Reduced mortality risk in malnourished hospitalized older adult patients with COPD treated with a specialized oral nutritional supplement: Sub-group analysis of the NOURISH study

Effects of oral supplementation of β -hydroxy-β -methylbutyrate on muscle mass and strength in individuals over the age of 50: a meta-analysis

Background

β-Hydroxy β-Methylbutyrate (HMB) has shown potential in improving muscle protein turnover, which may be important for preventing muscle degradation in aging populations. The aim of this meta-analysis is to clarify the impact of HMB oral supplementation on muscle-related indicators and discover the interaction between dosage and duration. The findings will provide a scientific basis for the use of HMB oral supplementation in the management of muscle attenuation.

Methods

A computer systems-based search for articles of randomized controlled trial (RCT) in the PubMed, Cochrane Library, Web of Science, ScienceDirect, EBSCO English databases and China Journal Full-Text Database (CNKI), Wan Fang Chinese databases, was conducted up to October 2023. Data were pooled using weighted mean difference (WMD) and 95% confidence intervals (95% CI).

Results

A total of 21 RCTs were included, involving 1935 participants, all of them were > 50 years old. Results showed a positive impact of HMB oral supplementation in improving muscle mass (appendicular skeletal muscle mass: WMD = 1.56 kg, 95% CI: 0.03-3.09 kg and lean mass: WMD = 0.28 kg, 95% CI: 0.16-0.41 kg), strength (handgrip strength: WMD = 0.54 kg, 95% CI: 0.04-1.04 kg and five-time chair stand test: WMD = -0.73 s, 95% CI: -1.35, -0.11 s), and physical function (gait speed: WMD = 0.06 m/s, 95% CI: 0.01-0.10 m/s). Subgroup analysis revealed that the effect of a dosage of 3 g/d had significant improvement, and the effect of supplementation duration lasting > 12 weeks had significant improvement, and a dosage of 3g/day for more than 12 weeks was recommended.

Conclusion

HMB oral supplementation can improve muscle mass, strength, and physical function. We recommend to implement supplementation at a dosage of 3 g for a duration exceeding 12 weeks to achieve optimal benefits.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/login, identifier 42024518958.

Efficacy of nutrient supplements in managing malnutrition and sarcopenia in Chronic Obstructive Pulmonary Disease (COPD) patients: a protocol for systematic review and meta-analysis

BACKGROUND

COPD patients suffering from malnutrition or sarcopenia often incur higher healthcare costs and experience adverse clinical outcomes. Despite this, the effectiveness of nutrient supplements in this population remains uncertain.

METHODS AND ANALYSIS

Two reviewers will independently search seven databases-PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, Chinese Biomedical Literature Database, and the Cochrane Library-for randomized controlled trials (RCTs) published before August 31, 2024. These RCTs should compare the effects of nutrient supplements against either a standard diet or placebo supplements in patients with COPD. The risk of bias in the included studies will be evaluated using the modified Jadad scale and the Cochrane Collaboration's risk of bias tool. Data synthesis will be conducted using RevMan software. Trial sequential analysis (TSA) will be applied to the primary outcomes. Additionally, subgroup and sensitivity analyses will be performed to assess the robustness of the findings.

ETHICS AND DISSEMINATION

Ethical approval is not required because this study is a secondary analysis of existing data. We will disseminate the findings through peer- reviewed publications.

SYSTEMATIC REVIEW REGISTRATION

CRD42024585694.

STRENGTHS AND LIMITATIONS OF THIS STUDY

This systematic review and meta-analysis provides a thorough assessment of the efficacy of nutrient supplements in COPD patients, covering a wide range of studies. ·The use of the modified Jadad scale and the Cochrane Collaboration's risk of bias tool ensures a robust evaluation of study quality. Additionally, trial sequential analysis and subgroup analyses are employed to enhance the robustness of the findings. ·The credibility of the evidence may be compromised due to the potential for uncertain study quality and limited sample sizes in some included trials.

Effect of oral nutrition supplements on anthropometric and functional parameters among community-dwelling older adults: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Oral nutrition supplement (ONS) prescription in older adults is affordable for preventing malnutrition through the use of multiple nutrients and energy products. However, there is a gap in knowledge regarding the benefits of ONS supplementation on anthropometric and functional parameters in malnourished older adults without complicated conditions, known as community-dwelling older people.

METHODS

Electronic databases, including PubMed/Medline, SCOPUS, Web of Science, and the Cochrane Central Register of Controlled Trials, were searched to answer this question through August 10, 2023. The study adhered to the PRISMA guidelines and was registered on PROSPERO. The Cochrane risk of bias tool assessed the quality of randomized controlled trials (RCTs). The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool was used to evaluate the certainty of evidence. In total, 12 RCTs (n = 1320) were initially included.

RESULTS

ONS had a positive effect on body weight (weighted mean difference (WMD): 1.33, 95% CI: 0.94, 1.72, P = 0.00) with moderate certainty, BMI (WMD: 0.36, 95% CI: 0.06, 0.68, P = 0.02), calf circumference (WMD: 0.27, 95% CI: 0.08, 0.46, P < 0.001) with low certainty and midarm circumference (WMD: 0.38, 95% CI: -0.14, 0.89, P = < 0.15, I2: 87.2 P < 0.00) with very low certainty. Significant improvements in grip strength (WMD: 1.012, 95% CI: 0.37, 1.65, P < 0.00) and a slightly positive change in gait speed (WMD: 0.04, 95% CI: 0.004.0.083, P = 0.03, I2:0.0, P:0.72) were also observed.

CONCLUSION

ONS in community-dwelling older persons without complicated conditions can also have beneficial effects in terms of anthropometric and functional parameters.

Beta-hydroxy-beta-methylbutyrate (HMB) improves daily activity and whole-body protein metabolism in Duchenne muscular dystrophy dogs: a pilot study

Duchenne muscular dystrophy (DMD) is a severe neuromuscular disease due to loss of dystrophin, leading to progressive muscle wasting and physical inactivity. In this pilot study, we studied the effect of daily supplementation of the anabolic substrate beta-hydroxy-beta-methylbutyrate (HMB) on whole body protein and amino acid kinetics using novel isotope methods and daily activity in a canine model of DMD. Six DMD dogs were administered 3 g daily of HMB or placebo for 28 days according to a randomized, placebo-controlled, double-blinded crossover design. We measured pre- and post-intervention daily activity, biochemistry markers, and whole-body amino acid kinetics. We tracked daily activity with an activity monitoring device and measured plasma creatine kinase and standard clinical biochemistry panels to monitor muscle and organ function. To calculate whole body and intracellular amino acid production, we administered in the postabsorptive state an IV stable isotope solution containing 20 amino acid tracers. We collected blood before and six times after until two hours post tracer pulse administration and measured amino acid enrichments and concentrations by LC-MS/MS, subsequently followed by (non) compartmental modeling of the decay enrichment curves. Results were expressed as mean with 95% CI. Whole body production, plasma concentrations, and intra-/extracellular compartmental analyses of various amino acids were attenuated in HMB-dosed DMD dogs. Specifically, the plasma concentration of hydroxyproline (marker of collagen breakdown) was significantly higher in the placebo group compared to the HMB group. The intra- and extracellular pool sizes and flux between the two compartments of hydroxyproline was reduced in HMB treated dogs. DMD dogs treated with HMB as compared to placebo had a respective 40% increase in exertional (play) (951 [827, 1075] versus 569 [491, 647]; p < 0.0001) and 10.5% increase in non-exertional (active) activity (15,366 [14742, 15990] versus 13,806 [13148,14466]; p = 0.0016). In addition, a 6% reduction was found in rest time after HMB supplementation compared to placebo (23,857 [23,130, 24,584], versus 25,363 [24500, 26225]; p = 0.0122). Creatine kinase was not statistically different between groups. We did not observe any adverse clinical or biochemical-related effects of HMB dosing. Daily HMB supplementation in DMD dogs can safely and positively influence protein and amino acid metabolism and improve overall daily activity.

