Oral nutritional support with or without exercise in the management of malnutrition in nutritionally vulnerable older people: A systematic review and meta-analysis

Background: Physical functioning declines with advancing age and compounds malnutrition, common in elderly populations. A dual-intervention combining oral nutritional support and exercise may delay these changes. Our aims were to assess whether exercise combined with oral nutritional support (ONS) has greater improvements on physical functioning, quality of life and nutritional status than nutrition intervention alone in nutritionally vulnerable older adults. Methods: Three electronic databases were searched for randomised controlled trials of older adults judged to be: sarcopenic, cachexic, frail, malnourished, and/or at risk of malnutrition, receiving ONS and exercise compared to nutrition intervention alone. Meta-analyses were performed using a fixed-effect model to calculate standardised mean difference (SMD) (hand-grip strength, limb strength, gait speed, timed up-and-go test (TUG), physical activity level and fat-free mass) or relative risk (hospitalisation) with 95% confidence intervals (Cis). Results: Eleven studies (n = 1459 participants) were included. ONS and exercise interventions varied considerably between studies. There was very low quality evidence that exercise combined with ONS compared to nutrition intervention alone resulted in significant improvements in limb strength (SMD = 0.33; 95% CI 0.13-0.53; P = 0.001) but low quality evidence of no effect on fat-free mass (SMD = 0.05; 95% CI 0.27 to 0.18; P = 0.70), physical activity level (SMD = 0.04; 95% Cl -0.26 to 0.33; P = 0.81) and TUG (mean difference = 0.80; 95% CI -2.06 to 0.47; P = 0.22). Moderate quality evidence from a small number of studies found no effect on handgrip strength and QOL. Low quality evidence of faster gait speeds were found in participants receiving ONS alone compared to combined intervention (SMD = 0.38; 95% CI 0.19 to 0.56; P < 0.0001). Conclusion: Combining exercise with ONS may provide additional improvements to muscle strength but had no effect on other measures of physical functioning, nutritional status or morbidity in nutritionally vulnerable older adults. Crown Copyright (C) 2017 Published by Elsevier Ltd. All rights reserved.