Malnutrition screening on hospital admission: impact of overweight and obesity on comparative performance of MUST and PG-SGA SF

Evaluation of nutritional intake and malnutrition in critically ill patients and its relationship with 28-day death

Malnutrition and risk for malnutrition in critically ill patients are associated with adverse outcomes. However, the adequacy of nutrient intake and its impact on malnutrition have not been entirely determined in previous studies. Above all, this study investigates the relationship between some nutrient intake and malnutrition levels and 28-day death. The observational study was done on patients over 18 years of age in Rafsanjan Intensive Care Unit (ICU) from April 21 to October 24, 2022. Subjective global assessment (SGA), modified nutrition risk in critically Ill (mNUTRIC) Score, demographic details and intake of some nutrients were assessed. Data was analyzed with SPSS 22 software, and a p-value of 0.05 was a significant level for all analysis.118 patients were studied. Malnutrition and mNUTRIC score are linked to 28-day mortality in logistic regression analysis (OR: 3.63, 95%CI 1.48-8.91, p = 0.004 and OR: 12.69, 95%CI 4.42-36.43, p < 0.001, respectively). There was no significant difference between the intake of some nutrients and malnutrition/ risk for malnutrition. This study reveals no relevance between nutrient intake with malnutrition and risk for malnutrition. Moreover, in malnourished patients, some nutrient intake was unrelated to the 28-day death. It is suggested that future studies be done with a larger sample size.

Criterion validity of the Global Leadership Initiative on Malnutrition criteria for malnutrition diagnosis compared with the Subjective Global Assessment: Results from a large observational study

AIM

The aim of this study was to assess the criterion validity of the Global Leadership Initiative on Malnutrition criteria compared to the subjective global assessment in a diverse inpatient population.

METHODS

This cross-sectional study was a retrospective analysis of point prevalence audit data. The prevalence of malnutrition determined by the Global Leadership Initiative on Malnutrition criteria was compared to the Subjective Global Assessment. Validity statistics were determined using all of the Global Leadership Initiative on Malnutrition criteria concurrently as well as each pair that could be used to diagnose malnutrition. Subgroup analysis was undertaken based on severe malnutrition, treatment group, age and body mass index.

RESULTS

Nine hundred and eighty-one patients were included (65.1 ± 18.6 years, 54.8% male). The prevalence of malnutrition was 36.7% using the Subjective Global Assessment and 36.1% using the Global Leadership Initiative on Malnutrition criteria. More patients were classified as severely malnourished using the Global Leadership Initiative on Malnutrition criteria (9.8% vs. 6.0%), whilst more rehabilitation patients were classified as malnourished using the Subjective Global Assessment (42.2% vs. 33.6%). The criterion validity of the Global Leadership Initiative on Malnutrition criteria was good, with a sensitivity of 92.5% (95% CI 90.9-94.2) and specificity of 96.6% (95% CI 95.5-97.8). There was a downward trend in sensitivity with increasing body mass index and a lower sensitivity in the rehabilitation population. The criterion validity was fair at best when each pair of the Global Leadership Initiative on Malnutrition criteria was considered independently of other criteria.

CONCLUSIONS

When all criteria are considered concurrently, the Global Leadership Initiative on Malnutrition criteria present good criterion validity and can be applied in clinical practice to diagnose malnutrition.

Energy and protein intake threshold modelling using nutrition dashboard technology and sensitivity of hospital malnutrition identification

AIMS

Hospital food provision/intake dashboards may improve malnutrition screening. The aim of this study was to use Nutrition Dashboard data to determine the optimal threshold for screening for malnutrition risk, and compare the accuracy of this method with estimated dietary requirements.

METHODS

Observational data were extracted from medical files and food service records of 267 patients for a 4-month period in a 99-bed hospital. Energy (2500-8000 kJ) and protein (30-90 g) thresholds were applied for Nutrition Dashboard categorisation by supply and intake of food. Deficits in estimated requirements (105 kJ/kg/day and 0.75 g/kg/day) were also applied as a comparative method. The association between Nutrition Dashboard categories and the Malnutrition Screening Tool was explored using generalised estimating equations.

RESULTS

A total of 267 patients and 1908 days of data were analysed. The use of estimated requirements for Nutrition Dashboard categorisation was not a statistically significant predictor of malnutrition risk. Application of energy (≤6000 kJ) and protein (≤65 g) thresholds for categorisation was significant (χ2 = 9.50, df = 3, p = 0.023). When 5000 kJ and 55 g of protein were used for categorisation, patients were more likely to be at malnutrition risk when within low supply (odds ratio = 2.11, p = 0.002) and low intake (odds ratio 2.23, p < 0.001) categories.

