Review Nutritional education for community dwelling older people: A systematic review of randomised controlled trials Kate Young a, *, Frances Bunn b , Daksha Trivedi b , Angela Dickinson b a School of Nursing, Midwifery and Social Work, University of Hertfordshire, United Kingdom b Centre for Research in Primary and Community Care, United Kingdom What is already known about the topic Older people are at increased risk of poor nutrition which has adverse consequences for health and well being. International Journal of Nursing Studies 48 (2011) 751–780 ARTICLE INFO Article history: Received 15 July 2010 Received in revised form 22 December 2010 Accepted 11 March 2011 Keywords: Nutrition Community health services Health education Nurses Aged Systematic review ABSTRACT Objectives: To evaluate the effectiveness of nutritional education or advice on physical function, emotional health, quality of life, nutritional indices, anthropometric indicators, mortality, service use and costs of care in people over 65 years of age living at home. Design: Systematic review of randomised controlled trials (RCTs). Data sources: PUBMED, CINAHL, PSYCINFO, the Cochrane Central Register of Controlled Trials and the National Research Register. Methods: We included studies evaluating nutritional education or advice for people aged 65 and over living in their own homes that measured one or more of the following outcomes: physical function, emotional well being, service use, dietary change and other anthropometric indicators. Studies were assessed for risk of bias on six domains. Due to high heterogeneity, results were not pooled but are reported narratively. Results: Twenty-three studies met our inclusion criteria. All but one of the interventions were delivered by health care professionals; ten were delivered by nurses. The review found evidence to suggest that nutritional education or advice can be used to positively influence diet and improve physical function. There was also evidence that some biochemical markers can be positively affected, although these are surrogate outcomes and are generally disease specific. Several studies indicated that complex interventions, with nutritional education as a component, also reduce depression. The evidence from this review on the impact on weight change was inconclusive. There was no evidence of an improvement in anxiety, quality of life, service use, costs of care or mortality. However, many studies were at moderate or high risk of bias, and for some outcomes the data were insufficient to make judgments about effectiveness. Conclusions: This review indicates that nutritional education or advice can positively affect physical function and diet, whilst complex interventions with nutritional education as a component, can reduce depression in people over 65 years who live at home. However, more research is needed to determine whether outcomes are influenced by types of intervention, morbidity, and socioeconomic circumstance of participants. Relevance to clinical practice: Nutritional education, alone or as part of a complex intervention, can improve diet and physical function and may reduce depression in the over 65s living at home. ß 2011 Elsevier Ltd. All rights reserved. * Corresponding author. Tel.: +44 01707 285147. E-mail addresses: [email protected], [email protected](K. Young). Contents lists available at ScienceDirect International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns 0020-7489/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2011.03.007
Transcript
International Journal of Nursing Studies 48 (2011) 751–780
Contents lists available at ScienceDirect
International Journal of Nursing Studies
journal homepage: www.elsevier.com/ijns
Review
Nutritional education for community dwelling older people: A systematicreview of randomised controlled trials
Kate Young a,*, Frances Bunn b, Daksha Trivedi b, Angela Dickinson b
a School of Nursing, Midwifery and Social Work, University of Hertfordshire, United Kingdomb Centre for Research in Primary and Community Care, United Kingdom
A R T I C L E I N F O
Article history:
Received 15 July 2010
Received in revised form 22 December 2010
Accepted 11 March 2011
Keywords:
Nutrition
Community health services
Health education
Nurses
Aged
Systematic review
A B S T R A C T
Objectives: To evaluate the effectiveness of nutritional education or advice on physical
function, emotional health, quality of life, nutritional indices, anthropometric indicators,
mortality, service use and costs of care in people over 65 years of age living at home.
Design: Systematic review of randomised controlled trials (RCTs).
Data sources: PUBMED, CINAHL, PSYCINFO, the Cochrane Central Register of Controlled
Trials and the National Research Register.
Methods: We included studies evaluating nutritional education or advice for people aged
65 and over living in their own homes that measured one or more of the following
outcomes: physical function, emotional well being, service use, dietary change and other
anthropometric indicators. Studies were assessed for risk of bias on six domains. Due to
high heterogeneity, results were not pooled but are reported narratively.
Results: Twenty-three studies met our inclusion criteria. All but one of the interventions
were delivered by health care professionals; ten were delivered by nurses. The review
found evidence to suggest that nutritional education or advice can be used to positively
influence diet and improve physical function. There was also evidence that some
biochemical markers can be positively affected, although these are surrogate outcomes
and are generally disease specific. Several studies indicated that complex interventions,
with nutritional education as a component, also reduce depression. The evidence from this
review on the impact on weight change was inconclusive. There was no evidence of an
improvement in anxiety, quality of life, service use, costs of care or mortality.
However, many studies were at moderate or high risk of bias, and for some outcomes
the data were insufficient to make judgments about effectiveness.
Conclusions: This review indicates that nutritional education or advice can positively
affect physical function and diet, whilst complex interventions with nutritional education
as a component, can reduce depression in people over 65 years who live at home. However,
more research is needed to determine whether outcomes are influenced by types of
intervention, morbidity, and socioeconomic circumstance of participants.
Relevance to clinical practice: Nutritional education, alone or as part of a complex
intervention, can improve diet and physical function and may reduce depression in the
K. Young et al. / International Journal of Nursing Studies 48 (2011) 751–780752
� A
number of educational interventions have beendeveloped to improve nutritional status.
What this paper adds
� T
he review identifies that nutritional education or advicecan improve diet and physical function and may reducedepression in older people. � T he educational interventions reviewed are within the
current scope of practice for community nurses and thereview provides evidence that nurses should spend timeon these types of activity.
� F urther research is needed to provide evidence on the
most effective approaches to enable older people toimprove their diets and thus health.
1. Introduction
Good diet along with a range of other lifestyle andenvironmental factors such as exercise is thought to delaythe onset of disease and frailty in the older population(Kirkwood, 2008). However, poor or undernutrition in theolder population is widely agreed to be a worldwideproblem (Visvanathan, 2003) with prevalence of under-nutrition in community dwelling people in industrialisednations estimated to be between 5% and 10% in olderpeople aged over 70 years (Posner et al., 1994, Elia andStratton, 2005, Stratton et al., 2004).
Although older people have been found to be apopulation group at risk of poor nutrition (NICE,2006a,b), the older population is extremely diverse andheterogeneous. The most recent national survey of the dietand nutritional status of older people in the UK (Finch et al.,1998) found that the majority of older people sampledwere adequately nourished, but that the diets of somesubgroups (low socio-economic groups, older age groupsand those living in institutions), gave cause for concern.
Margetts et al. (2003) have found that a lowerconsumption of energy, meat products or fruit andvegetables are associated with poor nutritional status inolder people, and that those at a high risk of undernutritionare likely to have a poorer health status. Poor nutritionalstatus is linked to many adverse health consequenceswhich affect functional status including reduced musclestrength, respiratory problems, poor mobility, low energy,decreased immune response, poor wound healing,impaired thermoregulation and declining psychosocialfunction and well being (Westergren et al., 2001; Evanset al., 2004; Chen et al., 2007) as well as the development ofdiseases such as cardiovascular disease (British HeartFoundation, 2006). Poor functional status also affectsdietary intake, this interaction leading to a downwardhealth spiral (Egbert, 1996).
In addition, poor nutritional status leads to significantcosts. The annual cost to the UK alone for the treatment fordisease–related malnutrition has been estimated at overseven billion pounds a year with about one billion of thatbeing spent on treating people living in their own homes(Elia et al., 2005a; Russell, 2007).
1.1. Health promotion and screening
Preventing illness and promoting the health of olderpeople have become an economic and a social priority,according to WHO (2003, 2009), and DH (2001, 2006).Nutrition is one of the domains included in the UK Single
Assessment Process (DH, 2001).However, health promotion and disease prevention
interventions have frequently excluded older people(Sahyoun and Anderson, 2009), perhaps because of apervading view within healthcare that older people areresistant to change despite evidence that they can be moreeffective at making changes to their diets than youngerpeople (Wing et al., 2004).
