of oral nutritional supplements as well as their costs and benefits. An
analysis of each brand of nutritional supplement was conducted by visiting the company’s
website and looking through the products offered as well as the different nutritional facts
associated with each of the products. Research on patient opinion of the products was also
conducted by visiting several different forums and websites in which patients and healthcare
professionals expressed their opinion of the different types of nutritional supplements as well as
preference on flavor and cost. Another important aspect that was researched was the possible
negative effects of nutritional supplements, if any.

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Results
I first wanted to research the different types of patients that were seen at hospitals in
order to get a better idea of what their nutritional needs would be. Although all hospitals see a
range of different patients that all have different needs, it is important that the hospital pick a
product that is able to be used for a wide variety of patients and can benefit each of them.
According to “The Association between Oral Nutritional Supplements and 30-Day Hospital
Readmissions of Malnourished Patients at a US Academic Medical Center” written by Mullin et
Al, malnutrition affects up to 50% of hospitalized patients, and as many know, the body needs
nutrition to heal, so malnutrition can lead to lengthened stays and other adverse effects including
hospital readmission. The article found that of the patients that were considered malnourished,
only 3.1% of these patients received oral nutritional supplements. Of the patients that did receive
the supplementation, there was a 38.8% decrease in readmission as compared to malnourished
patients who did not receive oral supplements. There was also an association between a shorter
length of stay and the supplementation being given within the first day of stay. After this I did
research on the demographics of the people of New Haven. I found that New Haven has a
population of 130,850 and has a demographic of 44.14% white, 32.96% black or African
American, 13.47% some other race, and less than 5% of each Asian and American Indian. The
majority of houses in New Haven are rentals and the city has a 25.86% poverty rate, which is
substantially higher than the national poverty which is 9.2%.
Research was also conducted on the food Food Desert: Geographic
supply in New Haven, where it was found that the city locations where residents’
of New Haven is known as a food dessert. An article access to affordable, healthy
written by the Yale school of medicine outlined how food options (fresh fruit and
the loss of several major supermarkets in the city has vegetables is restricted or
led to large amounts of people having to travel a great nonexistent due to absence of
distance to get groceries, and many people in the city grocery stores within convenient
of New Haven do not have this form of transportation. traveling distance.
Without the ability to access fresh produce, the
citizen’s of New Haven are left to travel great
distances to get this produce, which isn’t possible for residents that don’t have transportation.
This leaves no choice but to get the quicker more convenient foods which in many cases are less
healthy and can’t provide adequate nutrition.
A final piece of research that was conducted was specific forms of dietary supplements.
From a thorough review of the products available, it was determined that there are several
different types of oral nutrients that can be chosen from. These include nutritional drinks,
powders, puddings, pre-thickened mixes and many more. The first type of nutritional supplement
was powdered, with a focus on Carnation instant breakfast option. While there are many other
different forms of powdered nutrition, much like you would see in stores like GNC, without
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individually packed portions like carnation offers, it is not likely that a hospital kitchens could
keep up with patient demand with an inefficient process like measuring out powder for each
patients. Carnation included 21g of several vitamins and minerals with 13g protein and 220
calories per packet, and also offered versions with probiotics, higher proteins and lighter calorie
options. They also include shake options, which include similar nutritional content, with less
protein and increased calories. There is also a higher protein version of the Carnation shake.
Other shakes that were researched included the brand Boost and Ensure. Boost had various
options including high protein, extra calories, glucose control, optimum, and calorie smart
versions. The nutritional data of many of the boost products were approximately 240 calories, 4g
fat, 10g protein and 20g sugar. Depending on the different variety of product these values
changed. Ensure also included several more varieties including an original, Ensure plus targeted
for weight gain, Ensure Enlive targeted for advanced nutrition, max protein, light nutrition, a
compact 4fl oz version, and a surgery immunonutrition shake. The last brand of nutritional
supplement that was considered was the brand Nutricia. The list below outlines the different
products that Nutricia offer’s for all age groups.

