dietary advice and nutritional supplements in the management of illness-related malnutrition:...

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Clinical Nutrition (2004) 23, 1267–1279

KEYWORDSystematicMeta-analyNutrition;Diet;DietarysupplemenWeight

0261-5614/$ - sdoi:10.1016/j.c

�CorrespondiE-mail addr

www.elsevier.com/locate/clnu

REVIEW

Dietary advice and nutritional supplements in themanagement of illness-related malnutrition:systematic review

Christine Baldwina,�, Tessa J. Parsonsb

aDepartment of Medicine & Therapeutics, Imperial College, University of London, Chelsea & WestminsterHospital, Fulham Road, London SW10 9NH, UKbCentre for Paediatric Epidemiology and Biostatistics, Institute of Child Health, 30 Guilford Street,London WC1N 1EH, UK

Received 27 May 2004; accepted 26 July 2004

Sreview;sis;

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ee front matter r 200lnu.2004.07.018

ng author. Tel: 44-208-ess: [email protected]

Summary Background and aims: This review investigated whether dietary adviceto improve nutritional intake in adults with illness-related malnutrition improvedmortality, morbidity, weight and energy intake, and whether oral nutritionalsupplements gave additional benefit, when given in combination with dietaryadvice.

Methods: Systematic review of randomised controlled trials comparing dietaryadvice with either (i) no advice, (ii) nutritional supplements or (iii) dietary adviceplus nutritional supplements, in people with illness-related malnutrition.

Results: Twenty-four trials (25 comparisons) met the inclusion criteria, including2135 randomised participants. Duration of follow-up ranged from 16 days to 24months. There was no significant difference in mortality or morbidity for eachcomparison. Groups receiving supplements gained significantly more weight (or lostsignificantly less weight) than those who received dietary advice, weighted meandifference 1.09 kg (0.29–1.90) (4 studies). There were no significant differences inweight and energy intake between groups for the other comparisons. Few data wereavailable for other outcomes.

Conclusions: Nutritional supplements may have a greater role than dietary advicein the short-term improvement of body weight in illness-related malnutrition. Thereis a lack of evidence to support dietary advice in the management of illness-relatedmalnutrition, but this is based on few, often poor quality, studies.r 2004 Elsevier Ltd. All rights reserved.

4 Elsevier Ltd. All rights reserved.

746-8144; fax: 44-208-746-8887.(C. Baldwin).

www.elsevier.com/locate/clnu

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C. Baldwin, T.J. Parsons1268

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1268

Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1268Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1268Data extraction and outcome measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1269Methodological quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1269Statistical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1269

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1269Methodological quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1274Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1274Morbidity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1274Weight change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1274Energy intake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1274

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1274

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1278

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1278

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1278

Introduction

Malnutrition is disturbingly common in developedcountries, with a reported prevalence of 9–55%among adults in hospital,1–4 and around 10% inpeople in the community with chronic illness.5–7

Malnutrition is a potentially serious complication ofillness associated with increased morbidity, mor-tality and increased length of stay in hospital2,8 andmay have adverse effects on the treatment andoutcome of illness.

The launch of UK Guidelines for the Detectionand Management of malnutrition9 highlights thelack of evidence for the management strategiesmost usually used: nutritional counselling to in-crease food intake, advice to modify food consti-tuents to increase the energy density and theprovision of oral nutritional supplements with orwithout dietary advice.

Oral nutritional supplements are available onprescription and easy to use. Two reviews havecautiously concluded that supplements may benefitmortality, weight change, and body function,10,11

but neither addressed the role of dietary advice. InEngland in 2002 expenditure on oral nutritionaccounted for £96million, and a number of studieshave highlighted problems with compliance.12–14

Increased food intake has potential advantages inthat it offers greater variety, can be tailored toindividual needs and may be associated with lowercosts to the health service. The provision of dietary

advice to increase food intake is a core dietetic skillbut whether it is effective in illness-relatedmalnutrition is unknown.

