A systematic review and meta-analysis of the effects of community use of oral nutritional supplements on clinical outcomes

Effect of oral nutritional supplements administration on the management of children with picky eating and underweight: A systematic review and meta-analysis

BACKGROUND & AIMS

Feeding difficulties, including picky eating and avoidant/restrictive food intake disorder (ARFID), are common in children and can result in inadequate nutrient intake, poor growth, and even undernutrition. Oral nutritional supplements (ONS) are specialized high-calorie, nutrient-rich products that are commonly recommended in clinical practice to help improve growth outcomes in children with feeding difficulties. This systematic review aims to evaluate the efficacy and safety of ONS in managing children with ARFID and/or picky eating alongside dietetic consultation (DC).

METHODS

We systematically searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE from 2000 to March 2024 for randomized controlled trials (RCTs) that compared the use of ONS (regardless of type and dosage) to any comparator in children of any age with ARFID or picky eating. The primary outcome was growth (reported using any measures) during the intervention.

RESULTS

We summarized 5 RCTs involving 874 randomised children with picky eating and underweight. All RCTs assessed the use of ONS with DC compared to DC only. In three RCTs, there was an increase in weight, weight-for-height and weight-for-age in the ONS + DC group compared to the control group. Inconsistencies were noted with regard to height and Body Mass Index (BMI). Adverse events were reported in all RCTs, with no difference found between groups at 90 days (meta-analysis of three RCTs; relative risk [RR] = 0.92, 95 % confidence interval [CI], 0.71 to 1.20, I2 = 17 %, n = 573) and at 180 days (1 RCT; RR = 1.16, 95 % Cl 0.85 to 1.59, n = 35) in the ONS + DC group compared to the control group. Fewer children with upper respiratory tract infections were found in the ONS + DC group compared to the DC only group in a meta-analysis of two RCTs (RR = 0.62, 95 % Cl, 0.42 to 0.91, n = 359, I2 = 0 %; number needed to harm [NNH] = 10.4). In all RCTs, adherence to pre-specified ONS intake was assessed as high.

DISCUSSION

This systematic review provides moderate evidence supporting the combined use of ONS and DC in managing picky eating and underweight in children. However, further research is needed to assess long-term outcomes and to better understand the potential benefits and risks of this approach.

Efficacy and safety of post-discharge oral nutritional supplements for patients with gastric cancer undergoing gastrectomy: a meta-analysis of randomized controlled trials

Objectives

To report the first and largest systematic review and meta-analysis of randomized controlled trials (RCT) to evaluated the efficacy and safety of post-discharge oral nutritional supplements (ONS) for patients with gastric cancer undergoing gastrectomy.

Design

Systematic review and meta-analysis.

Eligibility criteria for selecting studies

RCT which evaluated the efficacy and/or safety of post-discharge ONS for patients with gastric cancer undergoing gastrectomy.

Data sources

We conducted a systematic literature retrieval via PubMed, Embase, Web of Science, and Cochrane until April, 2023 for relevant RCTs.

Data analysis

Outcomes of meta-analysis included absolute change of body weight, % change of body weight, absolute change of body composition, absolute change of laboratory parameters and adverse events. All the relevant data were analyzed by Review Manager 5.4.1 and Stata 15.1.

Results

5 RCTs including 1,586 patients (804 in ONS group versus 782 in control group) were included for meta-analysis. The two groups were comparable in age, gender (male), weight at baseline, BMI at baseline, albumin at baseline, and hemoglobin at baseline. Meta-analysis revealed a significant lower absolute body weight loss (WMD: 0.75; 95% CI: 0.11, 1.40; p = 0.02) and % body weight loss (WMD: 1.15; 95% CI: 0.20, 2.11; p = 0.02) in the ONS group compared with the control (regular diet/dietary advice) group. Moreover, this study did not observe a significant difference between the two groups for adverse events rate (RR: 1.11; 95% CI: 0.81, 1.53; p = 0.52).

Conclusion

ONS was significantly effective and safe in improving postoperative weight loss for patients with gastric cancer undergoing gastrectomy.

Systematic review registration

Identifier, CRD42023414678, https://www.crd.york.ac.uk/PROSPERO/.