CONCLUSIONS

Nutrition Dashboard categories are associated with an increased risk of malnutrition when categorised using thresholds of up to 6000 kJ and 65 g protein. Technologies like the Nutrition Dashboard present innovative opportunities for dietitians to utilise nutrition informatics to enhance and optimise nutrition care.

GLIM Achieves Best Diagnostic Performance in Non-Cancer Patients with Low BMI: A Hierarchical Bayesian Latent-Class Meta-Analysis

CONTEXT

Global Leadership Initiative on Malnutrition (GLIM) and Patient-Generated Subjective Global Assessment (PG-SGA) are commonly used nutrition assessment tools, whose performance does not reach a consensus due to different and imperfect reference standards.

OBJECTIVE

This study aimed to evaluate and compare the diagnostic accuracy of GLIM and PG-SGA, using a hierarchical Bayesian latent class model, in the absence of a gold standard.

DATA SOURCES

A systematic search was undertaken in PubMed, Embase, and Web of Science from inception to October 2022. Diagnostic test studies comparing (1) the GLIM and/or (2) PG-SGA with "semi-gold" standard assessment tools for malnutrition were included.

DATA EXTRACTION

Two authors independently extracted data on sensitivity, specificity, and other key characteristics. The methodological quality of each included study was appraised according to the criteria in the Quality Assessment of Diagnostic Accuracy Studies-2.

DATA ANALYSIS

A total of 45 studies, comprising 20 876 individuals evaluated for GLIM and 11 575 for PG-SGA, were included. The pooled sensitivity was 0.833 (95% CI 0.744 to 0.896) for GLIM and 0.874 (0.797 to 0.925) for PG-SGA, while the pooled specificity was 0.837 (0.780 to 0.882) for GLIM and 0.778 (0.707 to 0.836) for PG-SGA. GLIM showed slightly better performance than PG-SGA, with a higher diagnostic odds ratio (25.791 vs 24.396). The diagnostic performance of GLIM was most effective in non-cancer patients with an average body mass index (BMI) of <24 kg/m2, followed by non-cancer patients with an average age of ≥60 years. PG-SGA was most powerful in cancer patients with an average age of <60 years, followed by cancer patients with an average BMI of <24 kg/m2.

CONCLUSION

Both GLIM and PG-SGA had moderately high diagnostic capabilities. GLIM was most effective in non-cancer patients with a low BMI, while PG-SGA was more applicable in cancer patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration No. CRD42022380409.

Age-Related Vulnerability to Malnutrition-Related Mortality: Younger Patients are at Risk

INTRODUCTION

Malnutrition among older adults continues to be a prevalent health concern. While literature has highlighted an increased risk of malnutrition mortality for adults older than 65 y, the age threshold at which malnutrition effects survival and mortality remains unexplored.

METHODS

Annual crude and age-adjusted malnutrition-related mortality data from 2009 to 2018 was extracted from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. We compared crude rates by year, 10-y age groups (15 to 85+ y), and disposition among age groups 65+ y using analysis of variance. We examined crude rates, year, and 10-y age groups (15 to 85+ y) using multiple linear regression. A Welch two sample t-test was used to compare the 10-y age groups 55-64 and 65-74 by crude rate.

RESULTS

From 2009 to 2018, there were 275,282 older adult malnutrition-related mortalities. The differences in crude rates by year from 2009 to 2018 (P < 0.001) and all 10-y age groups were significant (P = 0.028). Differences in crude rates by disposition among age groups 65+ were not significant (P = 0.062). A multiple linear regression between crude rates between years 2009 and 2018 by all 10-y age groups showed a significant association (β = 0.06, 95% CI: 0.03, 0.09, P < 0.001). The difference between the annual crude rate for 10-y age groups 55-64 y and 65-74 y was significant (95% CI = 7.49, 13.41, P value <0.001).

CONCLUSIONS

Increasing age correlates with higher rates of malnutrition mortality. While nourishment should be a priority for all patients, preventing malnutrition must be a priority for all care with the goal of survival and future research.

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.

Do nutritional assessment scores have a relationship with transthyretin levels?

Introduction

Background and aims: nutritional screening tools assess factors like weight loss, BMI, food intake, and disease severity to determine a patient's nutritional risk and needed care. Plasma transthyretin is a practical measurement used to assess nutritional evolution due to its rapid response to food intake. This study examines the relationship between nutritional scores, transthyretin protein levels, and the possibility of death. Methods: the sample consisted of 302 patients hospitalized in the wards or intensive care unit of a public teaching hospital, using parenteral nutrition as the primary source of nutrition. Five nutritional screening tools were applied, and patient charts were verified for transthyretin levels. Results: from the sample, 260 were adults, and 42 were children, with a mean age of 48.3 years. When evaluating the patient's outcome in relation to the scores, the Malnutrition Universal Screening Tool proved to be better at predicting death (p-value = 0.02). None of the scores were related to transthyretin levels, showing that lower transthyretin values did not influence nutritional risk. Conclusion: we believe early identification of nutritional risk through nutritional scores is necessary for better nutritional monitoring to minimize unfavorable outcomes. This study corroborates the more recent concept that transthyretin is not useful for determining unfavorable outcomes in hospitalized patients with a severe inflammatory process. In clinical practice, identifying a patient at nutritional risk according to the Malnutrition Universal Screening Tool and promoting adequate nutritional monitoring may reduce mortality.

