-
1.
Individualised nutritional support in medical inpatients at nutritional risk: a randomised clinical trial.
Schuetz, P, Fehr, R, Baechli, V, Geiser, M, Deiss, M, Gomes, F, Kutz, A, Tribolet, P, Bregenzer, T, Braun, N, et al
Lancet (London, England). 2019;(10188):2312-2321
Abstract
BACKGROUND Guidelines recommend the use of nutritional support during hospital stays for medical patients (patients not critically ill and not undergoing surgical procedures) at risk of malnutrition. However, the supporting evidence for this recommendation is insufficient, and there is growing concern about the possible negative effects of nutritional therapy during acute illness on recovery and clinical outcomes. Our aim was thus to test the hypothesis that protocol-guided individualised nutritional support to reach protein and caloric goals reduces the risk of adverse clinical outcomes in medical inpatients at nutritional risk. METHODS The Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) is a pragmatic, investigator-initiated, open-label, multicentre study. We recruited medical patients at nutritional risk (nutritional risk screening 2002 [NRS 2002] score ≥3 points) and with an expected length of hospital stay of more than 4 days from eight Swiss hospitals. These participants were randomly assigned (1:1) to receive either protocol-guided individualised nutritional support to reach protein and caloric goals (intervention group) or standard hospital food (control group). Randomisation was done with variable block sizes and stratification according to study site and severity of malnutrition using an interactive web-response system. In the intervention group, individualised nutritional support goals were defined by specialist dietitians and nutritional support was initiated no later than 48 h after admission. Patients in the control group received no dietary consultation. The composite primary endpoint was any adverse clinical outcome defined as all-cause mortality, admission to intensive care, non-elective hospital readmission, major complications, and decline in functional status at 30 days, and it was measured in all randomised patients who completed the trial. This trial is registered with ClinicalTrials.gov, number NCT02517476. FINDINGS 5015 patients were screened, and 2088 were recruited and monitored between April 1, 2014, and Feb 28, 2018. 1050 patients were assigned to the intervention group and 1038 to the control group. 60 patients withdrew consent during the course of the trial (35 in the intervention group and 25 in the control group). During the hospital stay, caloric goals were reached in 800 (79%) and protein goals in 770 (76%) of 1015 patients in the intervention group. By 30 days, 232 (23%) patients in the intervention group experienced an adverse clinical outcome, compared with 272 (27%) of 1013 patients in the control group (adjusted odds ratio [OR] 0·79 [95% CI 0·64-0·97], p=0·023). By day 30, 73 [7%] patients had died in the intervention group compared with 100 [10%] patients in the control group (adjusted OR 0·65 [0·47-0·91], p=0·011). There was no difference in the proportion of patients who experienced side-effects from nutritional support between the intervention and the control group (162 [16%] vs 145 [14%], adjusted OR 1·16 [0·90-1·51], p=0·26). INTERPRETATION In medical inpatients at nutritional risk, the use of individualised nutritional support during the hospital stay improved important clinical outcomes, including survival, compared with standard hospital food. These findings strongly support the concept of systematically screening medical inpatients on hospital admission regarding nutritional risk, independent of their medical condition, followed by a nutritional assessment and introduction of individualised nutritional support in patients at risk. FUNDING The Swiss National Science Foundation and the Research Council of the Kantonsspital Aarau, Switzerland.
-
2.
Malnutrition and sarcopenia.
Sieber, CC
Aging clinical and experimental research. 2019;(6):793-798
Abstract
Risk for or established malnutrition is frequent in older adults, accompanied by functional limitations, increased morbidity and mortality. Protein-energy malnutrition is often observed and leads besides other predisposing factors to sarcopenia, the increased loss of muscle mass with aging. Sarcopenia is an integral correlate of the physical component of the frailty syndrome. Even though sarcopenia often reaches levels where mobility, balance and functionality on overall are hampered, its diagnosis has not become part of the standard diagnostic and therapeutic repertoire of geriatric medicine. This will hopefully change with a recently published revised international definition of sarcopenia, as well an own ICD-number. From a pathophysiological point of view, both malnutrition and sarcopenia share many components, a low-inflammatory state (inflamm-aging) being an important one. Nutritional interventions with and without parallel physical activity programs can prevent and often also reverse sarcopenia. It is hoped that upcoming even more potent nutritional treatment options-including for sarcopenic obesity-will lower the burden of malnutrition and sarcopenia for many older adults.
