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

Association of admission cortisol levels with outcomes and treatment response in patients at nutritional risk : A secondary analysis of a randomized clinical trial.

INTRODUCTION Cortisol is a metabolically active stress hormone that may play a role in the pathogenesis of malnutrition. We studied the association between admission cortisol levels and nutritional parameters, disease severity, and response to nutritional support among medical inpatients at nutritional risk. METHODS Admission cortisol was measured in a subset of 764 patients participating in the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a multicentre, randomized-controlled trial that compared individualized nutritional support with usual nutritional care. RESULTS Overall, mean cortisol levels were 570 (± 293) nmol/L and significantly higher in patients with high nutritional risk (NRS ≥ 5) and in patients reporting loss of appetite. Cortisol levels in the highest quartile (> 723 nmol/l) were associated with adverse outcomes including mortality at 30 days and 5 years (adjusted HR 2.31, [95%CI 1.47 to 3.62], p = 0.001 and 1.51, [95%CI 1.23 to 1.87], p < 0.001). Nutritional treatment tended to be more effective regarding mortality reduction in patients with high vs. low cortisol levels (adjusted OR of nutritional support 0.54, [95%CI 0.24 to 1.24] vs. OR 1.11, [95%CI 0.6 to 2.04], p for interaction = 0.134). This effect was most pronounced in the subgroup of patients with severe malnutrition (NRS 2002 ≥ 5, p for interaction = 0.047). CONCLUSION This secondary analysis of a randomized nutritional trial suggests that cortisol levels are linked to nutritional and clinical outcome among multimorbid medical patients at nutritional risk and may help to improve risk assessment, as well as response to nutritional treatment. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02517476

Six-month outcomes after individualized nutritional support during the hospital stay in medical patients at nutritional risk: Secondary analysis of a prospective randomized trial.

BACKGROUND Among medical inpatients at risk of malnutrition, the use of individualized nutritional support during the hospital stay was found to reduce complications and improve mortality at short-term. We evaluated clinical outcomes at 6-months follow-up. METHODS We randomly assigned 2028 patients to receive protocol-guided individualized nutritional support to reach protein and energy goals (intervention group) or hospital food as usual (control group) during the hospital stay. The intervention was discontinued at hospital discharge and further nutritional support was based on the discretion of the treating team. We had complete follow-up information of 1995 patients (98%), which were included in the final analysis. The primary endpoint was all-cause mortality at 6-months. Prespecified secondary end points included non-elective hospital readmissions, functional outcome and quality of life. RESULTS At 6-month, 231 of 994 (23.2%) intervention group patients had died compared to 246 of 999 (24.6%) control group patients, resulting in a hazard ratio for death of 0.90 (95%CI 0.76 to 1.08, p = 0.277). Compared to control patients, intervention group patients had similar rates of hospital readmission (27.3% vs. 27.6%, HR 1.00 (95%CI 0.84 to 1.18), p = 0.974), falls (11.2% vs. 10.9%, HR 0.96 (95%CI 0.72 to 1.27), p = 0.773) and similar quality of life and activities of daily living scores. INTERPRETATION While individualized nutritional support during the hospital stay significantly reduced short-term mortality, there was no legacy effect on longer term outcomes. Future trials should investigate whether continuation of nutritional support after hospital discharge reduces the high malnutrition-associated mortality rates in this vulnerable patient population. TRIAL REGISTRATION ClinicalTrials.gov number, NCT02517476

Association of Sociodemographic, Socioeconomic and Lifestyle Characteristics with Low Protein and Energy Intake in the Healthy Swiss Population

A balanced diet has the goal of providing adequate amounts of different nutrients to promote and maintain physical and psychological health. Our aim was to study the association between different sociodemographic, socioeconomic and lifestyle factors and low energy or protein intake among the Swiss population. This is a cross-sectional cohort study based on the national nutritional survey “MenuCH”, which is the first representative, detailed assessment of dietary habits in the adult Swiss population conducted in 2014/2015. We compared the mean protein and caloric intake based on two 24 h recall nutritional assessments with current recommendations based on resting metabolic rate calculation and DACH guidelines. A total of 1919 participants with a median age of 46 years and 53% females were included. Overall, 10.9% and 20.2% of participants had an energy and protein intake, respectively, below the dietary reference values. However, a high income (>9000 CHF per month) reduced the risk of low energy intake (OR 0.49 [0.26–0.94], p = 0.032), obesity (OR 6.55 [3.77–11.38], p p = 0.016) was associated with higher risk. Regarding low protein intake, the most important risk factors were an age group of 65–75 years (OR 2.94 [1.57–5.52], p = 0.001) and female gender (OR 1.73 [1.15–2.6], p = 0.008). Regular meat consumption reduced the risk of low protein intake (OR of 0.23 (0.1–0.53), p = 0.001). Within this survey, several socio-economic and lifestyle factors were associated with low energy and protein intake in the healthy Swiss population. A bunderstanding of these factors may help to reduce the risk of malnutrition

