The cost effectiveness of personalized dietary advice to increase protein intake in older adults with lower habitual protein intake: a randomized controlled trial

Ilse Reinders, Marjolein Visser, Satu K Jyväkorpi, Riikka T Niskanen, Judith E Bosmans, Ângela Jornada Ben, Ingeborg A Brouwer, Lothar D Kuijper, Margreet R Olthof, Kaisu H Pitkälä, Rachel Vijlbrief, Merja H Suominen, Hanneke A H Wijnhoven, Ilse Reinders, Marjolein Visser, Satu K Jyväkorpi, Riikka T Niskanen, Judith E Bosmans, Ângela Jornada Ben, Ingeborg A Brouwer, Lothar D Kuijper, Margreet R Olthof, Kaisu H Pitkälä, Rachel Vijlbrief, Merja H Suominen, Hanneke A H Wijnhoven

Abstract

Purpose: To examine the cost effectiveness of dietary advice to increase protein intake on 6-month change in physical functioning among older adults.

Methods: In this multicenter randomized controlled trial, 276 community-dwelling older adults with a habitual protein intake < 1.0 g/kg adjusted body weight (aBW)/d were randomly assigned to either Intervention 1; advice to increase protein intake to ≥ 1.2 g/kg aBW/d (PROT, n = 96), Intervention 2; similar advice and in addition advice to consume protein (en)rich(ed) foods within half an hour after usual physical activity (PROT + TIMING, n = 89), or continue the habitual diet with no advice (CON, n = 91). Primary outcome was 6-month change in 400-m walk time. Secondary outcomes were 6-month change in physical performance, leg extension strength, grip strength, body composition, self-reported mobility limitations and quality of life. We evaluated cost effectiveness from a societal perspective.

Results: Compared to CON, a positive effect on walk time was observed for PROT; - 12.4 s (95%CI, - 21.8 to - 2.9), and for PROT + TIMING; - 4.9 s (95%CI, - 14.5 to 4.7). Leg extension strength significantly increased in PROT (+ 32.6 N (95%CI, 10.6-54.5)) and PROT + TIMING (+ 24.3 N (95%CI, 0.2-48.5)) compared to CON. No significant intervention effects were observed for the other secondary outcomes. From a societal perspective, PROT was cost effective compared to CON.

Conclusion: Dietary advice to increase protein intake to ≥ 1.2 g/kg aBW/d improved 400-m walk time and leg strength among older adults with a lower habitual protein intake. From a societal perspective, PROT was considered cost-effective compared to CON. These findings support the need for re-evaluating the protein RDA of 0.8 g/kg BW/d for older adults.

Trial registration: The trial has been registered at ClinicalTrials.gov (NCT03712306). Date of registration: October 2018. Registry name: The (Cost) Effectiveness of Increasing Protein Intake on Physical Functioning in Older Adults. Trial Identifier: NCT03712306.

Keywords: 400 m walk; Physical functioning; Protein intake; Protein recommendation; RCT; Timing.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Randomization and participants flow of the PROMISS Randomized Clinical Trial. aCut-off values of the Pro55+ screener depended on response rates; when response rates to recruitment strategies were low, the cut-off of > 0.15 was applied, while when response rates to recruitment strategies were high, the cut-off of > 0.30 was applied. bDue to the spread of COVID-19 some participants did not want to come to the clinic to perform the measurements, and measured data were therefore missing. Data collected by questionnaires were obtained. cMissing data were imputed via multiple imputation for the primary analysis of change in 400-m walk time
Fig. 2
Fig. 2
Categories of protein intake at 3 time points during the PROMISS trial. Protein intake was expressed in grams per kilogram adjusted body weight per day (g/kg aBW/d). Participants were included when habitual protein intake was

Fig. 3

Change in 400-m walk time.…

Fig. 3

Change in 400-m walk time. Values are means and the bars represent the…

Fig. 3
Change in 400-m walk time. Values are means and the bars represent the 95% CI of the mean. CON = no intervention (slower walkers N = 44, faster walkers N = 47); PROT = personalized dietary advice aimed at increasing protein intake to at least 1.2 g/kg aBW/d (slower walkers N = 51, faster walkers N = 45); and PROT+TIMING = personalized dietary advice aimed at increasing protein intake to at least 1.2 g/kg aBW/d plus advice to time protein intake in close proximity of usual physical activity (slower walkers N = 44, faster walkers N = 46)

Fig. 4

Cost-effectiveness planes (CE-plane) from the…

Fig. 4

Cost-effectiveness planes (CE-plane) from the societal perspective. Cost-effectiveness planes (CE-plane) from the societal…

Fig. 4
Cost-effectiveness planes (CE-plane) from the societal perspective. Cost-effectiveness planes (CE-plane) from the societal perspective showing the incremental cost-effectiveness ratio point estimate (red dot) and the distribution of the 5000 replications of the bootstrapped cost-effective pairs (blue dots). Cost-effectiveness acceptability curves (CEAC) indicating the probability of cost-effectiveness (y-axis) for different willingness-to-pay (WTP) thresholds per unit of effect gained (x-axis)
Fig. 3
Fig. 3
Change in 400-m walk time. Values are means and the bars represent the 95% CI of the mean. CON = no intervention (slower walkers N = 44, faster walkers N = 47); PROT = personalized dietary advice aimed at increasing protein intake to at least 1.2 g/kg aBW/d (slower walkers N = 51, faster walkers N = 45); and PROT+TIMING = personalized dietary advice aimed at increasing protein intake to at least 1.2 g/kg aBW/d plus advice to time protein intake in close proximity of usual physical activity (slower walkers N = 44, faster walkers N = 46)
Fig. 4
Fig. 4
Cost-effectiveness planes (CE-plane) from the societal perspective. Cost-effectiveness planes (CE-plane) from the societal perspective showing the incremental cost-effectiveness ratio point estimate (red dot) and the distribution of the 5000 replications of the bootstrapped cost-effective pairs (blue dots). Cost-effectiveness acceptability curves (CEAC) indicating the probability of cost-effectiveness (y-axis) for different willingness-to-pay (WTP) thresholds per unit of effect gained (x-axis)

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