The Role of Nutrition and Nutritional Supplements in the Prevention and Treatment of Malnutrition in Chronic Obstructive Pulmonary Disease: Current Approaches in Nutrition Therapy

PURPOSE OF REVIEW

Malnutrition is a significant comorbidity in Chronic Obstructive Pulmonary Disease (COPD), contributing to disease progression and reduced quality of life. This narrative review examines the role of nutritional therapy in the prevention and management of malnutrition in COPD, emphasizing evidence-based approaches and their clinical implications.

RECENT FINDINGS

COPD patients face increased metabolic demands, systemic inflammation, and reduced dietary intake, resulting in muscle wasting, sarcopenia, and cachexia. Recent evidence highlights the efficacy of targeted nutritional strategies, including essential amino acid supplementation, omega-3 fatty acids, vitamin D, and antioxidants, in improving respiratory function, muscle strength, and patient well-being. Comprehensive nutritional assessments and personalized interventions are increasingly recognized as critical components of COPD care. However, long-term efficacy data remain limited. Nutritional therapy plays a pivotal role in managing malnutrition and improving clinical outcomes in COPD. This review synthesizes the latest evidence, identifies gaps in current research, and proposes strategies for integrating personalized nutrition into COPD care. Future studies are needed to establish the long-term benefits of these interventions and to develop tailored nutritional guidelines for COPD patients.

Adherence to Oral Nutritional Supplements: A Review of Trends in Intervention Characteristics and Terminology Use Since the Year 2000

Research on disease-related malnutrition and adherence to oral nutritional supplements (ONS) has increased in recent years. To guide future studies, it is important to identify trends in terminology use and intervention characteristics. This review aimed to map characteristics of research investigating adherence to ONS in patients with disease-related malnutrition and explore changes over time. This review is a secondary analysis of quantitative studies from a systematic mixed-studies review. Online databases, including PubMed, Cinahl, Cochrane Central Register of Controlled Trials, and APA PsycInfo, were searched to identify studies published from 2000 to March 2022. A quantitative content analysis of extracted data was performed, and the Mixed Methods Appraisal Tool (MMAT) was used to assess methodological risk of bias. This review includes 137 articles, over half of which are randomized controlled trials (52%). The term "oral nutritional supplements" was used in 40% of the studies. Adherence to ONS was mainly described by the term "compliance" (69%). It was most common to offer ready-made milk-based ONS (56%) and ONS as a sole intervention (51%). The prescribed dose of ONS was fixed in 64% of studies and individualized in 22% of studies. There was variation in the methods used to assess adherence to ONS, and adherence was not reported in nearly a fifth of studies. There was an increase in methodological quality over time (p = 0.024). To ensure better understanding and increase the rigor and reproducibility of ONS intervention research, it is crucial to standardize the terminology used and to describe the interventions clearly.

Association between geriatric nutritional risk index and adverse outcomes in critical ill patients with chronic obstructive pulmonary disease: a cohort study of 2824 older adults

OBJECTIVES

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide, particularly among the elderly, resulting in high rates of intensive care unit (ICU) admissions. Malnutrition is common in elderly patients and has been associated with poor prognosis in patients with COPD. However, its impact in the ICU setting remains incompletely defined. The objective of this study is to examine the association between malnutrition, as measured by the Geriatric Nutritional Risk Index (GNRI), and adverse outcomes in older patients with COPD in the ICU.

METHODS

A cohort study of 2,824 older COPD patients admitted to the ICU from 2008 to 2019 was conducted. The association between GNRI scores and outcomes including in-hospital mortality, risk of pressure injuries, and length of ICU stay was evaluated. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. A causal mediation analysis was employed to identify potential mediating variables and to calculate the proportion mediated.

RESULTS

The median age of study participants was approximately 75 years, with 1,281 (45.4%) being female. Lower GNRI scores (GNRI ≤ 98) were significantly associated with increased in-hospital mortality (OR: 1.48, 95% CI: 1.08-2.05, p = 0.015), higher incidence of pressure injuries (OR: 1.97, 95% CI: 1.54-2.54, p < 0.001), and longer ICU stays (OR: 1.51, 95% CI: 1.18-1.94, p = 0.001). Mediation analysis indicated that pressure injury accounted for approximately 22.9% of the association between malnutrition and in-hospital mortality.

CONCLUSIONS

Lower GNRI scores, indicative of malnutrition, are associated with adverse outcomes in elderly ICU patients with COPD. The findings highlight the importance of early nutritional assessment and intervention in this high-risk group to improve survival and reduce complications.

Addressing Inflammaging and Disease-Related Malnutrition: Adequacy of Oral Nutritional Supplements in Clinical Care

BACKGROUND

Disease-related malnutrition, with or without inflammation, in older adults is currently emerging as a public health priority. The use of Foods for Special Medical Purposes, including Oral Nutritional Supplements, and supplements is crucial to support patients in achieving their nutritional needs. Therefore, this article aims to comprehensively provide an analysis of the adequacy of FSMPs in meeting the nutritional requirements of different age-related diseases and takes into account the emerging role of inflammation. Moreover, it provides an identikit of the ideal products, following the pathology-specific guidelines.

METHODS

Data on 132 products were gathered through face-to-face meetings with companies' consultants. Specifically, information on energy, macronutrient, and micronutrient contents were collected, as well as on texture and flavors, osmolarity, cost, and packaging.

RESULTS

Most FSMPs met the daily recommendations for energy and protein intake. Nonetheless, few products contained β-hydroxy-β-methylbutyrate, optimal Branched-Chain Amino Acids ratios, arginine, glutamine, and omega-3 fatty acids. Furthermore, a marked predominance of FSMPs with a high osmolarity (85.7%), sweet taste (72%), and only animal protein content (79.5%) was observed. Cost analysis of FSMPs revealed a mean cost of EUR 5.35/portion. Products were mostly adequate for cancer, neurodegenerative diseases, diabetes, inflammatory bowel disease, end-stage kidney disease, dysphagiam and chronic obstructive pulmonary disease. However, gaps have been found for sarcopenia and abdominal surgery.

CONCLUSION

In light of the current market landscape, there is a need for a comprehensive regulation that indicates the optimal composition of FSMPs and the production of such products to tackle disease-related malnutrition.

Characterizing and Predicting Outcomes in Critically Ill Patients Receiving Low or High Protein Doses with Moderate Energy Support: A Retrospective Study

BACKGROUND

Finding the best energy and protein dose and timing for critically ill patients remains challenging. Distinct populations may react differently to protein load. This study aimed to characterize and predict outcomes of critically ill patients who received moderate energy and high or low protein doses during their stay in the intensive care unit (ICU).

METHODS

The cohort included 646 adult patients (70% men and 30% women) hospitalized in Beilinson Hospital ICU (Petah Tikva, Israel) for over 5 days between 2011 and 2018. Patients received 10-20 kcal/kg/day and were classified into two groups: low (LP) and high (HP) protein support (≤1 g/kg/day vs. >1 g/kg/day), the LP group comprising 531 patients (82%) and the HP group 115 patients (18%). Multiple logistic regression was used to describe associations between patients' characteristics and 90-day survival in the LP and HP groups.

RESULTS

Among LP, increased age, APACHE II, and receiving supplemental parenteral nutrition (SPN) were associated with decreased survival (OR = 0.986, 95% CI [0.973, 0.999]; OR = 0.915, 95% CI [0.886, 0.944], OR = 0.579, 95% CI [0.366, 0.917]). Trauma admission was associated with increased survival (OR = 1.826, 95% CI [1.001, 3.329]). Among HP, increased age was associated with decreased survival (OR = 0.956, 95% CI [0.924, 0.998]). Higher BMI was associated with improved survival (OR = 1.137, 95% CI [1.028, 1.258]). Likewise, in the HP group, the BMI of elderly survivors was higher compared to non-survivors (27.1 ± 6.2 vs. 24.7 ± 4.8, t (113) = 2.3, p < 0.05).

