Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults

Prognostic Impact of Nutritional Status After Transcatheter Edge-to-Edge Mitral Valve Repair: The MIVNUT Registry

Background Malnutrition is associated with poor prognosis in several cardiovascular diseases. However, its prognostic impact in patients undergoing transcatheter edge-to-edge mitral valve repair (TEER) is not well known. This study sought to assess the prevalence, clinical associations, and prognostic consequences of malnutrition in patients undergoing TEER. Methods and Results A total of 892 patients undergoing TEER from the international MIVNUT (Mitral Valve Repair and Nutritional Status) registry were studied. Malnutrition status was assessed with the Controlling Nutritional Status score. The association of nutritional status with mortality was analyzed with multivariable Cox regression models, whereas the association with heart failure admission was assessed by Fine-Gray models, with death as a competing risk. According to the Controlling Nutritional Status score, 74.4% of patients with TEER had any degree of malnutrition at the time of TEER (75.1% in patients with body mass index <25 kg/m², 72.1% in those with body mass index ≥25 kg/m²). However, only 20% had moderate-severe malnutrition. TEER was successful in most of patients (94.2%). During a median follow-up of 1.6 years (interquartile range, 0.6-3.0), 267 (29.9%) patients died and 256 patients (28.7%) were admitted for heart failure after TEER. Compared with normal nutritional status moderate-severe malnutrition resulted a strong predictor of mortality (adjusted hazard ratio [HR], 2.1 [95% CI, 1.1-2.4]; P<0.001) and heart failure admission (adjusted subdistribution HR, 1.6 [95% CI, 1.1-2.4]; P=0.015). Conclusions Malnutrition is common among patients submitted to TEER, and moderate-severe malnutrition is strongly associated with increased mortality and heart failure readmission. Assessment of nutritional status in these patients may help to improve risk stratification.

Individualised Nutritional Care for Disease-Related Malnutrition: Improving Outcomes by Focusing on What Matters to Patients

Delivering care that meets patients' preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients' preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient's specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.

Individualised Nutritional Care for Disease-Related Malnutrition: Improving Outcomes by Focusing on What Matters to Patients

Delivering care that meets patients’ preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients’ preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient’s specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.

Development of a Tool for Determining the Equivalence of Nutritional Supplements to Diabetic Food Exchanges

Malnutrition is a prevalent issue in hospitals, nursing homes and the community setting. Nutritional products can be used by dietitians to supplement people’s diet by adding energy, macronutrients and other constituents. The aim of the present work was (i) to create a database of nutritional products with information on their energy and macronutrient content, (ii) to estimate the food exchanges of each product and assist in diet plan development for malnourished persons and (iii) to provide a tool for calculation of food exchanges of newly developed products not included in the database. We searched the web for nutritional supplements, and an electronic database with 461 products was generated with data regarding the contained energy and macronutrients of each entry. The following companies were included: Abbott Nutrition, Nestle Nutrition, Nutricia North America, Nutricia Global, Nutricia Europe & Middle East, Axcan Pharma Inc., Kate Farms, Global Health, High Protein, NutriMedical BV, Hormel Health Labs, Hormel Health Labs/Diamond Crystal Brands, Lyons Magnus, Mead Johnson, Medical Nutrition USA Inc., Medtrition, Nutritional Designs Inc., Nutrisens, Humana (Germany), and Vitaflo USA. The created database facilitates product comparisons and categorization into several groups according to energy and protein content. In addition, a tool was created to determine food exchanges for each supplement per serving and/or food exchanges for newly developed products by simply inserting their macronutrient content. The developed tool can facilitate dietitians in comparing products and incorporating them into diet plans, if needed. Such tools may thus serve clinical practice, may be used in dietary or other smart applications and can familiarize dietitians with the digital epoch.

Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults

BACKGROUND

Disease-related malnutrition has been reported in 10% to 55% of people in hospital and the community and is associated with significant health and social-care costs. Dietary advice (DA) encouraging consumption of energy- and nutrient-rich foods rather than oral nutritional supplements (ONS) may be an initial treatment.

OBJECTIVES

To examine evidence that DA with/without ONS in adults with disease-related malnutrition improves survival, weight, anthropometry and quality of life (QoL).

SEARCH METHODS

We identified relevant publications from comprehensive electronic database searches and handsearching. Last search: 01 March 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of DA with/without ONS in adults with disease-related malnutrition in any healthcare setting compared with no advice, ONS or DA alone.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility, risk of bias, extracted data and graded evidence.

MAIN RESULTS

We included 94, mostly parallel, RCTs (102 comparisons; 10,284 adults) across many conditions possibly explaining the high heterogeneity.  Participants were mostly older people in hospital, residential care and the community, with limited reporting on their sex. Studies lasted from one month to 6.5 years.  DA versus no advice - 24 RCTs (3523 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.87 (95% confidence interval (CI) 0.26 to 2.96), or at later time points. We had no three-month data, but advice may make little or no difference to hospitalisations, or days in hospital after four to six months and up to 12 months. A similar effect was seen for complications at up to three months, MD 0.00 (95% CI -0.32 to 0.32) and between four and six months. Advice may improve weight after three months, MD 0.97 kg (95% CI 0.06 to 1.87) continuing at four to six months and up to 12 months; and may result in a greater gain in fat-free mass (FFM) after 12 months, but not earlier. It may also improve global QoL at up to three months, MD 3.30 (95% CI 1.47 to 5.13), but not later. DA versus ONS - 12 RCTs (852 participants) All outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.66 (95% CI 0.34 to 1.26), or at later time points. Either intervention may make little or no difference to hospitalisations at three months, RR 0.36 (95% CI 0.04 to 3.24), but ONS may reduce hospitalisations up to six months. There was little or no difference between groups in weight change at three months, MD -0.14 kg (95% CI -2.01 to 1.74), or between four to six months. Advice (one study) may lead to better global QoL scores but only after 12 months. No study reported days in hospital, complications or FFM. DA versus DA plus ONS - 22 RCTs (1286 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.92 (95% CI 0.47 to 1.80) or at later time points. At three months advice may lead to fewer hospitalisations, RR 1.70 (95% CI 1.04 to 2.77), but not at up to six months. There may be little or no effect on length of hospital stay at up to three months, MD -1.07 (95% CI -4.10 to 1.97). At three months DA plus ONS may lead to fewer complications, RR 0.75 (95% CI o.56 to 0.99); greater weight gain, MD 1.15 kg (95% CI 0.42 to 1.87); and better global QoL scores, MD 0.33 (95% CI 0.09 to 0.57), but this was not seen at other time points. There was no effect on FFM at three months. DA plus ONS if required versus no advice or ONS - 31 RCTs (3308 participants) Evidence was moderate- to low-certainty. There may be little or no effect on mortality at three months, RR 0.82 (95% CI 0.58 to 1.16) or at later time points. Similarly, little or no effect on hospitalisations at three months, RR 0.83 (95% CI 0.59 to 1.15), at four to six months and up to 12 months; on days in hospital at three months, MD -0.12 (95% CI -2.48 to 2.25) or for complications at any time point. At three months, advice plus ONS probably improve weight, MD 1.25 kg (95% CI 0.73 to 1.76) and may improve FFM, 0.82 (95% CI 0.35 to 1.29), but these effects were not seen later. There may be little or no effect of either intervention on global QoL scores at three months, but advice plus ONS may improve scores at up to 12 months. DA plus ONS versus no advice or ONS - 13 RCTs (1315 participants) Evidence was low- to very low-certainty. There may be little or no effect on mortality after three months, RR 0.91 (95% CI 0.55 to 1.52) or at later time points. No study reported hospitalisations and there may be little or no effect on days in hospital after three months, MD -1.81 (95% CI -3.65 to 0.04) or six months. Advice plus ONS may lead to fewer complications up to three months, MD 0.42 (95% CI 0.20 to 0.89) (one study). Interventions may make little or no difference to weight at three months, MD 1.08 kg (95% CI -0.17 to 2.33); however, advice plus ONS may improve weight at four to six months and up to 12 months. Interventions may make little or no difference in FFM or global QoL scores at any time point.

