The effect of a protein intervention on muscle mass, muscle strength and physical performance in elderly during a period of immobility : a systematic review

Date:

06-01-2017

Time period:

Semester 7

Thesis title:

The effect of a protein intervention on muscle mass,

muscle strength and physical performance in elderly

during a period of immobility, a systematic review

Students:

Lisa van der Spijk, Terence Meeuwenoord

T

HESIS

THE

EFFECT

OF

A

PROTEIN

INTERVENTION

ON

MUSCLE

MASS,

MUSCLE

STRENGTH

AND

PHYSICAL

PERFORMANCE

IN

ELDERLY

DURING

A

PERIOD

OF

2

Content

Introduction ... 4

Methods ... 6

Results ... 8

Discussion ... 16

Conclusion and recommendations ... 19

Appendix A: list of search terms ... 22

3

Abstract

Background & aims

Sarcopenic declines in muscle mass and strength are punctuated by periods of muscle disuse that can accelerate losses of muscle mass and strength. Protein supplementation might be a promising strategy to prevent or treat the loss of muscle mass during hospitalization. The aim of this systematic review is to summarize the effect of a protein intervention on sarcopenia during a period of hospitalization in elderly

Methods

PubMed and Scopus databases were searched using predefined search terms. Only English or Dutch studies reporting outcome data relevant to muscle mass, muscle strength or physical performance; relating to protein intake in an elderly (>65 years old), hospitalized population; with a minimum length of stay of ≥4 consecutive days during the intervention period were selected.

Results

The 7 included articles in this systematic review were all randomized controlled trials (RCT). A significant change in one of the muscle mass measurements was reported 4 times (lean mass, appendicular skeletal muscle mass, body cell mass and fat free mass) among 2 of the 6 concerning studies. No significant change was found in muscle strength and physical performance.

Conclusion

In conclusion, this study indicates that a protein intervention did not increase or maintain muscle mass, muscle strength and physical performance significantly more than control groups in hospitalized, elderly populations. A protein intake well above RDA (>1.27 g/kg/day) may suppress muscle strength and physical performance deterioration during hospitalization, but findings related to protein intake and muscle mass were inconclusive. Clearly more research regarding the effect of protein intake on sarcopenia outcome measures in a hospitalized setting is required.

4

Introduction

The share of older people in The Netherlands is rising. This is primarily caused by improvements in health care, the well-known baby boom and by the lower fertility rates which leads to a decline in children per household.(1) Besides the growing share of elderly in The Netherlands, life expectancy continues to increase. At this moment, Dutch women will live for 83 years on average, 63.5 years of which are considered Healthy Life Years. For Dutch men, life expectancy is 79.4 years of which 64 years are regarded as Healthy Life Years. As people grow older they become more prone to age-related changes and diseases.(2)

A pervasive symptom of aging is sarcopenia. This is an age-related decline in muscle mass, muscle strength and physical performance. The prevalence of sarcopenia in the age group of 65 years and older is 5 to 10%. This figure continues to rise progressively with age.(3) As muscle mass declines and muscle strength deteriorates, it will gradually affect someone’s ability to perform ordinary physical tasks. Subsequently, elderly will become less autonomous, thus becoming reliant on external help.(4)

There are numerous factors that can influence the advance of sarcopenia. In particular, during a period of hospitalization the whole process of physical deterioration is accelerated.(5,6) As illustrated in figure 1, periods of “catabolic crisis”, i.e. hospitalization, leads to a higher loss of lean mass over time as compared to the traditional decline in lean mass.(5) Consequently, elderly that are subject to periods of inactivity will sooner -become frail and experience a decrease in quality of life.(7) This is further supported by research that shows that, although the prevalence of sarcopenia may vary from 5 to 10 percent at the age of 65, the existence of sarcopenia increases to 68 percent in the nursing home population. This is probably due to the combination of ageing and more frequent or chronic periods of bed rest.(8) Moreover, as muscle mass and muscle function decline over time, hospitalization duration, need for rehabilitation after hospital discharge increases, occurrence of falls and mortality rates increase.(9-11)

Figure 1. Model of age-related muscle loss punctuated by episodes of acute illness or injury and characterized by accelerated muscle loss and incomplete recovery.(5)

5

To counter this, research suggests that dietary protein may prevent the loss of muscle mass. Protein is an important building block that requires extra attention as it plays an essential role in maintaining and building muscle.(6) The recommended dietary allowance (RDA) of protein intake for elderly may be greater than 0.8 g/kg/day. Evidence indicates that protein intake greater than the RDA can improve muscle mass, strength and function in elderly.(11)

Reviews on the topic of protein intake and its effect on sarcopenia on hospitalized elderly emphasize the

importance of protein and its preserving role on muscle mass and muscle function.(5, 13)However, these reviews did not exclusively research the effect of protein intake and there is no overview of the current literature on the topic. In general, a greater understanding of the functional benefit of a protein intervention during hospitalization is needed. This knowledge is especially important for preserving the autonomy of elderly. Therefore we performed a search of the literature of published studies to answer the following research question: what is the effect of a protein intervention on muscle mass, muscle strength and physical performance of elderly during a period of hospitalization? To answer the main question, the following sub-questions have been composed:

- What is the effect of protein intake on muscle mass during hospitalization? - What is the effect of protein intake on muscle strength during hospitalization? - What is the effect of protein intake on physical performance during hospitalization?

The goal of this systematic review is to summarize the effect of a protein intervention on sarcopenia during a period of hospitalization in elderly. With this, an encompassing insight may be offered into the role of protein on sarcopenia in a hospital setting.

6

Methods

Data sources

PubMed and Scopus were used to select all articles researching the effect of protein on muscle mass, muscle strength and physical performance in an elderly, hospitalized population. These two databases combined offered access to a wide variety of publications and were accessible through the institution’s library: Amsterdam University of Applied Sciences (AUAS).

Search strategy

An extensive set of search words was created in order to find all research regarding the topic of this systematic review. Said search words were initially gathered by deriving them from the research question and from top of the head knowledge of the field. Furthermore, research articles of similar studies and dictionaries were consulted for synonyms. Boolean Operators and MeSH terms were used to further broaden or specify a search. An overview of search words and search strings has been enclosed in the appendix section of this document.

Inclusion and exclusion criteria

The inclusion criteria were as follows: the article must have been published in either English or Dutch; reporting outcome data relevant to muscle mass, muscle strength or physical performance; relating to protein intake in an elderly (>65 years old), hospitalized population; with a minimum length of stay of ≥4 consecutive days during the intervention period. Studies were excluded if the study population, or a part of the study population, was diagnosed with a condition that may, besides as a result of sarcopenia, interfere with body composition and physical performance measurements. For instance, a movement impairing disease like Parkinson’s. The inclusion and exclusion criteria are summarizes in table 1.

