Introduction
Methods
Selection Criteria
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For bone fracture incidence, any measure of BMD, e.g. bone mineral density (BMD), bone mineral content (BMC) or total bone mass.
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For muscle sarcopenia or dynapenia (age-associated loss of muscle strength) incidence, skeletal muscle mass.
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For functional status mobility scores or other validated functional status measures, e.g. Barthel Index or Activities of Daily Living (ADL).
Search Methods for Identification of Studies
Data Collection and Assessment of Risk of Bias
Data Synthesis
Results
Study/location | Participants | N (I/C) | Intervention/duration | Outcome measures | Summary risk of bias |
---|---|---|---|---|---|
Omega-3 intervention studies: | |||||
Baxheinrich 2012/Germany [39] | Metabolic syndrome patients. Mean age (sd): 52.3 (10.6) int., 50.3 (9.8) control | 95 (47/48) | Rapeseed oil and margarine (3.5 g/d ALA) versus olive oil/6 months | Primary: lean mass % | Moderate/high |
Clark 2016/UK [68] | Adults with DM or impaired glucose. Mean age (sd): 61.8 (NR) int., 58.1 (NR) control | 33 (16/17) | FO capsules (3.9 g EPA + DHA) versus maize oil/9 months | Primary: Lean mass % and kg | Moderate/high |
Dasarathy 2015/USA [60] | NASH patients with DM. Mean age (sd): 51.5 (6.9) int., 49.8 (12.1) control | 37 (18/19) | FO capsules (5.8 g EPA + DHA) versus corn oil/11 months | Primary: Lean mass, bone mass | Moderate/high |
Dodin 2005/Canada [40] | Healthy menopausal women. Mean age (sd): 54.0 (4.0) int., 55.4 (4.5) control | 199 (101/98) | Flaxseed (9.1 g/d ALA) versus wheat germ/12 months | Primary: BMD | Moderate/high |
EPOCH 2011/Australia [69] | Healthy older adults with no cognitive impairment. Mean age NR, but 65–90 recruited | 391 (195/196) | FO capsules (2.3 g EPA + DHA) versus olive oil/18 months | Primary: Yale Physical Activity Survey (not reported) | Moderate/high |
FOSTAR 2016/Australia [70] | Adults with knee osteoarthritis. Mean age (sd): 60.8 (10) int., 61.1 (10) control | 202 (101/101) | FO supplement (4.5 g/d EPA + DHA) versus sunola + fish (0.45 g EPA + DHA)/2 years | Primary: BMD, WOMAC function score | Low |
Gruenwald 2009/Germany [58] | People with moderate-to-severe hip/knee osteoarthritis. Age, mean (sd) yrs: control 62.4 (8), intervention 62.2 (7.7) | 177 (90/87) | FO capsules (600 mg/d EPA + DHA) ± glucosamine sulphate/6 months | Primary: WOMAC function score | Low |
Older post-menopausal women. Age, mean (sd) yrs: control 75 (7), intervention 75 (6) | 126 (85/41) | FO capsules (1.2 g/d EPA + DHA) versus olive oil/26 weeks | Primary: Fracture incidence Secondary: walking speed, repeated chair rises, hand grip, OC, BAP, NTX, PTH | Moderate/high | |
MAPT 2017/France and Monaco [55] | Elderly adults ≥ 70 years with memory complaint but no dementia Mean age (sd): 75·6(4·7) and 74.4 (4.4)int., 75·1 (4·3) and 75 (4.1)control | 1680** (840/840) | Omega-3 (1.025 g/d EPA + DHA) versus paraffin oil (± multi-domain intervention)/3 years | Primary: Short physical performance battery (SPPB), Fried frailty criteria (gait speed) | Low |
