Nutritional Management and Outcomes in Malnourished Medical Inpatients in 2020: The Evidence Is Growing!

Access to adequate food is a fundamental human right [...]

Nutritional screening tools in daily clinical practice: the focus on cancer

Introduction: Malnutrition is a common and under-recognized problem in cancer patients. It has been correlated to a large number of physical, psychological, and clinically relevant adverse effects in oncology patients, including impaired tolerance to anticancer therapy, adverse reactions, and reduced quality of life. Consequently, tailored strategies to identify patients at nutritional risk are essential to implement nutritional support effectively and to reduce cancer morbidity. Purpose of a nutritional screening tool: A screening tool should be an easy, standardized, rapid, noninvasive, and cost-effective diagnostic tool to identify cancer patients at nutritional risk in daily clinical practice. If patients at risk for malnutrition are identified early, many cases may be treated or prevented, with beneficial effects on patient outcome and subsequent reductions of health care costs. Screening tools: This article discusses the Malnutrition Universal Screening Tool, the Nutritional Risk Screening, the Mini Nutritional Assessment—Short Form®, the scored Patient-Generated Subjective Global Assessment (PG-SGA), and the Malnutrition Screening Tool (MST) in an oncology setting. Conclusions: Clinical institutions should implement an appropriate and validated screening tool and assessment protocol, which should contain an action plan. To date, the MST and the PG-SGA are the best validated screening tools for use in oncology patients. The PG-SGA is an assessment tool with screening components, whereas the MST is a pure screening tool and, therefore, quick and easy to use for trained as well as untrained staff. Further validation of all nutrition screening tools is needed, as well as further research to evaluate the benefits of nutrition screening and support with regard to outcome

Distribution of oral nutritional supplements with medication: Is there a benefit? A systematic review

Introduction: Disease related Malnutrition remains a major burden for patients and healthcare systems. The Medication Pass Nutritional Supplement Program (MEDPass) involves providing patients with oral nutritional supplements (ONS) in unusually small amounts three to four times a day during medication rounds. This systematic review aims to evaluate the impact of MEDPass ONS administration on compliance, total energy and protein intake, food intake, body weight (BW), and handgrip strength (HGS) in hospitalized adults and nursing home residents. Methods: We conducted a systematic literature search in the databases MEDLINE, Embase, Sciencedirect and the Cochrane Library. Included study types were randomized controlled trials (RCT), non-randomized controlled trials (non-RCT) and before-after studies. Validated tools specific to the study design were used to assess included studies. Results: Ten studies were identified with two being RCTs, three non-RCTs and five before-after trials. Compliance increased by 23.4-66% with MEDPass administration, resulting in compliance rates of 72.7-96%. With MEDPass administration, BW increased by 1-6.8% or remained stable. The assessed evidence on total energy intake is ambiguous for protein, with a trend towards an increased intake. Trials on energy intake from food show mixed results as well. One study suggests a slight increase in HGS. The included studies predominantly raise concerns for bias. Conclusion: We conclude that MEDPass ONS administration increases compliance in hospitalized adults and nursing home residents. For all other outcomes, robust and well-powered trials are necessary

Nutritional Risk Screening in Cancer Patients: The First Step Toward Better Clinical Outcome

Disease-related malnutrition is highly prevalent among cancer patients, with 40-80% suffering from it during the course of their disease. Malnutrition is associated with numerous negative outcomes such as: longer hospital stays, increased morbidity and mortality rates, delayed wound healing, as well as decreased muscle function, autonomy and quality of life. In cancer patients, malnutrition negatively affects treatment tolerance (including anti-cancer drugs, surgery, chemo- and radiotherapy), increases side effects, causes adverse reactions, treatment interruptions, postoperative complications and higher readmission rates. Conversely, anti-cancer treatments are also known to affect body composition and impair nutritional status. Tailoring early nutritional therapy to patients' needs has been shown to prevent, treat and limit the negative consequences of malnutrition and is likely to improve overall prognosis. As the optimisation of treatment outcomes is top priority and evidence for nutritional therapy is growing, it is increasingly recognized as a significant intervention and an autonomous component of multimodal cancer care. The proactive implementation of nutritional screening and assessment is essential for patients suffering from cancer - given the interaction of clinical, metabolic, pharmacological factors with systemic inflammation; and suppressed appetite with accelerated muscle protein catabolism. At the same time, a nutritional care plan must be established, and adequate individualized nutritional intervention started rapidly. Screening tools for nutritional risk should be validated, standardized, non-invasive, quick and easy-to-use in daily clinical practice. Such tools must be able to identify patients who are already malnourished, as well as those at risk for malnutrition, in order to prevent or treat malnutrition and reduce negative outcomes. This review investigates the predictive value of commonly used screening tools, as well as the sensitivity and specificity of their individual components for improving clinical outcomes in oncologic populations. Healthcare professionals' awareness of malnutrition in cancer patients and the pertinence of early nutritional screening must be raised in order to plan the best possible intervention and follow-up during the patients' ordeal with the disease

Distribution of oral nutritional supplements with medication: Is there a benefit? A systematic review.