A scoping review of preoperative weight loss interventions on postoperative outcomes for patients with gastrointestinal cancer

BACKGROUND

Obesity is associated with increased risk of surgical complications in some settings.

OBJECTIVE

As a precursor to a systematic review, we conducted a scoping review of intentional preoperative weight loss to describe these interventions, their feasibility and effectiveness for patients with gastrointestinal cancer.

METHODS

In April 2024, Ovid MEDLINE, EMBASE, CINAHL, and Google Scholar were searched for primary studies of intentional weight loss before elective gastrointestinal cancer surgery. Extracted data encompassed recruitment and attrition, intervention types, adherence, anthropometric and body composition changes, and surgical outcomes. Study quality was assessed using the Risk of Bias In Non-randomized Studies of Interventions tool.

RESULTS

The search produced 7 articles (4 non-randomized clinical trials), which were all conducted in Japan, and involved 258 participants with a baseline BMI ≥25 kg/m2. Weight loss interventions included dietary modification (n = 3), exercise (n = 1), and combination (n = 3). None of the articles reported rates of recruitment, 2 adherence (97-100 %), and 4 reported attrition rates (0-18 %). All reported weight reductions of -1.3 to -6 kg and 4.5-6.9 % (n = 7), compared to baseline. Three of four non-randomized trials observed a reduction in postoperative complications, as compared to control; yet all trials were at critical risk of bias.

CONCLUSION

Strong conclusions could not be made due to the limited reporting and critical risk of bias; further systematic review is not recommended at this time. To establish more robust evidence, there is a clear need for high-quality trials.

Malnutrition in patients with obesity: An overview perspective

Malnutrition in patients with obesity presents a complex and often overlooked clinical challenge. Although obesity is traditionally associated with overnutrition and excessive caloric intake, it can also coincide with varying degrees of malnutrition. The etiopathogenesis of obesity is multifaceted and may arise from several factors such as poor diet quality, nutrient deficiencies despite excess calorie consumption, genetics, and metabolic abnormalities affecting nutrient absorption and utilization. Moreover, a chronic low-grade inflammatory state resulting from excess adipose tissue, commonly observed in obesity, can further exacerbate malnutrition by altering nutrient metabolism and increasing metabolic demands. The dual burden of obesity and malnutrition poses significant risks, including immune dysfunction, delayed wound healing, anemia, metabolic disturbances, and deficiencies in micronutrients such as vitamin D, iron, magnesium, and zinc, among others. Malnutrition is often neglected or not given enough attention in individuals with obesity undergoing rapid weight loss through aggressive caloric restriction, pharmacological therapies, and/or surgical interventions. These factors often exacerbate vulnerability to nutrition deficiencies. We advocate for healthcare practitioners to prioritize nutrition assessment and initiate medical intervention strategies tailored to address both excessive caloric intake and insufficient consumption of essential nutrients. Raising awareness among healthcare professionals and the general population about the critical role of adequate nutrition in caring for patients with obesity is vital for mitigating the adverse health effects associated with malnutrition in this population.

Impact of frailty, malnutrition and socioeconomic status on perioperative outcomes

BACKGROUND

Frailty, malnutrition and low socioeconomic status may mutually perpetuate each other in a self-reinforcing and interdependent manner. The intertwined nature of these factors may be overlooked when investigating impacts on perioperative outcomes. This study aimed to investigate the impact of frailty, malnutrition and socioeconomic status on perioperative outcomes.

METHODS

A multicentre cohort study involving six Australian tertiary hospitals was undertaken. All consecutive surgical patients who underwent an operation were included. Frailty was defined by the Hospital Frailty Risk Score, malnutrition by the Malnutrition Universal Screening Tool (MUST) and low socioeconomic status by the Index of Relative Socioeconomic Disadvantage. Linear mixed-effects and binary logistic generalised estimated equation models were performed for the outcomes: inpatient mortality, length of stay, 30-day readmission and re-operation.

