The impact of food fortification on weight and cardiometabolic outcomes in community based elderly individuals: A systematic review

Background: Food fortification is widely recommended by dietitians in clinical practice (1). High intakes of saturated fat are associated with an increased risk of cardiovascular disease (CVD) and account for 45% of deaths from non-communicable diseases (2). Data suggests that 83.3% of adults aged 65 years and over exceed the daily recommendation of saturated fat intake (3). The aim of this review was to examine whether food fortification is a healthy approach in the elderly population and what impact it has on weight, body mass index (BMI) and cardiometabolic outcomes (blood pressure, total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides and HbA1C). Methods: CINAHL, MEDLINE, Academic Search Complete, the Cochrane Library and SCOPUS were searched in April 2020. Reference lists of obtained studies were also examined. Studies were included if they met the following criteria: adults > 65 years living in the community or residential service; mean BMI <18.5kg/m2 or identified as being malnourished/ at risk of malnutrition using a validated screening tool; food fortification from everyday foods or dietary advice. Studies that included oral nutritional supplements (ONS) alongside food fortification were excluded. Risk of bias was assessed using the Cochrane risk of bias tool (4). Results: 435 studies were identified from the search. Five studies met the inclusion criteria and were included in the review: three randomised controlled trials and two cluster randomised trials (n=356, mean age 68.9 - 90.9 years). Two studies researched home living individuals and the other three studies were conducted in residential services. In two studies common ingredients (e.g double cream, butter, whole milk) were used to fortify the current diet while the remaining studies provided dietary information. One of these studies also provided the intervention group with a supply of milk powder alongside dietary information. Participants in the intervention groups across all five studies experienced an increase in weight (range 0.48 - 2kg) which was greatest in those that received fortification through common ingredients (+ 1.3kg p = 0.03, +2kg p = 0.001) or milk powder (+ 1.2kg no p value). The control group of this study who received only a leaflet with food fortification advice that was not discussed with them had lost weight (-0.9kg) at 12 months. Only two studies examined changes in BMI with both finding a statistically significant difference (p=0.042, p =0.007). None of the studies reported on cardiometabolic outcomes. All studies showed substantial risk of bias. Discussion: Findings support the use of food fortification within dietetic practice to promote weight gain. Weight gain was greatest in the studies where participants received the energy dense foods compared to those where only dietary advice was provided. It could be suggested that just providing individual with written information is ineffective as a result of the control group who received this losing weight. None of the studies had assessed the impact on cardiometabolic outcomes and therefore more studies are required in this area. Conclusion: Food fortification was found to have an increase in weight and BMI. None of the studies reported on the impact of food fortification on cardiometabolic outcomes. References: 1. Baldwin, C., and Weekes, C. E. (2012) ‘Dietary advice with or without oral nutritional supplements for diseaserelated malnutrition in adults’. Cochrane Database of Systematic Reviews. (9), CD002008 2. Scientific Advisory Committee on Nutrition (2019) Saturated fats and health. Available from :https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/814995/SACN_rep ort_on_saturated _fat_ and_health [Accessed 26th January 2020] 3. Bates.B., Cox., L., Nicholson, P. et al. (2016) National Diet and Nutrition Survey Results from Years 5 and 6. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/551352/NDNS_Y5_ 6_UK_Main_Text [Accessed 21st January 2020] 4. Higgins, J. P. T., Saviovic, J., Page, M.J. et al. (2019) Revised Cochrane risk-of-bias tool for randomized trials (RoB 2). Available from <https://sites.google.com/site/riskofbiastool/welcome/rob-2-0-tool/current-version-of-rob2?authuser=0> [Accessed 1st May 2020]