OBJECTIVES Disease-related malnutrition remains a major burden for patients and health care systems. The Medication Pass Nutritional Supplement Program (MEDPass) involves providing patients with oral nutritional supplements (ONS) in unusually small amounts three to four times per day during medication rounds. This systematic review aims to evaluate the impact of MEDPass ONS administration on compliance, total energy and protein intake, food intake, body weight and handgrip strength in hospitalized adults and nursing-home residents. METHODS We conducted a systematic literature search in the databases MEDLINE, Embase, ScienceDirect, and the Cochrane Library and included randomized controlled trials (RCTs), non-RCTs, and before-after studies. Validated tools specific to the study design were used to assess the included studies. RESULTS Ten studies were identified, including two RCTs, three non-RCTs, and five before-after trials. Compliance increased by 23.4% to 66% with MEDPass administration, resulting in compliance rates of 72.7% to 96%. With MEDPass administration, body weight increased by 1% to 6.8% or remained stable. The assessed evidence on total energy intake is ambiguous for protein, with a trend toward an increased intake. Trials on energy intake from food show mixed results as well. One study suggested a slight increase in handgrip strength. The included studies predominantly raise concerns for bias. CONCLUSIONS We conclude that MEDPass ONS administration increases compliance in hospitalized adults and nursing-home residents. For all other outcomes, robust and well-powered trials are necessary

Trends of physical fitness related to weight status: An analysis including over 412,000 Swiss young male conscripts from 2007 to 2022.

OBJECTIVE The high prevalence of obesity among young adults in the civilian population pose challenges in recruiting physically fit soldiers. We assessed the trend of physical fitness related to weight status among Swiss male conscripts. METHODS Cross-sectional data of medical examination data during mandatory conscription for the Swiss Armed Forces, 2007-2022 (N = 412,186). The conscription physical test (CPT) assessed five aspects of physical fitness, each aspect scoring 0-25, one component being an endurance test (ET). CPT and ET categories were defined as per military guidelines: "Insufficient", "Sufficient", "Good", "Very Good" and "Excellent". Weight status was based on body mass index (BMI). RESULTS Conscripts with obesity (BMI ≥ 30 kg/m2) and overweight (BMI 25-29.99) had significantly (p < 0.001) lower CPT and ET scores compared to normal weight [multivariable-adjusted mean: 54.7 ± 0.1 and 66.5 ± 0.1, vs. 73.6 ± 0.1 for CPT; 8.8 ± 0.1 and 12.5 ± 0.1, vs. 15.3 ± 0.1 for ET] and a higher likelihood to be categorized as "Insufficient" [weighted relative-risk ratio and (95 %CI): 70.4 (63.7-77.7) and 2.35 (2.16-2.55) for CPT; 77.1 (71.0-83.7) and 3.05 (2.91-3.20) for ET] or "Sufficient" [7.67 (7.38-7.97) and 2.02 (1.99-2.06) for CPT; 8.93 (8.37-9.52) and 2.02 (1.98-2.06) for ET]. Compared to normal weight conscripts, the CPT and ET scores decreased over the conscription years for conscripts with obesity (multivariable-adjusted mean yearly change: -0.11 ± 0.02 for CPT; -0.032 ± 0.007 for ET) and overweight (-0.16 ± 0.01 for CPT and -0.044 ± 0.004 for ET). CONCLUSION Male Swiss conscripts with overweight and obesity have lower physical fitness than normal weight conscripts, and this condition tends to worsen over the conscription years

Nutrient and fluid requirements in post-bariatric patients performing physical activity: A systematic review.

