Journal of Human Nutrition and Dietetics

CLINICAL NUTRITION
Dietary counselling with or without oral nutritional
supplements in the management of malnourished patients:
a systematic review and meta-analysis of randomised
controlled trials
C. Baldwin* & C. E. Weekes 
*Diabetes and Nutritional Sciences Division, King’s College London, London, UK
 Department of Nutrition and Dietetics, Guys and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK

Keywords
dietitian, food, malnutrition, oral nutritional
support, systematic review.
Correspondence
C. Baldwin, Diabetes and Nutritional Sciences
Division, King’s College London, Franklin
Wilkins Building, 150 Stamford Street, London
SE1 9NH, UK.
Tel.: +44 (0)207 848 4318
Fax: +44 (0)207 848 4500
E-mail: christine.baldwin@kcl.ac.uk
How to cite this article
Baldwin C. & Weekes C.E. (2012) Dietary
counselling with or without oral nutritional
supplements in the management of malnour-
ished patients: a systematic review and
meta-analysis of randomised controlled trials.
J Hum Nutr Diet. 25, 411–426
doi:10.1111/j.1365-277X.2012.01264.x
Abstract
Dietary counselling and oral nutritional supplements (ONS) are recommended
for managing malnutrition. A recent systematic review demonstrated (in sepa-
rate analyses) that dietary counselling and dietary counselling with ONS
improved energy intake, weight and some indices of body composition,
although there was considerable heterogeneity. The present analysis aimed to
examine the effects on mortality and nutritional indices of dietary counselling
given with or without ONS and to explore the heterogeneity in the meta-analy-
ses aiming to characterise the groups most likely to benefit from these inter-
ventions. A systematic review and meta-analysis was performed using Cochrane
methodology. Twenty-six studies were included in the analysis: 12 comparing
dietary counselling with usual care and 14 comparing dietary counselling and
ONS if required with usual care (2123 participants). Quality of studies varied.
Dietary counselling given with or without ONS had no effect on mortality
[relative risk (fixed) = 1.12; 95% confidence interval = 0.86–1.46] but was
associated with significant but heterogeneous benefits to weight [mean differ-
ence (random) = 1.7 kg; 95% confidence interval = 0.86–2.55], energy intake
and some aspects of body composition. Subgroup analyses taking into account
clinical background, age, nutritional status, type and length of intervention
failed to reveal any differences in mortality, weight change and energy intake
between groups. There were insufficient data on functional outcomes to
explore these findings. Dietary counselling given with or without ONS is effec-
tive at increasing nutritional intake and weight but adequately-powered studies
in similar patient populations and standardised for factors that might account
for variations in response are required.

Evidence from meta-analyses in patients with similar

Introduction
Malnutrition is a potentially serious complication of ill-
ness, which is associated with increased morbidity, mor-
tality and length of stay in hospital (Norman et al., 2008).
Advice to improve intake using dietary counselling and/or
oral nutritional supplements (ONS) is often recom-
mended for managing people identified as malnourished
(Thomas, 2001).
clinical backgrounds supports the use of ONS in the
management of some malnourished individuals (Arends
et al., 2006; Ockenga et al., 2006; Plauth et al., 2006;
Koretz et al., 2007; Stratton & Elia, 2007). Combined
analyses conducted across studies in patients from a vari-
ety of clinical backgrounds suggest that the use of ONS
is associated with significant reductions in mortality,
improvements in length of stay and reduced rates of

ª 2012 The Authors

Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd. 411
 Dietetic interventions in malnourished patients
complications and weight gain, and these analyses have
been used to derive general recommendations about the
use of oral nutritional support (NCC-AC, 2006). Interest-
ingly, meta-analyses of the effects of ONS that are con-
fined to specific clinical conditions (Arends et al., 2006;
Ockenga et al., 2006; Plauth et al., 2006; Volkert et al.,
2006; Koretz et al., 2007) have mostly failed to replicate
the beneficial effects seen in analyses where several clinical
conditions are combined (Stratton et al., 2003; NCC-AC,
2006). This observation may not only result from the lim-
ited number of studies in some patient groups, but also
may suggest that some patient groups benefit from ONS
more than others. Constraints on staff numbers and time
mean that it is important to be able to identify the
patients who are most likely to benefit from nutritional
interventions to allow effective allocation of resources.
ONS are associated with considerable costs to health-
care providers and compliance can be poor (Lawson
et al., 2000; Bruce et al., 2003; Hobday et al., 2010). Die-
tary counselling has potential advantages in that it can
offer greater variety, can be tailored to the needs of an
individual and may be associated with lower healthcare
costs. The use of dietary counselling and dietary counsel-
ling together with ONS is widely recommended (Thomas,
2001) in the management of malnutrition, although the
evidence base for these interventions is unclear.
A systematic review, originally conducted in 2001 and
last updated in 2011, demonstrated that the use of dietary
counselling alone or when given with ONS was associated
with significant improvements in weight and some indices
of body composition, although there was significant het-
erogeneity in many of the analyses, suggesting that the
benefits may be confined to only some groups of patients
(Baldwin & Weekes, 2011). A frequent question is
whether the heterogeneity arises from the combination of
groups that vary according to a range of characteristics
and specifically clinical background. The evidence base to
answer this question has not been explored.
The provision of dietary counselling with or without
ONS is frequently the first-line method used to manage
malnourished patients. The review published in the Coch-
rane Library examines these two nutritional interventions
as separate entities, although they are closely-related strat-
egies, predominately based on improving intake from
food. Dietetic practice usually utilises both food and sup-
plements as appropriate; therefore, combining these two
methods increases the power to estimate the effect of the
type of care provided in the real life context of dietetic
practice. The aims of this analysis were to undertake a
combined analysis of dietary counselling alone and die-
tary counselling with ONS if required and to explore the
heterogeneity in the analyses to characterise the patient
groups most likely to benefit from these interventions
412
C. Baldwin and C. E. Weekes
and the magnitude of the effects to be expected. An addi-
tional aim was to examine whether there were any bene-
fits to mortality in specific patient groups that were
masked by grouping studies from different backgrounds
together.
Materials and methods
A systematic review was conducted, according to the
methods outlined by the Cochrane Collaboration
(Higgins & Green, 2009). A summary of our methodol-
ogy is outlined below; further details have been given pre-
viously (Baldwin & Weekes, 2011).
Identification of studies
The searches undertaken to identify the studies for the
present analysis have been derived from a series of
searches conducted from 1998 to 2010 (Fig. 1). Publica-
tions describing randomised controlled trials of dietary
counselling given with or without ONS in patients with
malnutrition or at risk of malnutrition were retrieved by
searching electronic databases. The strategies for the
searches from 2002 to 2005 and from 2005 to 2010 are
provided in the Supporting information (Appendix S1).
All languages were included and publications not in Eng-
lish, but considered to meet the inclusion criteria from
the abstract, were translated.
The search strategy used to identify studies has evolved
according to changes in information technology and devel-
opment of the search strategy and selection of appropriate
databases has been undertaken with counselling from an
expert librarian.
Reports of additional trials that may have been missed
were sought by assessing the bibliographic references of
all retrieved studies and the reference lists of key reviews
(Stratton & Elia, 1999; Stratton et al., 2003; NCC-AC,
2006), and the authors of all included studies were con-
tacted. No hand-searching has been undertaken. In 2002,
experts in clinical nutrition, manufacturers of oral nutri-
tional supplements and all members of the British Die-
tetic Association were contacted to identify any other
studies that might be in progress.
Selection of studies
Studies were included if they were in adults in any care
setting who were malnourished or judged to be at nutri-
tional risk (their clinical condition and/or treatment may
mean that food intake would be reduced for a number of
days) (NCC-AC, 2006) and included one of the following
comparisons: (i) dietary counselling compared with rou-
tine care or (ii) dietary counselling and ONS if required
ª 2012 The Authors
Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.
 C. Baldwin and C. E. Weekes Dietetic interventions in malnourished patients