-
3.
Effects of Preventive Nutrition Interventions among Adolescents on Health and Nutritional Status in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis.
Salam, RA, Das, JK, Ahmed, W, Irfan, O, Sheikh, SS, Bhutta, ZA
Nutrients. 2019;(1)
Abstract
The objective of this review was to assess the impact of preventive nutrition interventions on health and nutritional status of adolescents aged 10-19 years in low- and middle-income countries (LMICs). We searched the databases until 5 February 2019 without any restrictions on publication, date, language, or publication status. A total of 10 studies (15 papers) including 10,802 participants assessing the impact of micronutrient supplementation/fortification were included in this review. We did not find any study assessing the impact of nutrition education and counseling or macronutrient supplementation among adolescents. Among primary outcomes, we are uncertain of the effect of iron supplementation with or without folic acid on anemia (daily supplementation; relative risk (RR): 1.04, 95% confidence interval (CI) 0.42, 2.57; one study; 1160 participants; low-quality evidence; weekly supplementation; RR: 1.07, 95% CI: 0.46, 2.52; one study; 1247 participants; low-quality evidence). We are also uncertain of the effect of various micronutrient supplementation/fortification on body mass index (BMI) (calcium/vitamin D supplementation; (MD: -0.01 kg/m2; 95% CI: -1.20, 1.17; two studies; 730 participants; I2 94%; very-low-quality evidence, iron supplementation with or without folic acid; MD: 0.47 kg/m2; 95% CI: -0.17, 1.11; two studies; 652 participants; I2 37%; very-low-quality evidence, zinc supplementation; MD: 0.35 kg/m2; 95% CI: -0.15, 0.85; one study; 382 participants; very-low-quality evidence) and multiple micronutrient (MMN) fortification; MD: 0.23 kg/m2, 95% CI: -0.11, 0.57; two studies; 943 participants; I2 22%; very-low-quality evidence). None of the included studies reported any other primary outcomes including morbidity or adverse effects. Among secondary outcomes, iron supplementation with or without folic acid may improve hemoglobin concentrations, and calcium/vitamin D supplementation may improve serum 25(OH)D levels, while calcium only supplementation and calcium and vitamin D supplementation may marginally improve total body bone mineral density (BMD). We are uncertain of the effect of MMN fortification on hemoglobin concentrations, calcium supplementation on total body bone mineral content (BMC), calcium + vitamin D supplementation on total body BMC, and zinc supplementation on zinc levels. There is limited evidence of micronutrient supplementation/fortification among adolescents, especially adolescent boys, on health and nutritional status in LMICs. These findings should be interpreted with caution due to the low quality and limited number of studies.
-
4.
The Impact of an mHealth Voice Message Service (mMitra) on Infant Care Knowledge, and Practices Among Low-Income Women in India: Findings from a Pseudo-Randomized Controlled Trial.
