Malnutrition screening tool and malnutrition universal screening tool as a predictors of prolonged hospital stay and hospital mortality: A cohort study

[Hospital malnutrition in Argentina: prevalence and nutritional risk prediction in hospitalized adults according to six nutritional screening tools (AANEP-2 Study)]

Introduction

Introduction: nutritional screening (NS) is crucial for early detection of malnutrition (MN) and prediction of "nutritional risk". Objectives: to establish the prevalence of hospital malnutrition by Subjective Global Assessment (SGA) and evaluate the agreement of NS tools and their ability to predict mortality (M), infectious (IC) and non-infectious complications, and prolonged stay (> 11 days). Methods: a multicenter, prospective, observational study was conducted. Nutritional status was assessed with SGA and simultaneously measured with Malnutrition Screening Tool (MST), Short Nutritional Assessment Questionnaire (SNAQ), Malnutrition Universal Screening Tool (MUST), Nutrition Risk Screening (NRS-2002), and Mini Nutritional Assessment Short Form (MNA-SF). All methods were classified into three categories for equivalence with SGA. Kappa was used to assess agreement and logistic regression, sensitivity, specificity, and area under the ROC curve for predictive ability. Results: a total of 1546 patients from 64 hospitals in Argentina were included, 52.6 % male, median age 58 years. According to SGA, hospital malnutrition prevalence was 48.06 % (95 % CI 45.57; 50.55), with 37 % moderately malnourished (B) and 11 % severely malnourished (C). MST showed the best agreement with SGA (k 0.41), and among methods, MST with SNAQ (k 0.52). Adverse outcomes were associated with MN by any method. SGA, MNA-SF, and NRS-2002 had the best predictive ability (ROC area 0.74 to 0.72 for M). IC were the hardest to predict (maximum ROC area 0.62). Sensitivities ranged from 60 to 96 %, and specificities were above 90 % for MN by SGA. Conclusions: variations in predictive ability among NS methods do not affect their clinical applicability.

Preventing and Managing Pre- and Postoperative Micronutrient Deficiencies: A Vital Component of Long-Term Success in Bariatric Surgery

Bariatric surgery (BS) is an effective treatment for severe obesity and its related comorbidities, such as type 2 diabetes and hypertension. However, the anatomical and physiological changes associated with these procedures significantly increase the risk of preoperative and postoperative micronutrient deficiencies, which can lead to severe complications such as anemia, osteoporosis, and neurological disorders. This narrative review examines the prevalence and clinical implications of micronutrient deficiencies in BS patients, as well as evidence-based strategies for their prevention and management. The most common deficiencies include iron, vitamin B12, folate, calcium, vitamin D, and fat-soluble vitamins (A, E, and K). Procedures with a hypoabsorptive component, such as Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD/DS), pose higher risks of deficiencies compared to restrictive procedures like sleeve gastrectomy (SG). Effective strategies involve the preoperative correction of deficiencies, continuous monitoring, and tailored supplementation. However, long-term adherence to supplementation tends to decrease over time, influenced by behavioral and socioeconomic factors. Hence, preventing and managing micronutrient deficiencies are crucial for the long-term success of BS. While current guidelines provide valuable recommendations, many are based on low-certainty evidence, underscoring the need for more robust studies. A multidisciplinary approach, combined with innovative strategies, such as telemedicine, can enhance adherence and achieve sustainable clinical outcomes.

Preoperative Nutrition in Bariatric Surgery: A Narrative Review on Enhancing Surgical Success and Patient Outcomes

Bariatric surgery has become the preferred treatment for individuals with morbid obesity. Nutrition is key in optimizing surgical outcomes by reducing risks and enhancing recovery. Preoperative strategies, such as reducing body fat, decreasing liver size, and improving metabolic profiles, have been shown to facilitate safer surgical procedures with fewer complications. This narrative review aims to provide an analysis of the fundamental role of preoperative nutritional management in improving bariatric surgery outcomes, emphasizing the importance of addressing specific nutritional challenges to enhance surgical safety, recovery, and overall health. Preoperative nutritional interventions focus on correcting comorbidities and nutritional deficiencies, particularly hypovitaminosis and micronutrient imbalances, through a multidisciplinary approach involving nutritionists and other healthcare professionals. These interventions not only prepare patients for the physiological demands of surgery but also initiate a period of adaptation to new dietary habits, aiming to improve long-term compliance and mitigate risks such as postoperative weight regain and dumping syndrome. Adopting dietary changes, such as very low-calorie or ketogenic diets 6-12 weeks before surgery, enhances adherence to postoperative restrictions and overall surgical success. Future research should focus on developing comprehensive guidelines for preoperative nutritional care to improve patient outcomes globally.

