Dietary counselling and food fortification versus oral nutritional supplements in the community Dr. Elizabeth Weekes Department of Nutrition & Dietetics Guy’s & St. Thomas’ NHS Foundation Trust London

(Baldwin et al., 2001; Stratton, Elia & Green, 2003) Introduction 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 versus 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 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 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 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 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 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 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 design Month 12 Baseline Month 6 M7 M9 M1 M3 W2 Intervention Follow-up

Dietary 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

Recruitment 59 completed baseline assessment Intervention n = 31 Control n = 28 50 completed 1 month assessment 40 completed 6 month assessment 37 (63 %) completed 12 month assessment Intervention n=20 Control n = 17

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)

Protein intake (g/day)

Dietary counselling Advice offered to the intervention group Offered Complied Snacks between meals Dessert at lunch and/or supper Fortify meals using recipes in the NAGE leaflet Change from low fat to full fat dairy products Increase fruit and/or vegetable intake Eat breakfast Separate dessert from main meal Change from “diet” products e.g. sweeteners Use Complan/Build-up soups Choose energy-dense foods from menus Share meals with family or friends Lunch clubs Referred for Meals-on-Wheels 21 15 14 11 4 2 6 1 21 (100 %) 7 (47 %) 11 (79 %) 2 (18 %) 9 (82 %) 2 (50 %) 2 (100 %) 6 (100 %) 1 (100 %)

NAGE leaflet

Dietary counselling Compliance Costs to patient Shopping Isolation “Healthy eating”

Food fortification using milk powder Method of fortification Number of patients (%) "Fortified Milk" added to: WMP added direct to: hot drinks cold drinks breakfast cereal/porridge milk puddings home-made milkshakes mashed potatoes soup porridge savoury sauces/gravy scrambled eggs yogurt or mousse 14 (45 %) 12 (39 %) 4 (13 %) 2 (6 %) 1 (3 %)

Food 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 supplements Costs to PCTs Costs to patient Supply and delivery Preparation

Cessation 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)

Weight change (kg)

Change in Quality of Life

Conclusions 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 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