UWL: Medical Food Supplements 2009
Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.
UWL: Indications for Medical Food Supplements
The Registered Dietitian (RD) should recommend medical food supplements for older adults who are undernourished or at risk of undernutrition (i.e., those who are frail, those who have infection, impaired wound healing, pressure ulcers, depression, early to moderate dementia and/or after hip fracture and orthopedic surgery). Studies support medical food supplementation as a method to provide energy and nutrient intake, promote weight gain and maintain or improve nutritional status or prevent undernutrition.
Risks/Harms of Implementing This Recommendation
Conditions of Application
Medical food supplements should be initiated as soon as possible for improved outcomes.
Potential Costs Associated with Application
- Medical food supplements may be costly
Two positive-quality systematic reviews were evaluated regarding nutritional supplementation in older adults. Both concluded that oral protein and energy supplementation produces a small but consistent weight gain in older adults (Milne et al, 2005; Avenell and Handoll, 2006).
Seven studies that were evaluated report an association between underweight, weight loss and/or poor nutrition status and prevalence of infection in adults over age 65 (Langmore et al, 2002; van der Steen et al, 2002; Barreto et al, 2003; Rothan-Tondeur et al, 2003; Dambach et al, 2005; Paillaud et al, 2005; Schmaltz et al, 2005).
- ESPEN Recommendation 2.1: "In patients who are undernourished or at risk of undernutrition use oral nutritional supplementation to increase energy, protein and micronutrient intake, maintain or improve nutritional status, and improve survival. In frail elderly use oral nutritional supplements (ONS) to improve or maintain nutritional status." (Grade A)
- ESPEN Recommendation 2.1: "In case of nutritional risk (e.g. insufficient nutritional intake, unintended weight loss >5% in 3 months or >10% in 6 months, body-mass index (BMI) < 20 kg/m2) initiate oral nutritional supplementation and/or tube feeding early." (Grade B)
- ESPEN Recommendation 2.7: "In demented patients oral nutritional supplements or tube feeding may lead to an improvement of nutritional status. In early to moderate dementia consider oral nutritional supplements -- and occasionally tube feeding -- to ensure adequate energy and nutrient supply and to prevent undernutrition." (Grade C)
Recommendation Strength Rationale
- Conclusion Statements in support of this recommendation received Grade I
- ESPEN recommendations received Grades A, B and/or C
- Risks/Harms of Implementing This Recommendation
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
What is the relationship between nutrient-dense oral supplements/fortified foods and weight gain in adults over age 65?
What is the evidence that underweight and/or weight loss is associated with prevalence of infection in adults over age 65?
Avenell A, Handoll HHG. Nutritional supplementation for hip fracture aftercare in older people. Cochrane Database Syst Rev 2006; (4): CD001880.
Milne AC, Potter J, Avenell A. Protein and energy supplementation in elderly people at risk for malnutrition. Cochrane Database Syst Rev 2005; (2): CD003288.
Barreto SM, Passos VM, Lima-Costa MF. Obesity and underweight among Brazilian elderly: The Bambui Health and Aging Study. Cad Saude Publica. 2003; 19(2): 605-512.
Dambach B, Salle A, Marteau C, Mouzet JB, Ghali A, Favreau AM, Berrut G, Ritz P. Energy requirements are not greater in elderly patients suffering from pressure ulcers. J Am Geriatr Soc 2005;53:478-482.
Langmore SE, Skarupski KA, Park PS, Fries BE. Predictors of aspiration pneumonia in nursing home residents. Dysphagia. 2002; 17(4): 298-307.
Paillaud E, Herbaud S, Caillet P, Lejonc JL, Campillo B, Bories PN. Relations between undernutrition and nosocomial infections in elderly patients. Age and Ageing. 2005; 34: 619-625.
Rothan-Tondeur M, Meaume S, Girard L, Weill-Engerer S, Lancien E, Abdelmalak S, Rufat P, Le Blanche AF. Risk factors for nosocomial pneumonia in a geriatric hospital: A control-case one-center study. J Am Geriatr Soc. 2003; 51: 997-1,001.
Schmaltz HN, Fried LP, Xue QL, Walston J, Leng SX, Semba RD. Chronic cytomegalovirus infection and inflammation are associated with prevalent frailty in community-dwelling older women. J Am Geriatr Soc. 2005; 53(5): 747-754.
van der Steen JT, Ooms ME, Mehr DR, van der Wal G, Ribbe MW. Severe dementia and adverse outcomes of nursing-home acquired pneumonia: evidence for mediation by functional and pathophysiological decline. J Am Geriatr Soc. 2002; 50 (3): 439-448.
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel, 2009. Accessible at www.npuap.org.
Volkert D, Berner YN, Berry E, Cederholm T, Coti Bertrand P, Milne A, Palmblad J, Schneider S, Sobotka L, Stanga Z, DGEM: Lenzen-Grossimlinghaus R, Krys U, Pirlich M, Herbst B, Schutz T, Schroer W, Weinrebe W, Ockenga J, Lochs H, ESPEN. ESPEN Guidelines on Enteral Nutrition: Geriatrics. Clin Nutr 2006;25(2):330-360.