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

Prevention and Treatment of Malnutrition in Older Adults Living in Long-Term Care or the Community: An Evidence-Based Nutrition Practice Guideline

Malnutrition in older adults can decrease quality of life and increase risk of morbidities and mortality. Accurate and timely identification of malnutrition, as well as subsequent implementation of effective interventions, are essential to decrease poor outcomes associated with malnutrition in older adults. The Academy of Nutrition and Dietetics Evidence Analysis Center conducted a systematic review of the literature to develop an evidence-based nutrition practice guideline for the prevention and treatment of malnutrition in older adults. The objective of this guideline was to provide evidence-based recommendations to identify, prevent, or treat protein-energy malnutrition in older adults (mean age ≥65 years) living in long-term care and community settings. This guideline provides 11 nutrition recommendations to inform shared decision making among dietitians, members of the health care team, family members or caregivers, and older adults living in long-term care or the community to prevent or treat malnutrition. Topics include dietitian effectiveness, nutrition assessment tools, oral nutrition supplements, food fortification, and home-delivered and congregate meals. Guideline implementation should include consideration of the importance of comprehensive individualized nutrition care for older adults. Future research is needed to address gaps that were identified related to the validity, reliability, and feasibility of nutrition assessment tools, as well as the effectiveness of dietitian interventions on outcomes of interest in older adults living in long-term care and the community.

Long-term association between malnutrition and all-cause mortality among older adults: A 10-years follow-up study

BACKGROUND & AIMS

Prior studies have shown an association between malnutrition and mortality. However, it is uncertain whether malnutrition assessed with the Mini Nutritional Assessment (MNA) instrument is suitable for providing long-term prognostic information regarding older adults admitted to hospital. The aim of the present study was to examine if MNA-assessed malnutrition was associated with long-term mortality in older adults admitted to hospital and for how long the association persisted.

METHODS

1768 older adults (≥65 years old) admitted to a Swedish hospital were assessed with the 18-item MNA during 2008-2009 and followed-up after 10 years. All-cause mortality (ACM) was analyzed separately for the five follow-up periods 0 to ≤2 years, >2 to ≤4 years, >4 to ≤6 years, >6 to ≤8 years, and >8 to ≤10 years using Cox regression models adjusted for important demographic, nutritional, and clinical confounders.

RESULTS

The participants were on average 78.1 years old at baseline, with 56.0% being females. At 10 years follow-up, 174 (94.1%) malnourished patients, 757 (75.9%) patients at risk of malnutrition, and 297 (50.7%) well-nourished patients had died. For all follow-up periods, malnourished patients and patients at risk of malnutrition had significantly higher risks of early death in the adjusted regression analyses when compared with well-nourished patients (all P < 0.05), with the highest risk observed for malnourished patients. For patients still alive at 8 years, the risk of death during the following two years was 2.7 times higher for patients being malnourished at baseline (P = 0.013) and 1.9 times higher for patients being at risk of malnutrition at baseline (P = 0.001), compared with patients being well-nourished at baseline.

CONCLUSIONS

MNA-assessed malnutrition is an important independent predictor of long-term mortality in older adults admitted to hospital and the association is consistent over 10 years of follow-up. In clinical practice, MNA may provide long-term prognostic information to rule out those at low risk of mortality and therefore in less need of further assessment and intervention, such that the resources can focus on those in actual need of nutritional support.

Towards developing a Core Outcome Set for malnutrition intervention studies in older adults: a scoping review to identify frequently used research outcomes

PURPOSE

To conduct a scoping review to provide a systematic overview of outcomes used in nutritional intervention studies focused on the treatment of protein-energy malnutrition in older adults.

METHODS

A systematic search of four electronic databases (Medline, EMBASE, CINAHL and Cochrane Central Register of Controlled Trials (CENTRAL) was performed to retrieve randomized controlled trials (RCTs), published until March 9, 2020, that evaluated the effect of nutritional interventions to treat protein-energy malnutrition in older adults and those at risk for malnutrition. Two authors screened titles, abstracts and full texts independently. One author extracted data that were cross-checked by another author.

RESULTS

Sixty-three articles reporting 60 RCTs were identified. Most frequently used outcomes included body weight/body mass index (75.0% of RCTs), dietary intake (61.7%), functional limitations (48.3%), handgrip strength (46.7%), and body circumference (40.0%). The frequencies differed by setting (community, hospital and long-term care). For some outcomes there was a preferred assessment method (e.g., Barthel index for functional limitations), while for other outcomes (e.g., functional performance) a much greater variation was observed.