Table 1. Inclusion and Exclusion criteria

Study selection

Two authors independently performed literature searches and eligibility assessment of articles. The search results were initially judged by title. Any leftover studies that may have fit the criteria were then assessed based on their abstracts. After which they were either excluded or evaluated further based on the full text. Finally both authors cross-checked each other’s searches and inclusions and discussed any disparities. Disagreements were revolved by consensus.

Criteria Inclusion Exclusion

Study type RCT’s, clinical trials, cohort studies, cross-sectional studies, case control studies

Any type not specified, animal studies

Study duration ≥4 days of hospitalization <4 days of hospitalization

Study population ≥65 years old <65 years old

Outcome At least one of the following: - Data on lean body

mass/muscle mass; - Muscle strength; - Physical performance

None of desired outcomes

Language English, Dutch Any language not specified

Availability Article full text is available through the institution’s library (AUAS)

7

A log of each author’s article selection process was kept. This log includes: title, author and DOI codes of articles for abstract screening, reason for exclusion based on abstract screening, articles for full text screening and reason for exclusion based on abstract screening. Finally, EndNote was used to keep track of the study selection process and to remove duplicates.

Synthesis of results

First of all, all data concerning the included studies’ characteristics was extracted and arranged in a table. This encompasses information on study type, study population, the intervention and length of stay. Subsequently, an assessment of study quality was done through The Delphi list for each individual study.(14) Relevant study results were then sorted for three main outcomes: muscle mass, muscle strength and physical performance. After which data was extracted and added to the corresponding table.

All data in the results section of this document has been extracted exactly as stated in the concerning research article. The extracted data is presented as specifically as possible by including mean outcome, standard deviation (SD, ±) and p-value if available. No figures were rounded up nor rounded down. Any additional information concerning specific tables is addressed in the captions below the tables. In each table articles were organized in chronological order, starting with the most recent.

8

Records identified through database searching (n = 5306)

Scr

ee

n

in

g

In

cl

u

d

ed

Id

en

tifi

cat

ion

through other sources (n = 1)

Records after duplicates removed (n = 4093)

Abstracts screened (n = 100)

Records excluded (n = 63)

Full-text articles assessed for eligibility

(n = 37)

Full-text articles excluded, with reasons (n = 30) Studies included in qualitative synthesis (n = 7) Records screened (n = 4093)

Results

Study selection

A flow chart has been added to illustrate the process of study selection (Figure 2).

_{The database}

search was done from November 4

to November 11

. The search identified a total of 5.306 articles and

1 record was retrieved through other sources. Of these, 100 were screened for eligibility based on

abstracts. Subsequently, 63 articles were excluded because of no hospitalization/bedrest (n=27), no

relevant measurements (n=17), subjects aged <65 (n=12) or a non-protein intervention (n=7). The

remaining 37 articles were then assessed for inclusion based on their full texts. Afterwards 29 studies

failed to meet the inclusion criteria for the following reasons: no hospitalization (n=7), no relevant

outcomes (n=7), subjects aged <65 (n=7), no relevant intervention (n=3), full text unavailable (n=4), no

link to protein (n=2). Ultimately 7 articles were included in this systematic review.

9

type

Intervention Length of hospital stay during intervention

Length of intervention Number of participants, (CG/IG) Mean age, years Sex CG IG M F Nishizaki K, et al. RCT 2 times HMB/Arg/Gln supplementation containing 2400 mg of HMB, 14000 mg of glutamine and 14000mg of L-arganine 19.1 ±3,7 for control group and 18,9 ±3,3 for intervention group

From 5 days before surgery to 28 days afterwards, 42 days after surgery follow up

23 (10/13) 70.5 ±5.4 11 12

Munk T, et al.

RCT standard hospital food service +

protein supplemented food service (with a minimum of 6g protein/dish)

10 days 10 days 84 (40/44) 74 75 34 47

Bouillanne O, et al.

RCT Protein pulse feeding; 78% of

protein intake at noon.

42 days 42 days 66 (36/30) 85,7 84.1 17 46

Ha L, et al. RCT Energy- and protein enriched meals, or established oral energy- and protein rich sip feedings (0,8 - 1,5 kcal and 0,04-0,1 g per mL), or enteral tube feeding (with 1,0 kcal and 4,0 kcal per mL)

> one week While in hospital, 3 month follow up 124 (66/58) 79.7 ±6.8 78.5 ±7.4 60 64 Ferrando A, et al.

RCT EAA group received a supplemental

3x 15 g of amino acids/day in addition to dietary intake

10 days 52 days: 8 days of stabilization, 10 days of bed rest, 4 weeks of rehabilitation 22 (12/10) 68 ±5 71 ±6 6 1 6 9 Bonnefoy M, et al. RCT Supplementation of 0.4g of

protein/kg/day. 3-5 sachets were given daily according to the subjects weight (< 50kg: 3 sachets; 50 - 59 kg: 4 sachets; ≥ 60kg: 5 sachets). 14 days 14 days 30 (15/15) 79.4 ±6.7 82.5 ±8.2 12 18 Bos C, et al.

RCT 10 days of oral supplementation of

400kcal, 30g protein, 50g carbs, 9g lipids and minerals

10 days 10 days 23 (6/17) 76 ±6

80 ±7

10 13

Characteristics of included studies

The 7 included articles in this systematic review were all randomized controlled trials (RCT). Each of the

study’s characteristics were extracted and charted in table 2. This table includes data on the authors,

study type, intervention design and study population. Across all 7 studies, the combined amount of

participants is 372, ranging from 22 to 124 per study. 5 studies provided supplementation consisting of

either protein (n=3) or specific amino acids (n=2). The remaining 2 studies adjusted the hospital menu by

adding protein to dishes (n=1) or had the intervention group on a protein pulse feeding diet (n=1).

Furthermore, the length of hospital stay during intervention ranged from over a week to 42 days and 2

studies performed follow up measurements post-intervention. Table 3 presents additional information

on the health condition of the elderly subjects along with protein and energy intakes during the study.

The Delphi list was used to assess the quality of included articles (table 4). Average compliancy with The

Delphi list of the 6 studies was 59%, while scores ranged from 33 to 89 percent.

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Table 3. Condition of elderly and nutritional information

NA, not available; CG, control group; IG, intervention group P ≤0.05, statistically significant.

Author Health condition of

elderly Protein intake P-value Energy intake P-value

CG IG CG IG Nishizaki K, et al. Patients diagnosed as having knee osteoarthritis g/day na Kcal/day na 62.6 ±4.2 63.7 ±4.1 1737 ±104 1765 ±107

Munk T, et al. Patients at

nutritional risk g/kg/day 0.003 Kcal/kg/day 0.013 0.7 ±0.3 0.9 ±0.4 82 ±33 103 ±39 Bouillanne O, et al. Malnourished or at risk of malnourishment g/kg/day 0.60 Kcal/kg/day 0.89 1.27 1.31 33.6 33.3 Ha L, et al. Patients admitted after an acute stroke g/kg/day kJ/kg/day Men Men 0.79 ±0.28 0.79 ±0.27 0.87 69 ±21 76 ±26 0.37 Women Women 0.65 ±0.23 0.88 ±0.32 0.001 59.7 ±19 83.2 ±31.3 0.005 Ferrando A, et al. Moderately active, healthy g/kg/day na

Calculated with Harris-benedict equation to maintain body weight throughout the study

na 0.8 1.4 Bonnefoy M, et al. Malnourished with catabolic status g/kg/day na Kcal/day na 0.88 ±0.47 1.01 ±0.29 1118 ±314 1247 ±348

Bos C, et al. Malnourished g/day <0,0002 MJ/day <0,005

Table 4. Quality assessment determined by The Delphi list

Authors 1a. Was a

method of randomization used? 1b. Was the treatment allocation concealed? 2. Were the groups similar at baseline regarding the most important prognostic indicators? 3. Were the eligibility criteria specified? 4. Was the outcome assessor blinded?

