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.

Determining the prevalence and severity of cancer cachexia in advanced non-small cell lung cancer and its relationship with chemotherapy outcomes.

PURPOSE: Cancer cachexia (CC) is a syndrome characterised by an ongoing loss of skeletal muscle mass associated with reduced tolerance to treatment. This study explored the prevalence and severity of CC in advanced non-small cell lung cancer (NSCLC) patients and determined its relationship with chemotherapy outcomes. METHODS: CC was classified into a four-stage model: no cachexia, pre-cachexia (PC), cachexia and refractory cachexia (RC) with categorisation determined from biochemical and body composition and performance assessment. Associations between the stage of cachexia and chemotherapy outcomes including radiological response, the number of chemotherapy cycles completed and the number of cycles delayed or dose reduced were explored. RESULTS: Twenty-four patients were included with 4 (18%) classified as having no cachexia, 4 (18%) PC, 3 (14%) cachexia (13.6%), and 11 (50%) RC. No association was observed between the stage of cachexia and the radiological response to chemotherapy number of cycles delayed or the number of cycle's dose reduced; however, there was an association with the number of cycles completed (p = 0.030). An association between C-reactive protein (CRP) and the number of chemotherapy cycles completed (p = 0.044) and the number of dose reductions (p = 0.044) was also identified. CONCLUSIONS: Limited conclusions can be drawn given the small sample size. However, the majority of patients presented with some degree of cachexia at diagnosis. A relationship was identified between the increasing severity of cachexia and a lower number of chemotherapy cycles completed, as well as between CRP and the number of chemotherapy cycles completed and the number of dose reductions required, and therefore warrants further exploration in larger studies.

Association of energy and protein intakes with length of stay, readmission and mortality in hospitalised patients with chronic obstructive pulmonary disease.

Low energy and protein intakes have been associated with an increased risk of malnutrition in outpatients with chronic obstructive pulmonary disease (COPD). We aimed to assess the energy and protein intakes of hospitalised COPD patients according to nutritional risk status and requirements, and the relative contribution from meals, snacks, drinks and oral nutritional supplements (ONS), and to examine whether either energy or protein intake predicts outcomes. Subjects were COPD patients (n 99) admitted to Landspitali University Hospital in 1 year (March 2015-March 2016). Patients were screened for nutritional risk using a validated screening tool, and energy and protein intake for 3 d, 1-5 d after admission to the hospital, was estimated using a validated plate diagram sheet. The percentage of patients reaching energy and protein intake ≥75 % of requirements was on average 59 and 37 %, respectively. Malnourished patients consumed less at mealtimes and more from ONS than lower-risk patients, resulting in no difference in total energy and protein intakes between groups. No clear associations between energy or protein intake and outcomes were found, although the association between energy intake, as percentage of requirement, and mortality at 12 months of follow-up was of borderline significance (OR 0·12; 95 % CI 0·01, 1·15; P=0·066). Energy and protein intakes during hospitalisation in the study population failed to meet requirements. Further studies are needed on how to increase energy and protein intakes during hospitalisation and after discharge and to assess whether higher intake in relation to requirement of hospitalised COPD patients results in better outcomes.

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

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.

Improving the Dietary Intake of Health Care Workers through Workplace Dietary Interventions: A Systematic Review and Meta-Analysis.