Nutricia Product Lines:

 Cow’s Milk Allergy
 Epilepsy
 Inherited Metabolic Disorders
 Pediatric Disease Related Malnutrition
 Frailty and Disease Related Malnutrition
 Oncology
 Early Alzheimer’s Disease
 Critical Care Nutrition and Medical Devices
 Stroke and Dysphagia
 Wound Care

The nutritional content of the products from Nutricia were similar to those of Boost and Ensure,
but the variety was much more widespread. The most important aspect to note about Nutricia is
the number of products offered for different age groups. Not only do they offer products for
adults, but also for children and geriatric groups as well. Nutricia has products offered that can fit
the needs of almost all of the possible patients that the hospital would see in different
departments.
Table 1 shows the different choices for oral nutritional supplements for adults specifically
as well as which brands offer a variety of products.
Table 1:

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 Type Style Company
Premade Liquid Milkshake Resource Energy (Nestle)
Ensure
Boost
Carnation Shake (Nestle)
Juice Nutricia (Fortisip)
Ensure
Nutricia (Fortijuice)
Powder Milkshake Resource Fruit (Nestle)
Ensure
Carnation Instant Breakfast (Nestle)
Pre-Thickened Milkshake Nutilis Stage 1
Dessert Nutilis Stage 2

From the research conducted, it is clear that oral nutritional supplements come in a wide
variety of products that can be beneficial to all types of patients. The possible negative effects of
these supplements is also important to note. It is important that even in malnourished patients, it
is recommended that nutritional supplements are not the only source of food and that they are
used in conjunction with whole or partial meals if the patient is able to eat whole foods. The
milkshakes and powders offer a wide variety of nutritional needs, but in the end the best source
of nutrition is still from foods and juices. There are also possible side effects that come along
with the consumption of these drinks that include constipation, diarrhea and vomiting. Many of
these items are available for purchase by the general public, and improper use outside of the
healthcare setting can lead to more severe consequences. These include seizures, irregular heart
rate, changes in mood or mental state, shortness of breath, muscle cramps and troubles breathing.
The vast majority of people who are able to consume food would benefit more from a balanced
meal than from these supplements due to the high sugar content in many of the drinks as well as
artificial sugars that are included in the supplements. The nutritional drinks can also be costly. It
is important that before the supplement is given, all of the medications that the patient is on are
considered as they can sometimes have a negative effect when interacting with certain drugs.
An interview was conducted with a current student in school to become a registered
dietician. She had emphasized the importance of fresh produce and grocery availability within
the community and how this can greatly impact the nutritional needs of the community. Because
of the location of the hospital, she too believed that oral nutritional supplementation would be
beneficial to the majority of patients that visited the hospital, especially those who are considered
malnourished, but that it should not be the only source of nutrition even for these groups. She
emphasized the importance of oral nutritional supplements in an inpatient healthcare setting
because of the benefits that it has proven to have with length of stay, infection rate, and physical
function within all age groups. The most important consideration that was brought about through
the interview was the consideration of long term use of these nutritional supplements because of
the high sugar content in many of the milkshakes and powders, she does not recommend long
term use of the supplements and rather short term use during hospital stays, chemotherapy, and
rehabilitation.

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Conclusion
From all of the data compiled for the recommendation report, I have come to few
conclusions. With the data that up to 50% of patients that come into hospitals can be considered
“malnourished”, one can see the importance of supplementation and the hospitals duty to
thoroughly research and consider all options to give their patients the best nutrition when they
are in their care. With over a 25% poverty rate in the city of New Haven, 1 in 4 patients is likely
to be struggling with money in some way or another, so it may not be possible that they are able
to afford the proper nutrition outside of the hospitals care, making it even more important for this
hospital to provide the best options for supplementation to ensure that the patients are able to
stay healthy. One of the most important aspects of the research was discovering that New Haven
does not have a lot of resources for people without adequate transportation for long distances.
Not only does the hospital have a responsibility to provide supplements like these nutritional
milkshakes but offering a wide variety of healthy foods and fresh produce for the patients to
order while at the hospital is just as important, as nutritional supplements work best when used in
conjunction with a balanced diet. There was not research conducted on the public transportation
available and where it drops patrons off, so this is not considered in analysis.
The first form of supplementation that was investigated was powdered supplementation,
which can be added to milk, water etc. One example of this was Carnation Instant Breakfast. It
seems as though from the different supplements that were researched, Carnation is not the best
option because many of its varieties are powder packets which must be mixed into drinks. With
hospital workers already being busy, mixing in the proper amount of mix for each patient seems
like an unrealistic idea. Carnation also offered the least amount of variety for different
populations. Boost included a lot of similar options to Ensure, even including a glucose control
option, but each of the brands contained very high sugar content for the majority of its products
and did not offer enough variety for patients other than adults and geriatric. Although many of
the hospital’s patients will be of this demographic, having a brand that is able to provide
supplementation for all demographics of patients including pediatrics would be the most
beneficial for the hospital. This is why Nutricia fits the mold best for the hospitals needs. With a
large variety of products that specialize in allergies, dementia care, wound care, and many others,
it is clear that Nutricia is the best option.

