营养不良老年人非药物干预临床实践指南

doi:10.12114/j.issn.1007-9572.2023.0074

中国全科医学 ›› 2023, Vol. 26 ›› Issue (17): 2055-2069.DOI: 10.12114/j.issn.1007-9572.2023.0074

• 指南·共识 • 下一篇

营养不良老年人非药物干预临床实践指南

中国老年护理联盟, 中南大学湘雅护理学院（中南大学湘雅泛海健康管理研究院）, 中南大学湘雅医院（国家老年疾病临床医学研究中心）, 北京医院（国家老年医学中心、国家老年疾病临床医学研究中心）, 李孟琦, 伍丽娜, 宁红婷, 冯辉^*()

410000　湖南省长沙市，中南大学湘雅护理学院

收稿日期:2023-02-11 修回日期:2023-02-21 出版日期:2023-06-15 发布日期:2023-02-28
通讯作者: 冯辉
执笔人
执笔人
执笔人
执笔人
基金资助:
国家重点研发计划项目(2020YFC2008602); 国家自然科学基金面上项目(72174212); 湖南省重点研发计划项目(2020SK2055)

Clinical Practice Guideline for Non-pharmacological Interventions for Malnourished Elderly

China Gerontological Nursing Alliance, Xiang Ya Nursing School Central South University (Xiangya Oceanwide Health Management Research Institute of Central South University), Xiangya Hospital Central South University (National Clinical Research Center for Geriatric Disorders), Beijing Hospital (National Center for Gerontology, National Clinical Research Center for Geriatric Disorders), LI Mengqi, WU Lina, NING Hongting, FENG Hui^*()

Xiang Ya Nursing School Central South University, Changsha 410000, China

Received:2023-02-11 Revised:2023-02-21 Published:2023-06-15 Online:2023-02-28
Contact: FENG Hui
About author:
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摘要/Abstract

摘要： 老年人是营养不良的高发人群，营养不良与众多不良临床结局密切相关，严重影响老年人的身体健康和生活质量，给家庭和社会造成沉重负担。因此，采取有效措施改善老年人的营养不良至关重要，非药物干预是改善营养状况的重要措施。然而，国内尚无专门针对营养不良老年人的非药物干预临床实践指南，因此，中国老年护理联盟、国家老年医学中心和国家老年疾病临床医学研究中心的营养专家，通过对老年人营养不良最新的国内外文献的全面检索与分析，采用推荐意见评估、制订及评价（GRADE）分级体系制订了本指南，针对营养不良老年人非药物干预提出9条推荐意见，以期能够改善老年人营养不良状况，提高生活质量。本指南侧重于可经口进食的营养不良老年人，聚焦于肠内营养，肠外营养不在本指南讨论范围内。

关键词: 营养不良, 老年人, 非药物干预, 膳食, 健康运动, 临床实践指南

Abstract:

The older adults are high risk population for malnutrition. Malnutrition is closely associated with numerous adverse clinical outcomes, which may seriously affect the physical health and life quality of the older adults, causing heavy burdens on families and society. Therefore, it is of great importance to take effective measures to improve malnutritionin the older adults, and non-pharmacological interventions have been proved to be important measures to improve nutritional status. However, there is no domestic clinical practice guideline for non-pharmacological interventions specifically for malnourished older adults. Therefore, nutrition experts from China Gerontological Nursing Alliance, National Center for Gerontology and National Clinical Research Center for Geriatric Disorders developed the guideline based on the Grading of Recommendation Assessment, Development and Evaluation (GRADE) including 9 recommendations of non-pharmacological intervention formal nourished older adults through a comprehensive search and analysis of the latest domestic and international literature on malnutrition in the elderly, in order to improve malnutrition and quality of life in the older adults. This guideline focuses on malnourished older adults who can be fed orally and enteral nutrition, parenteral nutrition is not covered by the scope of this guideline.