CONCLUSIONS

Our results show that in patients with moderate energy support and low protein administration, survivors were younger, with a lower APACHE II score, mainly suffering from trauma and without renal failure. In the patients receiving high protein support, younger patients with a high BMI not suffering from sepsis were more likely to survive. We suggest confirming these findings with prospective RCTs.

Practical Guidelines by the Andalusian Group for Nutrition Reflection and Investigation (GARIN) on Nutritional Management of Patients with Chronic Obstructive Pulmonary Disease: A Review

Malnutrition is common in chronic obstructive pulmonary disease (COPD) patients and is associated with worse lung function and greater severity. This review by the Andalusian Group for Nutrition Reflection and Investigation (GARIN) addresses the nutritional management of adult COPD patients, focusing on Morphofunctional Nutritional Assessment and intervention in clinical practice. A systematic literature search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, followed by critical appraisal based on Scottish Intercollegiate Guidelines Network (SIGN) guidelines. Recommendations were graded according to the European Society for Clinical Nutrition and Metabolism (ESPEN) system. The results were discussed among GARIN members, with consensus determined using a Likert scale. A total of 24 recommendations were made: 2(A), 6(B), 2(O), and 14(GPP). Consensus exceeded 90% for 17 recommendations and was 75-90% for 7. The care of COPD patients is approached from a nutritional perspective, emphasizing nutritional screening, morphofunctional assessment, and food intake in early disease stages. Nutritional interventions include dietary advice, recommendations on food group intake, and the impact of specialized nutritional treatment, particularly oral nutritional supplements. Other critical aspects, such as physical activity and quality of life, are also analyzed. These recommendations provide practical guidance for managing COPD patients nutritionally in clinical practice.

Functional and metabolic effects of omega-3 polyunsaturated fatty acid supplementation and the role of β-hydroxy-β-methylbutyrate addition in chronic obstructive pulmonary disease: A randomized clinical trial

INTRODUCTION

Short-term (4 weeks) supplementation with n-3 polyunsaturated fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) has recently been shown to improve protein metabolism in a dose dependent way in normal weight patients with Chronic Obstructive Pulmonary Disease (COPD). Furthermore, EPA/DHA supplementation was able to increase extremity lean soft tissue but not muscle function. No studies are available combining n-3 PUFAs and the leucine metabolite β-hydroxy-β-methylbutyrate (HMB) supplementation in chronic clinical conditions. Whether adding HMB to daily EPA/DHA supplementation for 10 weeks enhances muscle and brain health, daily functional performance, and quality of life of patients with COPD by further improving their protein and amino acid homeostasis remains unknown.

METHODS

Patients with COPD (GOLD: II-IV, n = 46) received daily for 10 weeks, according to a randomized double-blind placebo-controlled three-group design, EPA/DHA (n = 16), EPA/DHA to which HMB was added (n = 14), or placebo (n = 16). The daily dose of 2.0 g of EPA/DHA or soy + corn oil as the placebo was provided via gel capsules, and 3.0 g of Ca-HMB or maltodextrin as placebo as powders. At pre- and post-intervention, a pulse mixture of multiple amino acids was administered to measure postabsorptive net protein breakdown (netPB as primary endpoint) and whole body production (WBP) and conversion rates of the amino acids. As secondary endpoints, lean soft tissue and fat mass were assessed by dual-energy X-ray absorptiometry, upper and lower muscle function by handgrip and single leg isokinetic dynamometry, brain (cognitive, wellbeing) health by assessments, daily functional performance by measuring 6-min walk distance, 4-m gait speed, and postural balance, and quality of life by questionnaire. Plasma enrichments and concentrations were analyzed by LC-MS/MS, and systemic inflammatory profile and metabolic hormones by Luminex.

RESULTS

HMB + EPA/DHA but not EPA/DHA supplementation increased postabsorptive netPB (p = 0.028), and WBPs of glutamine (p = 0.024), taurine (p = 0.039), and tyrosine (p = 0.036). Both EPA/DHA and HMB + EPA/DHA supplementation resulted in increased WBP of phenylalanine (p < 0.05). EPA/DHA but not HMB + EPA/DHA was able to increase WBP of arginine (p = 0.030), citrulline (p = 0.008), valine (p = 0.038), and conversion of citrulline to arginine (p = 0.009). Whole body and extremity fat mass were reduced after HMB + EPA/DHA supplementation only, whereas lean soft tissue was increased after EPA/DHA (p = 0.049) and HMB + EPA/DHA (p = 0.073). No other significant findings were observed. Reductions in several proinflammatory cytokines were observed in the HMB + EPA/DHA group including IL-2, IL-17, IL-6, IL-12P40, and TNF-β (p < 0.05).

CONCLUSIONS

Ten weeks of supplementation with 2 g of EPA/DHA daily is sufficient to induce muscle gain in COPD but HMB is needed to induce fat loss. Whether HMB is solely responsible for the fat mass loss or has a synergistic effect with EPA/DHA remains unclear. The increase in net protein breakdown observed with HMB + EPA/DHA supplementation may indicate a beneficial enhanced protein turnover cycling associated with increased lean soft tissue.

CLINICAL TRIAL REGISTRY

ClinicalTrials.gov; NCT03796455.

Genetic information supports a causal relationship between trace elements, inflammatory proteins, and COPD: evidence from a Mendelian randomization analysis

Objective

Dietary factors and nutritional status may be among the risk factors for Chronic Obstructive Pulmonary Disease (COPD). There exists a certain correlation between trace elements and COPD. Through Mendelian Randomization (MR) analysis, we investigated the causal relationships between trace elements, inflammatory proteins, and COPD.

Methods

We employed MR, multivariable MR (MVMR), and two-step MR (TSMR) approaches to assess the causal links between 15 trace elements and COPD, with 91 inflammatory proteins serving as mediators to further elucidate the tripartite causal relationships.

Results

Trace elements such as Folate (OR = 1.293, 95%CI 1.027-1.628; p = 0.029), Vitamin D (OR = 1.331, 95%CI 1.071-1.654; p = 0.010), Vitamin B12 (OR = 1.424, 95%CI 1.108-1.828; p = 0.006), and Iron (OR = 0.741, 95%CI 0.580-0.946; p = 0.016) demonstrated causal relationships with COPD. No causal relationship was observed in reverse MR. After adjusting for BMI, Folate (OR = 1.633, 95%CI 1.098-2.429; p = 0.015), Iron (OR = 0.507, 95%CI 0.31-0.778; p = 0.001), and Vitamin D (OR = 1.511, 95%CI 1.029-2.217; p = 0.034) were identified as independent risk factors for COPD, whereas Vitamin B12 (OR = 1.118, 95%CI 0.751-1.666; p = 0.581) was not. Mediation analysis indicated that CDCP1 (5.76%) may play a mediating role between Iron and COPD.

Conclusion

Trace elements such as Folate, Vitamin D, Vitamin B12, and Iron have causal relationships with COPD. After BMI adjustment, Folate, Vitamin D, and Iron emerge as independent risk factors. Furthermore, the inflammatory protein CDCP1 may partially mediate the causal relationship between Iron and COPD, offering a scientific basis for dietary recommendations that could benefit COPD patients. The supplementation of trace elements may be advantageous for individuals suffering from COPD.

