Comparison of three oral sip-feed supplements in patients with cancer

A comparative intervention trial of deer milk and an oral nutritional supplement efficacy for improving older adults' nutritional status, muscle mass and physical performance

OBJECTIVES

To compare the effectiveness of deer milk (DM) for improving nutritional status, muscle mass and physical performance with that of a commercially available oral nutritional supplement (ONS) in older women.

METHODS

This study was an 11-week randomised, double-blind, parallel group study. Healthy women (N = 120) aged 65-80 years, the majority having a body mass index (BMI) < 25 kg/m2 were recruited. The women were randomly assigned to either 200 ml DM or a commercial ONS for 11 weeks. Data on habitual macronutrient intake, nutritional status (Mini Nutrition Assessment-Short Form, MNA-SF; ≤7 malnourished, 8-11 at risk of malnutrition, ≥12 normal nutrition), anthropometrics/body composition, and physical performance were collected. Blood samples were collected for metabolic markers.

RESULTS

102 women (DM 45, ONS 57) completed the study, of whom 29% had a dietary protein intake of <1 g/kg body weight per day, and 38% at risk of malnutrition. There were no between group differences in percentage change in MNA-SF score and body composition (P > 0.05), but a trend for a difference in handgrip strength (DM 11.7 ± 49.8% vs. ONS -2.42 ± 17.9%, P = 0.06). Further exploratory analysis showed that there was a trend for a between group difference in percentage change in MNA-SF score, favoring DM (DM 7.72 + 13.0% vs. ONS 0.63 + 9.25%, P = 0.06) only in women at risk of malnutrition. There was also a between group difference in percentage change in muscle mass (DM 1.68 ± 2.77% vs. ONS -0.18 ± 2.81%, P = 0.02) in women with BMI ≥25 kg/m2 and in handgrip strength (DM 10.6 ± 23.6% vs. ONS -5.03 ± 18.1%, P < 0.01) in women with BMI<25 kg/m2. Total cholesterol, LDL and LDL:HDL ratio did not change over time (P > 0.05), but there was a between group difference in percentage change in these markers (total cholesterol: DM 3.01 ± 6.97% vs. ONS -2.65 ± 9.92%, P < 0.01; LDL: DM 4.22 ± 14.9% vs. ONS -6.05 ± 17.6%, P < 0.01; LDL:HDL ratio: DM: 2.27 ± 16.4% vs. ONS: -5.78 ± 18.2%, P = 0.02).

CONCLUSION

Baseline nutritional status and BMI may modulate nutritional status, muscle mass and physical performance response to DM (as compared with ONS), suggesting DM may improve nutritional status and physical performance in women at risk of malnutrition and/or with lower BMI, and improve muscle mass in women with a higher BMI. The study was registered with the Australian New Zealand Clinical Trial Registry ACTRN12621000650897p.

Factors Affecting Adherence, Intake, and Perceived Palatability of Oral Nutritional Supplements: A Literature Review

Oral nutritional supplements (ONS) are a clinically effective and relatively inexpensive way to supplement the diet of patients with, or at risk of, undernutrition. Good adherence is a primary determinant of the effectiveness of ONS. However adherence can be problematic for those with the greatest clinical need, such as undernourished older adults. This review aimed to appraise the available literature for the factors (contextual, personal and product related) affecting patient adherence and perceived palatability of ONS, identify areas requiring improvement and uncover gaps in the evidence to guide the focus of future research. Contextual factors identified were healthcare staff and the timing of administration. Personal factors included sensory changes and motivation which alter experience of and desire to consume ONS. The product's sensory characteristics determined palatability and intake, but undesirable attributes, such as off-flavours, can stem from nutritional ingredients. The contribution made by aroma to older adults' experience of ONS was a comparatively under-researched area. Further research should address this evidence gap to optimise the flavour, aroma profile and palatability for undernourished older consumers, thereby optimising intake. A combined multidisciplinary effort involving strategic expansion of research, industry development and clinical practice should simultaneously address the factors identified, to provide the best approach to improve adherence.