The workplace has been identified as a potential location for dietary intervention delivery due to the amount of time spent and the meals eaten in this setting. It is recommended that interventions are tailored to specific occupational groups, and to date, there is limited synthesis of the evidence relating to health care workers. This review characterizes and evaluates the effectiveness of dietary interventions in health care workers to aid the design and implementation of interventions. The MEDLINE database was searched to September 2020. The reference list of an umbrella review was hand-searched for additional titles against inclusion criteria. The search included 1) population, 2) intervention, and 3) work environment. Studies were assessed for risk of bias. Harvest plots and forest plots were created to display study quality, direction, and size of effect of selected primary (energy, fruit and vegetable, and fat intake) and secondary outcomes (weight, BMI, blood pressure, and serum cholesterol concentrations). Thirty-nine articles assessing 34 interventions were eligible for inclusion. Intervention types most commonly used were environmental, educational, educational plus behavioral, and behavioral. Due to the heterogeneity in study design and intervention type, results were largely inconclusive. For dietary outcomes, interventions produced small-moderate favorable changes in fruit, vegetable, and fat intake. Decreased fat intake was mainly observed in environmental interventions and increases in fruit and vegetable intake were observed when an educational and/or behavioral component was present. Interventions producing weight loss were mostly nonrandomized trials involving education and physical activity. Total and LDL cholesterol decreased in interventions involving physical activity. Meta-analyses revealed significant decreases in energy intake, weight, blood pressure, total cholesterol, and LDL cholesterol in nonrandomized trials where data were available. Much more research is needed into strategies to promote diet quality improvement in health care workers. A protocol for this review is registered at PROSPERO (CRD42021234906).

Cannabinoid interventions for improving cachexia outcomes in cancer: a systematic review and meta-analysis.

Cancer-associated cachexia (CAC) is a wasting syndrome characterized by involuntary weight loss and anorexia. Clear definition and diagnostic criteria for CAC are lacking, which makes it difficult to estimate its prevalence, to interpret research and to compare studies. There is no standard treatment to manage CAC, but previous studies support the use of cannabinoids for cachexia in other chronic diseases including HIV and multiple sclerosis. However, only a few randomized controlled trials (RCTs) and one meta-analysis of this intervention in cancer populations are available. Non-randomized studies of interventions (NRSIs) are often excluded from reviews due to variable methodology and potential for biases. This review aimed to consider NRSIs alongside RCTs to provide a complete summary of the available evidence that clinical decision makers could use in future investigations. Literature searches were conducted using three databases for relevant RCTs or NRSIs according to Cochrane methodology. Abstract and full texts of retrieved manuscripts were selected and retrieved by two investigators based on the PRISMA-A guidelines, and risk of bias and quality of evidence assessments were performed. Outcome data on weight, appetite, quality of life, performance status, adverse effects, and mortality were combined by narrative synthesis and meta-analysis where possible. Ten studies were included, four of which were RCTs and six NRSIs matching the eligibility criteria. Very low-quality evidence from meta-analysis suggested no significant benefits of cannabinoids for appetite compared with control (standardized mean difference: -0.02; 95% confidence interval: -0.51, 0.46; P = 0.93). Patient-reported observations from NRSIs suggested improvements in appetite. Another meta-analysis of moderate quality evidence showed that cannabinoids were significantly less efficient than active or inactive control on quality of life (standardized mean difference: -0.25; 95% confidence interval: -0.43, -0.07; P = 0.007). The effectiveness of cannabinoids alone to improve outcomes of CAC remains unclear. Low-quality evidence from both RCTs and NRSIs shows no significant benefits of cannabinoids for weight gain, appetite stimulation, and better quality of life, three important outcomes of cachexia. Higher quality research integrating cannabinoids into multi-modal therapies may offer better opportunities for developing CAC-specific treatments. This review also highlights that findings from non-randomized studies of interventions (NRSIs) can provide evidence of the effects of an intervention and advocate for the feasibility of larger RCTs.

