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systematic reniew and meta-analysis of the effects of high protein oral nutritional supplements

Ageing Research Reviews 11 (2012) 278–296

Contents lists available at SciVerse ScienceDirect

systematic reniew and meta-analysis of the effects of high protein oral nutritional supplements

systematic reniew and meta-analysis of the effects of high protein oral nutritional supplements

Ageing Research

Reviews

j o u r n a l h o m e p a g e :w w w.e l s e v i e r.c o m /l o c a t e /a r

r

Review

Systematic review and meta-analysis of the effects of high protein oral nutritional supplements

A.L.Cawood a ,b ,∗,M.Elia a ,R.J.Stratton a

a Institute of Human Nutrition,University of Southampton,Southampton,UK b

Medical Affairs,Nutricia Ltd,Trowbridge,UK

a r t i c l e

i n f o

Article history:

Received 2September 2011

Received in revised form 4December 2011Accepted 14December 2011

Available online 22 December 2011

Keywords:Meta-analysis Protein

Supplement Nutrition

Oral nutritional supplements

a b s t r a c t

Disease-related malnutrition is common,detrimentally affecting the patient and healthcare economy.Although use of high protein oral nutritional supplements (ONS)has been recommended to counteract the catabolic effects of disease and to facilitate recovery from illness,there is a lack of systematically obtained evidence to support these recommendations.This systematic review involving 36randomised controlled trials (RCT)(n =3790)(mean age 74years;83%of trials in patients >65years)and a series of meta-analyses of high protein ONS (>20%energy from protein)demonstrated a range of effects across settings and patient groups in favour of the high protein ONS group.These included reduced complications (odds ratio (OR)0.68(95%CI 0.55–0.83),p <0.001,10RCT,n =1830);reduced readmissions to hospital (OR 0.59(95%CI 0.41–0.84),p =0.004,2RCT,n =546);improved grip strength (1.76kg (95%CI 0.36–3.17),p <0.014,4RCT,n =219);increased intake of protein (p <0.001)and energy (p <0.001)with little reduction in normal food intake and improvements in weight (p <0.001).There was inadequate information to compare standard ONS (<20%energy from protein)with high protein ONS (>20%energy from protein).The systematic review and meta-analysis provides evidence that high protein supplements produce clinical benefits,with economic implications.

© 2011 Elsevier B.V. All rights reserved.

1.Introduction

The prevalence of disease related malnutrition is common across all health and social care settings including hospitals,care homes,and sheltered housing (Waitzberg et al.,2001;Stratton et al.,2003;Kruizenga et al.,2003;Russell and Elia,2009;Elia and Russell,2009a ).Overall,more than 3million people in the UK are malnourished or at risk of malnutrition,with people aged over 65years accounting for about 1.3million of these (Elia and Russell,2009b ).Despite this,malnutrition continues to remain undetected and undertreated (Elia and Russell,2009b )causing a variety of detrimental effects at enormous cost to the individual and health-care system (Elia and Stratton,2009).This is because malnutrition not only predisposes to disease,but it also adversely affects dis-ease outcome in a variety of ways.For example,impaired immunity predisposes to infections and the ability of the body to recover from infections,muscle weakness and immobility predispose to falls,venous thromboembolism and pressure ulcers.Malnutrition

∗Corresponding author at:Institute of Human Nutrition (MP113),Southampton General Hospital,Tremona Road,Southampton SO166YD,UK.Tel.:+4407738024718.

E-mail addresses:A.L.Cawood@http://www.wendangku.net/doc/b4781f1ac281e53a5802ff34.html (A.L.Cawood),elia@http://www.wendangku.net/doc/b4781f1ac281e53a5802ff34.html (M.Elia),rjs@http://www.wendangku.net/doc/b4781f1ac281e53a5802ff34.html (R.J.Stratton).

delays recovery from illness,increases complications,and resource use,such as frequency of hospital admissions and length of hospital stay (Elia,2006).

Since reduced dietary intake is a major cause of malnutri-tion,various authorities including NICE (National Institute for Health and Clinical Excellence)(NICE,2006)recommend improv-ing dietary intake using a range of nutrition support strategies,including dietary counselling,oral nutritional supplements (ONS)and artificial nutritional support.Many of these strategies not only aim to increase energy but also the contribution of protein to total energy intake and there are several reasons for this.First,the intake of protein is believed to be inadequate in a sizeable proportion of the free living population,especially older people (65years and over),where 20%of the population do not meet the Reference Nutri-ent Intake (RNI)for protein in the UK (Finch et al.,1998).Inadequate protein intake is even more likely to occur in patients with disease-related malnutrition because appetite is often poor due to the effects of a wide range of diseases,including infective,malignant,and traumatic conditions.Second,patients with disease-related malnutrition tend to be sedentary,ingesting less food with less protein and other nutrients,which means that nutrient deficien-cies including protein are more likely to occur (WHO,2007).If a normal protein intake was to be maintained in the face of reduced energy intake,protein would need to account for a greater pro-portion of total dietary energy,which should be considered when

1568-1637/$–see front matter © 2011 Elsevier B.V. All rights reserved.doi:10.1016/j.arr.2011.12.008