RESULTS

A total of 21 976 patients were included. After controlling for confounders, malnutrition and socioeconomic status, patients at high risk of frailty have a mean hospital length of stay 3.46 times longer (mean ratio = 3.46; 95% confidence interval (CI): 3.20, 3.73; P value < .001), odds of 30-day readmission 2.4 times higher (odds ratio = 2.40; 95% CI: 2.19, 2.63; P value < .001) and odds of in-hospital mortality 12.89 times greater than patients with low risk of frailty (odds ratio = 12.89; 95% CI: 4.51, 36.69; P value < .001). Elevated MUST scores were also significantly associated with worse outcomes, but to a lesser extent. Socioeconomic status had no association with outcomes.

CONCLUSION

Perioperative risk evaluation should consider both frailty and malnutrition as separate, significant risk factors. Despite strong causal links with frailty and malnutrition, socioeconomic disadvantage is not associated with worse postoperative outcomes. Additional studies regarding the prospective identification of these patients with implementation of strategies to mitigate frailty and malnutrition and assessment of perioperative risk are required.

Malnutrition and Fall Risk in Older Adults: A Comprehensive Assessment Across Different Living Situations

BACKGROUND

Malnutrition among older adults is associated with numerous adverse effects, including increased morbidity, mortality, prolonged hospital stays, and a heightened risk of falls. This study aims to investigate the prevalence of malnutrition in different groups of older adults using the F-MNA, anthropometry, and s-albumin and the association between nutritional status and fall risk.

METHODS

A total of 228 participants aged 60 years and older were divided into three groups: (1) patients in an internal medicine ward, (2) individuals living in family homes, and (3) residents of care homes. Disease profiles, nutritional status (assessed using the F-MNA and SNAQ), body composition, fall risk, and biochemical markers were evaluated.

RESULTS

The results indicated the highest prevalence of malnutrition among hospitalized individuals. Fall risk was associated with age, calf circumference, the F-MNA, the SNAQ, serum albumin levels, residence in a care home, comorbidities, and the number of medications taken daily. Regression analysis revealed that age, calf circumference, and residence in a care home were independent predictors of fall risk in older adults.

CONCLUSION

Older adults are at significant risk of malnutrition, with the risk notably increasing during hospitalization and long-term stays in care homes. Hospitalized individuals had the poorest nutritional status and were at significant risk of further weight loss, underscoring the importance of post-discharge care and rehabilitation.

Effect of malnutrition at admission on length of hospital stay among adult surgical patients in Wolaita Sodo University Comprehensive Specialized Hospital, South Ethiopia: prospective cohort study

Background

Malnutrition in hospitalized patients remains a major public health problem in both developed and developing countries. Even though malnourished patients are more prone to stay longer in hospital, there is limited data regarding the magnitude of malnutrition and its effect on length of stay among surgical in patients in Ethiopia while nutritional assessment is also often a neglected component of the health service practice.

Objective

This study aims to assess the prevalence of malnutrition at admission and its effect on the length of hospital stay among adult surgical patients in Wolaita Sodo University Comprehensive Specialized Hospital, South Ethiopia, 2022.

Methods

A facility-based prospective cohort study was conducted among 398 admitted surgical adult patients. Participants in the study were chosen using a convenient sampling technique. Subjective global assessment was used to determine the nutritional status of patients with a minimum stay of 24 h within 48 h after admission (SGA). Data were collected by open data kit (ODK) version 2022.3.3 software while Stata version 14.1 software was employed for statistical analysis. Cox regression model was used to determine the effect of malnutrition on the length of hospital stay (LOS) after adjusted for several potential confounders taken at admission. Adjusted hazard ratio (HR) with 95% confidence interval was used to show the effect of malnutrition.

Results

The prevalence of hospital malnutrition at admission was 64.32% (95% CI: 59-69%) according to subjective global assessment (SGA) classification. Adult surgical patients who were malnourished at admission had higher median LOS (12 days: 95% CI: 11-13) as compared to well-nourished patients (8 days: 95% CI: 8-9), which means adult surgical patients who were malnourished at admission were at a higher risk of reduced chance of discharge with improvement (prolonged LOS) (AHR: 0.37, 95% CI: 0.29-0.47) as compared to well-nourished patients. The presence of comorbidity (AHR: 0.68, 95% CI: 0.50-90), poly medication (AHR: 0.69, 95% CI: 0.55-0.86), and history of admission (AHR: 0.70, 95% CI: 0.55-0.87) within the previous 5 years were found to be the significant covariates of LOS.

Conclusion

The magnitude of hospital malnutrition at admission was found to be high. Malnourished patients at admission had a higher risk of prolonged length of hospital stay as compared to well-nourished patients. The presence of comorbidity, poly medication, and history of admission were found to be the significant covariates of LOS. All stakeholders should pay attention to reducing the magnitude of malnutrition and its covariates to improve the burden of LOS.

