Diagnostic criteria for malnutrition - An ESPEN Consensus Statement

Protein-energy wasting significantly increases healthcare utilization and costs among patients with chronic kidney disease: a propensity-score matched cohort study

BACKGROUND

Disease-related malnutrition is highly prevalent, and has prognostic implications for patients with chronic kidney disease (CKD); however, few studies have investigated the impact of malnutrition, or protein-energy wasting (PEW), on healthcare utilization and medical expenditure among CKD patients.

METHODS

Using claim data from the National Health Insurance in Taiwan, this study identified patients with CKD between 2009-2013 and categorized them into those with mild, moderate, or severe CKD. Cases with PEW after CKD was diagnosed were propensity-score matched with controls in a 1:4 ratio. Healthcare resource utilization metrics were compared, including outpatient and emergency department visits, frequency and duration of hospitalization, and the cumulative costs associated with different CKD severity.

RESULTS

From among 347,501 CKD patients, eligible cohorts of 66,872 with mild CKD (49.2%), 27,122 with moderate CKD (19.9%), and 42,013 with severe CKD (30.9%) were selected. Malnourished CKD patients had significantly higher rates of hospitalization (p < .001 for all severities) and re-admission (p = .015 for mild CKD, p = .002 for severe CKD) than non-malnourished controls. Cumulative medical costs for outpatient and emergency visits, and hospitalization, were significantly higher among all malnourished CKD patients than non-malnourished ones (p < .001); total medical costs were also higher among malnourished patients with mild (62.9%), moderate (59.6%), or severe (43.6%) CKD compared to non-malnourished patients (p < .001).

CONCLUSIONS

In a nationally-representative cohort, CKD patients with PEW had significantly more healthcare resource utilization and higher aggregate medical costs than those without, across the spectrum of CKD: preventing PEW in CKD patients should receive high priority if we would like to reduce medical costs.

Assessment of adult malnutrition and prognosis with bioelectrical impedance analysis: phase angle and impedance ratio

PURPOSE OF REVIEW

Malnutrition affects prognosis in many groups of patients. Although screening tools are available to identify adults at risk for poor nutritional status, a need exists to improve the assessment of malnutrition by identifying the loss of functional tissues that can lead to frailty, compromised physical function, and increased risk of morbidity and mortality, particularly among hospitalized and ill patients and older adults. Bioimpedance analysis (BIA) offers a practical approach to identify malnutrition and prognosis by assessing whole-body cell membrane quality and depicting fluid distribution for an individual.

RECENT FINDINGS

Two novel applications of BIA afford opportunities to safely, rapidly, and noninvasively assess nutritional status and prognosis. One method utilizes single-frequency phase-sensitive measurements to determine phase angle, evaluate nutritional status, and relate it to prognosis, mortality, and functional outcomes. Another approach uses the ratio of multifrequency impedance values to indicate altered fluid distribution and predict prognosis.

SUMMARY

Use of basic BIA measurements, independent of use of regression prediction models and assumptions of constant chemical composition of the fat-free body, enables new options for practical assessment and clinical evaluation of impaired nutritional status and prognosis among hospitalized patients and elders that potentially can contribute to improved patient care and clinical outcomes. However, these novel applications have some technical and physiological limitations that should be considered.

A requiem for BMI in the clinical setting

PURPOSE OF REVIEW

Quetelet reported in the nineteenth century that body weight varies across adults with the square of height. Quetelet's index, now known as BMI, is accepted by most health organizations as a first-level measure of body fat and as a screening tool for diagnosing excess adiposity. Modern imaging methods now, however, indicate that BMI has limited predictive value for estimating body fat and lean mass at the individual level. The use of BMI as a measure of body composition in the clinical setting should therefore be challenged.

RECENT FINDINGS

Recent studies enrolling cancer and surgical patients reported discrepant outcomes when BMI was used as a body composition surrogate. Sarcopenia, loss of muscle mass and function, which affects the elderly and those with chronic and acute diseases, is not accurately diagnosed with BMI. The distribution of adipose tissue is not characterized by BMI, specific measures of which have greater predictive value for metabolic impairments and clinical outcomes.

SUMMARY

BMI, as the traditional tool for assessing malnutrition and obesity, is not appropriate to accurately differentiate between important body weight components and therefore should not be used for making clinically important decisions at the individual patient level.

Current clinical nutrition practices in critically ill patients in Latin America: a multinational observational study

Background

Malnutrition in critically ill adults in the intensive care unit (ICU) is associated with a significantly elevated risk of mortality. Adequate nutrition therapy is crucial to optimise outcomes. Currently, there is a paucity of such data in Latin America. Our aims were to characterise current clinical nutrition practices in the ICU setting in Latin America and evaluate whether current practices meet caloric and protein requirements in critically ill patients receiving nutrition therapy.

Methods

We conducted a cross-sectional, retrospective, observational study in eight Latin American countries (Argentina, Brazil, Chile, Colombia, Ecuador, Mexico, Panama, and Peru). Eligible patients were critically ill adults hospitalised in the ICU and receiving enteral nutrition (EN) and/or parenteral nutrition (PN) on the Screening Day and the previous day (day −1). Caloric and protein balance on day –1, nutritional status, and prescribed nutrition therapy were recorded. Multivariable logistic regression analysis was performed to identify independent predictors of reaching daily caloric and protein targets.

Results

The analysis included 1053 patients from 116 hospitals. Evaluation of nutritional status showed that 74.1% of patients had suspected/moderate or severe malnutrition according to the Subjective Global Assessment. Prescribed nutrition therapy included EN alone (79.9%), PN alone (9.4%), and EN + PN (10.7%). Caloric intake met >90% of the daily target in 59.7% of patients on day –1; a caloric deficit was present in 40.3%, with a mean (±SD) daily caloric deficit of –688.8 ± 455.2 kcal. Multivariable logistic regression analysis showed that combined administration of EN + PN was associated with a statistically significant increase in the probability of meeting >90% of daily caloric and protein targets compared with EN alone (odds ratio, 1.56; 95% confidence interval, 1.02–2.39; p = 0.038).

Conclusions

In the ICU setting in Latin America, malnutrition was highly prevalent and caloric intake failed to meet targeted energy delivery in 40% of critically ill adults receiving nutrition therapy. Supplemental administration of PN was associated with improved energy and protein delivery; however, PN use was low. Collectively, these findings suggest an opportunity for more effective utilisation of supplemental PN in critically ill adults who fail to receive adequate nutrition from EN alone.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1805-z) contains supplementary material, which is available to authorized users.

Handgrip strength values of Portuguese older adults: a population based study

Background

Handgrip strength is used to identify sarcopenia and frailty phenotypes, being a potential predictor of mortality in older adults. However, uniformity is lacking in the reference values. This study aimed to describe handgrip strength values of older population aged ≥65 years in Portugal, considering the possible influence of anthropometric parameters.

