dr. elizabeth weekes department of nutrition & dietetics guys & st. thomas nhs foundation...
TRANSCRIPT
Dr. Elizabeth WeekesDepartment of Nutrition & DieteticsGuy’s & St. Thomas’ NHS Foundation TrustLondon
Dietary counselling and food fortificationDietary counselling and food fortificationversusversus oral nutritional supplements oral nutritional supplements in the communityin the community
IntroductionIntroduction
Role for proprietary nutritional supplements in disease-related malnutrition is well established
Relative lack of evidence for the role of dietary counselling and/or food fortification, especially
in the community
(Baldwin et al., 2001; Stratton, Elia & Green, 2003)
Food first Food first versusversus oral nutritional supplements oral nutritional supplements
Tailored advice and counselling of carers may improve compliance, especially in chronic disease
Food and drink provide more variety in flavour, texture and consistency
Changes in dietary behaviour may persist beyond the intervention period
Food fortification may help patients with poor appetite and/or early satiety
Dietary counselling in the communityDietary counselling in the community
Imes et al., (1987,1988)- 137 outpatients with Crohn’s disease- 6 months dietary counselling- ↑ energy and micronutrient intakes- ↑ incidence of remission; ↓ length of hospital stay- ↓ time lost from work- Effects continued through further 6 months of
follow-up
Dietary counselling in the communityDietary counselling in the community
Macia et al., (1991) - 93 Cancer patients receiving radiotherapy- Head & neck (HN), breast (B) and abdo-pelvic (AP)- Individual dietary programme for up to 2 years- HN and AP controls ↓ weight, MAC and TSF while
intervention group maintained- B no differences between groups (better nourished)- No measures of functional status
Food fortification in the communityFood fortification in the community
De Jong et al., (1999)
- 145 free-living, frail elderly
- Nutrient-dense foods, exercise, both or control
- ↑ micronutrient intake and vitamin status in supplemented
- No measures of nutritional or functional status
Extra meals or snacks in the communityExtra meals or snacks in the community
Kretser et al., (2003)
- 203 housebound elderly
- MoW or MoW + snacks for 6 months
- ↑ weight in supplemented
- functional improvements associated with BMI
and age rather than intervention
Extra meals or snacks in the communityExtra meals or snacks in the community
Gollub et al., (2004)
- 381 frail, housebound elderly
- Breakfast + lunch vs. lunch alone for 6 months
- ↑ energy intake and food security
- ↓ depressive symptoms
- No difference in QoL scores
- No assessment of nutritional status
Research questionsResearch questions
Can six months intervention with dietary counselling and food fortification result in weight gain in outpatients with COPD?
Is weight gain associated with measurable clinical benefit for the patient?
Study designStudy design
Baseline Month 6 Month 12
Intervention
Follow-up
M1 M3 M7 M9W2
Dietary counselling and food fortificationDietary counselling and food fortification
Intervention- Experienced dietitian- Advice tailored to clinical condition,
lifestyle and preferences etc.- Six months free supply of milk
powder for food fortification(Pluspints, Kerry Foods, Eire)
- NAGE leaflet, written advice and practical demonstrations
Control- NAGE leaflet
RecruitmentRecruitment
59 completed baseline assessmentIntervention n = 31
Control n = 28
50 completed 1 month assessment
37 (63 %) completed 12 month assessmentIntervention n=20
Control n = 17
40 completed 6 month assessment
Patient characteristics (n = 59)Patient characteristics (n = 59)
Intervention
N = 31
Control
N = 28
Females:Males
Age (years)
Weight (kg)
Body mass index (kg/m2)
FEV1 (% predicted)
Energy intake (kcal/day)
Protein intake (g/day)
