Age and Ageing 2015; 44: 245251 The Author 2014.

uthor 2014. Published by Oxford University Press on behalf of the British Geriatrics Society.
doi: 10.1093/ageing/afu150 All rights reserved. For Permissions, please email: journals.permissions@oup.com
Published electronically 16 October 2014

An innovative solid oral nutritional supplement

to fight weight loss and anorexia: open,
randomised controlled trial of efficacy in
institutionalised, malnourished older adults
VALERIE POUYSSEGUR1,2, PATRICE BROCKER3, STPHANE M. SCHNEIDER4, JEAN LUC PHILIP5, PHILIPPE BARAT6,
EWA REICHERT7, FREDERIC BREUGNON8, DIDIER BRUNET9, BRUNO CIVALLERI10, JEAN PAUL SOLERE11,
LINE BENSUSSAN12, LAURENCE LUPI-PEGURIER1,2
1
MICORALIS Laboratory, School of Dentistry, University Nice Sophia Antipolis, Nice, France
2
Department of Dentistry, Nice University Hospital, Nice, France
3
Department of Geriatrics, Nice University Hospital, Nice, France
4
Department of Nutrition, Nice University Hospital, Nice, France
5
Fondation Pauliani, Nice, France
6
EHPAD Tiers Temps, Nice, France
7
La Serena, Clinique Saint Georges, Nice, France
8
EHPAD Les Jardins de la Clairire, Nice, France
9
EHPAD Mariposa, Nice, France
10
EHPAD Les Amaryllis, Nice, France
11
EHPAD Sainte Juliette, Nice, France
12
EHPAD Villa Foch, Nice, France
Address correspondence to: V. Pouyssegur. Tel: (+33) 492001111; Fax: (+33) 492001263. Email: valerie.pouyssegur-rougier@unice.fr

Abstract

Background and objective: to evaluate the impact of a solid nutritional supplement on the weight gain of institutionalised
older adults >70 years with protein-energy malnutrition. The innovation of these high-protein and high-energy cookies was
the texture adapted to edentulous patients (Protibis, Solidages, France).
Design: an open, multicentre, randomised controlled trial.
Setting: seven nursing homes.
Participants: one hundred and seventy-ve malnourished older adults, aged 86 8 years.
Intervention: all participants received the standard institutional diet. In addition, Intervention group participants received
eight cookies daily (11.5 g protein; 244 kcal) for 6 weeks (w0w6).
Measurements: ve visits (w4, w0, w6, w10 and w18). Main outcome: percentage of weight gain from w0 to w6 (body
mass in kg). Secondary outcomes: appetite, rated using a numerical scale (0: no appetite to 10: extremely good appetite);
current episodes of pressure ulcers and diarrhea.
Results: average weight increased in Intervention group (n = 88) compared with Control group (n = 87) without cookies sup-
plementation (+1.6 versus 0.7%, P = 0.038). Weight gain persisted 1 month (+3.0 versus 0.2%, P = 0.025) and 3 months
after the end of cookies consumption (+3.9 versus 0.9%, P = 0.003), with diarrhea reduction (P = 0.027). There was a syner-
gistic effect with liquid/creamy dietary supplements. Subgroup analysis conrmed the positive impact of cookies supplementa-
tion alone on weight increase (P = 0.024), appetite increase (P = 0.009) and pressure ulcers reduction (P = 0.031).
Conclusion: the trial suggested that, to ght against anorexia, the stimulation of touch (nger food; chewing, even on edentu-
lous gums) and hearing (intra-oral sounds) could be valuable alternatives to sight, smell and taste alterations.

Keywords: anorexia, diarrhea, dietary supplement, pressure ulcer, protein-energy malnutrition, older people

245
V. Pouyssegur et al.
Introduction
Protein-energy malnutrition is common in older people, ran-
ging from 410% of community-dwelling seniors, 1538%
of nursing home residents to 3070% of hospitalised older
patients [1]. The main risk factors are alteration of cognitive
functions, frequent acute and chronic diseases, poverty and
social isolation, the use of >34 drugs/day, smell, taste,
vision, auditory and motor alterations and increased ener-
getic needs (surgery, roaming patients). Oral problems con-
stitute another risk of malnutrition, including swallowing
difculties, dry mouth, oral pain, periodontitis and teeth mo-
bility, edentulousness and poorly tted dentures [13].