AUTHORS' CONCLUSIONS

We found no evidence of an effect of any intervention on mortality. There may be weight gain with DA and with DA plus ONS in the short term, but the benefits of DA when compared with ONS are uncertain. The size and direction of effect and the length of intervention and follow-up required for benefits to emerge were inconsistent for all other outcomes.  There were too few data for many outcomes to allow meaningful conclusions. Studies focusing on both patient-centred and healthcare outcomes are needed to address the questions in this review.

The association of oral function with dietary intake and nutritional status among older adults: Latest evidence from epidemiological studies

Inadequate and poor quality of diet and malnutrition are common and associated with adverse health outcomes, including morbidity and mortality, among older persons. This review aimed to establish the latest evidence from studies investigating the association between oral function and nutrition among older adults. An electronic search of MEDLINE using PubMed for literature published in English between March 2018 and March 2021 was conducted, and 27 papers were identified. The selected studies comprised 23 observational studies (17 cross-sectional and 6 longitudinal studies) and 4 interventional studies. Most of the observational studies demonstrated the following associations in older adults: older adults with poor oral function are likely to have poorer dietary intake and poorer nutritional status, and malnourished older adults are likely to have poorer oral function. The results of the intervention studies demonstrated that the combination of prosthodontic treatment and dietary counseling is more effective for improving dietary intake and nutritional status in older persons with tooth loss than the prosthodontic treatment alone. Our review confirmed that a relationship exists between oral function and nutrition and revealed the need for additional high-quality studies investigating comprehensive oral function, rather than a single aspect of oral function, with regard to nutritional status.

Metabolic Remodeling in Skeletal Muscle Atrophy as a Therapeutic Target

Skeletal muscle is a highly responsive tissue, able to remodel its size and metabolism in response to external demand. Muscle fibers can vary from fast glycolytic to slow oxidative, and their frequency in a specific muscle is tightly regulated by fiber maturation, innervation, or external causes. Atrophic conditions, including aging, amyotrophic lateral sclerosis, and cancer-induced cachexia, differ in the causative factors and molecular signaling leading to muscle wasting; nevertheless, all of these conditions are characterized by metabolic remodeling, which contributes to the pathological progression of muscle atrophy. Here, we discuss how changes in muscle metabolism can be used as a therapeutic target and review the evidence in support of nutritional interventions and/or physical exercise as tools for counteracting muscle wasting in atrophic conditions.

Nutritional Intervention Improves Nutrition Outcomes in Stomach and Colon Cancer Patients Receiving Chemotherapy: Finding from a Quasi-Experiment in Vietnam

Background: Evidence on the effects of nutritional interventions on gastrointestinal cancer patients receiving chemotherapy is not well documented. This study aims to assess the effects of nutritional intervention in patients diagnosed with stomach and colon cancer receiving chemotherapy in Vietnam. Methods: A quasi-experiment with intervention and control groups for pre- and post-intervention was carried out in cancer patients receiving chemotherapy in a university hospital in Vietnam. Patients in the intervention group were provided nutritional counseling, personalized specific dietary advice, and received oral nutrition supplements (ONSs) while patients in the control group only received nutrition counseling. Results: The weight in the intervention and control group after 2 months increased significantly by 1.4 ± 2.6 kg and 0.4 ± 2.3 kg, respectively. Muscle mass increased by 1.2 ± 4.1 cm in the intervention group, while those in the control group decreased by 0.55 ± 2.77 cm. There was no statistical significance between two groups after intervention in terms of Mid–Upper Arm Circumference (MUAC) and percentage of fat. The percentage of malnutrition based on the Scored Patient-Generated Subjective Global Assessment (PG-SGA) and Body Mass Index (BMI) declined after the intervention in both groups. According to the average treatment effect on the treated (ATT) using the propensity score matching and DiD method, participants receiving the intervention were more likely to have a higher score of weight (Coef = 0.84; 95%CI = 0.47; 2.16) and muscle mass (Coef = 1.08; 95%CI = 0.09; 2.06) between pre- and post-intervention. By contrast, the PG-SGA scores on treated participants were more likely to decrease after the intervention (Coef = −1.28; 95%CI = −4.39; −0.84). After matching, being female, living in rural areas, or having stomach cancer were still positively related to being moderately/severely malnourished by the PG-SGA, and these findings were statistically significant (p < 0.05). Conclusion: The nutritional interventions had a positive effect on weight gain, muscle mass, and reduced malnutrition. Further studies with a longer follow-up duration are needed to confirm the effects of the intervention.

The provision of recipes and single-use herb/spice packets to increase egg and protein intake in community-dwelling older adults: a randomised controlled trial

OBJECTIVE

This study investigated the impact of recipe and single-use herb/spice packet provision on egg intake and protein intake in community-dwelling individuals aged over 55 years.

DESIGN

Using a randomised-controlled intervention design, 100 older adults were randomised to receive (n 53) or not receive (n 47) high-protein egg-based recipes and herb/spice packets through the post for 12 weeks, from June to December 2016. Egg intake, protein intake, adverse events, lean body mass and functional measures of lean body mass were measured at baseline, after the 12 weeks and after a further 12 weeks.

SETTING

Bournemouth, UK.

PARTICIPANTS

Community-dwelling older adults.

RESULTS

Intention-to-treat data were analysed using regression, controlling for various demographic and lifestyle characteristics. Ninety-three individuals (intervention, n 50; control, n 43) completed assessments at all three time points. Egg intakes increased by end of intervention in both groups (mean: 4-5 eggs/month). After a further 12 weeks, higher egg intakes were sustained in the intervention group, while egg intakes in the control group returned to baseline levels (between-group difference: β = -0·124, P = 0·047). No differences were found in other measures (largest β = -0·106, P = 0·12).

CONCLUSIONS

The provision of high-protein egg-based recipes and single-use herb/spice packets over 12 weeks increased egg intakes up to 12 weeks after end of intervention. Other factors may explain increased egg intakes during the intervention, but the sustained effects most plausibly result directly from recipe provision. Limited effects in other measures suggest that the recipes may have replaced as opposed to added to existing protein intakes.

[Nutritional recovery after discharge in hospitalized children with malnutrition]

OBJECTIVE

To investigate the nutritional recovery status of children with moderate or severe malnutrition during hospitalization after discharge.

METHODS

The children with moderate or severe malnutrition were given nutrition support during hospitalization. They received a regular follow-up and nutrition guidance after discharge. The weight-for-age and height-for-age Z-scores reaching above -2 SD were considered the nutrition criterion for ending follow-up.

RESULTS

Among the 298 children with moderate or severe malnutrition, 174 (58.4%) reached the criterion for ending follow-up, 100 (33.6%) were lost to follow-up, 18 (6.0%) died, and 6 (2.0%) did not reach the criterion for ending follow-up after 18 months of follow-up. The children with malnutrition in the department of surgery had a significantly higher proportion of children reaching the criterion for ending follow-up than those in the department of internal medicine (P<0.05). The children with severe malnutrition had a significantly higher loss to follow-up rate than those with moderate nutrition (P<0.05). The majority of children with emaciation reached the criterion for ending follow-up at month 3 after discharge, while those with growth retardation reached such the criterion at months 3-6 after discharge. Up to 1 year after discharge, more than 80% of the children with different types of malnutrition reached the nutrition criterion for ending follow-up.

CONCLUSIONS

Most of the children with malnutrition who adhere to follow-up can reach the expected nutrition criterion within 1 year after discharge. The children with growth retardation have slower nutritional recovery than those with emaciation.

