There is much uncertainty about the value of dietary advice and dietary supplements. If these interventions do anything at all, then surely this would show in malnourished patients. And if any effect can be demonstrated, then surely with a hard endpoint, such as survival. This study tested the hypothesis; it investigated the effect on survival after 6 months of treatment involving individual dietary advice and oral nutritional supplements in older malnourished adults after discharge from hospital.
This multicentre randomised controlled trial was supported by grants from Region Västmanland, Uppsala-Örebro Regional Research Foundation (RFR), and the Swedish National Board of Health and Welfare. It included 671 patients aged 65 years who were malnourished or at risk of malnutrition when admitted to hospital between 2010 and 2014, and followed up after 8.2 years (median 4.1 years). Patients were randomised to receive:
- dietary advice,
- oral nutritional supplements,
- a combination of both,
- routine care.
The intervention started at discharge from the hospital and continued for 6 months, with survival being the main outcome measure.
During the follow-up period 398 (59.3%) participants died. At follow-up, the survival rates were
- 36.9% for dietary advice,
- 42.4% for oral nutritional supplements,
- 40.2% for dietary advice combined with oral nutritional supplements,
- 43.3% for the control group.
After stratifying the participants according to nutritional status, survival still did not differ significantly between the treatment arms (log-rank test p = 0.480 and p = 0.298 for the 506 participants at risk of malnutrition and the 165 malnourished participants, respectively).
The authors concluded that oral nutritional supplements with or without dietary advice, or dietary advice alone, do not improve the survival of malnourished older adults. These results do not support the routine use of supplements in older malnourished adults, provided that survival is the aim of the treatment.
The findings of this trial seem perhaps counter-intuitive and they contradict the current Cochrane review on the subject. I nevertheless feel that this is an interesting, rigorous and important study. It deserves to be publicised widely – perhaps more widely than the ‘Upsala Journal of Medical Science’ would afford.
8 Responses to Dietary Supplements Do Not Increase Survival in Malnourished Adults
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Basic life concept, eat food and you will not have malnourishment. If a community that is suppressed, have whoever is supplying vitamins to spend money on actual food instead. Actual real food is cheaper than supplements, even if basics of protein and carbs by rice and potatoes. Both are much cheaper than vitamins and much more fulfilling. I am almost certain that supplement supplier will contest basic consumption.
Please note that the dietary supplements used in this trial were essentially protein and calories; these sorts of supplements are frequently prescribed for people who are unable to eat normally (e.g. due to advanced cancer or other serious disease affecting their diet). There are many of these available (e.g. Ensure, Hycal, Fresubin, Fortisip…). They are quite different from the supplements sold in health food shops. They come in a variety of flavours (fruity, milky, sweet, savoury) though the ones I have tried haven’t been particularly appetising.
Generally you need to take about eight of these a day to substitute for a normal diet, though I have never met anybody who was able to manage more than two.
The authors noted that some people in the control group had seen a dietician separately from the trial, and also that the ordinary diet supplied in the hospital was nutritionally adequte. They also pointed out that there may be benefits other than on survival from improving nutritional status, for instance on activity and quality of life, though this was not addressed by the trial.
good point!
but the authors also stated that the supplements contained vitamins and minerals
Yes, they have to contain vitamins and minerals in order to be nutritionally complete. But their primary purpose is to provide protein and calories:
“All patients randomised to oral nutritional supplements were asked to drink 1–2 bottles per day, depending on the energy content of the supplement, to provide 400 kcal/day and 12–20 g protein. The participants were allowed to choose between different flavours and brands to increase their compliance. Protein-dense supplements with a complete vitamin and mineral content were offered first. Only if these were not tolerated were the participants offered supplements with lower protein content. The supplements had a volume of 125–200 ml/bottle, energy density 1.25–2.4 kcal/mL, and protein content 4–9.4 g/100 ml.”
The study fell well short of its recruitment target so was underpowered. Even so the effect size differences are negligible.
“nutritional supplements” and “dietary advice” are pretty broad terms that could cover anything from the sublime to the ridiculous. For instance telling someone to take the DRI is practically a recommendation for starvation; they might avoid scurvy if they were lucky. Studies like these seemed designed to make people think that supplements are useless rather than trying to test something really useful.
Roger,
What is DRI? I am guessing that you mean daily recommended intake (of vitamins etc.), in which case you have missed the point of what this study is about – the researchers were trying to get calories and protein into their at-risk patients.
Scurvy these days is very rare – I have only seen one case in my career, which was an elderly schizophrenic man living alone with a very strange diet.
DRI: https://en.m.wikipedia.org/wiki/Dietary_Reference_Intake