Supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults

BACKGROUND

Supportive interventions such as serving meals in a dining room environment or the use of assistants to feed patients are frequently recommended for the management of nutritionally vulnerable groups. Such interventions are included in many policy and guideline documents and have implications for staff time but may incur additional costs, yet there appears to be a lack of evidence for their efficacy.

OBJECTIVES

To assess the effects of supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults.

SEARCH METHODS

We identified publications from comprehensive searches of the Cochrane Library, MEDLINE, Embase, AMED, British Nursing Index, CINAHL, SCOPUS, ISI Web of Science databases, scrutiny of the reference lists of included trials and related systematic reviews and handsearching the abstracts of relevant meetings. The date of the last search for all databases was 31 March 2013. Additional searches of CENTRAL, MEDLINE, ClinicalTrials.gov and WHO ICTRP were undertaken to September 2016. The date of the last search for these databases was 14 September 2016.

SELECTION CRITERIA

Randomised controlled trials of supportive interventions given with the aim of enhancing dietary intake in nutritionally vulnerable adults compared with usual care.

DATA COLLECTION AND ANALYSIS

Three review authors and for the final search, the editor, selected trials from titles and abstracts and independently assessed eligibility of selected trials. Two review authors independently extracted data and assessed risk of bias, as well as evaluating overall quality of the evidence utilising the GRADE instrument, and then agreed as they entered data into the review. The likelihood of clinical heterogeneity amongst trials was judged to be high as trials were in populations with widely different clinical backgrounds, conducted in different healthcare settings and despite some grouping of similar interventions, involved interventions that varied considerably. We were only able, therefore, to conduct meta-analyses for the outcome measures, 'all-cause mortality', 'hospitalisation' and 'nutritional status (weight change)'.

MAIN RESULTS

Forty-one trials (10,681 participants) met the inclusion criteria. Trials were grouped according to similar interventions (changes to organisation of nutritional care (N = 13; 3456 participants), changes to the feeding environment (N = 5; 351 participants), modification of meal profile or pattern (N = 12; 649 participants), additional supplementation of meals (N = 10; 6022 participants) and home meal delivery systems (N = 1; 203 participants). Follow-up ranged from 'duration of hospital stay' to 12 months.The overall quality of evidence was moderate to very low, with the majority of trials judged to be at an unclear risk of bias in several risk of bias domains. The risk ratio (RR) for all-cause mortality was 0.78 (95% confidence interval (CI) 0.66 to 0.92); P = 0.004; 12 trials; 6683 participants; moderate-quality evidence. This translates into 26 (95% CI 9 to 41) fewer cases of death per 1000 participants in favour of supportive interventions. The RR for number of participants with any medical complication ranged from 1.42 in favour of control compared with 0.59 in favour of supportive interventions (very low-quality evidence). Only five trials (4451 participants) investigated health-related quality of life showing no substantial differences between intervention and comparator groups. Information on patient satisfaction was unreliable. The effects of supportive interventions versus comparators on hospitalisation showed a mean difference (MD) of -0.5 days (95% CI -2.6 to 1.6); P = 0.65; 5 trials; 667 participants; very low-quality evidence. Only three of 41 included trials (4108 participants; very low-quality evidence) reported on adverse events, describing intolerance to the supplement (diarrhoea, vomiting; 5/34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567/2017 participants). Meta-analysis across 17 trials with adequate data on weight change revealed an overall improvement in weight in favour of supportive interventions versus control: MD 0.6 kg (95% CI 0.21 to 1.02); 2024 participants; moderate-quality evidence. A total of 27 trials investigated nutritional intake with a majority of trials not finding marked differences in energy intake between intervention and comparator groups. Only three trials (1152 participants) reported some data on economic costs but did not use accepted health economic methods (very low-quality evidence).

AUTHORS' CONCLUSIONS

There is evidence of moderate to very low quality to suggest that supportive interventions to improve nutritional care results in minimal weight gain. Most of the evidence for the lower risk of all-cause mortality for supportive interventions comes from hospital-based trials and more research is needed to confirm this effect. There is very low-quality evidence regarding adverse effects; therefore whilst some of these interventions are advocated at a national level clinicians should recognise the lack of clear evidence to support their role. This review highlights the importance of assessing patient-important outcomes in future research.