Perceived acceptability of partial enteral nutrition (PEN) using oral nutritional supplement drinks in adolescent and adult Crohn's disease outpatients: A feasibility study

BACKGROUND AND AIMS

Studies, mainly in Japanese cohorts, have shown that partial enteral nutrition (PEN) including oral nutritional supplement (ONS) drinks can prolong disease remission and increase drug effectiveness in Crohn's disease (CD). Acceptability is a key feasibility parameter to determine whether PEN is a viable treatment option in UK CD patients. We report the results of a single centre cross-sectional feasibility study carried out to investigate perceived acceptability of PEN using ONS drinks and whether ONS preference varies with sex, nutritional status or phenylthiocarbamide (PTC) sensitivity.

METHODS

Patients with a confirmed CD diagnosis were recruited using convenience sampling from an adult and adolescent gastroenterology outpatient clinic over 3 years. Blind taste testing of 5 polymeric ONS drinks were conducted using a validated 9-point hedonic rating scale followed by completion of an acceptability questionnaire based on the preferred ONS drink. A subset of patients took home the preferred ONS drink for a 7-day ONS study.

RESULTS

105 CD patients (55 males), aged 34.9 (±15.4) years were recruited and 28 patients completed the 7-day ONS study. Overall impression scores did not significantly vary with nutritional status, sex, BMI, handgrip strength (HGS), mid-upper arm circumference (MUAC) or PTC sensitivity. Ensure plus milkshake™ rated highest for overall impression (6.5, p=<0.0001) and all other organoleptic properties (p < 0.0001). The main perceived benefits of using ONS drinks as PEN related to assurance of nutrient intake (89%), convenience (86%), and improvement of gut symptoms (85%). The main perceived barriers related to reduction in pleasure from eating and drinking (56%), struggling with drink storage (54%) having less energy and feeling more tired than if eating 3 solid meals daily (52%). 65% of patients would consider using ONS drinks as PEN as a maintenance treatment option. 81% of patients felt confident-very confident about consuming ONS drinks daily as PEN for three months but this dropped to 64% and 37% at 6 and 12 months, respectively. There was a significant drop in perceived ease of use of ONS drinks as PEN after the 7-day ONS study (P = 0.01).

CONCLUSION

Use of ONS drinks as PEN have high perceived benefits and appear to be a feasible option for short-term use of 3-6 months in CD patients. However, confidence in long-term use of ONS drinks as PEN is low mainly due to the perceived social impact. Future studies should assess longer trial periods and volume of ONS drinks to increase the validity of these findings.

Identification of aroma compounds in a commonly prescribed oral nutritional supplement and associated changes in olfactory abilities with human ageing

Undernutrition is prevalent in the older adult population. Oral nutritional supplements (ONS) are a clinically effective nutritional intervention, however, patient acceptance of ONS can be limited by their palatability. While sensory attributes such as sweetness and mouthfeel have been investigated, the contribution made by aroma to the perceived flavour of ONS has not been studied. Firstly, this research aimed to identify the aroma active compounds within a commonly prescribed ONS using estimated odour activity values (OAV) and gas chromatography olfactometry mass spectrometry (GC-O-MS). Secondly, age related differences in olfactory detection were explored. Eight aroma active compounds were identified within the ONS, including diacetyl (sweet), isoamyl acetate (banana), dimethyl trisulfide (sulfur) and methanethiol (sulfur). When compared with younger adults (n = 24, 18–44 years), older adults (n = 24, 62–80 years) had higher detection thresholds for all aroma compounds and this was significant for isoamyl acetate (sweet, fruity) and methanethiol (sulfur) (p = 0.01 and p = 0.03, respectively). Thus, a decline in olfactory sensitivity was present in the older subjects included in the study, and this reduced detection sensitivity was aroma specific. Thus, older adults’ flavour perception of ONS likely depends on the combined effect of product factors (the aroma profile) along with age related consumer factors (the degree of impairment in perception). This is a fundamental study which will aid future research into how the aroma profile, and associated age related impairments in perception, shape the global perception of ONS for nutritionally at risk older individuals.