Searches to November November 2002 to November 2003 to November 2005 to

2002 November 2003 November 2005 February 2005 Additional records
Identification
Databases: Databases: Databases: Databases: 11 studies from
• Cochrane • Medline • Medline • Medline reference lists of
• Medline • Embase • Embase • Embase included studies and
• Embase • Cinahl • Cinahl • Cinahl reviews
• Cinahl • Cancerlit • Cancerlit • Scopus
• ERIC • AMED • AMED • ISI Web of Science
• Dissertation abstracts

Total: 33 435 Total: 88 Total: 204 Total: 10 346

44 084 records screened after removal of duplicates

Screening

43 953 records excluded

131 full-text articles assessed for eligibility

Eligibility

106 full-text articles excluded

25 studies from searches

Included

(26 studies in total; 25 from searches + 1 known to author)

Figure 1 Search strategy, study selection and process of identification of suitable trials. CI, confidence interval; DC, dietary counselling; ONS, oral
nutritional supplements.

compared with routine care. Outcomes considered for
this review were mortality, weight, body composition
assessed by mid-arm muscle circumference or triceps
skinfold thickness, and energy intake.
Dietary counselling was defined as instruction to mod-
ify food intake, with the aim of improving nutritional
intake. In the second category, trials were included only if
ONS was a secondary measure to dietary counselling.
Data extraction and outcome measures
Titles and abstracts were reviewed on the screen by one
reviewer (CB). Potentially relevant studies were assessed
for inclusion independently by two reviewers, who also
extracted data from all included studies independently.
The details extracted from each trial comprised: year
and journal of publication, details of patient population,
including clinical condition, intended treatment, nutri-
tional status at study inclusion (malnourished/at nutri-
tional risk) and demographic information, details of the
intervention and the comparison, number of patients
randomised to each group and attrition, outcome data on
mortality, weight, body composition and energy intake.
Where information on study design, quality or data were
unclear, the authors were contacted for additional infor-
mation.
For data to be entered into a meta-analysis, it is neces-
sary to have sufficient information for both the interven-
tion and comparison groups to derive a mean (SD)
change for continuous variables (weight, energy intake,
etc.) or the numbers experiencing the event of interest
and the total number in the group for dichotomous vari-
ables (deaths). These data have either been available from
the paper or the review authors have obtained these from
the study investigators where possible. Unfortunately, for
a number of outcomes, it was not possible to obtain data
in a format that can be entered into a meta-analysis.
Where data on mean change for the intervention group
and control group were presented with a P-value of the
change, this was used to derive the SD of the mean
change. Where mean change data were presented without
a P-value, the SDs were imputed according to the Coch-
rane Handbook (Higgins & Green, 2009).
Methodological quality
The methodological quality of each study was assessed
according to criteria described by Schulz et al. (1995) and

ª 2012 The Authors

Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd. 413
 Dietetic interventions in malnourished patients C. Baldwin and C. E. Weekes

specified by Cochrane. This assessment included an exam- Results

ination of the method of randomisation and adequacy of
Twenty-six studies, including 2123 randomised partici-
group allocation, whether the study outcomes were
pants, fulfilled the inclusion criteria for this review
assessed blinded to treatment group and whether the
(Fig. 1). There were twelve studies for dietary counsel-
number of participants lost to follow-up or excluded
ling compared with routine care (Dixon, 1984; Imes
from the study was recorded. Studies were examined to
et al., 1988; Macia et al., 1991; Ollenschlager et al., 1992;
ensure that all the outcome variables stated in the meth-
Wong et al., 2004; Manguso et al., 2005; Ravasco et al.,
ods section were presented in the results and that groups
2005a,b; Campbell et al., 2008; Rydwik et al., 2008;
were similar at baseline.
Weekes et al., 2009; Baldwin et al., 2011) and 14 studies
for dietary counselling plus ONS if required compared
Statistical analysis with routine care (Moloney et al., 1983; Chandra &
Puri, 1985; Evans et al., 1987; Rogers et al., 1992; Ove-
Data on outcomes from all studies were combined in a
sen et al., 1993; Ganzoni et al., 1994; Lovik et al., 1996;
meta-analysis. The rationale for combining studies was
Jensen & Hessov, 1997; Berneis et al., 2000; Forli et al.,
that the aims of the intervention and the methods used
2001; Persson et al., 2002, 2007; Hampson et al., 2003;
reflected the current dietetic management of malnour-
Isenring et al., 2004). Studies included participants from
ished and at risk patients across all clinical conditions.
a variety of clinical backgrounds and the length of
For continuous outcomes, such as change in weight, data
intervention varied from 10 days to 24 months
were combined across studies using a mean difference
(Table 1).
[95% confidence interval (CI)] (Higgins & Green, 2009).
All studies from which data could be extracted reported
For binary outcomes, such as mortality, the data were
outcome data from baseline to the end of the interven-
combined using risk ratios (95% CI) using the Mantel–
tion. Five studies (Moloney et al., 1983; Manguso et al.,
Haenszel method. Fixed effect models were used unless
2005; Rydwik et al., 2008; Weekes et al., 2009; Baldwin
significant heterogeneity was present. The results of meta-
et al., 2011) continued to follow-up patients after the end
analyses were inspected for heterogeneity and tested using
of intervention. The length of the additional follow-up
the chi-squared test and by using the I2 statistic (Higgins
period varied from 3 to 10½ months. Only three of the
et al., 2003). P < 0.1 rather than <0.05 was used as evi-
five studies that included additional follow-up contained
dence of statistical heterogeneity for the chi-squared test.
data that could be entered into a meta-analysis; therefore,
The I2 statistic describes the percentage of total variation
an analysis from end of intervention to the end of follow-
across studies that are a result of heterogeneity rather
up was not undertaken.
than by chance (Higgins et al., 2003). The values of I2 lie
Data and additional information was requested from
between 0% and 100%. A simplified categorisation of
25 authors and received from 20. Not all authors pro-
heterogeneity was used; low (I2 0–33%), moderate (I2
vided the information requested. The SD of the mean
34–66%) and high (I2 ‡ 67%) (Higgins et al., 2003).
change was calculated for data from four studies (Molo-
Where heterogeneity was evident between studies, this
ney et al., 1983; Macia et al., 1991; Rogers et al., 1992;
was investigated and a random effects meta-analysis was
Berneis et al., 2000).
performed.
Planned subgroup analyses were undertaken on data
from both comparison groups combined (dietary counsel-
Study quality
ling versus routine care and dietary counselling plus sup-
plements if required versus routine care) as follows: No study met all the criteria and therefore all studies
l Type of intervention (dietary counselling alone or die- have been judged to be at risk of bias for one or more
tary counselling given with oral nutritional supplements if reasons (Table 2). In particular, blind assessment of
considered appropriate). some outcomes was reported in only six studies (Imes
l Diagnosis (cancer, gastrointestinal, elderly, respiratory, et al., 1988; Macia et al., 1991; Ganzoni et al., 1994;
osteoporosis, renal disease). Jensen & Hessov, 1997; Forli et al., 2001; Manguso et al.,
l Age (<65 and >65 years). 2005).
l Nutritional status at inclusion (>50% patients mal- Three of the identified studies did not report any usu-
nourished; <50% patients malnourished or population able data (Dixon, 1984; Chandra & Puri, 1985; Jensen &
likely to be at risk of malnutrition). Hessov, 1997). All studies reported the outcomes speci-
l Study quality (adequate defined on the basis of fied, although not all of the data were in a usable format.
description of randomisation and group allocation). The characteristics defining study quality are summarised
l Length of intervention (0–3, 4–6, >6 months). in Table 2.

