Community Pharmacists' Opinions on Nutritional Counseling for Oral Nutritional Supplements: An Exploratory Qualitative Study

Community pharmacists are vital in assisting patients and advising them on how to best manage their health. Community pharmacists are well-positioned to counsel patients on topics such as diet and lifestyle in addition to providing drugs. People who have trouble getting enough of certain nutrients from their regular diets are often advised to take oral nutritional supplements (ONS). These nutritional aids are meant to fill nutritional gaps and promote all-around wellness. Community pharmacists are in a prime position to advise and assist patients who are curious about or utilizing over-the-counter nutritional supplements (ONS), thus their involvement in this area is expanding. In this introductory piece, we will inquire into how community pharmacists feel about giving dietary advice to patients with ONS, and we will focus on the possible advantages and disadvantages of doing so.[1] Community pharmacists who provide nutritional counseling analyze patients' needs, educate them, and make specific suggestions to better their health. Monitoring of effectiveness and adherence, as well as talks concerning the appropriateness of ONS, are all part of this therapy. Safe and successful use of ONS depends on the expertise of community pharmacists, who have extensive training in medication usage and management, including drug-nutrient interactions. Because of their extensive knowledge of medication management, they are in a prime position to warn patients of possible drug interactions and provide individualized suggestions.[2] Community pharmacists' views on dietary advice for ONS differ depending on their background, education, and personal philosophy. Some pharmacists see this responsibility as an opportunity to further their mission of improving people's health. They value nutrition's role in illness prevention and treatment and see ONS counseling as a chance to boost patients' dietary intake, improve their quality of life, and decrease the risk of malnutrition-related consequences.[3] Community pharmacists may confront obstacles in their pursuit of providing dietary guidance for ONS. Inability to provide patients full assistance due to lack of time, insufficient funds, and inadequate expertise in nutrition counseling. Patients who are not open to guidance or who are reluctant to modify their eating habits provide another challenge for community pharmacists. Pharmacists need strong communication skills to involve patients in their healthcare and help them feel like they have a voice in their treatment decisions if they are to succeed in overcoming these obstacles.[4] Despite these obstacles, community pharmacists have a unique opportunity to improve patients' nutritional health through the provision of individualized counseling and assistance. Due to their open availability and high patient contact, they are seen as reliable healthcare professionals who

working together may improve nutritional advice and provide more comprehensive care for their patients.[5-6]

Since this is uncharted territory in the clinical setting, a qualitative exploratory approach is the method of choice. In particular, there is less research on the use of ONS in community pharmacies, and much less on the significance of primary health care in the management of community malnutrition. This qualitative approach was chosen after a desk review was performed to whittle down the available literature, establish the current state of the art, & choose the specific areas of pharmacists' jobs to investigate. We used the Boolean operators "oral nutritonal supplements," "neighborhood pharmacists," "dietitians," or "primary care" to search PUBMED for relevant articles. Using this summary as a foundation, we produced an initial interview script consisting of 26 questions and piloted it with three community pharmacists. Three of the questions were modified and four were taken out of the final, to-be-used version after this pilot. The intended recipients were community pharmacists working in Saudi. Topics for the sample were provided by respondents themselves, as per the tenets of snowball sampling [7]. All of the pharmacists who were contacted were required to work in community pharmacy at the time of the survey and to have at least three decades of professional expertise in community pharmacy, regardless of a rural or urban setting. The initial three years of experience were considered mandatory since it is sufficient time for the expert to acquire a broad understanding of the field. The invitation wouldn't be extended to a pharmacist who didn't meet these criteria. In the first two months of 2023, we used the video conferencing app Zoom [8] to conduct in-depth interviews. Because of its user-friendliness and recording capabilities, Zoom is a useful tool for interview transcribing [9]. Two community pharmacists were contacted by the researchers, and both volunteered to take part in the study when they were contacted and determined to meet the inclusion criteria. Before conducting any interviews, we made sure all participants understood the study's purpose and signed a permission form permitting us to record their conversations. The interview proceeded once agreement to participate was given. After the interview was over, the researcher requested contact information for two additional professionals that might be interested in participating. We reached out to them again to see if time and day. This process continued continuously throughout the duration of data collection. Sixteen interviews were conducted with pharmacists from a sample of 19 different establishments. To further mitigate memory bias, the interviewer (PT) transcribed the interviews verbatim, just after they were conducted. One researcher (PT) performed an initial thematic analysis of the transcripts, utilizing a Microsoft Excel® spreadsheet to keep track of the transcripts and emerging topics. Another researcher (JG) examined the transcripts and identified other categories and themes. The group of authors then got together to discuss the themes in further depth and agree on a final list. Descriptive statistics were also used to quantitative data. The Saudi Institutional Ethics Committee looked over the research and gave it the thumbs up.