There is a clear case for opportunistic nutritionalscreening of older people when they come into contactwith primary care services to identify those who couldbenefit from appropriate interventions and health promo-tion activities (Edington, 1999). A number of nutritionalscreening and assessment tools have been developed toassist health professionals in this task (Green and Watson,2006; Elia et al., 2005b). Studies have shown, however, thatthe introduction of tools does not always improvesubsequent care (Perry, 1997; Jordon et al., 2003).Nutritional care is often poorly performed by nurses; interms of both consistency and comprehensiveness forindividual patients (BAPEN, 2009). Reasons for this areunclear, especially as the majority of nurses’ report thatnutrition is important to the maintenance of good health(RCN, 2007a,b). There is some evidence that nurses, likeother healthcare workers, are ambivalent about providingnutritional care (Christensson et al., 2003; RCN, 2007a,b).
1.2. Role of community health professionals (HPs)/
community nurses
Effective screening is needed to identify those at risk ofpoor nutrition, but it is essential that following this, actioncan be taken to address any nutritional risks identified.Edington (1999) argues that practice and community nursessee most of the patients at risk of undernutrition based in thecommunity and therefore are ideally placed to carry outscreening. However, despite this potential, there is lessevidence to demonstrate the effectiveness of the healthpromotion aspect of nurses’ role (Kennelly et al., 2010), withone study finding that there were substantial differences inthe performance of individual nurses that impacted on theoutcomes of programmes (Stuck et al., 2000). More recently,evidence suggests that a range of preventive interventionscarried out in the home by nurses can have a positive effecton health, functional status, mortality rates, admission tohospital and costs (Markle-Reid et al., 2006). However, it isimportant to acknowledge that although nutritional educa-tion, opportunistic screening and follow up were oftenincluded, they were not the focus of this study.
Community practice is acknowledged to be unpredict-able and changeable and as such it requires nurses to beresponsive, flexible and adaptable (QNI, 2006). Nurses inthe UK are increasingly encouraged to choose from a widerange of educational materials and media suitable fordifferent environments (DH, 2010a, DH, 2010b). BAPEN
Box 1. Inclusion criteria by types of outcome.
Physical function, mental health and quality of life measures
Physical function measuresa
Ability to perform activities of daily livingb
Cognitive function: depression and anxietyb
Quality of life measuresb
Nutritional indices
Dietary change reported as any of the following: use of salt in
cooking or eating, use of variety of fats in cooking or eating; fruit,
vegetable, milk, types of fat, fibre, energy, salt intake or mean
dietary intakec
Dietary intake reported as actual fruit, vegetable, types of milk,
types of fat, fibre, energy, salt intake or mean dietary intakec
Prevalence of malnutritionb
Anthropometric measures
Body Mass indexd
Grip strengthd
Biochemical indicatorsd
Mortality, service use and costs of care
Mortality reported as one of the following: numbers of deaths,
Death rates, Kaplan Meier survival curvesd
Admission as an in-patient to hospital reported as any of the
following: number of episodes, mean number of admissions per
patient, number or percentages of patients who were admitted to
hospitald
Length of in-patient stay (s) reported as total number of daysd
Number GP or nursing or social services visits reported as any of
the following: mean visits per patient, number of visits per patient,
median visits per patientd
Costs of Care reported as any of the following: total costs in
currency, mean cost per patient, mean cost per patient based on
average costs per unit of care, or by medical insurance payment
made in currencyd
a As defined by any validated instrument and/or standardised,
commonly used clinical measure.b As defined by any validated instrument.c As measured by any self reports, food diaries or any validated
instrument.d As measured/reported either by professionals, health service
records, patient records,or by patients or relatives.
K. Young et al. / International Journal of Nursing Studies 48 (2011) 751–780 753
(2009) and the European Nutrition for Health Alliance(2006) both call for further training on nutrition for allhealth professionals.
Laws et al. (2010) have recently argued that primaryhealth care offers an ideal setting for individually focusedlifestyle interventions but little attention has been paid tothe work of community nurses despite nurses consideringthis as an appropriate aspect of their role (RCN, 2007a,b).Nutrition has been identified in the UK as one high prioritynursing research area, particularly in regard to theevaluation of care interventions and patient outcomes(Ross et al., 2004).
Barriers to achieving good nutrition in the communityhave been cited and include: lack of client motivation, lowincomes of clients, low levels of client education, clientswith long history of eating fast food, poor access toaffordable and nutritious fresh food and lack of nurse time(RCN, 2007a,b).
It is worth noting that most research and clinical workhas concentrated on nutritional interventions provided inacute care (NICE, 2006a,b; Cartwright, 2007), and much ofthis has focused on the use of dietary supplementation toprevent or treat malnutrition (e.g. Elia et al., 2005b).
There is a need therefore for a systematic review toassess whether interventions involving nutritional educa-tion for people aged over 65 years who live in their ownhomes can impact on physical function, mental health,quality of life, anthropometric measures, mortality, serviceuse and costs of care.
2. Objectives
To examine whether a range of nutritional educationinterventions can be used by health care professionals toimprove physical function, mental health and quality oflife, nutritional indices, anthropometric measures, mor-tality, service use and costs of care in people over 65 yearsof age who live at home.
3. Methods
The inclusion criteria and methods for the review werepre-specified in a protocol. To reduce the likelihood ofintroducing bias post-hoc changes were not made.
3.1. Inclusion criteria
We included randomised controlled trials (RCTs) ofnutritional educational interventions for people over theage of 65 years living in their own homes. We excludedRCTs with participants living in residential or shelteredhousing where food is provided. We included any type ofnutritional intervention that contained dietary advice andeducation, and/or the provision of information. Thisincluded studies where nutritional education was the solecomponent and those where it was part of a more complexintervention, such as those involving education on diet andexercise. As the review was originally intended to informnursing practice, we were interested in interventions thateither were, or had the potential to be, delivered by nurses.We excluded interventions relating to parenteral/enteral
feeds, medications, and the prescription of sip/supplemen-tary feeds as these were considered discreet activities intheir own right within the field of nutritional intervention.The specified outcomes were physical function, mentalhealth, quality of life, nutritional indices, anthropometricmeasures, mortality and service use (shown in Box 1).
There were no date restrictions for inclusion in thereview but studies were limited to English languagepublications only.
3.2. Search strategy
We searched the following electronic databases:Cochrane Database of Systematic Reviews, CochraneDatabase of Abstracts of Effectiveness, Cochrane CentralRegister of Controlled Trials, Pubmed, CINAHL, PsycInfo,National Research Register in July 2008. A full list of searchterms can be seen in Box 2. In addition we used ‘lateralsearching’ techniques such as those recommended whensearching for studies on complex interventions (Green-halgh and Peacock, 2005). This included checking allreference lists, contacting experts and tracking citations.
Box 2. Search terms (Pubmed).
Concept 1:
Nutrit* [tw] OR Malnutrit* [tw] OR Malnourish* [tw] OR
Undernourish* [tw] OR Under-nourish* [tw] OR Undernutrit* [tw]
OR Under-nutrit* [tw] OR Diet [tw] Or Diet* [tw]
OR (Food OR diet) NEAR (intake OR management)[tw]
OR Eating NEAR (difficult* OR problem* or Disability) [tw]
MeSH
OR Nutritional status [mh] OR Nutrition therapy [mh] OR Nutrition
assessment [mh] OR Nutrition therapy [mh] OR Nutrition disorders
[mh] OR Nutritional requirements [mh] OR Malnutrition [mh] OR
Protein-energy malnutrition [mh] OR Food [mh] OR Food,
formulated [mh] OR Food, fortified [mh] OR Food services
[mh] After Perry et al. (2005)
Concept 2:
Elderly [tw] OR Elder* [tw] OR Senior [tw] OR Frail [tw] OR
Geriatric* [tw] OR ‘‘old people’’ [tw] OR ‘‘Older people’’ [tw] OR
‘‘over 65’’ [tw] OR ‘‘old adult’’ [tw] OR ‘‘older adult’’ [tw] OR ‘‘old
person’’ [tw] OR ‘‘older person’’ [tw]
MeSH
OR Aged [mh] OR Aged, 80 and over [mh] OR Frail Elderly [mh] OR
Health service for the Aged [mh] OR Geriatric Nursing [mh] OR
Geriatric Assessment [mh]
Concept 3:
Community [tw] OR ‘‘primary health care’’ [tw] OR ‘‘primary care’’
[tw] OR ‘‘community-dwelling’’ [tw]
MeSH.