The resulting protein-energy malnutrition has four car-
dinal symptoms: asthenia, apathy, anorexia and loss of weight,
with a modication of the physical body composition, im-
munodeciency and subsequent frailty. There is an increased
frequency of falls, infections (inhalation pneumonia), pres-
sure ulcers, fatigue, dependence, depression, dementia pro-
gression and mortality [14]. This disease-to-disease spiral is
difcult to reverse, and malnutrition increases the risk of
hospital admissions and subsequent resettlement in an
institution [5].
Nutritional care must aim to preserve the oral route, and
enteral or parenteral route is an ultimate medical option. It is
recommended that the number of meals and snacks offered
during the day should be increased instead of offering bigger
meals, because anorexic patients prefer small-sized portions.
It is also recommended to avoid night starvation >12 h, to
prefer high-protein and/or high-calorie food adapted to
patients preferences and to give help if necessary during
meals [1, 6]. Dieticians can recommend to enrich food with
eggs, cream, grated cheese, powdered milk and in some cases
with milk protein powder [1, 2]. However, patients may com-
plain of a monotonous milky taste [79]. Besides, home-
made enriched dishes generally have a soft texture (soups,
bchamel sauces, gratins, puddings, etc. ). If necessary, care-
givers can prescribe brand dietary supplements, which are
generally provided as sweet dairy drinks (sip-feeds) or
creams, enriched in protein and/or energy [1]. High-protein
cookies are generally not proposed to older adults, because
their hard texture is not convenient for edentulous people.
However, edentulous patients often complain of the monot-
ony of mixed, mashed and soft food, which is a well-known
cause of anorexia [9, 10].
To help to prevent and ght against malnutrition in older
adults, a solid dietary supplement designed for people with
chewing difculties has been developed. This supplement
was in the form of a high-protein and high-energy cookie.
The innovation relied on the texture of the cookie, specical-
ly designed for patients who regained the pleasure to crunch
and chew, despite a poor dental health or edentulousness
[11]. A preliminary study has shown that 30 institutionalised
older people enjoyed the taste and texture of these butter
cookies (Protibis, Solidages, France) [12]. In a second pre-
liminary test involving 15 institutionalised older adults with
weight loss, patients were given an average number of
246
4.5 0.5 cookies daily (range: 3.95.3) for 2 months. The
average intake was 6.4 g of protein and 137 kcal daily. Weight
remained stable (1.5% weight variation) or increased for
60% of the subjects (4 and 5 subjects, respectively) after this
2-month period of cookies consumption (unpublished data).
In this study, we hypothesised that a 6-week consumption
period of this innovative oral nutritional supplement (ONS)
would enhance the percentage of weight gain in institutiona-
lised, malnourished older adults. We also wanted to investi-
gate the impact of cookies consumption on other parameters
such as appetite, meal consumption, calories intake, current
episodes of pressure ulcers and diarrhea, number of falls,
fractures, infection episodes, antibiotic days and death.
Methods
Participants
This study was an open, multicentre, randomised controlled
trial in seven nursing homes [1315]. Main inclusion criteria
were age over 70 and malnutrition (Figure 1). Prescription of
home-made sweets enriched with milk proteins and/or
liquid or creamy ONSs (dairy supplements) was not an ex-
clusion criteria. The protocol was approved by the local
Ethics Committee (Espace Ethique Azuren, Nice
University Hospital) (Supplementary data, Appendix 1 avail-
able in Age and Ageing online).
Nutritional intervention
All participants received the usual food regimen of the insti-
tution. Patients who were prescribed dairy dietary supple-
ments continue to take them. Participants in the Intervention
group additionally received eight Protibis cookies daily for
6 weeks. There was no commercial sponsorship. Each cookie
weighed 6.5 g and contained 1.44 g of protein and 30.5 kcal.
