Oral nutritional interventions in frail older people who are malnourished or at risk of malnutrition: a systematic review

Katie Thomson, Stephen Rice, Oluwatomi Arisa, Eugenie Johnson, Louise Tanner, Christopher Marshall, Tumi Sotire, Catherine Richmond, Hannah O'Keefe, Wael Mohammed, Margot Gosney, Anne Raffle, Barbara Hanratty, Claire T McEvoy, Dawn Craig, Sheena E Ramsay

Research output: Contribution to journalArticlepeer-review

9 Citations (Scopus)
56 Downloads (Pure)

Abstract

Background
Malnutrition worsens the health of frail older adults. Current treatments for malnutrition may include prescribed oral nutritional supplements, which are multinutrient products containing macronutrients and micronutrients.

Objective
To assess the effectiveness and cost-effectiveness of oral nutritional supplements (with or without other dietary interventions) in frail older people who are malnourished or at risk of malnutrition.

Data sources
MEDLINE, EMBASE, Cochrane Library, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and grey literature were searched from inception to 13 September 2021.

Review methods
A systematic review and meta-analysis was conducted to evaluate the effectiveness and cost-effectiveness of oral nutritional supplements in frail older people (aged ≥ 65 years) who are malnourished or at risk of malnutrition (defined as undernutrition as per National Institute for Health and Care Excellence guidelines). Meta-analysis and network meta-analysis were undertaken, where feasible, along with a narrative synthesis. A cost-effectiveness review was reported narratively. A de novo model was developed using effectiveness evidence identified in the systematic review to estimate the cost-effectiveness of oral nutritional supplements. 

Results
Eleven studies (n = 822 participants) were included in the effectiveness review, six of which were fully or partly funded by industry. Meta-analyses suggested positive effects of oral nutritional supplements compared with standard care for energy intake (kcal) (standardised mean difference 1.02, 95% confidence interval 0.15 to 1.88; very low quality evidence) and poor mobility (mean difference 0.03, p < 0.00001, 95% confidence interval 0.02 to 0.04; very low quality evidence) but no evidence of an effect for body weight (mean difference 1.31, 95% confidence interval –0.05 to 2.66; very low quality evidence) and body mass index (mean difference 0.54, 95% confidence interval –0.03 to 1.11; very low quality evidence). Pooled results for other outcomes were statistically non-significant. There was mixed narrative evidence regarding the effect of oral nutritional supplements on quality of life. Network meta-analysis could be conducted only for body weight and grip strength; there was evidence of an effect for oral nutritional supplements compared with standard care for body weight only. Study quality was mixed; the randomisation method was typically poorly reported. One economic evaluation, in a care home setting, was included. This was a well-conducted study showing that oral nutritional supplements could be cost-effective. Cost-effectiveness analysis suggested that oral nutritional supplements may only be cost-effective for people with lower body mass index (< 21 kg/m2) using cheaper oral nutritional supplements products that require minimal staff time to administer.

Limitations
The review scope was narrow in focus as few primary studies used frailty measures (or our proxy criteria). This resulted in only 11 included studies. The small evidence base and varied quality of evidence meant that it was not possible to determine accurate estimates of the effectiveness or cost-effectiveness of oral nutritional supplements. Furthermore, only English-language publications were considered.

Conclusions
Overall, the review found little evidence of oral nutritional supplements having significant effects on reducing malnutrition or its adverse outcomes in frail older adults.
Original languageEnglish
Number of pages112
JournalHealth technology assessment (Winchester, England)
Volume26
Issue number51
DOIs
Publication statusPublished - 01 Dec 2022

Keywords

  • Cost-Benefit Analysis
  • FRAILTY
  • DIETARY SUPPLEMENTS
  • AGED
  • Aged
  • Quality of Life
  • MALNUTRITION
  • Humans
  • Frail Elderly
  • Malnutrition - therapy
  • Body Weight

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