Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults

Background Disease-related malnutrition has been reported in 10% to 55% of people in hospital and the community and is associated with significant health and social-care costs. Dietary advice (DA) encouraging consumption of energy- and nutrient-rich foods rather than oral nutritional supplements (ONS) may be an initial treatment. Objectives To examine evidence that DA with/without ONS in adults with disease-related malnutrition improves survival, weight, anthropometry and quality of life (QoL). Search methods We identified relevant publications from comprehensive electronic database searches and handsearching. Last search: 01 March 2021. Selection criteria Randomised controlled trials (RCTs) of DA with/without ONS in adultswith disease-related malnutrition in any healthcare setting compared with no advice, ONS or DA alone. Data collection and analysis Two authors independently assessed study eligibility, risk of bias, extracted data and graded evidence. Main results We included 94, mostly parallel, RCTs (102 comparisons; 10,284 adults) across many conditions possiblyexplaining the highheterogeneity. Participants were mostly older people in hospital, residential care and the community, with limited reporting on their sex. Studies lasted from one month to 6.5 years. DA versus no advice -24 RCTs (3523 participants) Most outcomes had low-certainty evidence. There may be little or no eNect on mortality aOer three months, RR 0.87 (95% confidence interval (CI) 0.26 to 2.96), or at later time points. We had no three-month data, but advicemay make little or no diNerence to hospitalisations, or days in hospital aOer fourto sixmonths and up to 12 months. A similar eNect was seen for complications at up to three months, MD 0.00 (95% CI -0.32 to 0.32) and between four and six months. Advice may improve weight aOer three months, MD 0.97 kg (95% CI 0.06 to 1.87) continuing at four to six monthsand up to 12 months; and may result in a greater gain in fat-free mass (FFM) aOer12 months,but not earlier. It may alsoimprove global QoL at up to three months, MD 3.30 (95% CI 1.47 to 5.13), but not later. DA versus ONS -12 RCTs (852 participants) All outcomes had low-certainty evidence. There may be little or no eNect on mortality aOer threemonths, RR 0.66 (95% CI 0.34 to 1.26), or at later time points. Either intervention may make little or no diNerence to hospitalisations at three months, RR 0.36 (95% CI 0.04 to 3.24), but ONS may reduce hospitalisations up to six months. There waslittle or no diNerence between groups in weight change at three months, MD -0.14 kg (95% CI -2.01 to 1.74), or between four to six months. Advice (one study) may lead to better global QoL scores but only aOer 12 months. No study reported days in hospital, complications or FFM. DA versus DA plus ONS -22 RCTs (1286 participants) Most outcomes had low-certainty evidence.There may be little or no eNect on mortality aOer three months,RR 0.92 (95% CI 0.47 to 1.80) or at later time points. At three months advice may lead to fewer hospitalisations,RR 1.70 (95% CI 1.04 to 2.77), but not at up to six months. There may be little or no eNect on length of hospital stayat up to three months, MD -1.07 (95% CI -4.10 to 1.97). At three months DA plus ONS may lead to fewer complications, RR 0.75 (95% CI o.56 to 0.99);greater weight gain,MD 1.15 kg (95% CI 0.42 to 1.87); and better global QoL scores, MD 0.33 (95% CI 0.09 to 0.57), but this was not seen at other time points. There was no eNect on FFM at three months. DA plus ONS if required versus no advice or ONS -31 RCTs (3308 participants) Evidence was moderate- to low-certainty. There may be little or no eNect on mortality at three months, RR 0.82 (95% CI 0.58 to 1.16) or at later time points. Similarly, little or no eNect on hospitalisationsat threemonths, RR 0.83 (95% CI 0.59 to 1.15), at four to six months and up to 12 months; on days in hospital at three months, MD -0.12 (95% CI -2.48 to 2.25)or for complications at any time point. At three months, advice plus ONS probably improve weight,MD 1.25 kg (95% CI 0.73 to 1.76) and may improve FFM, 0.82 (95% CI 0.35 to 1.29), but these eNects were not seen later. There may be little or no eNect of either intervention on global QoL scores at three months, but advice plus ONS may improvescores at up to 12 months. DA plus ONS versus no advice or ONS -13 RCTs (1315 participants) Evidence waslow- to very low-certainty. There may be little or no eNect on mortality aOer threemonths,RR 0.91 (95% CI 0.55 to 1.52) or at later time points. No studyreported hospitalisations and there may be little or no eNect on days in hospitalaOer three months,MD -1.81 (95% CI -3.65 to 0.04) or six months. Advice plus ONS may lead to fewer complications up to three months, MD 0.42 (95% CI 0.20 to 0.89) (one study). Interventions may make little or no diNerence to weight at three months,MD 1.08 kg (95% CI -0.17 to 2. 33); however,advice plus ONS may improve weight at four to six months and up to 12 months. Interventions may make little or no diNerence in FFM or global QoL scores at any time point. Authors' conclusions We found no evidence of an eNect of any intervention on mortality.There may be weight gain with DA and with DA plus ONS in the short term, but the benefits of DA when compared with ONS are uncertain.The size and direction of eNect and the length of intervention and follow-up required for benefits to emerge were inconsistent for all other outcomes. There were too few data for many outcomes to allow meaningful conclusions.Studies focusing on both patient-centred and healthcare outcomes are needed to address the questions in this review.