MEMO 2008/Netherlands [71] | Independently living people aged ≥ 65 Mean age (sd), years: 69.9 (3.4) int high dose, 70.1 (3.7) control | 202 (96/106)* | Omega-3 (1.8 g/d EPA + DHA) versus high oleic acid sunflower oil/6 months | Primary: WHOQOL-BREF (Physical health domain 7–35) | Moderate/high |
Norouzi 2014/Iran [72] | Patients with chronic traumatic spinal cord injury. Mean age (sd): 51.15 (13.43) int., 54.12 (11.76) control | 110 (55/55) | Omega-3 (1 g/d EPA + DHA) versus unclear placebo/14 months | Primary: FIM + FAM (locomotion subscale) | Moderate/high |
NutriStroke 2009/Italy [73] | Stroke survivors in a rehab unit. Mean age (sd): 61.3 (13.6) n3, 66.3 (11.4) n3 + antiox int., 68.4 (12.6) placebo, 65.1 (12.8) antiox-control | 72** (38/34) | FO capsules (0.5 g/d EPA + DHA) versus unclear placebo (± antioxidants)/12 months | Primary: Rivermead Mobility Index (RMI) | Moderate/high |
OMEGA AD 2006/Sweden [74] | People with mild-to-moderate Alzheimer’s disease. Mean age (sd): 72.6 (9.0) int., 72.9 (8.6) control. | 204 (103/101) | Omega-3 (2.32 g/d EPA + DHA) versus. corn oil/6 months | Primary: Arm muscle circumference | Moderate/high |
Salari Sharif 2010/Iran [22] | Osteoporotic post-menopausal women. Age (Mean): 60.0 (5.6), int., 63 (8.9) control | 25 (13/12) | Omega-3 capsules (0.9 g/d n3 fats) versus unclear placebo/6 months | Secondary: OC, BAP, PTH, PYD | Moderate/high |
Sinn 2012/Australia [53] | Older people with mild cognitive impairment. Mean age (sd): 74.88 (5.06) intEPA, 74.22 (7.00) IntDHA, 73 (3.96) = LAgroup | 54 (18, 18/18) | EPA-rich FO (1·67 g EPA + 0·16 g DHA/d) versus DHA-rich FO (1·55 g DHA + 0·40 g EPA/d) versus safflower oil (2·2 g LA/d)/6 months | Primary: SF-36 physical functioning (results not reported) | Low |
Smith 2015/USA [75] | Healthy older adults. Mean age (sd) yrs: 68 (5) int., 69 (7) control | 60 (40/20) | Omega-3 capsules (3.36/d EPA + DHA) versus corn oil/6 months | Primary: Thigh Muscle mass. Secondary: hand grip, 1-RM strength | Moderate/high |
Stammers 1992/UK [51] | Patients with clinical diagnosis of osteoarthritis. Mean age (sd) yrs: 67 (NR) int., 69 (NR) control. | 86 (44/42) | Cod liver oil (786 mg/d EPA) versus olive oil/24 weeks | Primary: VAL of disability | Moderate/high |
Sufolom3 2010/France [56] | People with a history of MI, unstable angina or ischaemic stroke. Mean age (sd): 61.1 (8.8) int., 60.8 (8.7) control | 2501(1248/1253) | Omega-3 capsules (0.6 g/d EPA + DHA) versus liquid paraffin capsules/4 years | Primary: SF-36-physical functioning | Low |
Tardivo 2015/Brazil [44] | Post-menopausal women with metabolic syndrome. Mean age (sd) years: 55.1 (6.6) int., 55.0 (7.3) control | 87 (44/43) | Omega-3 capsules (0.9 g/d EPA + DHA) versus nil/6 months | Primary: Muscle mass % | Moderate/high |
Tartiban 2011/Iran [45] | Sedentary post-menopausal women. Mean age (sd) yrs: 59.7 (2.3) int with exercise, 63.1 (7.5) int alone, 61.4 (6.9) exercise alone, 58.9 (8.1) no int | 79** (41/38) | FO capsules (0.9 g/d EPA + DHA) versus nil (± exercise)/6 months | Primary: BMD Secondary: OC, CTX, PTH | Moderate/high |
Vanlint 2012/Australia [46] | Sedentary post-menopausal women. Mean age (sd) yrs: 59.2 (NR) overall, not reported by arm. | 40 (20/20) | Algal oil capsules (0.4 g/d DHA) versus corn oil/12 months | Primary: BMD Secondary: CTX | Moderate/high |