Methods

A cross-sectional study was conducted in Portugal, among 1500 older adults aged ≥65 years old, according to “The Nutrition UP 65 Study Protocol”. Demographic data were collected and cognitive performance, subjective general health, physical activity, anthropometric parameters and nutritional status were assessed and analysed. Handgrip strength data was obtained with a Jamar dynamometer. A Pubmed/Medline search was carried out to compare handgrip strength data between Portuguese older adults and other older populations.

Results

Handgrip strength was higher among men than among women (30.3 ± 9.2 Kgf vs 18 ± 5.4 Kgf, p < 0.001, respectively). In general, handgrip strength values of Portuguese older adults were lower than other older populations. In our sample, age, cognitive and nutritional status, self-reported sitting time and practice of physical activity were significantly correlated with handgrip strength in both sexes. Concerning anthropometric parameters, height was the most significantly correlated with handgrip strength (r = 0.34, p < 0.001, in women and r = 0.40, p < 0.001, in men).

Conclusion

This study described, for the first time, handgrip strength values of Portuguese population aged ≥65 years, according to age and to sex-specific tertiles of height. The definition of handgrip strength reference values in this age group merits further reflection.

Assessment of Nutritional Status, Digestion and Absorption, and Quality of Life in Patients with Locally Advanced Pancreatic Cancer

BACKGROUND AND AIM

To provide a comprehensive quantitative assessment of nutritional status, digestion and absorption, and quality of life (QoL) in patients with locally advanced pancreatic cancer (LAPC).

METHODS

Sixteen patients with LAPC were prospectively assessed for weight loss (WL), body mass index (BMI), fat-free mass index (FFMI), handgrip strength (HGS), dietary macronutrient intake, serum vitamin levels, resting and total energy expenditure (REE and TEE, indirect calorimetry), intestinal absorption capacity and fecal losses (bomb calorimetry), exocrine pancreatic function (fecal elastase-1 (FE1)), and gastrointestinal quality of life (GIQLI).

RESULTS

Two patients had a low BMI, 10 patients had WL > 10%/6 months, 8 patients had a FFMI < P10, and 8 patients had a HGS < P10. Measured REE was 33% higher (P = 0.002) than predicted REE. TEE was significantly higher than daily energy intake (P = 0.047). Malabsorption (<85%) of energy, fat, protein, and carbohydrates was observed in, respectively, 9, 8, 12, and 10 patients. FE1 levels were low (<200 μg/g) in 13 patients. Total QoL scored 71% (ample satisfactory).

CONCLUSION

Patients with LAPC have a severely impaired nutritional status, most likely as a result of an increased REE and malabsorption due to exocrine pancreatic insufficiency. The trial is registered with PANFIRE clinicaltrials.gov NCT01939665.

Is there a J-shaped relationship between the fatty liver index and risk of microalbuminuria in the general population?

BACKGROUND

We investigated whether the fatty liver index (FLI), as a clinical indicator of hepatic fat accumulation based on body mass index, gamma-glutamyl-transferase, triglycerides, and waist circumference, has an association with microalbuminuria.

METHODS

We analyzed anthropometric and biochemical data from a nation-wide, population-based, cross-sectional study. A total of 1605 participants included were healthy native Korean 40years or older and divided into quintiles according to their log-FLI and sex. Microalbuminuria was defined as urine albumin/creatinine ratio (UACR) between 30 and 300mg/g.

RESULTS

Participants in higher quintiles of log-FLI were more obese and hypertensive and had greater glycemic exposure, poorer lipid profiles, and greater increases in log-UACR compared with lower quintiles. Linear regression analysis demonstrated that log-FLI was associated with systolic and diastolic blood pressure, body mass index, waist circumference, fasting plasma glucose, glycated hemoglobin, and log-UACR. In logistic regression adjusted for age, sex, body mass index, waist circumference, and fasting plasma glucose, the OR of microalbuminuria was elevated in quintile 1 (adjusted OR=2.161, 95% CI=0.453-10.31) and quintile 5 (adjusted OR=6.387, 95% CI=1.317-51.58), when compared to quintile 2.

CONCLUSIONS

There appears to be a J-shaped association between FLI and UACR in healthy general population.

BMI calculation in older people: The effect of using direct and surrogate measures of height in a community-based setting

BACKGROUND & AIMS

There is currently no consensus on which measure of height should be used in older people's body mass index (BMI) calculation. Most estimates of nutritional status include a measurement of body weight and height which should be reliable and accurate, however at present several different methods are used interchangeably. BMI, a key marker in malnutrition assessment, does not reflect age-related changes in height or changes in body composition such as loss of muscle mass or presence of oedema. The aim of this pilot study was to assess how the use of direct and surrogate measures of height impacts on BMI calculation in people aged ≥75 years.

METHODS

A cross-sectional study of 64 free-living older people (75-96 yrs) quantified height by two direct measurements, current height (H_C), and self-report (H_R) and surrogate equations using knee height (H_K) and ulna length (H_U). BMI calculated from current height measurement (BMI_C) was compared with BMI calculated using self-reported height (BMI_R) and height estimated from surrogate equations for knee height (BMI_K) and ulna length (BMI_U).

RESULTS

Median difference of BMI_C-BMI_R was 2.31 kg/m². BMI_K gave the closest correlation to BMI_C. The percentage of study participants identified at increased risk of under-nutrition (BMI < 20 kg/m²) varied depending on which measure of height was used to calculate BMI; from 5% (BMI_C), 7.8% (BMI_K), 12.5% (BMI_U), to 14% (BMI_R) respectively.

CONCLUSIONS

The results of this pilot study in a relatively healthy sample of older people suggest that interchangeable use of current and reported height in people ≥75 years can introduce substantial significant systematic error. This discrepancy could impact nutritional assessment of older people in poor health and lead to misclassification during nutritional screening if other visual and clinical clues are not taken into account. This could result in long-term clinical and cost implications if individuals who need nutrition support are not correctly identified. A consensus is required on which method should be used to quantify height in older people to improve accuracy of nutritional assessment and clinical care.

Concordance of the new ESPEN criteria with low phase angle in defining early stages of malnutrition in cardiac surgery

BACKGROUND & AIMS

The aim of this study was to evaluate the incidence of malnutrition (MN) in cardiac surgery patients by implementing the new ESPEN diagnostic criteria and to determine whether these criteria are concordant with the bioelectrical impedance analysis (BIA) provided phase angle (PA) in predicting early stages of malnutrition.

