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Oral nutritional interventions in frail older people who are malnourished or at risk of malnutrition: a systematic review

Lookup NU author(s): Dr Katie ThomsonORCiD, Stephen RiceORCiD, Oluwatomi Arisa, Eugenie Johnson, Dr Louise TannerORCiD, Dr Christopher Marshall, Tumi Sotire, Catherine Richmond, Hannah O'Keefe, Wael MohammedORCiD, Professor Barbara Hanratty, Professor Dawn CraigORCiD, Professor Sheena Ramsay



This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0).


BackgroundMalnutrition worsens the health of frail older adults. Current treatments for malnutrition may include prescribed oral nutritional supplements, which are multinutrient products containing macronutrients and micronutrients.ObjectiveTo assess the effectiveness and cost-effectiveness of oral nutritional supplements (with or without other dietary interventions) in frail older people who are malnourished or at risk of malnutrition.Data sourcesMEDLINE, EMBASE, Cochrane Library, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and grey literature were searched from inception to 13 September 2021.Review methodsA systematic review and meta-analysis was conducted to evaluate the effectiveness and cost-effectiveness of oral nutritional supplements in frail older people (aged ≥ 65 years) who are malnourished or at risk of malnutrition (defined as undernutrition as per National Institute for Health and Care Excellence guidelines). Meta-analysis and network meta-analysis were undertaken, where feasible, along with a narrative synthesis. A cost-effectiveness review was reported narratively. A de novo model was developed using effectiveness evidence identified in the systematic review to estimate the cost-effectiveness of oral nutritional supplements.ResultsEleven studies (n = 822 participants) were included in the effectiveness review, six of which were fully or partly funded by industry. Meta-analyses suggested positive effects of oral nutritional supplements compared with standard care for energy intake (kcal) (standardised mean difference 1.02, 95% confidence interval 0.15 to 1.88; very low quality evidence) and poor mobility (mean difference 0.03, p < 0.00001, 95% confidence interval 0.02 to 0.04; very low quality evidence) but no evidence of an effect for body weight (mean difference 1.31, 95% confidence interval –0.05 to 2.66; very low quality evidence) and body mass index (mean difference 0.54, 95% confidence interval –0.03 to 1.11; very low quality evidence). Pooled results for other outcomes were statistically non-significant. There was mixed narrative evidence regarding the effect of oral nutritional supplements on quality of life. Network meta-analysis could be conducted only for body weight and grip strength; there was evidence of an effect for oral nutritional supplements compared with standard care for body weight only. Study quality was mixed; the randomisation method was typically poorly reported. One economic evaluation, in a care home setting, was included. This was a well-conducted study showing that oral nutritional supplements could be cost-effective. Cost-effectiveness analysis suggested that oral nutritional supplements may only be cost-effective for people with lower body mass index (< 21 kg/m2) using cheaper oral nutritional supplements products that require minimal staff time to administer.LimitationsThe review scope was narrow in focus as few primary studies used frailty measures (or our proxy criteria). This resulted in only 11 included studies. The small evidence base and varied quality of evidence meant that it was not possible to determine accurate estimates of the effectiveness or cost-effectiveness of oral nutritional supplements. Furthermore, only English-language publications were considered.ConclusionsOverall, the review found little evidence of oral nutritional supplements having significant effects on reducing malnutrition or its adverse outcomes in frail older adults.Future workFuture research should focus on independent, high-quality, adequately powered studies to investigate oral nutritional supplements alongside other nutritional interventions, with longer-term follow-up and detailed analysis of determinants, intervention components and cost-effectiveness.Study registrationThis study is registered as PROSPERO CRD42020170906.FundingThis project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 51. See the NIHR Journals Library website for further project information.

Publication metadata

Author(s): Thomson K, Rice S, Arisa O, Johnson E, Tanner L, Marshall C, Sotire T, Richmond C, O'Keefe H, Mohammed W, Gosney M, Raffle A, Hanratty B, McEvoy CT, Craig D, Ramsay SE

Publication type: Article

Publication status: Published

Journal: Health Technology Assessment

Year: 2022

Volume: 26

Issue: 51

Print publication date: 19/12/2022

Online publication date: 19/12/2022

Acceptance date: 01/12/2022

Date deposited: 30/12/2022

ISSN (print): 1366-5278

ISSN (electronic): 2046-4924

Publisher: NIHR


DOI: 10.3310/CCQF1608


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