Effects of Oral Nutritional Supplement with β-Hydroxy-β-methylbutyrate (HMB) on Biochemical and Hematological Indices in Community-Dwelling Older Adults at Risk of Malnutrition: Findings from the SHIELD Study

Malnutrition may result in abnormal biochemical and hematological indices. This planned prespecified analysis investigated the effects of a specialized oral nutritional supplement (ONS) on biochemical and hematological indices in community-dwelling older adults at risk of malnutrition. In the Strengthening Health in ELDerly through nutrition (SHIELD) study, 811 older adults aged 65 years and above took part in this randomized, double-blind, placebo-controlled, multi-center study. Participants were randomly allocated to either a complete and balanced specialized ONS (each serving provides 262 kcal, 10.5 g protein, 7.75 µg vitamin D3, and 0.74 g calcium β-hydroxy-β-methylbutyrate) and dietary counselling (intervention group) or a placebo and dietary counselling (placebo group). Both groups consumed study products twice a day for 180 days. Data were collected at baseline, day 90, and day 180. Blood analysis results at follow-up visits were analyzed using repeated measures analysis of covariance with adjustments for confounders. Overall, when compared with the placebo group, the intervention group showed significantly greater urea (6.0 mmol/L vs. 5.4 mmol/L, p < 0.001), urea to creatinine ratio (4.39 vs. 4.26, p < 0.001), prealbumin (24.9 mg/dL vs. 24.0 mg/dL, p < 0.001), vitamin B12 (480.0 pmol/L vs. 420.1 pmol/L, p < 0.001), and globulin levels (26.8 g/L vs. 26.5 g/L, p = 0.032). The intervention group also had a significantly higher absolute reticulocyte count (62.0 × 103/µL vs. 58.2 × 103/µL, overall p < 0.001) and mean platelet volume (10.0 fL vs. 9.9 fL, overall p = 0.003). Furthermore, significant improvements were seen in total protein at day 90 (71.7 g/L vs. 71.1 g/L, p = 0.017) and in absolute monocyte count at day 90 (0.50 × 103/µL vs. 0.47 × 103/µL, p = 0.009) in the intervention group. In conclusion, daily consumption of a specialized ONS for six months led to significant improvements in biochemical and hematological indices in community-dwelling older adults at risk of malnutrition.

Nutritional Support in Malnourished Outpatients with Chronic Obstructive Pulmonary Disease (COPD): A Randomized Controlled Pilot Study

(1) Background: The evidence for nutritional support in COPD is almost entirely based on ready-to-drink oral nutritional supplements (ONSs). This study aimed to explore the effectiveness of powdered ONSs alongside individualized dietary counseling in the management of malnutrition. (2) Methods: Malnourished outpatients with COPD were randomized to receive either routine care (Group A: counseling + recommended to purchase powdered ONSs) or an enhanced intervention (Group B: counseling + provision of powdered ONSs at no cost to the patient) for 12 weeks. Outcomes of interest were nutritional intake, weight status, and quality of life. (3) Results: A total of 33 outpatients were included, categorized as follows: Group A (n = 21); Group B (n = 12); severely malnourished (n = 9), moderately malnourished (n = 24), mean BMI 18.0 SD 2.5 kg/m2. No differences were observed between groups at baseline or at week 12; however, analysis of the whole cohort (Group A + B) revealed nutrition intervention resulted in significant improvements in protein intake (+25.4 SD 53.4 g/d; p = 0.040), weight (+1.1 SD 2.6 kg; p = 0.032) and quality of life (-4.4 SD 10.0; p = 0.040). Only 41.2% of Group A and 58.3% of Group B reported consuming ONSs at week 12. Adherence to ONSs was associated with weight gain (+1.9 SD 2.5 kg vs. +0.4 SD 2.5 kg; p = 0.098). (4) Conclusions: Nutritional support results in significant improvements in nutrition status and quality of life in malnourished outpatients with COPD. However, improvements are associated with adherence to ONSs, suggesting the type of ONSs and how they are provided are important considerations in clinical practice and future studies.

Systematic review and meta-analysis of nutrient supplements for treating sarcopenia in people with chronic obstructive pulmonary disease

Individuals with chronic obstructive pulmonary disease (COPD) are prone to malnutrition and sarcopenia as a result of nutritional deficiencies and increased energy metabolism. However, the effects of nutrient supplements (NS) on treating sarcopenia in patients with COPD are not well established from systematic evidence. This meta-analysis examined the effect of NS on sarcopenia in patients with COPD. A systematic search of multiple databases was conducted, and 29 randomized controlled trials involving 1625 participants (age, mean [SD] = 67.9 [7.8] years) were analyzed. NS demonstrated significant improvements in body weight (MD,1.33 kg; 95% CI, 0.60, 2.05 kg; P = 0.0003; I2 = 87%), fat-free mass index (MD, 0.74 kg/m2; 95% CI, 0.21, 1.27 kg/m2; P = 0.007; I2 = 75%), and 6-min walk test (MD, 19.43 m; 95% CI, 4.91, 33.94 m; P = 0.009; I2 = 81%) compared with control. However, NS had nonsignificant effects on handgrip strength (SMD, 0.36; 95% CI, - 0.15, 0.88; P = 0.16; I2 = 87%) and quadriceps muscle strength (SMD, 0.11; 95% CI, -  0.06, 0.27; P = 0.20; I2 = 25%) compared with the control. In conclusion, NS may be an effective treatment for improving body composition and physical performance in COPD. Future studies should explore the effects of intervention durations, specific NS types, or combined training in patients with COPD and sarcopenia.

ESPEN practical guideline: Nutritional support for polymorbid medical inpatients

BACKGROUND

Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and healthcare costs.

AIM

As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.

METHODS

The 2023 update adheres to the standard operating procedures for ESPEN guidelines. We undertook a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g., published guidelines), until July 12th, 2022. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (including SIGN grading), which was followed by submission to Delphi voting. Here, the practical version of the guideline is presented which has been shortened and equipped with flow charts for patients care.

RESULTS

32 recommendations (7× A, 11× B, 10× O and 4× GPP), which encompass different aspects of nutritional support were included from the scientific guideline including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. Here, the practical version of the guideline is presented which has been shortened and equipped with flow charts for patients care.

CONCLUSIONS

Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated practical guideline offers an evidence-based nutritional approach to polymorbid medical inpatients and may improve their outcomes.

Association between endogenous plasma beta-hydroxy-beta-methylbutyrate levels and frailty in community-dwelling older people

BACKGROUND

Frailty is a key element in healthy ageing in which muscle performance plays a main role. Beta-hydroxy-beta-methylbutyrate (HMB) supplementation has shown favourable effects in modulating protein synthesis, improving muscle mass and function in interventional studies. Decreased age-related endogenous HMB levels have been shown in previous studies. The aim of the present study is to assess whether there is an association between endogenous plasma HMB levels and frailty.

METHODS

Data from 1290 subjects (56.98% women; mean ± standard deviation age 74.6 ± 5.95 years) from the Toledo Study for Healthy Aging were obtained. Participants had their frailty status qualified according to Fried's Frailty Phenotype (FFP) score and the Frailty Trait Scale in its 12-domain version (FTS-12). Plasma HMB levels were analysed by an ultrahigh-performance liquid chromatography tandem mass spectrometry. Differences between groups (frail vs. non-frail) were tested using Mann-Whitney U test, Kruskal-Wallis test and chi-squared test. The association between HMB and frailty was assessed by multivariate linear and logistic regressions when frailty was analysed as continuous and binary, respectively. Models were adjusted by age, gender, comorbidity, body composition and protein intake.