Prognostic evaluation of nutrition risk screening tools in hospitalized adults with normal weight range, overweight, or obesity: A comparative analysis

BACKGROUND

Many nutrition risk screening tools include low body mass index (BMI). It remains uncertain whether it affects the validity of these tools in patients with overweight or obesity. We aimed to determine the frequency of malnutrition risk and evaluate its association with hospital length of stay in hospitalized adults according to BMI classification.

METHODS

Secondary analysis involving inpatients with BMI ≥ 18.5 kg/m2. Malnutrition risk was assessed using the Nutritional Risk Screening 2002 (NRS-2002), Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool, Short Nutritional Assessment Questionnaire, and Nutritional Risk in Emergency-2017. Length of hospital stay, in-hospital mortality, readmission, and mortality within 6 months postdischarge were considered as outcomes.

RESULTS

Among the 582 patients analyzed, the malnutrition risk ranged from 34.5% to 49.7% in patients with normal weight (n = 171), 20.8% to 33.9% in patients with overweight (n = 221), and 5.3% to 22.1% in patients with obesity (n = 190). Malnutrition risk by the NRS-2002 was associated with prolonged hospital stay, regardless of BMI category, and with 6-month hospital readmission in normal weight and those with obesity. The MST was associated with prolonged hospital stay, mortality, and hospital readmission in 6 months in normal-weight patients and with the first two outcomes in patients with overweight. No tool was associated with in-hospital death.

CONCLUSION

The prognostic value of nutrition risk screening tools varies according to BMI: the MST appears to be more appropriate for normal-weight and overweight patients, whereas the NRS-2002 may be more suitable for patients with obesity.

Nutritional Support in the Prevention and Treatment of Pressure Ulcers in Healthy Aging: A Systematic Review of Nursing Interventions in Community Care

Introduction: Pressure ulcers (PUs) represent a significant challenge in chronic care, particularly among the elderly with reduced mobility. They result in substantial socio-healthcare costs and negatively impact patients' psychological well-being. Malnutrition is a key risk factor, hindering healing and increasing the risk of complications. As such, appropriate nutritional interventions are crucial for managing PUs. However, these interventions are often underestimated in clinical practice, underscoring the need for a more comprehensive approach to elder care and healthy aging. Objectives: The primary objective of this study was to identify the best scientific evidence on nutritional interventions implemented by nurses in community settings to prevent complications related to PUs. Additionally, qualitative and quantitative outcomes reported in the included studies were analyzed. Method: This systematic review was conducted following PRISMA international guidelines. Searches were performed in PubMed, Scopus, Embase, and CINAHL databases. A predefined search strategy using Boolean operators was employed, and two researchers independently selected papers, with a third researcher resolving any discrepancies. Additional sources and manual reviews were conducted to minimize selection bias. Results: Out of 1003 records, 6 studies were included. Findings indicate that nurses play a fundamental role in managing PUs in community settings through specific nutritional intervention assistance processes. These healthcare professionals are pivotal in the prevention, care, and rehabilitation of vulnerable individuals with PUs. Conclusions: Nurses are strategic in the management of PUs within community care for frail populations. With nutritional support that plays a key role in both preventing and accelerating the healing of PUs. Policymakers are encouraged to invest in nursing roles to enhance assistance in community contexts, supporting healthy aging and lifestyle medicine approaches.

Summary of Evidence on Nutritional Management for Patients Undergoing Chemotherapy

OBJECTIVE

This paper aims to consolidate the most robust evidence on nutritional strategies for patients undergoing chemotherapy, offering evidence-based guidance for clinical practice. The review highlights critical evidence gaps in nutritional therapy for advanced gastric cancer (AGC) patients undergoing systemic therapy, integrating findings from both prospective and retrospective studies.

METHOD

According to the "6S" evidence resource pyramid model, clinical decision-making tools, guidelines, expert consensus, and systematic reviews on nutritional management for chemotherapy patients were systematically retrieved from national and international databases. The methodological quality of the selected literature was evaluated using AGREE II for guidelines, the JBI Evidence-Based Healthcare Center's standards for systematic reviews, and expert consensus developed by evidence-based practice experts.

RESULTS

A total of 47 articles were analyzed, consisting of 12 guidelines, 12 expert consensus statements, and 23 systematic reviews. The findings were categorized into five dimensions: interdisciplinary collaboration, nutritional screening and assessment, nutritional requirements, nutritional therapy, and discharge and follow-up, resulting in the identification of 62 pieces of relevant evidence.