Wang 2016/China [76] | Type 2 diabetic patients with abdominal obesity. Mean age (sd): 64.6 (5.5) int., 66.3 (5.1) control | 100 (50/50) | FO capsules/d (2.4 g/d EPA + DHA) versus corn oil capsules/6 months | Primary: Muscle mass, lean mass | Moderate/high |
WELCOME 2014/UK [77] | Patients with NAFLD. Mean age (sd): 48.6 (11.1) int., 54 (9.6) control. | 103 (51/52) | Omega-3 capsules (3.36 g/d EPA + DHA) versus olive oil capsules/15–18 months | Primary: Lean mass | Moderate/high |
Omega-6 intervention studies | |||||
Glamt 1993/UK and Finland [49] | People with mild diabetic neuropathy. Age, mean (sd) yrs: control 52.9 (11.4), intervention 53.3 (11.1) | 111 (54/57) | EPO (0.48 g/d GLA) versus paraffin/1 year | Secondary: Arm and leg muscle strength | Moderate/high |
Mixed PUFA intervention studies | |||||
Bassey 2000/UK [38] | Healthy post-menopausal women aged 50–65 years. Mean age (SD): 58 (4.6) int., 55 (4.6) control. | 45 (21/24) | EPO + FO capsules plus calcium versus calcium (4.4 g/d PUFA)/12 months | Primary: BMD. Secondary: Leg extensor power OC, BSAP, NTX, uHyp, PTH, | Moderate/high |
Kruger 1998/South Africa [43] | Women from old age homes with osteoporosis/osteopenia. Age, mean (sd) yrs: control 77.2 (6.4), intervention 78.66 (5.77) | 60 (29/31) | EPO + FO (4.5 g/d PUFA, 4.1 n6, 0.4 n3) versus coconut oil/18 months | Primary: BMD. Secondary: walking speed, hand grip, OC, NTX, BAP, PTH, PICP, DPD, urinary Ca | Moderate/high |
Diabetic (or with CVD risk) men 55–80 years and women 60–80 years. Mean age (sd) years: 68.4 (6.0) int., 67.8 (6.5) control | 175 (85/90)§ | 30 g/d mixed nuts (rich in ALA and LA) versus extra-virgin olive oil (+Med diet advice)/1 year | Primary: BMD Secondary: OC, CTX, P1NP, PTH, BAP, urinary Ca/creatinine, DPD | Moderate/high | |
Diabetic (or with CVD risk) men 55–80 years and women 60–80 years | 234 (102/112)§ | 30 g/d mixed nuts (rich in ALA and LA) versus extra-virgin olive oil (+Med diet advice)/2 years | Primary: FFM | Moderate/high |
Effects of Higher Omega-3
Higher versus lower omega-3 for musculoskeletal health and functional status in older adults | ||||||
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Patient or population: older adults with or without musculoskeletal health problems Setting: community or institutional Intervention: Higher omega-3 intake Comparison: lower omega-3 intake | ||||||
Outcomes | Anticipated absolute effects* (95% CI) | Relative effect (95% CI) | № of participants (studies) | Certainty of the evidence (Grade) | Comments | |
Risk with lower omega-3 | Risk with higher omega-3 | |||||
Fracture incidence | 24 per 1000 | 4 per 1000 (0 to 95) | RR 0.16 (0.01 to 3.91) | 126 (1 RCT) | ⨁◯◯◯ very lowa,b,c | The effect of increasing omega-3 fats on fracture incidence is unclear as the evidence is of very low quality. Downgraded once for risk of bias, twice for imprecision |
Lumbar BMD, g/cm2 | The mean lumbar BMD was 1.15 g/cm2 | The mean lumbar BMD in the intervention group was 0.03 g/cm2 higher (0.02 lower to 0.07 higher) | – | 463 (4 RCTs) | ⨁⨁◯◯ lowd,e | Increasing omega-3 may slightly increase lumbar BMD (as change was > 2% of baseline). Downgraded once each for inconsistency and imprecision |
Femoral neck BMD, g/cm2 | The mean femoral neck BMD was 0.97 g/cm2 | The mean femoral neck BMD in the intervention group was 0.04 g/cm2 higher (0 to 0.08 higher) | – | 463 (4 RCTs) | ⨁◯◯◯ very lowd,e,f | The effect of increasing omega-3 fats on femoral neck BMD is unclear as the evidence is of very low quality. Downgraded once each for risk of bias, inconsistency and imprecision |
