Nutritional care using oral nutritional supplements: 22 questions every clinician Asks—Answered by global experts in a Delphi consensus study

Background/aims: Malnutrition is a common clinical problem causing poor outcomes, including longer hospital stays, complications, functional decline, and mortality. Oral nutritional supplements (ONS) are a key component of medical nutrition therapy for patients who cannot meet their nutritional needs through diet alone. Despite their proven effectiveness, ONS use in practice remains inconsistent due to the lack of comprehensive, practice-based, and internationally validated guidelines. In 2023, the Turkish Clinical Enteral and Parenteral Nutrition Society (KEPAN) developed a national consensus report to address this gap. To enhance international validity and applicability, this study aimed to validate and refine those recommendations through a global Delphi process involving multidisciplinary experts. Methods: A two-round modified Delphi study was conducted between February 2023 and March 2024. Twenty-two experts from 13 countries and various disciplines (internal medicine, gastroenterology, geriatrics, surgery, family medicine, physiatry, clinical nutrition, dietetics, etc.) rated 22 predefined recommendations using a 5-point Likert scale. Consensus was defined as a median score ≥4 with a 25th percentile ≥4. Expert comments were reviewed and incorporated, and recent international guidelines were used to update the supporting commentaries as well. Results: Seventeen recommendations achieved consensus in round 1, and the remaining five in round 2. The final internationally validated set of recommendations covers practical aspects of ONS use including: (1) indications for initiation, dose, timing, and product selection; (2) monitoring strategies, adherence, and management of taste, tolerance, and other common problems; and (3) condition-specific considerations across diabetes, chronic kidney disease, cirrhosis, congestive heart failure, chronic obstructive pulmonary disease, neurological diseases, pressure injuries, surgery, cancer, geriatrics and multimorbidity, as well as guidance on continuation and discontinuation of ONS. The refined recommendations emphasize the food-first principle, individualized decision-making, and multidisciplinary collaboration to optimize person-centered nutritional care. Conclusions: This study delivers the first internationally validated, expert-informed recommendations on ONS use, providing a standardized and adaptable framework for global implementation. Familiarity with and application of these recommendations in clinical practice should lead to improved nutritional care, better adherence, enhanced patient outcomes, and more efficient, person-centered use of ONS across several healthcare settings.