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Impact of food fortification on nutritional outcomes andsatisfaction in the older people: A systematic literature

review protocolAlexia Geny, Maïté Petitjean, Virginie van Wymelbeke-Delannoy, Claire

Sulmont- Rossé

To cite this version:Alexia Geny, Maïté Petitjean, Virginie van Wymelbeke-Delannoy, Claire Sulmont- Rossé. Impact offood fortification on nutritional outcomes and satisfaction in the older people: A systematic literaturereview protocol. 2021. �hal-03180038�

IMPACT OF FOOD FORTIFICATION ON NUTRITIONAL

OUTCOMES AND SATISFACTION IN THE OLDER PEOPLE:

A SYSTEMATIC LITERATURE REVIEW PROTOCOL

Alexia Geny1, Maïté Petitjean

1, Virginie Van Wymelbeke-Delannoy

1,2, Claire Sulmont-

Rossé1*

1 Centre des Sciences du Goût et de l'Alimentation, AgroSup Dijon, CNRS, INRAE,

Université de Bourgogne Franche-Comté, F-21000 Dijon, France

2 CHU Dijon Bourgogne, Unité de recherche Pôle Personnes Âgées, Dijon, France

Corresponding author

* Claire Sulmont-Rossé: claire.sulmont-rosse@inrae.fr

Keywords

Aged, enrichment, supplementation, malnutrition, nutritional intake, nutritional status

ABSTRACT

Malnutrition, a recognized pathology in the older adults, corresponds to an imbalance of

nutritional intake compared to the body's needs. To treat this disease, several alternatives can

be used, among which there is food fortification. Food-based fortification (also known as

dietary enrichment) corresponds to the addition of conventional foods or high calorie and/or

nutrients ingredients in the person's meals and dishes. It is a strategy used to treat moderate

and severe malnutrition but can be employed as prevention. In this context, the purpose of the

present study was to conduct a systematic review of all studies related to the nutritional and

satisfaction issue of fortified foods dedicated to elderlies. This review is expected (1) to

describe the solutions that have been developed in the area of food-based fortification, (2) to

evaluate whether these solutions can be relevant and effective levers to preserve or improve

nutritional outcomes of older people, and (3) to shed light on the acceptability of these

solutions in older people to better understand their needs.

INTRODUCTION

Malnutrition, a recognized pathology in the older population, corresponds to an imbalance of

nutritional intake compared to the body's needs. This imbalance leads to weight loss, a

decrease in muscle reserves and an alteration of the body's defences. In the older people,

malnutrition increases the risk of falls and therefore fractures. It contributes to the increase in

infectious morbidity (Hiesmayr et al., 2009), nosocomial infections (Schaible & Kaufmann,

2007) and the appearance of pressure ulcers (Litchford et al., 2014). Without care,

malnutrition induces or worsens a state of fragility and dependence, and affects the quality

and expectancy of life of our elders (Hiesmayr et al., 2009; Ferry, 2012). According to the

French High Authority of Health (Haute Autorité de Santé (HAS), 2007) about 4 % of older

people living at home are suffering from malnutrition. In nursing home, this prevalence varies

between 15 % and 38 %. Meanwhile in hospital, where pathologies, pain and psychological

stress are added, prevalence of malnutrition goes up to 30-70 %.

Different nutritional support strategies are recommended by the HAS (2007) to treat

malnutrition in the older subject. The objective is to achieve an energy intake of 30 to 40

kcal/kg/day and a protein intake of 1.2 to 1.5 g of protein/kg/day, depending on the health

background. The choice of nutritional support strategies depends on the patient's nutritional

status and spontaneous energy and protein intakes. The nature and severity of any disease and

associated disabilities (e.g. swallowing disorders) should also be taken into account. HAS

recommends to manage moderate malnutrition based on dietary counselling and food

fortification. In the event of failure and/or severe malnutrition, in addition, the prescription of

Oral Nutritional Supplements (ONS) is advocated. Finally, in the event of failure or due to

swallowing disorders, artificial nutrition encompassing enteral nutritional support (i.e. tube

feeding) or parenteral nutritional support (i.e. intravenous feeding) may be considered.

