The role of non-dietetic healthcare professionals in managing interventions among adults at risk of malnutrition: A systematic review

A Conceptual Study on Characterizing the Complexity of Nutritional Interventions for Malnourished Older Adults in Hospital Settings: An Umbrella Review Approach

INTRODUCTION

Malnutrition is a widespread and intricate issue among hospitalized adults, necessitating a wide variety of nutritional strategies to address its root causes and repercussions. The primary objective of this study is to systematically categorize nutritional interventions into simple or complex, based on their resource allocation, strategies employed, and predictors of intervention complexity in the context of adult malnutrition in hospital settings.

METHODS

A conceptual evaluation of 100 nutritional intervention studies for adult malnutrition was conducted based on data from a recent umbrella review (patient population of mean age > 60 years). The complexity of interventions was categorized using the Medical Research Council 2021 Framework for Complex Interventions. A logistic regression analysis was employed to recognize variables predicting the complexity of interventions.

RESULTS

Interventions were divided into three principal categories: education and training (ET), exogenous nutrient provision (EN), and environment and services (ES). Most interventions (66%) addressed two or more of these areas. A majority of interventions were delivered in a hospital (n = 75) or a hospital-to-community setting (n = 25), with 64 studies being classified as complex interventions. The logistic regression analysis revealed three variables associated with intervention complexity: the number of strategies utilized, the targeted areas, and the involvement of healthcare professionals. Complex interventions were more likely to be tailored to individual needs and engage multiple healthcare providers.

CONCLUSIONS

The study underlines the importance of considering intervention complexity in addressing adult malnutrition. Findings advocate for a comprehensive approach to characterizing and evaluating nutritional interventions in future research. Subsequent investigations should explore optimal balances between intervention complexity and resource allocation, and assess the effectiveness of complex interventions across various settings, while considering novel approaches like telehealth.

An Umbrella Review and Meta-analysis of Interventions, Excluding Enteral and Parenteral Nutrition, Initiated in the Hospital for Adults with or at Risk of Malnutrition

BACKGROUND

Multiple systematic reviews and meta-analyses (SRMAs) on various nutritional interventions in hospitalized patients with or at risk of malnutrition are available, but disagreements among findings raise questions about their validity in guiding practice.

OBJECTIVES

We conducted an umbrella review (a systematic review of systematic reviews in which all appropriate studies included in SRMAs are combined) to assess the quality of reviews, identify the types of interventions available (excluding enteral and parenteral nutrition), and re-analyze the effectiveness of interventions.

METHODS

The databases MEDLINE/PubMed, CINAHL, Embase, The Cochrane Library, and Google Scholar were searched. AMSTAR-2 was used for quality assessment and GRADE for certainty of evidence. Updated meta-analyses with risk of bias (ROB) by Cochrane ROB 2.0 were performed. Pooled effects were reported as relative risk (RR), with zero-events and publication bias adjustments, and trial sequential analysis (TSA) performed for mortality, readmissions, complications, length of stay, and quality of life.

RESULTS

A total of 66 randomized controlled trials were cited by the 19 SRMAs included in this umbrella review, and their data extracted and analyzed. Most clinical outcomes were discordant with variable effect sizes in both directions. In trials with low ROB, interventions targeting nutritional intake reduce mortality at 30 d (15 studies, n: 4156, RR: 0.72, 95% CI: 0.55, 0.94, P: 0.02, I2: 6%, Certainty: High), 6 mo (27 studies, n: 6387, RR: 0.81, 95% CI: 0.71, 0.92, P = 0.001, I2: 4%, Certainty: Moderate), and 12 mo (27 studies, n: 6387, RR: 0.80, 95% CI: 0.67, 0.95, P: 0.01, I2: 33%, Certainty: Moderate), with TSA verifying an adequate sample size and robustness of the meta-analysis.

CONCLUSION

Existing evidence is sufficient to show that nutritional intervention is effective for mortality outcomes at 30 d, 6 mo, and 12 mo. Future clinical trials should focus on the effect of nutritional interventions on other clinical outcomes.

TRIAL REGISTRATION NUMBER

The protocol is registered on PROSPERO (CRD42022341031).

Malnutrition knowledge among nursing staff in four European countries: A cross-sectional study

BACKGROUND

Nursing staff must have sufficient knowledge in order to adequately prevent and treat malnutrition. However, only a marginal amount of information on this topic is available in the literature.

OBJECTIVES

This paper provides a comparison of the malnutrition knowledge among nursing staff in Austria, the Czech Republic, the Netherlands, and Turkey and presents factors associated with the malnutrition knowledge of nursing staff.

DESIGN

A cross-sectional study was performed.

SETTING AND PARTICIPANTS

Nursing staff from different care settings in Austria, the Czech Republic, the Netherlands, and Turkey participated in the study.

METHODS

The KoM-G 2.0 (Knowledge of Malnutrition - Geriatric) questionnaire was used for data collection.

