The cost effectiveness of personalized dietary advice to increase protein intake in older adults with lower habitual protein intake : a randomized controlled trial

Purpose To examine the cost effectiveness of dietary advice to increase protein intake on 6-month change in physical functioning among older adults. Methods In this multicenter randomized controlled trial, 276 community-dwelling older adults with a habitual protein intake = 1.2 g/kg aBW/d (PROT, n = 96), Intervention 2; similar advice and in addition advice to consume protein (en)rich(ed) foods within half an hour after usual physical activity (PROT + TIMING, n = 89), or continue the habitual diet with no advice (CON, n = 91). Primary outcome was 6-month change in 400-m walk time. Secondary outcomes were 6-month change in physical performance, leg extension strength, grip strength, body composition, self-reported mobility limitations and quality of life. We evaluated cost effectiveness from a societal perspective. Results Compared to CON, a positive effect on walk time was observed for PROT; - 12.4 s (95%CI, - 21.8 to - 2.9), and for PROT + TIMING; - 4.9 s (95%CI, - 14.5 to 4.7). Leg extension strength significantly increased in PROT (+ 32.6 N (95%CI, 10.6-54.5)) and PROT + TIMING (+ 24.3 N (95%CI, 0.2-48.5)) compared to CON. No significant intervention effects were observed for the other secondary outcomes. From a societal perspective, PROT was cost effective compared to CON. Conclusion Dietary advice to increase protein intake to >= 1.2 g/kg aBW/d improved 400-m walk time and leg strength among older adults with a lower habitual protein intake. From a societal perspective, PROT was considered cost-effective compared to CON. These findings support the need for re-evaluating the protein RDA of 0.8 g/kg BW/d for older adults.Peer reviewe

Genomic investigations of unexplained acute hepatitis in children

Since its first identification in Scotland, over 1,000 cases of unexplained paediatric hepatitis in children have been reported worldwide, including 278 cases in the UK1. Here we report an investigation of 38 cases, 66 age-matched immunocompetent controls and 21 immunocompromised comparator participants, using a combination of genomic, transcriptomic, proteomic and immunohistochemical methods. We detected high levels of adeno-associated virus 2 (AAV2) DNA in the liver, blood, plasma or stool from 27 of 28 cases. We found low levels of adenovirus (HAdV) and human herpesvirus 6B (HHV-6B) in 23 of 31 and 16 of 23, respectively, of the cases tested. By contrast, AAV2 was infrequently detected and at low titre in the blood or the liver from control children with HAdV, even when profoundly immunosuppressed. AAV2, HAdV and HHV-6 phylogeny excluded the emergence of novel strains in cases. Histological analyses of explanted livers showed enrichment for T cells and B lineage cells. Proteomic comparison of liver tissue from cases and healthy controls identified increased expression of HLA class 2, immunoglobulin variable regions and complement proteins. HAdV and AAV2 proteins were not detected in the livers. Instead, we identified AAV2 DNA complexes reflecting both HAdV-mediated and HHV-6B-mediated replication. We hypothesize that high levels of abnormal AAV2 replication products aided by HAdV and, in severe cases, HHV-6B may have triggered immune-mediated hepatic disease in genetically and immunologically predisposed children

Perspectives on the causes of undernutrition of community-dwelling older adults: A qualitative study

Objectives: Undernutrition is a major health concern particularly in vulnerable older adults. The present study aimed to reveal the causes of undernutrition as reported by community-dwelling older adults. Design: Twenty-five semi-structured interviews and two focus group discussions were performed and analyzed. Setting: Community-dwelling. Participants: Older adults. Measurements: A questionnaire on demographics, Short Nutritional Assessment Questionnaire 65+ and interviews on the potential causes of undernutrition. Results: 33 older adults agreed to participate in the interviews and focus groups. Our findings indicate that a wide variety of causes of undernutrition, both modifiable and non-modifiable, were mentioned by the older adults. Many modifiable causes of undernutrition were reported in the mental, social or food & appetite theme, such as poor food quality provided by meal services, the inability to do groceries, loneliness and mourning. Non-modifiable causes included, forgetfulness, aging, surgery and hospitalization. Conclusions: This study provides guidance to better understand the underlying causes of undernutrition from an older adult’s perspective. The modifiable causes provide specific direction towards practical implications that might decrease or prevent undernutrition. Non-modifiable causes should raise awareness of an increased risk of undernutrition by health professionals in primary and secondary care, caregivers and family members

Factors associated with (risk of) undernutrition in community-dwelling older adults receiving home care: a cross-sectional study in the Netherlands

