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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.
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2.
Feeding should be individualized in the critically ill patients.
Berger, MM, Pichard, C
Current opinion in critical care. 2019;(4):307-313
Abstract
PURPOSE OF REVIEW Any critical care therapy requires individual adaptation, despite standardization of the concepts supporting them. Among these therapies, nutrition care has been repeatedly shown to influence clinical outcome. Individualized feeding is the next needed step towards optimal global critical care. RECENT FINDINGS Both underfeeding and overfeeding generate complications and should be prevented. The long forgotten endogenous energy production, maximal during the first 3 to 4 days, should be integrated in the nutrition plan, through a slow progression of feeding, as full feeding may result in early overfeeding. Accurate and repeated indirect calorimetry is becoming possible thanks to the recent development of a reliable, easy to use and affordable indirect calorimeter. The optimal timing of the prescription of the measured energy expenditure values as goal remains to be determined. Optimal protein prescription remains difficult as no clinically available tool has yet been identified reflecting the body needs. SUMMARY Although energy expenditure can now be measured, we miss indicators of early endogenous energy production and of protein needs. A pragmatic ramping up of extrinsic energy provision by nutrition support reduces the risk of overfeeding-related adverse effects.
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3.
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.
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The utility of nutritional supportive care with an eicosapentaenoic acid (EPA)-enriched nutrition agent during pre-operative chemoradiotherapy for pancreatic cancer: Prospective randomized control study.
Akita, H, Takahashi, H, Asukai, K, Tomokuni, A, Wada, H, Marukawa, S, Yamasaki, T, Yanagimoto, Y, Takahashi, Y, Sugimura, K, et al
Clinical nutrition ESPEN. 2019;:148-153
Abstract
BACKGROUND & AIMS Neoadjuvant chemoradiotherapy (NACRT) for pancreatic cancer (PC) is potentially associated with various toxicities, which can lead to impaired nutritional status. Eicosapentaenoic acid (EPA) can reduce proinflammatory cytokines and positively influence cancer cachexia syndrome. The aim of this study is to clarify the utility of EPA enriched nutrition support during NACRT for PC. METHODS We randomly assigned 62 patients with PC that received NACRT to either a nutrition intervention (NI) or a normal diet (ND). Patients in the NI group received 2 bottles/day (550 kcal/day) of an EPA-enriched nutrition supplement during NACRT. The primary endpoints were the before-to-after NACRT ratios (post/pre ratios) of skeletal muscle mass and psoas major muscle area (PMA). The secondary endpoints were the post/pre ratios of other nutritional parameters and treatment-related toxicities. RESULTS Only 14 patients (45.2%) in the NI group consumed more than 50% of the EPA-enriched supplement provided. The post/pre ratio of skeletal muscle mass in the NI group (0.99 ± 0.060) was not significantly different from that of the ND group (0.96 ± 0.079, p = 0.102). However, patients that consumed ≥50% of the EPA-enriched supplement (the good intake group) had significantly higher skeletal muscle mass ratios than patients in the ND group (p = 0.042). The PMA ratio was significantly higher in the NI group (0.96 ± 0.081) than in the ND group (0.89 ± 0.072, p = 0.001). The NI and ND groups were not significantly different in other nutritional parameters or in NACRT-related toxicity. CONCLUSIONS We found that EPA-enriched intake could potentially improve the nutritional status of patients with PC that received NACRT, but it was difficult for many patients to drink, due to its disagreeable taste. University Hospital Medical Information Network (http://www.umin.ac.jp), registration number UMIN000033589, https://upload.umin.ac.jp/cgi-bin/ctr_e/ctr_view.cgi?recptno=R000038300.
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Nutritional interventions in elderly gastrointestinal cancer patients: the evidence from randomized controlled trials.
