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Correspondence to Dr Evelina Liljeberg; evelina.liljeberg@ikv.uu.se Background Disease-related malnutrition is increasingly recognised as an unwanted consequence of acute and chronic disease.1 A range of guidelines within different clinical fields and settings recommend the use of oral nutritional supplements (ONS) as part of nutrition therapy for disease-related malnutrition, when food-based strategies alone are insufficient.2–7 Using ONS within nutrition therapy has also proven to be cost-effective.8–10 A common approach in most guidelines is to state that ONS should be initiated without focusing much on how best to do this.4 5 There are guidelines that include some descriptions on how to prescribe ONS,2 3 7 for example, to take patient preferences into account,2 but these guidelines focus on the broader concept of malnutrition treatment and do not comprehensively cover all aspects of ONS adherence. [...]guidance is needed on how ONS should be prescribed to optimise ONS consumption and adherence, to support clinical practice. Adherence is defined as ‘The extent to which a person’s behaviour—taking medication, following a diet and/or executing lifestyle changes—corresponds with agreed recommendations from a healthcare provider’ (Sabaté, p3).12 The terms adherence and compliance are often used interchangeably in the literature.11 Adherence can be difficult to achieve, especially in chronic conditions where therapy is needed for longer periods.12 Optimising adherence to ONS is important, since beneficial effects on nutritional intake and nutritional status are dependent on patients’ consumption of ONS.13 14 The WHO recognises the need for a systems approach when addressing adherence to long-term therapies.12 This system approach looks beyond the individual patient and addresses aspects of the healthcare system, including incentives for healthcare professionals. Individually tailored ONS prescription includes providing ONS samples, offering a variety of flavours, planning the timing of ONS intake and deciding on the type of ONS product and the amount to be taken daily.17–19 Previous research suggests that liquid format and ready-made ONS17 in a small volume/with high energy density13 17 26 may facilitate adherence, whereas excessive volume may be a barrier.17 19 Previous research further supports ‘in between meals’ as the preferred time for taking ONS.26 To further support adherence, the ONS prescriber should discuss and inform patients on the optimal serving style and preferred consumption method for the ONS, for example, to inform patients that ONS can be served chilled, or mixed with other ingredients to alter/enhance flavour, or served in small doses (eg, together with medication administration rounds for inpatients) (Step 4).17 18 27 Identifying preferred personal consumption methods may be important for all patients, but perhaps most important for older adults.18 For example, previous research has found mixed results regarding older adults, with some preferring to drink the ONS from the bottle using a straw,28 while others prefer it served in a glass or beaker.29 The practice pattern further recommends supporting patients with strategies to counteract any ONS-related side effects (Step 5), since this has been described as a central barrier to ONS adherence in previous research.17 The ONS prescriber should also consider any age-related physiological changes such as olfactory impairments or sensory decline that can alter the perception of ONS in older adults.18 The last step (Step 6) of the individual-level recommendations highlights the importance of meeting the patient regularly —by phone, face-to-face or during home visits—to follow-up on the ONS prescription (reassessing and revisiting steps 1—5, if needed).17 The evidence also confirms that adherence to ONS often declines over time, especially among patients with cancer.17 Consequently, a long treatment duration should be avoided if possible.

Malnutrition predicts preterm death, but whether this is valid irrespective of the cause of death is unknown. The aim of the present study was to determine whether malnutrition is associated with cause-specific mortality in older adults. This cohort study was conducted in Sweden and included 1767 individuals aged ≥65 years admitted to hospital in 2008–2009. On the basis of the Mini Nutritional Assessment instrument, nutritional risk was assessed as well nourished (score 24–30), at risk of malnutrition (score 17–23·5) or malnourished (score <17). Cause of death was classified according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, into twenty different causes of death. Data were analysed using Cox proportional hazards regression models. At baseline, 55·1 % were at risk of malnutrition, and 9·4 % of the participants were malnourished. During a median follow-up of 5·1 years, 839 participants (47·5 %) died. The multiple Cox regression model identified significant associations (hazard ratio (HR)) between malnutrition and risk of malnutrition, respectively, and death due to neoplasms (HR 2·43 and 1·32); mental or behavioural disorders (HR 5·73 and 5·44); diseases of the nervous (HR 4·39 and 2·08), circulatory (HR 1·95 and 1·57) or respiratory system (HR 2·19 and 1·49); and symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (HR 2·23 and 1·43). Malnutrition and risk of malnutrition are associated with increased mortality regardless of the cause of death, which emphasises the need for nutritional screening to identify older adults who may require nutritional support in order to avoid preterm death.