Nutritional supplementation of very old people at hospital discharge increases muscle strength: a randomised controlled trial

BACKGROUND

Undernutrition is common in older people admitted to hospital, but little is known about how nutritional state changes after discharge.

OBJECTIVE

This randomised controlled trial was designed to examine the effect of oral nutritional supplementation of undernourished very old people prepared to take supplements after hospital discharge following acute illness.

METHODS

Participants aged>or=75 years with a BMI<or=24 kg/m2 and triceps skin fold thickness or mid-arm muscle circumference below the 10th centile and/or weight loss>or=5% during an acute hospital stay were allocated at random to either oral nutritional supplementation for 8 weeks from hospital discharge or to usual care. Primary outcome was change in weight, secondary outcomes were handgrip strength and anthropometry.

RESULTS

Of 198 patients eligible to participate, 136 patients (mean age 85 years) were randomised and 76/136 (56%) completed the study. Twenty percent (13/66) of the intervention group withdrew after only 2 weeks, citing intolerance of the supplements. Using intention-to-treat analysis, body weight increased by a mean of 1.6 and 2.2% in the control and intervention groups, respectively, but this between-group difference was not significant (p = 0.188). However, handgrip strength increased more (p=0.055) in the intervention group (13.9%) than in the control group (7.2%).

CONCLUSIONS

Oral nutritional supplementation was associated with a greater increase in handgrip strength than in non-supplemented controls and this observation merits further study.

Dietary advice and nutritional supplements in the management of illness-related malnutrition: systematic review

BACKGROUND AND AIMS

This review investigated whether dietary advice to improve nutritional intake in adults with illness-related malnutrition improved mortality, morbidity, weight and energy intake, and whether oral nutritional supplements gave additional benefit, when given in combination with dietary advice.

METHODS

Systematic review of randomised controlled trials comparing dietary advice with either (i) no advice, (ii) nutritional supplements or (iii) dietary advice plus nutritional supplements, in people with illness-related malnutrition.

RESULTS

Twenty-four trials (25 comparisons) met the inclusion criteria, including 2135 randomised participants. Duration of follow-up ranged from 16 days to 24 months. There was no significant difference in mortality or morbidity for each comparison. Groups receiving supplements gained significantly more weight (or lost significantly less weight) than those who received dietary advice, weighted mean difference 1.09 kg (0.29-1.90) (4 studies). There were no significant differences in weight and energy intake between groups for the other comparisons. Few data were available for other outcomes.

CONCLUSIONS

Nutritional supplements may have a greater role than dietary advice in the short-term improvement of body weight in illness-related malnutrition. There is a lack of evidence to support dietary advice in the management of illness-related malnutrition, but this is based on few, often poor quality, studies.

Does additional feeding support provided by health care assistants improve nutritional status and outcome in acutely ill older in-patients?—a randomised control trial

BACKGROUND & AIMS

Malnutrition is common in the elderly and increases morbidity and mortality. Most attempts to reverse malnutrition have used liquid supplements, but the findings are inconsistent. This study tests a new approach using a randomised-controlled design. The aim was to examine whether health care assistants, trained to provide additional support with feeding, can improve acutely ill elderly in-patients' clinical outcomes.

METHODS

The study was carried out on three acute medicine for the elderly wards at Hammersmith Hospitals NHS Trust, London. In all, 592 patients, all over 65 years old, were recruited.

RESULTS

The results showed that the median time patients received feeding support was 16 days, and the assisted group was given less intravenous antibiotics (P=0.007). However, the groups did not differ in markers of nutritional status, Barthel score, grip strength, length of stay or mortality.

CONCLUSION

It was concluded that the use of health care assistants in this specialised role, in an acute setting, without change to the food provision or without targeting higher risk patients, reduced the need for intravenous antibiotics. However, the intervention did not improve nutritional status or have an effect on length of stay in the time span studied. The results highlight the difficulties of improving the intake of acutely ill elderly patients during a hospital stay.

