Incomplete descriptions of oral nutritional supplement interventions in reports of randomised controlled trials

Adherence to Oral Nutritional Supplements: A Review of Trends in Intervention Characteristics and Terminology Use Since the Year 2000

Research on disease-related malnutrition and adherence to oral nutritional supplements (ONS) has increased in recent years. To guide future studies, it is important to identify trends in terminology use and intervention characteristics. This review aimed to map characteristics of research investigating adherence to ONS in patients with disease-related malnutrition and explore changes over time. This review is a secondary analysis of quantitative studies from a systematic mixed-studies review. Online databases, including PubMed, Cinahl, Cochrane Central Register of Controlled Trials, and APA PsycInfo, were searched to identify studies published from 2000 to March 2022. A quantitative content analysis of extracted data was performed, and the Mixed Methods Appraisal Tool (MMAT) was used to assess methodological risk of bias. This review includes 137 articles, over half of which are randomized controlled trials (52%). The term "oral nutritional supplements" was used in 40% of the studies. Adherence to ONS was mainly described by the term "compliance" (69%). It was most common to offer ready-made milk-based ONS (56%) and ONS as a sole intervention (51%). The prescribed dose of ONS was fixed in 64% of studies and individualized in 22% of studies. There was variation in the methods used to assess adherence to ONS, and adherence was not reported in nearly a fifth of studies. There was an increase in methodological quality over time (p = 0.024). To ensure better understanding and increase the rigor and reproducibility of ONS intervention research, it is crucial to standardize the terminology used and to describe the interventions clearly.

Nutritional Support in Malnourished Outpatients with Chronic Obstructive Pulmonary Disease (COPD): A Randomized Controlled Pilot Study

(1) Background: The evidence for nutritional support in COPD is almost entirely based on ready-to-drink oral nutritional supplements (ONSs). This study aimed to explore the effectiveness of powdered ONSs alongside individualized dietary counseling in the management of malnutrition. (2) Methods: Malnourished outpatients with COPD were randomized to receive either routine care (Group A: counseling + recommended to purchase powdered ONSs) or an enhanced intervention (Group B: counseling + provision of powdered ONSs at no cost to the patient) for 12 weeks. Outcomes of interest were nutritional intake, weight status, and quality of life. (3) Results: A total of 33 outpatients were included, categorized as follows: Group A (n = 21); Group B (n = 12); severely malnourished (n = 9), moderately malnourished (n = 24), mean BMI 18.0 SD 2.5 kg/m2. No differences were observed between groups at baseline or at week 12; however, analysis of the whole cohort (Group A + B) revealed nutrition intervention resulted in significant improvements in protein intake (+25.4 SD 53.4 g/d; p = 0.040), weight (+1.1 SD 2.6 kg; p = 0.032) and quality of life (-4.4 SD 10.0; p = 0.040). Only 41.2% of Group A and 58.3% of Group B reported consuming ONSs at week 12. Adherence to ONSs was associated with weight gain (+1.9 SD 2.5 kg vs. +0.4 SD 2.5 kg; p = 0.098). (4) Conclusions: Nutritional support results in significant improvements in nutrition status and quality of life in malnourished outpatients with COPD. However, improvements are associated with adherence to ONSs, suggesting the type of ONSs and how they are provided are important considerations in clinical practice and future studies.

Reporting characteristics of nonsurgical periodontal therapy trials registered in ClinicalTrials.gov: an observational study

Aim: To evaluate the completeness of the description of nonsurgical periodontal therapy interventions in clinical trials registered in ClinicalTrials.gov and correspondence of registered information for trial participants and outcome measures with published articles. Materials & methods: We retrieved data from ClinicalTrials.gov and corresponding publications. The completeness of intervention reporting was assessed using the Template for Intervention Description and Replication (TIDieR) checklist for oral hygiene instructions (OHI), professional mechanical plaque removal (PMPR), and subgingival instrumentation, antiseptics and antibiotics. The completeness of registration of trial protocol information was assessed according to the WHO Trial Registration DataSet for participant information (enrollment, sample size calculation, age, gender, condition) and primary/secondary outcome measures. Results: 79 included trials involved OHI (n = 38 trials, 48.1%), PMPR (n = 19, 24.1%), antiseptics (n = 11, 12.7%), or antibiotics (n = 11, 12.7%). There was a great variety in the terms used to describe these interventions. Most of the analyzed trials (93.7%) were completed and did not provide any data on study phase (74.7%). The description of intervention in the registry in ClinicalTrials.gov was inadequate for all analyzed interventions, with description inconsistencies in matching publications. There were also discrepancies in registered and published outcomes: for 39 trials with published results, 18 had different registered and reported primary outcomes, and 29 different registered and reported secondary outcomes. Conclusion: The completeness of the description of nonsurgical therapy of periodontitis in clinical trials is unsatisfactory, reducing the quality of translation of the new evidence and procedures into clinical practice. Significant discrepancy in registered and reported trial outcomes calls into question the validity of reported results and relevance for practice.