CONCLUSIONS

The study provides comprehensive, evidence-based recommendations for nutritional management in chemotherapy patients. Application of the evidence should be adapted to specific clinical scenarios, patient conditions, preferences, and expert judgment to ensure both feasibility and relevance in clinical practice.

CONTRIBUTIONS

This review consolidates diverse nutritional management strategies into a unified framework, addressing evidence gaps in AGC under systemic therapy. Integrating prospective and retrospective studies with interdisciplinary insights provides evidence-based recommendations to enhance patient care through personalized and standardized approaches.

Systemic Inflammation in Oncologic Patients Undergoing Systemic Treatment and Receiving Whey Protein-Based Nutritional Support

There is increasing evidence about the role of inflammation in sarcopenia and tumor progression; thus, its modulation would represent a valuable strategy for improving clinical outcomes in patients with cancer. Several studies have reported that whey protein has significant anti-inflammatory and antioxidant characteristics in humans. We aimed to evaluate the effects of whey protein-based oral nutritional support on circulating cytokines in patients with solid tumors undergoing systemic treatment. Forty-six patients with solid tumors of different origin and undergoing systemic treatment were evaluated. Nutritional support with two daily whey protein-based oral supplements was administered. Circulating levels of IL-6, IL-8, IL-10, MCP-1 and IP-10 were determined. Nutritional evaluation included anthropometric, instrumental and biochemical parameters. Over 63% of the evaluated patients underwent surgery, 56.5% required chemotherapy and almost 50% received combined treatment. Patients with resected primary tumor presented with lower baseline IL-6 (p < 0.05) and IP-10 (p < 0.001); after three months of nutritional support, they presented with lower IL-8 (p < 0.05) and tended to present lower IL-6 and IP-10 (p = 0.053 and 0.067, respectively). Significant positive correlations between circulating cytokines, C-reactive protein and ferritin were observed; similarly, negative correlations with anthropometric and biochemical nutritional parameters were noticed (p < 0.05). We did not observe significant changes in circulating cytokine levels (IL-6, IL-8, IL-10, MCP-1 and IP-10) in patients with cancer undergoing systemic treatment after three months of nutritional support with whey protein-based oral supplements. According to a univariate analysis in our cohort, circulating IL-8 was associated with mortality in these patients, additionally, MCP-1 and IP-10 tended to correlate; but an age- and sex-adjusted multivariate analysis revealed that only baseline MCP-1 was significantly associated with mortality (OR 1.03 (95% CI: 1.00-1.05)). In conclusion, surgery of the primary solid tumor and combination treatment allow significant reduction in circulating cytokine levels, which remained stable while patients received nutritional support with whey protein-based oral supplements over three months. The role of MCP-1 as an independent factor for mortality in these patients should be further evaluated.

Validity of nutrition screening tools for risk of malnutrition among hospitalized adult patients: A systematic review and meta-analysis

BACKGROUNDS & AIMS

Malnutrition is prevalent among hospitalized patients in developed countries, contributing to negative health outcomes and increased healthcare costs. Timely identification and management of malnutrition are crucial. The lack of a universally accepted definition and standardized diagnostic criteria for malnutrition has led to the development of various screening tools, each with varying validity. This complicates early identification of malnutrition, hindering effective intervention strategies. This systematic review and meta-analysis aimed to identify the most valid and reliable nutritional screening tool for assessing the risk of malnutrition in hospitalized adults.

METHODS

A systematic literature search was conducted to identify validation studies published from inception to November 2023, in the Pubmed/MEDLINE, Embase, and CINAHL databases. This systematic review was registered in INPLASY (INPLASY202090028). The risk of bias and quality of included studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies version 2 (QUADAS-2). Meta-analyses were performed for screening tools accuracy using the symmetric hierarchical summary receiver operative characteristics models.

RESULTS

Of the 1646 articles retrieved, 60 met the inclusion criteria and were included in the systematic review, and 21 were included in the meta-analysis. A total of 51 malnutrition risk screening tools and 9 reference standards were identified. The meta-analyses assessed four common malnutrition risk screening tools against two reference standards (Subjective Global Assessment [SGA] and European Society for Clinical Nutrition and Metabolism [ESPEN] criteria). The Malnutrition Universal Screening Tool (MUST) vs SGA had a sensitivity (95% Confidence Interval) of 0.84 (0.73-0.91), and specificity of 0.85 (0.75-0.91). The MUST vs ESPEN had a sensitivity of 0.97 (0.53-0.99) and specificity of 0.80 (0.50-0.94). The Malnutrition Screening Tool (MST) vs SGA had a sensitivity of 0.81 (0.67-0.90) and specificity of 0.79 (0.72-0.74). The Mini Nutritional Assessment-Short Form (MNA-SF) vs ESPEN had a sensitivity of 0.99 (0.41-0.99) and specificity of 0.60 (0.45-0.73). The Nutrition Universal Screening Tool-2002 (NRS-2002) vs SGA had a sensitivity of 0.76 (0.58-0.87) and specificity of 0.86 (0.76-0.93).