It contained 22% of weight in proteins. Total energy content
in proteins was 19% with an animal/vegetable protein ratio
of 3.5 and a glycaemic index of 46.1. Ingredients were wheat
our, fresh butter, milk protein (casein), sugar, vanilla aroma,
baking powder and salt. There was no palm oil or other vege-
table oil. Eight cookies were distributed in the breakfast and/
or in the snack (total 52 g of cookies: 11.5 g of protein and
244 kcal as daily supplementation).
Study design and measures
The study was designed with ve visits (w4, w0, w6, w10
and w18). There was an initial period of 4 weeks to observe
weight evolution, without intervention (w4 to w0).
Participants in the Intervention group received Protibis
cookies for 6 weeks (w0w6). There was then a follow-up
period in both groups with two visits (w10 and w18),
respectively, 1 and 3 months after the end of cookies con-
sumption. At w4 routine, medical data were collected from
patients medical les.
 Nutritional supplement to fight weight loss and anorexia
Figure 1. Study prole.
The main outcome assessment was the percentage of
weight gain from w0 to w6 (body mass in kg). Secondary
outcome was appetite, rated by the participant or by the
nursing staff using a numerical scale ranging from 0 (abso-
lutely no appetite) to 10 (extremely good appetite) [16].
To compare the calorie supplement actually consumed
from w0 to w6 between the two groups, dietary intakes were
measured during 5 days (d0, d3, d6, d40 and d42). Food and
beverage consumption was scored as the percentage of each
serving actually consumed (score 0, 1/3, 2/3 and 1). In one
nursing home (Tiers Temps, Le Cannet), calorie count was
done by the dietician in charge of the menus. We recorded
current episodes of pressure ulcers and diarrhea at baseline
(w4), and current episode or previous episode of pressure
ulcer and diarrhea since the last visit (w0, w6, w10 and
w18). The number of falls, fractures after falls, infection epi-
sodes, antibiotic days and deaths from w0 to w18 was also
recorded at w18. Data analysis methodology is detailed in
Supplementary data, Appendix 1 available in Age and Ageing
online.
Results
The study was performed from January 2010 until May 2013.
A total of 216 patients were randomised, but only 175 patients
fullled the inclusion visit at w4 and 154 could be analysed
for the main outcome (Figure 1; Table 1). There was full ad-
herence to the protocol (cookies consumption). No harm or
side effect attributed to Protibis cookies was reported.
Primary outcome
In this population of malnourished older people, there was a
mean loss of weight the month before intervention, both in
the Intervention and in the Control group (0.7 versus
0.1%, respectively). At the end of supplementation with
Protibis cookies, patients in the Intervention group had a sig-
nicant and persistent weight gain compared with the
Control group. The average percentage of weight variation
was as follows: from w0 to w6 (+1.6 versus 0.7%), from
w0 to w10 (+3.0 versus 0.2%) and from w0 to w18
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V. Pouyssegur et al.

Table 1. Comparison of baseline characteristics

Intervention group (n = 88) Control group (n = 87) T-test P value
....................................................................................