Dietary advice and oral nutritional supplements do not increase survival in older malnourished adults: a multicentre randomised controlled trial

Objectives: The study aimed to investigate the effect on survival after 6 months of treatment involving individual dietary advice and oral nutritional supplements in older malnourished adults after discharge from hospital.Methods: This multicentre randomised controlled trial included 671 patients aged 65 years who were malnourished or at risk of malnutrition when admitted to hospital between 2010 and 2014, and followed up after 8.2 years (median 4.1 years). Patients were randomised to receive dietary advice or oral nutritional supplements, separate or in combination, or routine care. The intervention started at discharge from the hospital and continued for 6 months, with survival being the main outcome measure.Results: During the follow-up period 398 (59.3%) participants died. At follow-up, the survival rates were 36.9% for dietary advice, 42.4% for oral nutritional supplements, 40.2% for dietary advice combined with oral nutritional supplements, and 43.3% for the control group (log-rank test p = 0.762). After stratifying the participants according to nutritional status, survival still did not differ significantly between the treatment arms (log-rank test p = 0.480 and p = 0.298 for the 506 participants at risk of malnutrition and the 165 malnourished participants, respectively).Conclusions: Oral nutritional supplements with or without dietary advice, or dietary advice alone, do not improve the survival of malnourished older adults. These results do not support the routine use of supplements in older malnourished adults, provided that survival is the aim of the treatment.Trial registration: ClinicalTrials.gov with ID: NCT01057914.

Effect of a double nutritional intervention on the nutritional status, functional capacity, and quality of life of patients with chronic heart failure: 12-month results from a randomized clinical trial

Introduction

Introduction: malnutrition is commonly associated with, and worsens the prognosis of heart failure. The management of chronic heart failure and its complications based only on the application of pharmacologic guidelines is incomplete. The benefits of interventions to improve nutritional status may be limited by the multifactorial nature of malnutrition. The objective of the present study was to determine whether nutritional advice and nutritional supplementation can improve the nutritional status of patients with chronic heart failure. Methods: we performed a randomized clinical trial on an intention-to-treat basis with blinded observers. We divided a sample of 76 patients into 2 groups: one that received structured advice combined with nutritional supplements for 12 weeks (test group), and one that received treatment as usual (control group). The outcome measure was nutritional status as evaluated using the Subjective Global Assessment and the Mini Nutritional Assessment tools. After 12 weeks of treatment the test group received a leaflet that served as a reminder. No further interventions were applied in either group. Patients were followed for 1 year. Results: at 3 months of follow-up nutritional status improved 4-fold in the test group, whereas no change was observed in the control group. At 9 months nutritional status in the intervention group had improved 2-fold with respect to the baseline visit, whereas no differences were recorded in the control group. Differences in mortality and length of stay at 1 year did not reach statistical significance.

Oral protein-based supplements versus placebo or no treatment for people with chronic kidney disease requiring dialysis

BACKGROUND

Malnutrition is common in patients with chronic kidney disease (CKD) on dialysis. Oral protein-based nutritional supplements are often provided to patients whose oral intake is otherwise insufficient to meet their energy and protein needs. Evidence for the effectiveness of oral protein-based nutritional supplements in this population is limited.

OBJECTIVES

The aims of this review were to determine the benefits and harms of using oral protein-based nutritional supplements to improve the nutritional state of patients with CKD requiring dialysis.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 12 December 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of patients with CKD requiring dialysis that compared oral protein-based nutritional supplements to no oral protein-based nutritional supplements or placebo.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for eligibility, risk of bias, and extracted data from individual studies. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference and 95% CI for continuous outcomes.

MAIN RESULTS

Twenty-two studies (1278 participants) were included in this review. All participants were adults on maintenance dialysis of whom 79% were on haemodialysis (HD) and 21% peritoneal dialysis. The follow-up period ranged from one to 12 months. The majority of studies were at unclear risk of selection, performance, and reporting bias. The detection bias was high for self-reported outcomes. Oral protein-based nutritional supplements probably lead to a higher mean change in serum albumin compared to the control group (16 studies, 790 participants: MD 0.19 g/dL, 95% CI 0.05 to 0.33; moderate certainty evidence), although there was considerable heterogeneity in the combined analysis (I² = 84%). The increase was more evident in HD participants (10 studies, 526 participants: MD 0.28 g/dL, 95% CI 0.11 to 0.46; P = 0.001 for overall effect) and malnourished participants (8 studies, 405 participants: MD 0.31 g/dL, 95% CI 0.10 to 0.52, P = 0.003 for overall effect). Oral protein-based nutritional supplements also probably leads to a higher mean serum albumin at the end of the intervention (14 studies, 715 participants: MD 0.14 g/dL, 95% CI 0 to 0.27; moderate certainty evidence), however heterogeneity was again high (I² = 80%). Again the increase was more evident in HD participants (9 studies, 498 participants: MD 0.21 g/dL, 95% CI 0.03 to 0.38; P = 0.02 for overall effect) and malnourished participants (7 studies, 377 participants: MD 0.25 g/dL, 95% CI 0.02 to 0.47; P = 0.03 for overall effect). Compared to placebo or no supplement, low certainty evidence showed oral protein-based nutritional supplements may result in a higher serum prealbumin (4 studies, 225 participants: MD 2.81 mg/dL, 95% CI 2.19 to 3.43), and mid-arm muscle circumference (4 studies, 216 participants: MD 1.33 cm, 95% CI 0.24 to 2.43) at the end of the intervention. Compared to placebo or no supplement, oral protein-based nutritional supplements may make little or no difference to weight (8 studies, 365 participants: MD 2.83 kg, 95% CI -0.43 to 6.09; low certainty evidence), body mass index (9 studies, 368 participants: MD -0.04 kg/m², 95% CI -0.74 to 0.66; moderate certainty evidence) and lean mass (5 studies, 189 participants: MD 1.27 kg, 95% CI -1.61 to 4.51; low certainty evidence). Due to very low quality of evidence, it is uncertain whether oral protein-based nutritional supplements affect triceps skinfold thickness, mid-arm circumference, C-reactive protein, Interleukin 6, serum potassium, or serum phosphate. There may be little or no difference in the risk of developing gastrointestinal intolerance between participants who received oral protein-based nutritional supplements compared with placebo or no supplement (6 studies, 426 participants: RR 2.81, 95% CI 0.58 to 13.65, low certainty evidence). It was not possible to draw conclusions about cost or quality of life, and deaths were not reported as a study outcome in any of the included studies.

AUTHORS' CONCLUSIONS

Overall, it is likely that oral protein-based nutritional supplements increase both mean change in serum albumin and serum albumin at end of intervention and may improve serum prealbumin and mid-arm muscle circumference. The improvement in serum albumin was more evident in haemodialysis and malnourished participants. However, it remains uncertain whether these results translate to improvement in nutritional status and clinically relevant outcomes such as death. Large well-designed RCTs in this population are required.

Ready-Made Oral Nutritional Supplements Improve Nutritional Outcomes and Reduce Health Care Use-A Randomised Trial in Older Malnourished People in Primary Care

Large trials assessing oral nutritional supplements (ONS) and dietary advice (DA) in primary care are lacking. This study examined effects of ONS + DA versus DA on intake, weight, QoL, healthcare use and satisfaction in malnourished free-living older people. Three hundred and eight people (71.5 ± 10.7y) were randomised to receive ONS + DA (n154) or DA (n154) for 12 weeks. At baseline, 4, 8, 12 weeks, intake, weight, QoL, healthcare use and satisfaction were measured. ONS + DA group (mean daily intake ONS 480 kcal; 21 g protein; 80% compliance) had significantly greater total energy and protein intakes (+401 kcal/d, p < 0.001; +15 g/d, p < 0.001) and weight gain (+0.8 kg; p < 0.001) compared to DA. QoL improved in both groups over time with a significant improvement in index with ONS + DA (p = 0.009). Significantly more participants found ONS + DA made a difference for them (p = 0.011), but no differences were found between groups using Euroqol. Compared to DA, healthcare use reduced with ONS + DA, (HCP visits by 34%, emergency admissions 50%, LOS 62%). Acceptability of both interventions was high (ONS 96%, DA 95%), with significantly more participants satisfied with ONS (89%) than DA (73%) (p = 0.009). This trial in primary care indicates that ONS are acceptable, make a difference to patients, significantly improve intake and weight, and reduce health care use with potential savings.