METHODS

A prospective study was conducted in a tertiary hospital. The nutritional state of the cardiac surgery patients was evaluated one day prior to cardiac surgery using the malnutrition screening tools NRS-2002, MUST and SF-MNA, and bioelectrical impedance analysis. Patients at risk of malnutrition were further studied in accordance with the ESPEN malnutrition diagnostic criteria. A BIA provided PA value of less than the 15th percentile of the age and gender group was set as a theoretical marker of early malnutrition. ROC AUC (receiver operating characteristic area under curve) analysis and other parameters were calculated to determine the concordance between the new ESPEN malnutrition diagnostic criteria and a low PA.

RESULTS

The study comprised 549 enrolled cardiac surgery patients. MN or risk of MN in accordance with at least one nutritional status assessment tool was diagnosed in 372 (67.75%) patients. MN, according to the new ESPEN malnutrition diagnostic criteria, was only diagnosed in 31 (5.6%) patients. Low PA was detected in 124 patients (22.6%), providing a higher MN rate. The ROC analysis and other concordance parameters showed that the new ESPEN diagnostic criteria (AUC 0.560, p = 0.042) were not concordant with a low PA.

CONCLUSION

Fewer patients are classified as malnourished by the new ESPEN definition as those identified by the BIA provided PA. Incorporation of the BIA provided PA into the new ESPEN definition may aid to diagnose the early stages of MN in the field of cardiac surgery.

Evaluation of Blood Biomarkers Associated with Risk of Malnutrition in Older Adults: A Systematic Review and Meta-Analysis

Malnutrition is a common yet under-recognized problem in hospitalized patients. The aim of this paper was to systematically review and evaluate malnutrition biomarkers among order adults. Eligible studies were identified through Cochrane, PubMed and the ProQuest Dialog. A meta-regression was performed on concentrations of biomarkers according to malnutrition risks classified by validated nutrition assessment tools. A total of 111 studies were included, representing 52,911 participants (55% female, 72 ± 17 years old) from various clinical settings (hospital, community, care homes). The estimated BMI (p < 0.001) and concentrations of albumin (p < 0.001), hemoglobin (p < 0.001), total cholesterol (p < 0.001), prealbumin (p < 0.001) and total protein (p < 0.05) among subjects at high malnutrition risk by MNA were significantly lower than those without a risk. Similar results were observed for malnutrition identified by SGA and NRS-2002. A sensitivity analysis by including patients with acute illness showed that albumin and prealbumin concentrations were dramatically reduced, indicating that they must be carefully interpreted in acute care settings. This review showed that BMI, hemoglobin, and total cholesterol are useful biomarkers of malnutrition in older adults. The reference ranges and cut-offs may need to be updated to avoid underdiagnosis of malnutrition.

Relationship between tongue strength, lip strength, and nutrition-related sarcopenia in older rehabilitation inpatients: a cross-sectional study

Objective

The objective of this study was to clarify the relationship between tongue strength, lip strength, and nutrition-related sarcopenia (NRS).

Patients and methods

A total of 201 older inpatients aged ≥65 years (70 men, median age: 84 years, interquartile range: 79–89 years) consecutively admitted for rehabilitation were included in this cross-sectional study. The main factors evaluated were the presence of NRS diagnosed by malnutrition using the Mini-Nutrition Assessment – Short Form, sarcopenia based on the criteria of the Asian Working Group for Sarcopenia, tongue strength, and lip strength. Other factors such as age, sex, comorbidity, physical function, cognitive function, and oral intake level were also assessed.

Results

In all, 78 (38.8%) patients were allocated to the NRS group, and 123 (61.2%) patients were allocated to the non-NRS group. The median tongue strength and lip strength (interquartile range) were significantly lower in the NRS group (tongue: 22.9 kPa [17.7–27.7 kPa] and lip: 7.2 N [5.6–9.8 N]) compared with the non-NRS group (tongue: 29.7 kPa [24.8–35.1 kPa] and lip: 9.9 N [8.4–12.3 N], P<0.001 for both). Multivariable logistic regression analysis showed that NRS was independently associated with tongue strength (odds ratio [OR] =0.93, 95% confidence interval [CI] 0.87–0.98, P=0.012) and lip strength (OR =0.76, 95% CI 0.66–0.88, P<0.001), even after adjusting for age, sex, comorbidity, physical function, cognitive function, and oral intake level.

Conclusion

The likelihood of occurrence of NRS decreased when tongue strength or lip strength increased. Tongue strength and lip strength may be important factors for preventing and improving NRS, regardless of the presence of low oral intake level in older rehabilitation inpatients.

Long-term effects of a computer-based nutritional training program for inpatient hospital care

RATIONALE

A previous short-term study showed that a computer-based training in eating and nutrition increased the probability for hospital inpatients at undernutrition (UN) risk to receive nutritional treatment and care without increasing overtreatment (providing nutritional treatment to those not at UN risk). The aim of this study was to investigate if a computer-based training in eating and nutrition influences the precision in nutritional treatment and care in a longer-term perspective.

METHOD

A preintervention and postintervention study was conducted with a cross-sectional design at each time points (baseline and 7 months postintervention). Hospital inpatients >18 years old at baseline (2013; n = 201) and follow-up (2014; n = 209) were included. A computer-based training was implemented during a period of 3 months with 297 (84%) participating registered nurses and nurse assistants. Undernutrition risk was screened for using the minimal eating observation and nutrition form-version II. Nutritional treatment and care was recorded using a standardized protocol.

RESULTS

The share of patients at UN risk that received energy-dense food (+25.2%) and dietician consultations (+22.3%) increased between baseline and follow-up, while fewer received oral nutritional supplements (-18.9%). "Overtreatment" (providing nutritional treatment to those not at UN risk) did not change between baseline and follow-up.

CONCLUSION

The computer-based training increased the provision of energy-dense food and dietician consultations to patients at UN risk without increasing overtreatment of patients without UN risk.

Prognostic value of combined preoperative prognostic nutritional index and body mass index in HCC after hepatectomy

BACKGROUND

Malnutrition and immunological status are associated with survival in many cancers. Prognostic nutritional index (PNI) and body mass index (BMI) are recognized immune-nutritional indices and associated with postoperative outcome in hepatocellular carcinoma (HCC) patients. However, this association is still controversial. Our aim was to determine whether the combination of PNI and BMI is better than either alone in HCC patients' prognosis.

MATERIAL AND METHODS

Preoperative PNI and BMI, patient demographics, clinical and pathological data from 322 HCC patients were collected and analyzed.

RESULTS

Low PNI was correlated with age, cirrhosis, total bilirubin (TBIL) ≥34.2 μmol/L, and recurrence. Likewise, low BMI was associated with TBIL ≥34.2 μmol/L, portal vein tumor thrombi (PVTT), tumor size, tumor differentiation, TNM stage, and recurrence. Multivariate analysis identified TNM stage, PVTT, tumor size, PNI, and BMI as independent predictors of outcome in HCC patients. Low PNI combined with BMI (PNI + BMI) accurately predicted poorer outcome, particularly in patients with TNM stage I HCC. The predictive range of PNI + BMI was more sensitive than that of either alone.

