Individualised nutritional support in medical inpatients: a practical guideline

Malnutrition has been defined as a “state resulting from lack of uptake or intake of nutrition, leading to altered body composition and body cell mass, as well as to diminished physical and mental function and impaired clinical outcome from disease.” Particularly for the multimorbid medical inpatient, there are multiple research studies linking malnutrition to adverse clinical outcomes independent of type of acute and chronic illnesses. Importantly, recent trials have shown that malnutrition is indeed a modifiable risk factor with specific individualised nutritional support interventions started at hospital admission having positive effects on the risk of complications, mortality, functional outcomes, rehospitalisation and quality of life. Understanding the optimal use of nutritional support in patients with acute illness is complex – as timing, route of delivery, and the amount and type of nutrients can all affect patient outcome. The aim of this narrative review is to provide a practical guideline for pragmatic and evidence-based assessment and treatment of medical inpatients at nutritional risk. We thereby focus on screening, patient assessment, definition of individual nutritional goals and nutritional support interventions that help patients to reach these goals. Keywords: nutrition, malnutrition, nutritional suppor

Handgrip Strength Values Depend on Tumor Entity and Predict 180-Day Mortality in Malnourished Cancer Patients.

BACKGROUND Cancer-related malnutrition is a prevalent condition associated with a loss of muscle mass and impaired functional status, leading to immunodeficiency, impaired quality of life and adverse clinical outcomes. Handgrip strength (HGS) is a practical measure to assess muscle strength in individual patients during clinical practice. However, HGS reference values refer to populations of healthy people, and population-specific values, such as those in the population of cancer patients, still need to be defined. METHODS Within a secondary analysis of a previous randomized controlled nutritional trial focusing on hospitalized cancer patients at risk for malnutrition, we investigated sex-specific HGS values stratified by age and tumor entity. Additionally, we examined the association between HGS and 180-day all-cause mortality. RESULTS We included data from 628 cancer patients, which were collected from eight hospitals in Switzerland. Depending on the age of patients, HGS varied among female patients from 7 kg to 26 kg and among male patients from 20.5 kg to 44 kg. An incremental decrease in handgrip strength by 10 kg resulted in a 50% increase in 180-day all-cause mortality (odds ratio 1.52 (95%CI 1.19 to 1.94), p = 0.001). CONCLUSION Our data provide evidence of the prognostic implications of HGS measurement in cancer patients and validate the prognostic value of handgrip strength in regard to long-term mortality. In addition, our results provide expected HGS values in the population of hospitalized malnourished cancer patients, which may allow better interpretation of values in individual patients

Management of Hyperglycemia in Hospitalized Patients Receiving Parenteral Nutrition.

Almost half of inpatients on parenteral nutrition experience hyperglycemia, which increases the risk of complications and mortality. The blood glucose target for hospitalized patients on parenteral nutrition is 7.8 to 10.0 mmol/L (140 to 180 mg/dL). For patients with diabetes, the same parenteral nutrition formulae as for patients without diabetes can be used, as long as blood glucose levels can be adequately controlled using insulin. Insulin can be delivered via the subcutaneous or intravenous route or, alternatively, added to parenteral nutrition admixtures. Combining parenteral with enteral and oral nutrition can improve glycemic control in patients with sufficient endogenous insulin stores. Intravenous insulin infusion is the preferred route of insulin delivery in critical care as doses can be rapidly adjusted to altered requirements. For stable patients, insulin can be added directly to the parenteral nutrition bag. If parenteral nutrition is infused continuously over 24 hours, the subcutaneous injection of a long-acting insulin combined with correctional bolus insulin may be adequate. The aim of this review is to give an overview of the management of parenteral nutrition-associated hyperglycemia in inpatients with diabetes

Association of Nutritional Parameters with Clinical Outcomes in Patients with Acute Myeloid Leukemia Undergoing Haematopoietic Stem Cell Transplantation.

INTRODUCTION In acute myeloid leukemia (AML) patients undergoing allogeneic haematopoietic stem cell transplantation (HSCT), there is uncertainty about the extent of influence nutritional parameters have on clinical outcomes. In this study, we investigated the association between initial body mass index (BMI) and weight loss during HSCT on clinical outcomes in a well-characterised cohort of AML patients. METHODS We analysed data of the Basel stem-cell transplantation registry ('KMT Kohorte') including all patients with AML undergoing first allogeneic HSCT from January 2003 to January 2014. We used multivariable regression models adjusted for prognostic indicators (European Group for Blood and Marrow Transplantation risk score and cytogenetics). RESULTS Mortality in the 156 AML patients (46% female, mean age 46 years) over the 10 years of follow-up was 57%. Compared to patients with a baseline BMI (kg/m2) of 20-25, a low BMI 7 vs. <2%) was associated with higher risk for bacterial infections (52 vs. 28%, OR 2.8, 95% CI 0.96-8.18, p = 0.059) and fungal infections (48 vs. 23%, OR 3.37, 95% CI 1.11-10.19, p = 0.032), and longer hospital stays (64 vs. 38 days, adjusted mean difference 25.6 days (15.7-35.5), p < 0.001). CONCLUSION In patients with AML, low initial BMI and more pronounced weight loss during HSCT are strong prognostic indicators associated with lower survival and worse disease outcomes. Intervention research is needed to investigate whether nutritional therapy can reverse these associations

Relationship of nutritional status, inflammation, and serum albumin levels during acute illness: A prospective study.

