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

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Presentation on theme: "Nutritional counselling or nutritional supplements – what is the evidence Christine Baldwin Department of Medicine & Therapeutics Imperial College London."— Presentation transcript:

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 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

3 Dietary counselling Evidence/policy or consensus Nutritional supplements What benefits Nothing

4 Current dietetic practice ….improving nutritional intake via ordinary foods and beverages is the first step in the process of providing nutritional support ….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 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 150 Oncology dietitians Case history patient with advanced disease and 18 % weight loss 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 40 % dietary advice alone 60% dietary advice and nutritional supplement 60% dietary advice and nutritional supplement Ayelet Spiro (personal communication)

7 What are we trying to achieve? Mortality Mortality Morbidity (length of hospital/complications) Morbidity (length of hospital/complications) change in weight and nutritional indices change in weight and nutritional indices change in clinical function change in clinical function energy intake energy intake cost cost

8 Oral nutritional supplements Weight and nutritional indices may be significantly improved in adults with supplements Weight and nutritional indices may be significantly improved in adults with supplements Unclear whether clinical improvements 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? Which studies are included? junk in, junk out junk in, junk out Definition of malnutrition Definition of malnutrition Interventions Interventions Study quality Study quality

12 Objectives Can dietary counselling improve survival and nutritional indices Can dietary counselling improve survival and nutritional indices Is there an additional effect of supplements when given in combination with dietary advice Is there an additional effect of supplements when given in combination with dietary advice Cochrane library Clinical Nutrition 2004

13 Types of studies RCTs of dietary advice RCTs of dietary advice no advice no advice nutritional supplements nutritional supplements dietary advice and nutritional supplements dietary advice and nutritional supplements Dietary advice & supplements vs. no advice Dietary advice & supplements vs. no advice

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

15 Types of interventions Dietary advice given by a dietitian or other health professional Dietary advice given by a dietitian or other health professional Oral nutritional supplements taken for any period of any time Oral nutritional supplements taken for any period of any time exclusion elemental and semi-elemental supplements exclusion elemental and semi-elemental supplements

16 Outcomes Clinical Clinical Nutritional Nutritional Economic Economic

17 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 months follow-up 6 weeks to 24 months Usable data from 14 trials Usable data from 14 trials Additional information or data obtained from 18 authors Additional information or data obtained from 18 authors

18 Results Mortality Mortality Insufficient information Insufficient information Morbidity Morbidity Insufficient information Insufficient information

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

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

21 Results

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

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

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


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