This systematic review examines the evidencefor the role of dietary advice in improvingmortality, morbidity, weight and energy intake inpeople with illness-related malnutrition and anyadditional effect of oral nutritional supplementswhen given in combination with dietary advice.

Methods

Our methodology is outlined below; further detailshave been given previously.15

Trials

Publications describing randomised controlledtrials (RCTs) of dietary advice were sought bysearching the following databases; Cochrane Con-trolled Trials Register, Medline (1966–November2002), Embase (1980–November 2002), Cinahl(1982–November 2002), CancerLit (January1999–November 2002), AMED (January 1999–No-vember 2002), ERIC (1992–1998), DissertationAbstracts (1861–July 2000) and the Cochrane CysticFibrosis and Genetic Disorders Group’s SpecialisedRegister of Controlled Trials (most recent searchNovember 2001). All languages were included.

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Dietary advice for illness-related malnutrition 1269

Reference lists of included studies were examinedfor additional reports of trials. Unpublished workwas sought by contacting experts in clinical nutri-tion, the membership of The British DieteticAssociationy and manufacturers of oral nutritionalsupplements.

Trials were included if they were in adults withillness-related malnutrition and included one of thefollowing comparisons; dietary advice comparedwith (i) no advice, (ii) oral nutritional supplements,or (iii) dietary advice plus oral nutritional supple-ments. Dietary advice was defined as instruction tomodify food intake, with the aim of improvingnutritional intake. Trials in which dietary advicewas given by a dietician or other health profes-sional were included. Oral nutritional supplementswere defined as whole protein enteral foodproducts, marketed for the management of dis-ease-related malnutrition. During searching anunanticipated additional group of trials was identi-fied, comparing dietary advice plus supplements ifrequired with no advice, and was included in thereview.

total references yielded n =33 435

not meeting inclusion criteria n =33 325

possible inclusion (scrutinised in detail)

Data extraction and outcome measures

Titles and abstracts were reviewed on screen byone reviewer (CB). Potentially relevant studieswere obtained and assessed for inclusion indepen-dently by two reviewers (CB and TP), who alsoextracted data from all included studies indepen-dently. Disagreements were resolved by discussionor referral to a third reviewer. Where informationon study design, quality and data were unclear,authors were contacted for additional information.

The primary outcome measures were mortality,morbidity (risk of hospital admission, length ofhospital stay) and change in body weight. Data onsecondary outcomes, changes in nutritional intake,nutritional status and clinical function, and costwere obtained where available.15 We report hereon the primary outcomes, and change in energyintake (secondary outcome).

n =110

included studiesn =24

not meeting inclusion criteria n =86
Methodological quality
Each trial was assessed for adequacy of allocationconcealment and blind assessment of outcomesother than mortality. Percentage follow-up wasrecorded.

yCompeting interests: CB was partially funded by the BritishDietetic Association.

Statistical analysis

For binary outcomes, data were combined using theMantel-Haenszel method with results presented asa relative risk (95% confidence intervals), and forcontinuous outcomes results are presented asweighted mean difference (95% confidence inter-vals). Fixed effects models were used unlesssignificant heterogeneity was present (w2-test forheterogeneity Po0:1), when a random effectsmodel was used. We used Review Manager softwareRevMan version 4.2 (Cochrane Collaboration, Ox-ford, UK).

Results

Searching yielded 33,435 papers, of which 110 wereobtained for detailed appraisal (Fig. 1). Twenty-four studies (25 comparisons), including 2135randomised participants, fulfilled the inclusioncriteria for this review. Five studies compareddietary advice with no advice,16–21 with data fromone study reported in 2 papers.17,18 Four studiescompared advice with supplements22–25 and ninestudies compared advice with advice plus supple-ments.16,26–33 An additional seven studies wereidentified which compared advice plus supplementsif required with no advice,34–42 with data fromtwo studies each reported in two papers.34,35,37,38

One study16 contributed to two comparisons.Studies included participants from a variety of

Figure 1 Selection process of eligible randomised con-trolled trials.