CONCLUSIONS

preoperative PNI/BMI is an independent predictor of outcome for HCC patients, especially in patients with early stage HCC. Intriguingly, the PNI + BMI combination can enhance the accuracy of prognosis.

Prevalence of malnutrition and validation of bioelectrical impedance analysis for the assessment of body composition in patients with systemic sclerosis

Objectives

The aims were to assess the prevalence of malnutrition and to validate bioelectrical impedance analysis (BIA) against whole-body DXA for the assessment of body composition in patients with SSc.

Methods

Malnutrition was defined as BMI <18.5 kg/m 2 or unintentional weight loss >10% in combination with a fat-free mass index (FFMI) <15 kg/m 2 for women or <17 kg/m 2 for men or BMI <20.0 kg/m 2 (age <70 years) or <22 kg/m 2 (age >70 years). Body composition was assessed in 72 patients with whole-body DXA (Hologic, Discovery A) and BIA (Bodystat Quadscan 400). The manufacturer's equation and the Geneva equation were used to estimate FFM and fat mass. The agreement between BIA and whole-body DXA was assessed with Bland-Altman analysis and intraclass correlation coefficient.

Results

Malnutrition was found in 8.3% (n = 6) and low FFMI in 20.8% (n = 15) of patients. The mean difference in FFM between BIA and DXA applying the Geneva equation was 0.02 ( s . d . 2.4) kg, intraclass correlation coefficient 0.97 (95% CI: 0.95, 0.98). Limits of agreement were ±4.6 kg. The manufacturer's equation was less adequate to predict FFM.

Conclusion

This study shows a relatively low prevalence of malnutrition in comparison with other studies, but a high prevalence of low FFMI, underlining the necessity of measuring body composition in SSc patients with a standardized and validated method. A good validity of BIA in determining FFM was found at a group level, while at an individual level the FFM may vary by 4.6 kg.

Association Between Malnutrition and Oral Health in Dutch Nursing Home Residents: Results of the LPZ Study

INTRODUCTION

According to the World Health Organization (WHO) and FDI World Dental Federation (FDI), malnutrition and bad oral health are of great concern to global health, especially among the older population. This study aimed to assess the associations between oral health problems ([artificial] teeth problems, chewing problems, and xerostomia) and malnutrition in residents of somatic and psychogeriatric wards in Dutch nursing homes.

METHODS

Data of the cross-sectional National Prevalence Measurement of Quality of Care study (Landelijke Prevalentiemeting Zorgproblemen study) in the Netherlands were used to evaluate nutritional status and oral health of 3220 residents, aged 65 or older and living in somatic or psychogeriatric wards in Dutch nursing homes. Cox regression was performed to calculate prevalence ratios (PR) of malnutrition among these residents.

RESULTS

Of the total study population, 11.7% were malnourished, 28.6% suffered from xerostomia, 25.6% suffered from chewing problems, and 10.1% experienced problems eating due to (artificial) teeth problems. Within somatic wards, 9.0% were malnourished, whereas 13.2% of residents in psychogeriatric wards were malnourished. Increased risk for malnutrition was found among psychogeriatric residents who had problems with eating due to (artificial) teeth problems (PR 1.6, 95% CI 1.1-2.3).

CONCLUSION

Poor oral health, mostly problems with eating due to (artificial) teeth problems, was associated with an almost twofold risk for malnutrition in older residents in Dutch nursing homes and even more so in psychogeriatric residents than in somatic residents.

Cachexia at diagnosis is associated with poor survival in head and neck cancer patients

CONCLUSIONS

One third of the patients had cachexia with an association of significantly shorter survival. These results suggest that combining HGS and MAMA seems to be a practical method to screen cachexia in patients with head and neck cancer and may also be used when assessing their prognosis.

OBJECTIVES

The aim of this study was to analyze the hypothesis that cachexia defined as both low mid-arm muscle area (MAMA) and handgrip strength (HGS) is associated with decreased survival in patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

Sixty-five consecutive patients with primary HNSCC were enrolled prior to cancer therapy. Cachexia was defined as low handgrip strength (HGS) and low mid-arm muscle area (MAMA). Nutritional status was assessed by patient-generated subjective global assessment (PG-SGA) and sarcopenia by low MAMA. Biochemical parameters reflecting nutritional status and S-25-OHD were measured.

RESULTS

Cachexia was seen in 31% and sarcopenia in 46% of patients. Altogether, 34% of patients were malnourished. Disease-free survival was 13 months (3-62) in cachectic patients, compared with 66 months (31-78) in non-cachectic patients (p = 0.009). S-25-OHD was 28 nmol/l in cachectic patients, compared with 46 nmol/l in non-cachectic patients (p = 0.009) and prealbumin 187 mg/l and 269 mg/l, respectively (p < 0.001).

Predictive Accuracy of Calf Circumference Measurements to Detect Decreased Skeletal Muscle Mass and European Society for Clinical Nutrition and Metabolism-Defined Malnutrition in Hospitalized Older Patients

Background/Aims: The ability to readily diagnose sarcopenia and malnutrition in a clinical setting is essential. This study is aimed at clarifying the calf circumference (CC) cut-off values for decreased skeletal muscle mass (SMM), according to the Asian Work Group for Sarcopenia's criteria definition of sarcopenia, and those for European Society for Clinical Nutrition and Metabolism-defined malnutrition, in hospitalized Japanese patients. Methods: The study involved 1,164 patients aged ≥65 years. Predictive CC cut-off values were determined using receiver operating curve (ROC) analyses. The predictive validity of the cut-off values was confirmed against in-hospital mortality. Results: There were 654 females and 510 males (mean age, 83.5 ± 8.2 years). Decreased SMM and malnutrition were observed in 80.4 and 32.8% of all patients, respectively. ROC analyses identified CCs of ≤29 cm (female, area under the curve [AUC] 0.791) and ≤30 cm (male, AUC 0.832) as cut-off values for decreased SMM, and CCs of ≤26 cm (female, AUC 0.798) and ≤28 cm (male, AUC 0.837) for malnutrition. CC cut-off values for SMM and malnutrition were independently correlated with in-hospital mortality. Conclusions: The study determined appropriate cut-off values for CC to identify decreased SMM and malnutrition according to the relevant guidelines.