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. Dietary advice encouraging the use of energy- and nutrient-rich foods rather than oral nutritional supplements has been suggested as the initial approach for managing disease-related malnutrition. OBJECTIVES: To examine evidence that dietary advice in adults with disease-related malnutrition improves survival, weight and anthropometry; to estimate the size of any additional effect of nutritional supplements combined with dietary advice and to compare the effects of dietary advice with oral nutritional supplements. SEARCH STRATEGY: Relevant publications were identified from comprehensive electronic database searches and handsearching.Last search: 14 February 2010. SELECTION CRITERIA: Randomised controlled trials of dietary advice with or without oral nutritional supplements in people with disease-related malnutrition in any health-care setting compared with no advice, oral nutritional supplements or dietary advice given alone. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial eligibility, risk of bias and extracted data. MAIN RESULTS: Forty-five studies (3186 participants) met the inclusion criteria; (dietary advice compared with: no advice (1053 participants); with oral nutritional supplements (332 participants); with dietary advice and oral nutritional supplements (731 participants); and dietary advice plus oral nutritional supplements compared with no additional intervention (1070 participants). Follow-up ranged from 18 days to 24 months. No comparison showed a significant difference between groups for mortality or morbidity. There was a significant change in weight found between groups when comparing dietary advice to no advice for interventions lasting greater than 12 months, mean difference 3.75 kg (95% confidence interval 0.97 to 6.53), and when all studies were combined, mean difference 1.47 kg (95% confidence interval 0.32 to 2.61) although there was significant heterogeneity in the combined analysis (I(2) = 90%). Similar improvements in weight were found for the comparison of dietary advice with nutritional supplements if required versus no advice, mean difference 2.20 kg (95% confidence interval 1.16 to 3.25). Dietary advice compared with no advice was also associated with significantly improved mid-arm muscle circumference when all studies were combined, but with moderate heterogeneity, mean difference 0.81 mm (95% confidence interval 0.31 to 1.31). Dietary advice given with nutritional supplements compared with dietary advice alone resulted in improvements in: mid-arm muscle circumference, mean difference -0.89 mm (95% confidence interval -1.35 to -0.43); triceps skinfold thickness, mean difference -1.22 mm (95% confidence interval -2.34 to -0.09); and grip strength, mean difference -1.67 kg (95% confidence interval -2.96 to -0.37), although the effects on triceps skinfold thickness and grip strength were heterogeneous. Dietary advice with supplements if required resulted in a significant increase in triceps skinfold thickness compared with no advice, mean difference 0.40 mm (95% confidence interval 0.10 to 0.70), although these results are from a single trial with only 29 participants. AUTHORS' CONCLUSIONS: Evidence of variable quality suggests that dietary advice with or without oral nutritional supplements may improve weight, body composition and grip strength. We found no evidence of benefit of dietary advice or oral nutritional supplements given alone or in combination on survival. Studies addressing the impact of nutritional interventions on nutritional, functional and patient-centred outcomes are needed.

The role of non-dietetic healthcare professionals in managing interventions among adults at risk of malnutrition: A systematic review.

BACKGROUND: Malnutrition is estimated to affect over three million people in the UK resulting in serious consequences on both the individuals' health and healthcare system. While dietitians are uniquely qualified to provide nutritional interventions, they have one of the lowest workforce numbers in the NHS making it difficult to tackle the malnutrition burden alone. Thus, innovative ways of working are needed. Non-dietetic health care professionals are often involved in the identification, assessment and treatment of malnutrition and research has shown benefits of their involvement in identification and management of nutritional issues, however their role in delivering nutritional interventions has not yet been evaluated. The aim of this systematic review is to collate evidence on the potential roles and effectiveness of non-dietetic healthcare professionals in providing nutritional interventions and their impact on patient-centred outcomes in malnourished or at-risk individuals. METHODS: Three electronic databases were searched on 10th October 2019. Titles and abstracts were initially screened, followed by full texts, against inclusion criteria and included/excluded studies by two authors independently. Data were extracted and tabulated where possible and grouped according to type of intervention and outcomes. Risk of bias and quality of evidence was assessed using the GRADE approach. Data were combined in the form of a narrative synthesis. RESULTS: Eighteen eligible studies were included; five involved feeding assistance, 10 involved implementing individualised nutrition monitoring or care plans and three were multi-factorial interventions. Interventions took place in a range of settings including hospital and long term care facilities. Very low and low quality evidence suggests that non-dietetic HCP interventions may improve weight, percent of patients reaching estimated energy requirements, quality of life, falls and frailty rate and patient satisfaction. Very low quality evidence suggests that non-dietetic HCP interventions may not improve mid-arm circumference, energy or protein intake, activities of daily living, handgrip strength or length of hospital stay. Low quality evidence suggests that non-dietetic HCP interventions have no effect on mortality. CONCLUSIONS: A lack of good quality evidence on the effectiveness of non-dietetic HCP delivered interventions on the management of malnutrition in adults makes it difficult to draw conclusions. However, this review has highlighted the types of interventions and potential roles of non-dietetic HCPs, providing a groundwork for further high-quality research such as feasibility studies in this area, for the effective management of malnutrition within clinical and community practice.