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Table 1 Characteristics of included studies.

Trial Totaln

Co-morbidity Nutritionalstatus at entry

Comparison details Outcomes ofinterestreported

Length offollow-up

Proportion offollow-upy (%)

Allocationconcealmentz

Dietary advice versus no adviceDixon16 36y Cancer (mainly

colorectal andlymphoma)

45% Weightloss in a 2month period orpersistentdifficulties witheating

Nutritional counselling providedby nurses versus home visitsonly versus no advice

Mortality,weight

4 Months 53 B

Hickson et al.21 592 Elderly acuteadmissions tomedical wards

None specified Feeding support, providedby health care assistants whowere trained to encourage andenable all aspects of feedingand to offer snacks and drinksversus usual ward care

Mortality,1

weight,1 energyintake

6 Months(mortality) 16days (otheroutcomes)

46–100 A

Imes et al.17,18 137 Crohn’s disease None specified Monthly dietary counselling toachieve the CanadianRecommended DietaryAllowances versus no advice

Mortality,1

hospitaladmissions,1

energy intake

6 Months 91–100 A

Macia et al.19 92 Cancer (headand neck,breast,abdomino-pelvic)

None specified Dietary instruction givenverbally and in writing versus noadvice

Weight Not clear inpaper

Not stated B

Ollenschlageret al.20

31 Acuteleukaemia

Unintentionalweight loss45%or actualweight 90% ofideal bodyweight

Daily dietary instruction andmodification of diet versus noadvice

Mortality,1

weight, energyintake

25.5 Weeks 94 B

Dietary advice versus supplementsGray-Donaldet al.22

50 Frail elderly Weight loss45% in lastmonth, 47.5%in last 3months, 410%in last 6 months

Weekly visits from a dietitianwith dietary counselling versus2� 235ml/day of a nutritionalsupplement

Mortality,1

weight,1 energyintake1

12 Weeks 92–100 A

C.Bald

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Kalnins et al.23 5 Cystic fibrosis o90% of weightfor height or45% reductionin weight forheight over 3months

Dietary counselling to increasefood intake by 20% ofrequirements versus anutritional supplement toincrease intake by 20% ofrequirements

Mortality,1


6 Months(mortality,weight) 3months (energyintake)

100 C

Schwenket al.24

50 HIV infection 45% of usualweight oractively losingweight in lastmonth

Dietary counselling to increasefood intake by 600 kcals versusnutritional supplements toincrease intake buy 600 kcals

Mortality,1

hospitaladmissions,1


8 Weeks 88–100% A

Turic et al.25 68 Elderly inresidentialhome

10% Weight lossin previous 6months, 45%weight loss inprevious monthor o90% idealbody weight

Usual diet plus 3 additionalsnacks or usual diet plus 8 oz ofnutritional supplement 3 timesdaily

Mortality,1


6 Weeks 63–100 A

Dietary advice versus dietary advice and supplementsArnold andRichter26

50 Cancer (headand neck)

None specified,mean pre-treatmentactual weightwas below usualweight for bothgroups ofpatients

Intensive dietary counsellingversus same plus nutritionalsupplements to provide anadditional 960–1080 kcal/day

Mortality,1


3 Months(mortality) 6months(weight)

94–100 B

Beattie et al.27 109 Post-operativesurgicalpatients

BMI o20 kg/m2,TSF or MAMCo15thpercentile or45% weightloss

Routine nutritionalmanagement versus same plus400ml of a 1.5 kcal/mlnutritional supplement

Mortality,1

weight,110 Weeks 93–100 A

Dixon16 18y Cancer (mainlycolorectal andlymphoma)

45% Weightloss in a 2month period orpersistentdifficulties witheating

Nutritional counselling versussame plus range of nutritionalsupplements

Weight 4 Months 50 B

Fuenzalidaet al.28

9 Chronicobstructivepulmonarydisease

45% Weightloss

Individualised diet plan toprovide 100% of RecommendedDaily intake versus same plus1080 kcal of a nutritionalsupplement

Mortality,1


6 Weeks 100 B

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Kendell et al.29 22z Orthognathicsurgery

None specified Dietary instruction givenverbally and in writing versussame plus nutritionalsupplement (1.5 kcal/ml) toprovide 50% minimum ofcalculated energy requirements

Weight, energyintake

6 Weeks 100 B

McCarthy30 40 Cancer (nothead or neck)

None specified Dietary advice versus same plus1.8 oz serving of supplementbetween meals and at bedtime.

