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Who benefits from nutritional support: what is the evidence?
No full textNutritional support, including oral nutritional supplements, enteral tube feeding and parenteral nutrition, can be an important part of the management of any patient. Malnutrition is common and costly, clinically and financially, if left untreated. In patients with, or at risk of, malnutrition, the appropriate use of nutritional support can prevent complications arising, produce other clinical, functional and financial benefits, and can be life saving in some situations. This article discusses the evidence from systematic reviews and meta-analyses of the effectiveness of nutritional support
A cost-utility analysis in patients receiving enteral tube feeding at home and in nursing homes
No full textA cost-utility analysis was undertaken of enteral tube feeding (ETF) in patients with cerebrovascular accident (CVA). Mortality during ETF was established in nursing homes (n7007) or at home (n2888). Quality of life was measured (EuroQol) on a sub-sample (n25). Quality adjusted life years (QALYs) over 3 years and the cost/QALY were calculated. The cost/QALY (£1=€1.482; 30/06/05) for patients receiving ETF at home was £12,817 (£10,351–£16,826 using 95% CI for quality of life) and insensitive to the frequency of home visits (50–150% of the average frequency; £11,851–£13,782), outcome of patients reverting to full oral feeding (0–100% survival; £11,023–£14,440), and computed outcome of a ‘control’ group not given ETF (0.125–0.25 year survival; £12,991–£14,006). The cost/QALY in nursing homes (£10,304–£68,064) varied depending on the state contribution to non-medical costs and is above and below the threshold (£30,000/QALY). The data suggest the cost-effectiveness of ETF in patients with CVA receiving ETF at home or in nursing homes, where the non-medical costs are paid privately, compares favourably with other interventions. The cost-effectiveness of ETF in nursing homes when the state pays all non-medical costs compares unfavourably with other treatments, raising economic, clinical, and ethical concerns.<br/
Deprivation linked to malnutrition risk and mortality in hospital
Get PDFThis study aimed to investigate the link between deprivation and in-hospital malnutrition and to assess any independent and interrelated effects of deprivation and malnutrition on clinical outcome in hospital. One thousand patients (mean age 71 (SD 19) years, mean BMI 25.6 (SD 5.4) kg/m(2)) were screened for malnutrition (using the Malnutrition Universal Screening Tool ('MUST')) and their clinical outcome assessed prospectively. The deprivation of patients' locality of residence prior to admission was recorded using the Index of Multiple Deprivation 2000 (IMD). Patients with medium and high malnutrition risk (42 %, n 420) were admitted from areas with significantly greater deprivation (lower ranks) than low-risk patients (IMD 3731 v. 3946; P<0.02). The prevalence of malnutrition increased by multiples of 1.14 (95 % CI 1.02, 1.28) for each increment in quartile of IMD rank. The odds of malnutrition of the most deprived quartile were greater than those of the least deprived quartile by a factor of 1.59 (95 % CI 1.11, 2.28). They were also greater for five of the six components of IMD deprivation (and by a factor of 1.73 (95 % CI 1.20, 2.49) for income and 1.69 (95 % CI 1.18, 2.42) for employment). Greater in-hospital mortality was associated with malnutrition, independently of IMD (or its individual components; odds ratio 2.04 (95 % CI 1.22, 3.44)). Length of stay was associated only with malnutrition risk (P<0.0005). This study highlights that in-hospital malnutrition and deprivation are interrelated, yet have independent, adverse associations with patient outcome. Effective strategies are required to tackle these common health inequalities in both clinical and public health settings
Geographical inequalities in nutrient status and risk of malnutrition among English people aged 65 y and older
No full textObjective: Geographical inequalities in health continue to be a problem within developed countries. This study investigated whether there were north-south geographical inequalities among older people living in England with respect to risk of protein-energy malnutrition and status of nutrients, particularly those derived from fruit and vegetables.Methods: A secondary analysis of data collected prospectively by the National Diet and Nutrition Survey of people aged 65 y and older was undertaken to assess geographical prevalence of risk of protein-energy malnutrition (1155 subjects) and nutrient status (881 to 1046 subjects).Results: A north-south gradient was found in risk of protein-energy malnutrition (19.4%, 12.3%, and 11.2% in the northern, central, and southern regions, respectively; P = 0.013, P for trend = 0.002). This was accompanied by a north-south gradient in the status of vitamin C (30, 38, and 46 ?mol/L in the respective regions, P < 0.001), which was associated with deficiency (<11 ?mol/L) in a third of subjects in the northern region, a range of carotenoids (P = 0.023 to <0.001), vitamin D (P < 0.001), and selenium (P < 0.001). These inequalities were accompanied by gradients in indices of health status and socioeconomic status, which could account only partly for the “geographical” inequalities. Circulating vitamin C and carotenoid concentrations were related to the intake of fruit and vegetables.Conclusions: This study suggests there is a north-south divide in the risk of protein-energy malnutrition and a range of nutrients, which have been implicated in the development of common chronic diseases
Should food or supplements be used in the community for the treatment of disease-related malnutrition?