OBJECTIVE: It is generally thought that causes of undernutrition are multifactorial, but there are limited quantitative studies performed. We therefore examined a wide range of potential factors associated with undernutrition in community-dwelling older adults. DESIGN: Cross-sectional study. SETTING: Community-dwelling older adults (≥65 years) receiving home care in the Netherlands. SUBJECTS: Data on potential factors associated with (risk of) undernutrition were collected among 300 older adults. Nutritional status was assessed by the SNAQ65+ instrument. Undernutrition was defined as mid-upper arm circumference <25 cm or unintentional weight loss of ≥4 kg in 6 months. Being at risk of undernutrition was defined as having poor appetite and inability to walk up and down stairs of fifteen steps, without resting. RESULTS: Of all participants, ninety-two (31·7 %) were undernourished and twenty-four (8·0 %) were at risk of undernutrition. Based on multivariate logistic regression analyses, the statistically significant factors associated with (risk of) undernutrition (P<0·05) were: unable to go outside (OR=5·39), intestinal problems (OR=2·88), smoking (OR=2·56), osteoporosis (OR=2·46), eating fewer than three snacks daily (OR=2·61), dependency in activities of daily living (OR=1·21), physical inactivity (OR=2·01), nausea (OR=2·50) and cancer (OR=2·84); a borderline significant factor was depression symptoms (OR=1·83, P=0·053). CONCLUSIONS: The study suggests that (risk of) undernutrition is a multifactorial problem and that associated factors can be found in several domains. These findings may support the development of intervention trials for the prevention and treatment of undernutrition in community-dwelling older adults

Targeting the underlying causes of undernutrition. Cost-effectiveness of a multifactorial personalized intervention in community-dwelling older adults: A randomized controlled trial

Background & aims: Undernutrition in old age is associated with increased morbidity, mortality and health care costs. Treatment by caloric supplementation results in weight gain, but compliance is poor in the long run. Few studies targeted underlying causes of undernutrition in community-dwelling older adults. This study aimed to evaluate the cost-effectiveness of a multifactorial personalized intervention focused on eliminating or managing the underlying causes of undernutrition to prevent and reduce undernutrition in comparison with usual care. Methods: A randomized controlled trial was performed among 155 community-dwelling older adults receiving home care with or at risk of undernutrition. The intervention included a personalized action plan and 6 months support. The control group received usual care. Body weight, and secondary outcomes were measured in both groups at baseline and 6 months follow-up. Multiple imputation, linear regression and generalized estimating equation analyses were used to analyze intervention effects. In the cost-effectiveness analyses regression models were bootstrapped to estimate statistical uncertainty. Results: This intervention showed no statistically significant effects on body weight, mid-upper arm circumference, grip strength, gait speed and 12-Item Short-Form Health Survey physical component scale as compared to usual care, but there was an effect on the 12-Item Short-Form Health Survey mental component scale (0-100) (β = 8.940, p. =0.001). Borderline significant intervention effects were found for both objective and subjective physical function measures, Short Physical Performance Battery (0-12) (β = 0.56, p. =0.08) and ADL-Barthel score (0-20) (β = 0.69, p. =0.09). Societal costs in the intervention group were statistically non-significantly lower than in the control group (mean difference -274; 95% CI -1111; 782). Cost-effectiveness acceptability curves showed that the probability of cost-effectiveness was 0.72 at a willingness-to-pay of 1000 €/kg weight gain and 0.80 at a willingness-to-pay of 20,000 €/quality-adjusted life year gained. Conclusions: This multifactorial personalized intervention showed a statistically non-significant effect and was not cost-effective on body-weight compared to usual care. We observed consistently beneficial treatment effects in the intervention group on all outcomes measures. Clinical trial registry number and website: NTR5184 (www.trialregister.nl)

Effectiveness and cost-effectiveness of personalised dietary advice aiming at increasing protein intake on physical functioning in community-dwelling older adults with lower habitual protein intake : rationale and design of the PROMISS randomised controlled trial

Introduction Short-term metabolic and observational studies suggest that protein intake above the recommended dietary allowance of 0.83 g/kg body weight (BW)/day may support preservation of lean body mass and physical function in old age, but evidence from randomised controlled trials is inconclusive. Methods and analysis The PRevention Of Malnutrition In Senior Subjects in the EU (PROMISS) trial examines the effect of personalised dietary advice aiming at increasing protein intake with or without advice regarding timing of protein intake to close proximity of usual physical activity, on change in physical functioning after 6 months among community-dwelling older adults (>= 65 years) with a habitual protein intake of Discussion The PROMISS trial will provide evidence whether increasing protein intake, and additionally optimising the timing of protein intake, has a positive effect on the course of physical functioning after 6 months among community-dwelling older adults with a habitual protein intake of Ethics and dissemination The study has been approved by the Ethics Committee of the Helsinki University Central Hospital, Finland (ID of the approval: HUS/1530/2018) and The Medical Ethical Committee of the Amsterdam UMC, location VUmc, Amsterdam, the Netherlands (ID of the approval: 2018.399). All participants provided written informed consent prior to being enrolled onto the study. Results will be submitted for publication in peer-reviewed journals and will be made available to stakeholders (ie, older adults, healthcare professionals and industry).Peer reviewe

Correction to: The cost effectiveness of personalized dietary advice to increase protein intake in older adults with lower habitual protein intake: a randomized controlled trial

In section “Change in 400‑m walk time”, second sentence should read as A intervention effect in the same direction was observed in PROT + TIMING, but not statistically significant; – 4.9 s (95% CI, – 14.5 to 4.7) (Table 3)