Objectives: The study aimed to investigate 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. Methods: This multicentre randomised controlled trial 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 or oral nutritional supplements, separate or in combination, or routine care. The intervention started at discharge from the hospital and continued for 6 months, with survival being the main outcome measure. Results: 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, and 43.3% for the control group (log-rank test p = 0.762). 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). Conclusions: 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. Trial registration: ClinicalTrials.gov with ID: NCT01057914

Objectives: A variety of non-evidence-based dietary advice on modified fibre and lactose intakes are provided to patients undergoing pelvic radiotherapy to counteract treatment-related bowel symptoms. More knowledge on the nutritional consequences of such advice is needed. This study aimed to explore how advice on modified fibre and lactose intakes during pelvic radiotherapy was associated with nutrient intakes amongst patients with prostate cancer. Methods: A total of 77 Swedish men who underwent radiotherapy (50/2 Gy + boost 20–30 Gy) in 2009–2014 due to prostate cancer were given dietary advice at radiotherapy onset (baseline) and at 4 and 8 weeks after radiotherapy onset, to modify their fibre and lactose intakes. At baseline, the participants completed a food frequency questionnaire (FFQ) and a 24-h dietary recall. At 4 and 8 weeks, the participants completed the FFQ and a 4-day estimated food record. Fibre and lactose intakes were measured by intake scores calculated from the FFQs. Multiple linear regression models were used to analyse associations between intake scores and fibre- and lactose-related nutrients. Results: In adjusted analyses, there were few significant associations between dietary advice on modified fibre and lactose intakes and observed intakes of fibre- and lactose-related nutrients. A more modified lactose intake was thus associated with a lower intake of calcium (P = 0.041), whilst a more modified fibre intake was associated with a higher value for the change in intake of vitamin C (P = 0.016). Conclusions: Dietary advice on modified fibre and lactose intake was in most cases not significantly associated with altered nutrient intakes, rather the energy and nutrient intakes were mostly stable during the pelvic radiotherapy. More research is needed on the nutritional consequences of dietary advice on modified fibre and lactose intakes to reach consensus on if they should continue to be provided in the clinic.

Malnutrition is common among older adults in health-care settings and is associated with decreased quality of life (QoL). The present study aimed to investigate the effect on health-related QoL (HRQoL) among older adults after 6 months of treatment with individual dietary advice (DA) and/or oral nutritional supplements (ONS), utilising 409 patients included in a multicentre randomised controlled trial of patients ≥ 65 years old, stratified according to nutrition status (malnourished/at risk of malnutrition), admitted to hospital in Sweden 2010–2014. Patients were randomised into four arms: DA, ONS, DA + ONS or routine care (control). The intervention started at discharge from hospital, with HRQoL measured using European QoL five-dimension, three-level (EQ-5D-3L) and European QoL-visual analogue scale (EQ-VAS) at baseline and at 6-month, 1-year and 3-year follow-ups. Data were analysed using the Kruskal–Wallis test and multiple linear regression. Overall, HRQoL increased from baseline to follow-ups, although the magnitude of change in EQ-5D-3L did not differ significantly between the four arms in any of the nutrition groups. However, a significant difference was observed for change in EQ-VAS from baseline to 6-month follow-up in the malnourished group, with mean changes of 22·4 and –3·4 points for the ONS and control groups, respectively (P = 0·009). In the multiple linear regression analyses, participants in the ONS arm had 27·5, 34·4 and 38·8 points larger increases in EQ-VAS from baseline to the 6-month (P = 0·011), 1-year (P = 0·007) and 3-year (P = 0·032), respectively, follow-ups than the control group. The use of ONS improved subjectively assessed HRQoL in these malnourished older adults.

