5. DETERMINE (13–15)
9.4 INTERVENTION WITH NUTRITIONAL (PROTEIN/CALORIE) SUPPLEMENTS
weight and a decrease in severity of disturbed behavior. The adverse reactions of euphoria, somnolence, and tiredness did not necessitate discontinuation of the treatment. Nonetheless, with the potential side effects of sedation and hallucina- tions, dronabinol may not be an appropriate choice for confused elderly patients or those prone to falls (46). A study comparing megestrol acetate and dronabinol treatment in advanced cancer patients showed superior effectiveness for megestrol;
combination therapy with the two drugs provided no additional benefit(53).
Anabolic drugs such as oxandrolone and nandrolone are known to produce increases in lean mass in body builders and have been considered for their potential benefit in frail older patients with loss of lean body mass and in those with chronic wasting conditions like COPD(54). Schroeder et al.(55)found that oxandrolone (10 mg twice daily) produced substantial increases in lean body mass as well as decreases in total body and trunk fat mass in older men (72&6 years). While such effects are hormonal, not nutritional, they could interact with nutritional para- meters like metabolic rate and insulin sensitivity. Anabolic agents have a host of potential side effects such as hepatotoxicity, hypogonadism, testicular atrophy, gynecomastia, and psychiatric disturbances. There is insufficient study in older subjects at this time to enable us to make clinical recommendations and their use is confined to controlled studies(56).
Various amino acids and fatty acids are listed in Table 9.4 but the potential for these compounds to be used as agents to improve weight status have not been fully studied. To date, findings regarding their benefits are not particularly encouraging.
A comparison of eicosapentaenoic acid (EPA) supplement with Megace treatment showed that subjects did not have better improvements for weight or appetite, whether the EPA was given alone or in combination with the Megace(57).
9.4 INTERVENTION WITH NUTRITIONAL (PROTEIN/CALORIE)
While the expense and the monotony of their use are definite concerns, there can be advantages for these products. Generally speaking, they (1) provide a ready source of nutrients, often including fortification with essential micronutrients, (2) help assure safety from food-borne illness and inadvertent contamination during preparation due to standardized manufacturing processes, and (3) provide easy access to nutrition, being ready to serve and suitable for long-term storage at room temperature.
The disadvantages of these supplements have been widely extolled. Concerns about relatively low protein content, lack of fiber and other beneficial components of natural foods, potential misuse as meal replacements, avoidance of liquid intake by elderly patients with urinary incontinence, and the chance of electrolyte and carbohydrate overload in diabetes and chronic renal insufficiency, respectively, have all been expressed (59–61). Fortunately, an evidence-based approach for decision-making about the effectiveness of these products is on the horizon as intervention trials continue to accumulate. The designs and findings of many of the trials published within the past 10 years are summarized in Table 9.6.
Two recent analyses have considered the overall trends for the effects of nutri- tional supplements on mortality outcomes. Milne et al. (62) reported a meta- analysis of 55 randomized trials evaluating the effect of nutritional supplements on 9,187 older participants. In long-term care subjects (receiving #35 days of intervention) who were undernourished at baseline, 75 years of age or older, and receiving greater than 1674 kJ in supplements, a reduced mortality was found. No such effect was observed for well-nourished patients receiving supplementation. In a systematic review, Koretz et al.(63)examined the effects of volitional nutritional support (VNS) on mortality. Based on the 16 trials included, there was an increased survival for malnourished and/or institutionalized geriatric patients receiving VNS.
Of these, two trials were of high quality (Price et al.(64)and Potter et al.(65)) and, although a mortality benefit was favored in these trials, neither showed a significant difference in survival due to VNS treatment. The findings of eight of the 11 studies presented in Table 9.6 show positive outcomes for body weight, nutrient intake, and/or nutritional status.
While we see a clear trend of positive findings with regard to the effects of these nutritional supplements, often the overall impact on outcomes is fairly modest.
Obviously, many factors that are not attributable to the formulation of the products affect clinical outcomes. For example, inconsistencies in the administration of nutritional supplements are commonly observed in the institutional setting. Sim- mons et al.(66)observed supplement provision in a nursing home setting where 88% of patients had an order to receive a supplement one to three times daily and 12% of patients had an order of four to six times daily and found supplements provided on average less than once per participant per day. Fewer than 10% of patients received the supplement consistent with their orders during the 2-day observation.