A systematic review of protein and energy supplementation for hip fracture aftercare in older people

OBJECTIVES

To evaluate whether protein and energy supplementation influences recovery after hip fracture.

DESIGN

Systematic review of randomised and quasi-randomised trials in people aged 65 y and over.

DATA SOURCES

We searched seven electronic databases from 1966 to April 2002, four journals and reference lists of relevant articles. We contacted trial investigators and experts for details of other trials.

MAIN OUTCOME MEASURES

Mortality, complications and unfavourable outcome (mortality or survivors with complications) were the primary outcomes. We also sought data on length of hospital stay, functional status after hip fracture, quality of life and compliance with supplementation.

RESULTS

In total, 12 randomised trials involving 898 participants were included. Nine trials evaluated protein and energy supplementation (five oral and four nasogastric feeding), and a further three trials tested oral protein supplementation. Potential biases resulting from inadequate allocation concealment and lack of assessor blinding and intention-to-treat analysis, as well as the limited outcome data, mean that the results must be interpreted with caution. Pooled data from eight of the nine trials evaluating protein and energy supplements showed no evidence for an effect on mortality (relative risk 0.92, 95% CI 0.56-1.50). Limited data from only three trials showed that oral protein and energy supplements may reduce unfavourable outcome (relative risk 0.52, 95% CI 0.32-0.84).

CONCLUSION

Based on limited evidence, oral protein and energy supplementation after hip fracture may reduce unfavourable outcome. Further evidence from good-quality randomised trials is required to inform clinical practice.

A comparison of three methods for estimating height in the acutely ill elderly population

BACKGROUND

Most estimates of nutritional status rely on accurate recording of not only body weight but also height. Standing height is difficult to measure accurately in older adults due to mobility problems and kyphosis. Surrogate methods have been developed to estimate height including arm-span, demi-span and knee height. There are currently little data on the accuracy of these methods in the sick elderly population or which method is the most suitable in the clinical situation.

OBJECTIVE

To compare three commonly used clinical measurements that can estimate height and analyse their agreement with current height. Also to evaluate which method can be used most frequently.

METHODS

We used data collected as part of a larger intervention trial, in which elderly in-patients (over 65 years), were measured for demi-span, half arm-span, knee height and standing height.

RESULTS

The results showed that demi-span and half arm-span could be measured in the largest proportions of our population, 75.6 and 72.3%, respectively. The correlation coefficients were high for all three estimates of height, r = 0.86 for demi-span, r = 0.87 for arm-span, and r = 0.89 for knee height (P < 0.0001 for all three). However, agreement analysis demonstrated very poor agreement between standing height and all the methods of estimation. The mean differences were 4.33 cm for demi-span, 7.04 cm for arm-span and -0.6 cm for knee height.

Food and nutritional care in hospitals: how to prevent undernutrition--report and guidelines from the Council of Europe

In 1999 the Council of Europe decided to collect information regarding Nutrition programmes in hospitals and for this purpose a network consisting of national experts from eight of the Partial Agreement member states was established. The aim was to review the current practice in Europe regarding hospital food provision, to highlight deficiencies and to issue guidelines to improve the nutritional care and support of hospitalized patients. Five major problems seemed to be common in this context: 1) lack of clearly defined responsibilities; 2) lack of sufficient education; 3) lack of influence of the patients; 4) lack of co-operation among all staff groups; and 5) lack of involvement from the hospital management. To solve the problems highlighted, a combined 'team-effort' is needed from national authorities and all staff involved in the nutritional care and support, including hospital managers.

Randomized controlled trials: the control group dilemma revisited

In some randomised controlled trials the nature of the therapy means that subjects cannot or should not be blinded. Such studies need careful design. Particular attention needs to be given to the choice of control group and the nature of the informed consent obtained from subjects, because these affect the precise research question being addressed. A survey of published studies was carried to investigate how these issues had been tackled. The paper summarizes key findings from the survey. If the research question is about the specific effect of a therapy sometimes a good case can be made for a second control group which is 'attention-controlled'. There is a need for more detailed justifications of such design decisions in published studies.