5. Was the care provider blinded? 6. Was the patient blinded? 7. Were point estimates and measures of variability presented for the primary outcome measures? 8. Did the analysis include an intention-to-treat analysis? Compliance percentage (%) Nishizaki K, et al.

yes UK yes yes UK no no yes No drop outs 56

Munk T, et al. yes yes yes yes yes no yes yes yes 89

Bouillanne O, et al.

yes yes yes yes no no no yes yes 67

Ha L, et al. yes yes yes yes yes no no yes no 67

Ferrando A, et al.

yes yes no yes UK UK yes yes no 56

Bonnefoy M, et al.

yes UK yes yes UK UK UK yes UK 44

Bos C, et al. no UK no yes UK UK no yes UK 33

Table 5. Overview of muscle mass results

NA, not available; NS, not significant; CG, control group; IG, intervention group Results shown as mean with standard deviation, if available (±).

P ≤0.05, statistically significant.

* Analyzes for covariance, using initial values. ** Adjusted for baseline/gender.

Author Protein intake

Muscle cross sectional area

(cm2)

P-value Lean mass

(kg) P-value Appendicular skeletal muscle mass (kg) P-value body cell mass (kg)

P-value Fat free mass

(kg) P-value

Leg lean mass

(kg) P-value CG IG CG IG CG IG CG IG CG IG CG IG CG IG Nishizaki K, et al. g/day %Change NS na na na na na na na na na 62.6 ±4.2 63.7 ±4.1 -3.6 ±33.8 9.1 ±16.6 Bouillanne O, et al. g/kg/day na na Mean change 0.012 0.010* Mean change _0.054 0.044* Mean change _0.003 0.003* na na na 1.27 1.31 -0.41 0.91 -0.19 0.51 -0.05 1.08 Ha L, et al. g/kg/day na na Men Δ na na Men Δ Men Δ na Men -0.1 ±0.6 0.2 ±0.9 0.76 -0.1 ±0.4 0.1 ±0.7 0.77 0.2 ±0.6 0.8 ±1.0 0.60 0.79 ±0.28 0.79 ±0.27

Women Δ Women Δ Women Δ

0.4 ±0.5 -0.1 ±0.5 0.48 0.3 ±0.4 -0.03 ±0.4 0.51 0.4 ±0.6 0.03 ±0.6 0.69 Women 0.65 ±0.23 0.88 ±0.32 Ferrando A, et al. g/kg/day na na Pre-bedrest 0.29 0.465** na na na na na na Pre-bedrest 0.77 0.931** 46.8 ±0.3 43.0 ±0.2 14.5 ±0.1 13.3 ±0.07 Post-bedrest Post-bedrest 0.8 1.4 45.3 ±0.3 42.1 ±0.2 13.6 ±0.1 12.5 ±0.07 %Change %Change -2.9 ±0.9 -2.0 ±0.7 -5.9 ±1.6 -6.3 ±1.8 Bonnefoy M, et al. g/kg/day na na na na na na na na Baseline NS na 0.88 ±0.47 1.01 ±0.29 39.5 ±6.8 40.9 ±8.1 After 40.0 ±8.2 40.7 ±8.3 Bos C, et al. g/day na na na na Baseline NS na na Baseline 0.02 na 52 71 14.1 ±4.3 14.0 ±2.6 38.3 ±9.7 36.7 ±5.4 Change Change 0.1 ±0.5 0.6 ±0.8 0.1 ±0.4 1.3 ±1.1

Muscle mass

Among the 7 included studies, 6 reported findings on muscle mass (Table 5). These 6 studies used a

variety of methods to measure muscle mass. The measurements used to evaluate muscle mass were:

muscle cross sectional area (MCSA, n=1), lean mass (LM, n=3), appendicular skeletal muscle mass

(ASMM, n=2), body cell mass (BCM, n=2), Fat free mass (FFM, n=3) and leg lean mass (LLM, n=1).

First of all, the one study that measured MCSA found no significant difference between the rectus

femoris of the non-operated side of the leg between both study groups.

Secondly, change in LM was

shown to be significant (p=0.012) in one study

_{, in contrast to the other two studies that measured}

change in LM.

_{Thirdly, ASMM was measured in two articles and neither of them reported a}

significant change between both groups.

_{However, when adjusted for covariance, the Bouillanne O,}

et al. study found a significant value (p’=0.044) in ASMM.

Moreover, the Bouillanne O, et al. study

reported a significance in BCM change (p=0.003), whereas the second study assessing BCM shows no

significance.

Next, one out of the three studies that measured FFM found a significant change after

the intervention.

The other two studies did not find a significant difference.

Lastly, no significant

changes were found in LLM by Ferrando A, et al.

In short, a significant change in one of the muscle mass measurements was reported 4 times among 2 of

the 6 concerning studies.

Muscle strength

Out of the included studies, 5 of them assessed the effect of a protein intervention on muscle strength

(Table 6).

_{In these studies, measurements used to evaluate muscle strength were knee extension}

strength (KES, n=1), hand grip strength (HGS, n= 3)

and stair ascent/descend power (n=1). The study that

evaluated KES also showed no significant difference between control and intervention group at any point

during the intervention.

_{Similarly, the three studies that included HGS measurements reported no}

significant change between control and intervention group post-intervention.

_{The one study that}

measured stair ascent/descent power, on the other hand, found a significantly lower decrease in the

intervention group compared to the control group. However, when adjusted for baseline data and

gender effect, changes in both stair ascent and stair descent power were no longer significant. The same

study measured standing plantar flexion strength by asking their subjects to stand on their right leg while

they rise onto the ball of their foot and then lowering their heel back to the ground as many times in 30

seconds. In the end. no significant change was found in muscle strength.

Physical performance

Two of the included studies performed physical performance measurements (Table 7).

Bouillanne O,

et al. assessed physical performance based on Activities of Daily Living (ADL) score. The ADL score

measured degree of disability, where a score of 0 equals ‘very dependent’ and a score of 6 indicates ‘full

function’. There was no significant effect for ADL score. Although mean score increased by 0.55 for the

intervention group as to a mean decrease of -0.03 for the control group.

