Protein and energy supplementation in elderly people at risk from malnutrition

Milne, Anne C; Potter, Jan; Vivanti, Angela; Avenell, Alison

doi:10.1002/14651858.cd003288.pub3

Cited by 849Nutrition and Health in AgingClinical Nutrition and GastroenterologyNutrition and Health Studies

Protein and energy supplementation in elderly people at risk from malnutrition

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Milne, Anne C, Potter, Jan, Vivanti, Angela, Avenell, Alison·2009·Cochrane Database of Systematic Reviews

DOI 10.1002/14651858.cd003288.pub3PMC PMC7144819

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Abstract

BACKGROUND: Evidence for the effectiveness of nutritional supplements containing protein and energy, often prescribed for older people, is limited. Malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition. OBJECTIVES: This review examined trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually as commercial 'sip-feeds'. SEARCH STRATEGY: We searched The Cochrane Library, MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials of oral protein and energy supplementation in older people, with the exception of groups recovering from cancer treatment or in critical care. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary. MAIN RESULTS: Sixty-two trials with 10,187 randomised participants have been included in the review. Maximum duration of intervention was 18 months. Most included trials had poor study quality. The pooled weighted mean difference (WMD) for percentage weight change showed a benefit of supplementation of 2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42 trials. There was no significant reduction in mortality in the supplemented compared with control groups (relative risk (RR) 0.92, CI 0.81 to 1.04) from 42 trials. Mortality results were statistically significant when limited to trials in which participants (N = 2461) were defined as undernourished (RR 0.79, 95% CI 0.64 to 0.97).The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75 to 0.99). Few trials were able to suggest any functional benefit from supplementation. The WMD for length of stay from 12 trials also showed no statistically significant effect (-0.8 days, 95% CI -2.8 to 1.3). Adverse effects included nausea or diarrhoea. AUTHORS' CONCLUSIONS: Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.

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The latest Cochrane update from 2009 indicates that protein-energy supplementation reduces mortality, especially in older, undernourished subjects and in patients with geriatric conditions.
“The latest Cochrane update from 2009 indicates that protein-energy supplementation reduces mortality, especially in older, undernourished subjects and in patients with geriatric conditions.74”
From Evidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group (2013) · cites this paper as [74]
Considerable evidence supports that supplemental protein or higher dietary protein intake by older people hospitalized for hip fracture could reduce risk for complications, improve bone mineral density, and reduce rehabilitation time.
“Considerable evidence supports the concept that supplemental protein or higher dietary protein intake by older people hospitalized for hip fracture could reduce risk for complications, 74,84,85 improve bone mineral density, 86,87 and reduce rehabilitation time (Table 4).86”
From Evidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group (2013) · cites this paper as [74]
Reduced mortality risk has been reported in undernourished, hospitalized geriatric patients where supplementation (at least 400 kcal/d) may assume a therapeutic role.
“Reduced mortality risk has been reported in undernourished, hospitalized geriatric patients where supplementation (at least 400 kcal/d) may assume a therapeutic role.74”
From Evidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group (2013) · cites this paper as [74]
Milne et al reviewed 62 studies on protein and energy supplementation in older people.
“Milne et al 74 reviewed a total of 62 studies on protein and energy supplementation in older people.”
From Evidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group (2013) · cites this paper as [74]
Findings from 3 comprehensive reviews/meta-analyses and 2 recently published clinical trials may suggest some beneficial effects of dietary protein on physical function, especially in individuals who are older, malnourished, frailer, and with interventions used for at least 3 months.
“However, findings from 3 comprehensive reviews/meta-analyses 73,74,84 and 2 recently published clinical trials 227,228 may suggest some beneficial effects, especially in individuals who are older, malnourished, frailer, and with interventions used for at least 3 months (Table 8).”
From Evidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group (2013) · cites this paper as [74]