Overall mortality for community-dwelling adults over 50 years at risk of malnutrition

BACKGROUND

It is well reported that malnutrition in acute care is associated with poorer health outcomes including increased mortality. However, the consequences of malnutrition on survival in community settings is uncertain. Malnutrition in people 65 years or over is often cited. Nevertheless, this study includes both middle-aged and older adults as current public health policy is highlighting the need to increase disease-free life years and is moving away from just extending life to increase overall longevity. The aim of this study is to describe the association of the risk of malnutrition using the Malnutrition Universal Screening Tool (MUST) with mortality in community-dwelling middle-aged and older adults.

METHODS

We used the UK Biobank to investigate the association between those at risk of malnutrition and mortality in participants aged ≥50 years. MUST identified risk of malnutrition and linked data to national death registries confirmed mortality. Years of life lost (YLL) and Cox proportional hazard models with hazard ratios (HR) and confidence intervals (CI) described risk associated with all-cause mortality.

RESULTS

There were 502 408 participants recruited, 117 830 were ≤50 years leaving 384 578 eligible participants. Based on MUST scores 63 495 (16.5%) were at risk of malnutrition with 401 missing some data and excluded. Incidence of mortality for at risk participants was 755 per 100 000 person-years, corresponding to 153 476 YLL. Of those at risk of malnutrition, 9.5% died versus 7.8% at low risk. Initial survival analysis reported an increased risk of mortality (HR 1.29, 95% CI: 1.25 to 1.33) that decreased after adjusting for confounders (HR 1.14, 95% CI: 1.11 to 1.18) in those at risk of malnutrition versus those at low risk.

CONCLUSIONS

Risk of malnutrition was associated with increased overall mortality. Modest effect sizes are demonstrated but are supportive of public health policies, which advocate wide-scale community, based nutritional screening for middle-aged and older adults.

Addressing Inflammaging and Disease-Related Malnutrition: Adequacy of Oral Nutritional Supplements in Clinical Care

BACKGROUND

Disease-related malnutrition, with or without inflammation, in older adults is currently emerging as a public health priority. The use of Foods for Special Medical Purposes, including Oral Nutritional Supplements, and supplements is crucial to support patients in achieving their nutritional needs. Therefore, this article aims to comprehensively provide an analysis of the adequacy of FSMPs in meeting the nutritional requirements of different age-related diseases and takes into account the emerging role of inflammation. Moreover, it provides an identikit of the ideal products, following the pathology-specific guidelines.

METHODS

Data on 132 products were gathered through face-to-face meetings with companies' consultants. Specifically, information on energy, macronutrient, and micronutrient contents were collected, as well as on texture and flavors, osmolarity, cost, and packaging.

RESULTS

Most FSMPs met the daily recommendations for energy and protein intake. Nonetheless, few products contained β-hydroxy-β-methylbutyrate, optimal Branched-Chain Amino Acids ratios, arginine, glutamine, and omega-3 fatty acids. Furthermore, a marked predominance of FSMPs with a high osmolarity (85.7%), sweet taste (72%), and only animal protein content (79.5%) was observed. Cost analysis of FSMPs revealed a mean cost of EUR 5.35/portion. Products were mostly adequate for cancer, neurodegenerative diseases, diabetes, inflammatory bowel disease, end-stage kidney disease, dysphagiam and chronic obstructive pulmonary disease. However, gaps have been found for sarcopenia and abdominal surgery.

CONCLUSION

In light of the current market landscape, there is a need for a comprehensive regulation that indicates the optimal composition of FSMPs and the production of such products to tackle disease-related malnutrition.

Predictive value of the controlling nutritional status (CONUT) score to assess long-term mortality (10 Years) in patients with hypertension

BACKGROUND AND AIMS

Malnutrition is associated with poor outcomes in patients with chronic diseases. The aim of this study is to investigate the prevalence of malnutrition in patients with hypertension and relationship between malnutrition severity and long-term mortality in these patients.

METHODS AND RESULTS

The study included 11,278 patients with hypertension from the National Health and Nutrition Examination Survey database. The degree of malnutrition was assessed using the Controlled Nutritional Status score, with patients divided into normal, mild, and moderate-to-severe groups. After 10 years of follow-up, the results showed that patients who died had higher CONUT scores, poorer nutritional status, and lower albumin, total cholesterol, and lymphocytes than those who survived (P < 0.05). The Kaplan-Meier analysis revealed that patients with poor nutritional status had a significantly higher risk of all-cause death. In the Non-Lipid Lowering Drugs group, the CONUT score (hazard ratio (HR): 1.225; 95% confidence interval (CI): 1.162-1.292; P < 0.0001), as well as mild (HR: 1.532; 95% CI 1.340-1.751; P < 0.0001) and moderate-to-severe malnutrition (HR: 2.797; 95% CI: 1.441-5.428; P = 0.0024), were independent predictors of long-term mortality. The competing risk regression models showed that cardiovascular and cerebrovascular mortality increased with increasing CONUT scores. The results were robust in both subgroup and sensitivity analyses.

