Objectives
To conduct a systematic review of the literature on prospective cohort studies examining associations between adherence to a Mediterranean diet and incident frailty and to perform a ...meta‐analysis to synthesize the pooled risk estimates.
Design
Systematic review and meta‐analysis.
Setting
Embase, MEDLINE, CINAHL, PsycINFO, and Cochrane Library were systematically searched on September 14, 2017. We reviewed references of included studies and relevant review papers and performed forward citation tracking for additional studies. Corresponding authors were contacted for additional data necessary for a meta‐analysis.
Participants
Community‐dwelling older adults (mean age ≥60).
Measurements
Incident frailty risk according to adherence to a Mediterranean diet.
Results
Two reviewers independently screened the title, , and full text to ascertain the eligibility of 125 studies that the systematic search of the literature identified, and four studies were included (5,789 older people with mean follow‐up of 3.9 years). Two reviewers extracted data from the studies independently. All four studies provided adjusted odds ratios (ORs) of incident frailty risk according to three Mediterranean diet score (MDS) groups (0–3, 4–5, and 6–9). Greater adherence to a Mediterranean diet was associated with significantly lower incident frailty risk (pooled OR = 0.62, 95% CI = 0.47–0.82, P = .001 for MDS 4–5; pooled OR = 0.44, 95% CI = 0.31–0.64, P < .001 for MDS 6–9) than poorer adherence (MDS 0–3). Neither significant heterogeneity (I2 = 0–16%, P = .30) nor evidence of publication bias was observed.
Conclusion
Greater adherence to a Mediterranean diet is associated with significantly lower risk of incident frailty in community‐dwelling older people. Future studies should confirm these findings and evaluate whether adherence to a Mediterranean diet can reduce the risk of frailty, including in non‐Mediterranean populations.
Purpose: Although the Mediterranean diet has been associated with a lower risk of hip fracture, the effect of other dietary patterns on bone density and risk of fracture is unknown. This scoping ...review aims to investigate the association between adherence to alternative dietary patterns (other than the traditional Mediterranean diet) and osteoporosis or osteoporotic fracture risk in older people. Methods: A systematic search was carried out on three electronic databases (Medline, EMBASE, and Scopus) to identify original papers studying the association between alternative dietary patterns (e.g., Baltic Sea Diet (BSD), modified/alternative Mediterranean diet in non-Mediterranean populations, Dietary Approaches to Stop Hypertension (DASH)) assessed using ‘prior’ methods (validated scores) and the risk of osteoporotic fracture or Bone Mineral Density (BMD) in people aged ≥50 (or reported average age of participants ≥ 60). Results from the included studies were presented in a narrative way. Results: Six observational (four prospective cohort and two cross-sectional) studies were included. There was no significant association between BMD and BSD or DASH scores. Higher adherence to DASH was associated with a lower risk of lumbar spine osteoporosis in women in one study, although it was not associated with the risk of hip fracture in another study with men and women. Higher adherence to aMED (alternative Mediterranean diet) was associated with a lower risk of hip fracture in one study, whereas higher adherence to mMED (modified Mediterranean diet) was associated with a lower risk of hip fracture in one study and had no significant result in another study. However, diet scores were heterogeneous across cohort studies. Conclusions: There is some evidence that a modified and alternative Mediterranean diet may reduce the risk of hip fracture, and DASH may improve lumbar spine BMD. Larger cohort studies are needed to validate these findings.