Supporting nutrition in frail older people: a qualitative study exploring views of primary care and community health professionals

BACKGROUND

Malnutrition is associated with increased morbidity and mortality, and is very common in frail older people. However, little is known about how weight loss in frail older people can be managed in primary care.

AIMS

To explore the views and practices of primary care and community professionals on the management of malnutrition in frail older people; identify components of potential primary care-based interventions for this group; and identify training and support required to deliver such interventions.

DESIGN AND SETTING

Qualitative study in primary care and community settings.

METHOD

Seven focus groups and an additional interview were conducted with general practice teams, frailty multidisciplinary teams (MDTs), and community dietitians in London and Hertfordshire, UK (n = 60 participants). Data were analysed using thematic analysis.

RESULTS

Primary care and community health professionals perceived malnutrition as a multifaceted problem. There was an agreement that there is a gap in care provided for malnutrition in the community. However, there were conflicting views regarding professional accountability. Challenges commonly reported by primary care professionals included overwhelming workload and lack of training in nutrition. Community MDT professionals and dietitians thought that an intervention to tackle malnutrition would be best placed in primary care and suggested opportunistic screening interventions. Education was an essential part of any intervention, complemented by social, emotional, and/or practical support for frailer or socially isolated older people.

CONCLUSIONS

Future interventions should include a multifaceted approach. Education tailored to the needs of older people, carers, and healthcare professionals is a necessary component of any intervention.

Economic Impact of Implementing Malnutrition Screening and Nutritional Management in Older Adults in General Practice

OBJECTIVES

Malnutrition is a common and significant public health problem, especially for older adults, as the consequences are costly. National guidelines (NICE CG32/QS24) highlight the need to identify and manage malnutrition, the implementation of which was deemed "high impact to produce cost savings". The 'Malnutrition Pathway', endorsed by NICE and other professional bodies, is a practical evidence-based guide to help community healthcare professionals (HCP) to implement guidance on malnutrition management. Published evaluations of its use are needed.

DESIGN

This service evaluation in older adults assessed the impact of implementing the 'Malnutrition Pathway' on health care use and costs, as well as the acceptability of the management strategies and effect on malnutrition risk.

SETTING

5 GP surgeries in Gloucestershire.

PARTICIPANTS

163 older adults (80±9 years) with a range of primary diagnoses, living in their own home, were screened using the Malnutrition Universal Screening Tool ('MUST') (n50 low risk (LR); n41 medium risk (MR); n72 high risk (HR)). All patients were managed according to risk (LR: no further management; MR: dietary advice (DA); and HR: DA plus two oral nutritional supplements (ONS) (1 serve 300kcal, 18g protein; 125ml).

MEASUREMENTS

At each review (6weeks, 3 and 6 months), 'MUST' score, compliance and satisfaction to their management plan were recorded. Healthcare use was collected from GP records 6 months before and after implementation of the pathway. A simple cost analysis was completed.

RESULTS

Implementing appropriate management of malnutrition led to significant reductions in hospital admissions (p=0.028), length of hospital stay (p=0.05), GP visits (p=0.007) and antibiotic prescriptions (p=0.05). Over 6 months, the costs to manage malnutrition (HCP time, ONS) were more than offset by the savings associated with these reductions in health care use (per patient savings of -£395.64 MR+HR; -£997.02 HR). The proportion of individuals at risk of malnutrition reduced over time, and patients reported being satisfied with the DA (97%) and ONS (96%), consuming 90% of their ONS prescription.

CONCLUSION

Managing malnutrition significantly reduces healthcare use, with a positive budget impact, in older malnourished patients in primary care. This represents an opportunity to improve patient care with benefit on health care spend.

Effectiveness of Tailored Dietary Counseling in Treating Malnourished Outpatients with Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial

BACKGROUND

Malnutrition in patients with chronic obstructive pulmonary disease (COPD) is common and associated with poor prognosis. Nutrition interventions are necessary, but there is a lack of evidence regarding the effectiveness of tailored nutrition advice.

OBJECTIVE

This study investigated whether tailored nutrition counseling could improve dietary intake, nutritional status, functional outcomes, and health-related quality of life (QoL) of malnourished outpatients with COPD.

DESIGN

We conducted a randomized controlled trial in which participants were randomly assigned to either the intervention group (IG) or the control group (CG).

PARTICIPANTS/SETTING

One hundred and twenty malnourished outpatients with COPD participated in the study between May and November 2017 at the National Lung Hospital, Hanoi, Vietnam.

INTERVENTION

The IG received tailored nutrition counseling once per month for 3 months based on a specifically developed written nutrition resource for COPD. The CG received the same educational resource at baseline without any discussion.

MAIN OUTCOME MEASURES

The main outcome measures were energy and protein intakes, body weight change, nutritional status (Subjective Global Assessment score), muscle strength, and QoL.

STATISTICAL ANALYSES

Differences between groups before and after the intervention were assessed using two-way repeated measures analysis of variance. Generalized estimating equation modeling was used to investigate the differences between groups over time.

RESULTS

At baseline, there were no significant differences in outcomes of interest between the two groups. After 3 months of intervention, time-intervention interactions for energy intake, protein intake, and body weight change were significant (945 kcal/day, 95% CI 792 to 1,099 kcal/day, P<0.001; 50.0 g protein/day, 95% CI 43.9 to 56.1 g protein/day, P<0.001; and 1.0 kg, 95% CI 0.5 to 1.5 kg, P<0.001, respectively). Subjective Global Assessment scores improved in the IG and worsened in the CG. Significant improvements were found in inspiratory muscle strength in the IG (5.4 cmH₂O, 95% CI 2.3 to 8.6 cmH₂O, P=0.001) and significant decreases in handgrip strength were found in the CG after 3 months of the intervention (1.4 kg, 95% CI 0.4 to 2.4 kg, P=0.007). There was a significant interaction effect for all QoL scores (analysis of variance two-way repeated, P≤0.003). The IG also significantly improved all QoL scores from baseline to 3 months (P<0.004).

CONCLUSIONS

Tailored nutritional counseling has the potential to improve dietary intakes, nutritional status, functional outcomes, and QoL in malnourished outpatients with COPD.

Nutritional issues in patients with cancer

Cancer is a catabolic inflammatory disease that causes patients to often experience weight loss, or even cachexia in severe cases. Undernourishment in patients with cancer impairs the quality of life and therapeutic response, further leading to poor prognosis. Active and frequent nutritional screening and assessment using valid tools are important for fast and appropriate nutritional intervention. Additionally, a suitable individualized nutritional intervention strategy should be established based on the nutritional assessment result. In general, nutritional intervention begins with nutritional counseling of patients diagnosed with cancer, and a well-planned nutritional counseling improves the treatment adherence and nutritional status. When planning nutritional supplementation for cancer patients, specific nutrients, including amino acids and fatty acids, should be considered. However, there has been no consistent result showing that any particular nutrient significantly improves the prognosis of cancer patients. Hence, continuous attention from clinical physicians is needed to plan nutritional improvement in patients with cancer.

