NUTRITION AND COMBINED NUTRITION PLUS PHYSICAL ACTIVITY - - PowerPoint PPT Presentation

NUTRITION AND COMBINED NUTRITION PLUS PHYSICAL ACTIVITY INTERVENTIONS FOR OLDER ADULTS LIVING WITH FRAILTY: A SYSTEMATIC REVIEW AND META-ANALYSIS

PREPARED AND PRESENTED FOR: NUTRITION AND PHYSICAL ACTIVITY CLINICAL PRACTICE GUIDELINES FOR OLDER ADULTS WITH FRAILTY STAKEHOLDER PANEL MEETING JUNE 29TH, 2020 HOSTED BY: THE CANADIAN FRAILTY NETWORK

On behalf of the McMaster Evidence Review and Synthesis T eam: Megan Racey, PhD Mohammad Usman Ali, MD Donna Fitzpatrick-Lewis, MSW Diana Sherifali, PhD

1

Disclaimer: The content of this presentation is confidential and may not be distributed or shared.

SCOPE OF THE PROBLEM

 Frailty is a leading contributor to functional decline and

early mortality in older adults.

 Frailty progression can be slowed and is potentially

reversible through nutrition interventions.

 As frailty is a multi-component condition which includes

physical factors such as reduced handgrip strength and gait speed, it is important to consider the enhanced impact that adequate nutrition could have on the benefits of physical activity in a frail population.

2

2.0M Canadians

in 10 years

1.5M Canadians

Falls Mobility decline Hospitalization Death

RESEARCH QUESTION

What is the effectiveness of nutrition interventions and nutrition interventions that include physical activity in older adults (age 65+ years) living with frailty or pre-frailty on clinical, patient important, or health utilization

• utcomes?

3

PICO

P – Older adults ≥ 65 years of age with frailty Must have formal definition of frailty using a tool, assessment of frailty, or established criteria 80% of study population is frail I – Any nutrition interventions in all settings from RCTs/CCTs or observational cohorts with a comparison group C – True comparison group, treatment as usual, standard care O – Health, mortality, physical, quality of life, health services use, frailty, mobility, diet quality, social/caregiver

4

Screening and extraction Data analysis Screening

• f articles

Data extraction PICO Inclusion / Exclusion criteria Search strategy Meta analysis of data Defining strategy

5

METHODS: CERTAINTY OF EVIDENCE (GRADE APPROACH)

 Common, systemic and transparent approach to grading certainty of evidence and strength of

recommendations

 Assess based on 5 categories:

• 1. Risk of bias
• 2. Inconsistency
• 3. Indirectness
• 4. Imprecision
• 5. Other consideration

 RCTs start as high certainty and can be downgraded; Observational studies start as low certainty and

can be upgraded Results in Certainty of Evidence:

 High, Moderate, Low, or

Very Low

6

METHODS: STATISTICAL ANALYSIS

 Continuous outcome data using standardized mean difference (SMD)

 SMDs 0.2-0.5 = small effect  SMDs 0.5-0.8 = medium effect  SMDs >0.8 = large effect

 Dichotomous outcome data using risk ratio (RR)  Studies assessed for Heterogeneity  Multi-level meta-analytic approach

7

RESULTS

8

PRISMA FLOWCHART

9

Records identified through database search N = 6733 Additional records identified through other sources* N = 2 Records after duplicates removed N = 3162 Records screened N = 3162 Records excluded N = 3039 Full-text articles assessed for eligibility N = 123 Full-text articles excluded, with reasons N = 108

• Study population (younger than 65, frailty not defined, clinical) (N = 61)

Not a nutrition intervention (N = 24) Too complex/Multi-component intervention (N = 3) Study design (N = 17) Full-text unavailable (N = 3) Studies included in qualitative synthesis N = 15** (26 articles) Studies included in quantitative synthesis (meta-analysis) N = 15

CHARACTERISTICS OF INCLUDED STUDIES

Majority of studies were;

 Location: Europe and Asia  Setting: Community-based  Frailty tool: Fried’s Frailty phenotype or cardiovascular health study criteria  Duration: 3 to 6 months  Intervention: Nutritional supplementation, fortified or enhanced foods, and nutrition or dietitian

counselling



Combined approach studies also focused on the same 3 nutrition interventions with most studies adding a resistance/strength training component. The physical activity occurred 1 to 2 times per week and between 30 minutes to over an hour in duration.

10

RESULTS OVERVIEW | EFFECTIVENESS OF INTERVENTIONS Nutrition

(and protein only supplementation)

Physical Mobility Health QoL Frailty Diet Quality

Combined Approach

Physical Mobility Health QoL Frailty Diet Quality

Protein supplementation subgroup had no QoL data. For all interventions, there was no data for mortality, health services use, or caregiver/social outcomes.