Health professional attitudes and perceptions of prehabilitation and nutrition before haematopoietic cell transplantation

BACKGROUND

Nutritional prehabilitation may improve haematopoietic cell transplantation (HCT) outcomes, although little evidence exists. The present study aimed to understand healthcare professional (HCP) perceptions of prehabilitation and nutritional care pre-HCT in UK centres.

METHODS

An anonymous online survey (developed and refined via content experts and piloting) was administered via email to multidisciplinary HCPs in 39 UK adult centres, between July 2021 and June 2022. Data are presented as proportions of responses. Routine provision denotes that care was provided >70% of time.

RESULTS

Seventy-seven percent (n = 66) of HCPs, representing 61.5% (n = 24) of UK adult HCT centres, responded. All HCPs supported prehabilitation, proposing feasible implementation between induction chemotherapy (60.4%; n = 40) and first HCT clinic (83.3%; n = 55). Only 12.5% (n = 3) of centres had a dedicated prehabilitation service. Nutrition (87.9%; n = 58), emotional wellbeing (92.4%; n = 61) and exercise (81.8%; n = 54) were considered very important constituents. HCPs within half of the HCT centres (n = 12 centres) reported routine use of nutrition screening pre-HCT with a validated tool; 66.7% of HCPs (n = 36) reported using the malnutrition universal screening tool (MUST). Sixty-two percent (n = 41) of HCPs reported those at risk, received nutritional assessments, predominantly by dietitians (91.6%; n = 22) using the dietetic care process (58.3%; n = 14). Body mass index (BMI) was the most frequently reported body composition measure used by HCPs (70.2%, n = 33). Of 59 respondents, non-dietitians most routinely provided dietary advice pre-HCT (82.4%; n = 28 vs. 68%; n = 17, p = 0.2); including high-energy/protein/fat and neutropenic diet advice. Prophylactic enteral feeding pre-HCT was rare, indicated by low BMI and significant unintentional weight loss. Just under half (n = 25 of 59, 42.4%) HCPs reported exercise advice was given routinely pre-HCT.

CONCLUSIONS

Nutrition and prehabilitation pre-HCT are considered important and deliverable by HCPs, but current provision in UK centres is limited and inconsistent.

Identifying malnutrition risk in hospitalized patients: an analysis of five tools in the light of GLIM criteria

BACKGROUND

The prompt identification of malnutrition among hospitalized patients using the appropriate screening tool is paramount. The objective of our study is to compare the most recommended screening tools concerning the new GLIM criteria for malnutrition in hospitalized patients.

METHODS

In this cross-sectional study, we analyzed the data on 1,397 patients receiving inpatient treatment at Bandırma Training and Research Hospital between August 2022 and May 2023 to assess and compare malnutrition in them. Patients who received inpatient treatment in the internal and surgical clinics of Bandırma Training and Research Hospital. In addition to the GLIM criteria, we used nutritional screening and assessment tools such as NRS-2002, MST, GMS, MUST, and SNAQ. The GLIM criteria were considered the gold standard for the evaluation of sensitivity and specificity. Receiver operating characteristic (ROC) curves for the five screening tools were also used to assess the ability to distinguish malnutrition-risk patients accurately.

RESULTS

The comparison of the performances of different screening tools in detecting malnutrition demonstrated that while the GMS had the highest sensitivity (87.40%), the NRS-2002 had the highest specificity (91.70%). The area under the Curve (AUC) value indicated that the predictive values of the NRS-2002, MST, GMS, and SNAQ were excellent, and the predictive value of the MUST was good (p < 0.001). While the GLIM criteria in particular appear to be an effective tool for detecting malnutrition in hospitalized individuals, other screening tools are also useful in assessing their malnutrition risk.

CONCLUSIONS

We emphasized MST's alignment with GLIM criteria, underscoring the importance of a multidisciplinary approach for early malnutrition diagnosis. Patients at risk of malnutrition can be diagnosed more quickly and accurately with appropriate screening tools and the effectiveness of treatments can be increased.

Baseline 25(OH)D level is a prognostic indicator for bariatric surgery readmission: a matched retrospective cohort study

Introduction

Managing postsurgical complications is crucial in optimizing the outcomes of bariatric surgery, for which preoperative nutritional assessment is essential. In this study, we aimed to evaluate and validate the efficacy of vitamin D levels as an immunonutritional biomarker for bariatric surgery prognosis.

Methods

This matched retrospective cohort study included adult patients who underwent bariatric surgery at a tertiary medical center in China between July 2021 and June 2022. Patients with insufficient and sufficient 25(OH)D (< 30 ng/mL) were matched in a 1:1 ratio. Follow-up records of readmission at 3 months, 6 months, and 1 year were obtained to identify prognostic indicators.