CONCLUSION

A large variation in outcomes, not only across but also within settings, was identified in nutritional intervention studies in malnourished older adults and those at risk. Furthermore, for many outcomes there was a large variation in the used assessment method. These results highlight the need for developing a Core Outcome Set for malnutrition intervention studies in older adults to facilitate future meta-analyses that may enhance our understanding on the effectiveness of treatment.

Effectiveness of Dietary Counselling With or Without Nutritional Supplementation in Hospitalised Patients who are Malnourished or at Risk of Malnutrition - A Systematic Review and Meta-Analysis

Background

Nutrition support is associated with improved survival and nonelective hospital readmission rates among malnourished medical inpatients; however, limited evidence supporting dietary counseling is available. We intend to determine the effect of dietary counseling with or without oral nutrition supplementation (ONS), compared with standard care, on hospitalized adults who are malnourished or at risk of malnutrition.

Methods

We searched MEDLINE/PubMed, CINAHL, Embase, Scopus, The Cochrane Library, and Google Scholar for studies listed from January 1, 2011, to August 31, 2021. Meta‐analysis was performed to obtain pooled risk ratios (RRs) and 95% CIs to estimate the effect. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to assess the certainty of the evidence.

Results

Sixteen studies were identified. Compared with standard care, dietary counseling with or without ONS probably does not reduce inpatient rates of 30‐day mortality (RR = 1.24; 0.60–2.55; I² = 45%; P = 0.56; moderate certainty), slightly reduces 6‐month mortality (RR = 0.83; 0.69–1.00; I² = 16%; P = 0.06; high certainty), reduces complications (RR = 0.85; 0.73–0.98; I² = 0%; P = 0.03; high certainty), and may slightly reduce readmission (RR = 0.83; 0.66–1.03; I² = 55%; P = 0.10; low certainty) but may not reduce length of stay (mean difference: −0.75 days; −1.66‐0.17; I² = 70%; P = 0.11; low certainty). Intervention may result in slight improvements in nutrition status/intake and weight/body mass index (low certainty).

Conclusions

There is an increase in the certainty of evidence regarding the positive impact of dietary counseling on outcomes. Future studies should standardize and provide details/frequencies of counseling methods and ONS adherence to determine dietary counseling effectiveness.

Implications of inappropriate prescription of oral nutritional supplements on the quality of life of cancer outpatients: a cross-sectional comparative study

Background and aims

Oral nutritional supplements (ONS) are considered a cornerstone in the treatment plan of malnutrition in cancer patients. However, the prevalence of inappropriate prescription of ONS is high. In this study, we aim to investigate the effect of inappropriate oral nutritional supplementation (consisting of prescription of ONS without evident clinical indication, or the absence of ONS when at risk of malnutrition) on the quality of life of cancer outpatients.

Methods

A cross-sectional comparative study was conducted in 104 cancer outpatients, receiving ONS without prior malnutrition risk screening (n = 51), and patients not receiving ONS (n = 53). Nutritional risk screening was performed using the abridged patient-generated subjective global assessment (ab-PG-SGA). The quality of life was assessed using EORTC QLQ-C30 version 3.0 questionnaire. Multivariate analysis was conducted to determine the predictors of quality-of-life scales. Age (years), malnutrition (ab-PG-SGA scores), BMI (kg/m²), TSF (mm), MUAC (cm), ONS (yes, no) were entered into the linear regression analysis as predictors (backward stepwise linear regression analysis).

Results

The prevalence of malnutrition risk (ab-PG-SGA ≥ 6) was 74%. The median score of the ab-PG-SGA for ONS receiving group was significantly higher (p = 0.045). Furthermore, univariate analysis showed that the scores of the global health status (QoL) and the role functioning (RF) scales were significantly lower for the ONS receiving group (p = 0.020 and p = 0.016, respectively). Multivariately, malnutrition, inappropriate ONS prescription, and triceps skin fold were found to be predictors of the RF scale, while malnutrition was the only predictor for the QoL.

Conclusion

The inappropriate ONS prescription does not improve nutritional status or quality of life of cancer outpatients.

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.