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

2. 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

4. 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

5. 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?

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

7. 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

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

9. Nutritional supplements- clinical benefits
Stratton, Green, Elia 2003

10. Draft NICE guideline version 2

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

12. 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

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

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

15. 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

16. Outcomes
Clinical
Nutritional
Economic

17. 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

18. Results
Mortality
Insufficient information
Morbidity

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

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

21. Results

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

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

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