To summarize, the use of commercial protein/calorie supplements should be reserved for patients who have specific limitations in their oral food intake, such as food intolerances, inability or unwillingness to eat adequate amounts of nutritious foods, and in situations where having the patient do their own food
Chapter 9/ Redefining Nutritional Frailty 169
Table 9.5
Compositional profiles of selected commercially available nutritional supplements Name of
product/
manufacturer Nutritional description
Boost/Nestle Ensure/Abbott Jevity/Cal/Abbott Osmolite/
Cal/Abbott
kcal/mL 1.01 1.06 1.06 1.06
Protein (g/L) 42 38 44.3 44.3
Protein source Milk protein concentrate
N/A N/A N/A
Carbohydrate (g/L)
173 169 154.7 143.9
Carbohydrate source
Corn syrup solids, sugar
N/A N/A N/A
Fat (g/L) total (t), saturated (s)
17.8 (t), 2 (s) 25 (t), 4 (s) 34.7 (t), N/A (s) 34.7 (t), N/A (s) Fat source Canola, high oleic
sunflower and corn oils
N/A N/A N/A
Fiber (g/mL) 0 0 0.0144 NA
Osmolality 610-670 mOsm/kg H2O
590-600 mOsm/
kg H2O
300 mOsm/kg H2O 300 mOsm/kg H2O Unit amount/
flavors
8 fl oz serving;
chocolate, vanilla, strawberry
8 fl oz serving;
vanilla, chocolate, strawberries and cream, butter pecan, coffee latte
8 fl oz serving;
unflavored, for tube feeding
8 fl oz serving;
unflavored
Web site http://www.boost.
com/healthcare professional.htm
http://abbott nutrition.com/
products/
products.
aspx?pid=222
http://abbott nutrition.com/
products/index.aspx
http://abbott nutrition.
com/
products /products.
aspx?
pid=32#
factlabel
Access date 11/12/2007 11/12/2007 11/12/2007 12/9/2008
Notes Novartis has boost glucose contro
N/A, information not available.
170 Bales and Ritchie
Promote/AbbottReplete/NestleSlimFast/SlimFastFoodsCarnation Instant Breakfast/Nestle
Clinutren/Nestle 110.680.76-0.791.25 62.562.430.74140 N/AN/AN/AN/SN/A 130113123127270 N/AN/AN/AN/AN/A 26(t),N/A(s)34(t)9.2(t),3.1(s)15.9(t),4.8(s)<2(t), ?(s) N/AN/AN/AN/AN/A NANA0.0150.003<0.002 340mOsm/kgH2O300mOsm/kgH2O (unflavored),350 mOsm/kgH2O(vanilla)
N/AN/AN/A 8flozserving;vanilla8.4flozserving;vanilla andunflavored11flozserving;Frenchvanilla, strawberriesn’cream,and cappuccinodelightcontain 180cals;creamymilkchocolate andrichchocolateroyale contain190cals 10.6ozserving; creamymilkchocolate, Frenchvanilla, strawberry cre`me
200mL(6.8oz)serving; orange,grapefruit,rasberry/ blackcurrant,pear/cherry http://abbottnutrition. com/products/ products. aspx?pid=35
http://www.nestle- nutrition. com/product.aspx? objectID=7DCD5E99- 7979-462C-99EA- 590C28B009FE http://www.slim-fast. com/products/products.asphttp://www.carnationin stantbreakfast.com/ Products/Details.aspx? ProductId=258A92B0- A7BA-4509-B5EB- 6C291AA4117B#
http://www.nestlenutrition. com/NR/rdonlyres/ 7019D37A-DBCB- 42D4-BDF1-DD330D0 A33A6/0/Clinutren Fruit.pdf 11/19/200711/19/200711/19/200711/19/200703/27/2008 Clinutrenalsoofferssoups, dessertsforthosewith chewing/swallowing problems, highfibermilkydrinks, highcalorie/proteinmilky drinks,highcalorie,and regularmilkydrinks
Chapter 9/ Redefining Nutritional Frailty 171
Table9.6 Studies* ofnutritionalsupplementswithmortality,weight,and/ornutritionalstatusoutcomes Characteristicsof geriatricstudy population N** andmean &SEMage, yearsStudydesignProtein/energy supply/dayIntervention duration
Mortality,BW,and nutritionaloutcomesin treatmentgroupReference Newlydischarged fromhospitalin theUK
