| 摘要: | 背景：吞嚥困難是因口咽部及食道結構或吞嚥神經系統受損而破壞口腔準備階段、口腔推進階段、咽部階段以及食道階段所導致。飲食調整（質地調整飲食和使用液體增稠劑）是治療吞嚥困難的重要部分，其目的是確保安全地將固體和液體食物運送到胃中，以防止誤吸。以往的研究並未證實飲食調整（質地調整飲食和液體增稠劑）能有效預防吸入性肺炎及改善吞嚥困難患者的食物攝取、營養狀況與生活品質。為在現有的證據上並彌補先前系統性回顧和統合分析中的缺失，本研究進行一項隨機對照試驗的統合分析，以確定飲食調整（質地調整飲食/液體增稠劑）對吞嚥困難患者的膳食營養攝取量（熱量、蛋白質、脂肪、碳水化合物、鈉、纖維）、誤吸、液體攝取與身體組成（身體質量指數和體重）。
方法：本研究於EMBASE、Cochrane Library、CINAHL、Web of Science、PubMed以及先前發表的系統性回顧和統合分析的參考文獻列表中進行全面的文獻搜尋，直到2023年4月。本研究將使用Cochrane風險偏倚評估工具2.0來評估納入研究的偏倚風險。資料將以全面統合分析 (comprehensive meta-analysis, CMA) 3.0軟體分析，並將採用隨機效應模型獲得聚合效應大小。以Hedge's g分析質地調整飲食和液體增稠劑對成人吞嚥困難連續型結果變量（熱量攝取量、蛋白質攝取量、碳水化合物攝取量、脂肪攝取量、纖維攝取量、鈉攝取量、液體攝取量和身體組成（身體質量指數和體重）聚合效應大小的測量，以及二元結果（吞嚥困難患者的誤吸）的綜合風險比，以評估質地調整飲食和液體增稠劑的影響。使用Cochran's Q統計的2檢定(p< 0.10)檢驗納入研究間的變異性，並由I^2統計指數以25%、50%及75%的閾值分別揭示低、中及高異質性。我們將進行子組分析和統合回歸以進行調節變數分析。
結果：本研究統合分析納入從電子資料庫和 Google 手動搜尋中檢索到的 3,854 項研究中總共 16篇隨機對照試驗，共 1,812 名吞嚥困難患者。吞嚥困難病人採用質地調整飲食/增稠液體介入措施與對照組相比對增加其熱量攝取量有顯著的小到中等影響 (Hedges’ g = 0.37, 95% CI = 0.05–0.68, p<0.024)；對蛋白質攝取量顯著增加 (Hedges’ g = 0.56, 95%CI = 0.13–0.99, p<0.05)，但對脂肪攝取量 (Hedge’s g: 0.46, 95% CI = -0.06–0.98) ；碳水化合物攝取 (Hedge’s g: -0.01, 95% CI = -0.39–0.36)；鈉攝取量 (Hedge’s g: 0.26, 95% CI = -0.15–0.67) ；纖維攝取量 (Hedge’s g: -0.36, 95% CI = -1.13–0.59) 與則未顯著改變。吞嚥困難病人採用增稠液體與非增稠液體相比顯著降低誤吸風險 (OR = 0.59, 95% CI = 0.44–0.79, p<0.001) 。增稠液體對增加液體攝取量有顯著的成效 (Hedge's g = 3.96, 95% CI = 0.75–7.16) 。質地調整飲食和增稠液體對改善身體質量指數 (Hedge's g = 0.20, 95% CI = -0.29–0.68) 和增加體重 (Hedge's g = 0.18, 95% CI = -0.16–0.52) 無顯著影響。
關鍵詞：成人，吞嚥困難，飲食調整、液體增稠劑，質地調整飲食，飲食營養、液體攝取、誤吸、統合分析。
Background: Dysphagia occurs due to disruptions in the oral-preparatory, oral-transit, pharyngeal, and esophageal phases as a result of impairment in the oropharyngeal and esophageal structures or swallowing neural network. Diet modification (texture-modified diets and thickened fluids) is a crucial part of dysphagia management by ensuring the safe transit of solid and liquid boluses and safeguarding the air way against aspiration and penetration among people with dysphagia. Prior studies have not convincingly demonstrated that diet modification (texture-modified diets / thickened fluids) can effectively prevent aspiration pneumonia nor improve oral intake, nutritional status, and quality of life for people with dysphagia. To build upon existing knowledge and address the gaps in previous systematic reviews and meta-analyses, we performed a meta-analysis of randomized controlled trials to determine and explore the efficacy of diet modification (texture-modified diets / thickened fluids) on dietary nutrients intake (energy, protein, fat, carbohydrate sodium, and fiber), aspiration, fluid intake, and body composition (body mass index and body weight) in people with dysphagia.