Key words: Malnutrition, Aged, Non-pharmacological Interventions, Diet, Health promotion, Clinical practice guideline

中国老年护理联盟,中南大学湘雅护理学院（中南大学湘雅泛海健康管理研究院）,中南大学湘雅医院（国家老年疾病临床医学研究中心）,等. 营养不良老年人非药物干预临床实践指南[J]. 中国全科医学, 2023, 26(17): 2055-2069. DOI: 10.12114/j.issn.1007-9572.2023.0074.
China Gerontological Nursing Alliance,Xiang Ya Nursing School Central South University (Xiangya Oceanwide Health Management Research Institute of Central South University),Xiangya Hospital Central South University (National Clinical Research Center for Geriatric Disorders), et al. Clinical Practice Guideline for Non-pharmacological Interventions for Malnourished Elderly[J]. Chinese General Practice, 2023, 26(17): 2055-2069. DOI: 10.12114/j.issn.1007-9572.2023.0074.

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[75]	BALACHANDRAN A T, STEELE J, ANGIELCZYK D，et al. Comparison of power training vs traditional strength training on physical function in older adults：a systematic review and meta-analysis[J]. JAMA Netw Open，2022，5(5):e2211623. DOI：10.1001/jamanetworkopen.2022.11623.
[76]	BOTTARO M, MACHADO S N, NOGUEIRA W，et al. Effect of high versus low-velocity resistance training on muscular fitness and functional performance in older men[J]. Eur J Appl Physiol，2007，99(3):257-264. DOI：10.1007/s00421-006-0343-1.
[77]	NOGUEIRA W, GENTIL P, MELLO S M，et al. Effects of power training on muscle thickness of older men[J]. Int J Sports Med，2009，30(3):200-204. DOI：10.1055/s-0028-1104584.
[78]	SERRA-PRAT M, SIST X, DOMENICH R，et al. Effectiveness of an intervention to prevent frailty in pre-frail community-dwelling older people consulting in primary care：a randomised controlled trial[J]. Age Ageing，2017，46(3):401-407. DOI：10.1093/ageing/afw242.
[79]	RYDWIK E, LAMMES E, FRÄNDIN K，et al. Effects of a physical and nutritional intervention program for frail elderly people over age 75. A randomized controlled pilot treatment trial[J]. Aging Clin Exp Res，2008，20(2):159-170. DOI：10.1007/BF03324763.
[80]	KIM H, SUZUKI T, KIM M，et al. Effects of exercise and milk fat globule membrane （MFGM） supplementation on body composition，physical function，and hematological parameters in community-dwelling frail Japanese women：a randomized double blind，placebo-controlled，follow-up trial[J]. PLoS One，2015，10(2):e0116256. DOI：10.1371/journal.pone.0116256.
[81]	BONNEFOY M, CORNU C, NORMAND S，et al. The effects of exercise and protein-energy supplements on body composition and muscle function in frail elderly individuals：a long-term controlled randomised study[J]. Br J Nutr，2003，89(5):731-739. DOI：10.1079/BJN2003836.
[82]	DE JONG N, CHIN A PAW M J, DE GROOT L C，et al. Dietary supplements and physical exercise affecting bone and body composition in frail elderly persons[J]. Am J Public Health，2000，90(6):947-954. DOI：10.2105/ajph.90.6.947.
[83]	CHIN A PAW M J, DE JONG N, SCHOUTEN E G，et al. Physical exercise and/or enriched foods for functional improvement in frail，independently living elderly：a randomized controlled trial[J]. Arch Phys Med Rehabil，2001，82(6):811-817. DOI：10.1053/apmr.2001.23278.
[84]	CHIN A PAW M J, DE JONG N, SCHOUTEN E G，et al. Physical exercise or micronutrient supplementation for the wellbeing of the frail elderly? A randomised controlled trial[J]. Br J Sports Med，2002，36(2):126-131. DOI：10.1136/bjsm.36.2.126.
[85]	MILLER M D, CROTTY M, WHITEHEAD C，et al. Nutritional supplementation and resistance training in nutritionally at risk older adults following lower limb fracture：a randomized controlled trial[J]. Clin Rehabil，2006，20(4):311-323. DOI：10.1191/0269215506cr942oa.
[86]	NG T P, FENG L, NYUNT M S，et al. Nutritional，physical，cognitive，and combination interventions and frailty reversal among older adults：a randomized controlled trial[J]. Am J Med，2015，128(11):1225-1236.e1. DOI：10.1016/j.amjmed.2015.06.017.
[87]	ROSENDAHL E, LINDELÖF N, LITTBRAND H，et al. High-intensity functional exercise program and protein-enriched energy supplement for older persons dependent in activities of daily living：a randomised controlled trial[J]. Aust J Physiother，2006，52(2):105-113. DOI：10.1016/s0004-9514(06)70045-9.
[88]	CARLSSON M, LITTBRAND H, GUSTAFSON Y，et al. Effects of high-intensity exercise and protein supplement on muscle mass in ADL dependent older people with and without malnutrition—a randomized controlled trial[J]. J Nutr Health Aging，2011，15(7):554-560. DOI：10.1007/s12603-011-0017-5.
[89]	RYDWIK E, FRÄNDIN K, AKNER G. Effects of a physical training and nutritional intervention program in frail elderly people regarding habitual physical activity level and activities of daily living—a randomized controlled pilot study[J]. Arch Gerontol Geriatr，2010，51(3):283-289. DOI：10.1016/j.archger.2009.12.001.
[90]	LAMMES E, RYDWIK E, AKNER G. Effects of nutritional intervention and physical training on energy intake，resting metabolic rate and body composition in frail elderly. A randomised，controlled pilot study[J]. J Nutr Health Aging，2012，16(2):162-167. DOI：10.1007/s12603-011-0157-7.
[91]	INGSTAD K, UHRENFELDT L, KYMRE I G，et al. Effectiveness of individualised nutritional care plans to reduce malnutrition during hospitalisation and up to 3 months post-discharge：a systematic scoping review[J]. BMJ Open，2020，10(11):e040439. DOI：10.1136/bmjopen-2020-040439.
[92]	BALDWIN C, DE VAN DER SCHUEREN M A, KRUIZENGA H M，et al. Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults[J]. Cochrane Database Syst Rev，2021，12(12):CD002008. DOI：10.1002/14651858.CD002008.pub5.
[93]	REZAMAND G, ESTÊVÃO M D, MORVARIDZADEH M，et al. Effects of vitamin D supplementation on bone health and bone-related parameters in HIV-infected patients：a systematic review and meta-analysis[J]. Clin Ther，2022，44(2):e11-25.e8. DOI：10.1016/j.clinthera.2021.12.012.
[94]	TRIVEDI D P. Effect of four monthly oral vitamin D3 （cholecalciferol） supplementation on fractures and mortality in men and women living in the community：randomised double blind controlled trial[J]. BMJ，2003，326(7387):469. DOI：10.1136/bmj.326.7387.469.
[95]	BALDWIN C, WEEKES C E. Dietary counselling with or without oral nutritional supplements in the management of malnourished patients：a systematic review and meta-analysis of randomised controlled trials[J]. J Hum Nutr Diet，2012，25(5):411-426. DOI：10.1111/j.1365-277X.2012.01264.x.
[96]	CORNISH S M, CORDINGLEY D M, SHAW K A，et al. Effects of Omega-3 supplementation alone and combined with resistance exercise on skeletal muscle in older adults：a systematic review and meta-analysis[J]. Nutrients，2022，14(11):2221. DOI：10.3390/nu14112221.