ª 2012 The Authors

414 Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.
 Table 1 Characteristics of included studies and information extracted from studies included in the present review
Methods used to determine
Total Co-morbidity (healthcare nutritional status Outcomes included in review Duration of intervention

ª 2012 The Authors

Trial (n) setting) (% malnourished) Comparison details (other outcomes reported) (length of follow-up)

Dietary counselling compared with routine care

Baldwin 186 Cancer Recent weight loss (100%) Group 1 RC Mortality*, weight* (QOL, HGS, 6 weeks (12 months)
C. Baldwin and C. E. Weekes

GI and lung (outpatients) Group 2 DC to › intake by energy intake)

2512 kJ (600 kcal) per day
Group 3 ONS providing 2461 kJ
(588 kcal) per day
Group 4 DC + ONS
Groups 1 and 2 used in this
analysis
Campbell 62 Chronic kidney disease SGA (intervention group Group 1 DC to › energy intake Mortality*, dietary intake*, 12 weeks (12 weeks)
(outpatients) 24% malnourished; Control and maintain protein intake weight* [nutritional status
group 11% malnourished) Group 2 RC (generic information (SGA), body composition (total
on nutrition) body potassium), biochemistry]
Dixon 36  Cancer C/R and >5% recent weight loss or Group 1 DC Mortality, weight Unclear (4 months)
lymphoma (outpatients) persistent difficulties with Group 2 Home visits

Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.
eating (100%) Group 3 RC
Imes 137 Crohn’s disease Not specified Group 1 DC to achieve Canadian Mortality*, hospital admissions, 6 months (6 months)
(outpatients) RDAs energy intake
Group 2 RC
Macia 92 Cancer Not specified Group 1 DC Weight Unclear (unclear)
H&N, breast, abdo-pelvic Group 2 RC
(not possible to tell)
Manguso 90 Liver cirrhosis (recruited Not specified Group 1 DC consisting of specific Weight*, MAMC*, TSF*, energy 3 months (6 months)
as inpatients) prescription for macronutrients intake* (Child’s score, First 3 months used in
and calcium biochemistry profile) this analysis
Group 2 RC
Ollenschlager 31 Acute leukaemia Recent weight loss >5% or Group 1 DC Mortality*, weight, energy intake Up to 25 weeks
(inpatients receiving >90% of ideal body weight Group 2 RC (25.5 weeks)
treatment) (100%)
Ravasco 66 Cancer PG-SGA (38% malnourished) Group 1 DC to achieve Mortality*, weight*, BMI, energy 42 days (3 months)
C/R receiving RT calculated energy and protein intake*, protein intake
(outpatients) requirements (symptom-induced morbidity,
Group 2 2 · 200 mL ONS QOL)
Group 3 RC
Groups 1 and 3 used in this
review
Dietetic interventions in malnourished patients

415
 Table 1 (Continued)

416
Methods used to determine
Total Co-morbidity (healthcare nutritional status Outcomes included in review Duration of intervention
Trial (n) setting) (% malnourished) Comparison details (other outcomes reported) (length of follow-up)

Ravasco 50 Cancer PG-SGA (60%) Group 1 DC to achieve Mortality*, weight*, energy 42 days (3 months)
H&N receiving RT calculated energy and protein intake* [nutritional status
(outpatients) requirements (PG-SGA), symptom-induced
Group 2 2 · 200 mL ONS morbidity, QOL]
Group 3 RC
Groups 1 and 3 used in this
review
Rydwik 48 Frail elderly (outpatients) Unintentional weight loss Group 1 DC to › energy intake Weight*, BMI, TSF*, energy 3 months (3 months)
>5% and/or BMI <20 kg/m2 Group 2 DC + exercise training intake* (muscle strength,
Dietetic interventions in malnourished patients

and low physical activity Group 3 Exercise training balance, time-to-up-and-go,

level (100%) Group 4 RC walking speed)
Groups 1 and 4 used in this
review
Weekes 66 COPD (outpatients) Recent weight loss and poor Group 1 DC to › nutrient intake Mortality*, weight*, BMI, TSF*, 6 months (12 months)
intake or BMI <18.5 kg/m2 Group 2 RC (dietary advice MAC, MAMC*, HGS*, energy
(100%) leaflet for people with small intake (cost, respiratory
appetite) function, respiratory muscle
function, QOL)
Wong 189 Osteoporotic fractures Not specified Group 1 DC to meet specific Mortality*, weight*, BMI, energy 4 months (4 months)
(outpatients) goals for energy, protein and intake*
calcium + 500 mg
calcium + anti-resorptive agent
versus
Group 2 RC + 500 mg
calcium + anti-resorptive agent
Dietary counselling with ONS if required compared with routine care
Berneis 15 HIV infection Recent weight loss or BMI Group 1 DC + ONS if required Weight*, energy intake* (lean 12 weeks
(outpatients) <21 kg/m2 or CD4 cell (target unspecified) and fat mass, macronutrient (12 weeks)
count <500 mm)3 (100%) Group 2 RC intake, immune function, QOL)
Chandra 30 Elderly (outpatients) Clinical and biochemical Group 1 DC + ONS if required Weight, TSF (biochemistry) 4 weeks (4 weeks)
parameters suggesting Group 2 RC
malnutrition (100%)
Evans 180à Cancer Patients stratified according Group 1 DC + ONS if required to Mortality, weight, energy intake 12 weeks (12 weeks)
C/R and lung to recent weight loss (46% achieve target energy intake
patients with >5% weight Group 2 RC
loss)
Forli 37 End stage lung disease BMI <18.7 kg/m2 (100%) Group 1 DC + ONS if wanted Mortality*, weight*, BMI, TSF*, 10–18 days
awaiting transplantation Group 2 RC MAMC*, MUAC*, respiratory (10–18 days)
(inpatients) function*
C. Baldwin and C. E. Weekes

Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.
ª 2012 The Authors
 Table 1 (Continued)
Methods used to determine
Total Co-morbidity (healthcare nutritional status Outcomes included in review Duration of intervention

ª 2012 The Authors

Trial (n) setting) (% malnourished) Comparison details (other outcomes reported) (length of follow-up)

Ganzoni 30 COPD (outpatients) Not specified (implies Group 1 DC + ONS if required Mortality*, weight* 12 months (12 months)
patients <90% ideal body Group 2 RC
weight)
C. Baldwin and C. E. Weekes

Hampson 71 Women with BMI <21 kg/m2 (100%) Group 1 DC + 2 · 200 mL Mortality*, weight, energy 12 months (12 months)
osteoporosis ONS + 1 g calcium and intake* (bone mineral density,
(outpatients) 800 units cholecalciferol fat mass, lean mass)
Group 2 RC + 1 g calcium and
800 units cholecalciferol
Isenring 60 Cancer Patient-generated-SGA Group 1 DC + ONS Mortality*, weight*, energy 12 weeks (12 weeks)
H&N & abdomen (35%) Group 2 RC (standard nutrition intake*, HGS [fat free mass
receiving RT booklet; participants could (BIA), QOL, change in PG-SGA
(outpatients) request referral to a dietitian) score]
Jensen 87 Post-surgical (inpatient Not specified Group 1 DC + ONS if required Weight, energy intake 110 days (110 days)
fi home) to achieve protein intake of
1.5 g kg)1 body weight
Group 2 RC

Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.
Lovik 61 Cancer Not specified Group 1 DC + ONS Mortality*, weight*, energy 6 weeks (6 weeks)
H&N Group 2 RC (standard intake
(mixture of inpatients and information sheet providing
outpatients) information on all aspects of
treatment including advice to
eat a nutritious diet)
Moloney 84 Cancer receiving RT Not specified Group 1 DC + ONS Mortality*, energy intake* 3–5 weeks (unclear)
(mixture of inpatients Group 2 RC (macro and micronutrient
and outpatients) intake)
Ovesen 137 Cancer Patients stratified for amount Group 1 DC + ONS if Mortality*, weight*, energy 5 months (5 months)
Lung, breast and ovary of prior weight loss >5% or required to intake*, TSF*
(outpatients) <5% in previous 3 months exceed Nordic RDAs
Group 2 RC
Persson 142 Cancer Weight loss >5% (25% no Group 1 DC + ONS if Mortality*, weight* energy Unclear (2 years)
et al. (2002) C/R and gastric weight loss, 75% weight required to intake
(outpatients) loss >5%) meet Nordic RDAs
Group 2 RC
Persson 108 Elderly acute admissions MNA score <10 (100%) Group 1 DC + ONS + Weight*, BMI, HGS*, energy Unclear (3.6–6.9
et al. (2007) (hospital fi multivitamin intake* (activities of daily living, months)
community) Group 2 RC (brief written dietary cognitive function, peak
advice) expiratory flow, QOL)
Dietetic interventions in malnourished patients