Acceptance of oat-based beverages tailored for patients with cancer

Oat-based beverages are a nutritious product with the potential to support increased nutrient intake of patients with cancer. The aim of this research was to evaluate the sensory acceptance of oat-based beverages and perceptions of oats among patients with cancer as future vehicles for nutrient delivery. In study 1, three flavors of oat-beverages were well accepted without significant difference in liking among flavors or serving temperature, or between patients with cancer and healthy participants. Patients with cancer more frequently rated the beverages as too sweet compared to healthy participants; flavor intensity was just about right for all participants. In the second study, one of two formulations fortified with protein and fish oil was not different in liking compared to the unfortified chocolate product. Patients associated oat food products with specific oat-based food products and oat health benefits in a free-word association task in the third study. Together, sensory acceptance and the perceived health benefits of oats indicate the potential for oats to be incorporated in fortified and unfortified products tailored for patients with cancer. PRACTICAL APPLICATION: The three studies presented here to assess the sensory acceptance of oat-based beverages and perceptions of oats among patients with cancer demonstrate that oats can be incorporated in fortified and unfortified products tailored for patients with cancer. Inadequate nutrition is highly prevalent among oncology patients and there is a lack of available products targeted to improve their nutritional intake. These findings can support product developers and sensory scientists in the development and evaluation of food products acceptable to this population.

Guidelines for parenteral and enteral nutrition in geriatric patients in China

Based on the expert consensus on parenteral and enteral nutrition support for geriatric patients in China in 2013, domestic multidisciplinary experts were gathered to summarize the new evidence in the field of elderly nutritional support at home and abroad. The 2013 consensus was comprehensively updated and upgraded to a guideline by referring to the World Health Organization (WHO) guidelines for the Grading of Recommendations Assessment, Development, and Evaluation system for grading evidence. These guidelines were divided into two parts: general conditions and common diseases. After discussion by all members of the academic group and consultation with relevant experts, 60 recommendations were ultimately established as standardized nutritional support in the field of geriatrics in China.

Effects of enteral nutritional rich in n-3 polyunsaturated fatty acids on the nutritional status of gastrointestinal cancer patients: a systematic review and meta-analysis

Postoperative malnutrition is a major issue among gastrointestinal cancer patients. Because n-3 polyunsaturated fatty acids (n-3 PUFAs) have immunological benefits, n-3 PUFAs are widely used in oral nutritional supplements (ONS). However, n-3 PUFAs in ONS reduced patients' compliance with ONS and affected the role of ONS in maintaining the postoperative nutritional status of patients. The aim of this study was to systematically explore the benefits of enteral nutrition rich in n-3 PUFAs in maintaining the nutritional status of patients after gastrointestinal surgery. Databases including PubMed, Web of Science, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang, and VIP databases were searched through March 16, 2019. The references of related reviews and studies were assessed up to March 16, 2019. The effect sizes from individual studies were calculated as the standardized mean difference (SMD), mean difference (MD), and risk ratio (RR) with 95% confidence intervals (95% CIs). A total of 11 studies (n = 977) were included. In this systematic review and meta-analysis, we observed that enteral supplementation of n-3 PUFAs had no significant effect on weight (MD, 1.09; 95% CI, -0.90, 3.08), body mass index (MD, 0.55; 95% CI, -1.45, 2.54), albumin (SMD, 0.39; 95% CI, -0.10, 0.87), wound infections (RR, 0.87, 95% CI, 0.57, 1.33), or pneumonia (RR, 0.98; 95% CI, 0.60, 1.59) in gastrointestinal cancer patients. Thus, compared with enteral nutritional without n-3 PUFAs, enteral nutritional rich in n-3 PUFAs has no significant effects on nutritional status, incidence of pneumonia, or wound infections among gastrointestinal cancer patients during postoperative convalescence.

Complete Oral Nutritional Supplements: Dietitian Preferences and Clinical Practice

