nutritional counselling or nutritional supplements – what is the evidence christine baldwin...
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Nutritional counselling or Nutritional counselling or nutritional supplements – what is nutritional supplements – what is the evidencethe evidence
Christine BaldwinChristine Baldwin
Department of Medicine & TherapeuticsDepartment of Medicine & Therapeutics
Imperial College LondonImperial College London
&&
The Royal Marsden HospitalsThe Royal Marsden Hospitals
Approximately 30-40% of patients Approximately 30-40% of patients do not receive care according to do not receive care according to present scientific evidence and present scientific evidence and about 20-25% of care is not about 20-25% of care is not needed or potentially harmfulneeded or potentially harmful
Heyland Heyland et alet al 2004 2004
Dietary counselling
Evidence/policy or consensus
Nutritional supplementsWhat benefits
Nothing
Current dietetic practiceCurrent dietetic practice
‘…‘….improving nutritional intake via ordinary .improving nutritional intake via ordinary foods and beverages is the first step in the foods and beverages is the first step in the process of providing nutritional support’process of providing nutritional support’
‘‘some people may need further support in some people may need further support in the form of sip feeds and other the form of sip feeds and other supplements’supplements’
Manual of Dietetic Practice 2001Manual of Dietetic Practice 2001
What do dietitians do?What do dietitians do?
150 Oncology dietitians150 Oncology dietitians Case history patient with advanced Case history patient with advanced
disease and 18 % weight lossdisease and 18 % weight loss
What would your first What would your first recommendation for recommendation for nutritional intervention be?nutritional intervention be?
What do dietitians do?What do dietitians do?
40 % dietary advice alone40 % dietary advice alone
60% dietary advice and nutritional 60% dietary advice and nutritional supplementsupplement
Ayelet Spiro (personal communication)
What are we trying to What are we trying to achieve?achieve?
MortalityMortality Morbidity (length of Morbidity (length of
hospital/complications)hospital/complications) change in weight and nutritional change in weight and nutritional
indicesindices change in clinical functionchange in clinical function energy intakeenergy intake costcost
Oral nutritional Oral nutritional supplementssupplements
Weight and nutritional indices may Weight and nutritional indices may be significantly improved in adults be significantly improved in adults with supplementswith supplements
Unclear whether clinical Unclear whether clinical improvementsimprovements
Potter et al BMJ1998Potter et al BMJ1998
Nutritional supplements- Nutritional supplements- clinical benefitsclinical benefits
Stratton, Green, Elia 2003
Draft NICE guideline version 2
Meta analysis –what does it Meta analysis –what does it mean?mean?
Which studies are included?Which studies are included? ‘‘junk in, junk out’junk in, junk out’
Definition of malnutritionDefinition of malnutrition
Interventions Interventions
Study qualityStudy quality
ObjectivesObjectives
Can dietary counselling improve Can dietary counselling improve survival and nutritional indicessurvival and nutritional indices
Is there an additional effect of Is there an additional effect of supplements when given in supplements when given in combination with dietary advicecombination with dietary advice
Cochrane libraryClinical Nutrition 2004
Types of studiesTypes of studies
RCT’s of dietary advice RCT’s of dietary advice no adviceno advice nutritional supplementsnutritional supplements dietary advice and nutritional dietary advice and nutritional
supplementssupplements
Dietary advice & supplements vs. no Dietary advice & supplements vs. no adviceadvice
Types of participantsTypes of participants
Adults >16 years with illness-Adults >16 years with illness-related malnutritionrelated malnutrition
exclusions pregnancy, anorexia exclusions pregnancy, anorexia nervosa, food insufficiencynervosa, food insufficiency
Types of interventionsTypes of interventions
Dietary advice given by a dietitian Dietary advice given by a dietitian or other health professionalor other health professional
Oral nutritional supplements taken Oral nutritional supplements taken for any period of any timefor any period of any time exclusion elemental and semi-exclusion elemental and semi-
elemental supplementselemental supplements
OutcomesOutcomes
ClinicalClinical
Nutritional Nutritional
EconomicEconomic
Results Results
24 trials ( 25 comparisions) 24 trials ( 25 comparisions) 2135 participants 2135 participants variety of clinical backgrounds variety of clinical backgrounds follow-up 6 weeks to 24 monthsfollow-up 6 weeks to 24 months
Usable data from 14 trialsUsable data from 14 trials Additional information or data Additional information or data
obtained from 18 authorsobtained from 18 authors
ResultsResults
MortalityMortality Insufficient informationInsufficient information
MorbidityMorbidity Insufficient informationInsufficient information
Results – weight changeResults – weight change
Dietary advice :Dietary advice : no adviceno advice dietary advice & supplementdietary advice & supplement
Dietary advice and supplements vs. no Dietary advice and supplements vs. no adviceadvice
No significant differences between No significant differences between groupsgroups
ResultsResults
Dietary advice vs supplementsDietary advice vs supplements Weight gainWeight gain energy intake energy intake
significantly improved in significantly improved in groupsgroups
consuming supplementsconsuming supplements
ResultsResults
ConclusionsConclusions
highlights lack of evidence for highlights lack of evidence for provision of dietary adviceprovision of dietary advice
Suggest that supplements have a Suggest that supplements have a greater role than dietary advicegreater role than dietary advice
ConclusionsConclusions
Absence of evidence is not Absence of evidence is not absence of effectabsence of effect
It may be possible to replicate the It may be possible to replicate the benefits associated with benefits associated with supplements using foodsupplements using food
RCT needed is:RCT needed is:
Group 1Group 1
Dietary adviceDietary adviceGroup 2Group 2
Dietary advice + Dietary advice + supplementsupplement
Group 3Group 3
Supplement onlySupplement onlyGroup 4Group 4
No interventionNo intervention