Dr. Elizabeth WeekesDepartment of Nutrition & DieteticsGuy’s & St. Thomas’ NHS Foundation TrustLondon

Dietary counselling and food fortificationDietary counselling and food fortificationversusversus oral nutritional supplements oral nutritional supplements in the communityin the community

IntroductionIntroduction

Role for proprietary nutritional supplements in disease-related malnutrition is well established

Relative lack of evidence for the role of dietary counselling and/or food fortification, especially

in the community

(Baldwin et al., 2001; Stratton, Elia & Green, 2003)

Food first Food first versusversus oral nutritional supplements oral nutritional supplements

Tailored advice and counselling of carers may improve compliance, especially in chronic disease

Food and drink provide more variety in flavour, texture and consistency

Changes in dietary behaviour may persist beyond the intervention period

Food fortification may help patients with poor appetite and/or early satiety

Dietary counselling in the communityDietary counselling in the community

Imes et al., (1987,1988)- 137 outpatients with Crohn’s disease- 6 months dietary counselling- ↑ energy and micronutrient intakes- ↑ incidence of remission; ↓ length of hospital stay- ↓ time lost from work- Effects continued through further 6 months of

follow-up

Dietary counselling in the communityDietary counselling in the community

Macia et al., (1991) - 93 Cancer patients receiving radiotherapy- Head & neck (HN), breast (B) and abdo-pelvic (AP)- Individual dietary programme for up to 2 years- HN and AP controls ↓ weight, MAC and TSF while

intervention group maintained- B no differences between groups (better nourished)- No measures of functional status

Food fortification in the communityFood fortification in the community

De Jong et al., (1999)

- 145 free-living, frail elderly

- Nutrient-dense foods, exercise, both or control

- ↑ micronutrient intake and vitamin status in supplemented

- No measures of nutritional or functional status

Extra meals or snacks in the communityExtra meals or snacks in the community

Kretser et al., (2003)

- 203 housebound elderly

- MoW or MoW + snacks for 6 months

- ↑ weight in supplemented

- functional improvements associated with BMI

and age rather than intervention

Extra meals or snacks in the communityExtra meals or snacks in the community

Gollub et al., (2004)

- 381 frail, housebound elderly

- Breakfast + lunch vs. lunch alone for 6 months

- ↑ energy intake and food security

- ↓ depressive symptoms

- No difference in QoL scores

- No assessment of nutritional status

Research questionsResearch questions

Can six months intervention with dietary counselling and food fortification result in weight gain in outpatients with COPD?

Is weight gain associated with measurable clinical benefit for the patient?

Study designStudy design

Baseline Month 6 Month 12

Intervention

Follow-up

M1 M3 M7 M9W2

Dietary counselling and food fortificationDietary counselling and food fortification

Intervention- Experienced dietitian- Advice tailored to clinical condition,

lifestyle and preferences etc.- Six months free supply of milk

powder for food fortification(Pluspints, Kerry Foods, Eire)

- NAGE leaflet, written advice and practical demonstrations

Control- NAGE leaflet

RecruitmentRecruitment

59 completed baseline assessmentIntervention n = 31

Control n = 28

50 completed 1 month assessment

37 (63 %) completed 12 month assessmentIntervention n=20

Control n = 17

40 completed 6 month assessment

Patient characteristics (n = 59)Patient characteristics (n = 59)

Intervention

N = 31

Control

N = 28

Females:Males

Age (years)

Weight (kg)

Body mass index (kg/m2)

FEV1 (% predicted)

Energy intake (kcal/day)

Protein intake (g/day)

15:16

68.9 (47 – 89)

54.5 (7.3)

19.9 (1.4)

30.9 (12.8)

1974 (371)

68.5 (11.6)

14:14

69.2 (46 – 85)

53.5 (8.5)

19.5 (1.9)

32.7 (14.6)

1931 (425)

66.1 (11.6)

Energy intake (kcal/day)Energy intake (kcal/day)