Mortality,1

energy intake4 Weeks 80 B

Murphy et al.31 22 HIV infection 45%involuntaryweight loss

Dietary counselling givenverbally and in writing toconsume a calculated amount ofenergy and protein per dayversus same plus 2� 235mlnutritional supplement

Mortality,1

weight, energyintake1

16 Weeks 73 C

Olejko andFonseca32

21** Orthognathicsurgery

None specified Dietary instruction givenverbally and in writing versussame plus nutritionalsupplement (1.5 kcal/ml) toprovide 50% minimum ofcalculated energy requirements

Mortality,1

weight, energyintake

6 Weeks 100 B

Rabeneck etal.33

118 HIV infection o90% of idealbody weight or410% weightloss in previous6 months

Nutritional counselling toachieve specific energy targetversus same plus nutritionalsupplement

Weight1 2–6 Weeks 86 B

Dietary advice and supplements if required versus no adviceEvans et al.34

andFoltz et al.35

180zz Cancer(colorectal andnon-small celllung)

Patientsstratifiedaccording toamount ofweight loss, 83/180 patientswith 45%weight loss

Nutritional counselling toachieve a target caloric intake,using supplements if requiredversus ad libitum food intake

Mortality,weight, energyintake

12 Weeks 71–97 A

Ganzoni et al.36 30 Chronicobstructive

None specified,but imply that

Nutritional counselling to use ahigh calorie diet using a variety

Mortality,1

weight11 Year 67 A

Table 1 (continued)

Trial Totaln

Co-morbidity Nutritionalstatus at entry

Comparison details Outcomes ofinterestreported

Length offollow-up

Proportion offollow-upy (%)

Allocationconcealmentz

C.Bald

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pulmonarydisease

patients atleast o90% oftheir ideal bodyweight

of methods including nutritionalsupplements if required versusno advice

Jensen andHessov37 andJensen38

87 Post-surgicalpatients(rangeof conditions)

None specified Dietary counselling to improvenutritional intake, aiming for aprotein intake of 1.5 g/kg, usingoral nutritional supplements ifrequired versus no advice

Weight, energyintake

110 Days 78–87 A

Lovik et al.39 61 Cancer (headand neck)

None specified Intensive dietary instructionincluding advice to usenutritional supplements ifrequired versus a standardinformation sheet providinginformation on all aspects oftreatment including advice toeat a nutritious diet

Mortality,1


6 Weeks 80–100 A

Ovesen et al.40 137 Cancer (non-small-cell lung,breast andovarian)

Patientsstratified foramount of priorweight loss45% or o5% inprevious 3months

Dietary instruction to exceedthe Nordic recommendedallowances using supplements ifrequired versus no advice


5 months 77 A

Persson et al.41 142 Colorectal orgastric cancer

o5% weightloss

Dietary advice by phone and inwriting to meet the Nordicrecommended allowances usingsupplements if required versusno advice


2 Years 47 A

Rogers et al.42 28 Chronicobstructivepulmonarydisease

Weight o90% ofideal bodyweight

Nutritional counselling toachieve a balanced meal planplus supplements if requiredversus no advice

Weight 4 Months 96 B

Outcomes with usable data.yProportion of follow-up—percentage depends on outcome.zadequacy of allocation concealment, A=adequate, B=unclear, C=inadequate.

yDixon–Paper reports 88 participants randomised to 5 groups. We have assumed 18 randomised to each group (therefore 36–2 groups). Advice group appears in 2 comparisons.

zKendell–Children excluded.