RESULTS

In total, 2056 participants from different care settings took part in the study. Between 11.7 % (Turkey) and 32.5 % (Austria) of the participants had high levels of malnutrition knowledge. The country itself was the factor most strongly associated with malnutrition knowledge. The nurses' educational level and specialised training of nursing staff were also significantly (p < 0.001) associated with malnutrition knowledge. Questions about "factors that should be considered during older persons' food intake" were most frequently answered correctly, while questions about "different aspects of nutritional screening" were less often answered correctly in all four countries.

CONCLUSIONS

This study was one of the first to describe the rather low level of malnutrition knowledge among nursing staff in different countries. The country itself was identified as the factor most strongly associated with the nurses' knowledge of malnutrition, while the nursing staff's basic education as well as further training were also detected as significant factors. These results indicate that it is necessary to extend and improve (academic) nursing education and to offer specialised training programmes which may improve nutritional care across country borders over the long run.

Nutritional risk, nutrition plan and risk of death in older health care service users with chronic diseases: A register-based cohort study

BACKGROUND AND AIMS

Nutritional risk in older health care service users is a well-known challenge. Nutritional risk screening and individualised nutrition plans are common strategies for preventing and treating malnutrition. The aim of the current study was to investigate whether nutritional risk is associated with an increased risk of death and whether a nutrition plan to those at nutritional risk could reduce this potential risk of death in community health care service users over 65 years of age.

METHODS

We conducted a register-based, prospective cohort study on older health care service users with chronic diseases. The study included persons ≥65 years of age receiving health care services from all municipalities in Norway from 2017 to 2018 (n = 45,656). Data on diagnoses, nutritional risk, nutrition plan and death were obtained from the Norwegian Registry for Primary Health Care (NRPHC) and the Norwegian Patient Registry (NPR). We used Cox regression models to estimate the associations of nutritional risk and use of a nutrition plan with the risk of death within three and six months. Analyses were performed within the following diagnostic strata: chronic obstructive pulmonary disease (COPD), dementia, type 2 diabetes, stroke, osteoporosis and heart failure. The analyses were adjusted for age, gender, living situation and comorbidity.

RESULTS

Of the 45,656 health care service users, 27,160 (60%) were at nutritional risk, and 4437 (10%) and 7262 (16%) died within three and six months, respectively. Among those at nutritional risk, 82% received a nutrition plan. Health care service users at nutritional risk had an increased risk of death compared to health care service users not at nutritional risk (13% vs 5% and 20% vs 10% at three and six months). Adjusted hazard ratios (HRs) for death within six months were 2.26 (95% confidence interval (CI): 1.95, 2.61) for health care service users with COPD, 2.15 (1.93, 2.41) for those with heart failure, 2.37 (1.99, 2.84) for those with osteoporosis, 2.07 (1.80, 2.38) for those with stroke, 2.65 (2.30, 3.06) for those with type 2 diabetes and 1.94 (1.74, 2.16) for those with dementia. The adjusted HRs were larger for death within three months than death within six months for all diagnoses. Nutrition plans were not associated with the risk of death for health care service users at nutritional risk with COPD, dementia or stroke. For health care service users at nutritional risk with type 2 diabetes, osteoporosis or heart failure, nutrition plans were associated with an increased risk of death within both three and six months (adjusted HR 1.56 (95% CI: 1.10, 2.21) and 1.45 (1.11, 1.88) for type 2 diabetes; 2.20 (1.38, 3.51) and 1.71 (1.25, 2.36) for osteoporosis and 1.37 (1.05, 1.78) and 1.39 (1.13, 1.72) for heart failure).

CONCLUSIONS

Nutritional risk was associated with the risk of earlier death in older health care service users with common chronic diseases in the community. Nutrition plans were associated with a higher risk of death in some groups in our study. This may be because we could not control sufficiently for disease severity, the indication for providing a nutrition plan or the degree of implementation of nutrition plans in community health care.

Dietitians’ Perspectives on the Coordination and Continuity of Nutrition Care for Malnourished or Frail Clients: A Qualitative Study

Malnutrition and frailty are common conditions that impact overall health and function. There is limited research exploring the barriers and enablers to providing coordinated nutrition care to malnourished or frail clients in the community (including transitions from hospital). This study aimed to explore dietitians’ experiences and perspectives on providing coordinated nutrition care for frail and malnourished clients identified in the community or being discharged from hospital. Semi-structured interviews with clinical/acute, community, and aged care dietitians across Australia and New Zealand were conducted. Interviews were 23–61 min long, audio recorded and transcribed verbatim. Data were analysed using inductive thematic analysis. Eighteen dietitians participated in interviews, including five clinical, eleven community, and two residential aged care dietitians. Three themes, describing key factors influencing the transition and coordination of nutrition care, emerged from the analysis: (i) referral and discharge planning practices, processes, and quality; (ii) dynamics and functions within the multidisciplinary team; and (iii) availability of community nutrition services. Guidelines advising on referral pathways for malnourished/frail clients, improved communication between acute and community dietitians and within the multidisciplinary team, and solutions for community dietetic resource shortages are required to improve the delivery of coordinated nutrition care to at-risk clients.