The effectiveness of trained volunteer delivered interventions in adults at risk of malnutrition: A systematic review and meta-analysis.

Malnutrition burden is high. Trained volunteers present a growing workforce in the NHS and are increasingly engaged in schemes that may be useful in tackling malnutrition in different settings. A recent systematic review of trained volunteers in a hospital setting reported improved patient satisfaction and some improvement in dietary intake of patients. This review explored the effectiveness of trained volunteers in delivering nutritional interventions in adults at risk of malnutrition in different care settings on patient-centred outcomes and aimed to identify and build an evidence base for a more defined role for trained volunteers in malnutrition prevention in the UK. Six electronic databases were searched to 30th October 2018. Abstracts and full texts of relevant studies of all study designs were screened by two authors independently. Studies were examined for risk of bias and overall quality of evidence of main outcomes was assessed using the GRADE approach. Narrative synthesis and meta-analyses (nutritional intake) were used to combine outcome data. Seventeen eligible studies were included. Three were conducted in the home setting and fourteen were hospital based. Low quality evidence from one small RCT showed significant improvements in physical performance and fear of falling resulting from a volunteer intervention in the home setting. Very low quality evidence from meta-analysis findings indicated that trained volunteer mealtime assistance significantly improved lunchtime energy intake but did not significantly improve daily total energy intake in hospitals. Very low quality evidence also suggested that volunteers improve patient experience and satisfaction and are safe. This paper identified some evidence to suggest trained volunteer interventions may be effective in improving some outcomes in nutritionally at-risk older adults in home and hospital settings. Considering the high prevalence and costs of malnutrition, adequately-powered research is needed in this area to identify the most effective use of resources.

Quality of the Evidence Supporting the Role of Oral Nutritional Supplements in the Management of Malnutrition: An Overview of Systematic Reviews and Meta-Analyses.

There is considerable heterogeneity across the findings of systematic reviews of oral nutritional supplement (ONS) interventions, presenting difficulties for healthcare decision-makers and patients alike. It is not known whether heterogeneity arises from differences in patient populations or relates to methodological rigor. This overview aimed to collate and compare findings from systematic reviews of ONSs compared with routine care in adult patients who were malnourished or at risk of malnutrition with any clinical condition and to examine their methodological quality. Three electronic databases were searched to July 2019, supplemented with hand-searching. Data on all outcomes were extracted and review methodological quality assessed using A MeaSurement Tool for Assessment of systematic Reviews (AMSTAR). Twenty-two reviews were included, 11 in groups from mixed clinical backgrounds and 11 in specific clinical conditions. Ninety-one meta-analyses were identified for 12 different outcomes but there was discordance between results. Significant benefits of ONSs were reported in 4 of 4 analyses of energy intake, 7 of 11 analyses of body weight, 7 of 22 analyses of mortality, 10 of 17 analyses of complications (total and infectious), 1 of 3 analyses of muscle strength, 4 of 9 analyses of body composition/nutritional status, 2 of 14 analyses of length of stay, and 2 of 5 analyses of hospital readmissions. Ten reviews were high quality (AMSTAR scores 8-11), 9 moderate (AMSTAR scores 3-8), and 3 poor (AMSTAR scores 0-3). Methodological deficiencies were limitations to searches, poor reporting of heterogeneity, and failure to incorporate quality of evidence into any recommendations. Discordance between reviews was not markedly reduced when only high-quality reviews were considered. Evidence for the effects of ONS in malnourished patients or those who are at risk of malnutrition is uncertain, and discordance in results can arise from differences in clinical background of patients or the etiological basis of malnutrition.