CONCLUSIONS

Malnutrition significantly impacts long-term mortality in hypertensive patients. The CONUT score may be a useful tool for assessing the nutritional status of patients with hypertension in the non-lipid-lowering population and for predicting their long-term mortality.

Omega-3 and Sports: Focus on Inflammation

Inflammation is expected in sports, especially when practiced at a high level. The human body is pushed toward its limit, and this is perceived as a "stressogenic agent". Athletes, especially elite ones, desire it because their bodies can react with super-compensation, i.e., improve muscle mass, strength, speed, resistance, and, therefore, athletic performance. Thus, the inflammatory stimuli should be there during training but also counteracted to have the body placed in the optimal conditions for reacting with super-compensation. In this sense, omega-3 fatty acids have been shown to have anti-inflammatory biochemical activity. In this review, we will present the biochemical mechanisms of action of omega-3 fatty acids through their mediators, specialized pro-resolving mediators, which have anti-inflammatory activity. A focus will be on studies on omega-3 fatty acid supplementation in sports, and we will provide indications for possible practical applications and future studies, which are undoubtedly necessary to clarify the omega-3 fatty acids used in sports practice.

[Trends in the characteristics of patients treated with nutritional supplements in the Northern Area of Gran Canaria in the period 2016 -2021]

Introduction

Aim: to assess the prescription of oral nutritional supplements (ONS) in the Northern Area of Gran Canaria in the period 2016-2021. Materials and methods: based on electronic prescription data, the first ONS prescription during 2016-2021 was analyzed considering age, gender, nutritional requirements (NR), body mass index (BMI), percentage of weight loss (%WL), albumin and number of prescribed ONS per patient. Results: 10,595 prescriptions were identified corresponding to 6661 patients with the following characteristics: 46.3 % men, mean age 72.84 ± 15.93 years, BMI 20.60 ± 3.98 kg/m2, %WL 11.89 ± 8.32 %; albumin 3.08 ± 0.63 g/dl. The most frequent etiologies of DRE were: neoplasms 42.6 %; degenerative processes of the CNS 28.9 %; stroke 3.9 %; short bowel syndrome 6.9 %, and inflammatory bowel disease (IBD) 5.5 %. The percentages of NR covered by the prescribed ONS were: 100 % in 8.9 % of cases, 50 % in 36.9 %, and 25 % in 54.2 %; 40.4 % of patients received 1 unit of ONS daily, 36.3 % took 2 units of ONS, and 23 % received > 3 units of ONS per day. Greater NR were associated with a greater number of ONS (p < 0.001), but 40.8 % of patients who needed to cover > 50 % of NR received only one unit of ONS. Conclusion: a significant percentage of patients with disease-related malnutrition (DRM) do not receive a number of ONS according to their NR.

Effects of a Specialized Oral Nutritional Supplement with Dietary Counseling on Nutritional Outcomes in Community-Dwelling Older Adults at Risk of Malnutrition: A Randomized Controlled Trial

This study investigated the effects of oral nutritional supplements (ONSs) along with dietary counseling (DC) in community-dwelling older adults at risk of malnutrition. In this randomized controlled trial, 196 older adults who were at risk of malnutrition, as identified by the Malnutrition Universal Screening Tool (MUST) were randomly assigned to receive ONSs twice daily with DC (intervention) or DC-only (control) for 60 days. Primary outcome was change in body weight from baseline to day 60. Nutritional status, energy, and macronutrient intakes were measured. A significant larger weight gain was observed in the intervention compared to the control from baseline to day 60 (1.50 ± 0.22 kg, p < 0.0001). The intervention group also showed a significantly greater increase in weight at day 30 (p < 0.0001). Intakes of energy and macronutrients were significantly higher in the intervention group compared to the control group at both days 30 and 60 (all p < 0.0001). The odds of achieving better nutritional status were significantly higher in the intervention group than in the control group (OR:3.9, 95% CI: 1.9, 8.2, p = 0.0001). ONS supplementation combined with DC significantly improved body weight and nutritional outcomes in community-dwelling older adults at risk of malnutrition.