417
 Dietetic interventions in malnourished patients C. Baldwin and C. E. Weekes

Duration of intervention
Mortality

HGS, handgrip strength; MAMC, mid-arm muscle circumference; MNA, Mini Nutritional Assessment; MUAC, mid-upper arm circumference; ONS, oral nutritional supplements; PG-SGA, patient-
4 months (4 months)
(length of follow-up)

BIA, bioelectrical impedance analysis; BMI, body mass index; COPD, chronic obstructive pulmonary disease; C/R, colorectal; DC, dietary counselling; GI, gastrointestinal; H&N, head and neck;
Data were available on mortality from 18 of 26 studies
and were combined to evaluate the effect of dietary coun-
selling with or without ONS on mortality (Imes et al.,
1988; Ollenschlager et al., 1992; Ovesen et al., 1993;
Ganzoni et al., 1994; Lovik et al., 1996; Forli et al., 2001;
Persson et al., 2002, 2007; Hampson et al., 2003; Isenring
et al., 2004; Wong et al., 2004; Manguso et al., 2005;
generated subjective global assessment; QOL, quality of life; RC, routine care; RT, radiotherapy; TSF, triceps skinfold thickness; RDA, recommended daily allowance. Ravasco et al., 2005a,b; Campbell et al., 2008; Rydwik
Outcomes included in review
(other outcomes reported)

et al., 2008; Weekes et al., 2009; Baldwin et al., 2011).

Weight*, MAMC*, TSF*

In five studies, there were no deaths (Imes et al., 1988;

Wong et al., 2004; Manguso et al., 2005; Ravasco et al.,
2005a,b). No difference in mortality was observed
between those participants who received dietary counsel-
ling or dietary counselling and supplements if required
Dixon – reports 88 participants randomised to five groups. We have assumed 18 randomised to each group (therefore 36 to two groups).

and those who received usual care [relative risk (RR)

(fixed effects model) = 1.12; P = 0.39; 95% CI = 0.86–
1.46]. No heterogeneity was observed in this analysis
(I2 = 0%; P = 0.73).
Group 1 DC + ONS
Comparison details

Subgroup analyses were conducted on the combined

results of dietary counselling given with or without ONS
Group 2 RC

on mortality to determine whether there were effects asso-

ciated with defined groups that were masked by the com-
bining of studies. Heterogeneity was low in all analyses
(I2 = 0–15%) and no effects on mortality were observed
(Table 3). The number of studies and number of partici-
pants for each subgroup analysis varied from 1 to 12 (62–
<90% of ideal body weight
Methods used to determine

975 participants), with the smallest number being found

in the analyses of clinical condition. There were eight
(% malnourished)

studies in patients with cancer and the result suggested no

nutritional status

effect of nutritional intervention on overall mortality [RR

(fixed effects model) = 1.20; 95% CI = 0.83–1.72] with no
(100%)

heterogeneity. The number of studies in the analyses of

Evans/Foltz – trial includes three arms; two arms combined in review.

data for other clinical backgrounds included too few stud-

ies and participants to be meaningful.
A number of clinical outcomes (e.g. hospital admis-
sions, disease severity, immune function and respiratory
Co-morbidity (healthcare

function) were reported in the included studies (Table 4);

COPD (hospital fi

however, there were insufficient data for any single out-

come to enable meaningful analysis.
community)
setting)

Weight
Data were available on weight change from 18 of 26 stud-
*Outcomes with usable data.

ies comparing dietary counselling alone or with ONS if

required with usual care (Macia et al., 1991; Rogers et al.,
Total
(n)

28
Table 1 (Continued)

1992; Ovesen et al., 1993; Ganzoni et al., 1994; Lovik

et al., 1996; Forli et al., 2001; Persson et al., 2002, 2007;
Isenring et al., 2004; Wong et al., 2004; Manguso et al.,
2005; Ravasco et al., 2005a,b; Campbell et al., 2008; Ryd-
Rogers

wik et al., 2008; Weekes et al., 2009; Baldwin et al., 2011),

Trial

although one study did not contribute estimable data

 

ª 2012 The Authors

418 Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.
 C. Baldwin and C. E. Weekes Dietetic interventions in malnourished patients

Table 2 Presence of indicators of study Generation Concealment Blinded Baseline

quality Trial of sequence of allocation assessment characteristics

Dietary counselling versus routine care

Baldwin   
Campbell   *
Dixon 
Imes   Clinical outcomes *
only
Macia   Clinical outcomes
only
Manguso    Nutritional outcomes 
only
Ollenschlager 
Ravasco (C/R)  
Ravasco (H&N)  
Rydwick 
Weekes   
Wong   
Dietary counselling plus ONS if required versus routine care
Berneis 
Chandra
Evans   
Forli   Clinical outcomes *
only
Ganzoni   
Hampson   *
Isenring   
Jensen    Clinical outcomes *
only
Lovik   
Moloney *
Ovesen   
Persson et al. (2002)   
Persson et al. (2007)
Rogers 

C/R, colorectal; H&N, head and neck; ONS, oral nutritional supplements.
*Some characteristics not similar at baseline.

in one arm (Ravasco et al., 2005a). Participants who
received dietary counselling and dietary counselling plus
ONS if required gained more weight than those who
received usual care [mean difference (MD) (random
effects) = 1.7 kg; P = 0.0001; 95% CI = 0.86–2.55]. High
heterogeneity between studies was observed in this analy-
sis (I2 = 89%; P < 0.00001) (Fig. 2).
The specified subgroup analyses were conducted on
this data set. Heterogeneity was moderate to high in all
subgroup analyses (39–92%), suggesting that the studies
were not sufficiently similar to allow conclusions to be
drawn (Table 3). In the subgroup analyses according to
clinical background, apart from cancer, there were few
studies in each clinical grouping, limiting any meaningful
interpretation. In the seven studies of patients with cancer
(Ovesen et al., 1993; Lovik et al., 1996; Persson et al.,
2002; Isenring et al., 2004; Ravasco et al., 2005a,b; Bald-
win et al., 2011), those who received dietary counselling
and supplements gained more weight than those who
received usual care [MD (random effects) = 2.98 kg;
P = 0.01; 95% CI = 0.64–5.31], although the effect was
very heterogeneous (I2 = 89%; P < 0.00001).
Subgroup analyses on type of intervention age, propor-
tion of patients malnourished or at nutritional risk, study
quality and length of intervention had little or no effect
on reducing heterogeneity. It is of note that patients
receiving dietary counselling plus nutritional supplements
if required gained more weight than patients receiving
dietary counselling alone (MD = 1.47 kg; 95% CI = 0.32–
2.16; MD = 2.20 kg; 95% CI = 1.16–3.25).
Body composition
Five studies comparing dietary counselling with or with-
out ONS with usual care contributed data on indices of
body composition, mid-arm muscle circumference

ª 2012 The Authors

Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd. 419
 Dietetic interventions in malnourished patients C. Baldwin and C. E. Weekes

Table 3 Summary of results from meta-analyses of mortality and weight

Number of Number of I2 result for
Comparison studies participants Analysis result heterogeneity