Results

A matched cohort of 452 patients with a mean age of 37.14 ± 9.25 years and involving 69.47% females was enrolled. Among them, 94.25 and 5.75% underwent sleeve gastrectomy and gastric bypass, respectively. Overall, 25 patients (5.54%) were readmitted during the 1-year follow-up. The prognostic nutritional index and controlling nutritional status scores calculated from inflammatory factors did not efficiently detect malnourishment. A low 25(OH)D level (3.58 [95% CI, 1.16-11.03]) and surgery season in summer or autumn (2.68 [95% CI, 1.05-6.83]) increased the risk of 1-year readmission in both the training and validation cohorts. The area under the receiver operating characteristic curve was 0.747 (95% CI, 0.640-0.855), with a positive clinical benefit in the decision curve analyses. The relationship between 25(OH)D and 6-month readmission was U-shaped.

Conclusion

Serum 25(OH)D levels have prognostic significance in bariatric surgery readmission. Hence, preferable 25(OH)D levels are recommended for patients undergoing bariatric surgery.

Malnutrition and visceral obesity predicted adverse short-term and long-term outcomes in patients undergoing proctectomy for rectal cancer

BACKGROUND

To the best of our knowledge, no previous studies have explored the relationship between visceral obesity and malnutrition. Therefore, this study has aimed to investigate the association between them in patients with rectal cancer.

METHODS

Patients with rectal cancer who underwent proctectomy were included. Malnutrition was defined according to the Global Leadership Initiative on Malnutrition (GLIM). Visceral obesity was measured using computed tomography (CT). The patients were classified into four groups according to the presence of malnutrition or visceral obesity. Univariate and multivariate logistic regression analyses were performed to evaluate risk factors for postoperative complications. Univariate and multivariate cox regression analyses were performed to evaluate the risk factors for overall survival (OS) and cancer-specific survival (CSS). Kaplan-Meier survival curves and log-rank tests were performed for the four groups.

RESULTS

This study enrolled 624 patients. 204 (32.7%) patients were included in the well-nourished non-visceral obesity (WN) group, 264 (42.3%) patients were included in the well-nourished visceral obesity (WO) group, 114 (18.3%) patients were included in the malnourished non-visceral obesity (MN) group, and 42 (6.7%) patients were included in the malnourished visceral obesity (MO) group. In the multivariate logistic regression analysis, the Charlson comorbidity index (CCI), MN, and MO were associated with postoperative complications. In the multivariate cox regression analysis, age, American Society of Anesthesiologists (ASA) score, tumor differentiation, tumor node metastasis (TNM), and MO were associated with worsened OS and CSS.

CONCLUSIONS

This study demonstrated that the combination of visceral obesity and malnutrition resulted in higher postoperative complication and mortality rates and was a good indicator of poor prognosis in patients with rectal cancer.

The Mini Nutritional Assessment-Short Form is more effective in predicting clinical outcomes among hospitalised patients with overweight than the Nutritional Risk Screening-2002

Understanding of the association between nutritional risk and clinical outcomes in hospitalised patients with overweight is still at an early stage. Given the lack of specific tools for the patient with overweight, the objective of this study was to compare two of the main general screening instruments for assessing nutritional risk in predicting clinical outcomes in a population of hospitalised patients with overweight. A retrospective study was carried out in a medium-sized hospital in Brazil, with patients ≥20 years old admitted between July 2017 and December 2019. Patients who were overweight and had records of Nutritional Risk Screening-2002 (NRS-2002) and Mini-Nutritional Assessment-Short Form (MNA-SF) in their medical files were included in the study. Clinical outcomes data (longer length of stay, readmission during the study period and mortality before the end of study or during hospitalisation) were obtained. The Kappa coefficient assessed agreement between both tools, and their performance for predicting outcomes was analysed using characteristic receiver operating curves (ROC). Data were collected from 643 patients. The prevalence of nutritional risk was 17.7% and 36.1% according to the NRS-2002 and MNA-SF (k = 0.390; p < 0.001), respectively. According to both tools, all clinical outcomes were significantly more common among individuals at nutritional risk (p < 0.05). Only the MNA-SF showed a significant percentage of predictions for readmission (57.2%) and death during hospitalisation (65.7%). For mortality until the end of the study, the area under the ROC curve was similar for MNA-SF (60.5%) and NRS-2002 (60.7%; p = 0.057). The MNA-SF detected a greater proportion of nutritional risk among hospitalised patients with overweight and better predicted all clinical outcomes compared to the NRS-2002 and should be used to screen patients with overweight for nutritional risk.

Preoperative dysphagia risk in community-dwelling adults aged ≥50 years: Prevalence and risk factors

BACKGROUND

Preoperative dysphagia screening is rare. The purpose of this study was to assess the prevalence and potential risk factors of preoperative dysphagia risk in adults preparing for surgery.