Food-based fortification (also known as dietary enrichment) is the act of increasing the energy

and nutrients intake of a meal without increasing its volume (HAS, 2007). This approach use

commonly consumed foods as vehicle to deliver fortificants (Aa, 2016). Fortificants can be:

(1) regular foods (e.g. adding extra ingredients such as semolina, oils, butter, cream, pureed

nuts, powdered milk, or egg whites to menu recipes), or (2) powdered modules (e.g. adding

unflavored powder of high protein (e.g., casein, whey protein) or carbohydrate (e.g.,

maltodextrin) content to the diet) (Douglas et al., 2017; Trabal & Farran-Codina, 2015). This

strategy has the advantage to better respect older people dietary habits and preferences as the

vehicle food can be replaced by another. This constitutes a significant advantage in this

population who is often reluctant to change their eating habits. By contrast, ONS are ready-to-

use food or drinks designed to provide macro- and micro-nutrients. They are used in addition

to the normal diet, and not as a food replacement, when diet alone is insufficient to meet daily

nutritional requirements. They exist in small volumes (100 to 300 ml), mainly under various

sweet forms (dairy drinks, fruit juice, cream). However, liking and intake are often poor

because of unacceptable mouthfeel and flavour characteristics over full portion sizes

(Methven et al., 2010). In fact, while some studies have reported good compliance (Hubbard

et al., 2012; Neelemaat et al., 2012), other have reported low compliance level (McMurdo et

al., 2009; Simmons & Patel, 2006).

Moreover, ONS use is often restricted to medical context. While available in the market, they

are usually prescribed by a physician and mainly used in hospital or institutions. Nowadays,

ONS are known to be an efficient tool to tackle undernutrition (Seguy et al., 2020, Smith et

al., 2020) although its status (medication, supplementation, food) sometimes remains unclear

between different parts of the health care team (Brindisi et al., 2020). On the contrary, food-

based fortification remains largely unknown and underused by older adults as well as by

caregivers and healthcare professionals although it is nowadays acknowledged to be a

relevant approach to prevent/treat malnutrition older people (Mills et al., 2018).

In this context, the purpose of the present study was to conduct a systematic review of all

studies related to the nutritional and satisfaction issue of fortified foods dedicated to older

people in the perspective to taking stock of food-based fortification. This review is expected

(1) to describe the solutions that have been developed in the area of food-based fortification,

(2) to evaluate whether these solutions can be relevant and effective levers to preserve or

improve nutritional outcomes of older people, and (3) to shed light on the acceptability of

these solutions in older people to better understand their needs.

METHODS

Our systematic review will follow the approach proposed by Xiao & Watson (2019) as well

as the methodology published by the Cochrane Training (Higgins et al., 2021). This

methodology summarizes the evidence available on a topic in order to convey the breadth and

depth of that topic. The protocol will be drafted using the Preferred Reporting Items for

Systematic Reviews and Meta-analysis Protocols (PRISMA-P; Shamseer et al., 2015).

Research question

The research question for this review is: “What are the objectives, characteristics and results

of existing research conducted on the nutritional issue or on the satisfaction among older

people receiving fortified foods?”

Eligibility criteria

The PICOS (Population, Intervention, Comparator, Outcome, Study design) eligibility criteria

will be as follows (Stone, 2002):

Population. Any studies focusing on adults aged 60 years and older living either at home, in

institution or in hospital will be relevant for inclusion. Older adults people of all nutritional

status, cognitive status and oral ability (e.g. chewing, swallowing) are eligible for inclusion.

Studies carried out in the context of a specific pathological condition (e.g. cardio

rehabilitation, renal failure, cancers, diabetes) will be excluded.