Perspectives on the application of CONSORT guidelines to randomised controlled trials in nutrition

PURPOSE

Reporting guidelines facilitate quality and completeness in research reporting. The CONsolidated Standards Of Reporting Trials (CONSORT) statement is widely applied to dietary and nutrition trials but has no extension specific to nutrition. Evidence suggests poor reporting in nutrition research. The Federation of European Nutrition Societies led an initiative to make recommendations for a nutrition extension to the CONSORT statement towards a more robust reporting of the evidence base.

METHODS

An international working group was formed of nutrition researchers from 14 institutions in 12 different countries and on five continents. Using meetings over a period of one year, we interrogated the CONSORT statement specifically for its application to report nutrition trials.

RESULTS

We provide a total of 28 new nutrition-specific recommendations or emphasised recommendations for the reporting of the introduction (three), methods (twelve), results (five) and discussion (eight). We also added two additional recommendations that were not allocated under the standard CONSORT headings.

CONCLUSION

We identify a need to provide guidance in addition to CONSORT to improve the quality and consistency of the reporting and propose key considerations for further development of formal guidelines for the reporting of nutrition trials. Readers are encouraged to engage in this process, provide comments and conduct specific studies to inform further work on the development of reporting guidelines for nutrition trials.

Barriers and Facilitators of Adherence to Oral Nutritional Supplements Among People Living With Cancer: A Systematic Review

This study aims to synthesize the barriers and facilitators of oral nutritional supplement adherence in people with cancer and assess levels of adherence. Databases including Embase, PubMed, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure, Wanfang Database, and Chinese Scientific Journal Database, were used to search articles before January 4, 2021. Eighteen studies with 1,267 participants met the inclusion criteria. All studies reported rates of adherence, ranging from 6.0% to 96.9%. Gastrointestinal intolerances and disliked tastes were considered common barriers to cancer patients' adherence, whereas the ONS management strategy was considered the most crucial facilitator of adherence. Health professionals can improve adherence through regular monitoring and guidance and incentive strategies, and paying attention to the management and prevention of adverse reactions when prescribing nutritional products.

TIDieR-telehealth: precision in reporting of telehealth interventions used in clinical trials - unique considerations for the Template for the Intervention Description and Replication (TIDieR) checklist

Background

Recent international health events have led to an increased proliferation of remotely delivered health interventions. Even with the pandemic seemingly coming under control, the experiences of the past year have fueled a growth in ideas and technology for increasing the scope of remote care delivery. Unfortunately, clinicians and health systems will have difficulty with the adoption and implementation of these interventions if ongoing and future clinical trials fail to report necessary details about execution, platforms, and infrastructure related to these interventions. The purpose was to develop guidance for reporting of telehealth interventions.

Methods

A working group from the US Pain Management Collaboratory developed guidance for complete reporting of telehealth interventions. The process went through 5-step process from conception to final checklist development with input for many stakeholders, to include all 11 primary investigators with trials in the Collaboratory.

Results

An extension focused on unique considerations relevant to telehealth interventions was developed for the Template for the Intervention Description and Replication (TIDieR) checklist.

Conclusion

The Telehealth Intervention guideline encourages use of the Template for the Intervention Description and Replication (TIDieR) checklist as a valuable tool (TIDieR-Telehealth) to improve the quality of research through a reporting guide of relevant interventions that will help maximize reproducibility and implementation.