RESULTS

HMB levels were lower in those aged ≥75 years than in those aged 65-74 years, with an inverse linear relationship between age and HMB levels (β = -0.031; P = 0.018), mainly accounted by males (β = -0.062; P = 0.002). HMB levels were higher in men (0.238 ± 0.065 vs. 0.193 ± 0.051 ng/mL; P ≤ 0.001). HMB levels were significantly lower in frail than in non-frail individuals: 0.204 ± 0.058 versus 0.217 ± 0.063 ng/dL (P = 0.001) according to the FFP and 0.203 ± 0.059 versus 0.219 ± 0.063 ng/mL (P < 0.001) according to FTS-12. These differences showed a dose-dependent profile when we compared them by quintiles of HMB (P for trend: 0.022; 0.012 and 0.0004, respectively, for FFP, FTS-12 binary and FTS-12 continuous). Variables associated with low HMB levels were body mass index, strength, exhaustion and weight loss. Frailty was associated with HMB levels in all the adjusted models, including the fully adjusted ones, no matter the tool used (odds ratio: 0.45 [0.26, 0.77] for FFP and 0.36 [0.20, 0.63] for FTS-12 binary; β = -4.76 [-7.29, -2.23] for FTS-12 score). This association was also observed when the analyses were done by quintiles, showing such association since Q4 (FFP), Q2 (FTS-12 binary) and Q3 (FTS-12 score). The associations were observed in the whole sample and in each gender.

CONCLUSIONS

There is an inverse association between HMB levels and frailty status. These findings support the design of targeted clinical trials to evaluate the effect of HMB supplementation in older frail people with low HMB levels.

Predictors of Readmission, for Patients with Chronic Obstructive Pulmonary Disease (COPD) - A Systematic Review

Introduction

Chronic obstructive pulmonary disease (COPD) is the third-leading cause of death globally and is responsible for over 3 million deaths annually. One of the factors contributing to the significant healthcare burden for these patients is readmission. The aim of this review is to describe significant predictors and prediction scores for all-cause and COPD-related readmission among patients with COPD.

Methods

A search was conducted in Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials, from database inception to June 7, 2022. Studies were included if they reported on patients at least 40 years old with COPD, readmission data within 1 year, and predictors of readmission. Study quality was assessed. Significant predictors of readmission and the degree of significance, as noted by the p-value, were extracted for each study. This review was registered on PROSPERO (CRD42022337035).

Results

In total, 242 articles reporting on 16,471,096 patients were included. There was a low risk of bias across the literature. Of these, 153 studies were observational, reporting on predictors; 57 studies were observational studies reporting on interventions; and 32 were randomized controlled trials of interventions. Sixty-four significant predictors for all-cause readmission and 23 for COPD-related readmission were reported across the literature. Significant predictors included 1) pre-admission patient characteristics, such as male sex, prior hospitalization, poor performance status, number and type of comorbidities, and use of long-term oxygen; 2) hospitalization details, such as length of stay, use of corticosteroids, and use of ventilatory support; 3) results of investigations, including anemia, lower FEV1, and higher eosinophil count; and 4) discharge characteristics, including use of home oxygen and discharge to long-term care or a skilled nursing facility.

Conclusion

The findings from this review may enable better predictive modeling and can be used by clinicians to better inform their clinical gestalt of readmission risk.

Impact of a specialized oral nutritional supplement on quality of life in older adults following hospitalization: Post-hoc analysis of the NOURISH trial

BACKGROUND & AIMS

Both during and after hospitalization, nutritional care with daily intake of oral nutritional supplements (ONS) improves health outcomes and decreases risk of mortality in malnourished older adults. In a post-hoc analysis of data from hospitalized older adults with malnutrition risk, we sought to determine whether consuming a specialized ONS (S-ONS) containing high protein and beta-hydroxy-beta-methylbutyrate (HMB) can also improve Quality of Life (QoL).

METHODS

We analyzed data from the NOURISH trial-a randomized, placebo-controlled, multi-center, double-blind study conducted in patients with congestive heart failure, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease. Patients received standard care + S-ONS or placebo beverage (target 2 servings/day) during hospitalization and for 90 days post-discharge. SF-36 and EQ-5D QoL outcomes were assessed at 0-, 30-, 60-, and 90-days post-discharge. To account for the missing QoL observations (27.7%) due to patient dropout, we used multiple imputation. Data represent differences between least squares mean (LSM) values with 95% Confidence Intervals for groups receiving S-ONS or placebo treatments.

RESULTS

The study population consisted of 622 patients of mean age ±standard deviation: 77.9 ± 8.4 years and of whom 52.1% were females. Patients consuming placebo had lower (worse) QoL domain scores than did those consuming S-ONS. Specifically for the SF-36 health domain scores, group differences (placebo vs S-ONS) in LSM were significant for the mental component summary at day 90 (-4.23 [-7.75, -0.71]; p = 0.019), the domains of mental health at days 60 (-3.76 [-7.40, -0.12]; p = 0.043) and 90 (-4.88 [-8.41, -1.34]; p = 0.007), vitality at day 90 (-3.33 [-6.65, -0.01]; p = 0.049) and social functioning at day 90 (-4.02 [-7.48,-0.55]; p = 0.023). Compared to placebo, differences in LSM values for the SF-36 general health domain were significant with improvement in the S-ONS group at hospital discharge and beyond: day 0 (-2.72 [-5.33, -0.11]; p = 0.041), day 30 (-3.08 [-6.09, -0.08]; p = 0.044), day 60 (-3.95 [-7.13, -0.76]; p = 0.015), and day 90 (-4.56 [-7.74, -1.38]; p = 0.005).

CONCLUSIONS

In hospitalized older adults with cardiopulmonary diseases and evidence of poor nutritional status, daily intake of S-ONS compared to placebo improved post-discharge QoL scores for mental health/cognition, vitality, social functioning, and general health. These QoL benefits complement survival benefits found in the original NOURISH trial analysis.

CLINICAL TRIAL REGISTRATION

NCT01626742.

Unintentional weight loss is reflected in worse one-year clinical outcomes among COPD outpatients

RATIONALE

Unintentional weight loss (UWL) is prevalent among patients with chronic obstructive pulmonary disease (COPD). However, little research has been done on UWL as an independent variable in terms of clinical outcome. The aim of this study was to investigate the association between BMI, UWL, and clinical outcome in terms of hospitalization, length of stay, exacerbations, mortality, and quality of life (QoL) within six months and one year in a hospital outpatient setting.

METHODS

A prospective single-center cohort study enrolled 200 patients from the COPD outpatient clinic between October 2020 and May 2021 at a Danish Hospital. At baseline, data was collected using patients' electronic journals and a quantitative questionnaire was gathered with a patient-reported UWL of 5% of body weight within three months. At six months and one-year follow-ups, data was collected using the patients' medical journals and a telephonic interview with the EQ-5D-5L and SARC-F questionnaire and the number of non-hospitalization exacerbations since inclusion. Data were analyzed using logistic and Cox hazard regression analysis.

RESULTS

A total of 187 patients were eligible for follow-up (mean age 69.2 years, 43.9% males, median BMI 26.8 kg/m2), and the prevalence of UWL was 13.4%. UWL was associated with an almost trifold risk of >five days stay (OR = 2.94, p = 0.021). Additionally, UWL was associated with a worse QoL. A higher risk of exacerbation was found in the underweight patients (OR = 4.94, p = 0.014). No significant difference in mortality was found.

CONCLUSION

UWL as a solitary factor is associated with increased hospital length of stay and a worse QoL. The results provide further evidence that implementation of regular screening for UWL in addition to BMI might be beneficial to include in international COPD guidelines for outpatient settings.

Impact of pharmacological and non-pharmacological interventions on mortality in chronic obstructive pulmonary disease (COPD) patients

PURPOSE

This review aimed to summarise evidence about the impact of pharmacological and non-pharmacological interventions on survival in COPD patients.

METHODS

We performed a narrative literature review on the effect of pharmacological and non-pharmacological interventions on survival in COPD patients.