Mortality
Combined analysis
Dietary counselling or dietary counselling plus ONS if 18 1491 RR (fixed) 1.11 (0.81, 1.51) 0%
required versus routine care
Dietary counselling versus routine care 10 887 RR (fixed) 1.54 (0.75, 3.18) 0%
Dietary counselling plus ONS if required versus routine 9 604 RR (fixed) 1.01 (0.72, 1.43) 0%
care
Subgroup analyses
Clinical condition
Cancer 8 695 RR (fixed) 1.20 (0.83, 1.72) 0%
Gastrointestinal disease 2 227 Not estimable (no events in
either study)
Elderly 2 156 RR (fixed) 0.66 (0.28, 1.53) 0%
Respiratory 3 130 RR (fixed) 0.95 (0.31, 2.92) 0%
Osteoporosis 2 221 RR (fixed) 0.32 (0.01, 7.7) NA (events in one
study only)
Renal 1 62 RR (fixed) 8.45 (0.47, 150.66) NA (only one study
in analysis)
Age
Under 65 years 7 484 RR (fixed) 1.34 (0.37, 4.83) 0%
Over 65 years 11 1008 RR (fixed) 1.09 (0.79, 1.51) 0%
Nutritional status
>50% malnourished 10 837 RR (fixed) 0.98 (0.71, 1.37) 0%
At risk population 8 654 RR (fixed) 2.52 (0.93, 6.85) 0%
Study quality
Adequate 12 975 RR (fixed) 1.20 (0.85, 1.69) 0%
Duration of intervention
1–3 months 9 741 RR (fixed) 1.58 (0.75, 3.33) 7%
4–6 months 6 590 RR (fixed) 1.31 (0.63, 2.00) 38%
>6 months 3 237 RR (fixed) 0.93 (0.60, 1.43) 0%
Weight change
Combined analysis
Dietary counselling or dietary counselling plus ONS if 18 1187 MD (random) 1.79 kg (1.02, 2.56)* 86%
required versus routine care
Dietary counselling versus routine care 9 733 MD (random) 1.47 kg (0.32, 2.16)* 90%
Dietary counselling plus ONS if required versus 9 454 MD (random) 2.20 kg (1.16, 3.25)* 63%
routine care
Subgroup analyses
Clinical condition
Cancer 8 618 MD (random) 2.63 kg (0.63, 4.63)* 87%
Gastrointestinal disease 1 90 MD (random) )0.58 kg ()1.47, NA (only one study
0.31) n analysis)
Elderly 2 131 MD (random) 2.07 kg ()1.75, 5.88) 92%
Respiratory 3 133 MD (random) 2.25 kg (0.79, 3.70)* 63%
Osteoporosis 1 150 MD (random) 0.41 kg (0.36, 0.46) NA (only one study
in analysis)
Renal 1 50 MD (random) )0.16 kg ()1.34, NA (only one study
1.02) in analysis)
HIV infection 1 15 MD (random) 1.80 kg ()3.13, 6.73) NA (only one study
in analysis)
Age
<65 years 7 347 MD (random) 2.69 kg (0.58, 4.80)* 93%
>65 years 11 840 MD (random) 1.25 kg (0.48, 2.02)* 70%
Nutritional status
>50% malnourished 10 599 MD (random) 1.57 kg (0.71, 2.43)* 62%

ª 2012 The Authors

420 Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.
 C. Baldwin and C. E. Weekes Dietetic interventions in malnourished patients

Table 3 (Continued)
Number of Number of I2 result for
Comparison studies participants Analysis result heterogeneity

At risk population 8 588 MD (random) 2.19 kg (0.73, 3.64)* 91%

Study quality
Adequate 11 735 MD (random) 1.98 kg (0.45, 3.51)* 88%
Duration of intervention
0–3 months 10 606 MD (random) 1.54 kg (0.20, 2.88)* 90%
4–6 months 5 412 MD (random) 2.14 kg (0.46, 3.82)* 88%
>6 months 3 169 MD (random) 2.63 kg (0.39, 4.88)* 39%
Change in energy intake
Combined analysis
Dietary counselling or dietary counselling plus ONS 13 830 MD (random) 900 kJ (172, 1628) 97%
if required versus routine care [215 kcal (41, 389)]*
Dietary counselling versus routine care 7 472 MD (random) 1079 kJ ()4.48, 2160) 98%
[258 kcal ()1.07, 516)]*
Dietary counselling plus ONS if required versus 6 358 MD (random) 661 kJ ()276, 1599) 84%
routine care [158 kcal ()66, 382)]*

MD, mean difference; NA, not available; ONS, oral nutritional supplements; RR, relative risk.
*Result statistically significant.

(MAMC) and triceps skinfold thickness (TSF) (Macia ing nutritional intervention had significantly greater
et al., 1991; Rogers et al., 1992; Ovesen et al., 1993; improvements in MAMC and TSF than groups receiving
Manguso et al., 2005; Weekes et al., 2009). Groups receiv- usual care. In the analysis of MAMC, there was high

Table 4 Summary of additional clinical and functional outcome measures and quality of life assessments reported in included studies
Dietary counselling versus routine care Dietary counselling + ONS if required versus routine care

Clinical Disease activity/severity (Imes et al., 1988; Manguso et al., 2005)
outcomes Need for surgery (Imes et al., 1988)
Disease remissions (Ollenschlager et al., 1992)
Change in medication (Imes et al., 1988; Weekes et al., 2009)
Reduction in temperature (Ollenschlager et al., 1992)
Days of work lost (Imes et al., 1988)
Hospital admissions (Imes et al., 1988; Weekes et al., 2009)
Change in symptoms (Macia et al., 1991; Ollenschlager et al.,
1992; Ravasco et al., 2005a,b)
Patient mobility assessments (Rydwik et al., 2008)
Respiratory function (Weekes et al., 2009)
Perceived dysnopea (Weekes et al., 2009)
Cost (Weekes et al., 2009)
Functional Handgrip strength (Baldwin et al., 2008; Weekes et al., 2009)
outcomes Performance status (Karnofsky) (Dixon, 1984)
Functional independence Measure (Rydwik et al., 2008)
Instrumental activities measure (Rydwik et al., 2008)
Health belief model (Rydwik et al., 2008)
Activities of daily living (Weekes et al., 2009)
Respiratory muscle function (Weekes et al., 2009)
Quality of life EORTC-QLQ-C30 (Ravasco et al., 2005a,b; Baldwin et al., 2008)
FAACT (Baldwin et al., 2008)
Linear Analogue Scale (Ollenschlager et al., 1992)
SF-36 (Weekes et al., 2009)
SGRQ (Weekes et al., 2009)
Immune function (Berneis et al., 2000)
CD4 count and markers of HIV infection (Berneis et al., 2000)
Tumour response to treatment (Evans et al., 1987; Ovesen
et al., 1993)
Respiratory function (Rogers et al., 1992; Ganzoni et al., 1994;
Jensen & Hessov, 1997; Persson et al., 2007)
Perceived dyspnoea (Rogers et al., 1992)
Handgrip strength (Rogers et al., 1992; Jensen & Hessov,
1997; Persson et al., 2007)
Physical function (walking distance) (Rogers et al., 1992;
Ganzoni et al., 1994)
Ordinal fatigue scale (Jensen & Hessov, 1997)
Lambert disability screening questionnaire (Jensen & Hessov,
1997)
Cognitive function (Persson et al., 2007)
Activities of daily living (Persson et al., 2007)
EORTC-QLQ-C30 (Persson et al., 2002; Isenring et al., 2004)
Medical outcomes study instrument (Berneis et al., 2000)
Quality of life index (Ovesen et al., 1993; Jensen & Hessov,
1997)
SF-36 (Persson et al., 2007)

ONS, oral nutritional supplements; EORTC, European Organisation for Research and Treatment of Cancer; FAACT, Functional Assessment of
Anorexia/Cachexia Therapy; SF36, Short Form Health Survey; SGRQ, St George’s Respiratory Questionnaire.