OR *Community health services [mh] OR Home care services [mh]
OR Community health cent* [mh] OR Public health nursing [mh]
NOT (long term care OR Intermediate care services OR residential
[tw] OR ‘‘nursing homes’’ [tw])
Concept 4:
Clinical Trial pt OR Randomized OR Placebo OR Drug therapy fs OR
Randomly OR Trial OR Groups RCT search filter developed by
Glanville et al. (2006)
Each concept was run as a separate search in Pubmed, as stated,
and then all concept searches were combined with the Boolean
operator AND.
Abbreviations show Pubmed syntax, as follows: fs = all fields;
mh = MeSH heading; pt = publication type; tw = text Words; words
enclosed by ‘‘ ’’ = appear exactly as written, i.e.appear together in text.
K. Young et al. / International Journal of Nursing Studies 48 (2011) 751–780754
3.3. Study screening
Electronic search results were downloaded into End-Note bibliographic software and duplicates deleted. Tworeviewers independently screened titles and abstractsagainst the predefined inclusion criteria. Full manuscriptsof all potentially relevant citations were obtained andthese were screened independently by two reviewersusing a screening form with clearly defined criteria. Anydisagreements were resolved by consensus or by discus-sion with a third reviewer.
3.4. Data extraction and critical appraisal
Data were extracted by two reviewers independentlyonto a pre-designed, piloted form. Data were collected onparticipants, intervention (including type, duration andwho it was delivered by), measurement tools, outcomes
and results. Interventions were classified as either nutri-tional education only or complex interventions (based onthe Medical Research Council, 2008 guidance, withcomplex involving several interactive components). Themethodological quality of studies was assessed usingcriteria based on those of the Cochrane Collaboration(Higgins and Green, 2009). This assesses the risk of bias onsix domains:
� S
equence generation – was the allocation sequenceadequately generated? � A llocation concealment – was allocation adequately
concealed?
� B linding of participants – was adequate knowledge of the
allocated intervention adequately concealed from out-come assessors?
� In complete outcome data – was this adequately
addressed for each outcome (this includes differentialattrition between groups)?
� S elective outcome reporting – are reports of the study
free of suggestion of selective outcome reporting?
� O ther sources of bias – was the study apparently free of
other problems that could put it at a high risk of bias?
Each domain was scored independently by tworeviewers as ‘Yes’ (meets the criteria), ‘No’ (does not meetthe criteria) or ‘Unclear’ (not enough information to judge).Disagreements were resolved by consensus or by discus-sion with a third reviewer. In addition, we used NationalInstitute of Health and Clinical Excellence (NICE) criteria toassess the applicability of studies to the UK (NICE,2006a,b). A study was scored on a scale of 1–4 with lowerscores indicating high applicability/generalisability(results are shown in Table 1).
3.5. Data analysis
Owing to heterogeneity in populations, interventionsand outcomes it was not considered appropriate to poolstudies in a meta-analysis. Instead a narrative and tabularsummary of findings is presented. Where data wereavailable, binary data were expressed as relative risks(RR) and continuous data as weighted mean differences(MD), both with 95% confidence intervals. However, wherethe data needed to calculate a RR or MD was unavailable inthe paper we used the alternative effect measures given.Table 2 includes an indication of whether results werestatistically significant or not. Analyses were conductedusing Microsoft Excel.
4. Characteristics of included studies
4.1. Articles selected
Database searches identified 1067 papers; 27 of whichmet the inclusion criteria. A further eight papers werediscovered through lateral searching. Together, thesepapers came from 23 separate studies. A flow chartdetailing the identification of studies can be found in Fig. 1.Details of the 23 primary studies, and any related papers,can be seen in Table 1.
Table 1
Key characteristics of included studies.
First author Study
population
Setting and
country
Sample size
Include power
calculation if
available
Description of intervention,
controls and provider
Duration and
intensity
Applicability
to UK
Azad 2008 Women with
heart failure 63–
89 years
Community
dwelling but
intervention in
out-patient
clinic
Country:
Canada
N = 91 (I = 45,
C = 46)
Loss to follow up
(FU). I = 0, C = 7
Power
calculation
(PC) = 0.8 to give
a 24.42 point
difference in
MLHFC score
effect size 0.58
Complex interventionIncluded medical care, exercise
Complex interventionHealth risk assessment, health
promotion/
disease prevention visit, FU classes
Counselling to improve exercise
behaviour,
promote a diet low in fat and
high in fibre,
and to complete advance directives
Control: Usual care which included HP
material when requested by patient or
ordered by physician. NB GHC provides
an existing set of services p. 38 to
which C would have had access.
Provider: Nurse in liaison with
physician
Sub-study 3 years after;
follow up at 24 months
and 48 months
4
Rich 1993,
1995, 1996
Hospitalised
coronary heart
disease
(CHD)
patient 70 years+
at risk of
readmission
Hospital to
community
Country: USA
N = 282 (I =
142, C = 140)
Loss to FU: Not
reported for
all outcomes
but QOL lost
156 patients = 55%.
They appear to
pick and choose
what numbers of
patients they use
for which outcome.
Rich (1993) says
‘‘No patient was
lost to follow up at
90 days’’ (p. 587)
PC: Not reported
Complex interventionIntensive education on CHD and its
treatment, individualised diet
assessment and instruction,
consultation with social services re
discharge package,
supplementary home visits and
phone calls by study team
Control: Usual care standard treatment
and services ordered by physician
Provider: Nurse, dietician and
unspecified member of study team.
Follow up 90 days
after discharge
or until death
4
Salminem 2005 CHD patients
aged 65
or older
Not specified
Country: Finland
N = 268 (I =
137, C = 131)
Loss to FU:
41 (24%)
PC: Not
reported
Complex interventionIncluded lectures (1 on diet/nutrition),
group discussions with dietary component,
group exercise sessions and social activities
Control: Standard treatment
Provider: Physicians,
physiotherapists, and nurses
16 months
16 lectures (90–
120 min long)
6 group discussions
6 exercise sessions
3 social activities
4
Abbreviations: N = Number; CABG = Coronary Artery Bypass Grafts; FU = Follow Up; HMO = Health Maintenance Organization; PC = Power Calculation; HRA = Health Risk Assessment; I = Intervention; LDL = Low
Density Lipoprotein; C = Control; CHD = Coronary Heart Disease; OA = Osteoarthritis; QOL = Quality of life; CVD = Cardiovascular disease; PUFA = PolyUnsaturated Fatty Acids.
Notes: Where relative risk (RR) or mean difference (MD) not given, report does not provide sufficient information for extraction. Information about p values quoted where given. – Indicates not measured.
Lengthy Lifestyle Interventions were defined as those which were more than 2 h over first 3 months; Brief Lifestyle Interventions were defined as those which were 2 h or less over first 3 months.
Indicates not measured.a FAST self reports and WOMAC Score.b Quality of Wellbeing Scale, subscale, Kaplan et al 1976.c Medical outcomes short form subscale (MOS SF36): mental health outcomes reported separately. Physical function not reported separately.
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Table 2, section 2
Nutritional indices.
Author Nutritional indices Lengthy
or brief*
lifestyle
intervention?