指南纳入的临床问题	结局指标
主题1：膳食指导	主要结局指标： 1.每日能量摄入（蛋白质、脂肪等） 2.体质指数（BMI）次要结局指标： 1.身体组成（肌肉组织含量、体脂肪等） 2.躯体功能（握力、步速等） 3.主观感受方面（生活质量、精力等）的评价 4.依从性
1.膳食指导是否能够有效改善存在营养风险或营养不良的老年人的营养状况？
2.何种形式（如网络、面对面等）的膳食指导对存在营养风险或营养不良的老年人有效？
3.针对存在营养风险或营养不良的老年人的最佳膳食指导开展的频率？
4.针对存在营养风险或营养不良的老年人的最佳膳食指导开展的周期？
5.不同类型的膳食指导对存在营养风险或营养不良的老年人是否都有效？
6.膳食指导具体如何改善存在营养风险或营养不良的老年人的营养状况及身体状况？
主题2：口服营养补充
1.口服营养补充是否能够有效改善存在营养风险或营养不良的老年人的营养状况？
2.口服营养补充的不同组分与不同形式？
3.对存在营养风险或营养不良的老年人进行口服营养补充的方式、补充量与时机（不同时间段）？
4.针对存在营养风险或营养不良的老年人的口服营养补充开展的频率？
5.针对存在营养风险或营养不良的老年人的口服营养补充开展的周期？
6.口服营养补充具体如何改善存在营养风险或营养不良的老年人的营养状况及身体状况？
主题3：运动干预
1.运动干预是否能够有效改善存在营养风险或营养不良的老年人的营养状况？
2.何种形式或类型（如抗阻运动、太极等）的运动干预对存在营养风险或营养不良的老年人有效？
3.针对存在营养风险或营养不良的老年人的运动干预的干预频率和周期？
4.如何开展针对营养不良老年人的运动干预？
5.运动干预具体如何改善存在营养风险或营养不良的老年人的营养状况及身体状况？
主题4：联合干预
1.针对存在营养风险或营养不良的老年人的联合干预包括哪些干预方式？
2.联合干预是否能够有效改善存在营养风险或营养不良的老年人的营养状况？
3.何种形式及怎样的干预组合对存在营养风险或营养不良的老年人有效？
4.针对存在营养风险或营养不良的老年人的联合干预的周期及开展条件？
5.联合干预具体如何改善存在营养风险或营养不良的老年人的营养状况及身体状况？