Recommendation
From the data collected, interviews conducted, and analysis it is my recommendation that
the hospital provide nutritional shakes for its patients. From my analysis of the specific brands of
shakes, my first recommendation would be Nutricia, with Ensure and Boost being the runner up.
Because Boost offers a diabetic friendly version, I would recommend that if not all products are
Boost, that this or another diabetic brand is offered to patients. I recommend that shakes are used
because they have a long shelf life, don’t have to be refrigerated until after opening, can easily be
taken on the go, and offer a wide variety of nutritional needs to fit all of the different types of
patients that the hospital will be seeing. One population that is seen in the hospital frequently and
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can highly benefit from nutritional shakes such as this is the senior population. It is usual that
seniors don’t have the kind of appetite that they once had, and many confused patients
sometimes refuse to eat. The flavor and simpleness of the shakes make it easier for healthcare
providers to entice the patients to intake and can know that although the patient did not have a
full meal, they are still getting adequate nutritional intake. Because of the location of the
hospital, these nutritional needs are extremely important. It is also important that nutritional
supplements are not used solely and rather in conjunction with balanced meals that are high in
protein and nutrients for every age group. Nutricia is the recommended brand because of the
different variety that it provides, especially to acutely sick patients who may not have a large
appetite because of the health problems that they are suffering with.
I also recommend that social work is involved with patients who are labeled as
malnourished and steps are taken to ensure that once the patient is discharged from the hospital
they are able to sustain adequate nutrition. With the city of New Haven considered a food desert,
help with groceries outside of the hospital is in the utmost of importance as it is likely that
patients will be hospitalized with similar problems if they are not able to access proper nutrition
at home.
Overall, there are several negative effects of the nutritional supplements, but if the
hospital implements proper procedure when supplying the drinks it is likely that the symptoms
will be mild and bearable for the majority of patients. It is recommended that each patient is
evaluated separately before supplementation is provided in order to ensure that the benefits of the
supplementation outweigh the possible negative effects. It is also recommended that at discharge
from the hospital, the use of these supplements is explained to the patients. Although they are
available to the general public, having healthcare providers explain that short term use outside of
the hospital is recommended rather than long term use because of the high sugar content.
Ensuring that the patients also use the supplements correctly and do not over consume the
products is also strongly recommended.

9
 Resources
Cassie, Steele, G., & Angelica. (2020, September 08). Ensure vs Boost - Which Nutritional
Shake is Better? Retrieved December 03, 2020, from
https://www.multiculturalcaregiving.net/ensure-vs-boost/

Dillon, J. (2010, November 26). City supermarket closes, leaving a "food desert" along Whalley
Avenue. Retrieved December 03, 2020, from https://medicine.yale.edu/news/yale-
medicine-magazine/city-supermarket-closes-leaving-a-food-desert-along/

Ehrlich, D. (2020, November 24). Think Twice About Giving Seniors Nutritional Supplement
Drinks or Shakes. Retrieved December 03, 2020, from
https://www.agingcare.com/articles/nutritional-drinks-seniors-elderly-problems-
139710.htm

New Haven, Connecticut Population 2020. (n.d.). Retrieved December 03, 2020, from
https://worldpopulationreview.com/us-cities/new-haven-ct-population

Mullin GE, Fan L, Sulo S, Partridge J. The Association between Oral Nutritional Supplements
and 30-Day Hospital Readmissions of Malnourished Patients at a US Academic Medical Center.
J Acad Nutr Diet. 2019 Jul;119(7):1168-1175. doi: 10.1016/j.jand.2019.01.014. Epub 2019 Apr
4. PMID: 30954446.

Products: Carnation Breakfast Essentials®. (n.d.). Retrieved December 03, 2020, from
https://www.carnationbreakfastessentials.com/products

Robert H. Shmerling, M. (2020, September 18). Harvard Health Ad Watch: Are nutritional
drinks actually good for you? Retrieved December 03, 2020, from
https://www.health.harvard.edu/blog/harvard-health-ad-watch-are-nutritional-drinks-
actually-good-for-you-2020032019204

10
Appendices
Interview Questions:
1. How important would you consider nutritional supplementation in an inpatient healthcare
setting?
2. What is the role of a dietician in the decision-making process on nutritional
supplementation?
3. What does the hospital consider most important when choosing a vender? Cost?
4. What nutritional needs are most important for the general hospital population?
5. In your opinion, does the pros to nutritional supplementation outweigh the cons?

Decision Matrix:
Factor Weight Oral Nutritional Supplement Brand
Boost Ensure Carnation Nutricia
Cost 0.3 4 4 3 4
Variety 0.2 3 3 2 5
Flavor 0.1 4 4 3 4
Shelf Life 0.1 4 4 5 5
Specialized Options 0.3 4 3 3 5
Total: 3.8 3.5 3 4.6

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