Adherences to oral nutritional supplementation among hospital outpatients: An online cross-sectional survey in Japan

Oral nutritional supplements (ONS) are multi-nutrient products used to increase the energy and nutrient intakes of patients. The aim of this study was to examine whether or not the adherence of patients varies according to their receiving prescription or over-the-counter ONS. Data were obtained from an online cross-sectional survey conducted with patients in Japan. A total of 107 patients who matched the inclusion criteria for the prescription ONS group and 148 who matched the criteria for the over-the-counter ONS group were further analyzed. In the prescription and over-the-counter ONS groups, the main medical reason for ONS consumption were “malnutrition” (48 patients [44.9%] vs. 63 patients [42.6%] p = 0.798], “frailty” (29 patients [27.1%] vs. 36 patients [24.3%] p = 0.663) and “aging” (25 patients [23.4%] vs. 30 patients [20.3%] p = 0.644). The proportion of “No particular disease” for prescription ONS consumption was significantly lower than that for over-the-counter ONS (6 patients [5.6%] vs. 24 patients [16.2%] p = 0.001). The body mass index of the prescription ONS group was significantly higher than that of the over-the-counter ONS group (21.1±4.38 kg/m² vs. 19.9±3.75 kg/m², p = 0.0161). In the prescription ONS group, all patients were given medical advice by doctors or registered dietitians. In contrast, in the over-the-counter ONS group, only 46 patients (31.1%) were given advice by doctors or registered dietitians (p<0.001). In the prescription ONS group, ONS was taken significantly more times and for a longer duration than in the over-the-counter ONS group (p<0.0001). However, among patients given advice by doctors or registered dietitians, there were no significant differences between the groups. Greater support by the medical team is still needed in order to maximize adherence to supplementation, especially concerning the calories, timing and period, so that benefits can be achieved and sustained.

Barriers and facilitators to screening and treating malnutrition in older adults living in the community: a mixed-methods synthesis

BACKGROUND

Malnutrition (specifically undernutrition) in older, community-dwelling adults reduces well-being and predisposes to disease. Implementation of screen-and-treat policies could help to systematically detect and treat at-risk and malnourished patients. We aimed to identify barriers and facilitators to implementing malnutrition screen and treat policies in primary/community care, which barriers have been addressed and which facilitators have been successfully incorporated in existing interventions.

METHOD

A data-base search was conducted using MEDLINE, Embase, PsycINFO, DARE, CINAHL, Cochrane Central and Cochrane Database of Systematic Reviews from 2012 to June 2016 to identify relevant qualitative and quantitative literature from primary/community care. Studies were included if participants were older, community-dwelling adults (65+) or healthcare professionals who would screen and treat such patients. Barriers and facilitators were extracted and mapped onto intervention features to determine whether these had addressed barriers.

RESULTS

Of a total of 2182 studies identified, 21 were included (6 qualitative, 12 quantitative and 3 mixed; 14 studies targeting patients and 7 targeting healthcare professionals). Facilitators addressing a wide range of barriers were identified, yet few interventions addressed psychosocial barriers to screen-and-treat policies for patients, such as loneliness and reluctance to be screened, or healthcare professionals' reservations about prescribing oral nutritional supplements.

CONCLUSION

The studies reviewed identified several barriers and facilitators and addressed some of these in intervention design, although a prominent gap appeared to be psychosocial barriers. No single included study addressed all barriers or made use of all facilitators, although this appears to be possible. Interventions aiming to implement screen-and-treat approaches to malnutrition in primary care should consider barriers that both patients and healthcare professionals may face.

REVIEW REGISTRATIONS

PROSPERO: CRD42017071398 . The review protocol was registered retrospectively.

Management of Malnutrition in Older Patients-Current Approaches, Evidence and Open Questions

Malnutrition is widespread in older people and represents a major geriatric syndrome with multifactorial etiology and severe consequences for health outcomes and quality of life. The aim of the present paper is to describe current approaches and evidence regarding malnutrition treatment and to highlight relevant knowledge gaps that need to be addressed. Recently published guidelines of the European Society for Clinical Nutrition and Metabolism (ESPEN) provide a summary of the available evidence and highlight the wide range of different measures that can be taken-from the identification and elimination of potential causes to enteral and parenteral nutrition-depending on the patient's abilities and needs. However, more than half of the recommendations therein are based on expert consensus because of a lack of evidence, and only three are concern patient-centred outcomes. Future research should further clarify the etiology of malnutrition and identify the most relevant causes in order to prevent malnutrition. Based on limited and partly conflicting evidence and the limitations of existing studies, it remains unclear which interventions are most effective in which patient groups, and if specific situations, diseases or etiologies of malnutrition require specific approaches. Patient-relevant outcomes such as functionality and quality of life need more attention, and research methodology should be harmonised to allow for the comparability of studies.

How effective is nutrition education aiming to prevent or treat malnutrition in community-dwelling older adults? A systematic review

BACKGROUND

While malnutrition is associated with adverse health outcomes in older adults, little is known about the effectiveness of nutrition education. This systematic review examines the evidence for educational interventions to improve nutritional and other health-related outcomes in community-dwelling older people.

METHODS

Systematic searches of three databases (Embase, Medline and CINAHL) were conducted. Studies testing educational interventions targeting older adults (mean age ≥ 60 years) or their caregivers were eligible for inclusion. Two authors independently assessed trial eligibility, risk of bias and extracted data. Study heterogeneity was high precluding meta-analysis, therefore a narrative synthesis was conducted.

RESULTS

Nine articles reporting on eight studies (n = 7 trials; 1 pre-post-intervention study) met inclusion criteria. There was considerable variability in the format of educational interventions. Nutrition education was either generic or personalised and the intensity was variable (1-6 sessions). We found some evidence (in five out of eight studies) that nutrition education may improve nutrition-related outcomes. Nutrition education involving caregivers was found to reduce nutritional risk in one study, and nutritional counselling following discharge from hospital was found to reduce the risk of readmission in another study. However, the overall quality of the studies was hampered by poor methodology, low sample size and attrition bias, and results need to be interpreted with caution.

CONCLUSIONS

Educational interventions may have potential to improve malnutrition-related outcomes in older people, but the strength of evidence is poor. More robust, larger studies are needed to ascertain the effectiveness of nutritional education interventions in this population.

The Challenge of Managing Undernutrition in Older People with Frailty

Many older people with frailty are at risk of malnutrition and poor health, yet there is evidence that improving nutrition and weight loss can reduce frailty. This will become more important as the number of older people with frailty increases worldwide in future. Identifying those at risk is challenging due to the difficulty of reaching and screening those older people most at risk, the large number of nutritional assessment tools used, and the lack of consensus on the criteria to make a diagnosis of malnutrition. The management of older people with or at risk of malnutrition should be multi-modal and multi-disciplinary, and all care staff have an important role in delivering appropriate nutritional advice and support. This paper will highlight a number of practical approaches that clinicians can take to manage malnutrition in older people with frailty in community and acute settings, including environmental changes to enhance mealtime experience, food fortification and supplementation.

High Adherence to Oral Nutrition Supplements Prescribed by Dietitians: A Cross-Sectional Study on Hospital Outpatients

Background

This study aimed to assess adherence to oral nutrition supplements (ONS) among hospital outpatients and to assess patient characteristics, experiences of ONS, and the characteristics of ONS prescriptions in clinical practice.

Methods

Hospital outpatients aged ≥18 years and prescribed ONS by a dietitian at a Swedish hospital were referred to the study from September 2016 to February 2017. Data were collected from structured telephone interviews, medical records, and a register of ONS delivered. Adherence to ONS was measured by dividing self‐reported intake of ONS (frequency question and 24‐hour recall question) by the amount prescribed and using the medication possession ratio (MPR).

Results

Of the 96 patients included (mean age 67 ± 13 years), 52% were male. The 2 most frequent medical diagnoses were malignancy and digestive system disease. Mean adherence to ONS was 93% measured by the frequency question, 87% measured by the 24‐hour recall question, and 76% according to MPR. The majority of the patients (83%) were prescribed 1–3 bottles of ONS/day. The average number of flavors of ONS delivered was 4.2. Before prescription, 69% of the patients had been allowed to taste the ONS and 92% had chosen the flavors to be prescribed. Over 75% liked the taste of the ONS and considered them to be good for their health.

Conclusions

Adherence to ONS was high in this population, which might be explained by the individual tailoring of ONS prescriptions by a dietitian, positive experiences of ONS, and the relatively young mean age of the participants.

