3.1.5 Other forms of oral nutritional intervention
- A variety of oral nutritional intervention strategies other than ONS are used in clinical practice for the management of malnutrition, including dietary advice, food snacks, and food fortification, although evidence of their effectiveness and cost-effectiveness is lacking.
Evidence for the benefits of dietary advice and food fortification in managing disease- related malnutrition is lacking or is of variable quality
- NICE (2006) was unable to demonstrate any evidence of the effect of dietary advice; studies were too small and heterogeneous to allow any conclusions to be drawn, and many failed to report outcomes of interest.30
- A review designed to assess the specific impact of the provision of adequate nutritional care (including the routine provision of food and drink) rather than proprietary nutritional support (e.g., ONS) concluded that there is a serious lack of evidence to support non-ONS interventions designed to improve nutritional care, meaning that firm conclusions for practice could not be made.140
- A systematic review of the effects of oral nutritional interventions in care homes (searches up to December 2009) did not identify any trials comparing dietary advice and routine care in this healthcare setting.7
- In a systematic review and meta-analysis of 94 RCTs in adults with DRM in a variety of healthcare settings (n = 10284), Baldwin and Weekes (2021) compared dietary advice (DA) with a) no DA, b) ONS, and c) DA + ONS. In addition, they compared DA + ONS if required with no DA or ONS, and DA plus ONS versus no advice or ONS. Table 3.5 summarises the main results and shows that DA alone may improve body weight and MAMC, but the studies are of variable quality. DA combined with ONS may lead to weight gain in the short term.84
- No significant differences were seen in any comparison between groups for mortality or morbidity. This is in contrast to previous systematic reviews (see Section 3.1.3.1 and 3.1.3.2). 84
- There was appreciable clinical (and statistical) heterogeneity between patient groups in these trials, and it is acknowledged that in most of the studies there was minimal information provided on the nature and intensity and duration of dietary advice provided. Within the groups using ONS, the amount, composition and duration of use varied considerably.84
Table 3.5
Summary of the main results for primary outcomes from a systematic review and meta-analysis of dietary advice (with or without ONS) for DRM in adults84
| Primary Outcomes | Measures | Comparison | Mean difference (95% CI) | Notes |
|---|---|---|---|---|
| Clinical | Mortality | No comparison showed a significant difference between groups | ||
| Morbidity* | ||||
| Nutritional status | Body weight | DA vs no DA | 0.97 kg (0.61–1.87) 1.61 kg (0.09 –3.13) 2.95 kg (0.75 – 5.16) |
Significantly greater weight gain in groups receiving dietary advice compared with groups receiving no advice across all time points. Heterogeneity was considerable at 3 months, four to six month and substantial at 12 months or over. |
| DA + ONS if required vs no DA and no ONS | 1.25 kg (0.73 – 1.76) | For interventions lasting up to 3 months. | ||
| DA + ONS vs no DA and no ONS | 1.88 kg (0.90 –2.87) 2.60 kg (1.42 – 3.78) |
Significantly greater weight gain in groups receiving dietary advice with ONS compared with the no advice and no ONS between 4 to 6 months and 7 to 12 months. Heterogeneity was substantial between 4 to 6 months. | ||
| DA vs DA + ONS | 1.15kg (0.42 – 1.87) | Significantly greater weight gain in group receiving dietary advice with ONS compared to dietary advice at 3 months (significant heterogeneity). | ||
| MAMC | DA vs no DA | 1.05 cm (0.71–1.39) 0.56 cm (0.07 – 1.04) |
Significant improvement in MAMC at 3 months and at 4 to 6 months. | |
*Measured as risk of hospital admission, readmission, length of hospital stay, and complications.
- A systematic review of the effects of oral nutritional intervention in care homes (searches up to December 2009) found that 1 fortification trial reported small non-significant changes in energy intake. No significant differences were reported in the few food fortification trials that reported functional outcomes, and no food fortification trials reported clinical outcomes.7 Trials of ONS in this review did not report functional outcomes; however, significant clinical outcomes such as reductions in infections and bed-days, improved pressure ulcer healing, and increases in energy intake and body weight were reported.7
- Food fortification is employed widely with the aim of increasing the energy and nutrient density of food; however, care should be taken with this approach since high levels of fortification have been shown to have detrimental effects on the aesthetic ratings of commonly fortified foods, such as soup and milk puddings, potentially making them unappealing and less likely to be consumed.141
- An RCT comparing the effectiveness of ONS with DA in care home residents (n = 104) at risk of malnutrition (using ‘MUST’ [medium and high risk]) showed that energy and protein intakes were significantly higher in residents randomised to receive ONS than in residents who received dietary advice. Appetite sensations were not significantly different between the 2 groups.142