BACKGROUND Low serum albumin levels resulting from inflammation-induced capillary leakage or disease-related anorexia during acute illness are associated with poor outcomes. We investigated the relationship of nutritional status and inflammation with low serum albumin levels and 30-day mortality in a large cohort. METHODS We prospectively enrolled adult patients in the medical emergency department of a Swiss tertiary care center and investigated associations of C-reactive protein (CRP) and Nutritional Risk Screening (NRS 2002) as markers of inflammation and poor nutritional status, respectively, with low serum albumin levels and mortality using multivariate regression analyses. RESULTS Of 2,465 patients, 1,019 (41%) had low serum albumin levels (20mg/L. Multivariate analyses adjusted for age, gender, diagnosis, and comorbidities revealed elevated CRP values (adjusted odds ratio [OR] 10.51, 95% confidence intervals [CI] 7.51 to 14.72, P<0.001) and increased malnutrition risk (adjusted OR 2.87, 95% CI 1.98 to 4.15, P<0.001) to be associated with low serum albumin levels, even adjusting for both parameters. Low serum albumin levels, elevated CRP values, and increased nutritional risk independently predicted 30-day mortality, with areas under the curve (AUCs) of 0.77, 0.70, and 0.75, respectively. Combination of these three parameters showed an AUC of 0.82 to predict mortality. CONCLUSIONS Elevated parameters of inflammation and high nutritional risk were independently associated with hypoalbuminemia. All three parameters independently predicted mortality. Combining them during initial evaluation of patients in emergency departments facilitates mortality risk stratification

Determinants of Treatment Toxicity in Patients with Soft Tissue Sarcomas.

Soft tissue sarcomas are rare malignant tumors. Traditionally, treatment is guided by patient and tumor characteristics. Data on the influence of patient characteristics, particularly nutritional status, on clinical outcomes are scarce. Body composition and its changes during treatment play an essential role in predicting toxicity, clinical outcomes, and mortality. This analysis aimed to investigate the relationship between treatment toxicity and body composition. Patients diagnosed with sarcoma who underwent first-line palliative chemotherapy between October 2017 and January 2020 were included. Baseline and follow-up computed tomographic scans at the third lumbar vertebra, available from diagnostic purposes, were analyzed using SliceOmatic software. Treatment toxicity was defined as a composite score of the Common Terminology Criteria for Adverse Events. Nutritional Risk Screening (NRS) 2002 score, psoas muscle thickness to height ratio, and comorbidity showed a significant association with overall toxicity, while skeletal muscle index and age showed a strong trend. In summary, the NRS 2002 tool must be routinely implemented in inpatient and outpatient settings for cancer patients, and nutritional therapy needs to become a fixed component of multimodal cancer treatment. Furthermore, validated standardized procedures for the quantification of muscle mass are needed to individualize and optimize cancer treatment

Association of Nutritional Support With Clinical Outcomes Among Medical Inpatients Who Are Malnourished or at Nutritional Risk: An Updated Systematic Review and Meta-analysis.

Importance Malnutrition affects a considerable proportion of the medical inpatient population. There is uncertainty regarding whether use of nutritional support during hospitalization in these patients positively alters their clinical outcomes. Objective To assess the association of nutritional support with clinical outcomes in medical inpatients who are malnourished or at nutritional risk. Data Sources For this updated systematic review and meta-analysis, a search of the Cochrane Library, MEDLINE, and Embase was conducted from January 1, 2015, to April 30, 2019; the included studies were published between 1982 and 2019. Study Selection A prespecified Cochrane protocol was followed to identify trials comparing oral and enteral nutritional support interventions with usual care and the association of these treatments with clinical outcomes in non-critically ill medical inpatients who were malnourished. Data Extraction and Synthesis Two reviewers independently extracted data and assessed risk of bias; data were pooled using a random-effects model. Main Outcomes and Measures The primary outcome was mortality. The secondary outcomes included nonelective hospital readmissions, length of hospital stay, infections, functional outcome, daily caloric and protein intake, and weight change. Results A total of 27 trials (n = 6803 patients) were included, of which 5 (n = 3067 patients) were published between 2015 and 2019. Patients receiving nutritional support compared with patients in the control group had significantly lower rates of mortality (230 of 2758 [8.3%] vs 307 of 2787 [11.0%]; odds ratio [OR], 0.73; 95% CI, 0.56-0.97). A sensitivity analysis suggested a more pronounced reduction in the risk of mortality in recent trials (2015 or later) (OR, 0.47; 95% CI, 0.28-0.79) compared with that in older studies (OR, 0.94; 95% CI, 0.72-1.22), in patients with established malnutrition (OR, 0.52; 95% CI, 0.34-0.80) compared with that in patients at nutritional risk (OR, 0.85; 95% CI, 0.62-1.18), and in trials with high protocol adherence (OR, 0.67; 95% CI, 0.54-0.84) compared with that in trials with low protocol adherence (OR, 0.88; 95% CI, 0.44-1.76). Nutritional support was also associated with a reduction in nonelective hospital readmissions (14.7% vs 18.0%; risk ratio, 0.76; 95% CI, 0.60-0.96), higher energy intake (mean difference, 365 kcal; 95% CI, 272-458 kcal) and protein intake (mean difference, 17.7 g; 95% CI, 12.1-23.3 g), and weight increase (0.73 kg; 95% CI, 0.32-1.13 kg). No significant differences were observed in rates of infections (OR, 0.86; 95% CI, 0.64-1.16), functional outcome (mean difference, 0.32; 95% CI, -0.51 to 1.15), and length of hospital stay (mean difference, -0.24; 95% CI, -0.58 to 0.09). Conclusions and Relevance This study's findings suggest that despite heterogeneity and varying methodological quality among trials, nutritional support was associated with improved survival and nonelective hospital readmission rates among medical inpatients who were malnourished and should therefore be considered when treating this population