Interventions to Support Older People's Involvement in Activities Related to Meals. A Systematic Review.

The objective of this systematic review is to assess whether old people should be actively involved in activities related to meals to support quality of life, nutritional status and functional abilities related to meals. Two electronic databases Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effectiveness were searched, supported by PubMed citation, snowball searches. Eleven primary studies were included. The quality was low. No studies assessed the effect on health-related quality of life. Three types of interventions to support activities related to meals were identified: Meal-related activities to facilitate improved autonomy seemed to overall improve nutritional intake, physical and social function related to meals, plus mealtime coping. Interventions of encouragement and reinforcement by staff to facilitate independence in eating seemed to have beneficial effect on nutritional intake and physical function related to meals. Interventions using food preparation and cooking to support participation seemed to have beneficial effects on social function related to meals and mealtime coping. There is an urgent need for good quality, adequately powered studies in this area and among old people in all health care settings.

Effect of two different nutritional supplements on postprandial glucose response and energy- and protein intake in hospitalised patients with COPD: A randomised cross-over study.

INTRODUCTION: Oral nutrition support is frequently used in treatment of malnutrition in patients with chronic obstructive pulmonary disease (COPD). Considering the use of corticoidsteroids in patients with COPD, little is known about the effect on postprandial glucose response and if they might interfere with glucose control. Our aims were to compare the effect of a liquid oral nutritional supplement (ONS) and semi solid inbetween meal snack (snack) on postprandial glucose and energy- and protein intake, and to compare the effect of timing of each intervention on postprandial glucose and energy- and protein intake. METHODS: Patients with COPD (n = 17) admitted to the Department of Pulmonary Medicine, Iceland and defined as at low or medium nutritional risk (score 0-3) were recruited. In a randomised cross-over design, subjects consumed ONS or snack either in a fasting state (study 1) or following breakfast (study 2) and postprandial glucose responses were assessed at regular intervals for two hours (t = 15, t = 30, t = 45, t = 60, t = 90, t = 120 min). Energy- and protein intake was estimated using a validated plate diagram sheet. Wilcoxon Signed-Rank test was used to compare the two interventions. RESULTS: In study 2, following breakfast, postprandial glucose was significantly higher after consuming ONS than the snack after 60 min (9.7 ± 2.4 mmol/L vs. 8.2 ± 3.2 mmol/L, p = 0.013 and 120 min 9.2 ± 3.2 mmol/L vs. 7.9 ± 2.4 mmol/L, p = 0.021, respectively). No difference was found in postprandial glucose concentrations between ONS and the snack when consumed after overnight fasting (study 1). No difference in energy or protein intake from hospital food was seen between supplement types neither in study 1 or 2. CONCLUSION: Lower postprandial glucose concentrations were associated with the snack compared to ONS when taken after a meal compared to either type directly after overnight fasting. The clinical relevance of higher postprandial blood glucose after consuming a liquid ONS after breakfast compared with a semi solid snack needs to be studied further.

Types of Interventions Targeting Dietary, Physical Activity, and Weight-Related Outcomes among University Students: A Systematic Review of Systematic Reviews.