OBJECTIVES The evidence for the benefits of physical activity in post-bariatric patients is growing. Nevertheless, it remains unclear whether nutritional regimens should be adapted to physical activity levels. The aim of this systematic review was to summarize current evidence regarding nutrient and fluid requirements in physically active post-bariatric patients. METHODS We conducted this systematic review according to the PRISMA guidelines. We searched MEDLINE, Embase, and the Cochrane Library for studies assessing nutritional aspects in physically active post-bariatric patients. Data were extracted based on a predefined, standardized form, and assessed for risk of bias. RESULTS Of 582 records, 8 studies were included, mostly implementing general fitness programs (30-60 min/d, 3-4 × /wk). There is no evidence for increased energy requirements in physically active post-bariatric patients. None of the studies determined energy, fat, or carbohydrate requirements. Most studies focused on protein, recommending a minimum intake of 60 g/d to preserve or increase muscle mass (upper limit 1.5 g protein/kg ideal body weight/d). Higher protein intake (108 g/d, thereof 48 g whey protein) combined with physical activity increased muscle strength. The effects of physical activity on micronutrient requirements remain unstudied, whereas fluid requirements appear to be increased. CONCLUSION The present findings strengthen the importance of adequate protein intake in physically active post-bariatric patients. Nutrient reference values for physically active post-bariatric patients are not definable based on the current evidence. Consequently, clinicians should pay special attention to the monitoring of macro- and micronutrients and fluid balance, especially when post-bariatric patients engage in high levels of physical activity

The influence of patients' nutritional risk, nutritional status, and energy density in MEDPass versus conventional administration of oral nutritional supplements - A secondary analysis of a randomized controlled trial.

OBJECTIVES The clinical influence of nutritional risk, nutritional status, and energy density of oral nutritional supplements (ONS) in MEDPass versus conventional administration of ONS is currently unknown. The aim of this analysis was to examine whether these variables have an impact on clinical outcomes. METHODS Secondary analysis of the intention to treat dataset of the randomized controlled MEDPass Trial in geriatric and medical inpatients. Patients in the intervention group received 4 × 50 ml ONS during the medication rounds (MEDPass mode), while those in the control group received ONS in a non-standardized manner. The examined endpoints included energy and protein coverage, ONS intake, handgrip strength (HGS), weight, appetite nausea and 30-day mortality. Three subgroup analyses for NRS 2002 total score (3, 4 or 5-7 points), NRS 2002 impaired nutritional status score (0, 1, 2 or 3 points) and energy density of the ONS (1.5 kcal/mL or 2 kcal/mL) were performed using linear and logistic regression with interaction and mixed effect models. RESULTS The data of 202 patients (103 women and 99 men) at nutritional risk (NRS total 2002 score ≥3), mean (SD) age 82.2 (6.5) years were included. There was no significant difference between the groups in the primary endpoint energy coverage in all three subgroup analyses. There were also no significant differences between the groups in the secondary endpoints of protein coverage, ONS intake, HGS, weight, appetite, nausea, and 30-day mortality. CONCLUSION The MEDPass mode of ONS administration was not superior to the conventional mode of administration in this study. ONS with high energy density (≥2 kcal/mL) should be offered since current evidence shows a tendency towards improved appetite, increased ONS and increased energy intake

Refeeding Syndrome: A Critical Reality in Patients with Chronic Disease

Malnutrition is one of the most frequent metabolic challenges in the population of chronically ill patients. This results in increased administration of nutritional therapy in inpatient settings, which poses the risk of side effects, in particular, the development of refeeding syndrome. If not managed accordingly, it leads to a significant rise in morbidity and mortality. However, despite its importance, evidence-based recommendations on the management of refeeding syndrome are largely lacking, and only a few randomized controlled trials have been conducted. In light of this, the aim of this review is to raise awareness of refeeding syndrome in chronically ill patients by critically reviewing recent literature and providing a short overview as well as diagnosis and treatment algorithms of this underreported metabolic condition. In summary, recent findings suggest undergoing risk assessment and stratification for every patient receiving nutritional therapy. According to this, adaptation of energy and fluid support during the replenishment phase should be implemented in the nutritional therapy for patients at high risk. Additionally, continuous monitoring should take place, and appropriate actions should be initiated when necessary

Glucocorticoid treatment, immobility, and constipation are associated with nutritional risk

Purpose: The hypothesis of this clinical study was to determine whether glucocorticoid use and immobility were associated with in-hospital nutritional risk. Methods: One hundred and one patients consecutively admitted to the medical wards were enrolled. Current medical conditions, symptoms, medical history, eating and drinking habits, diagnosis, laboratory findings, medications, and anthropometrics were recorded. The Nutrition Risk Score 2002 (NRS-2002) was used as a screening instrument to identify nutritional risk. Results: The results confirmed that glucocorticoid use and immobility are independently associated with nutritional risk determined by the NRS-2002. Constipation could be determined as an additional cofactor independently associated with nutritional risk. Conclusions: Glucocorticoid treatment, immobility, and constipation are associated with nutritional risk in a mixed hospitalized population. The presence of long-time glucocorticoid use, immobility, or constipation should alert the clinician to check for nutritional status, which is an important factor in mortality and morbidit