**Olejko–Trial includes 3 arms, 2 arms combined in review, but 3 children excluded.

zzEvans/Foltz–Trial includes 3 arms, 2 arms combined in review.

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clinical backgrounds, and follow-up varied from 16days to 24 months (Table 1). Additional informationwas requested from 24 authors and receivedfrom 18.

Methodological quality

Allocation concealment was adequate in12 studies,17,18,21,22,24,25,27,34–41 inadequatein two studies,23,31 and unclear in ten stu-dies.16,19,20,26,28–30,32,33,42 In one study36 outcomeassessment was blind (information obtained fromthe authors). Percentage follow-up varied from 46%to 100%. Most of the trials were small (half had 50or less participants), and of short duration (almosthalf were for 3 months or less).

Mortality

There was no significant difference in mortality forany of the comparisons we investigated (Fig. 2).The relative risks (95% CI) were, for dietary advicecompared with (i) no advice, 0.95 (0.75–1.21), (ii)oral supplements, 0.33 (0.04–2.99), (iii) dietaryadvice plus supplements, 0.12 (0.01–2.25), and fordietary advice with supplements if required com-pared with no advice, 2.53 (0.63–10.15). Theseresults were based on 220,21, 122, 126, and 236,39

studies, respectively, with a further 1 (informationfrom author),17,18 3,23–25 5,27,28,30–32, and 0 studies,respectively, reporting no deaths in either group.

Morbidity

Two trials reported hospital admissions.17,18,24

The relative risk was not significantly differentfor dietary advice compared with (i) no advice,0.91 (0.48–1.72)17,18 or (ii) supplements, 0.36(0.04–3.24).24

Weight change

There were no significant differences betweendietary advice compared with (i) no advice, (ii)dietary advice plus supplements and (iii) dietaryadvice given with supplements if required andcompared with no advice, in terms of weightchange. The group difference for dietary advicecompared with no advice was �0.03 kg(�0.69–0.63), but this was from one study only,at 16 days and data were only available for 49% ofrandomised participants (Fig. 3). The pooled effectfrom four studies26–28,33 of dietary advice comparedwith dietary advice plus supplements gave aweighted mean difference (WMD) of �1.34 kg

(�3.75, 1.07). There was significant heterogeneitybetween studies (w2 ¼ 20:2; P ¼ 0:0002) and so arandom effects model was used. The group differ-ence (from 1 study)31 for dietary advice plussupplements if required compared with no advicewas 1.10 kg (�0.96–3.16) (Fig. 3). The pooledeffect from four studies22–25 indicated that thosereceiving supplements had significantly greaterweight gain (or lower weight loss) than thosereceiving dietary advice, WMD 1.09 kg (0.29–1.90)with no evidence of heterogeneity (w2 ¼ 0:99;P ¼ 0:80) (Fig. 3).

Energy intake

Energy intake data were available for two compar-isons: advice versus supplements (four stu-dies),22–25 and advice versus advice plussupplements (one study)31 (Fig. 4). The pooledeffect indicated that energy intake was signifi-cantly greater in those receiving supplementscompared with those receiving dietary advice,WMD 91 kcals (23–159), with no significant hetero-geneity between studies (w2 ¼ 0:89; P ¼ 0:83). Theone trial comparing dietary advice with dietaryadvice plus supplements31 suggested no differencein energy intake between groups; WMD �61 kcals(�698–575).

Discussion

This systematic review has yielded three principalfindings. Firstly, there is no evidence to support theuse of dietary counselling in the management ofillness-related malnutrition. Secondly, oral nutri-tional supplements may be associated with sig-nificant advantages in the management of weightloss compared with dietary counselling. Thirdly,these results indicate the need for well-conductedrandomised trials to assess the impact of dietarycounselling and nutritional supplements used in-dividually or in combination on clinical endpoints.