Bozzetti, F
Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. 2019;(3):721-727
Abstract
Literature concerning nutritional interventions in elderly patients with gastrointestinal cancer, with special reference to randomized clinical trials, has been critically reviewed. This segment of oncologic population was found to be penalized by a high prevalence of malnutrition and sarcopenia which translated in an increased rate of toxicity from chemotherapy, poor compliance with oncologic treatments, and, finally, with a poor prognosis. Attempts to reverse this condition included a potentiation of nutrients intake which should sequentially proceed through the use of dietary counseling and administration of standard or ω-3 fatty acid-enriched oral supplements to finally come to enteral or parenteral nutrition. Randomized clinical trials investigating the effects of simple dietary advice and use of standard oral supplements were disappointing as regards long-term compliance and results. Nutritional and clinical benefits were reported with the use of ω-3 fatty acid-enriched oral supplements and especially with long-term supplemental parenteral nutrition. Despite the general recommendation of the scientific community that emphasizes the use of the enteral route, whenever possible, for delivering the nutritional support, it appears from the literature that more consistent benefits can be achieved, especially in the long-term nutritional support, when an insufficient oral nutrition is partnered with intravenous nutrition.
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The potential role of nutrition on lens pathology: a systematic review and meta-analysis.
Sideri, O, Tsaousis, KT, Li, HJ, Viskadouraki, M, Tsinopoulos, IT
Survey of ophthalmology. 2019;(5):668-678
Abstract
Oxidative stress is one of the main mechanisms of lens opacification, and certain nutritional antioxidants are suspected to have a protective effect. To examine the role of these nutritional antioxidants on cataract prevention, we searched major databases and reviewed current evidence regarding the protective effect of nutritive antioxidants. We included observational studies that investigate the association between one or more of the following micronutrients and cataract: vitamin A, vitamin C, vitamin E, lutein, zeaxanthin, α- and β-carotene. Two independent authors extracted data and assessed their quality. We pooled results for overall cataract incidence for all types of cataract and separately for nuclear, cortical, and posterior subcapsular cataract. We did not perform sensitivity analysis. Twenty-five studies were included in the qualitative and 24 in the quantitative part of the study, with a total of 295,821 participants over 30 years old. Results from pooled analysis showed a protective effect of antioxidants on cataract, but not all of them reached statistical significance. Statistically significant results were reached for vitamin C (odds ratio [OR] = 0.88, 95% confidence interval [CI] [0.81, 0.97]), beta-carotene (OR = 0.89, 95% CI [0.83, 0.95]), and lutein and zeaxanthin (OR = 0.92, 95% CI [0.85, 0.99]). We did not find statistically significant results for vitamin E (OR = 0.84, 95% CI [0.70, 1.01]), vitamin A (OR = 0.90, 95% CI [0.80, 1.00]), or alpha-carotene (OR = 0.92, 95% CI [0.85, 1.00]). The present study shows a relation between certain antioxidants and cataract, but further studies, especially interventional, are needed to confirm this hypothesis.
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7.
Cachexia/Protein energy wasting syndrome in CKD: Causation and treatment.
Oliveira, EA, Zheng, R, Carter, CE, Mak, RH
Seminars in dialysis. 2019;(6):493-499
Abstract
Cachexia is a multifactorial syndrome defined by significant body weight loss, fat and muscle mass reduction, and increased protein catabolism. Protein energy wasting (PEW) is characterized as a syndrome of adverse changes in nutrition and body composition being highly prevalent in patients with CKD, especially in those undergoing dialysis, and it is associated with high morbidity and mortality in this population. Multiple mechanisms are involved in the genesis of these adverse nutritional changes in CKD patients. There is no obvious distinction between PEW and cachexia from a pathophysiologic standpoint and should be considered as part of the spectrum of the same nutritional disorder in CKD with similar management approaches for prevention and treatment based on current understanding. A plethora of factors can affect the nutritional status of CKD patients requiring a combination of therapeutic approaches to prevent or reverse protein and energy depletion. At present, there is no effective pharmacologic intervention that prevents or attenuates muscle atrophy in catabolic conditions like CKD. Prevention and treatment of uremic muscle wasting involve optimal nutritional support, correction of acidosis, and physical exercise. There has been emerging consistent evidence that active treatment, perhaps by combining nutritional interventions and resistance exercise, may be able to improve but not totally reverse or prevent the supervening muscle wasting and weakness. Active research into more direct pharmacological treatment based on basic mechanistic research is much needed for this unmet medical need in patients with CKD.
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8.
Nutrition Management in Acute Pancreatitis.
