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J Hum Nutr Diet. 2018 Jun;31(3):379-389. doi: 10.1111/jhn.12529. Epub 2018 Jan 10.

Can fortified foods and snacks increase the energy and protein intake of hospitalised older patients? A systematic review.

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Academic Geriatric Medicine, University of Southampton, Southampton General Hospital Mailpoint, Southampton, UK.
National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Wessex, University of Southampton, Southampton, UK.



Undernutrition affects over 44% of hospitalised older people, who often dislike oral nutritional supplements (ONS). This review summarises the evidence for an alternative strategy, using energy and protein dense meals (via fortification) or snacks (supplementation) to increase the dietary energy and protein intake of older inpatients.


A search was conducted through PubMed, EMBASE, CINAHL and the Cochrane database of systematic reviews (May 1996 to May 2016) that used fortification or supplementation to increase the energy or protein intake of patients (mean age ≥60 years) in hospitals or rehabilitation centres.


Ten articles (546 patients, mean age 60-83 years) were identified. Compared with usual nutritional care, six studies using either energy or protein based fortification and supplementation significantly increased intake of energy (250-450 kcal day-1 ) or protein (12-16 g day-1 ). Two studies enriched menus with both energy and protein, and significantly increased both energy (698 kcal day-1 and 21 kJ kg-1 ) and protein (16 g and 0.2 g kg-1 ) intake compared to usual care. ONS was similar to supplementation in one study but superior to fortification in another. Four studies reported good acceptability of enriched products and two studies that found they were cost-effective.


Compared with usual nutritional care, energy- and protein-based fortification and supplementation could be employed as an effective, well-tolerated and cost-effective intervention to improve dietary intake amongst older inpatients. This strategy may be particularly useful for patients with cognitive impairment who struggle with ONS, and clinical trials are required to compare these approaches and establish their impact on functional outcomes.


fortified; hospital; malnutrition; older patients; snacks; supplementation


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