15:16
68.9 (47 – 89)
54.5 (7.3)
19.9 (1.4)
30.9 (12.8)
1974 (371)
68.5 (11.6)
14:14
69.2 (46 – 85)
53.5 (8.5)
19.5 (1.9)
32.7 (14.6)
1931 (425)
66.1 (11.6)
Energy intake (kcal/day)Energy intake (kcal/day)
19262064
18801715
0
500
1000
1500
2000
2500
kcal
/day
Intervention (n = 20)
Control (n = 17)
Months 1 to 6 Months 7 to 12
Protein intake (g/day)Protein intake (g/day)
69.4
77.1
65.0
56.9
0
10
20
30
40
50
60
70
80
90
g/da
y
Intervention (n = 20)
Control (n = 17)
Months 1 to 6 Months 7 to 12
Advice offered to the intervention group Offered Complied
Snacks between mealsDessert at lunch and/or supperFortify meals using recipes in the NAGE leafletChange from low fat to full fat dairy productsIncrease fruit and/or vegetable intake Eat breakfastSeparate dessert from main mealChange from “diet” products e.g. sweetenersUse Complan/Build-up soups
Choose energy-dense foods from menusShare meals with family or friendsLunch clubsReferred for Meals-on-Wheels
21151411114442
6221
21 (100 %)7 (47 %)
11 (79 %)2 (18 %)9 (82 %)2 (50 %)2 (50 %)2 (50 %)
2 (100 %)
6 (100 %)2 (100 %)2 (100 %)1 (100 %)
Dietary counsellingDietary counselling
NAGE leafletNAGE leaflet
Dietary counsellingDietary counselling
Compliance
Costs to patient
Shopping
Isolation
“Healthy eating”
Method of fortification Number of patients (%)
"Fortified Milk" added to:
WMP added direct to:
hot drinkscold drinksbreakfast cereal/porridgemilk puddingshome-made milkshakes
mashed potatoessoupporridgesavoury sauces/gravyscrambled eggsyogurt or mousse
14 (45 %)14 (45 %)12 (39 %)4 (13 %)2 (6 %)
4 (13 %)2 (6 %)2 (6 %)2 (6 %)1 (3 %)1 (3 %)
Food fortification using milk powderFood fortification using milk powder
Food fortification using milk powderFood fortification using milk powder
23 (74 %) used milk powder
for six months Provided 129 (+ 70) kcal/day Appearance adequate or good Response to flavour, texture
and consistency more variable 5 (22 %) bought WMP during
follow-up period 4 (17 %) stated they would use
WMP if they lost weight
Milk powder vs. oral nutritional supplementsMilk powder vs. oral nutritional supplements
Costs to PCTs
Costs to patient
Supply and delivery
Preparation
Cessation of nutritional supplementsCessation of nutritional supplements
Nutritional intake and body weight decreased towards baseline levels within 2 – 3 months(O’Morain et al., 1984; Knowles et al., 1988; Arnold & Richter et al., 1989; Woo et al., 1994; Edington et al., 2004)
Some loss of functional benefits (Efthimiou et al., 1988)
-4
-3
-2
-1
0
1
2
3
4
5
Time (months)
Wei
ght c
hang
e (k
g)
InterventionControl
3 6 9 12
Weight change (kg)Weight change (kg)
-15
-10
-5
0
5
10
Ch
ang
e in
SG
RQ
Tot
al s
core
Intervention
Control
6 months(n = 37)
12 months(n = 34)
Change in Quality of LifeChange in Quality of Life
ConclusionsConclusions
• It was possible to achieve weight gain in outpatients with COPD, using dietary counselling and food fortification
• Both dietary counselling and food fortification contributed to the increased energy and protein intakes
• Weight was maintained for at least six months after intervention ceased
• Improvements in some variables persisted beyond the intervention period e.g. Quality of Life
Future researchFuture research
Evaluate the specific impact of each strategy (dietary counselling, food fortification, oral nutritional supplements) alone or in combination
Effects of cessation of intervention need further investigation
Prospective cost-effectiveness analyses
Patient group, care setting and the professional giving advice may all affect results
“But, in chronic cases …where the fatal issue is often determined by mere protracted starvation, I had rather not enumerate the instances I have known where a little ingenuity, and a great deal of perseverance, might have averted the result.”
Florence Nightingale, 1859