Ramanathan, M, Aadam, AA
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2019;:S7-S12
Abstract
Acute pancreatitis (AP) is one of the most prevalent gastrointestinal conditions necessitating inpatient care. In the United States, over 275,000 patients are hospitalized for management of AP, with an estimate that over $2.5 billion is spent annually in treatment, with incidence continuing to rise. AP is a highly inflammatory and catabolic state, putting all patients with the condition at risk of malnutrition. Numerous approaches to nutrition support in pancreatitis have been evaluated and remain controversial. In this narrative review, we aim to give an overview of indications for nutrition and approach to management of nutrition in severe and predicted severe AP based on currently available data.
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Muscle-targeted nutritional support for rehabilitation in patients with parkinsonian syndrome.
Barichella, M, Cereda, E, Pinelli, G, Iorio, L, Caroli, D, Masiero, I, Ferri, V, Cassani, E, Bolliri, C, Caronni, S, et al
Neurology. 2019;(5):e485-e496
Abstract
OBJECTIVE We evaluated the efficacy of muscle-targeted nutritional support on the functional outcomes of multidisciplinary intensive rehabilitation treatment (MIRT) in patients with Parkinson disease (PD) or parkinsonism. METHODS We conducted a pragmatic, bicentric, randomized (1:1), assessor-blind controlled trial (Protein, Leucine and Vitamin D Enhancing Rehabilitation [PRO-LEADER]; April 2017 to January 2018) in cognitively intact patients with PD or parkinsonism and undergoing a 30-day MIRT. Patients (n = 150) received a standard hospital diet with or without a whey protein-based nutritional supplement enriched with leucine and vitamin D twice daily. The primary efficacy endpoint was the increase in the distance walked during a 6-minute walking test (6MWT). Secondary endpoints were changes in 4-meter walking speed, Timed Up and Go test (TUG), Berg balance scale, handgrip strength, Self-assessment Parkinson's Disease Disability Scale, body weight, and skeletal muscle mass (SMM). RESULTS Nutritional support resulted in greater increase in the distance walked during 6MWT (mean 69.6 meters [95% confidence interval (CI) 60.7-78.6]) than no support (51.8 meters [95% CI 37.0-66.7]): center-adjusted mean difference, 18.1 meters (95% CI 0.9-35.3) (p = 0.039). Further adjustment for changes in dopaminergic therapy and SMM yielded consistent results: mean difference, 18.0 meters (95% CI 0.7-35.2) (p = 0.043). A meaningful effect was also found for the following secondary endpoints: 4-meter walking speed (p = 0.032), TUG (p = 0.046), SMM, and SMM index (p = 0.029). Six patients discontinued the nutritional therapy due to mild side effects. CONCLUSION The consumption of a whey protein-based nutritional formula enriched with leucine and vitamin D with MIRT improved lower extremity function and preserved muscle mass in patients with PD or parkinsonism.Clinicaltrials.gov IDENTIFIER NCT03124277. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that for patients with parkinsonism undergoing intensive rehabilitation, a whey protein-based nutritional formula enriched with leucine and vitamin D increased distance walked on the 6MWT.
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Malnutrition in pulmonary arterial hypertension: a possible role for dietary intervention.
Kwant, CT, Ruiter, G, Vonk Noordegraaf, A
Current opinion in pulmonary medicine. 2019;(5):405-409
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Abstract
PURPOSE OF REVIEW The last decade's progress has been made in the pharmacological treatment of pulmonary arterial hypertension (PAH). The role of nutrition in relation to quality of life in this group of patients is not investigated yet. In addition to avoiding salt and high-fluid intake based on left heart failure diet, there is no evidence-based diet recommendation for PAH. RECENT FINDINGS It was recently demonstrated that patients with PAH suffer from malnutrition resulting in iron and vitamin D deficiency and glucose/insulin resistance. Recent experimental studies suggest that besides reduced malabsorption of important nutrients, the microbiome of the gut is also less diverse in PAH. In this review, we summarize the current knowledge on malnutrition and dietary intake in PAH. We discuss the possible underlying mechanisms and discuss novel therapeutic interventions validated in patients with left heart failure. SUMMARY Large-scaled studies on dietary interventions are needed in PAH.