Total proximal femur BMD, g/cm2 | The mean total proximal femur BMD was 0.87 g/cm2 | The mean total proximal femur BMD in the intervention group was 0.03 g/cm2 higher (0.3 lower to 0.36 higher) | – | 37 (1 RCT) | ⨁◯◯◯ very lowb,g | The effect of increasing omega-3 fats on proximal femur BMD is unclear as the evidence is of very low quality. Downgraded once for indirectness and twice for imprecision |
Muscle mass (various measures) | Data combined using SMD | No suggestion of a statistically significant effect, SMD = 0.38, suggesting small-to-moderate effect size | – | 476 (7 RCTs) | ⨁◯◯◯ very lowh,I,j | The effect of increasing omega-3 fats on muscle mass is unclear as the evidence is of a very low quality. Downgraded once each for risk of bias, inconsistency and indirectness |
Total bone mass, kg | The mean total bone mass (kg) (omega3) as 24.6 kg | The mean total bone mass in the intervention group was 0.2 kg higher (2.8 lower to 3.2 higher) | – | 37 (1 RCT) | ⨁⨁◯◯ lowa,k,l,m | Increasing omega-3 intake may have little or no effect on total bone mass. One trial only. Downgraded for risk of bias and imprecision |
Measures of functional status (various measures) | Data combined using SMD | No suggestion of a statistically significant effect, SMD = − 0.04 suggesting little or no effect | – | 4166 (9 RCTs) | ⨁⨁◯◯ lowe,n | Increasing omega-3 may have little or no effect on various measures of functional status. Downgraded once each for indirectness and publication bias |
Fractures
Bone Density
Bone Mineral Density (BMD)
Skeletal Muscle Mass
Functional Status
Secondary Outcomes
Measures of Physical Performance/Strength
Effects of Omega-6
Primary Outcomes
Secondary Outcomes
Effects of Mixed Total PUFA
Higher versus lower total PUFA for musculoskeletal health and functional status in older adults | ||||||
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Patient or population: older adults with or without musculoskeletal health problems Setting: community or institutional Intervention: Higher total PUFA intake Comparison: Lower total PUFA intake | ||||||
Outcomes | Anticipated absolute effects* (95% CI) | Relative effect (95% CI) | No. of participants (studies) | Certainty of the evidence (GRADE) | Comments | |
Risk with lower total PUFA | Risk with higher total PUFA | |||||
Fracture incidence | 0 | No evidence found | ||||
BMD (total body, lumbar and calcaneal combined), g/cm2 | Mean BMD at baseline was 0.9 g/cm2 | The mean BMD in the intervention group was no different (0.01 g/cm2 lower to 0.02 higher) | – | 245 (3 RCTs) | ⨁⨁◯◯ lowa,b,c | Increasing total PUFA may have little or no effect on BMD. Data combined from studies reporting BMD at various sites. Downgraded once each for risk of bias and indirectness |
Muscle mass, fat-free mass, kg | The mean fat-free mass at baseline was 50 kg | The mean fat-free mass in the intervention group was 0.5 kg lower (1.63 lower to 0.63 higher) | – | 214 (1 RCT) | ⨁⨁◯◯ lowa,c,d | Increasing total PUFA may have little or no effect on fat-free mass. Downgraded once each for risk of bias and indirectness |
Total bone mass, kg | 0 | No evidence found | ||||
Measures of functional status | 0 | No evidence found |