Methods: Through comprehensively conducted literature search in EMBASE, Cochrane Library, Ovid-Medline, CINAHL, Web of Science, PubMed, and reference lists of previous published systematic reviews and meta-analyses until November, 2023. The quality of the included studies was assessed by the Cochrane Risk of Bias Assessment tool 2.0. Data analysis was performed in Comprehensive Meta-analysis (CMA) 3.0 with the random-effects model being adopted for the pooled effect size of continuous and binary outcomes. The Hedge’s g was used as the effect measure for the pooled effect size for continuous outcomes (dietary nutrients intake (energy, lipid, fat, protein, sodium, fiber, and carbohydrate), fluid intake, body composition (body mass index and weight status), and product appreciation) and pooled odds ratio (OR) for binary outcome (aspiration). Statistical heterogeneity among the included studies was examined using a X^2-based test using Cochran's Q statistic (P < 0.10) and quantified by the I^2statistic with cut-off scores of 25%, 50%, and 75% revealing low, moderate, and high heterogeneity, respectively.
Results: A total of 16 randomized controlled trials from 3,854 studies retrieved from electronic databases and manual search in Google with 1,812 people with dysphagia were included in this meta-analysis. Texture-modified diets and thickened fluids revealed a significant small to medium effect on increasing energy intake with Hedge's g = 0.37 (95% CI = 0.05–0.68, p<0.024) and protein intake with Hedge's g = 0.56 (95% CI = 0.13–0.99, p<0.05). Texture-modified diets revealed non-significant effect on increasing carbohydrate intake (Hedge’s g: -0.01, 95% CI = -0.39–0.36), fat intake fat intake (Hedge’s g: 0.46, 95% CI= -0.06 – 0.98), sodium intake (Hedge’s g: 0.26, 95% CI = -0.15–0.67), and fiber intake (Hedge’s g: -0.36, 95% CI = -1.13–0.59) compared to control diet. Thickened fluids revealed a significant reduced risk of aspiration with OR = 0.59 (95% CI = 0.44–0.79, p<0.001) compared to non-thickened fluids. Thickened fluids demonstrated a significant large effect in increasing fluid intake with Hedge's g = 3.96 (95% CI = 0.75–7.16) compared with control. Texture-modified diets and thickened fluids had a non-significant effect on improving body mass index with Hedge's g = 0.20 (95% CI = -0.29–0.68) and increasing body weight with Hedge's g = 0.18 (95% CI = -0.16–0.52) compared to control diet.
Conclusions: The findings of this meta-analysis demenstrate that texture-modified diets and thickened fluids increase dietary intake of energy and protein intake in people with dysphagia. In addition, the findings of the meta-analysis also reveal that thickened fluids prevent aspiration, and thickened fluids increase fluid intake in people with dysphagia.
Keywords: Adult, Dysphagia, Diet Modification, Thickened Fluids, Texture-modified diets, Dietary Nutrients, Fluid Intake, Aspiration, Meta-Analysis |