The second study contains one physical performance measurements: floor transfer time. This

measurement required subjects to move from a standing position to a sitting position with legs extended

and to then stand up again. Floor transfer time showed a significant change between the two study

groups.

Table 6. Overview of muscle strength results

NA, not available; NS, not significant; N, newton; CG, control group; IG, intervention group Results shown as mean with standard deviation, if available (±).

P ≤0.05, statistically significant.

* Analyzes for covariance, using initial values. ** Adjusted for baseline/gender.

Author Protein intake

Knee extension strength, non-operated side (Nm/kg) P-value Hand grip strength (kg)

P-value Stair ascent power

(Nm/s) P-value Stair descent power (Nm/s) P-value Standing plantar flexion (rep/30sec) P-value CG IG CG IG CG IG CG IG CG IG CG IG Nishizaki K, et al. g/day Baseline NS na Na na na na na na na 62.6 ±4.2 63.7 ±4.1 1.3 ±0.7 1.3 ±0.4 Post-intervention 1.2 ±0.5 1.2 ±0.3 Munk T, et al. g/kg/day na Mean change 0.76 na na na na na na 0.7 ±0.3 0.9 ±0.4 -0.4 ±4.3 -0.1 ±2.9 Bouillanne O, et al. g/kg/day na Mean change (N) 0.41 0.271* na na na na na na 1.27 1.31 10.88 -0.17 Ferrando A, et al. g/kg/day na na na Pre-bedrest 0.029 0.061** Pre-bedrest 0.026 0.100** Pre-bedrest 0.054 0.20** 407.2 ±69.9 293.5 ±37.2 440.5 ±75.7 320.6 ±43.1 21.8 ±3.4 21.8 ±1.4

Post-bedrest Post-bedrest Post-bedrest

0.8 1.4 336.5 ±47.6 284.2 ±43.0 339.6 ±50.6 290.3 ±45.9 20.9 ±2.8 21.4 ±2.5

%Change %Change %Change

-14 ±4 -2 ±5 -21 ±4 -8 ±4 -0.19 ±0.04 -0.019 ±0.10 Bos C, et al. g/day na Baseline NS na na na na na na 52 71 20.0 ±11.4 12.5 ±9.9 Change 0.0 ±2.0 1.9 ±5.2

Table 7. Overview of physical performance results

Author Protein intake Activities of Daily

Living score P-value

Floor transfer

(s) P-value

CG IG CG IG CG IG

Bouillanne O, et al.

g/kg/day Baseline mean

0.125 0.118* na na 1.27 1.31 _Change 4 3.5 -0.03 0.55 Ferrando A, et al. g/kg/day na na Pre-bedrest 0.027 0.016** 8.3 ±1.1 9.6 ±1.6 Post-bedrest 0.8 1.4 12.8 ±2.3 10.5 ±1.7 %Change 51 ±17 13 ±7

NA, not available; s, seconds; CG, control group; IG, intervention group Results shown as mean with standard deviation, if available (±). P ≤0.05, statistically significant.

* Analyzes for covariance, using initial values. ** Adjusted for baseline/gender.

Discussion

This systematic review of 7 randomized controlled trials aimed to review the present literature on the effect of a protein intervention on muscle mass, muscle strength and physical performance in an elderly, hospitalized population. Out of the 7 included studies, 6 of them reported findings on muscle mass, 5 reported data on muscle strength and 2 studies reported findings on physical performance. Data on muscle mass changes were inconclusive: 4 significant differences across multiple measurement methods were detected, though this does not outweigh the amount of non-significant measurements addressed in this study.Furthermore, studies that assessed muscle strength and physical performance changes between study groups reported no definite significant differences apart from floor transfer time.

In light of the inconclusive results on muscle mass, it is worthwhile to highlight some additional information concerning the nature of the results. First and foremost, 3 out of the 4 significant changes that were measured across the 6 included studies were reported in the Bouillanne O, et al. study. This study concludes that protein pulse feeding improves LM, ASMM and BCM in hospitalized elderly, even though both study groups had similar protein intakes (1.27 g/kg vs 1.31 g/kg). What this study also demonstrated is that the control group, despite the relatively high protein intake (1.27 g/kg), saw a mean decrease in LM, ASMM and BCM, in contrast to the

intervention groups where the three measurements showed a mean increase. Thus suggesting that a sheer increase in protein intake to preserve muscle mass may not be sufficient and additional methods, like pulse feeding protein, should be considered. An important side note to these specific findings is that baseline data for LM, ASMM and BCM was significantly different: the control group had significantly higher statistics (LM: p=0.03; ASMM: p=0.04; BCM: p=0.01). This may have affected the final measurements in favor of the intervention group due to lower starting values.(18)

None of the other studies that measured LM, ASMM and BCM reported significant changes, and mean changes were not consistently in favor of the control nor the intervention group. (19,20,22) This despite the fact that in the concerning articles, protein and energy intake was significantly higher in most of the intervention groups. Only the men in the study groups of the Ha L, et al. study had no significantly higher protein and energy intakes.

FFM was assessed in 3 studies, one of which reported a significant change between elderly control and elderly supplemented group (p=0.02).(22) However, this significance is based on data from a small study population (n=23) where the study groups were unevenly distributed (6 vs 17). Consequently, this lowers the population validity due to possible overrepresentation of outliers and as a result hurting the external validation.

Although muscle strength outcomes were generally not significant across the included studies, it is important to address some background information. In two out of the three studies that measured HGS, the higher protein groups had less of a mean decrease(21) or more of a mean increase(22) in HGS at the end of the intervention compared to the lower protein group. This result could have multiple causes. First of all, it could be due to the difference in protein intake between control and intervention groups; which would support a recommendation for a high protein intake for hospitalized elderly to suppress muscle strength deterioration. Another explanation for the difference in favor of the higher protein group could be the lower baseline stats of the intervention group. As reported in table 6, the control and intervention groups’ baseline measurements for HGS are unequal in the Bos C, et al study.(22) Subsequently, this disparity may have affected the final changes in HGS. The Munk T. et al study, on the other hand, contains no record of HGS baseline measurements.(17) Finally, the mean HGS results concerning the two studies may be skewed by outliers within groups. As seen in table 6, the standard deviations of both control and intervention groups are quite high relatively to the mean changes. In contrast to the two studies described above, the Bouillanne O, et alstudy that reported findings on HGS showed mean changes in favor of the control group. It is, however, important to note that both groups in this study had similar protein intakes. And these results could be attributed to the fact that the control group received their protein spread throughout the day, rather than having 72% of protein delivered at noon like the intervention group. Besides relatively high protein intakes of both groups, it is interesting to see that HGS for both groups did not decrease and was thus retained or improved throughout the course of the Bouillanne O, et al. study.(18) Similar results were reported by Ferrando A, et al:

17

overall, decreases in muscle strength measurements were lower in the high protein group (1.4 g/kg) compared to the control group (0.8 g/kg).(20) This, combined with the results on muscle strength from Bouillanne O, et al., shows a trend towards the preservation of muscle strength in relation to a high protein intake (>1.27 g/kg).