Salt Use Fruit intake Vegetable intake Dairy/fat intake Fibre
intake
Other dietary
changes
Overall dietary
change Scores
Prevalence
Malnutrition
Complex interventionsCampbell 1998b;
Murchie 2003;
Campbell 1998a
CHD patients
– – – Fat intake at
1 yeard: Reduction,
p = 0.001
RR = 1.16,CI = 1.03–
1.31 Fat intake at 4
yrsd: No difference
RR = 0.97, CI = 0.89–
1.89
– – – – Brief
Elder 1995
Over 65s
– – – – No difference,
p = 0.9991
– – – Lengthy
Harari 2004
Constipated and faecally
impaired stroke patients
– – – – – Increased
modifications to
diet and fluid intake
to control bowels
RR 1.85 (1.02–3.34),
p = 0.017
– – Brief
Hjerkinn 2005
Men with high risk CVD
– – – Overall fat intake
reduction,
p< 0.001;
Saturated fat
reduction,
p< 0.001;
Monounsaturated
fat reduction,
p = 0.007;
Polyunsaturated fat
reduction, p = 0.045
– Carbohydrate
intake increased,
p = 0.001
Protein intake No
difference
– – Brief
Ho 1991
Over 50s
– – – – No difference,
ES = 0.14, p = 0.550
– – – Brief
Lewin 2002
Newly diagnosed Angina
pectoris patients
– – – – – – Self reports dietary
change increased,
RR 2.12 (1.41–3.20),
p< 0.001;
DINE score: No
difference
– Brief
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Table 2, section 2 (Continued )
Author Nutritional indices Lengthy
or brief*
lifestyle
intervention?
Salt Use Fruit intake Vegetable intake Dairy/fat intake Fibre
intake
Other dietary
changes
Overall dietary
change Scores
Prevalence
Malnutrition
Masley 2001
CAD patients
– Fruit and Veg intake (self
report) increased, p = 0.0002
Total fat intake: No
difference,
p = 0.405;
Saturated fat
intake: No
difference,
p=0.105;
Monounsaturated
fat intake: Increase,
p=0.001
– – – – Lengthy
Middleton 2005
Patients following carotid
enterarterectomy
– – – – – – Self reports dietary
change increased,
RR 2.44 (1.49–4.02),
p = 0.001
– Lengthy
Patrick 1999
Over 65s
– – – Dietary fat and fibre intake: no difference
RR = 1.12 (0.94–1.32)
Dietary fat intake only: reduction, p = 0.005
– – – Lengthy
Salminem 2005
CHD patients over 65 yrs
– – – Type of milk
consumed: no
difference
Type of fat used in
cooking/on bread:
no difference
– – – – Lengthy
Nutritional education onlyBarnason 2003
CABG patients
In cooking: No
difference RR
0.42 (0.16–
1.11)
Whilst eating:
No difference
RR 0.47 (0.05–
4.74)
– – – – – Overall dietary
modification score:
No difference ES
0.24
– Brief
Bernstein 2002
Functionally impaired
community dwelling
over 65s
– Change of
Servings per
Day Increased,
p = 0.01
MD = 0.6,
CI =�0.09–1.29
Change of Servings per
Day Increased, p< 0.01
MD = 0.05,
CI =�0.15–1.15
Milk and Dairy
intake: Increased,
p< 0.01
MD = 0.8, CI = 0.01–
1.59
– – – – Lengthy
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Edentulous patients
– Intake in grams
or decilitres:
Increased,
p = 0.002
MD = 148,
CI = 66.36–
229.64
Intake in grams or
decilitres:Borderline
increase: p = 0.057
MD = 49,
CI =�2.55–100.55
– – – – – Brief
Fruit + veg intake in grams or decilitres:
increased, p = 0.001,
ES 0.93; MD=197, CI=89.7–304.33
Campbell 2008
CKD patients
– – – – – Energy intake:
increased, adjusted
MD = 22.1 (12.80–
31.50),
p< 0.001
– Reduction,
p< 0.01
Lengthy
Whelton 1998;
Kumanyika 2002
Hypertensive patients
– – – – – No difference in %
RDA for
micronutrient
intakes
– – Lengthy
Notes: Where relative risk (RR) or mean difference (MD) not given, report does not provide sufficient information for extraction. Information about p values quoted where given. – Indicates not measured.
Lengthy Lifestyle Interventions were defined as those which were more than 2 h over first 3 months; Brief Lifestyle Interventions were defined as those which were 2 h or less over first 3 months.
Indicates not measured.d Low fat DINE Score <30.
Table 2, section 3
Anthropometric measures.
Author Anthropometric measures Lengthy or
brief lifestyle
intervention?
Body Mass Index
(BMI)
Weight Cholesterol/lipid management Other biochemical factors
Complex interventionsCampbell 1998a,b;
Murchie 2003
– – Lipid management increased: RR 1.91
(1.59–2.29), p< 0.001;
Lipid management no difference: RR 1.08
(0.97–1.21)
– Brief
Elder 1995
Over 65s
No difference,
ES = 0.04,
p = 0.10
– – – Lengthy
Hjerkinn 2005
Men over 65 with CVD
Reduction,
p = 0.005
– No difference – Brief
Ives 1993
Over 65s with serum
cholesterol >240 g/dl
– – Serum Cholesterol: No difference
Self reports efforts to lower cholesterol
increase, p = 0.0003
– Varied length
K.
Yo
un
get
al./In
terna
tion
al
Jou
rna
lo
fN
ursin
gStu
dies
48
(20
11
)7
51
–7
80
76
7
Table 2, section 3 (Continued )
Author Anthropometric measures Lengthy or
brief lifestyle
intervention?
Body Mass Index
(BMI)
Weight Cholesterol/lipid management Other biochemical factors
Lewin 2002
Newly diagnosed
Angina pectoris patients
No difference – – – Brief
Masley 2001
CAD patients
– – LDL: No difference
Fasting lipids: No difference
– Lengthy
Messier, 2000,2004;
Miller 2002a, 2004
Obese adults with OA
– Reduction as %
weight lost
p = 0.007
– Fasting plasma glucose reduction: ES
4.83, p< 0.05
Lengthy
Middleton, 2005
Patients following
carotid endarterectomy
– – No difference,
p = 0.12
– Brief
Miller 2006, 2008
Obese adults with OA
Reduction,
ES = 0.53
Reduction,
p< 0.01
– Inflammatory biomarkers for OA: No
difference except STNFR, which showed
improvement p = 0.03
Lengthy
Patrick 1999
Over 65s
No difference
p = 0.314
– – – Lengthy
Salminem 2005
Over 65 yrs
– – Women: total serum and LDL
cholesterol reduction,
p< 0.05 Men: no differencee
– Lengthy
Nutritional Education onlyBernstein 2002
Functionally impaired
community dwelling over 65s
Borderline
increase,
p = 0.06
Borderline
increase,
p = 0.06
– – Lengthy
Bradbury 2006
Edentulous patients
No difference,
ES = 0.32,
p = 0.497
– – – Brief
Campbell 2008
CKD patients
No difference,
adjusted
MD = 3.6 (�1.0–
8.7) p = 0.1
No difference,
MD = 0.14
(�1.30–1.60)
– Albumin decreased: MD �0.23 (�0.40–
0.05), ES 0.60
Lengthy
Whelton 1998; Kumanyika 2002
Hypertensive patients
– Reduction,
p< 0.001;
weight
loss> 4.5 kg RR
3.38 (2.45–4.67)
– Excretion of urinary sodium: reduction
RR 3.80 (2.85–5.08), p< 0.001
Lengthy
Notes: Where relative risk (RR) or mean difference (MD) not given, report does not provide sufficient information for extraction. Information about p values quoted where given. – Indicates not measured.
Lengthy Lifestyle Interventions were defined as those which were more than 2 h over first 3 months; Brief Lifestyle Interventions were defined as those which were 2 h or less over first 3 months.
Indicates not measured.e Values for men and women not given together.
K.
Yo
un
get
al./In
terna
tion
al
Jou
rna
lo
fN
ursin
gStu
dies
48
(20
11
)7
51
–7
80
76
8
Table 2, section 4
Mortality, service use and costs of care.
Author Mortality Service use: Costs of care Lengthy or
brief lifestyle
intervention?