指南纳入的临床问题	结局指标
主题1：膳食指导	主要结局指标： 1.每日能量摄入（蛋白质、脂肪等） 2.体质指数（BMI）次要结局指标： 1.身体组成（肌肉组织含量、体脂肪等） 2.躯体功能（握力、步速等） 3.主观感受方面（生活质量、精力等）的评价 4.依从性
1.膳食指导是否能够有效改善存在营养风险或营养不良的老年人的营养状况？
2.何种形式（如网络、面对面等）的膳食指导对存在营养风险或营养不良的老年人有效？
3.针对存在营养风险或营养不良的老年人的最佳膳食指导开展的频率？
4.针对存在营养风险或营养不良的老年人的最佳膳食指导开展的周期？
5.不同类型的膳食指导对存在营养风险或营养不良的老年人是否都有效？
6.膳食指导具体如何改善存在营养风险或营养不良的老年人的营养状况及身体状况？
主题2：口服营养补充
1.口服营养补充是否能够有效改善存在营养风险或营养不良的老年人的营养状况？
2.口服营养补充的不同组分与不同形式？
3.对存在营养风险或营养不良的老年人进行口服营养补充的方式、补充量与时机（不同时间段）？
4.针对存在营养风险或营养不良的老年人的口服营养补充开展的频率？
5.针对存在营养风险或营养不良的老年人的口服营养补充开展的周期？
6.口服营养补充具体如何改善存在营养风险或营养不良的老年人的营养状况及身体状况？
主题3：运动干预
1.运动干预是否能够有效改善存在营养风险或营养不良的老年人的营养状况？
2.何种形式或类型（如抗阻运动、太极等）的运动干预对存在营养风险或营养不良的老年人有效？
3.针对存在营养风险或营养不良的老年人的运动干预的干预频率和周期？
4.如何开展针对营养不良老年人的运动干预？
5.运动干预具体如何改善存在营养风险或营养不良的老年人的营养状况及身体状况？
主题4：联合干预
1.针对存在营养风险或营养不良的老年人的联合干预包括哪些干预方式？
2.联合干预是否能够有效改善存在营养风险或营养不良的老年人的营养状况？
3.何种形式及怎样的干预组合对存在营养风险或营养不良的老年人有效？
4.针对存在营养风险或营养不良的老年人的联合干预的周期及开展条件？
5.联合干预具体如何改善存在营养风险或营养不良的老年人的营养状况及身体状况？