RESULTS

Inhaled therapies are central to reduce symptoms in COPD. In particular, inhaled steroids seem to have the greatest effect on mortality. Despite the anti-inflammatory effects attributed to statins, their benefit in COPD has been shown only in cases of combined cardiovascular diseases. The use of beta-blockers in COPD has not been associated with increased COPD-related mortality and a beneficial effect on all-cause mortality has even been shown in COPD patients with cardiovascular diseases. Influenza and pneumococcal vaccination reduced the occurrence of exacerbations and mortality due to COPD. In addition, long-term oxygen therapy (LTOT) (≥15h/day) in COPD patients with severe hypoxemia had a positive effect on survival. Regarding non-pharmacological interventions, it has been demonstrated that smoking cessation, treatment compliance and nutritional supplementation for underweight patients also have a positive effect on survival. Non-invasive ventilation results were dependent on patient PaCO2 levels. In patients with advanced COPD, further prospective studies are needed to know the effect of bronchoscopic lung volume reduction and lung transplant on COPD survival. Regarding lung transplant, a survival benefit in patients with a pre-transplant BODE score of ≥7 has been shown in retrospective studies.

CONCLUSION

Most of the studies did not evaluate survival as the main criteria and further long-term studies on the global management of COPD are required.

The Possible Role of Food and Diet in the Quality of Life in Patients with COPD-A State-of-the-Art Review

Diet has been described as a modifiable risk factor for the development and progression of chronic diseases, and emerging evidence increasingly points to its preventive and therapeutic role in chronic obstructive pulmonary disease (COPD). While the relationship between the underlying disease and diet is natural in conditions such as metabolic disorders, obesity, diabetes, etc., the direct effect is not so evident in chronic obstructive pulmonary disease. Poor diet quality and the development of nutrient deficiencies in respiratory diseases, including COPD, can be associated with disease-specific factors such as the exacerbation of respiratory symptoms. These symptoms can be improved by dietary interventions, leading to positive changes in the pathogenesis of the disease and the quality of life of patients. Therefore, our aim was to review the latest randomized controlled trials (RCTs) of dietary interventions in chronic respiratory patients and describe their effects on respiratory function, physical activity, systemic inflammatory parameters, and quality of life. We conducted a literature search on dietary interventions for COPD patients in the PubMed, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials (CENTRAL) databases, focusing on publications from 1 July 2018 to 1 July 2023. We used specific keywords and MESH terms, focusing on RCTs. A total of 26 articles and 1811 COPD patients were included in this review. On the basis of our findings, dietary interventions, in particular components of the Mediterranean diet such as protein, omega-3 polyunsaturated fatty acids, and vegetables, appear to have beneficial effects in patients with chronic respiratory diseases, and their application is beneficial. However, long-term follow-up studies are still needed to examine the effects of dietary interventions in this patient population.

ESPEN guideline on nutritional support for polymorbid medical inpatients

BACKGROUND

Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and cost of care.

AIM

As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.

METHODS

This update adheres to the standard operating procedures for ESPEN guidelines. We did a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g. published guidelines), until July 12th. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (incl. SIGN grading), which was followed by submission to Delphi voting.

RESULTS

From a total of 3527 retrieved abstracts, 60 new relevant studies were analyzed and used to generate a guideline draft that proposed 32 recommendations (7x A, 11x B, 10x O and 4x GPP), which encompass different aspects of nutritional support including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. The results of the first online voting showed a strong consensus (agreement of >90%) on 100% of the recommendations. Therefore, no final consensus conference was needed.

CONCLUSIONS

Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated guideline offers an evidence-based nutritional approach to the polymorbid medical inpatients and may improve their outcomes.

Nutritional Interventions: Dietary Protein Needs and Influences on Skeletal Muscle of Older Adults

BACKGROUND

This narrative review describes foundational and emerging evidence of how dietary protein intakes may influence muscle-related attributes of older adults.

METHODS

PubMed was used to identify pertinent research.

RESULTS

Among medically stable older adults, protein intakes below the recommended dietary allowance (RDA) (0.8 g/kg body weight [BW]/d) exacerbate age-related reductions in muscle size, quality, and function. Dietary patterns with total protein intakes at or moderately above the RDA, including one or preferably more meals containing sufficient dietary protein to maximize protein anabolism, promote muscle size and function. Some observational studies suggest protein intakes from 1.0 to 1.6 g/kg BW/d may promote greater muscle strength and function more so than muscle size. Experimental findings from randomized controlled feeding trials indicate protein intakes greater than the RDA (averaging ~1.3 g/kg BW/d) do not influence indices of lean body mass or muscle and physical functions with non-stressed conditions, but positively influence changes in lean body mass with purposeful catabolic (energy restriction) or anabolic (resistance exercise training) stressors. Among older adults with diagnosed medical conditions or acute illness, specialized protein or amino acid supplements that stimulate muscle protein synthesis and improve protein nutritional status may attenuate the loss of muscle mass and function and improve survival of malnourished patients. Observational studies favor animal versus plant protein sources for sarcopenia-related parameters.

CONCLUSIONS

Quantity, quality, and patterning of dietary protein consumed by older adults with varied metabolic states, and hormonal and health status influence the nutritional needs and therapeutic use of protein to support muscle size and function.

A 1-year follow-up study in patients with idiopathic pulmonary fibrosis regarding adverse outcomes to unintended weight loss

OBJECTIVES

Malnutrition in pulmonary fibrosis may influence clinical outcomes negatively. This project aimed to investigate if weight, unintended weight loss (UWL) at baseline and weight development, and signs of sarcopenia measured by the strength, assistance with the walking, rising from a chair, climbing stairs, and falls questionnaire (SARC-F) are associated with hospital admissions and mortality for idiopathic pulmonary fibrosis outpatients in ≤1 y as well as referral to pulmonary rehabilitation.

METHODS

At baseline, prevalence of weight and UWL were sought in a cross-sectional questionnaire study, consecutively, including 100 patients in an outpatient clinic. Medical records were sought for time from diagnosis and comorbidities. One year after inclusion weight, UWL and SARC-F were collected by phone interviews, and medical records were revisited for clinical outcomes.

RESULTS

Of the 100 patients, two patients died and seven were lost to follow-up. The prevalence of UWL increased within the year (10-13%), and the amount of UWL increased (9.1-11.8 kg). Patients with a UWL at baseline had a significantly higher risk of mortality (odds ratio = 29.8; P = 0.037). UWL at baseline was associated with risk of hospital admissions (odds ratio = 14.7; P = 0.009). Based on the results from SARC-F, 20.9% have signs of sarcopenia. UWL at follow-up was associated with the risk of sarcopenia by SARC-F. Patients with risk of sarcopenia and those with body mass index ≥30 kg/m² were to a higher degree offered pulmonary rehabilitation; however, participation was low.

CONCLUSIONS

UWL at baseline was significantly associated with risk of hospital admissions and mortality in ≤1 y in idiopathic pulmonary fibrosis outpatients. Patients with signs of sarcopenia and body mass index ≥30 kg/m² were most often referred to pulmonary rehabilitation.

A paradigm shift in clinical nutrition

The current clinical nutrition paradigm is that decreased caloric intake, resulting in a caloric deficit, is central to the development disease-related malnutrition (DRM). In following with this paradigm, one should assume that nutrition interventions with artificially administered nutrition (food substitution paradigm) aimed at preventing a caloric deficit should result in the prevention and/or successful treatment of DRM. However, clear evidence demonstrates that the DRM observed in diverse illnesses is at least partially resistant to nutrition interventions aimed at preventing the development of a caloric deficit. Simply put, DRM cannot be prevented nor resolved through a nutrition intervention aimed solely on replacing what the person cannot or will not eat. It is time to stop oversimplifying nutrition therapy in clinical nutrition interventions as a food substitution issue, focusing instead on developing and testing innovative hypotheses aimed at a mechanistic understanding of how DRM develops. Through this effort, new paradigms should evolve. The aim of this opinion paper is to provide an overview of why we need a shift in the current paradigm.

Nutritional rehabilitation after acute illness among older patients: A systematic review and meta-analysis

BACKGROUND & AIMS

Acute illness can lead to disability and reduced quality of life in older patients. The aim of this systematic review was to evaluate the effect of nutritional rehabilitation provided during and after hospitalisation for an acute event on functional status, muscle mass, discharge destination and quality of life of older patients.