Oral nutritional supplements (ONS) are frequently prescribed for those at risk of malnutrition. Palatability is an important factor in long-term compliance. ONS selection is typically dietitian led, but the degree to which individual perceptions of palatability influence dietitian clinical decision making is unclear. This study aimed to explore factors that influence dietitians' ONS clinical practice, evaluate dietitian hedonic preferences and overall impression of specific ONS products, and study phenylthiocarbamide (PTC) sensitivity in relation to ONS hedonic ratings. Dietitians were recruited from six urban teaching hospitals. They completed a 10-item Clinical Practices Questionnaire prior to taste testing five samples of three ONS products. A 7-point hedonic Likert scale recorded ONS palatability ratings. A PTC test was conducted. Thirty-one dietitians were recruited. Nutritional value, patient palatability, patient acceptability, tolerance and hospital contracts were the factors identified as most likely to influence ONS prescription. All ONS were consistently highly rated for overall impression. The high-protein ONS was most highly rated for all hedonic characteristics. Taste was the highest rated hedonic characteristic across all products. No statistically significant relationship was found between PTC sensitivity and ONS overall impression. The key drivers of ONS dietitian clinical practice were identified. ONS hedonic characteristics and overall impression were highly rated, which suggested this range of products had wide appeal for dietetic professionals. The taste and consistency of the ONS were rated better than other hedonic characteristics (appearance, smell, aftertaste).

Oral protein–energy supplements for children with chronic disease:systematic review

Growth failure and poor nutritional status are features of children with chronic disease. Oral protein–energy supplements are one of a number of interventions provided with the aim of improving nutritional status in these children. The present paper describes a Cochrane systematic review assessing the efficacy of these products in children with chronic disease. The objective was to examine the evidence that in children with chronic disease oral protein–energy supplements alter nutrient intake, nutritional indices, survival and quality of life. All randomised controlled trials of the use of oral protein–energy supplements in children with chronic disease were identified through searching electronic databases and hand searching the abstract books of nutrition conferences. Studies identified were independently assessed for eligibility and methodological quality, and data on outcomes of interest were combined in a meta-analysis where possible. Two trials were eligible for inclusion in the review, both of which were undertaken with children with cystic fibrosis. No statistical differences could be found between treatment and control groups when data from both studies were combined. Oral protein–energy supplements are widely used to improve the nutritional status of children with chronic disease. No conclusions can be drawn on the efficacy of these products based on the limited data available. Further randomised controlled trials are required to investigate the use of these products in children with chronic disease. Until further data are available, these products should be used with caution.

Taste preferences for oral nutrition supplements in patients before and after pelvic radiotherapy: A double-blind controlled study

BACKGROUND & AIMS

No data exists about the effect of pelvic radiotherapy on taste preference for oral nutrition supplements, including elemental diet, which may prevent gastrointestinal symptoms if taken during pelvic radiotherapy. This double blind study aimed to: (1) examine the palatability of elemental, peptide and polymeric oral nutrition supplements in patients with pelvic malignancies compared with healthy controls (2) assess changes in taste preference following pelvic radiotherapy (3) develop a reliable scale to measure taste preference.

METHODS

Subjects blind tasted six 30ml oral nutrition supplement samples, one duplicated, before and after 5 weeks of treatment (or the same time interval for controls). A Likert scale was used to score preference.

RESULTS

Fifty patients and 50 controls were recruited. Before radiotherapy, patients had a lower mean preference for the peptide formulation than the other oral nutrition supplements (P<0.001). There were no significant differences in preferences between patients and controls (P>0.2 all supplements). Radiotherapy did not affect supplement preference.

CONCLUSIONS

Patients with pelvic malignancy and healthy controls rate elemental nutritional supplements as highly as polymeric supplements and significantly better than peptide supplements. This trend continues even after pelvic radiotherapy. A Likert scale is a reliable tool in this scenario.

Effect of providing fortified meals and between-meal snacks on energy and protein intake of hospital patients

This study aimed to evaluate whether food fortification and snacks could increase the energy and protein intakes of hospital patients. The control group of 82 consecutive admissions on medical, elderly care and orthopaedic wards ate freely from the hospital menu. Subsequently, an intervention group of 62 patients were offered fortified food and snacks, providing an extra 22.2|g protein/day and 966 kcal/day in addition to the standard menu. Fortification significantly increased energy intake in the intervention group (P = 0.007, independent samples t-test), having the greatest effect on groups with the lowest energy intake, that is male and female orthopaedic, female medical and female elderly patients (84 cent of total). The increases in energy intake were 21.3 cent, 21.4 cent, 23 cent and 19.6 cent respectively. Although the increased energy and protein intake represented 25.6 cent and 22.5 cent respectively, of the supplements given, and suggested that wastage was high, it was nevertheless sufficient to remove energy deficit. We therefore propose that provision of fortified food and snacks is a convenient method of improving the nutritional intakes of hospital patients.