Malnutrition is common in heart failure (HF), and it is associated with higher hospital readmission and mortality rates. This review aims to answer the question whether nutritional interventions ...aiming to increase protein and energy intake are effective at improving outcomes for patients with HF who are malnourished or at risk of malnutrition or cachexia. Systematic searches of four databases (Medline, Embase, CINAHL and Cochrane Central Register of Controlled Trials (CENTRAL)) were conducted on 21 June 2019. Randomized controlled trials (RCTs) or other interventional studies using protein or energy supplementation for adult HF patients who are malnourished or at risk of malnutrition or cachexia were included. Two independent reviewers assessed study eligibility and risk of bias. Five studies (four RCTs and one pilot RCT) met the inclusion criteria. The majority of studies were small and of limited quality. The pooled weighted mean difference (WMD) for body weight showed a benefit from the nutritional intervention by 3.83 kg (95% confidence interval (CI) 0.17 to 7.50,
P
= 0.04) from three trials with no significant benefit for triceps skinfold thickness (WMD = − 2.14 mm, 95% CI − 9.07 to 4.79,
P
= 0.55) from two trials. The combination of personalized nutrition intervention with conventional treatment led to a decrease in all-cause mortality and hospital readmission in one study. Findings of this review suggest that nutritional interventions could potentially improve outcomes in HF patients who are malnourished or at risk of malnutrition. However, the strength of the evidence is poor, and more robust studies with a larger number of participants are needed.
Mild frailty or pre-frailty is common and yet is potentially reversible. Preventing progression to worsening frailty may benefit individuals and lower health/social care costs. However, we know ...little about effective approaches to preventing frailty progression.
(1) To develop an evidence- and theory-based home-based health promotion intervention for older people with mild frailty. (2) To assess feasibility, costs and acceptability of (i) the intervention and (ii) a full-scale clinical effectiveness and cost-effectiveness randomised controlled trial (RCT).
Evidence reviews, qualitative studies, intervention development and a feasibility RCT with process evaluation.
Two systematic reviews (including systematic searches of 14 databases and registries, 1990-2016 and 1980-2014), a state-of-the-art review (from inception to 2015) and policy review identified effective components for our intervention. We collected data on health priorities and potential intervention components from semistructured interviews and focus groups with older people (aged 65-94 years) (
= 44), carers (
= 12) and health/social care professionals (
= 27). These data, and our evidence reviews, fed into development of the 'HomeHealth' intervention in collaboration with older people and multidisciplinary stakeholders. 'HomeHealth' comprised 3-6 sessions with a support worker trained in behaviour change techniques, communication skills, exercise, nutrition and mood. Participants addressed self-directed independence and well-being goals, supported through education, skills training, enabling individuals to overcome barriers, providing feedback, maximising motivation and promoting habit formation.
Single-blind RCT, individually randomised to 'HomeHealth' or treatment as usual (TAU).
Community settings in London and Hertfordshire, UK.
A total of 51 community-dwelling adults aged ≥ 65 years with mild frailty.
Feasibility - recruitment, retention, acceptability and intervention costs. Clinical and health economic outcome data at 6 months included functioning, frailty status, well-being, psychological distress, quality of life, capability and NHS and societal service utilisation/costs.
We successfully recruited to target, with good 6-month retention (94%). Trial procedures were acceptable with minimal missing data. Individual randomisation was feasible. The intervention was acceptable, with good fidelity and modest delivery costs (£307 per patient). A total of 96% of participants identified at least one goal, which were mostly exercise related (73%). We found significantly better functioning (Barthel Index +1.68;
= 0.004), better grip strength (+6.48 kg;
= 0.02), reduced psychological distress (12-item General Health Questionnaire -3.92;
= 0.01) and increased capability-adjusted life-years +0.017; 95% confidence interval (CI) 0.001 to 0.031 at 6 months in the intervention arm than the TAU arm, with no differences in other outcomes. NHS and carer support costs were variable but, overall, were lower in the intervention arm than the TAU arm. The main limitation was difficulty maintaining outcome assessor blinding.
Evidence is lacking to inform frailty prevention service design, with no large-scale trials of multidomain interventions. From stakeholder/public perspectives, new frailty prevention services should be personalised and encompass multiple domains, particularly socialising and mobility, and can be delivered by trained non-specialists. Our multicomponent health promotion intervention was acceptable and delivered at modest cost. Our small study shows promise for improving clinical outcomes, including functioning and independence. A full-scale individually RCT is feasible.
A large, definitive RCT of the HomeHealth service is warranted.
This study is registered as PROSPERO CRD42014010370 and Current Controlled Trials ISRCTN11986672.
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in
; Vol. 21, No. 73. See the NIHR Journals Library website for further project information.