Predicting long-term mortality in hospitalized elderly patients using the new ESPEN definition

The European Society of Clinical Nutrition and Metabolism (ESPEN) recently published new diagnostic criteria for malnutrition. The aim of this study was to evaluate whether malnutrition by the new ESPEN diagnostic criteria can predict long-term mortality in elderly inpatients. We conducted a prospective study in the acute geriatric wards. Malnutrition was defined according to the new ESPEN criteria and the Mini Nutritional Assessment (MNA), respectively. The survival status was determined by telephone interviews at 3-years. A total of 437 elderly adults were included. According to the new ESPEN criteria, 66 participants (15.1%) were malnourished. According to the MNA, 45 participants (10.3%) were identified as malnourished. The 3-year all-cause mortality was 41.7% in participants with malnutrition defined by the ESPEN criteria and 15.3% in participants without malnutrition (p < 0.001). After adjusting for relevant confounders, malnutrition defined by the ESPEN criteria was a significant predictor of 3-year all-cause mortality (hazard ratio [HR] 2.98, 95% confidence interval [CI] 1.87-4.86). However, malnutrition defined by the MNA was not a significant predictor of 3-year all-cause mortality (HR 1.67, 95% CI 0.89-2.31). In conclusion, the new ESPEN diagnostic criteria for malnutrition are reliable in predicting 3-year all-cause mortality among elderly inpatients.

Systemic interleukin-9 in inflammatory bowel disease: Association with mucosal healing in ulcerative colitis

AIM

To evaluate circulating IL9 in inflammatory bowel disease and disease-associated anemia/cachexia and assess its potential as a mucosal healing marker.

METHODS

Serum IL9 as well as other cytokines (IL1β, IL6, IL13, IFNγ, TNFα, and VEGF-A) were determined in 293 individuals: 97 patients with Crohn’s disease (CD) and 74 with ulcerative colitis (UC) and in 122 apparently healthy controls. The clinical activity of CD and UC was expressed in terms of the Crohn’s Disease Activity Index (CDAI) and the Mayo Scoring System (MDAI), respectively, and the severity of bowel inflammation in UC patients was assessed using Mayo endoscopic score. Cytokine concentrations were measured by a flow cytometry-based method using Luminex xMAP^® technology. High-sensitive C-reactive protein concentrations (hsCRP) were determined in CD and UC patients using the enhanced immunoturbidimetric method.

RESULTS

Systemic IL9 was significantly lower in healthy individuals [9 pg/mL (95%CI: 8.2-10)] than in patients with inflammatory bowel disease (IBD): both inactive [14.3 pg/mL (11.9-19.9)] and active [27.6 pg/mL (24.5-32), P < 0.0001]. Cytokine concentrations were significantly higher in active CD [27.4 pg/mL (23.4-32.2)] and in active UC [32.7 pg/mL (27-38.9)] compared to inactive diseases [15.9 pg/mL (10.8-23.4) in CD and 19.4 pg/mL (13.9-27.1) in UC, P = 0.001]. IL9 correlated weakly with CDAI (ρ = 0.32, P = 0.003) and MDAI (ρ = 0.35, P = 0.002) and strongly with endoscopic inflammation in UC (ρ = 0.74, P < 0.0001). As a negative marker of mucosal healing (MH), IL9 had an accuracy superior to hsCRP and IL6 [97% (P < 0.0001), 67% (P = 0.071), and 55% (P = 0.525), respectively]. IL9 was significantly higher in cachectic IBD patients [30.25 pg/mL (24.4-37.5) vs 21.88 pg/mL (18-26.5), P = 0.026] and negatively correlated with hemoglobin concentrations (ρ = -0.27, P < 0.001). Multiple regression showed IL1β and IL13 to be the independent predictors of circulating IL9 in healthy individuals, IFNγ or IL6 in active and inactive UC, respectively, and IL13 and VEGF-A in both active and inactive CD.

CONCLUSION

The systemic IL9 level is higher in IBD and corresponds with endoscopic inflammation, suggesting its possible application as a negative marker of mucosal healing in UC.

FAT-FREE MASS, METABOLICALLY HEALTHY OBESITY, AND TYPE 2 DIABETES IN SEVERELY OBESE ASIAN ADULTS

OBJECTIVE

To determine whether fat free mass (FFM) is independently associated with the metabolically healthy obesity (MHO) phenotype, the metabolic syndrome (MS), and type 2 diabetes (T2D) in obese Asian adults.

METHODS

Obese patients (body mass index [BMI] ≥25 kg/m²) seeking weight management at an academic medical center from 2007 to 2016 were included. FFM was measured by bioelectrical impedance.

RESULTS

Of the 552 patients (67.0% female, median age 40.5 years, median BMI 38.3 kg/m²), MHO was present in 19%, MS in 55.4%, and T2D in 32.6%. In multivariate models, higher fat-free mass index (FFMI) was independently associated with the metabolically abnormal obesity (MAO) phenotype, (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.09-1.37), and increased risk of MS (OR 1.12, 95% CI 1.03-1.22) in women but not in men. Older age was independently associated with the MAO phenotype (OR 1.06, 95% CI 1.04-1.09 in women; OR 1.06, 95% CI 1.02-1.09 in men), MS (OR 1.05, 95% CI 1.03-1.06 in women; OR 1.05, 95% CI 1.02-1.07 in men), and T2D (OR 1.07, 95% CI 1.05-1.09 in women; OR 1.06, 95% CI 1.04-1.09 in men). Waist-hip ratio was independently associated with the MAO phenotype in men (OR 1.08, 95% CI 1.01-1.15), while waist circumference was associated with T2D in women (OR 1.03, 95% CI 1.01-1.05).

CONCLUSION

Older age, central fat distribution, and-in contrast to previous findings-an increase in FFMI among women were independent predictors of adverse metabolic health in this cohort of middle-aged obese Asian adults. Further studies are required to elucidate underlying mechanisms and therapeutic implications of these findings.

ABBREVIATIONS

BIA = bioelectrical impedance analysis BMI = body mass index CI = confidence interval DXA = dual-energy X-ray absorptiometry FFM = fat-free mass FFMI = fat-free mass index FM = fat mass HbA1c = glycated hemoglobin A1c MAO = metabolically abnormal obesity MHO = metabolically healthy obesity MS = metabolic syndrome OR = odds ratio T2D = type 2 diabetes WC = waist circumference WHR = waist-hip-ratio.

Special nutrition intervention is required for muscle protective efficacy of physical exercise in elderly people at highest risk of sarcopenia

Progressive loss of muscle mass and strength is a physiological consequence of aging, and without interventions, it usually deteriorates into sarcopenia. In this study, the hypothesis that combined special nutritional-physiotherapeutical intervention to prevent or reverse this biological deterioration in elderly people was tested. The effects of the regular resistance muscle training (PT, n = 17) alone and the combined exercise + special nutrition therapy containing whey protein and vitamin D (PT + NT, n = 17) were monitored for 3 months in 34 elderly patients (12 men and 22 women; mean age: 66.47 years) randomly distributed into two groups at a long-term care facility. Physical exercise alone did not result in significant improvement in skeletal muscle mass or strength, whereas combined intervention significantly increased the muscle strength (22.51 ± 2.35 vs. 24.54 ± 2.65, [Formula: see text] ± SEM, kg, p = 0.027). When therapeutic responses to the intervention were compared, a significant advantage of PT + NT over PT was found. The same trend was found when the non-significant post-therapeutic alterations (χ² test) of the distribution of normal vs. pre-sarcopenic + sarcopenic conditions within the two groups were compared. Combined intervention (PT + NT) is necessary for the efficient protection of the musculature in the high-risk elderly patients.