Intervention. Any nutritional intervention will be relevant for inclusion (e.g. studies providing

food-based fortification: the act of increasing the energy and nutrients intake of a meal

without increasing its volume). Fortification in energy, macronutrients or micronutrients will

be eligible for inclusion as well as any combination among the three. In addition, studies

without an intervention (e.g. observational studies) will be eligible for inclusion. We will

exclude from the review: (1) studies targeting only oral nutritional supplements (ONS), non-

food dietary supplement or bio-fortification (crop genetically modified), and (2) intervention

targeting artificial nutrition (e.g. tube feeding, parenteral feeding, enteral feeding).

Comparators. Any comparator will be relevant for inclusion (e.g. studies comparing fortified

food with standard food or with ONS, or studies comparing two types of fortified food). In

addition, studies without a comparator will be eligible for inclusion.

Outcomes. Three categories of outcomes associated will be considered: (1) characterization of

the nutritional intake (e.g. dietary pattern, nutrient intake), (2) characterization of the

nutritional status (e.g. Body Mass Index – BMI, weight, undernutrition) and (3)

characterization of the satisfaction (e.g. liking, preference, pleasure).

Study design. All type of study design including observational and interventional design as

well as all period of times and duration of follow-up will be eligible.

Others. No restriction on the date of publication will be made. Given the 6-month timeline,

only publications written in English and French will be considered for inclusion. Conference

abstracts, editorials, narrative review and non-scientific literature (e.g. articles on websites)

will be excluded.

Information sources and search strategy

After repeated attempts and adjustments, a search strategy combining both thesaurus and free-

text terms was developed to retrieve articles of interest in the following databases: PubMed,

Web of Science (WOS) and Scopus (Supplementary File 1). Separate title, abstract, and

keywords searches will be conducted for older people, fortified foods and outcomes on 2021,

January. The results for the three separate search strings will be combined to identify relevant

articles. Afterwards, references from primary selected articles, reviews and systematic

reviews will be checked manually for further screening in case they were not identified during

the whole search process. After removing the duplicates, titles, abstracts and full texts will be

screened by two independent reviewers against the agreed inclusion and exclusion criteria.

For each screening level, a training exercise will be conducted prior to the starting of the

screening process on a random sample of 100 titles and abstracts and 10 full-text to ensure

high inter-reviewer reliability. Disagreements between reviewers will be resolved by

consensus or by consulting a third reviewer. The reasons for exclusion will be recorded at the

full-text stage.

Charting the data

A standardized data abstraction form was developed a priori and revised, as needed, after the

completion of a training exercise completed on a sample of 5 articles. All included studies

will be abstracted by two reviewers, independently, with conflicts resolved by a third

reviewer. The data abstraction form will include the following items:

- Article identifiers (authors, year of publication)

- Study identifiers (objective, design, country)

- Population (age, gender, sample size, inclusion and exclusion criteria)

- Intervention (description of the food-based fortification solutions)

- Comparator (if applicable)

- Outcomes (endpoints, measurement method, main results)

Quality assessment

All included studies will be assessed for quality by two reviewers, independently, with

conflicts resolved by a discussion until consensus was reached. The quality of the articles will

be assessed by using the quality assessment criteria developed by Kmet et al. (2004). The

criteria will be the following:

1. Is the objective of the study sufficiently described?

2. Is the study design evident and appropriate?

3. Is the method of subject selection described and appropriate?

4. If interventional and random allocation was possible, was it described?

5. If interventional and blinding of investigators was possible, was it reported?

6. If interventional and blinding of subjects was possible, was it reported?

7. Are subject characteristics sufficiently described?

8. Are outcome measures well defined and robust to measurement?

9. Is the sample size appropriate?

10. Are analytic methods described, justified and appropriate?

11. Is some estimate of variance reported for main results?

12. Are they controlled for confounding?

13. Are the results reported in sufficient detail?

14. Are the conclusions supported by results?

Each question can be answered with ‘yes’, ‘partial’, ‘no’ and ‘not applicable’. The associated

scoring manual of Kmet et al. (2004) will be used to calculate the quality score as it is

described below:

In addition, the description quality of the food-based fortification solutions (type of food

vehicle, type of fortificant, concentration) will be assessed (but not included in the quality

score).

