Study by Changi General Hospital, SingHealth Polyclinics and Abbott found that 80 percent of elderly in Singapore at risk of malnutrition have low muscle mass. Dr Agnes Siew Ling Tey, Senior Clinical Scientist, Nutrition R&D Centre for Asia Pacific, Abbott shares more on the study findings and how they will be used for application in future nutrition intervention to improve physical function and health of the elderly.
New Phase Two findings from the SHIELD study by Changi General Hospital (CGH), SingHealth Polyclinics (SHP), and Abbott – which aims to strengthen health in the elderly through nutrition – revealed that improved nutritional intake reduced the risk of malnutrition by almost three-fold and promoted better health. The double-blind clinical study of 811 participants, aged 65 and up, recently published in Clinical Nutrition, examined the effects of consuming oral nutritional supplements along with individualised dietary counselling to enhance health outcomes of older adults living in the community who are at risk of malnutrition.
When compared to the control group who received individualised dietary counselling and a placebo supplement over six months, the group of 405 participants who received individualised dietary counselling and consumed two servings of a specialized oral nutritional supplement containing beta-hydroxy-beta-methyl-butyrate (HMB)* each day showed:
- Improvements in overall health outcomes without hospital admission or readmission, with at least 5 percent weight gain.
- Three times lower risk of malnutrition.
- Improved vitamin D status.
- Enhanced physical function, specifically increased leg strength and improved handgrip strength.
To gain further insights to this Phase Two Study, we spoke to Dr. Agnes Siew Ling Tey, Senior Clinical Scientist Nutrition R&D Centre for Asia Pacific, Abbott.
1. Why was beta-hydroxy-beta-methylbutyrate (HMB) selected as the nutritional supplement to be examined in the study?
Abbott has been researching the impact of nutrition in adults for more than 45 years, with more than 200 published studies on aging and chronic disease.
HMB has been extensively studied with well-established benefits in reducing muscle breakdown and improving muscle strength and quality. In addition, several recent studies reported that ONS containing HMB significantly improved recovery and clinical outcomes in hospitalized patients.
The SHIELD study extends our knowledge from the aforementioned studies as it aimed to determine the effects of ONS containing HMB (twice a day) with dietary counseling on clinical, nutritional, and functional outcomes, compared to placebo supplement (twice a day) with dietary counseling, in 811 community-dwelling older adults at risk of malnutrition.
To our knowledge, no randomized placebo-controlled trial to date has been specifically designed to investigate the long-term effects of ONS on these outcomes in this population group. This is important because this large and growing segment of the aging population is at risk but able to respond to a simple, economical pre-emptive nutritional intervention, thus potentially forestalling clinical, nutritional, and functional decline.
2. How is the consumption of HMB supplements related to vitamin D status in older adults?
In the previous phase of the SHIELD study research, it was found that one in two (52%) of well-nourished community-dwelling older adults had low vitamin D levels.
In the latest phase of the SHIELD study, we found that 60 percent of the older adults at risk of malnutrition had low vitamin D levels at baseline. The intervention group received nutritional intervention in the form of two servings of a specialized oral nutritional supplement containing HMB. Two servings of the intervention product provide 15.5 mcg (620 IU) of vitamin D, which is 78 percent of the Recommended Dietary Allowance for adults aged above 70 years.
We discovered that the nutritional intervention led to a significant improvement in vitamin D status in the intervention group which was 4.2-times more likely to have better vitamin D status compared to the placebo group.
3. What did the dietary advice to the study participants comprise of?
In the course of the SHIELD study, participants were provided with dietary counselling based on their individual energy requirements. The dietary advice was additionally tailored based on their underlying health conditions, food allergy (if any), food preference, and cultural practice. The healthy eating guideline for older adults from Changi General Hospital was used to develop the content for the dietary counselling.
All participants were advised to meet their daily energy requirement through food sources based on a healthy eating guideline from Changi General Hospital, with additional supplementation from the study product assigned to them, which was either a specialized oral nutritional supplement containing HMB (intervention group) or a placebo supplement (placebo group). Participants had also received guidance for incorporating the study products into their usual diet. Participants were asked to consume the study product between their meals.
4. How was the dietary counselling meant to support the consumption of oral nutrition supplements containing HMB?
The SHIELD study was a double-blind study, in which both researchers (including dietitians) and participants were not made aware of the group that the participants were assigned to (intervention or placebo). Hence, the role of the dietitian was to provide dietary counselling as standard of care for both groups. In addition, the dietitian provided support on ways that participants could incorporate the study products into their usual diet. Eating a well-balanced diet provides the elderly with the necessary nutrients to help them to stay healthy.
5. Based on the results, what is the recommendation for healthcare professionals when providing dietary advice to older adults?
The SHIELD study showed that specialized oral nutritional supplements containing HMB, along with dietary counselling, improved nutritional status, muscle strength, and overall health in older adults who are at risk of malnutrition. Due to the nature of the study design, these benefits are attributable to the ONS component of the intervention, above and beyond the benefits from dietary counselling alone. Hence, healthcare professionals can consider recommending such specialized oral nutritional supplements to rapidly enhance the nutritional status for better overall health and muscle strength in older adults at risk of malnutrition.
6. Besides the use of oral nutritional supplements, what other ways can older adults have sufficient intake of HMB from their diet?
Two servings of the specialized oral nutritional supplements provide 1.5 g of HMB. HMB can also be found in protein-rich food sources such as milk and Greek yogurt, soybeans, beef, chicken, and catfish. However, it can be challenging to increase the amount of HMB in one’s diet, naturally through food alone, as less than 5 percent of dietary leucine is converted to HMB. For example, approximately 7 chicken breasts or 50 eggs or 10 cups of soybeans would be required to provide 1.5 g of HMB.
The recommended daily allowance for HMB has not been established. However, research has shown that HMB levels in the body decline with age. In the elderly population, it will be very difficult for them to obtain HMB by diet alone due to challenges such as a decreased sense of taste, difficulty in chewing and swallowing, and loss of appetite.
7. From this clinical trial what kinds of public health strategies can be recommended to promote better nutrition and muscle health in older adults?
More than half of the world’s older people live in Asia. The SHIELD study provides pivotal data for future guidelines on screening for malnutrition and low muscle mass. The study findings also offer significant insight into the role of nutritional intervention, such as specialized oral nutritional supplements containing HMB, for improving health and physical function of Asian community-dwelling older adults at risk of malnutrition.
In addition, the latest SHIELD study findings demonstrate the importance of screening and early assessment to identify risk of malnutrition and low muscle mass in the elderly. The findings also demonstrate the value of early intervention through nutrition to support good health and physical function in the elderly at risk of malnutrition. Early intervention through good nutrition is critical in helping older adults to live an independent and meaningful life while avoiding debilitating adverse health outcomes related to malnutrition and low muscle mass.
The SHIELD findings can guide and inform the development of specific public health interventions and healthcare policies on improving muscle health and healthy aging, contributing to minimizing the burden on healthcare resources. As nutritional intervention through specialized oral nutritional supplements with HMB is a cost-effective solution, governments can consider increasing awareness of and access to evidence-based and effective nutrition solutions to improve population health.
The cross-disciplinary nature of the SHIELD research team has resulted in a holistic approach on the development of science-based products and evidence-based interventions to address the challenges of malnutrition in community-dwelling older adults. In terms of the next steps, we will be looking at the sustained impact of ONS on health and functional outcomes. [APBN]
About the Interviewee
Dr. Agnes Siew Ling Tey, Senior Clinical Scientist, Nutrition R&D Centre for Asia Pacific, Abbott