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

"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

Management of disease-related malnutrition for patients being treated in hospital

Disease-related malnutrition in adult patients who have been admitted to hospital is a syndrome associated with substantially increased morbidity, disability, short-term and long-term mortality, impaired recovery from illness, and cost of care. There is uncertainty regarding optimal diagnostic criteria, definitions for malnutrition, and how to identify patients who would benefit from nutritional intervention. Malnutrition has become the focus of research aimed at translating current knowledge of its pathophysiology into improved diagnosis and treatment. Researchers are particularly interested in developing nutritional interventions that reverse the negative effects of disease-related malnutrition in the hospital setting. High-quality randomised trials have provided evidence that nutritional therapy can reduce morbidity and other complications associated with malnutrition in some patients. Screening of patients for risk of malnutrition at hospital admission, followed by nutritional assessment and individualised nutritional interventions for malnourished patients, should become part of routine clinical care and multimodal treatment in hospitals worldwide

Low T3 syndrome upon admission and response to nutritional support in malnourished medical inpatients.

INTRODUCTION During illness, deiodination of thyroxine (T4) to triiodothyronine (T3) is down regulated. This is called "low T3 syndrome", an adaptive metabolic mechanism to reduce energy expenditure and prevent catabolism. We investigated the prognostic role of low T3 syndrome in patients at nutritional risk regarding mortality, clinical outcomes and response to nutritional support. METHODS This is a secondary analysis of the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a randomized-controlled Swiss multicenter trial comparing effects of individualized nutritional support with usual care in adult medical inpatients at nutritional risk. The primary endpoint was all-cause mortality over 30-,180-days and 5-years. RESULTS We had complete data including fT3 concentration of 801/2028 (39.5%) patients from the initial trial. Of these 492 (61.4%) had low T3 syndrome (fT3 < 3.2 pmol/l). Low T3 syndrome was associated with higher mortality over 30 days (adjusted hazard ratio 1.97 [95%CI 1.17 to 3.31], p 0.011) and other adverse clinical outcomes. Nutritional support only lowered mortality in the group of patients with but not in those without low T3 syndrome (adjusted odds ratio of nutritional support of 0.82 [95%CI 0.47 to 1.41] vs. 1.47 [95%CI 0.55 to 3.94]). This finding, however, was not significant in interaction analysis (p for interaction = 0.401). CONCLUSIONS Our secondary analysis of a randomized trial suggests that medical inpatients at nutritional risk with low T3 syndrome have a substantial increase in mortality and may show a more pronounced beneficial response to nutritional support interventions

Effect of Anti-Inflammatory Diets on Pain in Rheumatoid Arthritis: A Systematic Review and Meta-Analysis

Various nutritional therapies have been proposed in rheumatoid arthritis, particularly diets rich in &omega;-3 fatty acids, which may lead to eicosanoid reduction. Our aim was to investigate the effect of potentially anti-inflammatory diets (Mediterranean, vegetarian, vegan, ketogenic) on pain. The primary outcome was pain on a 10 cm visual analogue scale. Secondary outcomes were C-reactive protein levels, erythrocyte sedimentation rate, health assessment questionnaire, disease activity score 28, tender/swollen joint counts, weight, and body mass index. We searched MEDLINE (OVID), Embase (Elsevier), and CINAHL for studies published from database inception to 12 November 2021. Two authors independently assessed studies for inclusion, extracted study data, and assessed the risk of bias. We performed a meta-analysis with all eligible randomized controlled trials using RevMan 5. We used mean differences or standardized mean differences and the inverse variance method of pooling using a random-effects model. The search retrieved 564 unique publications, of which we included 12 in the systematic review and 7 in the meta-analysis. All studies had a high risk of bias and the evidence was very low. The main conclusion is that anti-inflammatory diets resulted in significantly lower pain than ordinary diets (&minus;9.22 mm; 95% CI &minus;14.15 to &minus;4.29; p = 0.0002; 7 RCTs, 326 participants)