Male [% (n)] 23.9 (21) 16.1 (14) 0.537
Age, year [mean (SD)] 85.4 7.1 86.8 7.1 0.751
Groupe Iso Ressource (GIR) [mean (SD)] 2.7 1.4 2.8 1.1 0.325
Mini Mental Score [mean (SD)] 18.1 8.4 18.1 8.3 0.976
Weight, kg [mean (SD)] 51.7 1.5 50.9 9.9 0.711
Weight loss >10% in 6 months [% (n)] 23.9 (21) 29.9 (26) 0.626
Weight loss >5% in 1 month [% (n)] 34.1 (30) 36.8 (32) 0.865
Body mass index, kg/m2 (size from ID card) [mean (SD)] 19.2 2.9 19.2 2.9 0.709
Mini Nutritional Assessment (MNA) [mean (SD)] 14.5 3.9 14.7 5.0 0.095
Albuminaemia, g/l [mean (SD)] 34.3 4.6 35.4 4.4 0.938
Appetite, score 010 [mean (SD)] 4.27 2.01 5.26 2.22 0.770
Pressure ulcer, current episode [% (n)] 20.5 (18) 9.2 (8) 0.055
Diarrhea, current episode [% (n)] 15.9 (14) 12.6 (11) 0.667
Masticatory ability,a % [mean (SD)] 32.5 36.8 35.6 37.0 0.810
Prescription of dairy ONS [% (n)] 44.3 (39) 32.2 (28) 0.040
Oral pain complaint [% (n)] 10.2 (9) 9.2 (8) 0.592
Dry mouth complaint [% (n)] 36.4 (32) 37.9 (33) 0.597
Edentulousness with chewing difficulties [% (n)] 23.9 (21) 19.5 (17) 0.347
Maxillary removable denture [% (n)] 25.0 (22) 19.5 (17) 0.546
Mandible removable denture [% (n)] 21.6 (19) 17.2 (15) 0.704

A total of 216 subjects were assessed for eligibility and randomised to the Intervention group or to the Control group (108 patients in each group). However, the
subjects participating in the study were frail elderly people suffering from malnutrition. Besides, many of them suffered from cognitive impairment too and we could
not obtain familys or tutors informed written consent. For these reasons, 41 participants were randomised following a pre-inclusion visit but could not perform the
inclusion visit 4 weeks before intervention (Intervention group: 20 subjects; Control group: 21 subjects). Case report form was completed and baseline characteristics
were obtained at w4 for the 88 remaining patients in the Intervention group and the 87 remaining patients in the Control group.
Groupe Iso Ressource (GIR), disability index of French Health Authorities ranging from 6 (complete autonomy) to 1 (sick bedridden); ID, identification card; ONS,
oral nutritional supplement.
a
Masticatory ability ranges from 0% (no antagonistic teeth) to 100% (16 pairs of antagonistic teeth); masticatory ability is impaired under 70% [11].

(+3.9 versus 0.9%). Category analysis conrmed these
results, with a weight decrease in both groups from w4 to
w0 (P = 0.245), followed by a signicant weight increase in
the Intervention group from w0 to w6 (P = 0.038), w0 to
w10 (P = 0.025) and w0 to w18 (P = 0.003) (Supplementary
data, Table 2 available in Age and Ageing online).
Secondary outcome
Mean appetite steadily increased in the Intervention group
from w0 to w18 (Supplementary data, Table 3 available in
Age and Ageing online). Supplementation with Protibis
cookies did not reduce or increase the quantity of food and
beverage eaten at meals (Supplementary data, Appendix 2
available in Age and Ageing online).
Other outcomes
There was a greater number of pressure ulcers in the
Intervention group at w4 (P = 0.055), but not at w0
(P = 0.184) (Table 1). Within-group analysis showed a signi-
cant reduction of pressure ulcer episodes from w0 to w6 in
the Intervention group (number of subjects) (23.98.0%;
n = 88; P = 0.001), but not in the Control group (15.36.9%;
n = 72; P = 0.11). Between-group analysis showed that, at the
end of the study, there were less diarrhea episodes in the
Intervention group than in the Control group (w18: 1.1%
(n = 80) versus 8.0% (n = 72); P = 0.027). Besides, at w6, we
observed a higher frequency of diarrhea among patients
consuming dairy ONSs than among other patients (11.9%
(n = 84) versus 2.1% (n = 62); P = 0.018). Other outcomes
were similar (Supplementary data, Appendix 2 available in Age
and Ageing online).
Exploratory analysis in four subgroups
Baseline characteristics of participants showed a higher pre-
scription rate of dairy dietary supplements in the Intervention
group (Table 1). In this group, patients who were prescribed
dairy supplements were given a mean number of 1.9 1.2
units daily, ranging from 1 to 6. In the Control group, they
received 1.8 1.5 units daily, ranging from 1 to 5.
We thus realised an exploratory analysis of four sub-
groups, No supplementation, Dairy ONSs, Protibis
cookies and Dairy ONSs and Protibis cookies, with 48, 27,
46 and 37 subjects, respectively. There was a synergistic
effect between cookies and other oral dietary supplements
(Figure 2). However, subgroup analysis conrmed the posi-
tive impact of cookies supplementation alone on weight in-
crease (P = 0.024), appetite increase (P = 0.009) and pressure
ulcers reduction (P = 0.031) (Supplementary data, Appendix
2 available in Age and Ageing online).