The Manual of Dietetic Practice43 states that thefirst step in the management of undernutrition is toconsider whether nutrient needs can be met byordinary food. This is supported by a report fromthe Council of Europe who surveyed practices ofnutritional care in 12 countries,44 and has become awidely accepted way of managing weight lossacross a range of clinical conditions9,11,43 with oralnutritional supplements being considered as analternative when steps to increase food intake havefailed. There are no UK national data available onthe amount of time spent by dietitians providing

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Review: Dietary advice for illness-related malnutrition in adultsComparison: 01 Dietary advice versus no adviceOutcome: 01 Mortality

Study advice no advice RR (fixed) Weight RR (fixed)or sub-category n/N n/N 95% CI % 95% CI

Hickson 2002 86/291 96/301 99.49 0.93 [0.73, 1.18]

Imes 1988 0/67 0/70 Not estimable

Ollenschlager 1992 2/15 0/16 0.51 5.31 [0.28, 102.38]

Total (95% CI) 373 387 100.00 0.95 [0.75, 1.21]

Total events: 88 (advice), 96 (no advice)Test for heterogeneity: Chi² = 1.34, df = 1 (P = 0.25), I² = 25.3%Test for overall effect: Z = 0.43 (P = 0.67)

0.1 0.2 0.5 1 2 5 10

Favours advice Favours no advice

Review: Dietary advice for illness-related malnutrition in adultsComparison: 02 Dietary advice versus supplementOutcome: 01 Mortality

Study advice supplements RR (fixed) Weight RR (fixed)or sub-category n/N n/N 95% CI % 95% CI

Gray -Donald 1995 1/25 3/25 100.00 0.33 [0.04, 2.99]

Kalnins 1996 0/2 0/3 Not estimable

Schwenk 1999 0/24 0/26 Not estimable

Turic 1998 0/30 0/38 Not estimable

Total (95% CI) 81 92 100.00 0.33 [0.04, 2.99]

Total events: 1 (advice), 3 (supplements)Test for heterogeneity: not applicableTest for overall effect: Z = 0.98 (P = 0.33)

0.01 0.1 1 10 100

Favours advice Favours supplements

Review: Dietary advice for illness-related malnutrition in adultsComparison: 03 Dietary advice versus dietary advice plus supplementOutcome: 01 Mortality

Study advice advice + supplements RR (fixed) Weight RR (fixed)or sub-category n/N n/N 95% CI % 95% CI

Arnold 1989 0/27 3/23 100.00 0.12 [0.01, 2.25]

Beattie 2000 0/54 0/55 Not estimable

Fuenzalida 1990 0/4 0/5 Not estimable

McCarthy 1999 0/20 0/20 Not estimable

Murphy 1992 0/11 0/11 Not estimable

Olejko 1984 0/7 0/14 Not estimable

Total (95% CI) 123 128 100.00 0.12 [0.01, 2.25]

Total events: 0 (advice), 3 (advice + supplements)Test for heterogeneity: not applicableTest for overall effect: Z = 1.41 (P = 0.16)

0.01 0.1 1 10 100

Favours advice Favours advice+supps

Review: Dietary advice for illness-related malnutrition in adultsComparison: 04 Dietary advice plus supplements versus no adviceOutcome: 01 mortality

Study advice+access supps no advice RR (fixed) Weight RR (fixed)or sub-category n/N n/N 95% CI % 95% CI

Ganzoni 1994 3/15 2/15 79.41 1.50 [0.29, 7.73]

Lovik 1996 3/27 0/25 20.59 6.50 [0.35, 119.88]

Total (95% CI) 42 40 100.00 2.53 [0.63, 10.15]

Total events: 6 (advice+access supps), 2 (no advice)Test for heterogeneity: Chi² = 0.79, df = 1 (P = 0.37), I² = 0%Test for overall effect: Z = 1.31 (P = 0.19)

0.01 0.1 1 10 100

Favours advice+supps Favours no advice

Figure 2 Meta analysis of mortality data for each of four comparisons. Summary odds ratios calculated using fixedeffects model.