A plethora of studies aiming to improve dietary, physical activity (PA), and weight-related (WR) outcomes among university students have been implemented and summarized in a series of systematic reviews, with unclear conclusions regarding their effectiveness. This overview aims to identify systematic reviews and meta-analyses of studies aiming to improve health outcomes in university students, to assess their methodological quality, to identify the different types of interventions used and outcomes assessed, and to estimate their overall effect. Four electronic databases were searched until 19 March, 2018 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The identified reviews were described and their methodological quality was rated. The studies of reviews were investigated to identify the different types of interventions used and outcomes assessed. Effectiveness was assessed by measuring the overall number of improved outcomes out of the total number of outcomes reported. As a result, 8 reviews were identified targeting food sales (n = 2), dietary (n = 3), PA (n = 1), WR (n = 1), or all outcomes (n = 1). The methodological quality of the reviews was moderate (n = 5) to low (n = 3). In all, the reviews included 122 studies, of which 36 used an environmental, 51 a face-to-face, 30 an e-intervention, and 5 a combined approach. Environmental interventions improved a moderate number of food sales (32 of 61) and dietary intake (22 of 47) outcomes. Face-to-face interventions improved a high number of dietary cognitive outcomes (15 of 18), a moderate number of dietary intake (28 of 65) and WR (11 of 18) outcomes, and a low number of PA behavioral (22 of 69) and cognitive (2 of 14) outcomes. E-interventions improved a high number of dietary cognitive variables (11 of 16) but had a low effect (≤33%) on the other types of outcomes. In conclusion, face-to-face and e-interventions improved cognitive variables toward diet or PA but were less effective in changing actual behaviors. Environmental interventions favorably changed food sales. Face-to-face and e-interventions moderately affected WR outcomes. Future research should focus on long-term studies.

Oral nutrition supplements and between-meal snacks for nutrition therapy in patients with COPD identified as at nutritional risk: a randomised feasibility trial.

Introduction: Intervention studies have mainly used oral nutritional supplements (ONS) for the management of patients with chronic obstructive pulmonary disease (COPD) identified as at nutritional risk. In this 12-month randomised feasibility trial, we assessed the (1) feasibility of the recruitment, retention and provision of two interventions: ONS and between-meal snacks (snacks) and (2) the potential impact of the provision of snacks and ONS on body weight and quality of life in patients with COPD. Methods: Hospitalised patients with COPD, at nutritional risk, were randomised to ONS (n=19) or snacks (n=15) providing 600 kcal and 22 g protein a day in addition to regular daily diet. The intervention started in hospital and was continued for 12 months after discharge from the hospital. Results: Study recruitment rate was n=34 (45%) and retention rate at 12 months was similar for both groups: n=13 (68%) in the ONS group and n=10 (67%) in the Snacks group. Both groups gained weight from baseline to 12 months (2.3±4.6 kg (p=0.060) in the ONS group and 4.4±6.4 kg (p=0.030) in the Snacks group). The St George's Respiratory Questionnaire total score improved from baseline to 12 months in both groups (score 3.9±11.0 (p=0.176) in the ONS group and score 8.9±14.1 (p=0.041) in the Snacks group). Discussion: In patients with COPD who are at nutritional risk snacks are at least as feasible and effective as ONS, however, adequately powered trials that take account of the difficulties in recruiting this patient group are required to confirm this effect.

Treatment of altered body composition in HIV-associated lipodystrophy: comparison of rosiglitazone, pravastatin, and recombinant human growth hormone.

PURPOSE: Treatment options for HIV-associated lipodystrophy syndrome (HALS) remain limited. The objective of this randomized open-label study was to compare three emerging therapies, rosiglitazone, pravastatin, and growth hormone alone and together, in men and women with HALS. METHOD: Sixty-four subjects received daily rosiglitazone (4 mg, n = 14), pravastatin (40 mg, n = 11), or rosiglitazone plus pravastatin (n = 13) for 48 weeks or recombinant human growth hormone (rhGH; Serostim 2 mg, 12 weeks, n = 13) alone or combined with rosiglitazone (n = 13). Primary endpoint was body composition change by dual X-ray absorptiometry (DXA) and computed tomography (CT). RESULTS: Rosiglitazone resulted in slow accrual of limb fat detected by DXA (+444 +/- 186 g; p < .05) but not CT. Pravastatin had no consistent significant effects on body composition, although it reduced total and LDL cholesterol. Negative interactions were observed between pravastatin and rosiglitazone. rhGH reduced abdominal fat by CT (-31 +/- 15 cm2, 26%; p < .05) and DXA (-1597 +/- 383 g, 27%; p < .05) and increased trunk and limb lean mass (+10% and +12%, respectively). However, effects largely disappeared within 12 weeks post treatment. rhGH alone impaired insulin sensitivity but not when combined with rosiglitazone. CONCLUSION: Prolonged rosiglitazone treatment slowly improves lipoatrophy. rhGH rapidly and selectively reduces visceral fat, although effects are short-lived; co-administered rosiglitazone abrogates rhGH-related insulin resistance.