METHODS

The Eating Assessment Tool (EAT-10), Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF), and Sarcopenia Screening Tool (SARC-F) were self-administered in adults preparing for surgery to identify dysphagia, malnutrition, and sarcopenia risk, respectively. Other variables collected include clinical demographics, fall risk, and surgical history associated with increased dysphagia risk. Descriptive summary statistics, univariate analysis, and logistic regression were performed as appropriate.

RESULTS

The median age was 69 years and preoperative dysphagia risk was 9.6%. Among 357 patients completing both EAT-10 and PG-SGA SF or SARC-F, 7.3% had preoperative dysphagia and malnutrition risk and 7.2% had preoperative dysphagia and sarcopenia risk. Preoperative dysphagia risk was 2.7 times greater in those with prior surgical history associated with increased risk of dysphagia, 2.2 times higher in women, and almost twice as high in Black patients and patients with fall risk. Logistic regression revealed significant odds ratios (ORs) for prior surgical history associated with increased risk of dysphagia (OR, 2.95; 95% CI, 1.62-5.40) and male sex (OR, 0.52; 95% CI, 0.29-0.94), and a significant relationship between preoperative dysphagia and malnutrition risk (OR, 4.56; 95% CI, 2.02-10.28) when controlling for clinical variables.

CONCLUSION

The high prevalence of dysphagia risk alone and in combination with malnutrition and sarcopenia risk in community-dwelling adults underscores the need for standardized preoperative screening and optimization prior to surgery.

Obesity and critical care nutrition: current practice gaps and directions for future research

Background

This review has been developed following a panel discussion with an international group of experts in the care of patients with obesity in the critical care setting and focuses on current best practices in malnutrition screening and assessment, estimation of energy needs for patients with obesity, the risks and management of sarcopenic obesity, the value of tailored nutrition recommendations, and the emerging role of immunonutrition. Patients admitted to the intensive care unit (ICU) increasingly present with overweight and obesity that require individualized nutrition considerations due to underlying comorbidities, immunological factors such as inflammation, and changes in energy expenditure and other aspects of metabolism. While research continues to accumulate, important knowledge gaps persist in recognizing and managing the complex nutritional needs in ICU patients with obesity. Available malnutrition screening and assessment tools are limited in patients with obesity due to a lack of validation and heterogeneous factors impacting nutrition status in this population. Estimations of energy and protein demands are also complex in patients with obesity and may include estimations based upon ideal, actual, or adjusted body weight. Evidence is still sparse on the role of immunonutrition in patients with obesity, but the presence of inflammation that impacts immune function may suggest a role for these nutrients in hemodynamically stable ICU patients. Educational efforts are needed for all clinicians who care for complex cases of critically ill patients with obesity, with a focus on strategies for optimal nutrition and the consideration of issues such as weight stigma and bias impacting the delivery of care.

Conclusions

Current nutritional strategies for these patients should be undertaken with a focus on individualized care that considers the whole person, including the possibility of preexisting comorbidities, altered metabolism, and chronic stigma, which may impact the provision of nutritional care. Additional research should focus on the applicability of current guidelines and evidence for nutrition therapy in populations with obesity, especially in the setting of critical illness.

Nutritional risk, not obesity, is associated with mortality in critically ill COVID-19 patients

Background

Despite the identification of obesity as a risk factor for higher rates of hospital and Intensive Care Unit (ICU) admissions and complications due to COVID-19, the association between obesity and mortality in critically ill COVID-19 patients remains controversial, and the nutritional risk is little considered. Hence, our study sought to evaluate the association between obesity, nutritional risk, and mortality in critically ill patients diagnosed with COVID-19.

Methods

Retrospective study were condutcted including adult critically ill COVID-19 patients admitted to an ICU between April 2020 and March 2021. Clinical and laboratory data were collected from electronic medical records. Obesity was classified by body mass index ≥ 30 kg/m^2. A mNUTRIC score of ≥ 5 indicated high nutritional risk. Multiple Cox Regression was used to estimate the association between mNUTRIC, obesity, and mortality.

Results

From 71 patients aged 59 (± 15) years, 71.8 % were male. The frequencies of obesity (58.7 %) and death (49.3 %) were high, but obesity was not associated with mortality. Based on mNUTRIC, 85.9 % of patients were at high nutritional risk, presenting a higher frequency of mortality than patients at low nutritional risk (50.8 % vs 40.0 %; p = 0.014). Multiple Cox Regression showed that for each unit increase in mNUTRIC score the probability of death almost doubled, regardless of the presence of obesity (HR = 1.74; p < 0.001).

Conclusions

A higher nutritional risk was positively associated with mortality in critically ill COVID-19 patients, regardless of obesity, showing the importance of early identification of nutritional risk for appropriate nutritional interventions in this population.