Discussion
To our knowledge, this is the rst trial investigating a solid
ONS adapted to people with masticatory impairment. The
percentage change in body weight during a 6-week trial

248
 Nutritional supplement to fight weight loss and anorexia
Figure 2. Subgroup analysis. Intervention period with Protibis cookies consumption took place from week0 to week6 (w0 to w6).
ONS: oral nutritional supplement.
period is a reference outcome for studies assaying nutritional
supplements. The meta-analysis involving older people at
risk of malnutrition was updated in 2009 [17]. It showed that
liquid ONSs (sip-feeds) during a 6-week period allowed an
average increase of 2.2% weight gain. Additional protein
doses ranged from 10 to 36 g daily. In the present study
involving older people suffering from true malnutrition, we
observed a weight gain at the end of the 6-week cookies con-
sumption period (+1.6%), followed by a persistent weight
increase lasting for 1 month (+ 3.0%) and 3 months after the
end of cookies consumption (+3.6%).
The supplement of proteins brought about by eight
Protibis cookies was limited to 11.5 g of protein and 244
kcal daily. This signicant and persistent weight gain and
appetite increase, despite this rather limited protein and
calorie supplementation, could have several explanations.
First, there was a good compliance with eight cookies a day,
while with sip-feeds in particular, the nursing staff cannot
easily control the quantities actually consumed and wasted.
Another explanation could be related to the solid texture of
cookies. Smeets et al. [18] reviewed stimuli involved in saliva-
tion and appetite, and how taste, texture and sight of food
trigger a cascade of pre-absorptive physiological responses,
called cephalic phase responses. In the present series, most
of participants had dental alterations (Table 1) and they were
given a soft diet. Cookies specic texture allowed easy crum-
bling between edentulous jaws. Chewing could have stimu-
lated saliva and other digestive secretions, facilitated the
processing of ingested food, the assimilation of all food sup-
plies and contributed to weight increase [9, 18]. Finally,
weight gain could result from the ght against anorexia,
based on the pleasure to eat a butter cookie with a non-
medical aspect [19]. Actually, butter taste is uncommon
among conventional ONSs. But in patients over 75 years, re-
strictive diets such as low-cholesterol diet avoiding butter
consumption are not recommended, because they increase
the risk of under-nutrition [20].
However, outcome determination and analysis was not
possible in a high proportion of patients, and the approach
taken (on-treatment analysis) could have led to bias in the
results. Another limitation of this study was the lack of
placebo, which introduces possible bias over some of the
assessments, particularly those which have a subjective
element such as appetite, percentage of normal diet and
uids remaining after a meal and pressure sores. As the
impact of this new solid ONS on pressure sores and diarrhea
was unanticipated, the questions in case report forms had
been limited to Current episode of pressure sore: yes/no
and Current episode of pressure diarrhea: yes/no. In the
absence of precise scoring, the present results should be con-
sidered as a preliminary screening. Besides, the main
outcome, weight gain, is presumed to be objective, but it can
be affected by the observer knowing which group a patient is
allocated to.
Another limitation of this study was the use of enriched
sweets and/or sip-feeds by 37.7% of the participants,
without randomisation. This was deliberate in the study
design, because we wanted to diversify the offer of protein
supplementation, without disturbing this frail population
composed of anorexic older people. Thus, we did not wish
249
V. Pouyssegur et al.
to substitute a dairy dietary supplement by a solid dietary
supplement. For this reason, we realised instead a subgroup
analysis which suggested that weight gain, appetite increase
and pressure ulcer reduction could be attributed to cookies
alone (Figure 2). We realised a sensitivity analysis, adjusting
percentage weight change at W18 and other parameters for
the use of ONS. We had to remove all observations with a
missing value for the percentage weight change from the ana-
lysis, and the lack of power did not allow us to eliminate
ONS as a potential confounder. Thus, due to the limited size
of the sample, the study results must be interpreted with
caution. However, unexpectedly, this trial suggested a syner-
gistic effect between liquid/creamy and solid oral supple-
ments. This outcome deserves further investigations, with a
precise scoring of the severity grade of pressure ulcer and
diarrhea episodes [21, 22].