Murthy, N, Chandrasekharan, S, Prakash, MP, Kaonga, NN, Peter, J, Ganju, A, Mechael, PN
Maternal and child health journal. 2019;(12):1658-1669
-
-
Free full text
-
Abstract
Objectives mHealth interventions for MNCH have been shown to improve uptake of antenatal and neonatal services in low- and middle-income countries (LMICs). However, little systematic analysis is available about their impact on infant health outcomes, such as reducing low birth weight or malnutrition among children under the age of five. The objective of this study is to determine if an age- and stage-based mobile phone voice messaging initiative for women, during pregnancy and up to 1 year after delivery, can reduce low birth weight and child malnutrition and improve women's infant care knowledge and practices. Methods We conducted a pseudo-randomized controlled trial among pregnant women from urban slums and low-income areas in Mumbai, India. Pregnant women, 18 years and older, speaking Hindi or Marathi were enrolled and assigned to receive mMitra messages (intervention group N = 1516) or not (Control group N = 500). Women in the intervention group received mMitra voice messages two times per week throughout their pregnancy and until their infant turned 1 year of age. Infant's birth weight, anthropometric data at 1 year of age, and status of immunization were obtained from Maternal Child Health (MCH) cards to assess impact on primary infant health outcomes. Women's infant health care practices and knowledge were assessed through interviews administered immediately after women enrolled in the study (Time 1), after they delivered their babies (Time 2), and after their babies turned 1 year old (Time 3). 15 infant care practices self-reported by women (Time 3) and knowledge on ten infant care topics (Time 2) were also compared between intervention and control arms. Results We observed a trend for increased odds of a baby being born at or above the ideal birth weight of 2.5 kg in the intervention group compared to controls (odds ratio (OR) 1.334, 95% confidence interval (CI) 0.983-1.839, p = 0.064). The intervention group performed significantly better on two infant care practice indicators: giving the infant supplementary feeding at 6 months of age (OR 1.4, 95% CI 1.08-1.82, p = 0.009) and fully immunizing the infant as prescribed under the Government of India's child immunization program (OR 1.531, 95% CI 1.141-2.055, p = 0.005). Women in the intervention group had increased odds of knowing that the baby should be given solid food by 6 months (OR 1.89, 95% CI 1.371-2.605, p < 0.01), that the baby needs to be given vaccines (OR 1.567, 95% CI 1.047-2.345, p = 0.028), and that the ideal birth weight is > 2.5 kg (OR 2.279, 95% CI 1.617-3.213, p < 0.01). Conclusions for Practice This study provides robust evidence that tailored mobile voice messages can significantly improve infant care practices and maternal knowledge that can positively impact infant child health. Furthermore, this is the first prospective study of a voice-based mHealth intervention to demonstrate a positive impact on infant birth weight, a health outcome of public health importance in many LMICs.
-
5.
Evidence-based nutrition for the malnourished, hospitalised patient: one bite at a time.
Merker, M, Gomes, F, Stanga, Z, Schuetz, P
Swiss medical weekly. 2019;:w20112
Abstract
Although malnutrition is a highly prevalent condition in the inpatient setting, particularly in older patients with multiple morbidities, the medical community has struggled to find efficient, evidence-based approaches for its prevention and treatment. From an evolutionary perspective, illness-related low appetite may be seen as a protective response with the goals to accelerate recovery from disease by improving autophagy. In line with this, earlier trials in the intensive care setting including severely ill patients have demonstrated unwarranted effects of overnutrition on patient outcomes. Uncertainties regarding the best approach to the malnourished inpatient in conjunction with a lack of strong trial data may, in part, explain the low level of attention that hospital medical staff have paid to the issue of malnutrition in the non-critical care inpatient setting. The recent Effect of early nutritional support on Frailty, Functional Outcomes and Recovery of malnourished medical inpatients Trial (EFFORT) study, however, has shown that individualized nutritional support reduces severe complications and improves mortality in medical inpatients, with positive effects on functional outcomes and quality of life. These results from a high quality effectiveness trial in conjunction with other studies, such as the NOURISH trial, should prompt us to improve our management of malnutrition in the inhospital setting. This procedure should start with a systematic screening for risk of malnutrition of admitted patients, effective assessment of nutritional status in multidisciplinary teams including dieticians, nurses and physicians, and early start of individualized adequate nutritional support of at risk patients to reach nutritional goals. Understanding the optimal use of nutritional support in patients with acute illness is complex because timing, route of delivery, and the amount and type of nutrients may all affect patient outcomes. Also, particularly for patients on the medical ward, factors like the logistics of catering, staffing to provide food and support the patient (i.e., number of nurses and dieticians), motivation/understanding of the patient to eat in defiance of appetite, the empathic human factor of nutritional care, the quality of meals, the taste of supplements, and unnecessary fasting for diagnostic or therapeutic procedures have a strong influence on nutritional care of patients. Further research and clinical trials are required to better understand, step by step, how we can use clinical nutrition best to maximize recovery of our patient and improve their functional status and their quality of life. Such evidence regarding nutritional therapy may allow us to implement personalized nutrition-driven interventions in the future.