CONCLUSIONS

The MUST demonstrated high accuracy in detecting malnutrition risk in hospitalized adults. However, the quality of the studies included varied greatly, possibly introducing bias in the results. Future research should compare tools within a specific patient population using a valid and universal gold standard to ensure improved patient care and outcomes.

Association between Controlling Nutritional Status (CONUT) Score and Body Composition, Inflammation and Frailty in Hospitalized Elderly Patients

The Controlling Nutritional Status (CONUT) score has demonstrated its ability to identify patients with poor nutritional status and predict various clinical outcomes. Our objective was to assess the association between the CONUT score, inflammatory status, and body composition, as well as its ability to identify patients at risk of frailty in hospitalized elderly patients.

METHODS

a total of 361 patients were retrospectively recruited and divided into three groups based on the CONUT score.

RESULTS

patients with a score ≥5 exhibited significantly higher levels of inflammatory markers, such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Neutrophil/Lymphocytes ratio (NLR), main platelet volume (MPV), and ferritin, compared to those with a lower score. Furthermore, these patients showed unfavorable changes in body composition, including a lower percentage of skeletal muscle mass (MM) and fat-free mass (FFM) and a higher percentage of fatty mass (FM). A positive correlation was found between the CONUT score and inflammatory markers, Geriatric Depression Scale Short Form (GDS-SF), and FM. Conversely, the Mini Nutritional Assessment (MNA), Mini-Mental Status Examination, activity daily living (ADL), instrumental activity daily living (IADL), Barthel index, FFM, and MM showed a negative correlation. Frailty was highly prevalent among patients with a higher CONUT score. The receiver operating characteristic (ROC) curve demonstrated high accuracy in identifying frail patients (sensitivity).

CONCLUSIONS

a high CONUT score is associated with a pro-inflammatory status as well as with unfavorable body composition. Additionally, it is a good tool to identify frailty among hospitalized elderly patients.

Malnutrition-related mortality trends in older adults in the United States from 1999 to 2020

BACKGROUND

Malnutrition mortality in older adults is underrepresented in scientific literature. This obscures any recent changes and hinders needed social change. This study aims to assess malnutrition mortality trends in older adults (≥ 65 years old) from 1999 to 2020 in the United States (U.S.).

METHODS

Mortality data from the Centers for Disease Control and Prevention's (CDC) Wide-Ranging Online Data for Epidemiology Research (WONDER) database were extracted. The ICD-10 Codes E40 - E46 were used to identify malnutrition deaths. Crude mortality rates (CMR) and age-adjusted mortality rates (AAMR) were extracted by gender, age, race, census region, and urban-rural classification. Joinpoint regression analysis was used to calculate annual percentage changes (APC) of AAMR by the permutation test and the parametric method was used to calculate 95% confidence intervals. Average Annual Percentage Changes (AAPC) were calculated as the weighted average of APCs.

RESULTS

Between 1999 and 2020, 93,244 older adults died from malnutrition. Malnutrition AAMR increased from 10.7 per 100,000 in 1999 to 25.0 per 100,000 in 2020. The mortality trend declined from 1999 to 2006 (APC = -8.8; 95% CI: -10.0, -7.5), plateaued till 2013, then began to rise from 2013 to 2020 with an APC of 22.4 (95% CI: 21.3, 23.5) and an overall AAPC of 3.9 (95% CI: 3.1, 4.7). Persons ≥ 85 years of age, females, Non-Hispanic Whites, residents of the West region of the U.S., and urban areas had the highest AAPCs in their respective groups.

CONCLUSION

Despite some initial decrements in malnutrition mortality among older adults in the U.S., the uptrend from 2013 to 2020 nullified all established progress. The end result is that malnutrition mortality rates represent a historical high. The burden of the mortality uptrends disproportionately affected certain demographics, namely persons ≥ 85 years of age, females, Non-Hispanic Whites, those living in the West region of the U.S., and urban areas. Effective interventions are strongly needed. Such interventions should aim to ensure food security and early detection and remedy of malnutrition among older adults through stronger government-funded programs and social support systems, increased funding for nursing homes, and more cohesive patient-centered medical care.