ª 2012 The Authors

Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd. 421
 Dietetic interventions in malnourished patients
Figure 2 Meta-analysis of the effects of oral nutritional intervention compared with no intervention on weight.
heterogeneity (I2 = 87%; P < 0.00001). In the analysis of
TSF, heterogeneity was low (I2 = 31%; P = 0.21).
Nutritional intake
Seven studies comparing dietary counselling with routine
care (Wong et al., 2004; Manguso et al., 2005; Ravasco
et al., 2005a,b; Campbell et al., 2008; Rydwik et al., 2008)
and six studies comparing dietary counselling plus ONS
with routine care (Moloney et al., 1983; Ovesen et al.,
1993; Berneis et al., 2000; Forli et al., 2001; Hampson
et al., 2003; Isenring et al., 2007) reported changes in
energy intake from the start to the end of intervention The
combined analysis and analysis of dietary counselling alone
suggested that nutritional intervention was associated with
significant improvements in energy intake. Heterogeneity
between studies, however, was high (I2 = 97%;
P < 0.00001 and I2 = 98%; P < 0.00001, respectively).
There was no significant difference between groups in the
analysis of dietary counselling plus ONS if required versus
usual care [MD 661 kJ (158 kcal; 95% CI = )66 to 382,
P = 0.17], although again heterogeneity was high in this
analysis (I2 = 84%; P < 0.0001).
The amount of weight gain achieved in groups receiv-
ing counselling and ONS was higher than that in groups
receiving dietary counselling alone, although the energy
intake data suggest that improvements in intake were
greater in the groups receiving counselling alone. The lack
of correspondence between improvements in energy
intake and weight gain suggests that there may be signifi-
cant errors in the reporting and analysis of food intake
data.
Functional status
Assessment of functional outcomes varied between stud-
ies, with some studies reporting universal outcomes such
422
C. Baldwin and C. E. Weekes
as handgrip strength and activities of daily living and oth-
ers reporting disease specific outcomes (Table 4). There
were insufficient data on any one outcome to enable
meaningful analysis.
Quality of life
Quality of life was assessed in eleven of the included stud-
ies; however, seven different quality of life questionnaires
were used and there was variation in the number of
domains reported for any one questionnaire; therefore,
no analyses were undertaken for this outcome.
Discussion
It has been demonstrated that dietary counselling given
with or without ONS is associated with significant bene-
fits to weight and energy intake but is not associated with
clinical benefits (Baldwin & Weekes, 2011). Examining
each of these closely-related intervention strategies sepa-
rately reduces the power of meta-analysis to detect any
effect that might be apparent by combining similar stud-
ies together and does not represent real life dietetic prac-
tice. In addition, the high levels of heterogeneity in the
analyses mean that it is impossible to identify which
patient groups are most likely to benefit from dietary
counselling and ONS-based interventions. The aim of the
present review was to examine the effects on mortality
and nutritional indices of dietary counselling given with
or without ONS and also to examine the heterogeneity in
the meta-analyses aiming to characterise the groups of
patients that derived the greatest benefits from these
interventions. The main findings were that dietary coun-
selling alone or combined with ONS had significant but
heterogeneous effects on weight, energy intake and body
composition. Subgroup analyses taking into account clini-
cal background of the patient, age, nutritional status at
ª 2012 The Authors
Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.
 C. Baldwin and C. E. Weekes
recruitment, type of intervention and length of interven-
tion failed to reveal any differences between groups in
analyses of both mortality, weight change and energy
intake, and heterogeneity within each subgroup remained
high. Overall, there was no evidence of an effect of die-
tary counselling given with or without ONS in malnour-
ished patients on mortality. In the absence of an effect on
mortality, the effect of these interventions on other out-
comes has continued to receive surprisingly little atten-
tion. Apart from a small number of studies assessing
changes in body composition, there were insufficient data
to determine whether dietary counselling given with or
without ONS has an effect on clinical, nutritional and
functional outcomes or quality of life. It remains to be
clarified whether the improvements in weight associated
with dietary counselling translate to improvements in
other outcomes.
Policy in the UK on the management of disease-related
malnutrition suggests that improvements in mortality,
weight and complication rates can be achieved with the
use of ONS (NCC-AC, 2006). The present review shows
that dietary counselling with or without ONS can result
in similar improvements in weight gain. However, both
the review by the National Institute for Health and Clini-
cal Excellence (NICE) and the present review exhibit con-
siderable heterogeneity and so the effect size for either
ONS or dietary counselling cannot be determined.
By contrast to the review by NICE, the present review
showed no effect of dietary counselling with or without
ONS on mortality. The review by NICE based their con-
clusion on 25 studies with almost 3000 randomised par-
ticipants (NCC-AC, 2006). The present review included
2123 patients in 26 studies of which five studies reported
no deaths. This finding suggests that dietary counselling
given with or without ONS may have no effect on mor-
tality rather than there being insufficient evidence. This
raises the question of whether dietary counselling is com-
parable with ONS and whether the combinations of
nutrients in ONS can be replicated in foods. Studies of
dietary counselling rarely report the details of specific
foods and combinations of foods used to increase nutri-
ent intake.
The identified studies were heterogeneous for a number
of factors and it is likely that these factors contributed to
the observed heterogeneity in the results. If we accept that
the effects of ONS (which derive mainly from analyses
that combine heterogeneous groups of patients and have
not been universally replicated in individual clinical con-
ditions) may be the result of the small number of studies
in some patient groups, then the same may be true for
interventions based on dietary counselling. In a meta-
analysis of protein-energy supplementation in elderly
patients, subgroup analysis was used to explore the results
ª 2012 The Authors
Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.
Dietetic interventions in malnourished patients
(Milne et al., 2009). Subgroup size varied from 22 partici-
pants to >8000 participants and benefits to mortality were
found for supplementation of malnourished compared to
normally nourished patients (25 studies, 2466 partici-
pants). The studies represented a wide range of clinical
conditions, although the numbers of participants with
any one condition were small with the exception of can-
cer. Even amongst studies conducted in cancer patients,
there was wide variation in site, stage and treatment. In
most of the included studies, the mean age of patients
was >65 years, although a wide age range was represented
overall. The majority of studies were conducted in outpa-
tients, with only seven studies including patients who
spent some time in hospital. Although it was possible to
obtain information on the duration of intervention in
most of the studies, there was almost no information on
the nature, intensity and content of the dietary counsel-
ling. In addition, details of the experience and training of
the dietitian giving the counselling were not reported.
Decisions on the nutritional management of patients by
healthcare staff are frequently based on experience
and judgement (Elia, 2011). The restrictive conditions
imposed by clinical trials often do not mirror the more
flexible conditions of clinical practice and therefore ques-
tions about day-to-day practice are difficult to answer.
Capra et al. (2002) has suggested that failure to imple-
ment the nutrition prescription and to monitor compli-
ance with the prescription could be responsible for the
‘negative’ findings of studies. However, in all studies,
there was a consistent aim of improving nutritional intake
with the goal of minimising weight loss or promoting
weight gain. The present review suggests that it is possible
to achieve an increase in energy intake and weight gain