dietary counselling and follow up to patients whohave lost weight, but with up to 55% of hospitaladmissions at nutritional risk it is likely that thetime, and therefore costs, to the National Health

Service are considerable. The findings of thisreview question whether this is an appropriatebasis for local and national policies on the manage-ment of illness-related malnutrition and suggest

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Figure 3 Meta analysis of weight change data for each of four comparisons. Summary weighed mean differencecalculated using fixed effects model. Random effects for comparison three.


that there may be advantages to the use of oralnutritional supplements in the short-term manage-ment of weight loss. The financial benefits ofproviding dietary counselling compared withproviding nutritional supplements cannot becalculated from the studies included in this reviewbut consideration needs to be given to whether it iscost effective for dietitians to give nutritionalcounselling compared with the routine prescriptionof oral nutritional supplements. However, absenceof evidence is not evidence of no effect. In all thetrials included in this review, the oral nutritionalsupplements were given by a dietitian. Until thereis further evidence in this area there is no reason tosuggest that patients with weight loss secondary to

illness should not continue to be managed byreferral to a dietitian.

Studies for this review were carried out in arange of clinical conditions and it is questionablewhether the studies should be combined in oneanalysis. However we have found no evidence thatpatients from different clinical backgrounds mightrespond differently to standard nutritional inter-vention, and therefore, we considered it appro-priate to combine studies. In addition, the foursmall studies comparing nutritional supplementswith dietary advice are in patients from variedclinical backgrounds (elderly, cystic fibrosis andHIV), but there is no statistical heterogeneity forweight change. Conversely, there is evidence of

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Review: Dietary advice for illness-related malnutrition in adultsComparison: 02 Dietary advice versus supplementOutcome: 04 Change in energy intake

Study advice supplements WMD (fixed) Weight WMD (fixed)or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Gray -Donald 1995 24 347.30(553.60) 22 537.90(805.70) 2.84 -190.60 [-593.59, 212.39]

Kalnins 1996 2 -15.50(1804.00) 3 -107.00(1255.00) 0.06 91.50 [-2783.85, 2966.85]

Schwenk 1999 21 338.10(556.30) 23 544.30(446.60) 5.12 -206.20 [-506.07, 93.67]

Turic 1998 22 -14.33(92.40) 21 67.18(138.67) 91.98 -81.51 [-152.28, -10.74]

Total (95% CI) 69 69 100.00 -90.90 [-158.77, -23.02]

Test for heterogeneity: Chi² = 0.89, df = 3 (P = 0.83), I² = 0%Test for overall effect: Z = 2.62 (P = 0.009)

-1000 -500 0 500 1000

Favours supplements Favours advice

Review: Dietary advice for illness-related malnutrition in adultsComparison: 03 Dietary advice versus dietary advice plus supplementOutcome: 04 Change in energy intake

Study advice advice + supplements WMD (fixed) Weight WMD (fixed)or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Murphy 1992 8 780.83(461.52) 8 842.02(794.46) 100.00 -61.19 [-697.86, 575.48]

Total (95% CI) 8 8 100.00 -61.19 [-697.86, 575.48]

Test for heterogeneity: not applicableTest for overall effect: Z = 0.19 (P = 0.85)

-1000 -500 0 500 1000

Favours advice+supps Favours advice

Figure 4 Meta analysis of energy intake data for two comparisons. Summary weight mean difference calculated usingfixed effects model. Change in energy intake.