Hospital
Readmissionsf
GP visits DN visits ER visits Personal
carer visits
Complex interventionsAzad 2008 No difference
RR 0.20 (0.01–
4.14)
Patients/carers
report no
difference,
p = 0.16
Increased,
p = 0.018
– No difference,
p = 0.408
– – Lengthy
Boult 2001 No difference
RR 0.93 (0.57–
1.53)
– – – – – No difference,
p = 0.93
OR = 0.60,
CI = 0.37–0.98
Lengthy
Campbell 1998b;
Murchie 2003;
Campbell 1998a
Reduction
RR 0.78 (0.61–
0.99)
Hospitalisations
reduced, RR 0.70
(0.56–0.87)
No difference,
p = 0.488
– – – – Brief
Harari 2004 – – Increased for
bowels: RR 3.00
(1.15–7.83)
No difference – No difference – Brief
Lopez-Cabezas 2006 Reduction
RR 0.43 (0.21–
0.89)
Number of
Readmissions:
No difference 12
months;
Number of
patients
readmitted: No
difference;
Adjusted
probability of
readmission
reduced, HR 0.56
(0.32–0.97)
– – – – Costs per patient
reduced for IG,
but not analysed
for statistical
significance
Brief
Masley 2001 – – – – – – No difference,
p = 0.2975
Lengthy
Patrick 1995, 1999 Borderline
Increase
RR 1.27 (0.99–
1.63), p = 0.062
– – – – – No difference,
p = 0.8
Lengthy
K.
Yo
un
get
al./In
terna
tion
al
Jou
rna
lo
fN
ursin
gStu
dies
48
(20
11
)7
51
–7
80
76
9
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s.
K. Young et al. / International Journal of Nursing Studies 48 (2011) 751–780770
Studies which met our inclusion criteria were publishedbetween 1991 and 2008. Thirteen studies were from theUnited States, four from United Kingdom, two fromAustralia and one study from each of Canada, Spain,Norway and Finland. Study size varied from 24 to 2558participants, with a skewed normal distribution towardsthe lower end (13 studies recruited less than 200participants).
4.2. Interventions (Table 1)
The interventions used were often multi-faceted, multi-disciplinary and varied in both length and type. Thirteenstudies included nutritional education by nurses with tendelivered solely by nurses and three by nurses and doctors.Ten studies had no nurse involved, with the interventiondelivered by dieticians or nutritionists in six, by doctors intwo, by a pharmacist in one and by a lay person in one.Three studies did not specify who delivered the interven-tion.
Interventions were all delivered by out-patient, hospi-tal outreach or community staff (with some beingdelivered remotely by telephone, computer, or by post),although two studies included participants who begantheir education as in-patients (Rich, 1995; Harari, 2004).Five studies had nutritional education as the soleconstituent of the programme, whilst the rest includedit as part of a more complex intervention including othercomponents such as individualised holistic care, healthylifestyle advice, exercise advice or screening. Of thesecomplex interventions, 12 studies offered nutritionaleducation as a major focus of the health promotionactivities, this was individualised in ten studies anddelivered in a standard way in the other two.
Studies varied in the format and intensities of strategiesemployed. Twenty studies used more than one educationalstrategy (18 studies used face to face consultations, 8provided telephone consultations, 10 engaged in class-room/group activities, 7 used written material). Theremaining three used a single strategy, either telephone(Barnason, 2003), individual consultations (Bernstein,2002) or classroom based interventions (Miller, 2002a).The intensity ranged from one off visits followed bytargeted leaflets and/or summaries from general practi-tioners (Harari, 2004), to six weeks of daily interactivetelephone contact (Barnason, 2003), to individualisedconsultation and telephone follow up for 12 weeks (Camp-bell, 2008), to individual and small group weekly meetingsover four months, followed by four months of fortnightlycontact and then monthly contact until 30 months(Kumanyika, 2002).
Studies varied in the length of intervention delivered.We classified these differences into two groups: thosewhich required 2 h or less over the first 3 months (whichwe termed ‘‘brief lifestyle interventions’’, nine studies),and those that required more than 2 h over the first 3months (termed ‘‘lengthy lifestyle interventions’’, 13studies). These classifications can be seen in Table 2.One study (Ives, 1993) did not fall into either categorybecause the intervention length varied according toindividual need.
Papers providing additional information to located studies n=8*
Already Excluded n=605 Further Exclusions n=341
(Not RCT n=20 Mean age not > 65yrs n=192 Not intervention type n=46 Not chosen outcomes n=41 Foreign Language Exclusions n=22 More than 1 reason n=13 Unable to obtain n=5)
Publications included in the review (27*+8*)
n=35
Number of separate RCTs included in the
review n=23
Full papers retrieved and screened
Double Screening of Abstracts from 200 randomly selected papers – 92% agreement Yes=53, Possible=315 Full copies to be retrieved and assessed for eligibility
Agreed exclusions
from abstracts
n=605
Titles and Abstract identified and screened n=1067
Fig. 1. Flow chart of study selection process.
K. Young et al. / International Journal of Nursing Studies 48 (2011) 751–780 771
K. Young et al. / International Journal of Nursing Studies 48 (2011) 751–780772
Although all studies involved education to improvenutritional intake, the specific aims of studies weredifferent. Ten interventions were designed to promotegeneral dietary improvement (reduced fat, salt, sugar,increased fibre, fruit and vegetables) whereas 13 offered amore targeted intervention such as reducing salt intake forparticipants with coronary artery disease (Barnason,2003), increasing fruit and vegetable intake for edentulouspatients (Bradbury, 2006) or increasing fibre and fluidintake for constipated and faecally impacted strokepatients (Harari, 2004).
4.3. Participants
The populations studied varied from the healthy (Elder,1995; Ho, 1991; Patrick, 1999) to the frail elderly (Boult,2001). Sixteen studies focused on specific diseasesincluding: cardiovascular disease (Azad, 2008; Barnason,2003; Campbell, 1998a,b; Harari, 2004; Hjerkinn, 2005;Whelton, 1998; Lewin, 2002; Lopez Cabezas, 2006; Masley,2001; Middleton, 2005; Rich, 1995; Salminem, 2005),chronic kidney disease (Campbell, 2008), diabetes (Miller,2002a) and osteoarthritis (OA) (Messier, 2004; Miller,2006). One (Ives, 1993) offered screening and healthpromotion to participants with high cholesterol levels whowere considered to be at high risk of cardiovasculardisease. Other studies included participants with generalfunctional impairment (Bernstein, 2002), and those whowere edentulous (Bradbury, 2006) or constipated (Harari,2004). Two studies (Boult, 2001; Rich, 1995) identifiedparticipants as high risk of using hospital or nursing homefacilities. Four studies (Boult, 2001; Ho, 1991; Harari, 2004;Rich, 1995) included more than one of the categoriesmentioned above.
Although two studies specified that participants wereoverweight (Messier, 2000; Miller, 2008), the majority didnot specify if participants were overweight, underweightor of normal weight. These studies appeared to drawgeneral inferences about the weight of participantsaccording to the condition being studied. For example,Campbell (2008) studied men with Stage 4 Chronic KidneyDisease and this group of people are more likely to beunderweight, whereas Kumanyika (2002) studied partici-pants with hypertension who as a group are more likely tobe overweight.
[()TD$FIG]
Adequate sequence generation?
Allocation concealment?
Blinding?
Incomplete outcome data addressed?
Free of selective reporting?
Free of other bias?
0%
Yes (low risk of bias) Unclear
Fig. 2. Review authors’ judgments about each methodological qual
4.4. Outcomes
Patient outcomes measured in the included studieswere divided into four categories. Within these categoriesthere was considerable heterogeneity in the way in whichoutcomes were measured (Box 1).
Studies addressed Body Mass Index (BMI) and weightdifferentially. Five studies treated participants on anindividual basis, with aims to lose or gain weight accordingto need (Bernstein, 2002; Bradbury, 2006; Campbell, 2008;Elder, 1995; Lewin, 2002). These studies reported weightchanges by intervention or control group, rather thanaccording to individual goal, so the results are difficult tointerpret. Three studies measured changes to BMI/weightfor each participant but did not report the specific aims ofthe intervention (Hjerkinn, 2005; Ho, 1991; Patrick, 1999),whilst three aimed to reduce participants weight (Kuma-nyika, 2002; Messier, 2004; Miller, 2008) and reportedtheir findings on this basis.