The Psychology of Nutrition with Advancing Age: Focus on Food Neophobia

Many factors impact on eating behaviour and nutritional status in older adults. Strategies can be suggested to combat the impact of these factors, including the development of novel food products, but food neophobia ("the reluctance to eat and/or avoidance of novel foods") may be a barrier to the acceptance of these foods/products. This work aimed to investigate associations between food neophobia, physical disadvantage, and demographic characteristics in adults over 55 years old. Cross-sectional data from 377 older adults was analysed for relationships between food neophobia scores and physical disadvantage (denture wearing, help with food shopping and/or preparing, and risk of sarcopenia), controlling for age group, gender, living status, education, and employment level. Initial analyses demonstrated higher food neophobia scores in association with denture wearing (Beta = 0.186, p = 0.001). However, when demographic characteristics were also considered, food neophobia scores were no longer related to denture wearing (Beta = 0.069, p = 0.226) but instead were related to a higher age, living alone, and a shorter education (smallest Beta = -0.104, p = 0.048). Food neophobia may thus act as a barrier to the consumption of novel foods/products in those who are of higher age, are living alone, and have a shorter education.

Efficacy of non-pharmacological interventions to treat malnutrition in older persons: A systematic review and meta-analysis. The SENATOR project ONTOP series and MaNuEL knowledge hub project

INTRODUCTION

We aimed to perform a review of SRs of non-pharmacological interventions in older patients with well-defined malnutrition using relevant outcomes agreed by a broad panel of experts.

METHODS

PubMed, Cochrane, EMBASE, and CINHAL databases were searched for SRs. Primary studies from those SRs were included. Quality assessment was undertaken using Cochrane and GRADE criteria.

RESULTS

Eighteen primary studies from seventeen SRs were included. Eleven RCTs compared oral nutritional supplementation (ONS) with usual care. No beneficial effects of ONS treatment, after performing two meta-analysis in body weight changes (six studies), mean difference: 0.59 (95%CI -0.08, 1.96) kg, and in body mass index changes (two studies), mean difference: 0.31 (95%CI -0.17, 0.79) kg/m2 were found. Neither in MNA scores, muscle strength, activities of daily living, timed Up&Go, quality of life and mortality. Results of other intervention studies (dietary counselling and ONS, ONS combined with exercise, nutrition delivery systems) were inconsistent. The overall quality of the evidence was very low due to risk of bias and small sample size.

CONCLUSIONS

This review has highlighted the lack of high quality evidence to indicate which interventions are effective in treating malnutrition in older people. High quality research studies are urgently needed in this area.

Goal-Directed Drinking Behaviors Can Be Modified Through Behavioral Mimicry

PURPOSE

This study tested whether behavioral mimicry can alter drinking behavior. It was hypothesized that participants would increase drinking behaviors given increased confederate drinking but not cup touching.

METHODS

Nineteen healthy adults (Mage = 20.32 years) completed 2 picture description tasks; during 1 task, a confederate frequently sipped water (complete drinking gesture), and during the other, the confederate touched her cup but did not drink (partial gesture). Outcome measures included number of drinks per minute, number of cup touches per minute, percentage of time spent drinking, and percentage of time spent touching the cup.

RESULTS

Participants spent more time drinking and had an increased drinking rate during the drinking condition versus the cup-touching condition. For a majority of participants, drinking rate increased during the drinking condition versus baseline. Drinking, but not cup touching, rate also increased given increased confederate cup touching for many.

CONCLUSIONS

Mimicry likely contributes to social modeling of drinking behaviors. This effect appears more robust given a complete target gesture (full drink); however, a partial goal-directed drinking gesture may also yield a mimicked response. Beyond the theoretical implications, these results provide directions for research investigating more naturalistic mechanisms for increasing dietary intake in various patient populations (e.g., individuals with dysphagia).

Malnutrition is associated with increased mortality in older adults regardless of the cause of death

Malnutrition predicts preterm death, but whether this is valid irrespective of the cause of death is unknown. The aim of the present study was to determine whether malnutrition is associated with cause-specific mortality in older adults. This cohort study was conducted in Sweden and included 1767 individuals aged ≥65 years admitted to hospital in 2008–2009. On the basis of the Mini Nutritional Assessment instrument, nutritional risk was assessed as well nourished (score 24–30), at risk of malnutrition (score 17–23·5) or malnourished (score <17). Cause of death was classified according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, into twenty different causes of death. Data were analysed using Cox proportional hazards regression models. At baseline, 55·1 % were at risk of malnutrition, and 9·4 % of the participants were malnourished. During a median follow-up of 5·1 years, 839 participants (47·5 %) died. The multiple Cox regression model identified significant associations (hazard ratio (HR)) between malnutrition and risk of malnutrition, respectively, and death due to neoplasms (HR 2·43 and 1·32); mental or behavioural disorders (HR 5·73 and 5·44); diseases of the nervous (HR 4·39 and 2·08), circulatory (HR 1·95 and 1·57) or respiratory system (HR 2·19 and 1·49); and symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (HR 2·23 and 1·43). Malnutrition and risk of malnutrition are associated with increased mortality regardless of the cause of death, which emphasises the need for nutritional screening to identify older adults who may require nutritional support in order to avoid preterm death.

Undernutrition: who cares? Perspectives of dietitians and older adults on undernutrition

Background

Many older adults are at risk of undernutrition. Dietitians play a key role in the management and treatment of undernutrition, but older adults have difficulties to comply with dietetic recommendations. This qualitative study investigated which barriers older adults experience in adhering to treatment for undernutrition. Current dietetic practices and older adults’ experiences were studied, and the potential to use protein-enriched regular products in undernutrition treatment was investigated.

Methods

We interviewed 18 older adults who were under treatment for undernutrition, and 13 dietitians. Semi-structured interview guides were used, and all interviews were audiotaped and transcribed verbatim. The interviews were coded with qualitative analysis software NVivo9, followed by content analysis to formulate main themes.

Results

The interviews resulted in seven themes, which related to three main topics: barriers for treating undernutrition in older adults, current dietetic treatment, and new strategies to complement current treatment. Low awareness and a lack of knowledge regarding undernutrition, physical limitations, and loss of appetite were found to be major barriers for treating undernutrition in older adults. Dietitians said to focus mostly on increasing energy and protein intake by recommending the use of regular food products that fit the needs and habits of the patient, before prescribing oral nutritional supplements. Dietitians considered enriched regular products to be useful if they fit with the habits of older adults, the portion sizes were kept small, if products were easy to open and prepare, had good palatability, and were offered in a variety of taste and textures.

Conclusions

Results from the interviews suggest that undernutrition awareness is low among older adults and they lack knowledge on how to manage undernutrition despite efforts taken by dietitians. Enriched regular products could enable older adults to better adhere to undernutrition treatment, provided that these products meet the needs and eating habits of older adults. If protein-enriched food products can replace regular, low-protein variants, older adults do not need to consume more, but can adhere to their usual pattern while consuming more protein.

A feasibility study of implementing grip strength measurement into routine hospital practice (GRImP): study protocol

BACKGROUND

Handgrip strength is a non-invasive marker of muscle strength, and low grip strength in hospital inpatients is associated with poor healthcare outcomes including longer length of stay, increased functional limitations, and mortality. Measuring grip strength is simple and inexpensive. However, grip strength measurement is not routinely used in clinical practice. The aim of this study is to evaluate the feasibility of implementing grip strength measurement into routine clinical practice.

METHODS/DESIGN

This feasibility study is a mixed methods design combining qualitative, quantitative, and economic elements and is based on the acute medical wards for older people in one hospital. The study consists of three phases: phase 1 will define current baseline practice for the identification of inpatients at high risk of poor healthcare outcomes, their nutrition, and mobility care through interviews and focus groups with staff as well as a review of patients' clinical records. Phase 2 will focus on the feasibility of developing and implementing a training programme using Normalisation Process Theory to enable nursing and medical staff to measure and interpret grip strength values. Following the training, grip strength will be measured routinely for older patients as part of admission procedures with the use of a care plan for those with low grip strength. Finally, phase 3 will evaluate the acceptability of grip strength measurement, its adoption, coverage, and basic costs using interviews and focus groups with staff and patients, and re-examination of clinical records.

DISCUSSION

The results of this study will inform the translation of grip strength measurement from a research tool into clinical practice to improve the identification of older inpatients at risk of poor healthcare outcomes.

