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

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