Effects of Oral Nutritional Supplement with β-Hydroxy-β-methylbutyrate (HMB) on Biochemical and Hematological Indices in Community-Dwelling Older Adults at Risk of Malnutrition: Findings from the SHIELD Study

Malnutrition may result in abnormal biochemical and hematological indices. This planned prespecified analysis investigated the effects of a specialized oral nutritional supplement (ONS) on biochemical and hematological indices in community-dwelling older adults at risk of malnutrition. In the Strengthening Health in ELDerly through nutrition (SHIELD) study, 811 older adults aged 65 years and above took part in this randomized, double-blind, placebo-controlled, multi-center study. Participants were randomly allocated to either a complete and balanced specialized ONS (each serving provides 262 kcal, 10.5 g protein, 7.75 µg vitamin D3, and 0.74 g calcium β-hydroxy-β-methylbutyrate) and dietary counselling (intervention group) or a placebo and dietary counselling (placebo group). Both groups consumed study products twice a day for 180 days. Data were collected at baseline, day 90, and day 180. Blood analysis results at follow-up visits were analyzed using repeated measures analysis of covariance with adjustments for confounders. Overall, when compared with the placebo group, the intervention group showed significantly greater urea (6.0 mmol/L vs. 5.4 mmol/L, p < 0.001), urea to creatinine ratio (4.39 vs. 4.26, p < 0.001), prealbumin (24.9 mg/dL vs. 24.0 mg/dL, p < 0.001), vitamin B12 (480.0 pmol/L vs. 420.1 pmol/L, p < 0.001), and globulin levels (26.8 g/L vs. 26.5 g/L, p = 0.032). The intervention group also had a significantly higher absolute reticulocyte count (62.0 × 103/µL vs. 58.2 × 103/µL, overall p < 0.001) and mean platelet volume (10.0 fL vs. 9.9 fL, overall p = 0.003). Furthermore, significant improvements were seen in total protein at day 90 (71.7 g/L vs. 71.1 g/L, p = 0.017) and in absolute monocyte count at day 90 (0.50 × 103/µL vs. 0.47 × 103/µL, p = 0.009) in the intervention group. In conclusion, daily consumption of a specialized ONS for six months led to significant improvements in biochemical and hematological indices in community-dwelling older adults at risk of malnutrition.

Managing malnutrition and multimorbidity in primary care: dietary approaches to reduce treatment burden

There are many health and nutrition implications of suffering from multimorbidity, which is a huge challenge facing health and social services. This review focuses on malnutrition, one of the nutritional consequences of multimorbidity. Malnutrition can result from the impact of chronic conditions and their management (polypharmacy) on appetite and nutritional intake, leading to an inability to meet nutritional requirements from food. Malnutrition (undernutrition) is prevalent in primary care and costly, the main cause being disease, accentuated by multiple morbidities. Most of the costs arise from the deleterious effects of malnutrition on individual's function, clinical outcome and recovery leading to a substantially greater burden on treatment and health care resources, costing at least £19·6 billion in England. Routine identification of malnutrition with screening should be part of the management of multimorbidity together with practical, effective ways of treating malnutrition that overcome anorexia where relevant. Nutritional interventions that improve nutritional intake have been shown to significantly reduce mortality in individuals with multimorbidities. In addition to food-based interventions, a more 'medicalised' dietary approach using liquid oral nutritional supplements (ONS) can be effective. ONS typically have little impact on appetite, effectively improve energy, protein and micronutrient intakes and may significantly improve functional measures. Reduced treatment burden can result from effective nutritional intervention with improved clinical outcomes (fewer infections, wounds), reducing health care use and costs. With the right investment in nutrition and dietetic resources, appropriate nutritional management plans can be put in place to optimally support the multimorbid patient benefitting the individual and the wider society.

A Conceptual Study on Characterizing the Complexity of Nutritional Interventions for Malnourished Older Adults in Hospital Settings: An Umbrella Review Approach

INTRODUCTION

Malnutrition is a widespread and intricate issue among hospitalized adults, necessitating a wide variety of nutritional strategies to address its root causes and repercussions. The primary objective of this study is to systematically categorize nutritional interventions into simple or complex, based on their resource allocation, strategies employed, and predictors of intervention complexity in the context of adult malnutrition in hospital settings.