Two components of the new ESPEN diagnostic criteria for malnutrition are independent predictors of lung function in hospitalized patients with chronic obstructive pulmonary disease (COPD)

INTRODUCTION

Low fat free mass index (FFMI) is a component of the ESPEN diagnosis criteria of malnutrition, that only when accompanied with weight loss is considered to be a determinant of malnutrition. Our aims were to assess the prevalence of malnutrition in patients with chronic obstructive pulmonary disease (COPD) applying the ESPEN criteria, and to examine the ability of different components of the criteria to predict COPD severity, length of stay (LOS), hospital readmissions within 30 days and mortality.

METHODS

Subjects were COPD patients (n = 121) admitted to Landspitali University Hospital from March 2015 to March 2016. Patients were screened for nutritional risk using Icelandic screening tool (ISS) and NRS-2002. Body composition was measured by bioelectrical impedance analysis (BIA). Lung function was measured by spirometry.

RESULTS

The prevalence of malnutrition according to the ESPEN criteria was 21%. The association between nutritional assessment, applying different components of the ESPEN criteria, and COPD severity was highly significant, with the highest risk being associated with low FFMI OR (95% CI) 4.77 (2.03, 11.20; p < 0.001). There was a trend towards higher risk of hospitalization for >7 days in subjects with low FFMI (OR 2.46 95% CI 0.92, 6.59; p = 0.074) and increased risk of 6 and 9 months' mortality (OR 2.72 95% CI 0.88, 8.39, P = 0.082 and OR 2.72 95% CI 0.94, 7.87, P = 0.065, respectively) in subjects diagnosed as malnourished by the ESPEN criteria.

CONCLUSION

This study describes the prevalence of malnutrition in hospitalized COPD patients using the ESPEN criteria from 2015. Our findings suggest that FFMI could be used independently of weight loss for the diagnosis of malnutrition in COPD patients, although there remain some problems associated with its measurement in the clinical setting.

Pressure ulcer is associated with malnutrition as assessed by Nutritional Risk Screening (NRS 2002) in a mixed hospital population

Background and aim: Pressure ulcers (PUs) and malnutrition represent a significant health problem for hospital inpatients. Satisfactory nutritional status is crucial for proper wound healing. Risk of malnutrition can be identified using standardized screening tools, such as the Nutritional Risk Screening (NRS) 2002.

Objective: The objective of this study was to examine whether nutritional status based on the NRS 2002 is associated with PU in hospital inpatients.

Design: The data for this cross-sectional analysis were based on 10 screening days between September 2012 and May 2014. All adult inpatients admitted to a medical or surgical ward on the screening days were evaluated for eligibility. Nursing students and ward nurses conducted the NRS 2002 initial screening and skin examinations for PU classification (Stages I–IV). A registered clinical dietician conducted all NRS 2002 final screenings.

Results: The sample consisted of 651 patients, with mean age 62.9 years. Skin examinations indicated an 8% PU prevalence. Factors associated with PUs included age ≥ 70 years, low body mass index (BMI) and hospitalization in the medical department. Based on the initial screening, 48% were at ‘Low risk’ for malnutrition and 52% were at ‘Possible risk’. After final screening, 34% of the sample was identified as ‘At risk’ for malnutrition. Patients identified at ‘Possible risk’ by the initial screening or ‘At risk’ by the final screening were more likely than patients at ‘Low risk’ to have a PU (OR = 2.58 and 2.55, respectively). Each of the three initial screening items was significantly associated PU, with ‘Is BMI<20?’ and ‘Ate less past week?’ having the strongest associations.

Conclusion: Nutritional risk using the NRS 2002 is associated with the presence of PU in a mixed hospital population. The final screening had a slightly stronger association with PU compared to the initial screening.

Age-dependent risk factors for malnutrition in traumatology and orthopedic patients

OBJECTIVE

The aim of this study was to investigate the prevalence of risk of malnutrition (RoM) in an orthopedic and traumatology patient cohort with a broad range of ages. In addition to the classical indicators for risk assessment (low body mass index, weight loss, and comorbidity), this study aimed to analyze the effects of lifestyle factors (eating pattern, smoking, physical activity) on RoM.

METHODS

The prospective cohort study included 1053 patients in a level 1 trauma center in Germany. RoM was assessed by Nutritional Risk Screening (NRS) 2002 and for the elderly additionally by Mini Nutritional Assessment (MNA). Age-dependent risk factors identified in univariate statistical analysis were used for multivariate logistic regression models.

RESULTS

The prevalence of patients at RoM (NRS ≥3) was 22%. In the three age categories (<50 y, 50-69 y, and ≥70 y), loss of appetite, weight loss, number of comorbidities, drugs and gastrointestinal symptoms significantly increased RoM in univariate statistical analysis. In patients ages ≥70 y, several disease- and lifestyle-related factors (not living at home, less frequent consumption of vegetables and whole meal bread, low physical activity, and smoking) were associated with RoM. Multivariate logistic regression model for the total study population identified weight loss (odds ratio [OR], 6.09; 95% confidence interval [CI], 4.14-8.83), loss of appetite (OR, 3.81; 95% CI, 2.52-5.78), age-specific low BMI (OR, 1.87; 95% CI, 1.18-2.97), number of drugs taken (OR, 1.19; 95% CI, 1.12-1.26), age (OR, 1.03; 95% CI, 1.02-1.04), and days per week with vegetable consumption (OR, 0.938; 95% CI, 0.89-0.99) as risk factors.

CONCLUSION

Malnutrition in trauma and orthopedic patients is not only a problem related to age. Lifestyle-related factors also contribute significantly to malnutrition in geriatric patients.

