Likely to Be Effective

Oral Nutritional Interventions

for Dyspnea

Oral nutritional interventions involve the provision of dietary advice or education with or without dietary modification or nutritional supplements. Nutritional supplements included in this type of intervention are those involving general protein-calorie supplements and multiple combinations of vitamins, minerals, and other compounds. Specific herbal supplements and some highly specific supplements such as carnitine and individual vitamins are considered as separate interventions.

Systematic Review/Meta-Analysis

Baldwin, C., Spiro, A., Ahern, R., & Emery, P.W. (2012). Oral nutritional interventions in malnourished patients with cancer: A systematic review and meta-analysis. Journal of the National Cancer Institute, 104, 371–385.

Purpose

STUDY PURPOSE: To examine the effect of oral nutritional interventions on outcomes among patients with cancer

TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy

DATABASES USED: MEDLINE. EMBASE, CINAHL®, Scopus, AMED, CANCERLIT, ERIC, Scopus, ISI Web of Science, and Cochrane Collaboration, 1998–2010
 
INCLUSION CRITERIA: RCT; adults with cancer judged to be malnourished or at risk for malnutrition; comparison of nutritional interventions with usual care. 

Literature Evaluated

TOTAL REFERENCES RETRIEVED: 44,073
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Study quality was evaluated according to criteria established and the Cochrane handbook. All studies were determined to be at risk of bias from one or more characteristics related to randomization and blinding to treatment allocation.

Sample Characteristics

  • FINAL NUMBER STUDIES INCLUDED = 13 in systematic review, 9 included in meta-analysis
  • TOTAL PATIENTS INCLUDED = 1,414
  • SAMPLE RANGE ACROSS STUDIES: 31–358
  • KEY SAMPLE CHARACTERISTICS: Various tumor types receiving adjuvant or neo adjuvant chemotherapy or radiotherapy

Phase of Care and Clinical Applications

  • PHASE OF CARE: Active anti-tumor treatment 

Results

Six studies compared dietary advice with routine care, three evaluated oral nutritional supplements, and seven compared dietary advice and oral supplements with usual care. Some studies included samples that were not malnourished, although all were at risk according to definitions established in the studies. Findings from meta-analysis showed high heterogeneity among studies. Results with studies causing the high heterogeneity removed were:
  • QOL and Functional Scales on EORTC: no significant effects 
  • Fatigue: no significant effects
  • Dyspnea: mean difference = –2.9 (95% CI [–4.0, –1.8], p < .001) (six studies)
  • Loss of appetite: mean difference = –2.35 (95% CI [–4.48, –0.22], p = .03) (seven studies)
  • There was no effect seen on survival and effects on body weight and energy intake was inconsistent.

Conclusions

Analysis indicates that oral nutritional interventions were associated with significant improvement in dyspnea and appetite symptom scales. It is unclear what the specific impacts of dietary counseling versus oral nutritional supplements were on these outcomes.

Limitations

  • Few studies retained in meta-analysis that addressed high heterogeneity.
  • Outcomes analyzed were based on only single-item scales on the EORTC.
  • Patients varied from those receiving adjuvant treatment to those receiving palliative care treatment.
  • Varied length of follow-up from three weeks to two years.

Nursing Implications

Nutritional interventions such as dietary counseling and oral nutritional supplementation may be helpful in managing symptoms of dyspnea and anorexia in patients cancer. Evidence does not provide strong support due to variability in timing of interventions, the exact nature of the interventions, actual nutritional status of patients included, and the timing of outcome data measurement. Nutritional interventions such as dietary counseling and oral nutritional supplement are low-risk interventions that may be helpful for some patients. Well-designed research and reporting in this area would be helpful to guide practice.

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