The aim of this systematic mixed-studies review is to summarise barriers/facilitators to adherence to and/or consumption of oral nutritional supplements (ONS) among patients with disease-related malnutrition. In March 2022, the Cochrane CENTRAL, PUBMED, PsycINFO (Ovid) and CINAHL were searched for articles with various study designs, published since 2000. Articles were identified on the basis of ‘population’ (patients ≥18 years with malnutrition/at nutritional risk), ‘intervention’ (ONS with ≥2 macronutrients and micronutrients), ‘comparison’ (any comparator/no comparator) and ‘outcome’ (factors affecting adherence or consumption) criteria. A sequential exploratory synthesis was conducted: first, a thematic synthesis was performed identifying barriers/facilitators; and second, the randomised controlled trials (RCTs) were used to support these findings. The five WHO dimensions of adherence guided the analysis. Study inclusion, data extraction, analysis and risk-of-bias assessment (MMAT 2018) were carried out independently by two researchers. From 21 835 screened articles, 171 were included with 42% RCTs and 20% qualitative studies. The two major populations were patients with malignancies (34%) and older adults (35%). In total, fifty-nine barriers/facilitators were identified. Patients’ health status, motivation, product tolerance and satisfaction as well as well-functioning healthcare routines and support were factors impacting ONS consumption. Few barriers/facilitators ( n = 13) were investigated in RCTs. Two of those were serving a small ONS volume and integrating ONS into ward routines. Given the complexity of ONS adherence, non-adherence to ONS should be addressed using a holistic approach. More studies are needed to investigate the effect of different approaches to increase adherence to ONS.

A higher fat content in the diet could be an advantage for preventing malnutrition among older adults. However, there is sparse scientific evidence to determine the optimal fat intake among older adults. This prospective cohort study examined whether a high energy intake of dietary fat among middle-aged and older adults is associated with the risk of malnutrition 10 years later. The study population comprised 725 Swedish men and women aged 53–80 years who had completed a questionnaire about dietary intake and lifestyle factors in 1997 (baseline) and whose nutritional status was assessed when admitted to the hospital in 2008–2009 (follow-up). At the follow-up, 383 (52·8 %) participants were identified as being at risk of malnutrition and fifty-two (7·2 %) were identified as malnourished. Multinomial logistic regression models were used to analyse the association between previous dietary fat intake and nutritional status later in life. Contrary to what was expected, a high energy intake from total fat, saturated fat and monounsaturated fat among middle-aged and older adults increased the risk of exhibiting malnutrition 10 years later. However, this applied only to individuals with a BMI<25 kg/m2 at the baseline. In conclusion, these findings suggest that preventive actions to counteract malnutrition in older adults should focus on limiting the intake of total fat in the diet by reducing consumption of food with a high content of saturated and monounsaturated fat.

Background: Oral nutritional supplements (ONS) are often recommended as part of a nutritional intervention for malnutrition. However, adherence to ONS prescription is challenging and there is a lack of knowledge about how ONS should be included in the nutritional care to maximise benefits for the patient and healthcare system. Research Objective: The objective was to identify barriers and facilitators of ONS adherence related to healthcare team and system-related factors among patients with malnutrition or at risk. Methods: This mixed-studies systematic review includes studies identified in the Cochrane Central Register of Controlled Trials, PUBMED, PsycINFO, and CINAHL in March 2022. Study inclusion (title/abstract screening, full text reading) and risk of bias assessment were performed according to systematic review standards. A sequential exploratory synthesis of data was conducted with a qualitative phase (thematic analysis) followed by a quantitative phase (descriptive statistics). The World Health Organization's five dimensions of adherence was used as a framework for categorizing the data and this preliminary analysis focuses on the healthcare team and system-related dimension. Results: In total, 21835 articles were screened, 507 articles were read in full text, and 171 articles were included in the review (RCT n = 71, non-RCT n = 41, Descriptive n = 21, Qualitative n =34, Mixed methods n = 4). Six analytical themes were identified. Within the theme 'Continuity of (ONS) care', well-functioning organizational routines and structure e.g., 'Integrate ONS into daily routine' (Facilitator) and 'Lack of communication in healthcare transitions' (Barrier) were key factors to achieve adherence to ONS. Discussion: The findings highlight the central role the healthcare team and system play for ONS adherence and suggest that healthcare professionals should adopt a holistic approach when ONS are included in the nutritional care. Future experimental studies investigating the effect of different healthcare approaches to adherence to ONS are needed.