数据库	检索策略	检索文献类型
国际指南网、苏格兰校际指南网、英国国家临床医学研究所、新西兰临床实践指南研究组、加拿大安大略注册护士协会、美国老年学学会、美国肠内肠外营养协会、欧洲肠外肠内营养学会、Up To Date、BMJ最佳临床实践	"malnutrition/undernutrition/malnourishment/protein deficiency/nutritional deficiency/energy deficiency/dietary deficiency/nutrition deficiency"	指南、专家共识
中国肠内肠外营养学会、医脉通	"营养不良/营养风险/营养状况"	指南、专家共识
PubMed	"malnutrition/undernutrition/malnourishment/undernourishment/underfeeding/insufficiencies/insufficiency/deficiencies/deficiency/protein deficiencies/protein deficiency/protein-deficiency/nutritional deficiencies/nutritional deficiency/energy deficiencies/energy deficiency/dietary deficiencies/dietary deficiency/nutrition deficiencies/nutrition deficiency"，"guideline/consensus/best practice/recommended practice"	指南、专家共识
中国知网、万方数据知识服务平台	"营养不良/营养风险/营养状况"，"指南/共识/规范/意见"	指南、专家共识
PubMed、Embase、CINAHL、Cochrane Library、JBI Library、PsycINFO、Psychology and Behavioral Sciences Collection、ProQuest	"old/older/aged/aging/elderly/elders/elder/seniors/senior/frail/geriatric"，"malnutrition/undernutrition/malnourishment/undernourishment/undernourishment/underfeeding/insufficiencies/insufficiency/deficiencies/deficiency/protein deficiencies/protein deficiency/nutritional deficiencies/nutritional deficiency/energy deficiencies/energy deficiency/dietary deficiencies/dietary deficiency/nutrition deficiencies/nutrition deficiency"，"oral nutritional supplements/diet therapy/dietary supplements/nutritional support/dietary services/dietary counselling/dietary advice/ dietary education/ multicomponent intervention"	系统评价、RCT
中国知网、万方数据知识服务平台	"老年/老人""营养不良/营养风险/营养状况""口服营养/口服肠内营养/营养补充/营养支持/膳食指导/营养指导/饮食指导/联合干预/联合护理干预/综合干预/综合护理干预"	系统评价、RCT

数据库	检索策略	检索文献类型
国际指南网、苏格兰校际指南网、英国国家临床医学研究所、新西兰临床实践指南研究组、加拿大安大略注册护士协会、美国老年学学会、美国肠内肠外营养协会、欧洲肠外肠内营养学会、Up To Date、BMJ最佳临床实践	"malnutrition/undernutrition/malnourishment/protein deficiency/nutritional deficiency/energy deficiency/dietary deficiency/nutrition deficiency"	指南、专家共识
中国肠内肠外营养学会、医脉通	"营养不良/营养风险/营养状况"	指南、专家共识
PubMed	"malnutrition/undernutrition/malnourishment/undernourishment/underfeeding/insufficiencies/insufficiency/deficiencies/deficiency/protein deficiencies/protein deficiency/protein-deficiency/nutritional deficiencies/nutritional deficiency/energy deficiencies/energy deficiency/dietary deficiencies/dietary deficiency/nutrition deficiencies/nutrition deficiency"，"guideline/consensus/best practice/recommended practice"	指南、专家共识
中国知网、万方数据知识服务平台	"营养不良/营养风险/营养状况"，"指南/共识/规范/意见"	指南、专家共识
PubMed、Embase、CINAHL、Cochrane Library、JBI Library、PsycINFO、Psychology and Behavioral Sciences Collection、ProQuest	"old/older/aged/aging/elderly/elders/elder/seniors/senior/frail/geriatric"，"malnutrition/undernutrition/malnourishment/undernourishment/undernourishment/underfeeding/insufficiencies/insufficiency/deficiencies/deficiency/protein deficiencies/protein deficiency/nutritional deficiencies/nutritional deficiency/energy deficiencies/energy deficiency/dietary deficiencies/dietary deficiency/nutrition deficiencies/nutrition deficiency"，"oral nutritional supplements/diet therapy/dietary supplements/nutritional support/dietary services/dietary counselling/dietary advice/ dietary education/ multicomponent intervention"	系统评价、RCT
中国知网、万方数据知识服务平台	"老年/老人""营养不良/营养风险/营养状况""口服营养/口服肠内营养/营养补充/营养支持/膳食指导/营养指导/饮食指导/联合干预/联合护理干预/综合干预/综合护理干预"	系统评价、RCT

分类	表示方式	具体含义
证据质量分级
高	A	非常确信效应估计值接近真实值
中	B	对效应估计值有中等程度信心，估计疗效可能接近真实值，也可能有很大差别
低	C	对效应估计值信心有限；估计值与真实值可能有很大差别
极低	D	对效应估计值几乎没有信心；估计值与真实值可能有很大差别
推荐意见分级
强推荐	推荐（1）	实施该干预措施利明显大于弊
弱推荐	建议（2）	实施该干预措施利可能大于弊
不清楚	无（3）	不清楚实施该干预措施利是否大于弊
弱不推荐	不建议（4）	实施该干预措施弊可能大于利
强不推荐	不推荐（5）	实施该干预措施弊明显大于利