Few of the studies in Milne et al's review supported functional benefits from protein-energy supplementation.
“Overall results showed that the risk of complications was reduced in 24 trials (relative risk [RR] 0.86, 95% CI 0.75e0.99),but few supported functional benefits from supplementation.”
From Evidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group (2013) · cites this paper as [74]
Nutrition, especially dietary protein intake, is known to affect overall function of the body.
“Nutrition, especially dietary protein intake, is known to affect overall function of the body.73,74,84,208e212”
From Evidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group (2013) · cites this paper as [74]
Protein-energy supplementation reduced the risk of complications in 24 trials (RR 0.86, 95% CI 0.75-0.99).
“Overall results showed that the risk of complications was reduced in 24 trials (relative risk [RR] 0.86, 95% CI 0.75e0.99),but few supported functional benefits from supplementation.”
From Evidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group (2013) · cites this paper as [74]
The mortality effect of ONS duration was no longer observed in the updated review in 2009.
“This effect was no longer observed in the updated review in 2009 (119), and this issue was not addressed in other SLRs.”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [119]
Subgroup analyses in the largest available SLR including 62 RCTs regarding mortality were consistently statistically significant when limited to trials where 400 kcal or more was provided per day by ONS.
“Subgroup analyses in the largest available SLR including 62 RCTs (119) regarding mortality were consistently statistically significant when limited to trials where 400 kcal J o u r n a l P r e -p r o o f or more was provided per day by ONS.”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [119]
Positive effects of ONS on dietary intake and body weight, and reduced risk of complications and readmissions were reported, whereas length of hospital stay and mortality risk were not significantly reduced.
“Altogether, positive effects of ONS on dietary intake (115, 116, 119, 121) and BW (115, 116, 119, 121), and reduced risk of complications (121) and readmissions (115, 120, 121) were reported, whereas the length of hospital stay (114, 115, 121) and mortality risk (114-116, 119, 121) were not significantly reduced.”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [119]
The most comprehensive review included 62 randomized or quasi-randomized clinical trials in older persons in a variety of settings and varying nutritional states.
“The most comprehensive review included 62 randomized or quasi-randomized clinical trials in older persons in a variety of settings and varying nutritional states (119).”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [119]
A systematic literature search found six high-quality SLRs that have assessed the efficacy of ONS versus usual care in older persons.
“A systematic literature search found six high-quality SLRs that have assessed the efficacy of ONS versus usual care in older persons (114-121).”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [119]

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Frailty Consensus: A Call to Action
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ESPEN guideline on clinical nutrition and hydration in geriatrics
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“A number of studies and 2 meta-analyses in older persons with malnutrition and/or illness have shown positive effects of nutritional supplementation.(28,29) However, these persons had some degree of cachexia and, thus, no conclusion on the effect of supplements on physiological sarcopenia can be drawn.”
The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty
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ESPEN guidelines on nutritional support for polymorbid internal medicine patients
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Meta-Analysis: Protein and Energy Supplementation in Older People
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Muscle loss: The new malnutrition challenge in clinical practice
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Potentially modifiable determinants of malnutrition in older adults: A systematic review
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Malnutrition is associated with increased mortality in older adults regardless of the cause of death
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Inflammation and nutrition: friend or foe?
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Authors: Milne, A. C., Potter, J., Vivanti, A., & Avenell, A.
Affiliations: Stonelea, Prospect Terrace, Port Elphinstone, Inverurie Aberdeen Aberdeenshire, Scotland UK AB51 3UN
South East Sydney and Illawarra Area Health Service; Aged Care Southern Hospital Network; LMB 8808 South Coast Mail Centre Wollongong New South Wales Australia 2521
Princess Alexandra Hospital (AU)
University of Aberdeen (GB)
ORCID: Vivanti, Angela
Avenell, Alison
Venue: Cochrane Database of Systematic Reviews
Publisher: Wiley
Published: 2009-04-15
Issue: 2
Pages: CD003288-CD003288
ISSN: 1361-6137 (ISSN-L)
1465-1858
DOI: 10.1002/14651858.cd003288.pub3
PMC: PMC7144819
OpenAlex: W1578200161
Cited by: 849
References: 242
Citations by year: 2026: 8 · 2025: 14 · 2024: 20 · 2023: 32 · 2022: 41 · 2021: 44 · 2020: 34 · 2019: 35 · 2018: 56 · 2017: 58 · 2016: 63 · 2015: 64 · 2014: 64 · 2013: 63 · 2012: 52
FWCI: 6.28
Type: journal article
Language: en
Open access: bronze
doi.org
Locations: Cochrane Database of Systematic Reviews (publishedVersion)
PubMed Central (publishedVersion)
PubMed (publishedVersion)
Topics: Health Sciences › Medicine › Physiology › Nutrition and Health in Aging
Health Sciences › Nursing › Nutrition and Dietetics › Clinical Nutrition and Gastroenterology
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutrition and Health Studies
Keywords: protein supplementation, energy supplementation, malnutrition, older adults, nutritional status, weight gain, mortality, complications, length of hospital stay, adverse effects, nausea, diarrhea, functional outcome, clinical outcomes, heterogeneity of results, publication bias, risk of bias assessment, conflicts of interest
MeSH terms: Aged, Energy Intake, Dietary Proteins, Humans, Length of Stay, Randomized Controlled Trials as Topic, Dietary Supplements, Malnutrition

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Protein and energy supplementation in elderly people at risk from malnutrition

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