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 29 TH , 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 1 Diana Sherifali, PhD Disclaimer: The content of this presentation is confidential and may not be distributed or shared.

SCOPE OF THE PROBLEM 2.0M Canadians  Frailty is a leading contributor to functional decline and in 10 years early mortality in older adults. 1.5M Canadians  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 Falls speed, it is important to consider the enhanced impact that Mobility decline adequate nutrition could have on the benefits of physical Hospitalization activity in a frail population. Death 2

What is the effectiveness of nutrition interventions and nutrition interventions that RESEARCH include physical activity in older adults (age 65+ QUESTION years) living with frailty or pre-frailty on clinical, patient important, or health utilization outcomes? 3

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 PICO 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

PICO Inclusion / Meta analysis of Screening Data Exclusion data of articles extraction criteria Search strategy Defining strategy Screening and extraction Data analysis 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 Results in Certainty of Evidence: 3. Indirectness  High, Moderate, Low, or Very Low 4. Imprecision 5. Other consideration  RCTs start as high certainty and can be downgraded; Observational studies start as low certainty and can be upgraded 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

Records identified Additional records through database identified through other search sources* N = 6733 N = 2 Records after duplicates removed N = 3162 Records screened Records excluded N = 3039 N = 3162 PRISMA FLOWCHART Full-text articles Full-text articles excluded, with reasons N = 108 assessed for eligibility ------------------------------------------------------------------------ N = 123 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) 9 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 Combined Approach (and protein only supplementation) Physical Physical Mobility Mobility Health Health QoL QoL Frailty Frailty Diet Quality 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 MODERATE Physical 7 | 694 Small; 0.16 (0.02, 0.29) 0.03 downgraded for risk of bias MODERATE Mobility 7 | 694 Small; 0.15 (0.001, 0.30) <0.05 downgraded for risk of bias LOW Health 4 | 284 No effect; -0.18 (-0.51, 0.16) 0.26 downgraded for risk of bias and imprecision MODERATE Frailty 3 | 255 Small; -0.22 (-0.44, -0.01) 0.04 downgraded for risk of bias VERY LOW Diet Quality 5 | 383 No effect; 0.10 (-0.47, 0.67) 0.68 downgraded for risk of bias, inconsistency, and imprecision MODERATE Quality of Life 1 | 243 No effect; -0.12 (-1.39, 1.15) 0.44 downgraded for imprecision Bold denotes significance p<0.05; N = total number of participants; SMD = standardized mean difference; CI = confidence interval 12

PROTEIN SUPPLEMENTATION Outcome # studies | N SMD (95% CI) p value GRADE rating MODERATE Physical 5 | 344 Small; 0.16 (0.01, 0.31) 0.03 downgraded for risk of bias MODERATE Mobility 5 | 344 Small; 0.20 (0.02, 0.39) 0.04 downgraded for risk of bias LOW Health 3 | 177 No effect; -0.12 (-0.58, 0.34) 0.53 downgraded for risk of bias and imprecision LOW Frailty 2 | 148 No effect; -0.18 (-0.45, 0.09) 0.15 downgraded for risk of bias and imprecision VERY LOW Diet Quality 4 | 297 No effect; -0.01 (-0.69, 0.67) 0.97 downgraded for risk of bias, inconsistency, and imprecision Bold denotes significance p<0.05; N = total number of participants; SMD = standardized mean difference; CI = confidence interval 13

COMBINED APPROACH Outcome # studies | N SMD (95% CI) p value GRADE rating MODERATE Physical 6 | 514 Small; 0.19 (0.06, 0.32) 0.007 downgraded for risk of bias MODERATE Mobility 6 | 514 Small; 0.25 (0.02, 0.48) 0.04 downgraded for risk of bias LOW Health 3 | 310 No effect; -0.05 (-0.42, 0.33) 0.72 downgraded for risk of bias and imprecision 2 | 213 Small; -0.41 (-0.68, -0.14) <0.01 MODERATE Frailty 3 | 359 RR 0.72 (0.52, 1.00) <0.05 downgraded for risk of bias VERY LOW Diet Quality 2 | 141 No effect; 0.53 (-0.98, 2.04) 0.49 downgraded for risk of bias, inconsistency, and imprecision LOW Quality of Life 3 | 267 No effect; 0.31(-0.05, 0.67) 0.07 downgraded for risk of bias and imprecision 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 14

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 outcomes.  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 https://www.youtube.com/watch?v=iGVEdNa1xFY 17

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.