Oral nutritional support with or without exercise in the management of malnutrition in nutritionally vulnerable older people: A systematic review and meta-analysis.

BACKGROUND: Physical functioning declines with advancing age and compounds malnutrition, common in elderly populations. A dual-intervention combining oral nutritional support and exercise may delay these changes. Our aims were to assess whether exercise combined with oral nutritional support (ONS) has greater improvements on physical functioning, quality of life and nutritional status than nutrition intervention alone in nutritionally vulnerable older adults. METHODS: Three electronic databases were searched for randomised controlled trials of older adults judged to be: sarcopenic, cachexic, frail, malnourished, and/or at risk of malnutrition, receiving ONS and exercise compared to nutrition intervention alone. Meta-analyses were performed using a fixed-effect model to calculate standardised mean difference (SMD) (hand-grip strength, limb strength, gait speed, timed up-and-go test (TUG), physical activity level and fat-free mass) or relative risk (hospitalisation) with 95% confidence intervals (CIs). RESULTS: Eleven studies (n = 1459 participants) were included. ONS and exercise interventions varied considerably between studies. There was very low quality evidence that exercise combined with ONS compared to nutrition intervention alone resulted in significant improvements in limb strength (SMD = 0.33; 95% CI 0.13-0.53; P = 0.001) but low quality evidence of no effect on fat-free mass (SMD = -0.05; 95% CI -0.27 to 0.18; P = 0.70), physical activity level (SMD = 0.04; 95% CI -0.26 to 0.33; P = 0.81) and TUG (mean difference = -0.80; 95% CI -2.06 to 0.47; P = 0.22). Moderate quality evidence from a small number of studies found no effect on handgrip strength and QOL. Low quality evidence of faster gait speeds were found in participants receiving ONS alone compared to combined intervention (SMD = 0.38; 95% CI 0.19 to 0.56; P < 0.0001). CONCLUSION: Combining exercise with ONS may provide additional improvements to muscle strength but had no effect on other measures of physical functioning, nutritional status or morbidity in nutritionally vulnerable older adults. CLINICAL TRIAL REGISTRY NUMBER AND WEBSITE: This trial was registered at http://www.crd.york.ac.uk/PROSPERO/ as CRD42015027323.

Two components of the new ESPEN diagnostic criteria for malnutrition are independent predictors of lung function in hospitalized patients with chronic obstructive pulmonary disease (COPD).

INTRODUCTION: Low fat free mass index (FFMI) is a component of the ESPEN diagnosis criteria of malnutrition, that only when accompanied with weight loss is considered to be a determinant of malnutrition. Our aims were to assess the prevalence of malnutrition in patients with chronic obstructive pulmonary disease (COPD) applying the ESPEN criteria, and to examine the ability of different components of the criteria to predict COPD severity, length of stay (LOS), hospital readmissions within 30 days and mortality. METHODS: Subjects were COPD patients (n = 121) admitted to Landspitali University Hospital from March 2015 to March 2016. Patients were screened for nutritional risk using Icelandic screening tool (ISS) and NRS-2002. Body composition was measured by bioelectrical impedance analysis (BIA). Lung function was measured by spirometry. RESULTS: The prevalence of malnutrition according to the ESPEN criteria was 21%. The association between nutritional assessment, applying different components of the ESPEN criteria, and COPD severity was highly significant, with the highest risk being associated with low FFMI OR (95% CI) 4.77 (2.03, 11.20; p < 0.001). There was a trend towards higher risk of hospitalization for >7 days in subjects with low FFMI (OR 2.46 95% CI 0.92, 6.59; p = 0.074) and increased risk of 6 and 9 months' mortality (OR 2.72 95% CI 0.88, 8.39, P = 0.082 and OR 2.72 95% CI 0.94, 7.87, P = 0.065, respectively) in subjects diagnosed as malnourished by the ESPEN criteria. CONCLUSION: This study describes the prevalence of malnutrition in hospitalized COPD patients using the ESPEN criteria from 2015. Our findings suggest that FFMI could be used independently of weight loss for the diagnosis of malnutrition in COPD patients, although there remain some problems associated with its measurement in the clinical setting.