Literature data showed that immobilisation, moisture and
incontinence as well as malnutrition were high-risk factors of
pressure ulcer [2327]. This trial involved older adults living
in nursing homes, frail but not bedridden. The reduction of
pressure ulcers could be related to higher protein intake or to
increased mobility, but we did not measure muscular tissue
gain, muscular strength or gait speed. However, these results
are in line with the meta-analysis of Milne et al. [17], who
concluded that oral dietary supplements had benets on
weight gain and pressure ulcer reduction.
Milne et al. [17] also reported that conventional liquid/
creamy dietary supplements could have adverse effects, such
as nausea and diarrhea. Conversely, the present study sug-
gested that regimen diversication with texture-adapted
cookies could reverse diarrhea episodes in some patients
who were prescribed dairy dietary supplements (Figure 2).
We observed appetite increase, but no case of nausea. The
adjunction of bres and probiotics has been proposed to
combat diarrhea induced by enteral nutrition [27]. In mal-
nourished older people with oral route feeding, a solid food
could also contribute to the reduction of diarrhea episodes.
An explanation could be that, when chewing a solid food,
the stimulation of digestive secretions could regulate the
balance of the luminal ecosystem.
The present results suggested that a solid diversication
to mixed and mashed food could help to ght anorexia. The
cookie form could facilitate nger food, dose repetition
through the day (no cold storage), autonomy during snacks,
better compliance and compliance control by the nursing
staff.
Conclusion
In conclusion, this innovative solid oral dietary supplement
allowed to diversify and to enrich in protein and calories the
diet of institutionalised older adults. The main outcomes
were a positive impact on weight and appetite, and a reduc-
tion of pressure ulcer and diarrhea episodes. This trial also
suggested that to ght against anorexia, the stimulation of
touch (nger food; chewing, even on edentulous gums) and
250
hearing (intra-oral sounds) could be valuable alternatives to
sight, smell and taste alterations.
Key points
A solid oral nutritional supplement with a specically
adapted texture can be chewed by edentulous older adults.
An oral nutritional supplement with a solid texture allows
to enrich diet with protein and calories under a small
volume.
The pleasure to crunch and chew is a way to ght anorexia
in older adults used to soft food.
Conflicts of interest
None declared.
Funding
This work was supported by the French Ministry of Higher
Education and Research (grant PTR200909037). Sponsor
played no role in the study.
Supplementary data
Supplementary data mentioned in the text are available to
subscribers in Age and Ageing online.
References
1. HASFrench Health Authorities. Professional Recommend-
ations. Care Strategy in Case of Protein-Energy Malnutrition
in Older Adults. http://www.has-sante.fr/portail/upload/
docs/application/pdf/denutrition_personne_agee_2007_-_
recommandations.pdf (April 2007, date last accessed).
2. Hort J, OBrien JT, Gianotti G et al. European Federation of
the Neurological Societies. EFNS guidelines for the diagnosis
and management of Alzheimer disease. Eur J Neurol 2010;
17: 123648.
3. Shah RC. Medical foods for Alzheimers disease. Drugs Aging
2011; 28: 4218.
4. Salva A, Andrieu S, Fernandez E et al. Health and nutrition
promotion program for patients with dementia (NutriAlz):
cluster randomized trial. J Nutr Health Aging 2011; 15:
82283.
5. Lafont C, Grard S, Voisin T et al. Reducing iatrogenic dis-
ability in the hospitalized frail elderly. J Nutr Health Aging
2011; 15: 64055.
6. Simmons SF, Keeler E, Zhuo X, Hickly KA, Sato HW,
Schnelle JF. Prevention of unintentional weight loss in nursing
home residents: controlled trial of feeding assistance. J Am
Geriatr Soc 2008; 56: 146673.
7. Bernstein MA, Tucker KL, Ryan ND et al. Higher dietary
variety is associated with better nutritional status in frail elderly
people. J Am Diet Assoc 2002; 102: 1096104.
8. Hollis JH, Henry CJ. Dietary variety and its effect on food
intake of elderly adults. J Hum Nutri Diet 2007; 20: 34551.