19262064

18801715

0

500

1000

1500

2000

2500

kcal

/day

Intervention (n = 20)

Control (n = 17)

Months 1 to 6 Months 7 to 12

Protein intake (g/day)Protein intake (g/day)

69.4

77.1

65.0

56.9

0

10

20

30

40

50

60

70

80

90

g/da

y

Intervention (n = 20)

Control (n = 17)

Months 1 to 6 Months 7 to 12

Advice offered to the intervention group Offered Complied

Snacks between mealsDessert at lunch and/or supperFortify meals using recipes in the NAGE leafletChange from low fat to full fat dairy productsIncrease fruit and/or vegetable intake Eat breakfastSeparate dessert from main mealChange from “diet” products e.g. sweetenersUse Complan/Build-up soups

Choose energy-dense foods from menusShare meals with family or friendsLunch clubsReferred for Meals-on-Wheels

21151411114442

6221

21 (100 %)7 (47 %)

11 (79 %)2 (18 %)9 (82 %)2 (50 %)2 (50 %)2 (50 %)

2 (100 %)

6 (100 %)2 (100 %)2 (100 %)1 (100 %)

Dietary counsellingDietary counselling

NAGE leafletNAGE leaflet

Dietary counsellingDietary counselling

Compliance

Costs to patient

Shopping

Isolation

“Healthy eating”

Method of fortification Number of patients (%)

"Fortified Milk" added to:

WMP added direct to:

hot drinkscold drinksbreakfast cereal/porridgemilk puddingshome-made milkshakes

mashed potatoessoupporridgesavoury sauces/gravyscrambled eggsyogurt or mousse

14 (45 %)14 (45 %)12 (39 %)4 (13 %)2 (6 %)

4 (13 %)2 (6 %)2 (6 %)2 (6 %)1 (3 %)1 (3 %)

Food fortification using milk powderFood fortification using milk powder

Food fortification using milk powderFood fortification using milk powder

23 (74 %) used milk powder

for six months Provided 129 (+ 70) kcal/day Appearance adequate or good Response to flavour, texture

and consistency more variable 5 (22 %) bought WMP during

follow-up period 4 (17 %) stated they would use

WMP if they lost weight

Milk powder vs. oral nutritional supplementsMilk powder vs. oral nutritional supplements

Costs to PCTs

Costs to patient

Supply and delivery

Preparation

Cessation of nutritional supplementsCessation of nutritional supplements

Nutritional intake and body weight decreased towards baseline levels within 2 – 3 months(O’Morain et al., 1984; Knowles et al., 1988; Arnold & Richter et al., 1989; Woo et al., 1994; Edington et al., 2004)

Some loss of functional benefits (Efthimiou et al., 1988)

-4

-3

-2

-1

0

1

2

3

4

5

Time (months)

Wei

ght c

hang

e (k

g)

InterventionControl

3 6 9 12

Weight change (kg)Weight change (kg)

-15

-10

-5

0

5

10

Ch

ang

e in

SG

RQ

Tot

al s

core

Intervention

Control

6 months(n = 37)

12 months(n = 34)

Change in Quality of LifeChange in Quality of Life

ConclusionsConclusions

• It was possible to achieve weight gain in outpatients with COPD, using dietary counselling and food fortification

• Both dietary counselling and food fortification contributed to the increased energy and protein intakes

• Weight was maintained for at least six months after intervention ceased

• Improvements in some variables persisted beyond the intervention period e.g. Quality of Life

Future researchFuture research

Evaluate the specific impact of each strategy (dietary counselling, food fortification, oral nutritional supplements) alone or in combination

Effects of cessation of intervention need further investigation

Prospective cost-effectiveness analyses

Patient group, care setting and the professional giving advice may all affect results

“But, in chronic cases …where the fatal issue is often determined by mere protracted starvation, I had rather not enumerate the instances I have known where a little ingenuity, and a great deal of perseverance, might have averted the result.”

Florence Nightingale, 1859