Malnutrition is associated with increased morbidity and mortality, and is very common in frail older people. However, little is known about how weight loss in frail older people can be managed in ...primary care.
To explore the views and practices of primary care and community professionals on the management of malnutrition in frail older people; identify components of potential primary care-based interventions for this group; and identify training and support required to deliver such interventions.
Qualitative study in primary care and community settings.
Seven focus groups and an additional interview were conducted with general practice teams, frailty multidisciplinary teams (MDTs), and community dietitians in London and Hertfordshire, UK (
= 60 participants). Data were analysed using thematic analysis.
Primary care and community health professionals perceived malnutrition as a multifaceted problem. There was an agreement that there is a gap in care provided for malnutrition in the community. However, there were conflicting views regarding professional accountability. Challenges commonly reported by primary care professionals included overwhelming workload and lack of training in nutrition. Community MDT professionals and dietitians thought that an intervention to tackle malnutrition would be best placed in primary care and suggested opportunistic screening interventions. Education was an essential part of any intervention, complemented by social, emotional, and/or practical support for frailer or socially isolated older people.
Future interventions should include a multifaceted approach. Education tailored to the needs of older people, carers, and healthcare professionals is a necessary component of any intervention.
The term sarcopenia was introduced in the late 1980s from the Greek words sarx and penia to describe an important change in body composition and function; a decline in lean body mass. Questions ...arising at the time included whether this was a disease or part of the normal ageing process, or when it was that this decline reached a critical point to be considered a disease. In the last two decades there has been a growing research interest in this field, and sarcopenia was recognized as a disease in the 10th Edition of the International Classification of Diseases in 2016. Yet, a diagnosis of sarcopenia is very rarely made or documented in medical records; despite being a clinical entity, it is not acknowledged as one that deserves attention in general practice. The importance and the challenges of the term sarcopenia from a primary care perspective is also explored.
•This systematic review investigates the association between adherence to the Nordic diet and frailty among older adults.•Three studies (2 prospective cohort, 1 cross-sectional) reported across 6 ...papers were identified.•Greater compliance with the Nordic diet was associated with reduced frailty risk in women (one study).•Greater adherence to Nordic diet was associated with improved muscle strength (one study) and physical performance (two studies) in women, but no significant results were observed in men (two studies).•Greater adherence to the Nordic diet was associated with better mobility and functioning (one study)
The Nordic or Baltic Sea diet is a healthy plant-based dietary pattern composed of foods originating from Nordic countries, closely related to the Mediterranean diet. Adherence to the Mediterranean diet has been found to be associated with a reduced risk of frailty. Although adherence to the Nordic diet has been associated with health benefits, little is known about its association with frailty.
To investigate the evidence from observational studies regarding the association between the Nordic/Baltic Sea diet and frailty among older adults.
Systematic review.
Three databases (Medline/Ovid, Embase/Ovid, and Scopus) were systematically searched in February 2023 for observational studies examining the association between adherence to the Nordic diet and frailty among adults ≥60 years. The two authors independently assessed the full text of the papers for eligibility of studies and risk of bias.
Three studies (the results of which were reported across 6 papers) met the inclusion criteria, among which one study (2 papers) included only women. Greater adherence to the Nordic diet was associated with a reduced risk of frailty measured by modified Fried criteria in women (one study). Moreover, greater adherence to the Nordic diet was associated with improved muscle (handgrip/leg) strength (one study) and physical performance (two studies), but these differences were seen only in women, with no significant results in men in two studies. Greater adherence to the Nordic diet was also associated with a lower risk of mobility limitations and improved ability to carry out self-care tasks (one study) and a borderline non-significant difference in Activities of Daily Living (one study). A meta-analysis was not performed due to heterogenous outcomes. Although all studies were of good quality, the results should be carefully interpreted due to methodological limitations.
Adherence to the Nordic diet could be promising in reducing frailty risk, but more robust studies with equal gender representation and frailty-specific outcomes are needed.