4.5. Assessment of risk of bias
An overall assessment of the risk of bias for each qualitydomain can be seen in Fig. 2 and the results for individualstudies are presented in Fig. 3. Although sequencegeneration was adequate in the majority of studies, lessthan 25% of studies were judged to have had adequateallocation concealment. The risk of bias from selectivereporting of outcomes was judged to be low in ten, high inthree and unclear in the rest. Only four studies met five ormore criteria (Campbell, 2008; Lewin, 2002; Lopez-Cabazas, 2006; Messier, 2000) and five met none of thecriteria (Elder, 1995; Ives, 1993, Miller, 2008; Patrick,1999; Salminen, 2005). However, in many studies inade-quate reporting made quality assessment difficult. Theimpact of possible biases is highlighted as appropriate inSection 5 and considered further in the limitations anddiscussion sections.
5. Results
In the following section the results are presentedaccording to the outcome categories outlined in Box 1. Inaddition, studies are further categorised as nutritionaleducation only against those interventions which include
25% 50% 75% 100%
No (high risk of bias)
ity item presented as percentages across all included studies.
[()TD$FIG]
Fig. 3. Methodological quality summary.
K. Young et al. / International Journal of Nursing Studies 48 (2011) 751–780 773
other health promotion activities. Finally, at the end of thesection, we consider whether the length of the interven-tion (i.e. brief versus lengthy) influences effectiveness.
5.1. Effectiveness on physical function, mental health and
quality of life outcomes (Table 2, section 1)
Seven studies reported physical function. The methodof measuring this ranged from self reporting of general orspecific physical function measures to timed completion ofspecific functional activities. Four studies (Azad, 2008,Campbell, 1998a,b; Lewin, 2002; Miller, 2008) comparedinterventions involving both nutritional and exercisecomponents (of varying methods and intensities) withcontrol groups that received no exercise or nutritionaleducation, three found significant improvements inphysical function. Messier (2000), assessed as low risk ofbias, compared three different interventions with atten-tion controls: nutritional education only, nutritionaleducation plus exercise and exercise only finding nodifferences in nutritional education only when comparedwith controls, but significantly better physical functionimprovements in nutritional education plus exercise whencompared with exercise groups. In the other two studies(Barnason, 2003, nutritional education only; Boult, 2001, acomplex intervention study), there were no exercisecomponents in intervention or control groups and theyboth reported significant improvements in physical func-tion.
Despite heterogeneity, the results were generallyconsistent with six out of seven studies reporting animprovement in physical function in the interventiongroups compared with the controls. The other study (Azad,2008) reported physical self maintenance scores (ratherthan physical function) and found no significant differ-ences between groups.
Nine studies examined cognitive, emotional function orquality of life. Two studies of complex interventionsmeasured anxiety as an outcome (Campbell, 1998b; Lewin,2002) but neither found a between group difference.However, a larger study with a longer duration ofintervention found significantly less ‘health worry’, asmeasured on the Quality of Wellbeing scale (Patrick, 1999)at 2 and 4 years follow up.
Five studies examined the effect of complex interven-tions on depression. Although two of these studies foundno effect on depression at 6 months (Azad, 2008) or 1 year(Campbell, 1998a), the other three studies showedsignificant improvements in depression scores in theintervention group compared with the controls at 6, 12and 18 months.
Quality of life was reported in five studies, all of whichinvolved complex interventions. In all but one study(Lopez-Cabezas, 2006) the intervention was delivered by anurse. Three disease specific studies (Azad, 2008; Harari,2004; Lopez-Cabezas, 2006) reported no effect on qualityof life measures. The remaining studies (Patrick, 1999;Rich, 1995) showed quality of life improved in theintervention groups when compared with the controls,although this should be interpreted with caution as Rich(1995) only reported on a subset of those included in the
K. Young et al. / International Journal of Nursing Studies 48 (2011) 751–780774
main study and Patrick (1999) began the study with acontrol group that had poorer quality of life scores than thecontrols.
5.2. Effectiveness on nutritional indices (Table 2, section 2)
Fifteen studies examined some form of dietary changealthough the focus of the interventions varied, with someaiming to increase dietary intake and others aiming toreduce fat or food intake. Three studies measured changesin the general population of over 65 year olds (Elder, 1995;Ho, 1991; Patrick, 1999), nine involved cardiovascularpatients, two people with functional impairment (Bern-stein, 2002; Bradbury, 2006) and one study focused onchronic kidney disease (Campbell, 2008).
5.2.1. Dietary fibre
Two studies measured dietary fibre (Elder, 1995; Ho,1991) and one measured dietary fat and fibre intakecombined (Patrick, 1999) but none found any evidence ofeffect. All involved complex interventions
5.2.2. Fruit and vegetable intake
Three studies evaluated fruit and vegetable intake. Twowere nutritional education only (Bernstein, 2002; Brad-bury, 2006) and one was a complex intervention (Masley,2001). Bernstein (2002) examined healthy eating amongstfunctionally impaired participants aged over 69 years, andreported an increase in fruit and vegetable intake, althoughour calculations reflect a non-significant reduction. Theother nutritional education only study reported that atailored intervention was successful in increasing fruit andvegetable use in edentulous patients (Bradbury, 2006).However, when analysed further, it was clear that this wasprimarily due to fruit intake rather than vegetable intake,some of which was due to increasing fruit juice intake inthis group. In the complex intervention study (Masley,2001), there was an increase in self-reported fruit andvegetable intake. An additional study (Harari, 2004)offering a complex intervention with stroke patients withfaecal continence problems, found the intervention groupmore likely to modify their diet than the controls (whichincluded increasing fruit and vegetable intake, althoughthis was not independently measured).
5.2.3. Dairy/fat intake
Six studies measured dairy or fat intake and all but one(Bernstein, 2002) involved complex interventions. Fourinvolved patients with cardiovascular disease (Campbell,1998b; Hjerkinn, 2005; Masley, 2001; Salminem, 2005),one included a general population of older people (Patrick,1999) and one involved functionally impaired older people(Berstein, 2002). In the cardiovascular studies the effectswere mixed. Two (Salminem, 2003; Masley, 2001) foundno effect on fat intake although the latter found an increasein use of monounsaturated fats in cooking oils in theintervention group when compared with the controls. Ofthe other cardiovascular studies one (Campbell, 1998a,b)showed an intervention effect on low fat DINE scores<30at 1 year, although this had disappeared at four years. Theother study (Hjerkinn, 2005) reported significant reduc-
tions in the amounts of saturated, monounsaturated,polyunsaturated and total fats as a percentage of energyat 36 months. However, this differed from the other studiesas it included additional telephone follow up andreminders every 6 months across the study period. Ofthe remaining two studies one (Patrick, 1999) reported areduction in fat intake and the other, which involvednutritional education only, found an increase in milk anddairy intake (Bernstein, 2002).
Together these studies provide some evidence tosuggest that nutritional education can lead to change infat intake in those over 65 years living at home but that itmay need to be sustained by using reinforcementstrategies. However, all the studies were judged to be atmoderate or high risk of bias.
5.2.4. Energy intake
Energy intake was measured in two studies, one (acomplex intervention) with participants who had cardio-vascular disease (Hjerkinn, 2005) and one (a nutritionaleducation only intervention) with participants who hadchronic kidney disease (CKD) (Campbell, 2008). Both studiesfound significant intervention effects, in the desireddirection, with energy intake decreasing in cardiovascularpatients and increasing in patients with chronic kidneydisease.
5.2.5. Salt use
Salt use was only measured in one nutritional educationonly study (Barnason, 2003) which found no effect on theuse of salt for cooking or whilst eating in CABG patients.However, this study was small and may not have beenpowered to detect an effect.