A qualitative exploration of dietitians' experiences of prescribing oral nutritional supplements to patients with malnutrition: A focus on shared tailoring and behaviour change support

BACKGROUND

Oral nutritional supplements (ONS) are commonly prescribed to patients with malnutrition. Dietitians have been suggested as preferred prescribers but generally lack ONS prescribing rights. How dietitians with prescribing rights experience their professional practice of prescribing ONS remains understudied. Thus, by exploring dietitians' experiences of prescribing ONS, the present study aimed to obtain a deeper understanding of specific aspects that are of importance for dietitians when providing a nutrition therapy including ONS.

METHODS

Qualitative individual interviews were conducted with 13 dietitians prescribing ONS to free-living adult outpatients with malnutrition or at nutritional risk in the hospital or primary care setting. Systematic text condensation was used for data analysis.

RESULTS

Two main categories signifying important aspects were identified and labelled: 'Shared tailoring of the ONS prescription' and 'Supporting and facilitating ONS use'. First, the dietitians described tailoring the ONS prescription together with the patient, having their acceptance as a prerequisite, and being flexible regarding products and amounts prescribed. Second, they described performing different communication strategies and organising of practical issues (e.g., ONS delivery and support from others) to support and facilitate patients' ONS usage.

CONCLUSIONS

The present study identifies patient involvement and the role of dietitians as behaviour change facilitators as two important aspects when dietitians prescribe ONS. These findings allow for dietitians' ideals and strategies on how to prescribe ONS to be made more visible, which can inform both clinical practice and clinical trials for future improvements in nutrition therapy to address malnutrition.

Factors influencing the efficacy of nutritional interventions on muscle mass in older adults: a systematic review and meta-analysis

CONTEXT

Nutritional interventions stimulate muscle protein synthesis in older adults. To optimize muscle mass preservation and gains, several factors, including type, dose, frequency, timing, duration, and adherence have to be considered.

OBJECTIVE

This systematic review and meta-analysis aimed to summarize these factors influencing the efficacy of nutritional interventions on muscle mass in older adults.

DATA SOURCES

A systematic search was performed using the electronic databases MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and SPORTDiscus from inception date to November 22, 2017, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria included randomized controlled trials, mean or median age ≥65 years, and reporting muscle mass at baseline and postintervention. Exclusion criteria included genetically inherited diseases, anabolic drugs or hormone therapies, neuromuscular electrical stimulation, chronic kidney disease, kidney failure, neuromuscular disorders, and cancer.

DATA EXTRACTION

Extracted data included study characteristics (ie, population, sample size, age, sex), muscle mass measurements (ie, method, measure, unit), effect of the intervention vs the control group, and nutritional intervention factors (ie, type, composition, dose, duration, frequency, timing, and adherence).

DATA ANALYSIS

Standardized mean differences and 95%CIs were calculated from baseline to postintervention. A meta-analysis was performed using a random-effects model and grouped by the type of intervention.

CONCLUSIONS

Twenty-nine studies were included, encompassing 2255 participants (mean age, 78.1 years; SD, 2.22). Amino acids, creatine, β-hydroxy-β-methylbutyrate, and protein with amino acids supplementation significantly improved muscle mass. No effect was found for protein supplementation alone, protein and other components, and polyunsaturated fatty acids. High interstudy variability was observed regarding the dose, duration, and frequency, coupled with inconsistency in reporting timing and adherence. Overall, several nutritional interventions could be effective to improve muscle mass measures in older adults. Because of the substantial variability of the intervention factors among studies, the optimum profile is yet to be established.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42018111306.

The Template for Intervention Description and Replication as a Measure of Intervention Reporting Quality: Rasch Analysis

Objective

To determine whether the 12 items of the Template for Intervention Description and Replication (TIDieR) can be combined into a single summary score reflecting intervention reporting completeness and quality.

Design

Systematic review and reanalysis of published data. After a systematic search of the published literature, 16 review articles were retrieved with 489 sets of 12 TIDieR ratings of experimental intervention, comparator, or the 2 combined as reported in primary studies. These 489 sets were recoded into a common format and analyzed using Rasch analysis for binary items.

Setting

Not applicable.

Participants

Not applicable.

Interventions

Not applicable.

Main Outcome Measures

Psychometric qualities of a Rasch Analysis-based TIDieR summary score.