One study measured knee extension strength on both operated and non-operated side of the leg. The decision was made to only include data on the non-operated side, because operated knee strength may have been influenced by too many individual factors unrelated to the protein supplementation. Among the four times knee extension strength was measured during the 42 day intervention, no significant difference was measured and outcomes of both groups were similar.(16)

There were two eligible studies that reported findings on physical performance. First of all, neither of the two groups (protein >1.27 g/kg) in the Bouillanne O, et al. study suffered a decrease in ADL score during the

intervention; comparable to the HGS scores of this study. The Ferrando A, et al. study showed a significant lower decrease in floor transfer time in favor of the high protein group (1.4 g/kg). This further indicates that a relatively high protein intake of >1.27 g/kg can suppress muscle strength and physical performance loss during

hospitalization.

There are multiple limitations to this study that should be considered when interpreting the results. Firstly, heterogeneity between studies exists on numerous aspects. The included studies have varying subject populations and intervention setups. Subject population size in the included studies ranged from a total of 22 subject to a total of 124. Looking at the included studies, 4 of them have total study populations consisting of ≤30 subject.(16,20-21) The low population studies are susceptible to outliers thus resulting in relatively high standard deviations and less reliable data. This is crucial to regard when judging data based on mean outcomes and when using this data to make predictions about an entire population. The second heterogeneous aspect is the intervention setups: most of the studies’ interventions are divergent. To elucidate: 4 out of the 7 studies increased protein intake in the

intervention group by means of supplementation(19-22), while 1 study increased protein intake through hospital menu changes(17) and 2 studies did not increase overall protein intake.(16,19) Besides the varying methods for applying protein interventions, 3 studies included additional nutrients or substances alongside protein in the intervention. (16,19,22)This complicates the overall correlation between protein intake and the outcomes, because there are additional variables confounding the results. The third heterogeneous aspect is the variability in study quality. Study quality ranged from 33% to 89% when assed by The Delphi list. The difference in study quality, i.e. caused by unavailable information, using or not using placebo’s or blinding the outcome assessor, may have affected overall study outcomes because of bias or placebo effects.In general, the described clinical diversity limits the comparability of results across studies and encourages emphasizes on a study’s individual results.

Another limitation that should be considered when analyzing the results is difference in energy intake between the control and intervention groups. This is an essential consideration because a caloric deficit can cause an unintended decrease of body weight and is accompanied by deficiencies of essential nutrients. This is closely related to

malnutrition, which is associated with a slow recovery, more and serious compilations and reduced muscle mass.(23,24) Out of the 7 included studies, 4 of them had intervention groups with overall higher (>100 kcal) energy intakes of which 2 were significant. (17,22) Also, 4 studies included malnourished or at risk subjects.(17,18,21,22) Although results of this systematic review show no clear benefit of higher protein intakes in elderly hospitalized population, any collateral effect caused by the energy difference and malnutrition cannot be excluded.

To summarize, the clinical diversity of included study and the role of energy intake places extra attention on careful analysis of the results and possible generalization of outcomes.

Apart from these limitations, we believe this systematic review offers reliable insight on the current knowledge concerning the effect of protein interventions on muscle mass, muscle strength and physical performance in an elderly, hospitalized population. The literature search and assessments were systematically carried out by each author individually. Two databases were screened for eligible articles and detailed logs were kept of the study selection process. Based on this, we deem it improbable that studies were missed. However, during study selection, only English studies were selected which may have led to language bias. We also treated protein intake data with care, which is an essential aspect of this study. Where protein intake reported as g/kg (n=5) is the most desirable, total g/day (n=2) was also found. Meaningfulness of total g/day relies on characteristics, i.e. weight, within groups. Due to homogeneity in weight between internal study groups of the studies that reported total g/day, it is safe to

18

state that difference in total protein intake per day amounts to a, relatively, comparable difference in g protein/kg.(16,22)

The inclusion of articles with malnourished, or at risk, patients (n=4) has advantages as well as drawbacks. The Dutch Malnutrition Steering Group determined that 15% of hospital patients were defined as undernourished; this figure is 39% in geriatric wards.(25) Because of the high share of malnourished patients, the inclusion of articles that included these patients adds to the overall representation of elderly hospital patients. However, as shortly

described earlier, malnutrition is associated with slow recovery, reduced muscle mass and increased length of stay.(23,24,26) This may negatively affect outcomes which, in turn, limits overall comparability with studies that did not include malnourished or at risk patients.

Current research suggests that the RDA of 0.8 g/kg protein for elderly may not be sufficient to counteract sarcopenia in a non-hospitalized setting. (27-31) Protein intakes ranging from 1.0 to 1.2 g/kg to even higher than 1.2 g/kg have been recommended to maintain or build muscle mass in a day to day setting.(26,30)Take into account that bedrest further induces loss of muscle mass, thus supporting the notion that a higher than RDA protein intake may be desirable in a hospitalized setting.(5,6,32-34) Conversely, the outcome of this study does not reinforce this idea. To elucidate: no strong evidence was found to suggest that an increased protein intake has a significant beneficial effect on muscle mass, muscle strength and physical performance over the standard, controlled nutritional support. Though there is some compelling evidence that a protein intake of 1.27 g/kg or higher can positively affect muscle strength and physical performance maintenance. However, due to the clinical diversity, low population sizes, additional variables like other nutrients within the intervention and energy intake differences among included studies, our findings may not be applicable to all elderly subjects.

19

Conclusion and recommendations

With regard to the current literature, only a single study was identified that explicitly researched the effect of a (increased) protein intervention on muscle mass, muscle strength and physical performance in an elderly,

hospitalized population. With this in mind we propose future research to tailor to this specific research question. As would be a good step forward in the ongoing battle against sarcopenia. This study revealed the current literature on the topic, along with its limitations. Knowing this, we believe future research should be able to set up studies to counter these limitations.Alternatively, because Bouillanne O, et al. showed promising results, it may be

advantageous to further uncover the effect of protein pulse feeding. In this study, though both groups had similar, high protein intakes, the protein pulse feeding group showed a significant increase in multiple muscle mass measurements compared to the control group and the protein pulse feeding group experienced mean no decrease in muscle strength and physical performance. More research needs to be done to confirm these positive effect of protein pulse feeding.

Moreover, it may be beneficial for future research to include physical activity as intervention in combination with an increased protein intake. This may provide new insights into the treatment of sarcopenia during hospitalization, because numerous reviews describe the positive effect of physical activity to enhance or maintain muscle mass and strength in a non-hospitalized setting.(35-37) For future reviews, adding physical activity interventions to the inclusion criteria will enlarge the number of included articles, thus improving the overall quality of the research.

Hospital dieticians may benefit from this research, because it can aid in the drafting of new dietary guidelines for optimal treatment during and after a period of hospitalization. Proper dietary guidelines for hospitals are especially important, because hospitals offer a far more controlled environment compared to domestic settings. Thus these guidelines, if followed up on, may in practice be more effective than dietary guidelines in general.