"Evidence-based medical nutrition - A difficult journey, but worth the effort!"

Evidence-based medicine is the art of combining "best external evidence", "clinical judgement" and "patient values" for improved daily clinical decision making and is the ultimate goal in modern medicine. Historically, in the field of medical nutrition, there had been a lack of strong evidence from large and high-quality trials resulting in often weak guideline recommendations and therefore insufficient implementation in clinical practice. Particularly in the field of malnutrition, the medical community has long struggled to find evidence-based approaches for effective management by means of screening, assessment and treatment of patients. With recent trials showing that individual medical nutrition therapy has strong effects on clinical outcomes, we should now aim to practice "evidence-based medical nutrition" (EBMN) by combining clinical judgement (e.g., thorough clinical assessment of the malnourished patient), patient preferences (e.g., integration of perspectives of patients and relatives, consideration of comorbidities to define specific energy/protein goals and appropriate route of medical nutrition therapy) and the most current scientific evidence (e.g., trial-supported use of nutritional interventions for individual patients). Such an approach may certainly be helpful to improve clinical outcomes of the vulnerable population of malnourished medical inpatients

Individual Evidence-Based Medical Nutrition in Medical In-Patients: Where do we Stand Today?

Evidenzbasierte Medizin berücksichtigt die Grundsätze „Beste wissenschaftliche Evidenz“, „Klinische Expertise“ und „Patientenpräferenzen“ und bildet damit die Basis der klinischen Entscheidungsfindung in der modernen Medizin. Ziel ist, die Ernährungsmedizin in gleicher Weise zu praktizieren. Groß angelegte klinische Studien sind Voraussetzung, um die Ernährungsmedizin wissenschaftlich auf das Niveau der evidenzbasierten Ernährungsmedizin zu heben. Die Ernährungsmedizinische Forschung steht traditionell vielen Herausforderungen gegenüber. Aufgrund fehlender, hochqualitativer randomisierter Studien war es in der Vergangenheit schwierig, einen hohen Evidenzgrad für Ernährungsmedizinische Fragestellungen zu erlangen und in einigen Bereichen der Ernährungsmedizin ist die Evidenz zur Wirksamkeit von Ernährungsinterventionen noch immer unzureichend. In den letzten Jahren wurden aber große Fortschritte auf dem Weg zur evidenzbasierten Ernährungsmedizin gemacht. Neue Erkenntnisse aus aktuellen, groß angelegten klinischen Studien und systematischen Analysen haben z. B. die bedeutenden klinischen Verbesserungen, die mit einer zielgerichteten Ernährungstherapie bei mangelernährten hospitalisierten Patienten assoziiert sind, aufgezeigt und damit eine wichtige Lücke im Wissen der Ernährungsmedizin geschlossen.Groß angelegte klinische Studien sind Voraussetzung, um die Ernährungsmedizin wissenschaftlich auf das Niveau der evidenzbasierten Ernährungsmedizin zu heben. Die Ernährungsmedizinische Forschung steht traditionell vielen Herausforderungen gegenüber. Aufgrund fehlender, hochqualitativer randomisierter Studien war es in der Vergangenheit schwierig, einen hohen Evidenzgrad für Ernährungsmedizinische Fragestellungen zu erlangen und in einigen Bereichen der Ernährungsmedizin ist die Evidenz zur Wirksamkeit von Ernährungsinterventionen noch immer unzureichend. In den letzten Jahren wurden aber große Fortschritte auf dem Weg zur evidenzbasierten Ernährungsmedizin gemacht. Neue Erkenntnisse aus aktuellen, groß angelegten klinischen Studien und systematischen Analysen haben z. B. die bedeutenden klinischen Verbesserungen, die mit einer zielgerichteten Ernährungstherapie bei mangelernährten hospitalisierten Patienten assoziiert sind, aufgezeigt und damit eine wichtige Lücke im Wissen der Ernährungsmedizin geschlossen