ABSTRACT Research on disease‐related malnutrition and adherence to oral nutritional supplements (ONS) has increased in recent years. To guide future studies, it is important to identify trends in terminology use and intervention characteristics. This review aimed to map characteristics of research investigating adherence to ONS in patients with disease‐related malnutrition and explore changes over time. This review is a secondary analysis of quantitative studies from a systematic mixed‐studies review. Online databases, including PubMed, Cinahl, Cochrane Central Register of Controlled Trials, and APA PsycInfo, were searched to identify studies published from 2000 to March 2022. A quantitative content analysis of extracted data was performed, and the Mixed Methods Appraisal Tool (MMAT) was used to assess methodological risk of bias. This review includes 137 articles, over half of which are randomized controlled trials (52%). The term “oral nutritional supplements” was used in 40% of the studies. Adherence to ONS was mainly described by the term “compliance” (69%). It was most common to offer ready‐made milk‐based ONS (56%) and ONS as a sole intervention (51%). The prescribed dose of ONS was fixed in 64% of studies and individualized in 22% of studies. There was variation in the methods used to assess adherence to ONS, and adherence was not reported in nearly a fifth of studies. There was an increase in methodological quality over time (p = 0.024). To ensure better understanding and increase the rigor and reproducibility of ONS intervention research, it is crucial to standardize the terminology used and to describe the interventions clearly. This review, encompassing 137 articles, mapped the characteristics of research on adherence to oral nutritional supplements (ONS) in patients with disease‐related malnutrition and explored changes over time. Key findings reveal a diverse range of terms used to describe ONS and adherence to this nutrition therapy. The ONS interventions frequently deviated from appropriate prescribing descriptions in nutrition guidelines, and there was a modest improvement in methodological quality over time.

Enhanced secondary preventive follow-up after stroke or transient ischemic attack (TIA) is necessary for improved adherence to recommendations regarding blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) levels. We investigated whether nurse-led, telephone-based follow-up was more efficient than usual care at improving BP and LDL-C levels at 12 months after hospital discharge. We randomized 537 patients to either nurse-led, telephone-based follow-up (intervention) or usual care (control). BP and LDL-C measurements were performed at 1 month (baseline) and 12 months post-discharge. Intervention group patients who did not meet target values at baseline received additional follow-up, including titration of medication and lifestyle counselling, to reach treatment goals (BP < 140/90 mmHg, LDL-C < 2.5 mmol/L). At 12 months, mean systolic BP, diastolic BP and LDL-C was 3.3 (95% CI 0.3 to 6.3) mmHg, 2.3 mmHg (95% CI 0.5 to 4.2) and 0.3 mmol/L (95% CI 0.1 to 0.4) lower in the intervention group compared to controls. Among participants with values above the treatment goal at baseline, the difference in systolic BP and LDL-C was more pronounced (8.0 mmHg, 95% CI 4.0 to 12.1, and 0.6 mmol/L, 95% CI 0.4 to 0.9). A larger proportion of the intervention group reached the treatment goal for systolic BP (68.5 vs. 56.8%, p = 0.008) and LDL-C (69.7% vs. 50.4%, p < 0.001). Nurse-led, telephone-based secondary preventive follow-up, including medication adjustment, was significantly more efficient than usual care at improving BP and LDL-C levels by 12 months post-discharge. ISRCTN Registry ISRCTN23868518.