While malnutrition is an important cause of morbidity and mortality in older people, it is commonly under-recognised. We know little on the views of community-dwelling older people and their carers ...regarding the management of malnutrition. The aim of the study was: (a) to explore views and dietary practices of older people at risk of malnutrition and their carers; (b) to identify gaps in knowledge, barriers and facilitators to healthy eating in later life; (c) to explore potential interventions for malnutrition in primary care.
A qualitative study was performed using semi-structured interviews with participants recruited from four general practices and a carers' focus group in London. Community-dwelling people aged ≥75, identified as malnourished or at risk of malnutrition (
= 24), and informal carers of older people (
= 9) were interviewed. Data were analysed using thematic analysis.
Older people at risk of malnutrition rarely recognise appetite or weight loss as a problem. Commonly held perceptions include that being thin is healthy and 'snacking' is unhealthy. Changes in household composition, physical or mental health conditions and cognitive impairment can lead to inadequate food intake. Most carers demonstrate an awareness of malnutrition, but also a lack of knowledge of what constitutes a nutritious diet. Although older people rarely seek any help, most would value advice from their GP/practice nurse, a dietitian or another trained professional.
Older people at risk of malnutrition and their carers lack knowledge on nutritional requirements in later life but are receptive to intervention. Training for health professionals in delivering tailored dietary advice should be considered.
Malnutrition (i.e., protein-energy malnutrition) in older adults has severe negative clinical consequences, emphasizing the need for effective treatments. Many, often small, randomized controlled ...trials (RCTs) testing the effectiveness of nutritional interventions for the treatment of malnutrition showed mixed results and a need for meta-analyses and data pooling has been expressed. However, evidence synthesis is hampered by the wide variety of outcomes and their method of assessment in previous RCTs. This paper describes the protocol for developing a Core Outcome Set (COS) for nutritional intervention studies in older adults with malnutrition and those at risk.
The project consists of five phases. The first phase consists of a scoping review to identify frequently used outcomes in published RCTs and select additional patient-reported outcomes. The second phase includes a modified Delphi Survey involving experienced researchers and health care professionals working in the field of malnutrition in older adults, followed by the third phase consisting of a consensus meeting to discuss and agree what critical outcomes need to be included in the COS. The fourth phase will determine how each COS outcome should be measured based on a systematic literature review and a second consensus meeting. This will be followed by a dissemination and implementation phase. Patient and Public Involvement (PPI) representatives will contribute to study design, oversight, consensus, and dissemination.
The result of this project is a COS that should be included in any RCT evaluating the effect of nutritional interventions in older adults with malnutrition and those at risk. This COS will facilitate comparison of RCT results, will increase efficient use of research resources and will reduce bias due to measurement of the outcome and publication bias. Ultimately, the COS will support clinical decision making by identifying the most effective approaches for treating and preventing malnutrition in older adults.
Depression, anxiety and insomnia often co-occur. However, there is a lack of research regarding how they cluster and how this is related to medication used to treat them.
To describe the frequencies ...and associations between depression, anxiety and insomnia, and treatment for these conditions in primary care.
A retrospective cohort study using UK electronic primary care records. We included individuals aged between 18 and 99 years old with one or more records suggesting they had a diagnosis, symptom or drug treatment for anxiety, depression or insomnia between 2015 and 2017. We report the conditional probabilities of having different combinations of diagnoses, symptoms and treatments recorded.
There were 1 325 960 records indicative of depression, anxiety or insomnia, for 739 834 individuals. Depression was the most common condition (
= 106 117 records), and SSRIs were the most commonly prescribed medication (
= 347 751 records). Overall, individuals with a record of anxiety were most likely to have co-occurring symptoms and diagnoses of other mental health conditions. For example, of the individuals with a record of generalised anxiety disorder (GAD), 24% also had a diagnosis of depression. In contrast, only 0.6% of those who had a diagnosis of depression had a diagnosis or symptom of GAD. Prescribing of more than one psychotropic medication within the same year was common. For example, of those who were prescribed an SNRI (serotonin-norepinephrine reuptake inhibitor), 40% were also prescribed an SSRI (selective serotonin reuptake inhibitor).
The conditional probabilities of co-occurring anxiety, depression and insomnia symptoms, diagnoses and treatments are high.
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