TRIAL REGISTRATION

Clinicaltrials.gov NCTO2447445.

Identifying and managing malnutrition in the community

Malnutrition affects more than 3 million people in the UK, most of whom live in the community. Malnutrition is both a cause and consequence of disease and can lead to increased mortality and morbidity, delayed recovery from illness and impaired body function which can make carrying out activities of daily living difficult. Managing malnutrition in the community involves identifying malnutrition using a universally validated screening tool and implementing appropriate care plans according to the degree of malnutrition. Regional and local guidance can be used to assist healthcare professionals to prescribe appropriate oral nutritional supplements and monitor nutritional aims and goals.

Nutritional advice for community patients: insights from a panel discussion

This article describes the conclusions of an expert panel that discussed four case studies; these were examples of patients typically encountered by nurses working in the community. The panel considered the nutritional and lifestyle advice that could be given by nurses relating to conditions such as irritable bowel syndrome (IBS), depression, chronic fatigue syndrome, vulnerability to common infections, elderly care, recurrent urinary tract infection, antibiotic use, and risk of type 2 diabetes. A general conclusion was the importance of motivational interviewing techniques in achieving full understanding of patients' concerns and to determine the best health strategy. As well as specific guidance appropriate for each disorder, a range of information sources for both health professionals and patients are listed in the paper. The panel noted that, although general nutritional advice can be given by nurses working at GP surgeries and in the community, patients should always be referred to registered dietitians or nutritionists if significant dietary changes are considered.

A cluster randomised feasibility trial evaluating nutritional interventions in the treatment of malnutrition in care home adult residents

Background

Protein energy malnutrition (PEM) predisposes individuals to disease, delays recovery from illness and reduces quality of life. Care home residents in the United Kingdom are especially vulnerable, with an estimated 30 to 42 % at risk. Evidence for nutritional interventions to address PEM in the care home setting is lacking. Widely used techniques include food-based intervention and/or the use of prescribed oral nutritional supplements. To define outcomes and optimise the design for an adequately powered definitive trial to compare the efficacy of established nutritional interventions in this setting, a cluster randomised feasibility trial with a 6-month intervention was undertaken.

Methods

Care home residents with or at risk of malnutrition were identified across six UK care home sites from September to December 2013. Homes were cluster randomised to standard care (SC), food-based intervention (FB) or oral nutritional supplement intervention (ONS), for 6 months. Key outcomes were trial feasibility and the acceptability of design, allocated interventions and outcome assessments. Anthropometry, dietary intake, healthcare resource usage and participant-reported outcome measures were assessed at baseline and at 3 and 6 months.

Results

All six care homes approached were recruited and retained. Of the 110 residents at risk of malnutrition, 85 % entered the trial, and 68 % completed the 6-month intervention. Pre-specified success criteria for feasibility were met for recruitment and retention, intervention acceptability (resident compliance ≥60 %) and measurement of weight, body mass index (BMI), mid-upper arm circumference and dietary intake (data completeness >80 %). Measurement of handgrip strength and triceps skinfold thickness was not found to be feasible in this population. The 95 % confidence interval (CI) data suggested sensitivity to change in dietary intake for weight, BMI and energy intake between baseline and 3 months when each intervention (FB and ONS) was compared with SC.

Conclusions

A definitive trial comparing the efficacy of nutritional support interventions in increasing weight and BMI in malnourished care home residents can be conducted. However, whilst the design was feasible, this trial has highlighted the lack of clinically and patient-relevant outcome measures that are appropriate for use in this setting for both research and clinical practice. In particular, this trial identified a need for a more simple measure of functional status, which considers the limitations of functional tests in the care home population.

Trial registration

Current Controlled Trials ISRCTN38047922, Date assigned: 22 April 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0952-2) contains supplementary material, which is available to authorized users.

Nutrition assessment, counseling, and support interventions to improve health-related outcomes in people living with HIV/AIDS: a systematic review of the literature

BACKGROUND

Although numerous studies have shown that severe to moderate wasting at the time of antiretroviral therapy initiation is strongly predictive of mortality, it remains unclear whether nutritional interventions at or before antiretroviral therapy initiation will improve outcomes. This review examines data on nutrition assessment, counseling, and support interventions in resource-limited settings.

METHODS

We identified articles published between 2005 and 2014 on the effectiveness of nutrition assessment, counseling, and support interventions, particularly its impact on 5 outcomes: mortality, morbidity, retention in care, quality of life, and/or prevention of ongoing HIV transmission. We rated the overall quality of individual articles and summarized the body of evidence and expected impact for each outcome.

RESULTS

Twenty-one articles met all inclusion criteria. The overall quality of evidence was weak, predominantly because of few studies being designed to directly address the question of interest. Only 2 studies were randomized trials with no food support control groups. The remainder were randomized studies of one type of food support versus another, cohort (nonrandomized) studies, or single-arm studies. Ratings of individual study quality ranged from "medium" to "weak," and the quality of the overall body of evidence ranged from "fair" to "poor." We rated the expected impact on all outcomes as "uncertain."

CONCLUSIONS

Rigorous better designed studies in resource-limited settings are urgently needed to understand the effectiveness of nutrition assessment and counseling alone, as well as studies to understand better modalities of food support (targeting, timing, composition, form, and duration) to improve both short- and long-term patient retention in care and treatment, and clinical outcomes.

Nutrition management of diabetes in acute care

Nutrition therapy in hospital includes the integration of diabetes into the care plan for the presenting condition, basic self-management education and care coordination to promote optimal glycemic control in hospital and an appropriate plan for discharge. Estimated nutrient requirements for people with diabetes are the same as those for the general population, and diets should be designed based on individual metabolic needs. Distribution of meals and snacks should employ a consistent carbohydrate meal-planning approach for both patient safety and management of glycemia. Referral to a registered dietitian for a full assessment is warranted for those at higher risk for hyperglycemia, including those on insulin or nutrition support. Consideration may be given to the use of lower carbohydrate oral nutrition supplements. A team approach should be employed to ensure there is coordination among blood glucose testing, insulin administration and meal timing. Self-management education should focus on patient safety, and an appropriate plan for discharge should be created to manage the ongoing needs of patients with this chronic disease.

That's why I take my ONS. Means-end chain as a novel approach to elucidate the personally relevant factors driving ONS consumption in nutritionally frail elderly users

Oral nutritional supplements (ONS) are a recommended form of nutritional intervention for older malnourished persons when a 'food first' approach and/or food fortification prove ineffective. The efficacy of ONS will depend on, amongst other factors, whether persons do, or do not, consume their prescribed amount. Factors influencing ONS consumption can be product, context, or person related. Whereas product and context have received some attention, little is known about the person factors driving ONS consumption. In addition, the relative importance of the product, context, and person factors to ONS consumption is not known. Using the means-end chain (MEC) method, the current study elucidated personally relevant factors (product, context, and person factors) related to ONS consumption in two groups of older nutritionally frail ONS users: community-dwelling persons and care home residents with mainly somatic disorders. To our knowledge, the current work is the first to apply the MEC method to study older nutritionally frail ONS users. Forty ONS users (n = 20 per group) were recruited via healthcare professionals. The level of frailty was assessed using the FRAIL scale. Both groups were interviewed for 30 to 45 minutes using the soft laddering technique. The laddering data were analysed using LadderUX software™. The MEC method appeared to work well in both groups. The majority of the participants took ONS on their doctor's or dietician's prescription as they trusted their advice. The community-dwelling group took ONS to prolong their independence, whereas the care home group reported values that related more to small improvements in quality of life. In addition, care home residents perceived themselves as dependent on their caregiver for their ONS arrangements, whereas this dependence was not reported by community-dwelling persons. Key insights from this work will enable doctors and dieticians to customize their nutritional interventions to ONS users' personal needs and thus positively impact health outcomes.

