Why Nutritional Supplements Matter for Dysphagia Patients

Dysphagia significantly increases the risk of malnutrition and dehydration. Patients who take longer to eat, fatigue during meals, or must restrict their diet to specific textures often fail to meet their nutritional requirements from food alone. Oral nutritional supplements (ONS) — commercially prepared, nutrient-dense liquid or semi-solid products — play an important role in bridging nutritional gaps.

However, not all supplements are appropriate for all dysphagia patients. The liquid consistency of standard supplement drinks may not be safe for patients prescribed thickened liquids, and the caloric density and macronutrient composition of different products vary significantly. This guide helps Hong Kong caregivers understand which products are available, how to use them safely, and where to obtain them.

Understanding IDDSI Levels of Supplements

Standard Ready-to-Drink Supplements (Level 0 — Thin)

Most commercially available supplement drinks in their standard form are Level 0 (thin liquid). These include:

• Ensure Original (Abbott)
• Fortisip Compact Protein (Nutricia)
• Resource 2.0 (Nestlé)
• Boost (Nestlé)

These cannot be given to patients prescribed thickened liquids without modification. They must be thickened to the prescribed IDDSI level before administration. See the section on thickening supplements below.

Pre-thickened Supplements

Some supplements are available in pre-thickened form that approximately meets IDDSI Level 1 (Slightly Thick) or Level 2 (Mildly Thick) without adding a separate thickener. Availability in Hong Kong is more limited than in the UK or Australia — confirm with the supplier.

Semi-solid / Pudding-style Supplements (Level 4)

Pudding-style oral nutritional supplements have a semi-solid consistency that generally meets IDDSI Level 4 (Pureed). These are available from several manufacturers:

• Forticare / Fortijuice puddings (Nutricia) — check current availability in HK
• Resource Pudding (Nestlé) — available in Hong Kong through medical nutrition suppliers
• Homemade fortified pudding using standard supplement drinks thickened to Level 4 with a food-grade thickener

Key Supplements Available in Hong Kong

Standard Liquid Supplements

Ensure Original (Abbott)

• 1 kcal/ml; 250ml per carton = 250 kcal
• Protein: 8.8g per 250ml
• Available at: PARKnSHOP, Wellcome, Watsons, HKSH pharmacy, most private hospital pharmacies
• Flavours: vanilla, chocolate, strawberry
• Note: Contains milk protein (casein and whey) — not suitable for dairy-free patients; soy-based alternatives exist

Ensure Plus (Abbott)

• 1.5 kcal/ml; 220ml per carton = 330 kcal
• Protein: 13.2g per 220ml
• Higher caloric density — suitable for patients with severe malnutrition or very limited intake volumes

Fortisip Compact Protein (Nutricia)

• 2.4 kcal/ml; 125ml per carton = 300 kcal
• Protein: 18g per 125ml — high protein concentration
• The small volume (125ml) is advantageous for patients who fatigue quickly during oral intake
• Available through: Nutricia HK (direct order), some private hospital pharmacies

Resource 2.0 (Nestlé)

• 2.0 kcal/ml; 200ml per carton = 400 kcal
• Available through Nestlé Health Science HK

Elemental / Semi-elemental Formulas

For patients with absorption issues (post-surgery, inflammatory bowel conditions), semi-elemental formulas provide pre-digested protein. These are specialised medical nutrition products — prescription typically required.

Specialised Disease-Specific Formulas

Thickening Supplements to the Prescribed IDDSI Level

Can All Supplements Be Thickened?

Most standard liquid supplements can be thickened, but the interaction between the supplement’s composition and the thickener can be unpredictable:

• Protein content matters: High-protein supplements may interact with xanthan gum thickeners differently than plain liquids. Some high-protein, high-electrolyte supplements thin out xanthan gum, reducing the IDDSI level achieved with the same thickener quantity.
• Always test: After adding thickener to any supplement, perform the IDDSI syringe flow test to confirm the correct level is achieved.
• Xanthan gum is generally more stable with nutritional supplements than starch-based thickeners.

Practical Thickening Protocol

1. Chill the supplement (thickener works slightly better at lower temperatures for some formulas)
2. Add the thickener to the supplement (not the reverse) — pour thickener into the liquid
3. Stir vigorously for 15–20 seconds
4. Allow to stand for 1–2 minutes (thickening continues after stirring)
5. Perform the IDDSI syringe flow test
6. Adjust if needed and re-test

Calorie Density and Volume Considerations

A key challenge for dysphagia patients is achieving adequate caloric intake in a reduced volume. Standard food provides approximately 0.5–1.0 kcal/ml once processed to pureed or minced form. Nutritional supplements range from 1.0 kcal/ml (standard) to 2.4 kcal/ml (compact/concentrated).

Approximate targets for typical elderly dysphagia patients:

• Caloric requirement: 1,500–1,800 kcal/day (varies by body weight, activity, and health status)
• A patient who can manage only 400ml of oral intake per day needs 2.0+ kcal/ml products to approach caloric requirements

Practical calorie calculation:

Where to Buy in Hong Kong

Retail Channels

• PARKnSHOP / Wellcome: Ensure Original and Plus; Glucerna; some Nestlé products
• Watsons / Mannings: Ensure range; Glucerna
• HKSH / Adventist Hospital pharmacy: Broader range including Fortisip; often require outpatient registration
• Eu Yan Sang (余仁生) select stores: Some medical nutrition products

Direct Medical Nutrition Suppliers

• Abbott Nutrition HK: Direct order possible; some products available through HA hospital dietary departments
• Nutricia HK: Fortisip, Fortijuice range; primarily through healthcare professional recommendation and medical nutrition suppliers
• Nestlé Health Science HK: Resource range; mainly through medical channels

NGO and Community Resources

• Community Geriatric Assessment Teams (CGAT): Can assess and recommend appropriate supplements via public healthcare referral
• Medical social workers at HA hospitals: Can assist with referral for subsidised medical nutrition for eligible patients

Frequently Asked Questions

Q: The patient refuses to drink supplement drinks because they taste like medicine. What can we do?

A: Flavour fatigue is extremely common. Strategies include: (1) alternating flavours — rotate vanilla, chocolate, berry; (2) serving chilled or over ice (confirm IDDSI level after temperature change); (3) using the supplement as a cooking ingredient — blend into fortified congee, fortified soup, or pureed dessert; (4) trying a different product brand. If oral supplement compliance remains very poor, consult the dietitian about whether nasogastric tube supplementation is needed.

Q: Are supplement drinks safe for patients with diabetes?

A: Standard supplement drinks contain significant carbohydrate and can raise blood glucose. Glucerna (Abbott) and other diabetes-specific formulas use slowly digested carbohydrates and have a lower glycaemic index. However, any nutritional supplement use in a patient with diabetes should be discussed with the prescribing doctor or dietitian.

Q: Can supplements replace meals entirely?

A: Nutritionally, concentrated supplements can provide complete nutrition, but they are best used to supplement rather than replace oral food intake where the patient can eat. Oral food intake maintains oral and pharyngeal motor function through use, and preserves the social and psychological role of meals. Supplements should supplement, not substitute.

Information on this page is for educational purposes. Nutritional supplement selection for medical conditions should involve the patient’s doctor and, where available, a registered dietitian.