Furthermore, geriatric patients can profit from our results: if further research shows promising outcomes by setting up protein intervention for hospitalized elderly, then hospitalized elderly patients may experience faster recovery, decreased hospitalization duration, lower occurrence of falls, a reduced mortality rate and an overall longer maintenance of quality of life.(7,9-11)

In conclusion, this study indicates that a protein intervention did not increase or maintain muscle mass, muscle strength and physical performance significantly more than control groups in hospitalized, elderly populations. A protein intake well above RDA (>1.27 g/kg/day) may suppress muscle strength and physical performance

deterioration during hospitalization, but findings related to protein intake and muscle mass were inconclusive. On the whole, more research regarding the effect of protein intake on sarcopenia in a hospitalized setting is required.

20

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7. Artaza-Artabe I, Sáez-López P, Sánchez-Hernández N, Fernández-Gutierrez N, Malafarina V. The relationship between nutrition and frailty: Effects of protein intake, nutritional supplementation, vitamin D and exercise on muscle metabolism in the elderly. A systematic review. Maturitas. Maturitas. 2016.

8. Landi F, Liperoti R, Fusco D, Mastropaolo S, et al. Prevalence and risk factors of sarcopenia among nursing home older residents. The journals of gerontology. 2012 Jan;67(1):48-55.

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the United States. Bureau UC, editor. US Government Printing Office; 2005; 23–209.

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15. PRISMA. Prisma-statement.org. 2016. Available from: http://www.prisma-statement.org/

16. Nishizaki K, Ikegami H, Tanaka Y, Imai R, Matsumura H. Effects of supplementation with a combination of beta-hydroxy-beta-methyl butyrate, L-arginine, and L-glutamine on postoperative recovery of quadriceps muscle strength after total knee arthroplasty. Asia Pacific journal of clinical nutrition. 2015;24(3):412-20.

17. Munk T, Beck AM, Holst M, Rosenbom E, Rasmussen HH, Nielsen MA, et al. Positive effect of protein-supplemented hospital food on protein intake in patients at nutritional risk: a randomised controlled trial. Journal of human nutrition and dietetics : the official journal of the British Dietetic Association. 2014;27(2):122-32. 18. Bouillanne O, Curis E, Hamon-Vilcot B, Nicolis I, Chretien P, Schauer N, et al. Impact of protein pulse feeding on lean mass in malnourished and at-risk hospitalized elderly patients: a randomized controlled trial. Clinical nutrition (Edinburgh, Scotland). 2013;32(2):186-92.

19. Ha L, Hauge T, Iversen PO. Body composition in older acute stroke patients after treatment with individualized, nutritional supplementation while in hospital. BMC geriatrics. 2010;10:75.

20. Ferrando AA, Paddon-Jones D, Hays NP, Kortebein P, Ronsen O, Williams RH, et al. EAA supplementation to increase nitrogen intake improves muscle function during bed rest in the elderly. Clinical nutrition. 2010;29(1):18-23.

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21. Bonnefoy M, Laville M, Ecochard R, Jusot JF, Normand S, Maillot S, et al. Effects of branched amino acids supplementation in malnourished elderly with catabolic status. The journal of nutrition, health & aging.

2010;14(7):579-84.

22. Bos C, Benamouzig R, Bruhat A, Roux C, Valensi P, Ferriere F, et al. Nutritional status after short-term dietary supplementation in hospitalized malnourished geriatric patients. Clinical nutrition. 2001;20(3):225-33. 23. Mensink PAJS, De Bont MAT, Remijnse-Meester TA, et al. Landelijke Eerstelijns Samenwerkingsafspraak Ondervoeding. Huisarts Wet. 2010;53(7):S7-10.

24. Jonkers C, Klos M, Kouwenoord K, et al. Richtlijn screening en behandeling van ondervoeding. 2011. 25. Kruizenga H, Keeken S, Weijs P, et al. Undernutrition screening survey in 564,063 patients: patients with a positive undernutrition screening score stay in hospital 1.4 d longer. Clinical Nutrition. 2016 Apr;103(4):1026-32 26. Pirlicha M, Schütza T, Normana K, et al. German hospital malnutrition study. Clinical Nutrition.

2006;25(4):563-572

27. Volpi E, Campbell WW, Dwyer JT, Johnson MA, Jensen GL, Morley JE, et al. Is the optimal level of protein intake for older adults greater than the recommended dietary allowance? The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2013;68(6):677-81.

28. Nowson C, O’Connell S. Protein Requirements and Recommendations for Older People: A Review. Nutrients. 2015;7(8):6874-99.

29. Deer RR, Volpi E. Protein intake and muscle function in older adults. Curr Opin Clin Nutr Metab Care. 2015;18(3):248-53.

30. Bauer J, Biolo G, Cederholm T, Cesari M, Cruz-Jentoft AJ, Morley JE, et al. Evidence-based

recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. Journal of the American Medical Directors Association. 2013;14(8):542-59.

31. Wolfe R. The role of dietary protein in optimizing muscle mass, function and health outcomes in older individuals. Br J Nutr. 2012;108(2):88-93.

32. Ikezoe T, Mori N, Nakamura M, Ichihashi N. Effects of age and inactivity due to prolonged bed rest on atrophy of trunk muscles. European journal of applied physiology. 2012;112(1):43-8.

33. Moriggi M, Vasso M, Fania C, Capitanio D, Bonifacio G, Salanova M, et al. Long term bed rest with and without vibration exercise countermeasures: effects on human muscle protein dysregulation. Proteomics. 2010;10(21):3756-74.

34. Kortebein P, Ferrando A, Lombeida J, Wolfe R, Evans WJ. Effect of 10 days of bed rest on skeletal muscle in healthy older adults. Jama. 2007;297(16):1772-4.

35. Iolascon G, Di Pietro G, Gimigliano F, et al. Physical exercise and sarcopenia in older people: position paper of the Italian Society of Orthopaedics and Medicine. Clinical Cases in Mineral and Bone Metabolism.

2014;11(3):215-221.

36. Montero-Fernández N, Serra-Rexach JA. Role of exercise on sarcopenia in the elderly. Eur J Phys Rehabil Med. 2013;49(1)131-43.

37. Pillard F, Laoudj-Chenivesse D, Carnac G, et al. Physical activity and sarcopenia. Clin Geriatr Med. 2011;27(3):449-70.