Collating, summarizing and reporting the results

A descriptive numerical summary of the included studies’ characteristics will be performed.

Tables and graphs will be created to reflect the overall number of studies included, study

designs and settings, publication years, the characteristics of the study populations, the

outcomes reported, and the countries where the studies were conducted. In line with

systematic literature review guidelines, an assessment of the quality of the included studies

was performed (Higgins et al., 2021; Xiao & Watson, 2019).

RESULTS AND DISCUSSION

After conducting a descriptive summary of the collected studies, the four following topics

are expected to be addressed:

- Description of food-based fortification solutions: which types of food are fortified?

Which nutrients are added? In what form? At which concentration?

- Assessment of fortified foods acceptability: to which extent older people like fortified

food? Does the sensory characteristics of fortified foods fulfil older people’ sensory

expectations and preferences?

- Assessment of the nutritional impact of food-based fortification: does older people who

received fortified food improve their nutritional status and nutritional intake compared

to a standard diet?

- Comparison of food-based fortification with other alternatives (e.g. dietary counselling,

ONS): does receiving fortified food is better accepted and/or provide a nutritional

benefit compared to other alternatives?

A preliminary literature inquiry has led to the identification of four systematic literature

reviews close to the present review:

- Trabal and Farran-Codina (2015) investigated whether dietary enrichment with

conventional foods and/or powdered modules can improve energy and protein intake in

older adults in hospital setting, long-care facilities or community setting. This review

included nine articles. Authors concluded that dietary enrichment is a valid intervention

to improve energy intake in older adults. However, while it seems to increase protein

intake too, there is not enough evidence of sufficient quality to confirm this observation.

- Morilla-Herrera et al. (2016) targeted all studies related to food-based fortification with

macronutrients to prevent the risk of malnutrition in older patients receiving hospital

services for acute or chronic disease, in older people living in nursing home and in older

people with home-care. This review encompassed seven articles and highlighted that

food-based fortification yields positive results in the total amount of ingested calories

and protein.

- Mills et al. (2018) explored the evidence for the use of energy and/or protein dense

meals (via fortification) or snacks (supplementation) to increase the dietary energy and

protein intake of older people in hospital or rehabilitation facilities. Ten articles were

identified. Authors reported that when compared with usual nutritional care, energy and

protein fortification and supplementation could be employed as an effective, well-

tolerated and cost-effective intervention to improve dietary intake among hospitalized

patients.

- Douglas et al. (2017) aimed to evaluate the use of common kitchen ingredients to fortify

foods on energy and protein intake among older adults being in acute care hospital,

long-term care setting or living at home. Ten articles were included. This review

suggested that food fortification was effective in increasing calorie and protein intake

among older individuals.

Table 1 presents the articles identified for each of these four SLR. Surprisingly, there are

several discrepancies between the article list of Mills et al. (2018) and Morilla-Herrera et al.

(2016) while there was large overlap between eligibility criteria of these two SLRs. Several

studies targeted hospitalized or institutionalized patients identified in Mills et al. (2018) were

not found in Morilla-Herrera et al. (2016) who targeted the same population, and conversely.

On the reverse, the article list was almost the same between Trabal & Farran-Codina (2015)

and Douglas et al. (2017) with one exception (the study of Trabal, 2014), while eligibility

criteria were somehow different (targeted population and intervention). Finally, while two

SLRs targeted older-people living at home (Douglas et al., 2017) with home-care (Trabal &

Farran-Codina, 2015), some studies that assessed the impact of food-fortification in home-

delivery meal service were missing (e.g., Charlton et al., 2013; Lipschitz et al., 1985). This

might be due to the small number of key-words used in the literature search. For instance,

Douglas et al. (2017) seems to have used only the term “home-delivered” to designed

beneficiary of “home-delivery meal”. However, the key-word “home-delivered” is not a

MeshTerm and is far from being the most frequent term to designate this type of home-care

service (Fleury et al., 2021). Similarly, the concept of “fortification” is not (yet) consensual.