Results

The data fit the Rasch model. Infit and outfit values were generally acceptable (range, 0.70-1.45). TIDieR was reasonably unidimensional in its structure. However, the person (here: study) separation ratio was 1.25 with a corresponding reliability of 0.61. In addition, the confidence interval around each estimate of reporting completeness was wide (model standard error of 0.78).

Conclusion

Several Rasch indicators suggested that TIDieR is not a strong instrument for assessing the quality of a researcher's reporting on an intervention. It is recommended that it be used with caution. Improvements in TIDieR itself may make it more helpful as a reporting tool.

Adherence to Oral Nutritional Supplements After Being Discharged from the Hospital is Low but Improves Outcome in Patients with Advanced Chronic Liver Disease

PURPOSE

Patients with advanced chronic liver disease (ACLD) often have a poor nutritional status. In the management, current guidelines recommend dietary counseling and oral nutritional supplements (ONS). Nutritional goals and adherence to ONS are difficult to achieve while studies addressing adherence are scarce. We aimed to evaluate adherence to ONS, the associated factors, and its impact on outcome among ALCD patients who are discharged from the hospital.

PATIENTS AND METHODS

We identified consecutive hospitalized patients with ACLD from the cirrhosis registry and ONS prescription at discharge. Baseline demographics, anthropometrics, hand-grip strength (HGS), nutritional, and laboratory parameters were recorded. Adherence was assessed at 30, 90, and 180 days, but not in patients who did not survive or in those who underwent liver transplantation (LT) before the time-point.

RESULTS

From the registry containing 1004 patients, we included 450 cases, the median age was 56.3 (IQR 47-62), 60% were males, 63.8% had alcoholic etiology, and the median model for end-stage liver disease score (MELD) was 16 (11-21). During follow-up, 13.6%, 23.6%, and 31.1% of patients have died within 30, 90, and 180 days, respectively, and 21 underwent LT. Adherence to ONS in surviving patients was observed in 46%, 26.1%, and 16.9% within 30, 90, and 180 days, respectively. Baseline refractory ascites (HR=0.43, 0.24-0.76), HGS (HR=1.03, 1.01-1.06), and mid-arm circumference (HR=0.93, 0.88-0.99) were independently associated with 30-day adherence. Among patients who survived beyond 30 days, adherents for >30 days had improved synthetic liver function, HGS, a higher probability of LT (HR=1.7, 1.03-2.8) and lower risk of death (HR=0.65, 0.45-0.89), particularly those with MELD>16 (OR=0.55, 0.36-0.85) and low HGS (OR=0.61, 0.39-0.93).

CONCLUSION

In ACLD patients after discharge, adherence to ONS steeply declined and was associated with baseline refractory ascites and low muscle strength. Adherence to ONS also improved liver function, muscle strength, and survival.

Overview of Reviews Using the Template for Intervention Description and Replication (TIDieR) as a Measure of Trial Intervention Reporting Quality

OBJECTIVE

To evaluate the quality of descriptions of interventions in health care research reports, based on a synthesis of reviews that used the Template for Intervention Description and Replication (TIDieR) to rate the completeness and quality of intervention reporting.

DESIGN

Overview of published reviews. In a systematic search of the literature, 56 review articles were retrieved that had evaluated 3454 primary studies (index articles) using all or most of the 12 TIDieR items, applied to experimental treatment only or treatment and comparator both, separately. If available, percentages "reported completely" were extracted based on the index article, the index article supplemented by related information, and these 2 supplemented by e-mailing the author. Information on the review's methodology was also extracted.

SETTING

Not applicable.

PARTICIPANTS

Not applicable.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Percentage of primary studies receiving "adequately reported" ratings on each of the 12 TIDieR items.

RESULTS

While for treatment arms TIDieR items 1 (name of treatment) and 2 (why of treatment) are generally judged to be reported adequately, the percentage is between 25% and 75% for most other items and is as low as 10% for item 10 (modifications). Comparators are reported even more poorly. Use of additional publications on a trial increased percentages "reported adequately" marginally; e-mailing resulted in significant increases in completeness of reporting. Rehabilitation trials were reported better than nonrehabilitation trials for some TIDieR items and worse for others.

CONCLUSIONS

Reporting on the interventions and comparators of trials is substandard. More extensive use of supplemental digital content and of versions of TIDieR customized for specific domains of research may improve the situation.

