1. 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

2. (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)

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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?

10. Study design Month 12 Baseline Month 6 M7 M9 M1 M3 W2 Intervention
Follow-up

11. 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

12. 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

13. 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)

14. Energy intake (kcal/day)

15. Protein intake (g/day)

16. 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 %)

17. NAGE leaflet

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

19. 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 %)

20. 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

21. Milk powder vs. oral nutritional supplements
Costs to PCTs
Costs to patient
Supply and delivery
Preparation

22. 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)

23. Weight change (kg)

24. Change in Quality of Life

25. 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

26. 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

27. “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