Food fortification vs. oral nutritional supplements in hospital Dr Rebecca Stratton Institute of Human Nutrition University of Southampton, UK © IHN The debate

© IHN DIET In hospital patients we should use diet (counselling, snacks, fortification) as the first line treatment of malnutrition SUPPLEMENTS In hospital patients, we should use a liquid supplement as the first line treatment of malnutrition versus

Rationale for oral nutritional support © IHN Dietary manipulation Food fortification using energy and protein rich food ingredients or commercially available energy or protein powders and liquids added to the diet Additional foods e.g. snacks, cakes, puddings Dietary counselling Usually by a dietitian, with the aim of maximising dietary intake, with an emphasis on energy and protein intakes. Oral nutritional supplements Typically multi-nutrient (macro- and micro-nutrients) liquids

Manual of Dietetic Practice (Ed. B. Thomas) In practice, nutritional support can be regarded as a graded process of increasing levels of intervention: Improving energy and nutrient intake from ordinary foods Fortifying the energy and nutrient content of ordinary foods Sip feed supplementation

Manual of Dietetic Practice (Ed. B. Thomas) If a patient is able to eat a normal diet, but in quantities insufficient to meet requirements, fortification of the diet should be considered….to maximise the energy and/or nitrogen content of the diet

Decision making – what is best? Evidence-based practice – evidence it works Provision of nutrition to meet requirements in a practical and safe way Duration and purpose of treatment Physiology, clinical condition – clinical judgement Costs Individual patient

Dietary fortification Oil Cream Sour cream Butter Milk Cheese Sugar Skimmed milk powder Commercial CHO/protein powder or liquids Aims to increase the energy and protein density of the diet © IHN Snacks – cakes biscuits puddings

Dietary fortification and snacks in hospitalised elderly (Odlund Olin et al 1996) Fortification Oil Butter Cream Sour cream Milk © IHN Snacks Sponge Danish pastries Crossover study (consecutive 6 weeks) of regular hospital food or high energy dense food Amount recorded judged by eye Functional ability recorded (mobility, activity, mental condition, fatigue etc)

Dietary fortification and snacks in hospitalised elderly (Odlund Olin et al 1996) © IHN

Dietary fortification What do we want to achieve? Improve the intake of a range of nutrients? Improve recovery? Randomised controlled trials assessing the impact of dietary fortification on clinical outcome, compared with routine care, are lacking © IHN

Potential strengths vs. limitations of dietary fortification in hospital patients Strengths No increase in food volume or quantity so may be suitable for anorexia Palatability? Extra energy Cheap Weaknesses May alter taste/sensory properties of food Other nutrients Ease of use/preparation In the patient with severe anorexia © IHN

Potential strengths vs. limitations of dietary snacks in hospital patients Strengths Availability Familiarity Palatability? Extra energy Cheap? Weaknesses Increase in food volume or quantity may be unsuitable for anorexia May be difficult for those with chewing or swallowing difficulties Other nutrients Ease of use/preparation © IHN

Dietary counselling Very few trials (< 10) have shown that dietary counselling can improve food intake (energy and protein intakes) and nutritional status (body weight) in the treatment of malnutrition Most trials do not mention who did the counselling, what form this took (written, oral instructions/advice), compliance with advice There are few well-designed randomised controlled trials addressing the impact of dietary counselling by a dietitian on patient outcome in the clinical setting © IHN

Dietary counselling in those with liver disease (Bories and Campillo 1994) © IHN Encouragement to improve food intake (and a diet providing 40kcal/kg/d) for one month in alcoholic cirrhosis Significant increase in energy and protein intakes despite reportedly adequate intakes initially Significant improvements in MAMC, TSF No control group

Potential strengths vs. limitations of dietary counselling in hospital patients Strengths All patients would benefit from seeing a dietitian Individualised and specific May avoid use of products? Weaknesses Time Availability of dietitians Expensive May not be an easy time to counsel patients (e.g. impaired consciousness, pain) © IHN

Other strategies Flavour enhancement of foods to improve food intake in hospital patients Improving the environment – dining areas, protected meal times, music Help with feeding Physical activity/rehabilitation © IHN