significant statistical heterogeneity amongst thestudies comparing dietary advice with dietaryadvice and supplements, which were also inpatients from varied clinical backgrounds. Otherfactors that might be expected to contribute to theheterogeneity include differences between studiesin the nutritional status of participants, attritionrates, allocation concealment, length of follow-upand methods of interventions. In all studiespatients either met the Malnutrition Advisory Groupguidelines9 for at risk of nutritional problems27,28,33

or were below their usual weight at study entry,26

and percentage follow-up was high (X86%), so thatneither of these factors is likely to explain theheterogeneity. In the study by Beattie et al.,allocation concealment was ‘‘adequate’’27 and inthe other three studies ‘‘unclear’’,26,28,33 butcontrary to what would be expected, the resultsreported by Beattie et al. showed the largest groupdifferences.27 Three studies were less than 3months duration,27,28,33 and one study was for 6months,26 although in this latter study the inter-vention was given for 10-weeks only. However,removing this longer study26 from the analysis didnot reduce the heterogeneity. In two studies,dietary advice seems to have been given quiteintensively,26,33 but there is very little informationfor the other two studies, in which the results werein favour of advice plus supplements.27,28 It ispossible that differences in the delivery of dietaryadvice contributed to the heterogeneity. We used avery broad definition of dietary advice, and there-fore the studies included in our review were varied

in this respect, with advice ranging from individualdietary counselling with support to the routineprovision of additional snack foods, although de-tails were often not reported. Due to smallnumbers of trials we were unable to investigatewhether the type or intensity of advice had animpact on study findings.

Our review includes studies conducted in primaryor secondary care settings, or a combination of thetwo, and there are potential differences betweensettings. Participants receiving dietary advice insecondary care may not have free access to extrafood, although there may be more encouragementto take any additional food or supplements thathave been prescribed. The factors that influencecompliance with a prescribed intervention areunknown and it is not known whether there aredifferences in compliance between primary andsecondary care settings. If such differences do existthey might also contribute to heterogeneity be-tween studies. Again, with such small numbers ofstudies we were unable to investigate this further.

An additional consideration is that study partici-pants receiving supplements may also be givendietary advice to increase food intake, advicewhich is not reported on in papers (e.g. Beattieet al.27). Considerable care was taken to checkdetails of the intervention with authors. One of thestrengths of this review is the high level of contactmade with authors.

The aim of this review was to determine theefficacy of dietary advice in adults with illness-related malnutrition to improve survival, weight

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and anthropometry. The overwhelming finding isthe absence of evidence that arises from the smallnumber of studies in this area and the poor qualityof the existing data. Ten of 25 studies were unableto contribute any data to the meta-analysis.

If supplements produce clinical benefits, such asreduced mortality, presumably they do so byincreasing nutrient intake. If a similar increase innutrient intake can be achieved by dietary means,similar clinical benefits would be expected tooccur. However it is not known which nutrient(s)are responsible for the benefit (protein, energy,vitamins, and trace elements). Protein and energyintake may be indices of dietary intake, but it maybe that specific fatty acids or vitamins may beresponsible for at least some of the clinicalbenefits.

Conclusions

There is insufficient evidence to establish whetherdietary advice improves the outcomes of patientswith illness-related malnutrition. Nutritional sup-plements may be beneficial in mitigating weightloss, but whether this can be sustained in thelonger term is uncertain, and evidence is lackingfor other outcomes. Many outstanding questionsremain, such as whether certain types of advice aremore effective then others, and if so, how theireffectiveness compares with that of supplements,whether the relative effectiveness of dietaryadvice and supplements differs between short andlong term periods, and whether different interven-tions are more effective in primary and secondarycare. Current data are extremely limited, andlarge, well-designed randomised controlled trialsare needed to address these issues.

Acknowledgements

This review was conducted as a Cochrane systema-tic review and the original version is available inthe Cochrane Library (Baldwin C, Parsons T, LoganS. Dietary advice for illness-related malnutrition inadults. The Cochrane Library, Issue 4, 2003.)

Christine Baldwin and Tessa Parsonsz conductedthe searches, selected studies for inclusion, en-tered data and prepared the analyses.

We are very grateful to staff at the CochraneCystic Fibrosis Group and the Systematic ReviewsTraining Unit, Institute of Child Health for their

zNo competing interests for Tessa Parsons.

help and support, Reinhard Wentz, Chelsea andWestminster Hospital, who conducted the mostrecent literature searches, and all the authors whokindly provided data or information for includedtrials.

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