Team Approach: Nutritional Assessment and Interventions in Elective Hip and Knee Arthroplasty

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Nutritional assessment is a critical element of routine preoperative assessment and should be approached by an interdisciplinary team that involves the primary care physician, dietitian, and orthopaedist.

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Patients should be stratified on the basis of their nutritional risk, which influences downstream optimization and deficiency reversal.

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The scientific literature indicates that nutritional supplementation affords protection against adverse outcomes and helps functional recovery, even among patients who are not at nutritional risk.

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Published investigations recommend a sufficient preoperative interval (at least 4 weeks) to ensure an adequate nutritional intervention in malnourished patients as opposed to regarding them as nonsurgical candidates.

Malnutrition Universal Screening Tool and Patient-Generated Subjective Global Assessment Short Form and their predictive validity in hospitalized patients

BACKGROUND AND AIMS

Malnutrition screening is a first step in the nutrition care process for hospitalized patients, to identify those at risk of malnutrition and associated worse outcome, preceding further assessment and intervention. Frequently used malnutrition screening tools including the Malnutrition Universal Screening Tool (MUST) mainly screen for characteristics of malnutrition, while the Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF) additionally includes risk factors for development of malnutrition, yielding a higher percentage of patients at risk. To investigate whether this translates into higher risk of worse outcome, we aimed to determine the predictive validity of MUST and PG-SGA SF for prolonged hospitalization >8 days, readmission, and mortality <6 months after hospital discharge.

METHODS

In this observational study, MUST was performed according to university hospital protocol. Additional screening using PG-SGA SF was performed within 24 h of hospital admission (high risk: MUST ≥ 2, PG_SGA SF ≥ 9). Associations of MUST and PG-SGA SF with outcomes were analyzed by logistic- and Cox PH-regression.

RESULTS

Of 430 patients analyzed (age 58 ± 16 years, 53% male, BMI 26.9 ± 5.5 kg/m²), MUST and PG-SGA SF identified 32 and 80 at high risk, respectively. One-hundred-eight patients had prolonged hospitalization, 109 were readmitted and 20 died. High risk by MUST was associated with mortality (HR = 3.9; 95% CI 1.3-12.2, P = 0.02), but not with other endpoints. High risk by PG-SGA SF was associated with prolonged hospitalization (OR = 2.5; 95% CI 1.3-5.0, P = 0.009), readmission (HR = 1.9; 95% CI 1.1-3.2, P = 0.03), and mortality (HR = 34.8; 95% CI 4.2-289.3, P = 0.001), independent of age, sex, hospital ward and previous hospitalization <6 months. In the 363/430 patients classified as low risk by MUST, high risk by PG-SGA SF was independently associated with higher risk of readmission (HR = 1.9; 95% CI 1.0-3.5, P = 0.04) and mortality (HR = 19.5; 95% CI 2.0-189.4, P = 0.01).

CONCLUSIONS

Whereas high malnutrition risk by MUST was only associated with mortality, PG-SGA SF was associated with higher risk of prolonged hospitalization, readmission, and mortality. In patients considered as low risk by MUST, high malnutrition risk by PG-SGA SF was also predictive of worse outcome. Our findings support the use of PG-SGA SF in routine care to identify patients at risk of malnutrition and worse outcome, and enable proactive interventions.

Chronic Dialysis Patients Are Depleted of Creatine: Review and Rationale for Intradialytic Creatine Supplementation

There is great need for the identification of new, potentially modifiable risk factors for the poor health-related quality of life (HRQoL) and of the excess risk of mortality in dialysis-dependent chronic kidney disease patients. Creatine is an essential contributor to cellular energy homeostasis, yet, on a daily basis, 1.6-1.7% of the total creatine pool is non-enzymatically degraded to creatinine and subsequently lost via urinary excretion, thereby necessitating a continuous supply of new creatine in order to remain in steady-state. Because of an insufficient ability to synthesize creatine, unopposed losses to the dialysis fluid, and insufficient intake due to dietary recommendations that are increasingly steered towards more plant-based diets, hemodialysis patients are prone to creatine deficiency, and may benefit from creatine supplementation. To avoid problems with compliance and fluid balance, and, furthermore, to prevent intradialytic losses of creatine to the dialysate, we aim to investigate the potential of intradialytic creatine supplementation in improving outcomes. Given the known physiological effects of creatine, intradialytic creatine supplementation may help to maintain creatine homeostasis among dialysis-dependent chronic kidney disease patients, and consequently improve muscle status, nutritional status, neurocognitive status, HRQoL. Additionally, we describe the rationale and design for a block-randomized, double-blind, placebo-controlled pilot study. The aim of the pilot study is to explore the creatine uptake in the circulation and tissues following different creatine supplementation dosages.