22

Appendix A: list of search terms

P I C O

Elderly, 65+ Protein intervention Standard protein intake Muscle mass

Aged (MeSH) Protein (MeSH) Muscles (MeSH)

"Elderly" (KW) Dietary protein (MeSH) "Muscle mass" (KW)

Aged, 80 and over (MeSH) Amino acid (MeSH) "Lean body mass" (KW)

"Senior" (KW) "Fat free mass" (KW)

"Older people" (KW) Sarcopenia (MeSH)

"Older person" (KW) "Muscular atrophy" (KW)

Aging (MeSH) "Muscle loss" (KW)

Hospitalized "Muscle decay" (KW)

Hospitalization (MeSH) Muscle strength

"Hospitalized" (KW) Muscle strength (MeSH)

"Hospitalised" (KW) "Strenght" (KW)

Bed rest (MeSH) "Muscle power" (KW)

"In hospital" (KW) Muscle weakness (MeSH)

“Hospital” (KW) "Physical strength" (KW)

Inpatients (MeSH) Physical performance

“In-patient” (KW) Physical fitness (MeSH)

Motor activity (MeSH) "Physical performance" (KW) "Physical function" (KW) "Functional mobility" (KW) Mobility limitation (MeSH) Activities of daily living (MeSH) Table 8. List of search terms

23

Appendix B: search strings

Search #

Query

1 aged

2 "elderly"

3 Aged, 80 and over

4 "senior"

5 "older people"

6 "older person"

7 Aging

8

((((((aged) OR "elderly") OR (Aged, 80 and over)) OR "senior") OR "older people")

OR "older person") OR Aging

9 Hospitalization

11 "hospitalized"

12 "hospitalised"

13 bed rest

14 "in hospital"

15 "hospital"

16 Inpatients

17 “in-patient”

18

(((((((hospitalization) OR "hospitalized") OR "hospitalised") OR bed rest) OR "in

hospital") OR "hospital") OR inpatients) OR "in-patient"

19 protein

20 dietary protein

21 amino acid

22

((protein) OR dietary protein) OR amino acid

23 Muscles

24 "muscle mass"

25 "lean body mass"

26 "fat free mass"

27 sarcopenia

28 "muscular atrophy"

29 "muscle loss"

30 "muscle decay"

31

(((((((Muscles) OR "muscle mass") OR "lean body mass") OR "fat free mass") OR

sarcopenia) OR "muscular atrophy") OR "muscle loss") OR "muscle decay"

32 muscle strength

33 "strength"

34 "muscle power"

35 muscle weakness

36 "physical strength"

24

37

((((muscle strength) OR "strength") OR "muscle power") OR muscle weakness) OR

"physical strength"

38 physical fitness

39 motor activity

40 "physical performance"

41 "physical function"

42 "functional mobility"

43 mobility limitation

44 activities of daily living

45

((((((physical fitness) OR motor activity) OR "physical performance") OR "physical

function") OR "functional mobility") OR mobility limitation) OR activities of daily

living

46 randomized controlled trial

47 clinical trial

48 cohort study

49 cross-sectional study

50 case control study

51 ((((randomized controlled trial) OR clinical trial) OR cohort study) OR

cross-sectional study) OR case control study

Muscle mass

8 AND 18 AND 22

AND 31 AND 51

(((((((((((aged) OR "elderly") OR (Aged, 80 and over)) OR "senior") OR "older

people") OR "older person") OR Aging)) AND ((((((((hospitalization) OR

"hospitalized") OR "hospitalised") OR bed rest) OR "in hospital") OR "hospital") OR

inpatients) OR "in-patient")) AND (((protein) OR dietary protein) OR amino acid))

AND ((((((((Muscles) OR "muscle mass") OR "lean body mass") OR "fat free mass")

OR sarcopenia) OR "muscular atrophy") OR "muscle loss") OR "muscle decay")) AND

(((((randomized controlled trial) OR clinical trial) OR cohort study) OR

cross-sectional study) OR case control study)

Muscle strength

8 AND 18 AND 22

AND 37 AND 51

(((((((((((aged) OR "elderly") OR (Aged, 80 and over)) OR "senior") OR "older

people") OR "older person") OR Aging)) AND ((((((((hospitalization) OR

"hospitalized") OR "hospitalised") OR bed rest) OR "in hospital") OR "hospital") OR

inpatients) OR "in-patient")) AND (((protein) OR dietary protein) OR amino acid))

AND (((((muscle strength) OR "strength") OR "muscle power") OR muscle weakness)

OR "physical strength")) AND (((((randomized controlled trial) OR clinical trial) OR

cohort study) OR cross-sectional study) OR case control study)

Physical

performance

8 AND 18 AND 22

AND 45 AND 51

(((((((((((aged) OR "elderly") OR (Aged, 80 and over)) OR "senior") OR "older

people") OR "older person") OR Aging)) AND ((((((((hospitalization) OR

"hospitalized") OR "hospitalised") OR bed rest) OR "in hospital") OR "hospital") OR

inpatients) OR "in-patient")) AND (((protein) OR dietary protein) OR amino acid))

AND (((((((physical fitness) OR motor activity) OR "physical performance") OR

"physical function") OR "functional mobility") OR mobility limitation) OR activities

of daily living)) AND (((((randomized controlled trial) OR clinical trial) OR cohort

study) OR cross-sectional study) OR case control study)

Beoordelingsformulier: scriptie afstudeerproject (AP) Voeding & Diëtetiek, Hogeschool van Amsterdam

Naam student: Lisa van der Spijk, Terence Meeuwenoord

Titel en nummer AO The effect of a protein intervention on muscle mass, muscle strength and physical performance in elderly during a period of hospitalization, a systematic review. 2017110

Opdrachtgever VITAMINE Naam examinator: L. Stanic-Jovic

Naam docentbegeleider: M. Tieland

Datum: 06-01-2017

Criterium B H onvoldoende voldoende goed Score

o/v/g Randvoorwaardelijke

eisen (weging 0%) Zie ook Taal-en schrijfwijzer (DLWO) en Handleiding Afstudeerproject

3 I Niet op tijd ingeleverd

Leesbaarheid

De afstudeeropdracht is een aaneenschakeling van stukken tekst, het geheel loopt niet. Een eigen schrijfstijl is niet herkenbaar. Er zijn veel grammaticale en spelfouten. De formulering is persoonlijk, subjectief, vaag en wijdlopig. Structuur

De indeling in hoofdstukken, paragrafen en alinea’s is niet duidelijk van de probleemstelling afgeleid, De titel van de afstudeeropdracht dekt de lading niet en / of de kopjes van de paragrafen dekken de inhoud van de paragraaf niet. Lay-out

De lay-out is rommelig. Beelden, tabellen en figuren ondersteunen de tekst en argumenten niet. Omvang

De omvang is te ruim, er zijn herhalingen en niet relevante onderdelen opgenomen.

De omvang overschrijdt de 35 pagina’s, exl bijlagen en literatuurlijst

Samenvatting

De samenvatting geeft niet duidelijk en bondig de inhoud van de scriptie weer. Bepaalde relevante onderdelen zijn niet opgenomen. De omvang overschrijdt de 500 woorden. Bronverwijzing

De verwijzing naar bronnen is een aantal keren niet goed toegepast. Er staan bronnen in de literatuurlijst die niet in de tekst terug te vinden zijn. Elektronische bronnen zijn verkeerd verwezen en geciteerd.