METHODS

The protocol for this systematic review was registered in PROSPERO (CRD42021264971). Articles were searched using Scopus, Medline, Google Scholar and Clinical.

TRIALS

gov. For studies included in the meta-analysis, Hedges'g standardized mean difference effect size was calculated and transformed in odds ratios.

RESULTS

We identified 7383 articles, of which 45 publications (41 trials, n = 8538 participants, mean age 80.35 ± 7.01 years.) were eligible for the systematic review. Patients were hospitalized for acute medical diseases (n = 6925) and fractures (n = 1063). The interventions included supplementation with a fixed amount of oral nutritional supplements (ONS, n = 17 trials), individualized diet plan (n = 3), combination of physical exercise with nutrition therapy (n = 14 trials), combination of anabolic agents with nutrition therapy (n = 5 trials). Overall nutritional rehabilitation improved functional status (Odds ratio 1.63 [1.15; 2.3], p = 0.003) and muscle mass (Odds ratio 2.61 [1.22; 5.5], p = 0.01), but not the quality of life or the discharge destination.

CONCLUSION

Nutritional rehabilitation was found to improve functional status and muscle mass. There is a need for larger studies involving older hospitalized patients.

Potential benefits of using an energy-dense, high-protein formula enriched with β-hydroxy-β-methylbutyrate, fructo-oligosaccharide, and vitamin D for enteral feeding in the ICU: A pilot case-control study in COVID-19 patients

OBJECTIVES

The aim of this study was to investigate the potential benefits of using an energy-dense, high-protein (HP) formula enriched with β-hydroxy-β-methylbutyrate (HMB), fructo-oligosaccharide (FOS), and vitamin D (VitD) for enteral feeding in the intensive care unit (ICU).

METHODS

This was a nested case-control multicenter study. Mechanically ventilated patients with COVID-19 in whom enteral nutrition was not contraindicated and receiving an energy-dense, HP-HMB-FOS-VitD formula (1.5 kcal/mL; 21.5% of calories from protein; n = 53) were matched (1:1) by age (±1 y), sex, body mass index (±1 kg/m²) and Sequential Organ Failure Assessment score (±1 point) and compared with patients fed with a standard HP, fiber-free formula (1.25-1.3 kcal/mL; 20% of calories from protein; n = 53). The primary end point was daily protein intake (g/kg) on day 4. Protein-calorie intake on day 7, gastrointestinal intolerance, and clinical outcomes were addressed as secondary end points.

RESULTS

The use of a HP-HMB-FOS-VitD formula resulted in higher protein intake on days 4 and 7 (P = 0.006 and P = 0.013, respectively), with similar energy intake but higher provision of calories from enteral nutrition at both times (P <0 .001 and P = 0.017, respectively). Gastrointestinal tolerance was superior, with fewer patients fed with a HP-HMB-FOS-VitD formula reporting at least one symptom of intolerance (55 versus 74%; odds ratio [OR], 0.43; 95% confidence interval [CI], 0.18-0.99; P = 0.046) and constipation (38 versus 66%; OR, 0.27; 95% CI, 0.12-0.61; P = 0.002). A lower rate of ICU-acquired infections was also observed (42 versus 72%; OR, 0.29; 95% CI, 0.13-0.65; P = 0.003), although no difference was found in mortality, ICU length of stay, and ventilation-free survival.

CONCLUSIONS

An energy-dense, HP-HMB-FOS-VitD formula provided a more satisfactory protein intake and a higher provision of caloric intake from enteral nutrition than a standard HP formula in mechanically ventilated patients with COVID-19. Lower rates of gastrointestinal intolerance and ICU-acquired infections were also observed.

Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission

Despite substantial progress in reducing the global impact of many non-communicable diseases, including heart disease and cancer, morbidity and mortality due to chronic respiratory disease continues to increase. This increase is driven primarily by the growing burden of chronic obstructive pulmonary disease (COPD), and has occurred despite the identification of cigarette smoking as the major risk factor for the disease more than 50 years ago. Many factors have contributed to what must now be considered a public health emergency: failure to limit the sale and consumption of tobacco products, unchecked exposure to environmental pollutants across the life course, and the ageing of the global population (partly as a result of improved outcomes for other conditions). Additionally, despite the heterogeneity of COPD, diagnostic approaches have not changed in decades and rely almost exclusively on post-bronchodilator spirometry, which is insensitive for early pathological changes, underused, often misinterpreted, and not predictive of symptoms. Furthermore, guidelines recommend only simplistic disease classification strategies, resulting in the same therapeutic approach for patients with widely differing conditions that are almost certainly driven by variable pathophysiological mechanisms. And, compared with other diseases with similar or less morbidity and mortality, the investment of financial and intellectual resources from both the public and private sector to advance understanding of COPD, reduce exposure to known risks, and develop new therapeutics has been woefully inadequate.

When is enteral nutrition indicated?

Enteral nutrition (EN) is a vital component of nutrition around the world. EN allows for delivery of nutrients to those who cannot maintain adequate nutrition by oral intake alone. Common questions regarding EN are when to initiate and in what scenarios it is safe. The answers to these questions are often complex and require an evidence-based approach. The Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) established an Enteral Nutrition Committtee to address the important questions surrounding the indications for EN. Consensus recommendations were established based on eight extremely clinically relevant questions regarding EN indications as deemed by the Enteral Nutrition Committee. These consensus recommendations may act as a guide for clinicians and stakeholders on difficult questions pertaining to indications for EN. This paper was approved by the ASPEN Board of Directors.

ω-3 polyunsaturated fatty acid supplementation improves postabsorptive and prandial protein metabolism in patients with chronic obstructive pulmonary disease: a randomized clinical trial

BACKGROUND

Disturbances in protein metabolism and impaired muscle health have been observed in chronic obstructive pulmonary disease (COPD). The ω-3 (n-3) PUFAs EPA and DHA are known for their anti-inflammatory and muscle health-enhancing properties.

OBJECTIVES

We examined whether daily EPA + DHA supplementation can improve daily protein homeostasis in patients with COPD by reducing postabsorptive whole-body protein breakdown (PB) and enhancing the anabolic response to feeding in a dose-dependent way.

METHODS

Normal-weight participants with moderate to severe COPD (n = 32) received daily for 4 wk, according to a randomized double-blind placebo controlled 3-group design, a high dose (3.5 g, n = 10) of EPA + DHA, a low dose (2.0 g, n = 10) of EPA + DHA, or placebo (olive oil, n = 12) via gel capsules. At pre- and postintervention, stable isotope tracers were infused to assess postabsorptive netPB [postabsorptive PB - protein synthesis (PS)] and the anabolic response (prandial netPS = prandial PS-PB) to a protein meal. In addition, muscle mass and function were measured.

RESULTS

Plasma phosphatidylcholine EPA and DHA concentrations were higher after 4 wk of supplementation in both EPA + DHA groups (P < 0.004), and there was a trend toward higher values for plasma EPA after the high compared with the low dose of EPA + DHA (P = 0.065). Postabsorptive PB was lower after 4 wk of the high dose of EPA + DHA, whereas netPB was lower independent of the dose of EPA + DHA (low dose, P = 0.037; high dose, P = 0.026). Prandial netPS was increased only after the high dose of EPA + DHA (P = 0.03). Extremity lean mass but not muscle function was increased, independent of the EPA + DHA dose (P < 0.05).

CONCLUSIONS

Daily n-3 PUFA supplementation for 4 wk induces a shift toward a positive daily protein homeostasis in patients with COPD in part in a dose-dependent way. Daily doses up to 3.5 g EPA and DHA are still well tolerated and lead to protein gain in these patients. This trial was registered at clinicaltrials.gov as NCT01624792.