A systematic scoping review of interventions to improve appropriate prescribing of oral nutritional supplements in primary care

BACKGROUND & AIMS

Oral nutritional supplements (ONS) are commonly used to treat malnutrition. Many patients are prescribed ONS without assessment of nutritional status. This conflicts with prescribing guidelines and has considerable cost implications. This scoping review aimed to provide an overview of interventions to improve appropriate ONS prescribing in primary care.

METHODS

A systematic scoping review was undertaken. PubMed, EMBASE and CINAHL were searched from inception to September 2018. Studies meeting inclusion criteria had to: evaluate interventions targeting ONS prescribing in primary care; use a comparative evaluation; be published in English. Two reviewers independently screened abstracts and extracted data relating to study design, intervention characteristics, outcome assessments and key findings. Extracted data were collated using figures, tables and accompanying descriptive summaries.

RESULTS

10 studies met inclusion criteria. All studies involved uncontrolled before-and-after designs. Interventions ranged from dietitian-led reviews of patients prescribed ONS to transfer of ONS prescribing privileges from general practitioners to dietitians. Post-intervention results showed improvements in ONS prescribing based on study-specific assessments of prescribing appropriateness and absolute reductions in prescribing, as well as potential cost-savings.

CONCLUSIONS

This review provides a detailed overview of interventions aimed at improving appropriate ONS prescribing in primary care. Interventions evaluated to date most commonly involved dietitians. However, use of controlled experimental design was lacking. Lack of consistency in defining appropriate ONS prescribing and assessment outcomes was apparent. Future research should attend to rigour during intervention development, evaluation and reporting in order to generate findings which could inform relevant policy and practice.

Drug-drug interaction trials incompletely described drug interventions in ClinicalTrials.gov and published articles: an observational study

OBJECTIVES

The aim of the study was to evaluate the completeness of intervention description in ClinicalTrials.gov and corresponding journal articles for registered and published drug-drug interaction (DDI) trials because complete and transparent description of interventions is particularly important for DDI.

STUDY DESIGN AND SETTING

Observational study of completed interventional trials on DDIs with up to two drugs within the Intervention registration element in ClinicalTrials.gov until October 2015. We used the Template for Intervention Description and Replication items to assess the quality of intervention description in both ClinicalTrials.gov Descriptive Information section and matching publications. Corresponding articles were identified in March 2019.

RESULTS

The description of 1,180 drug interventions registered for 642 DDI trials mostly lacked information on the intervention provider (99.7%), adherence strategies (99.2%), procedure (83.8%), location (71.3%), and dosage form (60.7%). Generic name (82.5%), dose (70.8%), and duration of administration (65.6%) were most frequently reported. Among 51 trials that had data reported both in ClinicalTrials.gov and publication, 60.8% were in phase 1. Less than half of 96 interventions had clear and matching description of dosage form, procedure, and route of administration in both sources.

CONCLUSION

DDI trials did not sufficiently report components required for complete intervention description. Further improvements in ClinicalTrials.gov registration requirements, including phase 1 trials, and more stringent publishing requirements for essential data on drug interventions, are needed to prevent patient risk in clinical practice regarding concomitant medication use.

Using the CONSORT statement to evaluate the completeness of reporting of addiction randomised trials: a cross-sectional review

OBJECTIVES

Evaluate the completeness of reporting of addiction randomised controlled trials (RCTs) using the Consolidated Standards of Reporting Trials (CONSORT) statement.

SETTING

Not applicable.

PARTICIPANTS

RCTs identified using a PubMed search of 15 addiction journals and a 5-year cross-section.

OUTCOME MEASURES

Completeness of reporting.

RESULTS

Our analysis of 394 addiction RCTs found that the mean number of CONSORT items reported was 19.2 (SD 5.2), out of a possible 31. Twelve items were reported in <50% of RCTs; similarly, 12 items were reported in >75% of RCTs. Journal endorsement of CONSORT was found to improve the number of CONSORT items reported.

CONCLUSIONS

Poor reporting quality may prohibit readers from critically appraising the methodological quality of addiction trials. We recommend journal endorsement of CONSORT since our study and those previous have shown that CONSORT endorsement improves the quality of reporting.

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.