5.2.6. General dietary improvement
Two complex intervention studies involved partici-pants with cardiovascular disease (Lewin, 2002; Middle-ton, 2005) and measured general dietary improvement.Both found that the intervention group reported moreimprovements to their diet than the control. However,Lewin (2002) was unable to find this difference reflected inestimated dietary intake using DINE scores.
5.2.7. Malnutrition
Only one study (Campbell, 2008) examined the pre-valence of malnutrition. This study involving patients withchronic kidney disease found a significant reduction inmalnutrition amongst those who had received the inter-vention.
5.3. Effectiveness on anthropometric measures (Table 2,
section 3)
5.3.1. Weight/BMI
Overall ten studies measured either, or in some cases both,weight and BMI, with eight reporting BMI and five weight.
Eight studies reported the effect of dietary interventionupon BMI. The aims of the interventions varied accordingto the population involved with some studies aiming toincrease BMI and others to decrease it. Only three studies,one nutrition education only (Bernstein, 2002) and two
K. Young et al. / International Journal of Nursing Studies 48 (2011) 751–780 775
involving complex interventions; (Hjerkinn, 2005; Miller,2006) found changes to BMI. These were consistent withthe aims stated or the participants’ needs. The Hjerkinnstudy (men with CVD over 65 who are more likely to beoverweight, offered vegetable spread and education) andthe Miller (2006) study (obese adults with Osteoarthritis,offering nutrition education, partial meal replacement andexercise) showed that interventions significantlydecreased BMI. The Bernstein (2002) study showed anon-significant trend towards increasing BMI in a func-tionally impaired population of over 65s given nutritionaleducation designed to increase food intake. Two of thesethree studies were at high risk of bias. The remaining fivestudies, which were of variable quality, found nosignificant intervention effect in the populations studied.
Five studies examined weight change amongst the over65s, three aiming to decrease weight and the other two(Campbell, 2008; Bernstein, 2002) aiming to increaseweight. Three studies showed an intervention effectconsistent with the study aims or participants’ needs,e.g. hypertentsion (Whelton, 1998; Kumanyika, 2002) andOA (Messier 2000, 2004; Miller, 2008), with a significantdecrease in weight following intervention. The fourthstudy (Campbell, 2008) showed no differences betweengroups in weight. However, this was an interventiondesigned to increase weight amongst CKD sufferers and itis likely that the severity of the disease overrode anypotential impact of the intervention. The remaining study(Bernstein, 2002) showed a non-significant trend towardsan increase in weight when compared with exercisecontrols.
Overall, six out of ten studies showed evidence of aneffect on either weight change or BMI which wereconsistent with the study aims or population needs.Studies reporting changes to BMI or weight were notnoticeably different in quality to those which reported nochange. We found similar effects for complex interventionsand nutritional education only interventions in bothmeasures, although the Messier (2004) study found dietand exercise groups lost significantly (p< 0.05) moreweight (5.7%) than those in the diet only group (4.9%).
5.3.2. Cholesterol/lipid management
Cholesterol was the most commonly measured bio-chemical outcome (six studies, all complex interventions).One study (Ives, 1993) reported that intervention groupsmade more effort than controls to lower cholesterol at 2–3 years, but this was not reflected in serum cholesterol. Twostudies (Campbell, 1998b; Middleton, 2005) found nosignificant difference in self-reported cholesterol levelsbetween control and intervention groups at final followup. However, during the Campbell (1998b) study itbecame standard practice for patients with high choles-terol to receive lipid lowering medication and this may bewhy differences in cholesterol reported at 12 months werenot sustained at year 4. Three other studies measuredcholesterol readings (Hjerkinn, 2005; Masley, 2001;Salminem, 2005), with outcome measurement varyingbetween 12 months and three years, but none showed anysignificant differences between intervention and controlgroups.
The evidence from these RCTs suggests that complexinterventions which include nutritional education are oflimited success in lowering cholesterol.
5.3.3. Disease specific biochemical markers
Three studies measured disease specific biochemicalmarkers (Campbell, 2008; Kumanyika, 2002; Miller, 2008).Nutritional education was effective in raising albuminlevels in patients with CKD (Campbell, 2008), and reducingsodium excretion in hypertensive patients (Kumanyika,2002); but as part of a complex intervention had mixedresults in influencing inflammatory biomarkers in patientswith OA (Miller, 2008)
Miller (2002a) measured fasting plasma glucose inadults with type 2 Diabetes, and found a significantreduction as a result of a complex intervention which wasconsistent with the reduction in weight found in this study.
5.4. Effectiveness on mortality, service use and costs of care
(see Table 2, section 4)
Eight studies measured outcomes in these categories,and all except one (Lopez Cabezas, 2006) used a nurse aspart of the team delivering the intervention. All studiesinvolved complex intervention and components other thaneducation may have contributed to the observed effects.
5.4.1. Mortality
Of the six studies that examined mortality, threefound no difference between intervention and control(Azad, 2008; Boult, 2001; Rich, 1995), one a non-significant trend towards an increase in mortality(Patrick, 1999) and two studies of nurse-led clinics(Campbell, 1998b; Lopez Cabezas, 2006) a reduction indeaths. In the study where mortality increased (Patrick,1999), the authors believe the introduction of ‘‘livingwills’’ as part of the intervention, may have confoundedmortality rates.
5.4.2. Service use
Of the four studies that addressed hospital readmission,three showed a reduction in admissions in the interventiongroup, whilst one (Azad, 2008) found no difference.
One study reported district nurse (DN) visits (Harari,2004), one emergency room (ER) visits (Azad, 2008) andthree studies reported GP visits (Azad, 2008; Campbell,1998a,b; Harari, 2004). There were no significant effects onDN or ER visits but there was some evidence of an increasein GP use at 6 months and 1 year (Azad, 2008; Harari,2004).
5.4.3. Costs of care
Five studies examined costs, but data from one (Rich,1995) was on an unspecified subset of patients and is,therefore, not included in our analysis. The other fourstudies reported no intervention effect, although in one(Boult, 2001), the intervention group used less home carethan the controls when adjusted for baseline use. This mayindicate that the intervention changed the mode of carebut did not reduce the overall costs of the treatmentrequired.
K. Young et al. / International Journal of Nursing Studies 48 (2011) 751–780776
5.5. Length of interventions and effectiveness
Table 2 shows the length of intervention, classified as‘‘brief’’ (2 h of less in first 3 months) or ‘‘lengthy’’ (morethan 2 h in first 3 months), for each study.
There was no evidence to suggest that the length of theintervention impacted on effectiveness. Indeed, for mostoutcomes brief interventions appeared as effective as morelengthy ones. One exception was mortality where briefcomplex interventions appeared to be more effective thanlonger interventions. However, this should be interpretedwith some caution as this is based on only five studies withdiffering endpoints. Two outcomes (weight and biochem-ical markers) were only measured for lengthy interven-tions.
6. Discussion
This systematic review included 23 studies thatexamined whether educational interventions can improvenutritional and functional outcomes in community dwell-ing people over 65 years of age. All but one of theinterventions were delivered by health care professionalsof which ten were delivered by nurses. In five studies theintervention consisted of nutritional education only but inthe majority of studies the nutrition education wasdelivered as part of a more complex health promotionpackage.
The review found evidence to suggest that nutritionaleducation (sometimes as part of a complex intervention)can positively influence diet, improve physical functionand reduce depression. There was also evidence that somebiochemical markers, such as albumin levels in patientswith CKD (Campbell, 2008), and sodium excretion inhypertensive patients (Kumanyika, 2002), can be posi-tively influenced. However, this should be interpreted withcaution as biochemical measures are surrogate outcomesand are generally disease specific. In addition, the extent towhich there is a predictive relationship between these andfunctional outcomes or morbidity is not clear. Theevidence from this review on the impact on weight changewas inconclusive. This is consistent with the findings froma recent meta-analysis that found a lack of good qualityevidence to support the efficacy of weight loss pro-grammes in this population (Witham and Avenell, 2010).
There was no evidence in our review of an improvementin anxiety, quality of life or service use. There was somesuggestion that mortality can be reduced by brief complexlifestyle interventions, but this is based on limitedevidence which was insufficient to make judgments abouteffectiveness.