with dietary counselling with or without ONS. Dietitians
provide nutritional support to patients from a variety of
clinical backgrounds and different healthcare settings.
From the findings of the present review, it is not possible
to be specific about the effects that can be achieved in
any one patient group and, indeed, it is likely that it will
vary according to all of the above variables. In addition,
the optimal length of intervention has yet to be deter-
mined. Although the included studies have measured a
range of other clinical, nutritional and functional out-
comes and quality of life, has not been possible to deter-
mine whether the improvements in energy intake and
weight were translated into other improvements because
of a lack of similar data between studies.
The quality of evidence in the present review is at best
low to moderate. The main issue is that, although
sequence generation and allocation concealment were
often adequate, very few studies were adequately blinded
and most were small and inadequately powered. It is
important to note that it is difficult to design an adequate
423
 Dietetic interventions in malnourished patients
placebo for dietary counselling and it is impossible to
prevent some patients in the control arm from seeking
other sources of dietary counselling that act as confound-
ers. Although dietary counselling can be compared with
usual care, this has varied enormously between studies. It
is possible to design studies where outcome assessment is
blinded, although this has not been achieved in many of
the included studies. A possible reason for this is inade-
quate funding for this type of research.
The original search strategy for this review was com-
prehensive (Avenell et al., 2001); there was no language
restriction on papers retrieved and two reviewers have
selected studies independently. However, no hand-search-
ing has been undertaken and searching of the grey litera-
ture has not been possible. Funnel plots undertaken on
some of the larger analyses suggest strong evidence of
publication bias. In particular, there was a lack of large
studies and studies with a negative outcome. The searches
undertaken for the Cochrane Library review and the sub-
sequent analysis were last updated in February 2010. Tar-
geted searches of PubMed have indicated that there may
now be a small number of new trials published that meet
the inclusion criteria of the present review. The possibil-
ity that inclusion of additional data would alter the con-
clusions of the present analysis cannot be ruled out,
although the purpose of the present analysis was to take
a more in-depth look at the findings of the recently pub-
lished Cochrane review and to be complimentary to that
review.
Research is needed in populations of patients similar
for nutritional status and risk category at study inclusion,
as defined using standard assessment tools, with a range
of clinical conditions where the stage and treatment
intent of the condition is clearly described in the hospital
setting and in a variety of community settings. More evi-
dence is needed for food-based interventions used in
standard dietetic practice, such as dietary counselling and
dietary counselling combined with ONS, aiming to deter-
mine whether these strategies do indeed offer similar ben-
efits to patients. Studies that compare dietary counselling
with ONS are particularly needed. Studies need to include
details of the type, intensity and duration of the interven-
tion, as well as record the nutrient content of any of the
improvements achieved. In addition, the level of expertise
of the person giving the counselling should be reported.
When designing studies, it is important to consider the
need for data on patient-centred and clinical outcomes
and also to consider whether any benefits identified are
continued beyond cessation of intervention. If no effect
of dietary counselling on clinical endpoints is demon-
strated, then it is of real importance that beneficial effects
on outcomes important to patients can be demonstrated
(Baldwin et al., 2008).
424
C. Baldwin and C. E. Weekes
Acknowledgments
We are grateful to the following individuals who pro-
vided additional data and information for the included
studies: Sharleen Imes (University of Alberta, Canada);
Guenter Ollenschlager (Cologne, Germany); Dr Brandli
(Surcher Hohenklinik Wald, Lausanne, Switzerland);
Martin Jensen (Denmark); Astrid Lovik (Norway); Robert
Rogers (University of Pittsburgh, PA, USA); Paula
Ravasco (Santa Maria University Hospital, Portugal); Dr
Samuel Y. Wong (Prince of Wales Hospital, Hong Kong);
Liv Forli (Rikshospitalet, Norway); Professor Ulrich Keller
(University Hospital, Basel, Switzerland); Dr Geeta
Hampson (St Thomas’ Hospital, London); Dr Christina
Persson (Akademiska sjukhuset, Uppsala, Sweden); Dr
Elizabeth Isenring (Flinders University, Adelaide, Austra-
lia); Dr Katrina Campbell (King’s College London); Dr
Francesco Manguso (Fredico II University of Naples,
Italy); Dr Elizabeth Rydwik (Karolinska Institutet,
Sweden); and Dr Margareta Persson and Professor T.
Cederholm (Uppsala University Hospital, Sweden). Addi-
tionally, I am grateful to Reinhard Wentz (Campus
Library Manager, Imperial College London, UK) and
Nick Woolley (Information Specialist, King’s College,
University of London, UK) for their help with developing
the search strategy. Early work on this review was under-
taken with the support of Dr Tessa Parsons (University
College London, UK).
Conflict of interests, source of funding and
authorship
The authors have no conflicts of interest to declare.
No funding was received for the conduct and interpreta-
tion of these analyses.
CB and CEW undertook the original systematic review
and meta-analyses described in this manuscript, as well as
all of the subgroup analyses presented. The interpretation
of the data represents the collective experience, thoughts
and ideas of both authors. The manuscript was drafted by
CB and critically reviewed by CEW. Both authors
approved the final version submitted for publication.
References
Arends, J., Bodoky, G., Bozzetti, F., Fearon, K., Muscaritoli,
M., Selga, G., van Bokhorst-de van der Schueren, M.A.,
von Meyenfeldt, M., Zurcher, G., Fietkau, R., Aulbert, E.,
Frick, B., Holm, M., Kneba, M., Mestrom, H.J. &
Zander, A. (2006) ESPEN guidelines on enteral nutrition:
non-surgical oncology. Clin. Nutr. 25, 245–259.
Avenell, A., Handoll, H.H. & Grant, A.M. (2001) Lessons for
search strategies from a systematic review, in The Cochrane
ª 2012 The Authors
Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.
 C. Baldwin and C. E. Weekes
Library, of nutritional supplementation trials in patients
after hip fracture. Am. J. Clin. Nutr. 73, 505–510.
Baldwin, C. & Weekes, C.E. (2011) Dietary advice with or
without oral nutritional supplements for disease-related
malnutrition in adults. Cochrane Database Syst. Rev. 9,
CD002008.
Baldwin, C., Weekes, C.E. & Campbell, K.L. (2008) Measuring
the effectiveness of dietetic interventions in nutritional sup-
port. J. Hum. Nutr. Diet. 21, 303–305.
Baldwin, C., Spiro, A., McGough, C., Norman, A.R., Gillbanks,
A., Thomas, K., O’Brien, M., Cunningham, D.C. & Andr-
eyev, H.J.N. (2011) Simple nutritional intervention in
patients with advanced cancers of the gastrointestinal tract,
non-small cell lung cancers or mesothelioma and weight loss
receiving chemotherapy: a randomised controlled trial.
J. Hum. Nutr. Diet. 24, 431–440.
Berneis, K., Battegay, M., Bassetti, S., Nuesch, R., Leisibach, A.,
Bilz, S. & Keller, U. (2000) Nutritional supplements com-
bined with dietary counselling diminish whole body protein
catabolism in HIV-infected patients. Eur. J. Clin. Invest.
30, 87–94.
Bruce, D., Laurance, I., McGuiness, M., Ridley, M. & Gold-
swain, P. (2003) Nutritional supplements after hip fracture:
poor compliance limits effectiveness. Clin. Nutr. 22, 497–500.
Campbell, K.L., Ash, S., Davies, P.S. & Bauer, J.D. (2008) Ran-
domized controlled trial of nutritional counseling on body
composition and dietary intake in severe CKD. Am. J.
Kidney Dis. 51, 748–758.
Capra, S., Bauer, J., Davidson, W. & Ash, S. (2002) Nutritional
therapy for cancer-induced weight loss. Nutr. Clin. Pract.
17, 210–213.
Chandra, R.K. & Puri, S. (1985) Nutritional support improves
antibody response to influenza virus vaccine in the elderly.
Br. Med. J. (Clin. Res. Ed) 291, 705–706.
Dixon, J. (1984) Effect of nursing interventions on nutritional
and performance status in cancer patients. Nurs. Res. 33,
330–335.
Elia, M. (2011) Oral nutritional support in patients with can-
cer of the gastrointestinal tract. J. Hum. Nutr. Diet. 24,
417–419.