A cluster randomised feasibility trial evaluating six-month nutritional interventions in the treatment of malnutrition in care home-dwelling adults: recruitment, data collection and protocol

Background

Protein energy malnutrition predisposes individuals to disease, delays recovery from illness and reduces quality of life. Care home residents are especially vulnerable, with an estimated 30%–42% at risk. There is no internationally agreed protocol for the nutritional treatment of malnutrition in the care home setting. Widely used techniques include food-based intervention and/or the use of prescribed oral nutritional supplements, but a trial comparing the efficacy of interventions is necessary. In order to define outcomes and optimise the design for an adequately powered, low risk of bias cluster randomised controlled trial, a feasibility trial with 6-month intervention is being run, to assess protocol procedures, recruitment and retention rates, consent processes and resident and staff acceptability.

Methods

Trial recruitment began in September 2013 and concluded in December 2013. Six privately run care homes in Solihull, England, were selected to establish feasibility within different care home types. Residents with or at risk of malnutrition with no existing dietetic intervention in place were considered for receipt of the allocated intervention. Randomisation took place at the care home level, using a computer-generated random number list to allocate each home to either a dietetic intervention arm (food-based or prescribed supplements) or the standard care arm, continued for 6 months. Dietetic intervention aimed to increase daily calorie intake by 600 kcal and protein by 20–25 g.

Results

The primary outcomes will be trial feasibility and acceptability of trial design and allocated interventions. A range of outcome assessments and data collection tools will be evaluated for feasibility, including change in nutrient intake, anthropometric parameters and patient-centric measures, such as quality of life and self-perceived appetite.

Conclusions

The complexities inherent in care home research has resulted in the under representation of this population in research trials. The results of this feasibility trial will be used to inform the development and design of a future cluster randomised controlled trial to compare food-based intervention with prescribed oral nutritional supplements (ONS) in the treatment of malnutrition within the care home population.

Trial registration

Current Controlled Trials ISRCTN38047922

Electronic supplementary material

The online version of this article (doi:10.1186/2055-5784-1-3) contains supplementary material, which is available to authorized users.

Potential barriers to effective MUST implementation

The Malnutrition Universal Screening Tool (MUST) is frequently cited as a simple screening tool for malnutrition. However, anecdotally, it seems that not all staff find it simple to use. If staff do not find MUST simple to complete, then screening is less likely to be completed accurately. Accurate completion of MUST is essential for malnutrition to be identified and treated, otherwise the nutritional needs of patients with unrecognised malnutrition may be neglected. The use of simplified versions of body mass index score, weight loss score and ulna-length charts together with ongoing training and support may help to improve accurate MUST completion. Audit of MUST completion must consider the accuracy of completion rather than completion alone. Therefore, those auditing MUST completion require a good understanding of the tool. This article draws on the author's own significant experience with applying the MUST tool and synthesises this with evidence from the literature to demonstrate the potential barriers to effective MUST implementation.

Concordance of effects of medical interventions on hospital admission and readmission rates with effects on mortality

BACKGROUND

Many clinical trials examine a composite outcome of admission to hospital and death, or infer a relationship between hospital admission and survival benefit. This assumes concordance of the outcomes "hospital admission" and "death." However, whether the effects of a treatment on hospital admissions and readmissions correlate to its effect on serious outcomes such as death is unknown. We aimed to assess the correlation and concordance of effects of medical interventions on admission rates and mortality.

METHODS

We searched the Cochrane Database of Systematic Reviews from its inception to January 2012 (issue 1, 2012) for systematic reviews of treatment comparisons that included meta-analyses for both admission and mortality outcomes. For each meta-analysis, we synthesized treatment effects on admissions and death, from respective randomized trials reporting those outcomes, using random-effects models. We then measured the concordance of directions of effect sizes and the correlation of summary estimates for the 2 outcomes.

RESULTS

We identified 61 meta-analyses including 398 trials reporting mortality and 182 trials reporting admission rates; 125 trials reported both outcomes. In 27.9% of comparisons, the point estimates of treatment effects for the 2 outcomes were in opposite directions; in 8.2% of trials, the 95% confidence intervals did not overlap. We found no significant correlation between effect sizes for admission and death (Pearson r = 0.07, p = 0.6). Our results were similar when we limited our analysis to trials reporting both outcomes.

INTERPRETATION

In this metaepidemiological study, admission and mortality outcomes did not correlate, and discordances occurred in about one-third of the treatment comparisons included in our analyses. Both outcomes convey useful information and should be reported separately, but extrapolating the benefits of admission to survival is unreliable and should be avoided.

Malnutrition and associated clinical outcomes in hospitalized patients aged 60 and older: an observational study in rural Wales

This is a prospective observational study of malnutrition and six-week clinical outcomes on a previously unstudied population of older hospital inpatients in rural Wales. One hundred and twenty-six of 152 patients older than 60 years identified on the wards surveyed were included. Patients unable to give informed consent and those too ill to participate were excluded. The main findings were that 55 (44%) were malnourished at the first assessment, that nutrition risk predicted mortality (P = 0.019), length of hospital stay (P = 0.026), and discharge destination (P = 0.005), that only 17 patients had received nutritional support, and that many of those who received support nevertheless had lost weight at the 6-week follow-up. This confirms previous research which suggests that, while malnutrition is associated with poorer clinical outcomes, nutrition support for older patients in hospital nevertheless is often insufficient.

Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults

BACKGROUND

It has been recognized that poor adherence can be a serious risk to the health and wellbeing of patients, and greater adherence to dietary advice is a critical component in preventing and managing chronic diseases.

OBJECTIVES

To assess the effects of interventions for enhancing adherence to dietary advice for preventing and managing chronic diseases in adults.

SEARCH METHODS

We searched the following electronic databases up to 29 September 2010: The Cochrane Library (issue 9 2010), PubMed, EMBASE (Embase.com), CINAHL (Ebsco) and PsycINFO (PsycNET) with no language restrictions. We also reviewed: a) recent years of relevant conferences, symposium and colloquium proceedings and abstracts; b) web-based registries of clinical trials; and c) the bibliographies of included studies.

SELECTION CRITERIA

We included randomized controlled trials that evaluated interventions enhancing adherence to dietary advice for preventing and managing chronic diseases in adults. Studies were eligible if the primary outcome was the client's adherence to dietary advice. We defined 'client' as an adult participating in a chronic disease prevention or chronic disease management study involving dietary advice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of the studies. They also assessed the risk of bias and extracted data using a modified version of the Cochrane Consumers and Communication Review Group data extraction template. Any discrepancies in judgement were resolved by discussion and consensus, or with a third review author. Because the studies differed widely with respect to interventions, measures of diet adherence, dietary advice, nature of the chronic diseases and duration of interventions and follow-up, we conducted a qualitative analysis. We classified included studies according to the function of the intervention and present results in a narrative table using vote counting for each category of intervention.

MAIN RESULTS

We included 38 studies involving 9445 participants. Among studies that measured diet adherence outcomes between an intervention group and a control/usual care group, 32 out of 123 diet adherence outcomes favoured the intervention group, 4 favoured the control group whereas 62 had no significant difference between groups (assessment was impossible for 25 diet adherence outcomes since data and/or statistical analyses needed for comparison between groups were not provided). Interventions shown to improve at least one diet adherence outcome are: telephone follow-up, video, contract, feedback, nutritional tools and more complex interventions including multiple interventions. However, these interventions also shown no difference in some diet adherence outcomes compared to a control/usual care group making inconclusive results about the most effective intervention to enhance dietary advice. The majority of studies reporting a diet adherence outcome favouring the intervention group compared to the control/usual care group in the short-term also reported no significant effect at later time points. Studies investigating interventions such as a group session, individual session, reminders, restriction and behaviour change techniques reported no diet adherence outcome showing a statistically significant difference favouring the intervention group. Finally, studies were generally of short duration and low quality, and adherence measures varied widely.

AUTHORS' CONCLUSIONS

There is a need for further, long-term, good-quality studies using more standardized and validated measures of adherence to identify the interventions that should be used in practice to enhance adherence to dietary advice in the context of a variety of chronic diseases.