-
6.
Malnutrition: evaluating the effectiveness of supplements.
Collins, AJ, Clemett, V, McNaughton, A
British journal of community nursing. 2019;(Sup7):S18-S25
Abstract
This article explores the effectiveness of oral nutritional supplements through a literature review. A literature search was performed throughout various medical databases and one article was selected for a critical appraisal. The study focused on the use of high-energy, low-volume supplements for people living in care homes who are at risk of malnutrtion or who are already manourished. The methods and conclusions of the study are then scrutinised. This article recommends further research to be carried out into the type and volume of supplements needed and the implementation of evidence-based practice.
-
7.
Effects of high-protein, high-calorie oral nutritional supplementation in malnourished older people in nursing homes: An observational, multi-center, prospective study (PROT-e-GER). Protocol and baseline population characteristics.
Malafarina, V, Serra Rexach, JA, Masanes, F, Cruz-Jentoft, AJ
Maturitas. 2019;:73-79
Abstract
INTRODUCTION Malnutrition is common among older people living in nursing homes. Poor nutritional status is associated with functional loss and with worse health. Oral nutritional supplementation (ONS) can be an effective means to counteract weight loss, improve nutritional status and reduce complications in malnourished older people living in nursing homes. The main objective of this study was to assess whether ONS over 12 weeks improved the nutritional status and physical function of malnourished older people living in nursing homes. METHODS This was a multi-center, prospective, observational study carried out in 53 nursing homes in Spain. Participants were aged 65 or over. They were prescribed a high-calorie, high-protein ONS to treat well documented malnutrition. Subjects who received enteral nutrition, had special nutritional requirements, or receiving end-of-life care were excluded. Anthropometric data were recorded (weight, height and BMI) as well as scores on nutritional and functional scales (MNA-SF, Barthel index, SPPB, grip strength and Functional Ambulation Categories, FAC) at the beginning of the study and after 12 weeks. Cognitive status, comorbidities and depressive symptoms were also assessed. Frailty status was assessed using the FRAIL scale. RESULTS 320 participants were included, of whom 253 completed the study (mean age 84.2 ± 7.1 years). Baseline BMI was 20.2 ± 2.8. A high prevalence of functional impairment (Barthel Index median 45, range 15-75; median SPPB 4, range 1-6) and cognitive impairment (MMSE median 12, 7-20) was found. DISCUSSION This study identified a population with malnutrition and a high degree of physical and mental disability that mirrors the typical population of many nursing homes. Analysis of the results of this study will help to determine the factors associated with malnutrition and the effect of nutritional intervention in practice.
-
8.
Nutrition risk screening in the ICU.
Kondrup, J
Current opinion in clinical nutrition and metabolic care. 2019;(2):159-161
Abstract
PURPOSE OF REVIEW To review recent studies that may help to identify patients in the ICU who benefit from nutrition support. RECENT FINDINGS One recent controlled trial did not show any clinical benefit of nutrition support among a sample of ICU patients who were hitherto believed to benefit from nutrition support. Several recent observational studies suggest benefit of nutrition support among patients who have a high nutric score, in itself derived from an observational study. SUMMARY Regrettably, the decision about nutrition support in ICU patients still depends on physiological reasoning: a high degree of inflammation/stress metabolism, which will last for a considerable time, especially among those who are fragile (already malnourished, elderly, those with chronic diseases and/or other comorbidities).
-
9.
Efficacy of non-pharmacological interventions to treat malnutrition in older persons: A systematic review and meta-analysis. The SENATOR project ONTOP series and MaNuEL knowledge hub project.