Drainage of malignant ascites: patient selection and perspectives

Malignant ascites (MA) is a sign of advanced cancer and poor prognosis. MA can result in impairment in quality of life (QOL) and significant symptoms. As a supportive treatment, ascites can be drained by paracentesis (PC), percutaneously implanted catheters (tunneled, untunneled, central venous catheters), or peritoneal ports, or peritoneovenous shunts. The aim of this study was to evaluate the effectiveness, safety, and patient-reported outcomes (PRO) of different drainage methods for the management of MA. A systematic review of the literature was performed, and 32 original articles met the inclusion criteria. Patients selected for permanent drain insertion demonstrated symptoms related to MA and had undergone repeated PC. The primary focus of the reviewed articles was procedural safety issues. The rate of technical success of drainage device installation was 100%. Most patients experienced improvements in symptom control after ascites drainage. When analyzed together, 19.7% (255/1297) of patients experienced any complication and 6.2% (81/1297) experienced serious adverse events during MA drainage. Complications were reported for every drainage method; however, the least occurred after PC or central venous catheter, while the most serious occurred after peritoneovenous shunts. Adverse events were as follows: catheter obstruction: 4.4%, infection: 4.1%, leakage: 3.5%, catheter dislodgment: 2.3%, hypotension: 0.6%, injuries during device insertion: 0.6%, renal impairment: 0.5%, electrolyte imbalance: 0.2%, other: 3.6%. PRO and QOL endpoints were available for 12 studies. When PRO were measured using an interview, a significant improvement in symptom control and QOL was reported in almost all patients. Once standardized questionnaires were used, improvements in symptomatic scores and role functioning were observed. Deterioration was observed in cognitive and emotional subscales. MA drainage is a safe and effective method to control symptoms associated with ascites, and should be perceived as a supportive care, that can be applied for those who need it at any time of their cancer trajectory. Patient selection should be performed using a thorough assessment of symptoms and QOL, and should not be delayed.

A Dedicated Nutritional Care Program (NUTRICARE) to reduce malnutrition in institutionalised dysphagic older people: A quasi-experimental study

AIMS AND OBJECTIVES

To assess the effects of a texture-modified food program for dysphagia on the nutritional, biochemical and functional profile in a cohort of institutionalised older people in Italy.

BACKGROUND

Dysphagic institutionalised older people, often also affected by dementia, are frequently exposed to malnutrition. Malnutrition in older people has negative effects on mortality, days of hospitalisation, infection, wound healing and risk of pressure injuries. Therefore, it is very important to prevent malnutrition in this frail population.

DESIGN

A pre-post study without a control group.

METHODS

The study included 479 dysphagic institutionalised older people from 20 nursing homes. Anthropometrical, biochemical, nutritional and functional parameters were collected retrospectively, 6 months before the study intervention, at time zero and, prospectively for 6 months after implementing the NUTRICARE food programme, for a total of nine evaluations. The NUTRICARE programme includes meals without nutritional supplementation, and personalised levels of density, viscosity, texture and particle size.

RESULTS

The total mean body mass index of our sample passed from 17.88-19.00; body weight averagely improved by 7.19%, as well as their nutritional and biochemical profiles. There was a progressive improvement of total protein and serum albumin values. Nutritional parameters (serum transferrin and lymphocytes) displayed similar changes. Plasma lymphocytes reached normal levels in 98.23% of the sample. Plasma creatinine levels remained steady throughout the study and within the normal range. No side effects were reported.

CONCLUSION

The NUTRICARE food programme with a adequate proteins, calories, balanced nutritional and bromatological properties, and appropriate texture and palatability significantly improved the nutritional, biochemical and functional profile in a cohort of institutionalised dysphagic older people.

RELEVANCE TO CLINICAL PRACTICE

The introduction of a balanced nutritional programme, using high-quality natural ingredients, appropriate texture and palatability can significantly improve health and quality of life in dysphagic older people.

Bioelectrical impedance analysis of head and neck cancer patients at presentation

CONCLUSION

Finnish head and neck cancer (HNC) patients show signs of severe malnutrition already at presentation, measured by bioelectric impedance analysis (BIA). BIA may be a practical method to detect malnutrition, analyze body composition, and to identify high-risk patients in this population.

OBJECTIVES

BIA is a validated method for evaluating body composition and detecting malnutrition. Low phase angle (PA) is associated with increased mortality and morbidity. Vector analysis (BIVA) provides a qualitative measure for hydration and cell mass, independent of body size. This study describes BIA results in Finnish HNC patients at presentation.

METHODS

Forty-one newly-diagnosed HNC patients at the Helsinki University Hospital were included. BIA measures (resistance, reactance, PA, fat-free mass index [FFMI], and fat mass index [FMI]), body mass index (BMI), and Charlson Comorbidity Index (CCI) were determined.

RESULTS

The majority of patients were men (78%), with a normal average BMI of 25.2. Low FFMI was seen in 44% of women and 28% of men. The PA (median = 4.6; IQ range = 4-5) was lower than the reference values in 76% (n = 31) of cases. In BIVA, only 13 (32%) of the patients were within normal range and 15 (37%) were plotted in the quadrant indicating malnutrition.

Prospective trial to evaluate the prognostic value of different nutritional assessment scores in pancreatic surgery (NURIMAS Pancreas)

BACKGROUND

Preoperative nutritional status has an impact on patients' clinical outcome. For pancreatic surgery, however, it is unclear which nutritional assessment scores adequately assess malnutrition associated with postoperative outcome.

METHODS

Patients scheduled for elective pancreatic surgery at the University of Heidelberg were screened for eligibility. Twelve nutritional assessment scores were calculated before operation, and patients were categorized as either at risk or not at risk for malnutrition by each score. The postoperative course was monitored prospectively by assessors blinded to the nutritional status. The primary endpoint was major complications evaluated for each score in a multivariable analysis corrected for known risk factors in pancreatic surgery.

RESULTS

Overall, 279 patients were analysed. A major complication occurred in 61 patients (21·9 per cent). The proportion of malnourished patients differed greatly among the scores, from 1·1 per cent (Nutritional Risk Index) to 79·6 per cent (Nutritional Risk Classification). In the multivariable analysis, only raised amylase level in drainage fluid on postoperative day 1 (odds ratio (OR) 4·91, 95 per cent c.i. 1·10 to 21·84; P = 0·037) and age (OR 1·05, 1·02 to 1·09; P = 0·005) were significantly associated with major complications; none of the scores was associated with, or predicted, postoperative complications.

CONCLUSION

None of the nutritional assessment scores defined malnutrition relevant to complications after pancreatic surgery and these scores may thus be abandoned.

Malnutrition or frailty? Overlap and evidence gaps in the diagnosis and treatment of frailty and malnutrition

There is increasing awareness of the detrimental health impact of frailty on older adults and of the high prevalence of malnutrition in this segment of the population. Experts in these 2 arenas need to be cognizant of the overlap in constructs, diagnosis, and treatment of frailty and malnutrition. There is a lack of consensus regarding the definition of malnutrition and how it should be assessed. While there is consensus on the definition of frailty, there is no agreement on how it should be measured. Separate assessment tools exist for both malnutrition and frailty; however, there is intersection between concepts and measures. This narrative review highlights some of the intersections within these screening/assessment tools, including weight loss/decreased body mass, functional capacity, and weakness (handgrip strength). The potential for identification of a minimal set of objective measures to identify, or at least consider risk for both conditions, is proposed. Frailty and malnutrition have also been shown to result in similar negative health outcomes and consequently common treatment strategies have been studied, including oral nutritional supplements. While many of the outcomes of treatment relate to both concepts of frailty and malnutrition, research questions are typically focused on the frailty concept, leading to possible gaps or missed opportunities in understanding the effect of complementary interventions on malnutrition. A better understanding of how these conditions overlap may improve treatment strategies for frail, malnourished, older adults.