Fifteen female along with a male pharmacist were included in the sample. The average age of the participants was 32 (range: 25-43) (Table 1). The average amount of time spent working in community pharmacy by these experts was 7 years. Years spent working at the same drugstore varied widely, from one to nineteen on average. In the survey, 10 participants reported working in an urban pharmacy, while the remaining six said they were employed in a rural environment. Even at pharmacies where nutrition consulting is not offered, all respondents reported that ONS was available for purchase. Many different factors were cited by pharmacists for recommending or selling these OTCs (Table 2). It was not surprising that clinical indications were the primary driver of counseling for ONS. All pharmacists reported providing advice on the recommended daily dose and time for administration as part of this counseling. In addition, only two were willing to provide details regarding the therapy's length, and only half knew about the storage precautions or necessity for refrigeration. Concerns were raised by pharmacists concerning the impact of certain pathologies and clinical circumstances on the counseling process while using an ONS. Eighty-four percent of respondents with diabetes, forty-seven percent with renal insufficiency, and thirty-seven percent with oncological/cancer concerns highlighted these clinical diseases as being essential during ONS counseling. Malnutrition and inability to move around

Patients having liver failure, stress ulcers/bedsores, those who are tube fed, those with neurological diseases, and those who are on many medications all need special consideration when pharmacists provide them nutritional supplement recommendations.

Our data analysis revealed three major topics about pharmacists' roles in counseling ONS users: the how and the why of counseling and following up with ONS users; the significance of interprofessional cooperation in following up with ONS users; and the training and Care for Patients using ONS Counseling and Supervision It was agreed upon by all respondents that following up with patients who had been counseled on an ONS was crucial, primarily to examine its progression but also to boost respondents' own faith in the product they were advising on or respondents' loyalty to the pharmacy. The faith in the goods and the advise offered might be bolstered by the patient's/client's response after the sale. Yes, I believe it is crucial to know whether it is working and the patient is improving. Your self-assurance for future therapy can only improve. Pharmacists benefit greatly from knowing whether or not their patients are seeing positive results from taking a prescribed supplement; if they are, we may have greater faith in the product and recommend it more often. There seems to be a significant role for self-assurance and belief in the product being marketed when advising an ONS. Most obviously, pharmacists have found that it is safer for patients with cancer to obtain a medical prescription before going to the pharmacy, which in turn makes patient counseling and follow-up easier. All agreed that this particular ONS should be used in accordance with the manufacturer's instructions: Cancer patients who use nutritional supplements.... I seldom provide advice. Because I don't know the specifics of the cancer patient's treatment plan, I always make an appointment to consult with the oncologist before recommending any supplements. (...) I'm always filled with dread. 11JO is a 27-year-old woman. Most pharmacists, when asked how they go about patient monitoring, stated they check in with patients whenever they come back to the pharmacy. Only two pharmacists reported conducting proactive assessments (i.e., setting up follow-up visits with the pharmacist at regular intervals). Two of the pharmacists said they didn't think follow-up was essential, or that the registered dietitians should offer it if it was. " I think it's very important, and then we wait for the patient to come back to the pharmacy (...) and we ask, "so how are you doing?," to see whether everything is going okay. The pharmacist describes it this way: "(...) we know individuals well, when we leave the drugstore & walk around the street, we meet them." We also inquire as to their mental and physical health, as well as their perspectives, results, and general well-being.

separate database. The availability of a specialized consultation for these patients was also a major factor in ensuring their continued follow-up. Due to the pharmacy's location in a residential area, two employees felt there was no need to register patient information: "It could be vital to have the information signed in, but it would be greater complex and it would already be too much, in my opinion." However, the passage of time is crucial. I wish I had the time to keep up with everyone, but that's an unrealistic goal. The high price of ONS was seen as the biggest deterrent to adherence by 53% of respondents, which in turn led to less counseling and sales chances. Lack of understanding about numerous properties of ONS, also impedes counseling. Because of the variety of options, choose the ONS that is best suited to a certain patient may be challenging. Since the elderly typically spend a great deal of money on medications, the high cost of this supplement can make it difficult for them to stick with the treatment plan. There should be some kind of assistance to help cover the expense of these supplements, or possibly be compensated for them, considering the importance they have to the user's health. 33-year-old 3ED female."We can suggest substituting a meal, but people often don't follow it because of the high costs." 8AG, Female, 25.