Malnutrition Imparts Worse Outcomes in Patients With Diverticulitis: A Nationwide Inpatient Sample Database Study

Introduction Studies show that malnutrition can lead to worsening morbidity and mortality in patients. However, to our knowledge, no large database study has been conducted describing the effects of malnutrition in patients with diverticulitis. In this article, we aim to assess the impact of pre-existing malnutrition on outcomes of patients admitted for diverticulitis. Methods Data between 2008 and 2014 from the Nationwide Inpatient Sample database were extracted. Inclusion criteria for both groups included patients with a primary diagnosis of diverticulitis using the International Classification of Diseases, Ninth Revision codes. Exclusion criteria included all patients less than 18 years of age. The test group consisted of patients with a primary diagnosis of diverticulitis and a concurrent diagnosis of malnutrition. In-hospital mortality, length of stay, total cost, and complications, including various forms of sepsis, perforation, bleeding, and GI bleeding, were compared between the two groups. Univariate and multivariate analyses were used to generate odds ratios. Multivariate analysis included age, sex, race, income quartile, and calculated Elixhauser scores. Elixhauser comorbidity scores predicting mortality and readmission were calculated based on weighted scores from 29 different comorbidities. Scores were compared between the two groups using univariate analysis. Results There were a total of 1,520,919 patients in the study, of which 427,679 (2.8%) had a pre-existing diagnosis of malnutrition. On univariate analysis, there was a significant increase in mortality in patients with malnutrition (OR: 10.2, p < 0.01). Additionally, patients with malnutrition appeared to have longer lengths of stay (mean: 12.9, p < 0.01) and greater cost of hospitalization (mean: 194436.82, p < 0.01). Patients with malnutrition had greater rates of sepsis events (OR: 12.0, p < 0.01), perforation (OR: 2.8, p < 0.01), and GI bleed (OR: 1.84, p < 0.01). On multivariate analysis, malnutrition appeared to significantly increase mortality (OR: 3.3, p < 0.01). Discussion Patients who present with diverticulitis with malnutrition appear to have significantly worse outcomes. We hypothesize that malnutrition leads to a shift in the gut microbiota, resulting in increased inflammation. As a result, these patients may have an increased risk of worse outcomes, such as sepsis and death. Addressing nutrition in patients with diverticulosis or those with a history of diverticulitis may improve outcomes. This abstract was previously presented at the Digestive Disease Week Conference on May 22, 2022. Abstracts accepted at the conference were published in supplements of the journals Gastroenterology and GIE: Gastrointestinal Endoscopy.

Malnutrition Increases Hospital Length of Stay and Mortality among Adult Inpatients with COVID-19

Background: Malnutrition has been linked to adverse health economic outcomes. There is a paucity of data on malnutrition in patients admitted with COVID-19. Methods: This is a retrospective cohort study consisting of 4311 COVID-19 adult (18 years and older) inpatients at 5 Johns Hopkins-affiliated hospitals between 1 March and 3 December 2020. Malnourishment was identified using the malnutrition universal screening tool (MUST), then confirmed by registered dietitians. Statistics were conducted with SAS v9.4 (Cary, NC, USA) software to examine the effect of malnutrition on mortality and hospital length of stay among COVID-19 inpatient encounters, while accounting for possible covariates in regression analysis predicting mortality or the log-transformed length of stay. Results: COVID-19 patients who were older, male, or had lower BMIs had a higher likelihood of mortality. Patients with malnutrition were 76% more likely to have mortality (p < 0.001) and to have a 105% longer hospital length of stay (p < 0.001). Overall, 12.9% (555/4311) of adult COVID-19 patients were diagnosed with malnutrition and were associated with an 87.9% increase in hospital length of stay (p < 0.001). Conclusions: In a cohort of COVID-19 adult inpatients, malnutrition was associated with a higher likelihood of mortality and increased hospital length of stay.

In-vivo production of branched-chain amino acids, branched-chain keto acids, and β-hydroxy β-methylbutyric acid

PURPOSE OF REVIEW

The branched-chain amino acids (BCAA), branched-chain keto acids (BCKA), and β-hydroxy β-methylbutyric acid (HMB) have regained interest as food ingredients in health and disease. To support nutritional strategies, it is critical to gain insight into the whole body and transorgan kinetics of these components. We, therefore, reviewed the most recent literature in this field on in vivo analysis of BCAA, BCKA, and HMB kinetics in health and disease.

RECENT FINDINGS

With a new comprehensive metabolic flux analysis BCAA, BCKA, and HMB whole body production, interconversion and disposal rates can be measured simultaneously. Recent studies have provided us with a better understanding of whole-body and transorgan kinetics under postabsorptive, postprandial, hibernating, and lactating conditions. In human pathophysiological conditions like COPD, obesity, and diabetes, the added value of BCAA kinetic measurements over the commonly used concentration measurements only, is discussed.

SUMMARY

This article highlights the importance of implementing BCAA, BCKA, and HMB kinetic studies to further advance the field by gaining more mechanistic insights and providing direction to the development of new targeted (nutritional) strategies.

A review on the Role of Oral Nutritional Supplements in Chronic Obstructive Pulmonary Disease

Due to the high smoking rate in developing countries and the rising aging population in high-income countries, the global prevalence of chronic obstructive pulmonary disease (COPD), estimated to be 11.7%, is increasing and is the third-leading cause of mortality. COPD is likely to be present in elderly individuals with impaired gastro-enteric functions. Gastrointestinal congestion, dyspnea, and anxiety are pathophysiological characteristics of COPD, contributing to poor appetite, reduced dietary intake, and high-energy expenditure. These factors are implicated in the progression of malnutrition in COPD patients. Malnutrition is detrimental to lung functions and is associated with an increased risk of infection, exacerbation and mortality, and a longer duration of hospitalization. Therefore, nutritional support to treat malnutrition in COPD patients is very vital. Oral nutritional supplements (ONS) may hold the key to COPD treatment. To clarify this statement, we review current evidence for ONS in COPD patients to benefit from clinical outcomes.

Impact of β-hydroxy-β-methylbutyrate (HMB) on muscle loss and protein metabolism in critically ill patients: A RCT

PURPOSE

Muscle wasting deteriorates life quality after critical illness and increases mortality. Wasting starts upon admission to intensive care unit (ICU). We aimed to determine whether β-hydroxy-β-methylbutyrate (HMB), a metabolite of leucine, can attenuate this process.

METHODS

Prospective randomized, placebo-controlled double blind trial.

INCLUSION CRITERIA

ICU patients depending on mechanical ventilation on day 3 having a functional gastrointestinal tract. They were randomized to HMB (3 g/day) or placebo (maltodextrin) from day 4 on for 30 days.

PRIMARY OUTCOME

magnitude of loss of skeletal muscle area (SMA) of the quadriceps femoris measured by ultrasound at days 4 and 15.

SECONDARY OUTCOMES

body composition, change in protein metabolism assessed by amino acids tracer pulse, and global health at 60 days. Data are mean [95% CI]. Statistics by ANCOVA with correction for confounders sex, age and/or BMI.

RESULTS

Thirty patients completed the trial, aged 65 [59, 71] years, SAPS2 score 48 [43, 52] and SOFA 8.5 [7.4, 9.7]. The loss of total SMA was 11% between days 4 and 15 (p < 0.001), but not different between the groups (p = 0.86). In the HMB group, net protein breakdown (Δ Estimate HMB-Placebo: -153 [-242, -63]; p = 0.0021) and production of several amino acid was significantly reduced, while phase angle increased more (0.66 [0.09, 1.24]; p = 0.0247), and SF-12 global health improved more (Δ Estimate HMB-Placebo: 27.39 [1.594, 53.19], p = 0.04).

CONCLUSION

HMB treatment did not significantly reduce muscle wasting over 10 days of observation (primary endpoint), but resulted in significantly improved amino acid metabolism, reduced net protein breakdown, a higher phase angle and better global health. CLINICALTRIALS.

GOV IDENTIFIER

NCT03628365.