No full textStrategies are needed for community-based treatment of disease-related malnutrition (DRM), which is a common debilitating condition that in the UK is estimated to cost >£7×10? annually. Whilst dietary fortification and counselling are often used as a first-line treatment for malnutrition, the numbers of dietitians available to undertake and oversee such practices are currently insufficient to address the extent of DRM in primary care. Although dietary fortification and counselling can improve nutritional (primarily energy) intake, the evidence base for this practice is weak and it needs addressing with well-designed trials that assess clinically-relevant outcome measures and costs. Liquid oral nutritional supplements (ONS) are increasingly used in the community, often in combination with dietary counselling. The larger evidence base of trials that have assessed ONS suggests that nutritional intake and some functional outcomes can be improved in some patient groups in the community. Although meta-analysis indicates significant reductions in mortality (odds ratio 0·59 (95% CI 0·48, 0·72), n 3258) and complication rates (odds ratio 0·41 (95% CI 0·31, 0·53), n 1710) with ONS v. routine care, few of these studies are community based. Thus, the impact of ONS on clinical outcome, healthcare use and costs requires further assessment. Similarly, the clinical and cost efficacy of other strategies (e.g. sensory enhancement, music, behavioural therapy), alone or in combination with other treatments, requires greater investigation in order to meet the challenge of treating DRM more effectively and cheaply in the future
Nutritional support in chronic obstructive pulmonary disease: a systematic review and meta-analysis
No full textBackground: The efficacy of nutritional support in the management of malnutrition in chronic obstructive pulmonary disease (COPD) is controversial. Previous meta-analyses, based on only cross-sectional analysis at the end of intervention trials, found no evidence of improved outcomes.Objective: The objective was to conduct a meta-analysis of randomized controlled trials (RCTs) to clarify the efficacy of nutritional support in improving intake, anthropometric measures, and grip strength in stable COPD.Design: Literature databases were searched to identify RCTs comparing nutritional support with controls in stable COPD.Results: Thirteen RCTs (n = 439) of nutritional support [dietary advice (1 RCT), oral nutritional supplements (ONS; 11 RCTs), and enteral tube feeding (1 RCT)] with a control comparison were identified. An analysis of the changes induced by nutritional support and those obtained only at the end of the intervention showed significantly greater increases in mean total protein and energy intakes with nutritional support of 14.8 g and 236 kcal daily. Meta-analyses also showed greater mean (±SE) improvements in favor of nutritional support for body weight (1.94 ± 0.26 kg, P < 0.001; 11 studies, n = 308) and grip strength (5.3%, P < 0.050; 4 studies, n = 156), which was not shown by ANOVA at the end of the intervention, largely because of bias associated with baseline imbalance between groups.Conclusion: This systematic review and meta-analysis showed that nutritional support, mainly in the form of ONS, improves total intake, anthropometric measures, and grip strength in COPD. These results contrast with the results of previous analyses that were based on only cross-sectional measures at the end of intervention trial
Cost-effectiveness of oral nutritional supplements in older malnourished care home residents
No full textBACKGROUND & AIMS:
Malnutrition is common in care home residents, but information on the cost-effectiveness of nutritional interventions is lacking. This study, involving a randomised trial in care home residents, aimed to examine whether oral nutritional supplements (ONS) are cost-effective relative to dietary advice.
METHODS:
An incremental cost-effectiveness analysis was undertaken prospectively in 104 older care home residents (88 ± 8 years) without overt dementia, who were randomised to receive either ONS or dietary advice for 12 weeks. Costs were estimated from resource use and quality adjusted life years (QALYs) from health-related quality of life, assessed using EuroQoL (EQ-5D-3L, time-trade-off) and mortality. The incremental cost-effectiveness ratio (ICER) was calculated using 'intention to treat' and 'complete case' analyses.
RESULTS:
The ONS group gained significantly more QALYs than the dietary advice group at significantly greater costs. The ICER (extra cost per QALY gained), adjusted for nutritional status, type of care, baseline costs and quality of life, was found to be £10,961 using the 'intention to treat' analysis (£190.60 (cost)/0.0174 (QALYs); n = 104) and £11,875 using 'complete case' analysis (£217.30/0.0183; n = 76) (2016 prices). Sensitivity analysis based on 'intention to treat' data indicated an 83% probability that the ICER was ≤£20,000 and 92% that it was ≤£30,000. With the 'complete case data' the probabilities were 80% and 90% respectively.