The effect of nutrition training for health care staff on learner and patient outcomes in adults: a systematic review and meta-analysis.

Background: Nutrition training for health care staff has been prioritized internationally as a key means of tackling malnutrition; however, there is a lack of clear evidence to support its implementation. Systematic reviews in other fields of training for health care staff indicate that training strategies may have a beneficial impact on learner and patient outcomes.Objectives: We assessed whether nutrition training for health care staff caring for nutritionally vulnerable adults resulted in improved learner and patient outcomes and evaluated the effectiveness of different training strategies.Design: A systematic review of trials of nutrition training for health care staff was conducted. Six databases were searched with key terms relating to malnutrition and nutrition training. Studies were categorized according to cognitive (didactic teaching), behavioral (practical implementation of skills), and psychological (individualized or group feedback and reflection) training strategies. Where sufficient data were available, meta-analysis was performed according to study design and training strategy. All study designs were eligible. The risk of bias was evaluated in accordance with Cochrane guidance.Results: Twenty-four studies met the eligibility criteria: 1 randomized controlled trial, 4 nonrandomized controlled trials, 3 quasi-experimental trials, 13 longitudinal pre-post trials, 2 qualitative studies, and 1 cross-sectional survey. Results from a number of low-quality studies suggest that nutrition training for health care staff may have a beneficial effect on staff nutrition knowledge, practice, and attitude as well as patient nutritional intake. There were insufficient data to determine whether any particular training strategy was more effective than the others.Conclusions: In the absence of high-quality evidence, low-quality studies suggest that nutrition training for health care staff has some positive effects. However, further randomized controlled trials are required to confirm overall efficacy and to explore the impact of training strategies on learner and patient outcomes.

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.

The palatability of milk-based and non-milk-based nutritional supplements in gastrointestinal cancer and the effect of chemotherapy.

INTRODUCTION: Oral nutritional supplements may have a role in the management of weight loss in patients with cancer. Information on preference for different types of nutritional supplements and the influence of taste changes and chemotherapy is limited. AIMS AND METHODS: This study aimed, in patients with gastrointestinal (GI) cancer, to determine the short-term preference for commonly used nutritional supplements compared with controls, to examine whether preference is altered by chemotherapy and to assess the reproducibility of taste assessments conducted using a Visual Analogue Scale (VAS). Patients with GI cancer and controls were asked to rate the acceptability of three oral nutritional supplements on a VAS before starting chemotherapy and after 6 weeks of chemotherapy. Supplements were presented in a random order in sealed containers and subjects were blinded to the type of product. One supplement was repeated at random within each set (four cups) to assess the reproducibility of responses. RESULTS: Sixty patients and 63 controls were included in the study, 47 patients and 47 controls were available for follow-up. Before the start of chemotherapy, patients had a higher mean preference for Calshake (5.9 cm) than Ensure plus (5.1 cm) and Fortijuce (3.2 cm) (P=0.025 and P<0.001). Calshake was the most preferred supplement in the control group (mean 6.6 cm), with no significant differences in preferences between patients and controls. There were no changes in preference for patients after 6 weeks of chemotherapy. The results for the control group similarly showed no change after 6 weeks. No significant differences were found between scores assigned to the supplement repeated in the random order for any product at either timepoint. DISCUSSION: Patients with GI cancers prefer the taste of fresh milk-based supplements and short-term preferences are not changed by chemotherapy. Preferences are similar between patients with GI cancers and people without cancer. A VAS is a reliable tool to assess taste preference. Further studies are needed to assess the patient compliance over longer periods and the reasons for non-compliance with prescriptions for nutritional supplements.