Correa-Pérez, A, Abraha, I, Cherubini, A, Collinson, A, Dardevet, D, de Groot, LCPGM, de van der Schueren, MAE, Hebestreit, A, Hickson, M, Jaramillo-Hidalgo, J, et al
Ageing research reviews. 2019;:27-48
Abstract
INTRODUCTION We aimed to perform a review of SRs of non-pharmacological interventions in older patients with well-defined malnutrition using relevant outcomes agreed by a broad panel of experts. METHODS PubMed, Cochrane, EMBASE, and CINHAL databases were searched for SRs. Primary studies from those SRs were included. Quality assessment was undertaken using Cochrane and GRADE criteria. RESULTS Eighteen primary studies from seventeen SRs were included. Eleven RCTs compared oral nutritional supplementation (ONS) with usual care. No beneficial effects of ONS treatment, after performing two meta-analysis in body weight changes (six studies), mean difference: 0.59 (95%CI -0.08, 1.96) kg, and in body mass index changes (two studies), mean difference: 0.31 (95%CI -0.17, 0.79) kg/m2 were found. Neither in MNA scores, muscle strength, activities of daily living, timed Up&Go, quality of life and mortality. Results of other intervention studies (dietary counselling and ONS, ONS combined with exercise, nutrition delivery systems) were inconsistent. The overall quality of the evidence was very low due to risk of bias and small sample size. CONCLUSIONS This review has highlighted the lack of high quality evidence to indicate which interventions are effective in treating malnutrition in older people. High quality research studies are urgently needed in this area.
-
10.
Impact of 3-week citrulline supplementation on postprandial protein metabolism in malnourished older patients: The Ciproage randomized controlled trial.
Bouillanne, O, Melchior, JC, Faure, C, Paul, M, Canouï-Poitrine, F, Boirie, Y, Chevenne, D, Forasassi, C, Guery, E, Herbaud, S, et al
Clinical nutrition (Edinburgh, Scotland). 2019;(2):564-574
Abstract
BACKGROUND Citrulline (CIT), is not extracted by the splanchnic area, can stimulate muscle protein synthesis and could potentially find clinical applications in conditions involving low amino acid (AA) intake, such as in malnourished older subjects. OBJECTIVE Our purpose was to research the effects of CIT supplementation on protein metabolism in particular on non-oxidative leucine disposal (NOLD, primary endpoint), and splanchnic extraction of amino acids in malnourished older patients. DESIGN This prospective randomized multicenter study determined whole-body and liver protein synthesis, splanchnic protein metabolism and appendicular skeletal muscle mass (ASMM) in 24 malnourished older patients [80-92 years; 18 women and 6 men] in inpatient rehabilitation units. All received an oral dose of 10 g of CIT or an equimolar mixture of six non-essential amino acids (NEAAs), as isonitrogenous placebo, for 3 weeks. RESULTS NOLD and albumin fractional synthesis rates were not different between the NEAA and CIT groups. Splanchnic extraction of dietary amino acid tended to decrease (p = 0.09) in the CIT group (45.2%) compared with the NEAA group (60.3%). Total differences in AA and NEAA area under the curves between fed-state and postabsorptive-state were significantly higher in the CIT than in the NEAA group. There were no significant differences for body mass index, fat mass (FM), lean mass (LM) or ASMM in the whole population except for a tendential decrease in FM for the citrulline group (p = 0.089). Compared with Day 1, lean mass and ASMM significantly increased (respectively p = 0.016 and p = 0.018) at Day 20 in CIT-treated women (mean respective increase of 1.7 kg and 1.1 kg), and fat mass significantly decreased (p = 0.001) at Day 20 in CIT-group women (mean decrease of 1.3 kg). CONCLUSIONS Our results demonstrate that CIT supplementation has no effect on whole-body protein synthesis or liver protein synthesis in malnourished older subjects. However, CIT supplementation was associated with a higher systemic AA availability. In the subgroup of women, CIT supplementation increased LM and ASMM, and decreased FM.