51/49,77& 5.3and79 &8.0 RCT600–1000kcalasa supplemented drink,pudding, orbar 8-Week intervention, f/u24weeks Nodifferencein nutritionalstatus betweengroupsat 24weeks
Edingtonetal.,2004 (100) Hospitalized geriatric patientsin France
39/41,82& 7.6and79 &6.1 RCT500kcaland21g proteinperday2MonthsIncreasedenergyintake, maintainedBW, increasedMNAscores (p=0.004)
Gazzotti,etal.,2003 (101) Nursinghome residentswho werenoteating well
29/11,NAPurposive samplingSupplements orderedbyown physician 3DaysBWwasnotpreserved, nearlyhalfcontinued toloseweight
Kayser-Jonesetal., 1998(102) Nursinghome residentsin France
13/22,85& 5.5and85 &5.5
RCT300–500kcalandup to37.5gprotein2MonthsIncreaseddailyprotein andenergyintake, increasedBW (1.5&0.4kg, 1.4&0.5kg)and nutritionalstatusfor malnourishedpatients andpatientsatriskof malnutrition, respectively
Lauque,etal.,2000 (103) (continued)
172 Bales and Ritchie
Table9.6 (continued) Characteristicsof geriatricstudy population N** andmean &SEMage, yearsStudydesignProtein/energy supply/dayIntervention duration
Mortality,BW,and nutritionaloutcomesin treatmentgroupReference Geriatricwards anddaycare centersin France
46/45,80& 5.9and78 &4.8 RCT300–500kcalandup to21gprotein3Months intervention, 6-monthf/u
IncreasedBW (1.90&2.33kg)andfat- freemass (0.78&1.20kg)at 3months,benefit maintainedat 6months (1.57&3.35kg)and (0.63&1.60kg), respectively
Lauque,etal.,2004 (104) Elderlypatients fromnursing careunitsofa geriatricfacility
n=143, 60–103, 83(median) Prospective (uncontrolled) intervention
1020–2040kcaland 42–84gprotein1–6YearsIncreasedBW(0.319kg/ monthfor0–23 months),(0.174kg/ monthfor24–60 months),and maintainedprotein status
Levinsonetal.,2005 (105) Eldersreceiving communityat- homecare service
42/41,82& 7.5and79 &6.1 RCT250kcal16WeeksIncreasedweightgain (1.62&1.77kg), excessiveweightloss stabilizedorreversed
Payetteetal.,2002 (106) Emergency admission patientsto elderlyunitin Scotland hospital
165/162, >60RCT540kcaland22.5g protein18MonthsReducedmortality (p<0.05),BWgain (p=0.003),andbetter energyintake (p=0.001)
Potteretal.,2001(65) (continued)
Chapter 9/ Redefining Nutritional Frailty 173
Table9.6 (continued) Characteristicsof geriatricstudy population N** andmean &SEMage, yearsStudydesignProtein/energy supply/dayIntervention duration
Mortality,BW,and nutritionaloutcomesin treatmentgroupReference Undernourished patients,post- hospital discharge
35/41, 85RCT600kcal,24g protein8Weeksafter hospital discharge Insignificant(p=0188) BWincrease,greater increaseinhandgrip strength
Priceetal.,2005(64) Psychogeriatric nursinghome residentsinthe Netherlands
19/16,85& 84and79 &8.8 RCT273kcaland8.5g protein3MonthsSignificantimprovement wasobservedforBW (1.4&2.4kg,p=0.03) andnutritionalstatus
Woutersetal.,2002 (107) Residence/ sheltered housingfor olderpeoplein theNetherlands
34/34,84& 63and81 &6.9 RCT250kcal,8.8g protein6MonthsIncreasedBWgain (1.6kg,p=0.03), increaseinand positiveinfluenceon sleep
Woutersetal.,2003 (108) * Onlystudiesconductedsince1997areincluded. **N,intervention/controlwheneverthisinformationisavailable. RCT,randomizedcontrolledtrial;BW,bodyweight;MNA,MiniNutritionalAssessment.
174 Bales and Ritchie
preparation is prohibited or unsafe. Timing of supplements with meals must be considered, recognizing that older adults reach satiation more quickly and have slower gastric emptying (67). Liquid dietary supplements should be adminis- tered between meals in order to optimize net energy consumption for the day (68).