Evans, W.K., Nixon, D.W., Daly, J.M., Ellenberg, S.S., Gardner,
L., Wolfe, E., Shepherd, F.A., Feld, R., Gralla, R., Fine, S.,
Kemeny, N., Jeejeebhoy, K.N., Heymsfield, S. & Hoffman,
F.A. (1987) A randomized study of oral nutritional support
versus ad lib nutritional intake during chemotherapy for
advanced colorectal and non-small-cell lung cancer. J. Clin.
Oncol. 5, 113–124.
Forli, L., Bjortuft, O., Vatn, M., Kofstad, J. & Boe, J. (2001) A
study of intensified dietary support in underweight candi-
dates for lung transplantation. Ann. Nutr. Metab. 45,
159–168.
Ganzoni, A., Heilig, P., Schonenberger, K., Hugli, O., Fitting,
J.W. & Brandli, O. (1994) High-caloric nutrition in chronic
obstructive lung disease. Schweiz. Rundsch. Med. Prax. 83,
13–16.
ª 2012 The Authors
Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.
Dietetic interventions in malnourished patients
Hampson, G., Martin, F.C., Moffat, K., Vaja, S., Sankaralin-
gam, S., Cheung, J., Blake, G.M. & Fogelman, I. (2003)
Effects of dietary improvement on bone metabolism in
elderly underweight women with osteoporosis: a randomised
controlled trial. Osteoporos. Int. 14, 750–756.
Higgins, J.P.T. & Green, S. (2009) Cochrane Handbook for Sys-
tematic Reviews of Interventions. Chichester: John Wiley &
Sons Ltd.
Higgins, J.P., Thompson, S.G., Deeks, J.J. & Altman, D.G. (2003)
Measuring inconsistency in meta-analyses. BMJ 327, 557–560.
Hobday, R., Sharott, P. & Aubrey, P. (2010) Clinical Oral
Nutrition Support Project (Adults). London: NHS London
Procurement Programme. Available at: http://www.lpp.nhs.
uk/page.asp?fldArea=2&fldMenu=6&fldSubMenu=6&fldKey=
101 (accessed on 31 May 2012).
Imes, S., Pinchbeck, B. & Thomson, A.B. (1988) Diet counsel-
ling improves the clinical course of patients with Crohn’s
disease. Digestion 39, 7–19.
Isenring, E.A., Capra, S. & Bauer, J.D. (2004) Nutrition inter-
vention is beneficial in oncology outpatients receiving radio-
therapy to the gastrointestinal or head and neck area.
Br. J. Cancer 91, 447–452.
Isenring, E.A., Bauer, J.D. & Capra, S. (2007) Nutrition sup-
port using the American Dietetic Association medical nutri-
tion therapy protocol for radiation oncology patients
improves dietary intake compared with standard practice.
J. Am. Diet. Assoc. 107, 404–412.
Jensen, M.B. & Hessov, I. (1997) Dietary supplementation at
home improves the regain of lean body mass after surgery.
Nutrition 13, 422–430.
Koretz, R.L., Avenell, A., Lipman, T.O., Braunschweig, C.L. &
Milne, A.C. (2007) Does enteral nutrition affect clinical out-
come? A systematic review of the randomized trials. Am. J.
Gastroenterol. 102, 412–429; quiz 468.
Lawson, R.M., Doshi, M.K., Ingoe, L.E. & Collingan, J.M.
(2000) Compliance of orthopedic patients with postopera-
tive oral nutritional supplementation. Clin. Nutr. 19,
171–175.
Lovik, A., Almendingen, K., Dotterud, M., Forli, L., Boysen,
M., Omarhus, M., Jacobsen, A.B. & Ose, T. (1996) Dietary
information after radiotherapy of head and neck cancer.
Tidsskr. Nor. Laegeforen. 116, 2303–2306.
Macia, E., Moran, J., Santos, J., Blanco, M., Mahedero, G. &
Salas, J. (1991) Nutritional evaluation and dietetic care in
cancer patients treated with radiotherapy: prospective study.
Nutrition 7, 205–209.
Manguso, F., D’Ambra, G., Menchise, A., Sollazzo, R. & D’Ag-
ostino, L. (2005) Effects of an appropriate oral diet on the
nutritional status of patients with HCV-related liver cirrho-
sis: a prospective study. Clin. Nutr. 24, 751–759.
Milne, A.C., Potter, J., Vivanti, A. & Avenell, A. (2009) Protein
and energy supplementation in elderly people at risk from
malnutrition. Cochrane Database Syst. Rev. 2, CD003288.
Moloney, M., Moriarty, M. & Daly, L. (1983) Controlled
studies of nutritional intake in patients with malignant
425
 Dietetic interventions in malnourished patients
disease undergoing treatment. Hum. Nutr. Appl. Nutr. 37,
30–35.
NCC-AC. (2006) Nutrition Support in Adults: Oral Nutrition
Support, Enteral Tube Feeding and Parenteral Nutrition.
London: Royal College of Surgeons England.
Norman, K., Pichard, C., Lochs, H. & Pirlich, M. (2008) Prog-
nostic impact of disease-related malnutrition. Clin. Nutr. 27,
5–15.
Ockenga, J., Grimble, R., Jonkers-Schuitema, C., Macallan, D.,
Melchior, J.C., Sauerwein, H.P., Schwenk, A. & Suttmann, U.
(2006) ESPEN guidelines on enteral nutrition: wasting in
HIV and other chronic infectious diseases. Clin. Nutr. 25,
319–329.
Ollenschlager, G., Thomas, W., Konkol, K., Diehl, V. & Roth,
E. (1992) Nutritional behaviour and quality of life during
oncological polychemotherapy: results of a prospective study
on the efficacy of oral nutrition therapy in patients with
acute leukaemia. Eur. J. Clin. Invest. 22, 546–553.
Ovesen, L., Allingstrup, L., Hannibal, J., Mortensen, E.L. &
Hansen, O.P. (1993) Effect of dietary counseling on food
intake, body weight, response rate, survival, and quality of
life in cancer patients undergoing chemotherapy: a prospec-
tive, randomized study. J. Clin. Oncol. 11, 2043–2049.
Persson, C.R., Johansson, B.B., Sjoden, P.O. & Glimelius, B.L.
(2002) A randomized study of nutritional support in
patients with colorectal and gastric cancer. Nutr. Cancer 42,
48–58.
Persson, M., Hytter-Landahl, A., Brismar, K. & Cederholm, T.
(2007) Nutritional supplementation and dietary advice in
geriatric patients at risk of malnutrition. Clin. Nutr. 26,
216–224.
Plauth, M., Cabre, E., Riggio, O., Assis-Camilo, M., Pirlich,
M., Kondrup, J., Ferenci, P., Holm, E., Vom Dahl, S., Mul-
ler, M.J. & Nolte, W. (2006) ESPEN guidelines on enteral
nutrition: liver disease. Clin. Nutr. 25, 285–294.
Ravasco, P., Monteiro-Grillo, I., Marques Vidal, P. &
Camilo, M.E. (2005a) Impact of nutrition on outcome: a
prospective randomized controlled trial in patients with
head and neck cancer undergoing radiotherapy. Head Neck
27, 659–668.
Ravasco, P., Monteiro-Grillo, I., Vidal, P.M. & Camilo, M.E.
(2005b) Dietary counseling improves patient outcomes: a
prospective, randomized, controlled trial in colorectal cancer
patients undergoing radiotherapy. J. Clin. Oncol. 23, 1431–
1438.
Rogers, R.M., Donahoe, M. & Costantino, J. (1992) Physiologic
effects of oral supplemental feeding in malnourished patients
with chronic obstructive pulmonary disease. A randomized
control study. Am. Rev. Respir. Dis. 146, 1511–1517.
426
C. Baldwin and C. E. Weekes
Rydwik, E., Lammes, E., Frandin, K. & Akner, G. (2008)
Effects of a physical and nutritional intervention program
for frail elderly people over age 75. A randomized controlled
pilot treatment trial. Aging Clin. Exp. Res. 20, 159–170.
Schulz, K.F., Chalmers, I., Hayes, R.J. & Altman, D.G. (1995)
Empirical evidence of bias. Dimensions of methodological
quality associated with estimates of treatment effects in con-
trolled trials. JAMA 273, 408–412.
Stratton, R.J. & Elia, M. (1999) A critical systematic analysis of
the use of oral nutritional supplements in the community.
Clin. Nutr. 18(Suppl. 2), 29–84.
Stratton, R.J. & Elia, M. (2007) A review of reviews: a new
look at the evidence for oral nutritional supplements in clin-
ical practice. Clin. Nutr. (Suppl.) 2, 5–23.
Stratton, R.J., Green, C.J. & Elia, M. (2003) Disease Related
Malnutrition: An Evidence-Based Approach to Treatment.
Wallingford: CABI Publishing.
Thomas, B. (2001) Manual of Dietetic Practice. London:
Blackwell Science.
Volkert, D., Berner, Y.N., Berry, E., Cederholm, T., Coti Ber-
trand, P., Milne, A., Palmblad, J., Schneider, S., Sobotka, L.,
Stanga, Z., Lenzen-Grossimlinghaus, R., Krys, U., Pirlich,
M., Herbst, B., Schutz, T., Schroer, W., Weinrebe, W., Ock-
enga, J. & Lochs, H. (2006) ESPEN guidelines on enteral
nutrition: geriatrics. Clin. Nutr. 25, 330–360.
Weekes, C.E., Emery, P.W. & Elia, M. (2009) Dietary counsel-
ling and food fortification in stable COPD: a randomised
trial. Thorax 64, 326–331.
Wong, S.Y., Lau, E.M., Lau, W.W. & Lynn, H.S. (2004) Is die-
tary counselling effective in increasing dietary calcium, pro-
tein and energy intake in patients with osteoporotic
fractures? A randomized controlled clinical trial. J. Hum.
Nutr. Diet. 17, 359–364.
Supporting information
Additional Supporting information may be found in the
online version of this article.
Appendix S1. Search strategy used from 2002 to 2005
on MEDLINE, EMBASE, CINAHL, CancerLit and AMED,
using OVID notation with slight variations.
Please note: Wiley-Blackwell are not responsible for the
content or functionality of any supporting materials sup-
plied by the authors. Any queries (other than missing
material) should be directed to the corresponding author
for the article.
ª 2012 The Authors
Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.