Op tijd ingeleverd Leesbaarheid

De afstudeeropdracht leest redelijk vlot, er zijn weinig grammaticale en spelfouten. De formulering is bondig, hier en daar wat algemeen en niet overal even formeel. Het verhaal is een lopend geheel. Structuur

De hoofdstukindeling is logisch afgeleid van de probleemstelling, maar de onderverdeling op lager niveau is voor verbetering vatbaar.

De titels van de afstudeeropdracht, de hoofdstukken en paragrafen zijn niet altijd kernachtig geformuleerd en representatief voor de inhoud.

Lay-out

Er zijn kleine fouten in de lay-out, maar die beïnvloeden de leesbaarheid niet. Een enkele keer is het gebruik van beelden, tabellen en figuren niet functioneel.

Omvang

De omvang is passend en ligt rond de 30 pagina’s, exclusief bijlagen en literatuurlijst

Samenvatting

De samenvatting is over het algemeen bondig geformuleerd en passend bij de inhoud. Bronverwijzing

In de verwijzing naar bronnen zijn een paar kleine fouten. Vancouver richtlijnen zijn consistent gebruikt. De meeste elektronische bronnen zijn correct verwezen en geciteerd.

Op tijd ingeleverd Leesbaarheid

De afstudeeropdracht is vlot leesbaar en in correct Nederlands of Engels geschreven: de formulering is bondig, concreet en formeel.

De rode draad in het verhaal is duidelijk. Structuur

De indeling in hoofdstukken, paragrafen en alinea’s is logisch afgeleid van de probleemstelling en duidelijk De titels van de afstudeeropdracht, de hoofdstukken en paragrafen zijn kernachtig geformuleerd en representatief voor het geheel. Ze kondigen de inhoud correct aan.

Lay-out

De lay-out is functioneel en professioneel. Gebruik van beelden, tabellen en figuren is functioneel en bijlagen worden benut waar nodig. Omvang

De omvang is passend, kernachtig en efficiënt. De omvang is maximaal 30 exclusief bijlagen en literatuurlijst

Samenvatting

De samenvatting is kernachtig geformuleerd en representatief voor de inhoud. De omvang is maximaal 500 woorden. De samenvatting leest vlot en is in correct Nederlands of Engels geschreven. Bronverwijzing

De verwijzing naar alle bronnen zijn correct volgens richtlijnen uit de Taal-en schrijfwijzer (afgeleid van Vancouver) uitgevoerd.

26

Criterium B H Cijfer 1,0- 5,0 Cijfer 5,5-7,5 Cijfer 8-10 Cijfer

1. correcte definiëring en consistente uitwerking probleemstelling 1 3 4 6 I II

Als niet aan de criteria voor 5,5-7,5 is voldaan.

De probleemstelling (en deelvragen) worden systematisch uitgewerkt in 55-75% van de scriptie

De probleemstelling (en deelvragen) worden systematisch uitgewerkt in 80-100% van de scriptie. Toelichting 2. verantwoording (onderzoeks)methode 1 3 6

II Als niet aan de criteria voor 5,5-7,5 is voldaan.

De gekozen methode sluit aan bij de probleemstelling en wordt inzichtelijk beargumenteerd.

(De methode staat zodanig beschreven dat het onderzoek herhaalbaar is)

+ De gekozen methode is informatiever beschreven en wetenschappelijk onderbouwd. Toelichting 3. juiste weergave resultaten 1 3 6 I II

Als niet aan de criteria voor 5,5-7,5 is voldaan.

De analyse van gegevens is correct uitgevoerd

De resultaten staan objectief, correct en overzichtelijk beschreven/gepresenteerd (resultaten komen voort uit het

onderzoek).Tabellen en figuren zijn conform regels.

+ De belangrijkste resultaten worden gescheiden van de minder belangrijke (bv in bijlage) in relatie tot de probleemstelling.

Toelichting

4. juistheid, opbouw en niveau van discussie en conclusie 1 3 6 I II IV

Als niet aan de criteria voor 5,5-7,5 is voldaan.

De resultaten worden correct geïnterpreteerd en vergeleken met de literatuur

Conclusie geeft antwoord op de probleemstelling. Sterke en zwakke punt worden correct benoemd.

+ De helicopterview wordt toegepast, waarbij relevante ontwikkelingen in de beroepspraktijk en aanverwante domeinen zijn beschreven.

Toelichting

5. concrete aanbevelingen die voortkomen uit het onderzoek/opdracht (indien eindproduct in bijlage zit wel meerekenen)

4 5

III Als niet aan de criteria voor 5,5-7,5 is voldaan.

Aanbevelingen vloeien logisch voort uit de discussie en conclusie.

+ De aanbevelingen zijn bruikbaar voor de organisatie en voor het gehele werkveld. + De aanbevelingen zijn creatief en innovatief

+ Er wordt een transfer gemaakt naar (ontwikkelingen in) andere werkvelden. Toelichting

27

Criterium B H Cijfer 1- 5,5 Cijfer 5,5-7,5 Cijfer 8-10 Cijfer

6. niveau en actualiteit (Engelstalige) literatuur

7 I II

Als niet aan de criteria voor 5,5-7,5 is voldaan

De student gebruikt wetenschappelijke literatuur die ingaat op recente ontwikkelingen en geeft dit in scriptie voldoende weer.

+ De student laat zien literatuur op een hoger niveau te integreren in de scriptie

Toelichting

Eindcijfer 1+2+3+4+5+6/6 =

Naam en handtekening Examinator/ docentbegeleider *: ……….

NB* = weghalen wat niet van toepassing is.

B= Beroepscompetenties Opleiding Voeding & Diëtetiek:

1.Advisering: Analyseren van problemen vragen en behoeften op het gebied van voeding, doelen stellen gebaseerd op wetenschappelijke inzichten en afstemming met stakeholders en daarover

adviseren, rekening houdend met relevante randvoorwaarden.

2.Begeleiding: Begeleiden van de uitvoering van adviezen gericht op problemen, vragen of behoeften op het gebied van voeding.

3. Rapportage: Registreren, evalueren en rapporteren van resultaten en procedures of richtlijnen ontwikkelen ter optimalisering van effecten van voeding

4. Marketing: Analyseren van een vraag van een onderneming/organisatie naar producten en/of diensten, doelen stellen en een strategie formuleren en implementeren, rekening houdend met

relevante randvoorwaarden.

5.Management Coördineren en aansturen van bedrijfsprocessen, gebaseerd op de strategie van de onderneming / organisatie / afdeling.

Vaststellen strategie, beleid en planning van een organisatie.

6.Onderzoek: Opzetten en uitvoeren van voeding gerelateerd praktijkgericht onderzoek, verwerken van gegevens en rapporteren van resultaten.

7. Professionalisering: Integer handelen, rekening houden met vertrouwensrelatie en ethische aspecten. Integreren nieuwe inzichten, werkwijzen, producten en diensten in de eigen werkzaamheden

en communiceert hierover. H= hbo-standaard

I Een gedegen theoretische basis II Het onderzoekend vermogen III Professioneel vakmanschap