CONCLUSION:
This pragmatic randomised trial involving one of the oldest populations subjected to a cost-utility analysis, suggests that use of oral nutritional supplements in care homes are cost-effective relative to dietary advice
Bolus tube feeding suppresses food intake and circulating ghrelin concentrations in healthy subjects in a short-term placebo-controlled trial
No full textBackground: previous investigations suggest continuous tube feeding (TF) schedules do not suppress appetite and food intake, but bolus TF has been little studied. OBJECTIVE: We tested the hypothesis that 1) bolus TF does not suppress appetite and food intake and 2) there is no interrelation between food intake and appetite mediators (including ghrelin). Design: a single-blind, placebo-controlled trial within which 6 healthy men [body mass index (in kg/m(2)): 21.1 +/- 1.61] received 3 d of bolus TF (6.93 +/- 0.38 MJ/d of 4.18 kJ/mL multinutrient feed). For 2 d before and after TF, placebo boluses (<0.4 MJ/d) were given by tube. Hourly tracking of appetite, weighed measurements of daily ad libitum food intake, and metabolic and hormonal (including ghrelin) measurements were undertaken. Results: total energy intake was significantly increased with bolus TF (18.2 +/- 1.86 MJ; P = 0.0005) despite a partial reduction in food intake compared with placebo periods (P = 0.013) and during the TF period (by 15%; P = 0.007). There was little change in hunger and fullness with bolus TF, and within-day temporal patterns did not differ whether TF or placebo was given. Changes in fasting concentrations of ghrelin (1003.6-756.0 pmol/L; P = 0.013) and other mediators (including leptin, insulin, and glucose) were significantly related to subsequent daily food intake (eg, ghrelin: r(2) = 0.81, P = 0.022). Conclusions: in this short-term study, subjects maintained appetite ratings during bolus TF by a significant reduction in food intake and changes in ghrelin and some appetite mediators related to subsequent daily food intake. Longer-term studies are required to fully ascertain the effect of TF on appetite, food intake, and appetite mediators<br/
Short-term continuous enteral tube feeding schedules did not suppress appetite and food intake in healthy men in a placebo-controlled trial
No full textTube feeding (TF) provides a model with which to study appetite when nutrient delivery bypasses the upper gastrointestinal (GI) tract and associated cephalic phase response. Nocturnal, diurnal and 24-h TF schedules are used clinically, but their effects on satiety have not been distinguished. This study tested two hypotheses: 1) bypassing the upper GI tract with TF has little satiating effect, and 2) diurnal TF suppresses appetite and food intake more than nocturnal or 24-h schedules. Six healthy men, residing in a metabolic suite, each received three continuous TF schedules (diurnal 12-h, nocturnal 12-h and 24-h; 6.86 ± 0.51 MJ/d) in random order for 3 d over separate 10-d periods.Two days before and after TF, a placebo feed (<0.4 MJ/d) was given. Weighed measurements of ad libitum food consumption, hourly tracking of appetite and metabolic and hormonal measurements were undertaken. Compared with placebo feeding, there was a nonsignificant reduction in oral intake (1.01–2.49 MJ reduction), little change in appetite sensations with TF and an increase in total energy intake from 14.88 to 20.42 ± 3.25 MJ. The schedules did not differ although diurnal TF was the most satiating. Changes in a variety of mediators (including leptin, insulin, cholecystokinin, metabolites and respiratory quotient) did not relate to immediate assessments of appetite and food intake. This trial suggests that continuous TF has little effect on satiety in healthy men over a period of 3 d, irrespective of the timing of the schedule. This could not be explained by changes in a variety of metabolic and hormonal signals within the time frame studied
Enteral nutritional support and use of diabetes-specific formulas for patients with diabetes. A systematic review and meta-analysis
Full text linkOBJECTIVE—The aim of this systematic review was to determine the benefits of nutritional support in patients with type 1 or type 2 diabetes. RESEARCH DESIGN AND METHODS—Studies utilizing an enteral nutritional support intervention (oral supplements or tube feeding) were identified using electronic databases and bibliography searches. Comparisons of interest were nutritional support versus routine care and standard versus diabetes-specific formulas (containing high proportions of monounsaturated fatty acids, fructose, and fiber). Outcomes of interest were measures of glycemia and lipid status, medication requirements, nutritional status, quality of life, complications, and mortality. Meta-analyses were performed where possible. RESULTS—A total of 23 studies (comprising 784 patients) of oral supplements (16 studies) and tube feeding (7 studies) were included in the review, and the majority compared diabetes-specific with standard formulas. Compared with standard formulas, diabetes-specific formulas significantly reduced postprandial rise in blood glucose (by 1.03 mmol/l [95% CI 0.58–1.47]; six randomized controlled trials [RCTs]), peak blood glucose concentration (by 1.59 mmol/l [86–2.32]; two RCTs), and glucose area under curve (by 7.96 mmol · l–1 · min–1 [2.25–13.66]; four RCTs, i.e., by 35%) with no significant effect on HDL, total cholesterol, or triglyceride concentrations. In addition, individual studies reported a reduced requirement for insulin (26–71% lower) and fewer complications with diabetes-specific compared with standard nutritional formulas. CONCLUSIONS—This systematic review shows that short- and long-term use of diabetes-specific formulas as oral supplements and tube feeds are associated with improved glycemic control compared with standard formulas. If such nutritional support is given long term, this may have implications for reducing chronic complications of diabetes, such as cardiovascular events
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