METHODS

A conceptual evaluation of 100 nutritional intervention studies for adult malnutrition was conducted based on data from a recent umbrella review (patient population of mean age > 60 years). The complexity of interventions was categorized using the Medical Research Council 2021 Framework for Complex Interventions. A logistic regression analysis was employed to recognize variables predicting the complexity of interventions.

RESULTS

Interventions were divided into three principal categories: education and training (ET), exogenous nutrient provision (EN), and environment and services (ES). Most interventions (66%) addressed two or more of these areas. A majority of interventions were delivered in a hospital (n = 75) or a hospital-to-community setting (n = 25), with 64 studies being classified as complex interventions. The logistic regression analysis revealed three variables associated with intervention complexity: the number of strategies utilized, the targeted areas, and the involvement of healthcare professionals. Complex interventions were more likely to be tailored to individual needs and engage multiple healthcare providers.

CONCLUSIONS

The study underlines the importance of considering intervention complexity in addressing adult malnutrition. Findings advocate for a comprehensive approach to characterizing and evaluating nutritional interventions in future research. Subsequent investigations should explore optimal balances between intervention complexity and resource allocation, and assess the effectiveness of complex interventions across various settings, while considering novel approaches like telehealth.

Positive correlation between persistence of medical nutrition therapy and overall survival in patients with head and neck cancer

Background: Several factors can affect overall survival of head and neck cancer (HNC) patients, including characteristics of the cancer disease and response to treatments. However, patients' nutritional status and the effectiveness of medical nutrition therapy (MNT) can also impact overall survival. The primary goal of our research was to collect real-life data on the use of MNT in HNC patients and to specifically investigate the correlation between survival and the duration of uninterrupted (persistent) nutrition. Method: The data of this retrospective, analytical, cohort study was collected from electronic healthcare records from the Hungarian National Health Insurance Fund Management. Overall, 38,675 HNC patients' data of the period between 2012 and 2021 was used. We applied multi-step exclusions to identify patient groups accurately and to avoid biasing factors. Statistical analysis was done by the Kaplan-Meier method, log-rank test, and Cox regression analysis. Results: Throughout the investigated period 16,871 (64%) patients received MNT therapy out of 26,253 newly diagnosed patients (≥18 years). In terms of the persistence of MNT, we divided the patients into three groups (1-3; 4-6; ≥7-month duration of MNT). When comparing these groups, we found that patients receiving long-term (≥7 months) MNT had a significantly longer overall survival (p < 0.0001) than those who received MNT for a shorter duration, both in locally advanced and recurrent/metastatic cases. Conclusion: The main outcome of the study is that there is a positive correlation between the persistence of MNT and the overall survival in HNC patients when nutritional intervention lasts several months. It highlights the responsibility of the specialists during the patient journey to use MNT early and to continue its use for as long as it is beneficial to the patients.

Optimized Refeeding vs. Standard Care in Malnourished Older Hospitalized Patients: A Prospective, Non-Randomized Cluster-Controlled Study in Geriatric Acute Care

Malnutrition is a prevalent geriatric syndrome with adverse health outcomes. This study aimed to assess the effectiveness of an optimized protocol for treatment of malnutrition in older hospitalized patients. We conducted a prospective, non-randomized cluster-controlled study with 156 malnourished patients in the intervention and 73 in the control group, determined using the Mini Nutritional Assessment-Short-Form. The intervention group received individualized nutritional care, including electrolyte and micronutrients monitoring, while the control received standard care. We primarily focused on complications such as infections, falls, unplanned hospital readmissions, and mortality, and secondarily focused on functional status and mobility improvements. Post-discharge follow-ups occurred at 3 and 6 months. Our findings demonstrated that the intervention group (age 82.3 ± 7.5 y, 69% female), exhibited greater previous weight loss (11.5 kg vs. 4.7 kg), more cognitive impairment and a longer hospital stay (19 days vs. 15 days). Binary logistic regression showed no difference in primary endpoint outcomes between groups during hospitalization. At 3- and 6-month follow-ups, the control group exhibited fewer adverse outcomes, particularly falls and readmissions. Both groups showed in-hospital functional improvements, but only controls maintained post-discharge mobility gains. The study concludes that the nutritional intervention did not outperform standard care, potentially due to study limitations and high-quality standard care in control group geriatric departments.