Oral nutritional supplements Nutritionally complete Suitable as a sole source of nutrition, but usually used as a supplement to food intake (usually sip feeds) Nutritionally incomplete Only suitable as a supplement to food intake – not suitable as a sole source of nutrition e.g. juice-based sip feeds, desserts, energy/protein powders/liquids © IHN

Systematic review of hospital ONS trials (58 trials, 34 RCT) (Stratton et al 2003) Burns COPD Elderly General Medical HIV/AIDS Liver disease Malignancy Neurology Oral/maxillofacial Orthopaedic Surgical (GI) © IHN

Oral nutritional supplements in hospital patients (Stratton et al 2003) 93% of all trials, 72% significant (n 42) 100% of RCT, 68% significant(n 25) Rana et al 1992 © IHN

Weight change with supplements in the hospital (Stratton et al 2003) © IHN

Improvements in function/outcome in hospital ONS trials (Stratton et al 2003) COPD Improved ventilatory capacity Elderly Improved functional status Increased activities of daily living Lower mortality (meta-analyses) Shorter hospital stays Orthopaedics Improved clinical course (complication and deaths) Retention of bone mineral density in femoral shaft Shorter hospital stays © IHN

Improvements in function/outcome in hospital ONS trials (Stratton et al 2003) Liver disease Lower mortality Improved markers of liver function Surgery Lower rate of post-op complications (meta- analyses) Retention of skeletal (hand-grip) muscle strength Improved physical and mental health/quality of life © IHN

ONS can reduce mortality (Stratton et al 2003) © IHN

ONS can reduce complication rates (Stratton et al 2003) © IHN

Reduced complication rates with ONS in GI surgical patients (Stratton et al 2005) TrialsOdds ratio (OR) (95% confidence interval (CI)) All (n 18) ( ) ONS (n 6) ( ) ETF (n 12) ( ) Wound infection, pneumonia, infections, post-op ileus, wound dehiscence, respiratory complications, unresolved peritonitis with relaparotomy © IHN

FOOD trial in CVA patients (Lancet 2005) Hospital diet (control) vs hospital diet + ONS (n 4012) Well nourished patients, able to swallow, started trial within one month of CVA, no measurement of food intake © IHN

Cost savings when treating malnutrition in with liquid supplements in hospital? © IHN (Stratton et al 2004)

BAPEN Health economic working party (Elia et al in press) Surgical studies (8 RCT) Consistently show a net cost saving in favour of supplementation –Reduced bed-stay costs of £1166 (£965-£1368) per patient –Reduced complication costs of £353 (£255-£431) per patient © IHN

Dietary counselling or supplements? A Cochrane review (Baldwin et al) Supplemented patients had significantly greater weight gain (or less loss) and significantly greater energy intakes than patients given dietary counselling, over 3 months no evidence for the use of dietary advice in the management of malnutrition © IHN

Dietary fortification vs. supplements Oral Nutritional Supplements (nutritionally complete sip feeds) Food Intervention (food first - current practice) Aim To compare the effects of food snacks with liquid supplements on appetite and food intake Risk of malnutrition MUST © IHN

Oral nutritional supplements vs. food snacks 50 fractured neck of femur patients admitted to Trauma and Orthopaedics, Southampton Medium and high risk using MUST and consenting Randomised to ONS or food snacks ad lib throughout hospital stay (minimum provision 600kcal daily) © IHN

The debate © IHN DIET In hospital patients we should use diet (counselling, snacks, fortification) as the first line treatment of malnutrition SUPPLEMENTS In hospital patients, we should use a liquid supplement as the first line treatment of malnutrition versus

Food vs. supplements? Effective, safe, quick and easy strategies are needed for the treatment of malnutrition in hospital. Evidence base for dietary counselling and dietary fortification is poor– RCT are needed of their effects on function, clinical outcome and costs. Larger evidence base for liquid multi-nutrient supplements, which can improve function and some outcomes – more studies are needed. Individualise treatments and use your clinical judgement to decide what is appropriate and be vocal in guiding others in their decisions. © IHN The debate