Increasing nutrient density in a food can also be designated by the concept “enrichment” or

“supplementation”. This last concept was not included in Trabal & Farran-Codina, 2015 and

Douglas et al., 2017, while it was used in Mills et al., 2018.

Finally, none of these reviews investigated the acceptability of food-based fortification

solution as one of the main outcome, nor considered the impact of micronutrient enrichment.

Table1. Review of the articles identified in the four systematic literature reviews close to the

present review.

Article Population Trabal 2015 Morilla-

Herrera 2016 Mills 2018

Douglas

2017

Barton et al., 2000 Hospital X X X X

Beelen et al., 2017 Nursing home

and hospital X

Campbell et al., 2013 Hospital X

Castellanos et al., 2009 Nursing home X X X

Cots et al., 2013 Hospital X

De Jong, 2001 Home care X

Gall et al., 1998 Hospital X X X X

Leslie et al., 2013 Nursing home X X

Lorefält et al., 2005 Hospital X X X

Munk et al., 2013 Hospital X

Ödlund Olin et al.,

1996 Hospital X X X

Ödlund Olin, 2003 Nursing home X X X

Silver et al., 2008 Nursing home X X

Smoliner et al., 2008 Nursing home X X X

Stelten et al., 2015 Hospital X

Trabal, 2014 Home X

Weekes et al., 2009 Home living X

Van Til et al., 2015 Hospital X

ACKNOWLEDGMENT

This work received funding by the French “Investissements d’Avenir” program, project

ISITE-BFC (contract ANR-15-IDEX-0003) and from ANR (ANR-20-HDHL-0003

FORTIPHY), Research Council Norway (RCN 321819), BBSRC (BB/V018329/1) under the

umbrella of the European Joint Programming Initiative “A Healthy Diet for a Healthy Life”

(JPI HDHL) and of the ERA-NET Cofund ERA-HDHL (GA N°696295 of the EU Horizon

2020 Research and Innovation Programme).

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Supplementary File 1. Search strategy in PubMed, Web of Science and Scopus. (For

PubMed, MeSH terms are in bold).

Old people

"aged" OR "older adults" OR "older" OR "senior" OR "aging" OR "ageing"

AND

Fortified food

"food, fortified" OR "enriched food" OR "enriched foods" OR "food enrichment" OR

"diet enrichment" OR "enriched diet" OR "enriched diets" OR "food fortification" OR

"supplemented food" OR "supplemented diet" OR "supplemented diets" OR "food

supplementation" OR "diet supplementation" OR "additional food" OR "additional foods"

OR "added food" OR "fortified drink" OR "fortified beverage" OR "enriched drink" OR

"enriched beverage" OR "enriched beverages" OR "dense food" OR "dense foods" OR

"dense diet" OR "dense diets" OR "food, formulated" OR "formulated food" OR

"fortified foods" OR "dietary enrichment"

AND

Outcomes

- Nutritional intake: "eating" OR "food intake" OR "dietary intake" OR "feed intake"

OR "food consumption" OR "diet pattern" OR "dietary pattern" OR "nutritional

intake" OR "protein intake" OR "energy intake" OR "nutritional requirement"

OR "nutritional requirements" OR "dietary protein" OR "dietary proteins" OR

"feeding" OR "feeding behavior"

OR

- Nutritional status: "nutritional status" OR "body weight" OR "weight" OR "Body

Mass Index" OR "BMI" OR "muscle mass" OR "malnutrition" OR

"undernutrition" OR "undernourished" OR "malnourished" OR "appetite" OR

"sarcopenia" OR "frail elderly" OR "frailty" OR "frail" OR "elder nutritional

physiological phenomena"

OR

- Satisfaction: "satisfaction" OR "preference" OR "preferences" OR "liking" OR

"acceptance" OR "palatability" OR "palatable" OR "expectation" OR

"expectations"