Malnutrition is associated with increased mortality in older adults regardless of the cause of death

Malnutrition predicts preterm death, but whether this is valid irrespective of the cause of death is unknown. The aim of the present study was to determine whether malnutrition is associated with cause-specific mortality in older adults. This cohort study was conducted in Sweden and included 1767 individuals aged ≥65 years admitted to hospital in 2008–2009. On the basis of the Mini Nutritional Assessment instrument, nutritional risk was assessed as well nourished (score 24–30), at risk of malnutrition (score 17–23·5) or malnourished (score <17). Cause of death was classified according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, into twenty different causes of death. Data were analysed using Cox proportional hazards regression models. At baseline, 55·1 % were at risk of malnutrition, and 9·4 % of the participants were malnourished. During a median follow-up of 5·1 years, 839 participants (47·5 %) died. The multiple Cox regression model identified significant associations (hazard ratio (HR)) between malnutrition and risk of malnutrition, respectively, and death due to neoplasms (HR 2·43 and 1·32); mental or behavioural disorders (HR 5·73 and 5·44); diseases of the nervous (HR 4·39 and 2·08), circulatory (HR 1·95 and 1·57) or respiratory system (HR 2·19 and 1·49); and symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (HR 2·23 and 1·43). Malnutrition and risk of malnutrition are associated with increased mortality regardless of the cause of death, which emphasises the need for nutritional screening to identify older adults who may require nutritional support in order to avoid preterm death.

A practical approach to nutritional screening and assessment in cirrhosis

Malnutrition is one of the most common complications of cirrhosis, associated with an increased risk of morbidity and mortality. As a potentially modifiable condition, it is of particular importance to identify malnourished patients so that nutritional therapy can be instituted. Nutrition screening and assessment are infrequently performed in patients with cirrhosis. The reasons for this are multifactorial, including the absence of a validated "rapid" screening tool, multiple definitions of what constitutes malnutrition, and challenges with interpreting body composition and laboratory results in the setting of volume overload and liver dysfunction. This article summarizes the clinically relevant evidence and presents key issues, tools, and clinical options that are applicable to patients with cirrhosis. The definition, etiology, and clinically relevant outcomes associated with malnutrition are reviewed. Rapid nutritional screening is differentiated from more detailed nutritional assessment. Nutritional assessment in special populations, including women and the obese, and the role of inflammation are discussed. Multicenter studies using a common nutritional screening/assessment strategy are the next steps to fast-track adoption and implementation of nutrition-related evaluations into routine clinical practice. (Hepatology 2017;65:1044-1057).

Malnutrition - An underestimated factor in the inpatient treatment of traumatology and orthopedic patients: A prospective evaluation of 1055 patients

INTRODUCTION

Suboptimal nutritional status is often observed among hospitalized patients across all medical specialties. The objective of the present study was to (1) analyze the prevalence of malnutrition in hospitalized orthopedic and trauma patients and (2) to evaluate the relationship between malnutrition and selected clinical outcomes.

MATERIALS AND METHODS

The prospective field study was conducted between 06/2014 and 06/2015 in a German level I trauma center (Department of Traumatology, Septic Trauma Surgery and Arthroplasty) with a total number of 1055 patients. At hospital admission, patients were checked for malnutrition using the validated Nutritional Risk Screening (NRS). Patients at risk for malnutrition were defined as NRS≥3. Quality of life (SF-36) was assessed to evaluate the physical and mental health status prior to hospitalization. Clinical outcomes under consideration included 1) rate of adverse events, 2) length of hospitalization, and 3) mobilization after operative and conservative treatment. Patients were included independently of surgical intervention or age.

RESULTS

22.3% (235) of our patients were at risk for malnutrition (NRS≥3) while a regular nutritional status (NRS<3) was diagnosed in 77.7% (819). The highest prevalence of malnutrition was found in Septic Surgery with 31.0% (106), followed by Traumatology with 19.2% (100) and Arthroplasty with 15.1% (29). Higher prevalence of malnutrition was observed among patients with typical fractures of the elderly, such as lumbar spine and pelvis (47.4%), proximal femur (36.4%) and proximal humeral (26.7%) fractures. Furthermore, patients at risk for malnutrition showed prolonged hospitalization (13.7±11.1 vs. 18.2±11.7days), delayed postoperative mobilization (2.2±2.9 vs. 4.0±4.9days) and delayed mobilization after conservative treatment (1.1±2.7 vs. 1.8±1.9days). A statistically significant correlation of NRS with each parameter (Spearman's rank correlation, p<0.05) was observed. The incidence of adverse events in patients at risk for malnutrition was statistically significantly higher compared to that of patients with a regular nutritional status (37.2% vs. 21.1%, p<0.001).

CONCLUSIONS

Malnutrition is widespread regarding hospitalized patients in the field of orthopedic and trauma surgery and results in suboptimal clinical outcome. It should be considered as an important factor that significantly contributes to delayed recovery. Especially elderly trauma patients and patients suffering from postoperative infections should be monitored carefully during hospitalization.

Food for thought: why does the medical community struggle with research about nutritional therapy in the acute care setting?

Although clinical nutrition is a frequently used intervention in inpatient care, high quality trials proving its effectiveness and safety when used in the acutely-ill polymorbid medical inpatient population are largely lacking. From an evolutionary perspective, illness-related low appetite is protective and part of the host response to improve recovery from disease. Large and well performed trials in the intensive care setting have shown deleterious effects of (parenteral) feeding strategies aiming at higher caloric intakes compared to lower intakes, raising the question of whether feeding per se may be simply maladaptive in acute severe illness. Outside critical care, similar large-scale studies are lacking with basic clinical questions regarding the optimal amount/composition of nutrition and best patient selection remaining largely unanswered. Also, the interplay of nutritional interventions and its influence on the microbiome remains largely unclear. Given the magnitude of morbidity caused by malnutrition and the high number of affected patients, it is surprising how little the medical community has invested in better understanding ways to improve this condition. It is now time to perform high-quality trials to better understand how to best deal with this condition in the acute care setting. Such trials will allow change from a one-size-fits-all approach, to more evidence-based, personalized nutritional interventions, ultimately improving patient outcomes. While there is ongoing discussion about definition of malnutrition, we should rather focus on the identification of patients who do or do not benefit from nutritional interventions.