 Nutritional supplement to fight weight loss and anorexia
9. Donini LM, Dominguez LJ, Barbagallo EM et al. Senile anor-
exia in different geriatric settings in Italy. J Nutr Health Aging
2011; 15: 77581.
10. Suzuki K, Nomura T, Sakurai M, Sugihara N, Yamanaka S,
Matsukubo T. Relationship between number of present teeth
and nutritional intake in institutionalized elderly. Bull Tokyo
Dent Coll 2005; 46: 13543.
11. Madinier I, Starita-Geribaldi M, Berthier F, Pesci-Bardon C,
Brocker P. Detection of mild hyposalivation in the elderly
based on the chewing time of specically-designed disc-tests:
diagnostic accuracy. J Am Geriatr Soc 2009; 57: 6916.
12. Philip JL. Protein rich cookies to ght malnutrition in
Alzheimers disease. La Revue de Griatrie 2012; 37: 1412.
13. Milne AC, Potter J, Avenell A. Cochrane collaboration. Protein
and energy supplementation in elderly people at risk for mal-
nutrition (Review). Cochrane Database Syst Rev 2005; 18:
CD003288.
14. Scientic Society of Food Hygiene. SSHA. [Sensorial
Evaluation, Methodology], 2nd edition. Paris, France:
Lavoisier, 1998.
15. Schulz KF, Altman DG, Moher D for the CONSORT Group.
CONSORT 2010 Statement: updated guidelines for reporting
parallel group randomized trials. Ann Int Med 2010; 152:
72632.
16. Simons JP, Aaronson NK, Vansteenkiste JF et al. Effects of
medroxyprogesterone acetate on appetite, weight, and quality
of life in advanced stage non-hormone-sensitive cancer: a
placebo-controlled multicenter study. J Clin Oncol 1996; 14:
107784.
17. Milne AC, Potter J, Vivanti A, Avenell A. Cochrane collabor-
ation. Protein and energy supplementation in elderly people at
risk for malnutrition (Review). Cochrane Database Syst Rev
2009; 15: CD003288.
18. Smeets PA, Erkener A, de Graaf C. Cephalic phase responses
and appetite. Nutr Rev 2010; 68: 64355.
19. Grabenhorst F, Rolls ET. The representation of oral fat texture
in the human somatosensory cortex. Hum Brain Mapp 2014;
35: 252130.
20. Zeanandin G, Molato O, Le Duff F, Gurin O, Hbuterne X,
Schneider SM. Impact of restricted diets on the risk of under-
nutrition in a free-living elderly population. Clin Nutr 2012;
31: 6373.
21. Black J, Baharestani MM, Cuddigan J et al. National pressure
ulcer advisory panels updated pressure ulcer staging system.
Dermatol Nurs 2007; 19: 3439.
22. Whelan K, Judd PA, Taylor MA. Assessment of fecal output
in patients receiving enteral tube feeding: validation of a novel
chart. Eur J Clin Nutr 2004; 58: 10307.
23. Padula WV, Mishra MK, Makic MB, Sullivan PW. Improving
the quality of pressure ulcer care with prevention. A cost-
effectiveness analysis. Med Care 2011; 49: 38592.
24. Reddy M, Gill SS, Kalkar SR, Wu W, Anderson PJ, Rochon
PA. Treatment of pressure ulcers: a systematic review. JAMA
2008; 300: 264762.
25. Cereda E, Gini A, Pedrolli C et al. Disease-specic, versus
standard, nutritional support for treatment of pressure ulcers
in institutionalized older adults: a randomized controlled trial.
J Am Geriatr Soc 2009; 57: 1395402.
26. Van Hanholt RD, Sobotka L, Meijer EP et al. Specic nutri-
tional support accelerates pressure ulcer healing and reduces
wound care intensity in non-malnourished patients. Nutrition
2010; 26: 86772.
27. Whelan K, Schneider SM. Mechanisms, prevention, and man-
agement of diarrhea in enteral nutrition. Curr Opin
Gastroenterol 2011; 27: 1529.
Received 7 February 2014; accepted in revised form 1 July
2014
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