A poor quality diet in older people has been found tobe associated with increased mortality and morbidityand health promotion aimed at this age group maycontribute to a healthier old age (Haveman-Nies et al.,2003). A recent systematic review (Bouman et al., 2008)concluded that intensive home visiting programmes(offering a range of tailored health promotion, includingnutritional education) may not improve health or serviceuse in older people with poor health living in high incomecountries. In contrast, this review found some evidence to
suggest that nutritional education, sometimes as onecomponent of a complex intervention, may improvephysical function, diet and depression for communitydwelling older people. However, our review has notfound sufficient evidence to determine whether thisimpacts on hospital readmissions or other service useand limited evidence on mortality.
The effectiveness of nutritional educational interven-tions for older people may be affected by a number of age-related factors. The increased likelihood of chronic illnessand potential co-morbidities such as poor dental or oralhealth, and abdominal discomfort may make dietaryimprovements harder in this age group. Diet may alsobe influenced by limited finances, modifications to dietbecause of disease (Kwong and Kwan, 2007) and socialisolation (Gustaffson and Sidenvall, 2002). Other factorsthat may impact on the success of nutritional educationinclude self efficacy, perceived health benefits and gender(Kwong and Kwan, 2007). Indeed, these issues werereflected in many of the studies in this review, withsixteen studies including participants with specific chronicillnesses and others involving participants who wereedentulous (Bradbury, 2006) or constipated (Harari,2004). It is possible that nutritional education or complexinterventions which are designed to address specificissues of concern will be more successful than thoseadopting a less focused intervention. However, there wasinsufficient evidence in this review to identify whetherthis is the case. The process by which diet acts as anintermediary between experience of health and illness,disease and disability in the older person is complex andmultifactorial making the design of studies in communitysettings particularly challenging.
It has been suggested that many nurses have ageistattitudes and regard dependency and disability as inevi-table in older people (Runciman et al., 2006). Thesuggestion from our review that older people can behelped to make positive changes to their diet maychallenge nurses’ assumptions about the nutritional selfcare ability of their patients and their roles in this area ofcare (Christensson et al., 2003; RCN, 2007a,b). In the UK,nurses recognise the importance of client education, butcite lack of time as a significant barrier to achieving goodnutrition in the community (RCN, 2007a,b). However,nine of the interventions in this review required less than2 h of professional time over a 3 month period and therewas no evidence to suggest that brief interventions wereless effective than more lengthy ones. In addition it maybe possible to use remote technological methods ofdelivery to address the gap between what nursesconsider desirable and what is achievable in a resourceconstrained environment (for example, Barnason, 2003).A recent RCT from the USA (Walker et al., 2009) found aneducational intervention involving newsletters to beeffective in improving eating habits in rural women aged50–69 years.
6.1. Strengths and limitations
We used systematic and rigorous methods to synthe-size the current evidence on interventions with a nutri-
K. Young et al. / International Journal of Nursing Studies 48 (2011) 751–780 777
tional education component for community dwelling olderpeople. However, there are a number of methodologicalissues that could have a bearing on the validity of theseresults. The review involved a diverse range of interven-tions, participants and outcomes. This heterogeneitymeant that meta-analysis was inappropriate and madecomparisons between studies more difficult. Nevertheless,despite this, we were able to make judgments about thestrength and consistency of the evidence.
Many of the studies reviewed involved complexinterventions of which nutritional education was onlyone component. In these studies it was difficult, therefore,to isolate the effectiveness of the nutritional aspect of theintervention from the other components. This difficulty isnot unique to our review as it has previously been notedthat nutritional interventions are often delivered as partof more complex health promotion interventions, whichcan lead to difficulties in drawing conclusions for clinicalpractice (Soderhamn et al., 2007). The reality of working incommunity healthcare is such that type and order ofactivity, consistency and professional expertise areapplied flexibly according to circumstance (QNI, 2006)and do not consist of easily isolated activities (Cowleyet al., 2000). The interventions of the studies included thisreview reflects the complexity of clinical work whichshould be evaluated for effectiveness (Craig et al., 2008).Systematic reviews such as ours attempt to incorporatethe reality of everyday practice in order to be of use forpractitioners. Throughout the review we have made itclear if the evidence relates to nutrition education only orto more complex interventions. We found evidence tosuggest that nutritional education alone can influence dietand physical function, but were unable to determinewhether changes to other outcomes were attributable tonutrition education or to other aspects of the complexinterventions.
Evaluating the effect on nutritional outcomes wasfurther complicated by the complexity associated withthe measurement of dietary related outcomes. Selfreports of food intake may be subject to measurementerror and may not accurately describe changes made(Macdiarmid and Blundell, 1997). Actual food intake isalso subject to measurement problems (Bingham et al.,1994), and variation exists between the methods used tocollect information on dietary intake (Soderhamn et al.,2007).
The quality of the studies varied although in themajority the risk of bias was assessed as moderate orhigh. Only five studies were judged to have adequateallocation concealment and poorly concealed trials mayintroduce selection bias and inflate treatment effects(Schulz et al., 1995). Only seven studies were judged tohave adequate blinding but this is not altogethersurprising as many outcomes are self-reported andblinding of patients and staff is not possible in studiessuch as these. In addition to the issues of bias, manystudies were small (13 studies recruited less than 200participants) and may have been underpowered todetect significant differences.
This review was restricted to randomised controlledtrials, which are considered to be the ‘gold standard’ for
answering questions about ‘what works’ (Higgins andGreen, 2009). We may have excluded important detailfrom other study designs employed in evaluating nursinginterventions such as qualitative research which mightprovide useful additional information about context,applicability and process. However, the 23 RCTs weincluded provide an important overview of effectivenessand highlight gaps that need to be addressed in futureresearch.
6.2. Implications for practice and research
Although not all of the interventions were delivered bynurses, they can all be considered a legitimate concern fornursing practice. With an increasing emphasis on ahealthier old age (WHO, 2010a,b), nurses are in a goodposition to lead, develop and research this area of work.Many of the interventions reviewed could be delivered topatients in an opportunistic way whilst they receive othernursing care. Where appropriate, nurses in the UK couldfollow the practices of nurses in other countries, inparticular the USA, who have addressed nutritionaleducation needs of a wider audience of older peopleusing new technologies, such as on-line support, directtelephone counselling and nurse-controlled computergenerated telephone advice. This review provides someevidence that community health professionals, includingnurses, can use a variety of nutritional educationinterventions to influence important patient outcomesin the older population. The consistency in results formany outcomes for both nutritional education only andcomplex interventions also suggests that nutritionaleducation is an important area of work which may beused flexibly according to circumstance by communitypractitioners.
This review highlights the need for further researchevaluating and comparing the effectiveness of a range ofnutritional educational interventions with older people.Decision making about dietary change is complex andhighly individual and there is a need for furtherevaluation of tailored, individualised interventionswhich focus on the benefits of dietary change. There isalso a need for greater reliability in tools for measuringpatient outcomes. In addition, a review of qualitativeresearch could help to identify barriers and facilitators todietary change in older people. There was limitedinformation on the effect of the interventions on serviceuse. It is possible that health education may empowerpatients and create a greater demand for service use(Harari, 2004). We found insufficient information todetermine how service use is influenced by nutritionaleducation in this population.
6.3. Conclusion
The over 65s are often regarded as having wellestablished dietary and lifestyle habits which are difficultto change (Runciman et al., 2006). This systematic reviewhas indicated that nutritional education can influencefunctional outcome, dietary change and other healthindicators in people over 65 years of age living at home,
K. Young et al. / International Journal of Nursing Studies 48 (2011) 751–780778
but there is limited evidence of their influence uponservice use or mortality. Further research is required in thisarea of study.
Acknowledgements
Grateful thanks is extended for statistical adviceprovided by Sam Norton, Centre for Lifespan and ChronicIllness Research, University of Hertfordshire. This reviewwas supported by a grant from Hertnet, The HertfordshirePrimary Care Research Network, UK.Conflict of interest
None declared.
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