营养不良老年人非药物干预临床实践指南

Clinical Practice Guideline for Non-pharmacological Interventions for Malnourished Elderly

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类别	推荐意见描述	证据质量等级	推荐强度等级
主题1：膳食指导（包括膳食指导、教育、咨询或建议等）	1.1膳食指导是建立在"知-信-行"理论基础上的营养干预手段。对存在营养风险或营养不良的老年人而言，膳食指导可作为营养干预的优先手段	中	强推荐
	1.2膳食指导由营养专科医务人员主导的膳食指导干预和自我管理的膳食指导干预组成，各方法、内容基本一致，可因地制宜进行选择	中	弱推荐
	频率：30~60 min·次^-1·周^-1	中	强推荐
	周期：通常6周为一个干预周期	中	强推荐
	方式：面对面或线上、线下结合开展	中	强推荐
	类型：由营养专科医务人员主导的膳食指导干预和自我管理的膳食指导干预	低	弱推荐
主题2：口服营养补充	2.1当存在营养风险或营养不良的老年人需进行营养支持时，ONS为首选方法	高	强推荐
主题2：口服营养补充	2.2推荐存在营养风险或营养不良的老年人进行标准整蛋白配方的全营养制剂ONS，当标准整蛋白配方的全营养制剂ONS补足能量后仍有蛋白质或者必需氨基酸摄入不足时，建议口服补充蛋白类或者必需氨基酸类，补充方法通常为小口啜饮	高	强推荐
	频率：2~3次/d	中	强推荐
	剂量/周期：标准整蛋白配方的全营养制剂ONS用量应达到400~600 kcal/d或补足老年人的蛋白质摄入量达到1.00~1.20 g·kg^-1·d^-1，经过30~90 d的补充周期，通常可改善老年人营养状态和临床结局	中	强推荐
	类型：蛋白质类（protein）、能量类（energy）和必需氨基酸补充剂（essential amino acid supplements），如肌酸补充（creatine supplements）和亮氨酸补充（leucine supplements）等多种类型	中	强推荐
	2.3当老年人存在某种特异性营养风险或营养不良情况时，应进行追加补充；推荐该类老年人根据营养需求选取含不同组分（或类型）的微量元素类作为补充，以满足身体对不同营养元素的需求；此外，还应定期监测以防止补充过量	中	强推荐
	频率：1~2次/d	中	强推荐
	周期：通常30 d为一个补充周期	中	强推荐
	类型：维生素和矿物质补充（vitamin and mineral supplements）、免疫营养素补充（immunonutrient supplements）等	低	强推荐
主题3：运动干预	3.1推荐存在营养风险或营养不良的老年人在身体状况允许的情况下进行运动干预，有效促进老年人营养吸收，进而增加其营养摄入和改善营养状况	中	强推荐
	3.2运动干预包括多种类型，可结合我国传统运动开展，应根据老年人的营养状况及躯体功能等情况确定运动类型及频率	低	强推荐
	频率：15~30 min/次，1次/d，1~3 d/周	低	强推荐
	周期：通常6周为一个干预周期。	低	强推荐
	方式：面对面或线上、线下结合开展	低	强推荐
	类型：抗阻力训练、传统中医运动干预和耐力训练等	极低	弱推荐
主题4：联合干预	4.1联合干预通过多学科团队协同合作，针对老年人的营养问题提出全方位的解决策略，以改善老年人的营养不良状况	中	强推荐
	4.2联合干预比单一的营养干预措施内容更加丰富，应考虑到各种干预内容间的互相促进作用，使干预效果达到最大化	中	强推荐
	周期：通常12周为一个干预周期	中	强推荐
	方式：面对面或线上、线下结合开展	中	强推荐
	团队：营养专科医务人员、全科医务人员、运动康复治疗师、社会工作者及志愿者等	低	强推荐
	类型：口服营养补充结合运动干预，口服营养补充结合膳食指导，口服营养补充结合膳食指导与运动干预等	中	强推荐

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