Both primary care physicians and specialists, as well as registered dietitians, were cited as having critical roles to play in the prescription, counseling, or follow-up of ONS. Doctors were sought out for complex cases, such as those involving cancer patients, due to their competence in nutrition advice, and dietitians were valued as partners in both patient counseling & follow-up. "Because they are more delicate patients with unique requirements (... ), we usually attempt to have that sort of counseling done less by the physician than by us in that circumstance. We counsel them, we tell them what's out there and how beneficial it may be, but we always recommend they consult with their doctor first (...) because this is the kind of patient who requires specialized attention. We recommend the fundamental care if it is prescribed by a physician. 25-year-old 8AG female. " A follow-up session with the patient to discuss his or her progress in terms of nutrition and whether or not his or her condition has improved is an option.

had never had ONS training. Most pharmacists who participated in ONS training felt they still lacked essential knowledge on the topic. The claimed explanations seem to be based on the rising frequency of these drugs in the product catalog of the pharmacies, which necessitates training. In most cases, manufacturers of ONS sent representatives to the pharmacy to conduct training, with one pharmacist saying, To make up for the shortage of training, many turned to their more seasoned coworkers for advice. It was also claimed that the information systems used by pharmacists were inadequate because of the lack of data they included.I don't believe there's much data on supplements in SIFARMA®, but that's just a guess. " Simply said, the best place to learn as much as possible is either the lab's or the product's website. I have no choice but to ask each other questions since I have no other means of gathering knowledge. 10F, age 26, PA. ―There is a dearth of information at the moment. I'd want to believe that the information, especially that found on the laboratories' website, is trustworthy. A "slight interaction alert" might be generated for any two things, but how important would that be? For this reason, SIFARMA® is somewhat useful, although it has very few customization options.

Three overarching themes emerged from the thematic analysis given here. The first topic addresses the technical side of counseling, or the skills required to correctly recommend a product to a certain client. The frequency with which ONS are dispensed has been shown to increase patients' trust in the counseling they receive; patients' compliance with ONS has been shown to decrease their trust in the counseling they receive; and patients' perception that the high cost of these ONS may discourage them from taking the medication as prescribed has decreased their trust in the counseling they receive and their efforts to provide a structured follow-up. The second common thread was the interprofessional partnerships that pharmacists see as beneficial to these patients. Here, pharmacists' lack of confidence in counseling certain patients leads them to refer those patients to physicians for more complex cases. Pharmacists also believed that the presence or involvement of a dietitian would improve treatment procedures and their results, giving credence to the high value placed on the profession of nutritionist. The last common thread was a need for additional formal education regarding ONS, preferably in a professional context but also at the undergraduate and

Although most pharmacists recognized the value of counseling, only a small percentage prompted patients to follow up with the pharmacy. Pharmacists took into account three factors while following up with a patient on ONS: (1) a patient care component emphasizing the pharmacist's caring role by identifying how a patient develops in response to a certain intervention; (1) the information provided by the ONS's companies, and there is the business aspect, which has to do with how long people think the pharmacy will be there. These pharmacists were well-known for their keen awareness of conditions coexisting with malnutrition, such as diabetes, renal failure, and dysphagia. Pharmacists' first instinct when faced with a cancer patient seeking ONS was to direct them to a doctor, suggesting they lacked confidence in counseling this population. Lack of training and instruction on nutritional care participants [10], patients' aversion to risk and the importance of validation, and patients' confusion and lack of confidence about the indication of an ONS all contribute to their uncertainty as well as lack of confidence. Similar to what has been seen elsewhere [11-12], pharmacists have cited qualified dietitians as an alternative to doctors. However, there appears to be some misunderstanding about the respective responsibilities of general practitioners or dietitians in treating patients with malnutrition. An independent nutritional evaluation conducted by a certified dietitian is required prior to the accurate prescription of the ONS [13-14]. [15] Highlight the role of registered dietitians in patient monitoring, since these professionals have the expertise to map out the best course of action for the duration of therapy. It's important to remember that in Portugal, ONS counseling is a specialized clinical ability of registered dietitians that isn't usually acknowledged by other health professionals [16-17]. However, there is still a need to better educate the public and health professionals about the roles and skillsets required to care for patients requiring nutritional interventions.

This study's findings suggest that counseling and dispensing ONS is less of a burden for pharmacists than following up with patients thereafter. In order to carry out follow-up effectively, pharmacists advise expanding the scope of interprofessional collaboration with dietitians and citing the need for education and training on ONS concerns and follow-up approaches and skills.

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Pharmacist, PSMMC, Riyadh, KSA