Elsevier

Clinical Nutrition

Volume 38, Issue 4, August 2019, Pages 1797-1806
Clinical Nutrition

Original article
Effectiveness of nutritional interventions in older adults at risk of malnutrition across different health care settings: Pooled analyses of individual participant data from nine randomized controlled trials

https://doi.org/10.1016/j.clnu.2018.07.023Get rights and content

Summary

Background & aims

Protein-energy malnutrition is a health concern among older adults. Improving nutritional status by increasing energy and protein intake likely benefits health. We therefore aimed to investigate effects of nutritional interventions in older adults (at risk of malnutrition) on change in energy intake and body weight, and explore if the intervention effect was modified by study or participants’ characteristics, analysing pooled individual participant data.

Methods

We searched for RCTs investigating the effect of dietary counseling, oral nutritional supplements (ONS) or both on energy intake and weight. Principle investigators of eligible studies provided individual participant data. We investigated the effect of nutritional intervention on meaningful increase in energy intake (>250 kcal/day) and meaningful weight gain (>1.0 kg). Logistic generalized estimating equations were performed and ORs with 95% CIs presented.

Results

We included data of nine studies with a total of 990 participants, aged 79.2 ± 8.2 years, 64.5% women and mean baseline BMI 23.9 ± 4.7 kg/m2. An non-significant intervention effect was observed for increase in energy intake (OR:1.59; 95% CI 0.95, 2.66) and a significant intervention effect for weight gain (OR:1.58; 95% CI 1.16, 2.17). Stratifying by type of intervention, an intervention effect on increase in energy intake was only observed for dietary counseling in combination with ONS (OR:2.28; 95% CI 1.90, 2.73). The intervention effect on increase in energy intake was greater for women, older participants, and those with lower BMI. Regarding weight gain, an intervention effect was observed for dietary counseling (OR:1.40; 95% CI 1.14, 1.73) and dietary counseling in combination with ONS (OR:2.48; 95% CI 1.92, 3.31). The intervention effect on weight gain was not influenced by participants’ characteristics.

Conclusions

Based on pooled data of older adults (at risk of malnutrition), nutritional interventions have a positive effect on energy intake and body weight. Dietary counseling combined with ONS is the most effective intervention.

Introduction

Protein-energy malnutrition is a significant health concern particularly affecting older adults. Its prevalence varies widely according to setting, i.e. less than 10% of independently living older adults are affected, whereas the prevalence increases up to 50% or more in nursing-home residents, geriatric patients in acute-care hospitals and patients in geriatric rehabilitation [1], [2]. Malnutrition in older adults is associated with several adverse health and clinical outcomes, such as reduced strength, increased risk of morbidity (e.g. the development of pressure ulcers, impaired wound-healing, infectious complications, hospital readmissions and increased length of hospital stay), higher mortality risk [3], [4], [5], as well as higher health care costs [6].

Studies summarizing the overall effects of nutritional intervention strategies on health outcomes by increasing energy intake, i.e. through oral nutritional supplements (ONS), dietary counseling or both, showed limited effects [7], [8], [9]. Some studies showed that nutritional support in malnourished older patients may also lead to improved health outcomes, such as hand grip strength, physical activity levels, cognitive function or quality of life [10], [11], [12], [13], [14], [15], [16], while others have found no significant effects of nutritional interventions on health outcomes [10], [17], [18], [19]. It may be possible that some nutritional intervention studies were not able to show improvements in health outcomes due to their low impact on energy intake or body weight, as this is a prerequisite for improving health outcomes. In addition, methodological shortcomings of some previous studies, such as small sample size, and differences between studies in setting, inclusion criteria and intervention strategies, may have contributed to the heterogeneity in study results [7]. Hence, it has been suggested to analyse individual participant data in order to take into account correlations of observations within studies and account for potential study bias [9]. A meta-analyses using aggregate data may overcome the shortcomings of individual studies [20] by allowing further investigation of treatment effects and interactions between treatment and factors such as study setting (hospital, community-dwelling, institutionalized), type of intervention (dietary counseling and/or ONS) or participants’ characteristics.

In this study, we have pooled individual participant data from nine international nutritional intervention studies performed among older adults at risk of malnutrition. This study aims to examine 1) the effect of the intervention on meaningful increase in energy intake and meaningful weight gain, 2) whether the intervention effect was modified by study characteristics or participants' characteristics, and 3) which study or participants’ characteristics predict meaningful increase in energy intake and weight among participants from control groups in order to investigate which participants improve nutritional status without receiving any intervention.

Section snippets

Search strategy

Our search for high quality nutritional intervention studies among older adults was based on two previous published reviews by Milne et al. [8] and de van der Schueren et al. [7]. In addition, we conducted a search in the database of MEDLINE. In the search strategy we combined text words and Medical Subject Headings terms without language restrictions. Search criteria included “nutritional support”, “diet”, “malnutrition”, “undernutrition”, “protein-energy malnutrition”. Furthermore, reference

Results

We identified 38 nutritional intervention studies that met our inclusion criteria. For eight studies, no contact information was available. Of the remaining 30 studies the principal investigators were contacted for contribution to the current study. Reasons for not contributing were as follows; no response (n = 6), data had been destroyed (n = 6), not able to provide the data (n = 5), not applicable (e.g. when it was not possible to separate intervention groups when a combined intervention was

Discussion

In this pooled analyses of individual data from nine international nutritional intervention studies in older adults at risk of malnutrition, we observed a positive intervention effect of nutritional intervention on energy intake and body weight versus control (research question 1). There was a positive intervention effect on both outcomes for providing dietary counseling and for providing dietary counseling with ONS, but not for providing ONS alone. Participants’ characteristics did not modify

Conclusions

We conclude that nutritional interventions are effective in increasing energy intake and body weight among older adults at risk of malnutrition. Dietary counseling with or without ONS was more effective compared to ONS alone, which shows the importance of active dietary counseling in the treatment of (risk of) malnutrition in older adults. The intervention effect on meaningful increase in energy intake was greater for women, those at higher age, and those with lower baseline BMI. Among

Authors contribution

The authors’ contributions were as follows; IR, DV and MV designed the research; IR collected, pooled and analysed the data and wrote the manuscript; MV had the primary responsibility for the final content; JWRT assisted with the statistical analyses; LCPGMG, AMB, MAES, DRS, HAHW, DV and MV conducted the original studies and provided data; all authors read and approved the final manuscript.

Conflicts of interest

The authors declare that they do not have conflict of interest.

Funding sources

This work was initiated by the Joint Programming Initiative ‘A Healthy Diet for a Healthy Life’. The funding agencies supporting the MaNuEL Knowledge Hub are (in alphabetical order of participating Member State): Austria: Federal Ministry of Science, Research and Economy; France: Ecole Supérieure d’Agricultires (ESA); Germany: Federal Ministry of Food and Agriculture represented by Federal Office of Agriculture and Food; Ireland: Department of Agriculture, Food and the Marine, and the Health

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