Nutritional counselling or nutritional supplements – what is the evidence Christine Baldwin Department of Medicine & Therapeutics Imperial College London & The Royal Marsden Hospitals

Approximately 30-40% of patients do not receive care according to present scientific evidence and about 20-25% of care is not needed or potentially harmful Heyland et al 2004

Current dietetic practice ‘….improving nutritional intake via ordinary foods and beverages is the first step in the process of providing nutritional support’ ‘some people may need further support in the form of sip feeds and other supplements’ Manual of Dietetic Practice 2001

What do dietitians do? 150 Oncology dietitians Case history patient with advanced disease and 18 % weight loss What would your first recommendation for nutritional intervention be?

What do dietitians do? 40 % dietary advice alone 60% dietary advice and nutritional supplement Ayelet Spiro (personal communication)

What are we trying to achieve? Mortality Morbidity (length of hospital/complications) change in weight and nutritional indices change in clinical function energy intake cost

Oral nutritional supplements Weight and nutritional indices may be significantly improved in adults with supplements Unclear whether clinical improvements Potter et al BMJ1998

Nutritional supplements- clinical benefits Stratton, Green, Elia 2003

Draft NICE guideline version 2

Meta analysis –what does it mean? Which studies are included? ‘junk in, junk out’ Definition of malnutrition Interventions Study quality

Objectives Can dietary counselling improve survival and nutritional indices Is there an additional effect of supplements when given in combination with dietary advice Cochrane library Clinical Nutrition 2004

Types of studies RCT’s of dietary advice no advice nutritional supplements dietary advice and nutritional supplements Dietary advice & supplements vs. no advice

Types of participants Adults >16 years with illness-related malnutrition exclusions pregnancy, anorexia nervosa, food insufficiency

Types of interventions Dietary advice given by a dietitian or other health professional Oral nutritional supplements taken for any period of any time exclusion elemental and semi-elemental supplements

Outcomes Clinical Nutritional Economic

Results 24 trials ( 25 comparisions) Usable data from 14 trials 2135 participants variety of clinical backgrounds follow-up 6 weeks to 24 months Usable data from 14 trials Additional information or data obtained from 18 authors

Results Mortality Insufficient information Morbidity

Results – weight change Dietary advice : no advice dietary advice & supplement Dietary advice and supplements vs. no advice No significant differences between groups

Results significantly improved in groups consuming supplements Dietary advice vs supplements Weight gain energy intake significantly improved in groups consuming supplements

Results

Conclusions highlights lack of evidence for provision of dietary advice Suggest that supplements have a greater role than dietary advice

Conclusions Absence of evidence is not absence of effect It may be possible to replicate the benefits associated with supplements using food

Dietary advice + supplement RCT needed is: Group 1 Dietary advice Group 2 Dietary advice + supplement Group 3 Supplement only Group 4 No intervention