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Meta-Analysis
. 2016 Dec 20;12(12):CD009840.
doi: 10.1002/14651858.CD009840.pub2.

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

Affiliations
Meta-Analysis

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

Christine Baldwin et al. Cochrane Database Syst Rev. .

Abstract

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

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

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

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

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

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

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

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Conflict of interest statement

Michelle Gibbs: this work was financially supported by a grant from the British Dietetic Association.

Katherine Kimber: none known.

Christine Baldwin: some of the early work on this review was funded by an educational grant from the British Dietetic Association. The grant was used to support the salary of two research assistants who contributed to the searching, study selection and writing of the review.

Christine Elizabeth Weekes: none known.

Figures

1
1
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2
Study flow diagram
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included trial.
4
4
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included trials.
5
5
Forest plot of comparison: 1 Supportive interventions for enhancing dietary intake versus comparators, outcome: 1.2 Nutritional status (weight change) (kg)
6
6
Forest plot of comparison: 1 Supportive interventions for enhancing dietary intake versus comparators, outcome: 1.4 All‐cause mortality
1.1
1.1. Analysis
Comparison 1 Supportive interventions for enhancing dietary intake versus comparators, Outcome 1 No. of participants with complications.
1.2
1.2. Analysis
Comparison 1 Supportive interventions for enhancing dietary intake versus comparators, Outcome 2 Nutritional status (weight change).
1.3
1.3. Analysis
Comparison 1 Supportive interventions for enhancing dietary intake versus comparators, Outcome 3 Hospitalisation.
1.4
1.4. Analysis
Comparison 1 Supportive interventions for enhancing dietary intake versus comparators, Outcome 4 All‐cause mortality.

Comment in

References

References to studies included in this review

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Edington 2004 {published data only}
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Espaulella 2000 {published data only}
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Fiatarone 1994 {published data only}
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Forster 2005 {published data only}
    1. Forster SE, Gariballa SE, Powers HJ. Function‐enabling diet (FED) study: a randomised, double‐blind, placebo‐controlled trial of the effects of energy, protein and micronutrient supplementation of hospitalised elderly patients. Proceedings of Nutrition Society 2005;64:25A.
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Gall 1998 {published data only}
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Gariballa 1998 {published data only}
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Gazzotti 2003 {published data only}
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Gegerle 1986 {published data only}
    1. Gegerle P, Bengoa JM, Delmi M, Rapin CH, Loizeau E, Vasey H. Dietary survey on the effect of an oral nutritional supplement after femoral neck fracture [Enquete alimentaire apres fracture du col du femur: effet d’un supplement dietetique sur les apports nutritonnels]. Schweizerische Rundschau fur Medizin Praxis 1986;75(32):933–5. - PubMed
Gil Gregorio 2003 {published data only}
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Goris 2003 {published data only}
    1. Goris AH, Vermeeren MA, Wouters EF, Schols AM, Westerterp KR. Energy balance in depleted ambulatory patients with chronic obstructive pulmonary disease: the effect of physical activity and oral nutritional supplementation. The British Journal of Nutrition 2003;89(5):725‐31. - PubMed
Hogarth 1996 {published data only}
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Hopkinson 2010 {published data only}
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Houles 2010 {published data only}
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Hubbard 2008 {published data only}
    1. Hubbard GP, Bolch R, Holdoway H, Beams A, Kerr A, Robertson D, et al. A randomised, controlled trial of the effects of an energy‐dense supplement on energy intake, appetite and blood lipids in malnourished community‐based elderly patients. Journal of Human Nutrition and Dietetics 2008;21(4):390‐1.
Hubsch 1992 {published data only}
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Huisman 2012 {published data only}
    1. Huisman EJ, Hoek B, Soest H, Nieuwkerk KM, Arends JE, Siersema PD, et al. Preventive versus "on‐demand" nutritional support during antiviral treatment for hepatitis C: a randomized controlled trial. Journal of Hepatology 2012;57(5):1069‐75. - PubMed
Isenring 2003 {published data only}
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Isenring 2004 {published data only}
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Jahnavi 2010 {published data only}
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James 2006 {published data only}
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Johnson 1993 {published data only}
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Keele 1997 {published data only}
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Kikutani 2006 {published data only}
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Kruizenga 2004 {published data only}
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Kuhlmann 1997 {published data only}
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Kwok 2001 {published data only}
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Kwok 2012 {published data only}
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Lauque 2000 {published data only}
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Lauque 2004 {published data only}
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Lawson 2000 {published data only}
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Le Cornu 2000 {published data only}
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Lee 2013 {published data only}
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Leon 2001 {published data only}
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Leon 2006 {published data only}
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MacFie 2000 {published data only}
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Mamhidir 2007 {published data only}
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Manders 2006 {published data only}
    1. Manders M. Nutritional care in old age: the effect of supplementation on nutritional status and performance [PhD thesis]. Wageningen: Wageningen University, 2006.
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McEvoy 1982 {published data only}
    1. McEvoy AW, James OF. The effect of a dietary supplement (Build‐up) on nutritional status in hospitalized elderly patients. Human Nutrition Applied Nutrition 1982;36(5):374‐6. - PubMed
McMurdo 2009 {published data only}
    1. McMurdo MET, Price RJG, Shields M, Potter J, Stott DJ. Should oral nutritional supplementation be given to undernourished older people upon hospital discharge? A controlled trial. Journal of the American Geriatrics Society 2009;57(12):2239‐45. - PubMed
Moretti 2009 {published data only}
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Navrátilová 2007 {published data only}
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Nayel 1992 {published data only}
    1. Nayel H, el‐Ghoneimy E, el‐Haddad S. Impact of nutritional supplementation on treatment delay and morbidity in patients with head and neck tumors treated with irradiation. Nutrition 1992;8(1):13‐8. - PubMed
Ödlund Olin 2003 {published data only}
    1. Ödlund Olin A, Armyr I, Soop M, Jerström S, Classon I, Cederholm T, et al. Energy‐dense meals improve energy intake in elderly residents in a nursing home. Clinical Nutrition (Edinburgh, Scotland) 2003;22(2):125‐31. - PubMed
Olin 1996 {published data only}
    1. Olin AO, Osterberg P, Hadell K, Armyr I, Jerstrom S, Ljungqvist O. Energy‐enriched hospital food to improve energy intake in elderly patients. JPEN Journal Parenteral & Enteral Nutrition 1996;20(2):93‐7. - PubMed
Otte 1989 {published data only}
    1. Otte KE, Ahlburg P, D'Amore F, Stellfeld M. Nutritional repletion in malnourished patients with emphysema. JPEN Journal Parenteral & Enteral Nutrition 1989;13(2):152‐6. - PubMed
Payette 2002 {published data only}
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Price 2005 {published data only}
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Rana 1992 {published data only}
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Richeson & Neil 2004 {published data only}
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Roberts 2013 {published data only}
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Robinson 2002 {published data only}
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Saudny‐Unterberger 1997 {published data only}
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Shinnar 1983 {published data only}
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Simmons 2004 {published data only}
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Smedley 2004 {published data only}
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Tkatch 1992 {published data only}
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Woo 1994 {published data only}
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    1. Parrott MD, Young KWH, Greenwood CE. Energy‐containing nutritional supplements can affect usual energy intake post supplementation in institutionalized seniors with probable Alzheimer's disease. Journal of the American Geriatrics Society 2006;54(9):1382‐7. - PubMed
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References to studies awaiting assessment

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References to other published versions of this review

Gibbs 2012
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