11

NUTRITION

Outcome # studies | N SMD (95% CI) p value GRADE rating Physical 7 | 694 Small; 0.16 (0.02, 0.29) 0.03 MODERATE

downgraded for risk of bias

Mobility 7 | 694 Small; 0.15 (0.001, 0.30) <0.05 MODERATE

downgraded for risk of bias

Health 4 | 284 No effect; -0.18 (-0.51, 0.16) 0.26 LOW

downgraded for risk of bias and imprecision

Frailty 3 | 255 Small; -0.22 (-0.44, -0.01) 0.04 MODERATE

downgraded for risk of bias

Diet Quality 5 | 383 No effect; 0.10 (-0.47, 0.67) 0.68 VERY LOW

downgraded for risk of bias, inconsistency, and imprecision

Quality of Life 1 | 243 No effect; -0.12 (-1.39, 1.15) 0.44 MODERATE

downgraded for imprecision

12

Bold denotes significance p<0.05; N = total number of participants; SMD = standardized mean difference; CI = confidence interval

PROTEIN SUPPLEMENTATION

Outcome # studies | N SMD (95% CI) p value GRADE rating Physical 5 | 344 Small; 0.16 (0.01, 0.31) 0.03 MODERATE

downgraded for risk of bias

Mobility 5 | 344 Small; 0.20 (0.02, 0.39) 0.04 MODERATE

downgraded for risk of bias

Health 3 | 177 No effect; -0.12 (-0.58, 0.34) 0.53 LOW

downgraded for risk of bias and imprecision

Frailty 2 | 148 No effect; -0.18 (-0.45, 0.09) 0.15 LOW

downgraded for risk of bias and imprecision

Diet Quality 4 | 297 No effect; -0.01 (-0.69, 0.67) 0.97 VERY LOW

downgraded for risk of bias, inconsistency, and imprecision

13

Bold denotes significance p<0.05; N = total number of participants; SMD = standardized mean difference; CI = confidence interval

COMBINED APPROACH

Outcome # studies | N SMD (95% CI) p value GRADE rating Physical 6 | 514 Small; 0.19 (0.06, 0.32) 0.007 MODERATE

downgraded for risk of bias

Mobility 6 | 514 Small; 0.25 (0.02, 0.48) 0.04 MODERATE

downgraded for risk of bias

Health 3 | 310 No effect; -0.05 (-0.42, 0.33) 0.72 LOW

downgraded for risk of bias and imprecision

Frailty 2 | 213 3 | 359 Small; -0.41 (-0.68, -0.14) RR 0.72 (0.52, 1.00) <0.01 <0.05 MODERATE

downgraded for risk of bias

Diet Quality 2 | 141 No effect; 0.53 (-0.98, 2.04) 0.49 VERY LOW

downgraded for risk of bias, inconsistency, and imprecision

Quality of Life 3 | 267 No effect; 0.31(-0.05, 0.67) 0.07 LOW

downgraded for risk of bias and imprecision

14

Bold denotes significance p<0.05; Italics for binary outcome; N = total number of participants; SMD = standardized mean difference; CI = confidence interval; RR = risk ratio

HARMS OR ADVERSE EVENTS OF THE INTERVENTION

 Few studies reported adverse effects or harms related to the interventions  Nutrition studies reported:  Nausea, diarrhea, dyspepsia, and acute illness  Combined approach studies reported:  Back pain related to physical exercise, other pain related to exercise (both

participants had RA), and heavy study burden

15

KEY FINDINGS & CONCLUSIONS

 Overall there appears to be a small benefit for nutrition and/or combined approach

interventions based on low to moderate certainty of evidence.

 Interventions had a significant effect, but small benefit, on mobility, physical and frailty

• utcomes.

 The direction and significance of effect estimates for combined approach

interventions and nutrition interventions were similar.

 The evidence supported the development of three recommendations for practice.

16

CREATING RECOMMENDATIONS FROM THE EVIDENCE: EVIDENCE TO DECISION MAKING TABLES

17

https://www.youtube.com/watch?v=iGVEdNa1xFY

CLINICAL PRACTICE GUIDELINES FOR OLDER ADULTS WITH FRAILTY

Three recommendations are supported by evidence from this review

• 1. We recommend nutritional strategies to enhance dietary intake in older adults

living with frailty and pre-frailty [strong recommendation; low certainty of evidence].

• 2. We suggest that older adults living with frailty or pre-frailty consume protein

fortified foods/supplements to enhance dietary intake [weak recommendation; low certainty of evidence].

• 3. We recommend that older adults who are living with frailty or pre-frailty adopt

combined physical activity and nutrition strategies [strong recommendation; low certainty of evidence].

18

ACKNOWLEDGEMENTS

This work would not have been possible without our partners. We acknowledge indirect and direct support from the following organizations and institutions:

 Canadian Frailty Network  McMaster Institute for Research and Aging (MIRA)  McMaster Evidence Review and Synthesis T

eam (MERST)

 Heather M. Arthur Population Health Research Institute/Hamilton Health Sciences

Chair in Inter-Professional Health Research

 School of Nursing, McMaster University

19

thank you

For more information or to hear more about our work, please contact MERST: raceym@mcmaster.ca fitzd@mcmaster.ca

20

Disclaimer: The content of this presentation is confidential and may not be distributed or shared.