Évaluation des apports alimentaires des malades hospitalisésFood intakes in in-hospital patients

Studies have shown that malnutrition may affect more than 50% of hospitalized patients. They observe a further deterioration in nutritional status during hospital stay. This deterioration may be explained by imbalance between energy and protein needs and low voluntary intake by patients. Although underfeeding is often attributable to disease or treatments, authors observe that more than 50% of causes are imputable to inadequate organization. This results in high food wastage with medical and economical consequences whose rate may be greater than 40%. Improvements of dietary intakes depend on the development of a screening and assessment system. This includes to promote an educational program for doctors and nurses, to modify the hospital diet according to the patients’ preferences and needs, to help and monitor dietary intakes in patients with undernutrition at admission or at risk of malnutrition.     

Outils et procédures de dépistage de la dénutrition et de son risque en milieu hospitalierTools and procedures for screening for malnutrition and its associated in risks in hospital

Malnutrition affects on average 20–50% of hospital inpatients and its negative repercussions in terms of morbi-mortality have been fully documented. Although this state of affairs is well known, there is little screening for malnutrition in hospitals. There is no single parameter indicating malnutrition, which instead has to be diagnosed based on anthropometric and biological data, and by multi-factorial indices of nutritional risk. Screening adapted to each of the four main classes of hospital care, acute medicine and surgery, intensive care, geriatrics and paediatrics needs to be systematically performed for every inpatient. To make malnutrition screening a natural part of the practice of care, we need to design training courses, which highlight the benefits in terms of length of stay, morbi-mortality and cost.     

Pour l’implantation des équipes transversales de nutrition clinique à l’hôpital : le plaidoyer du pédiatreNutrition support teams in the hospitals: why and how?

Despite major advances in the quality of care in many other areas, the prevalence of malnutrition in hospitals is high and has not decreased over the last 20 years. Young children are especially threatened. Malnutrition is associated with an increase in morbidity and mortality in hospitalized patients, induces an increase in length of stay and thus, in hospital costs. The nutritional risk in hospitalized patients is related to the underlying disease and to the organization of feeding and nutrition in the hospitals. Moreover, most of the physicians and other professionals do not have enough knowledge in the area of nutrition. Therefore, the intervention of professionals specialized in nutrition is needed. These professionals must be well organized and coordinated. Two different kinds of nutritional support boards exist in hospitals. Nutrition advisory (steering) boards which include all categories of professionals involved in feeding and nutrition, set broad policies about patients’ meal service and nutrition, but do not envisage patients on an individual basis. By contrast, nutrition (support) teams (NT) are little clinical units (even without devoted beds), involving a small number of nutrition specialists including at least one senior physician, to which patients should be referred individually. The main objective of the NT is to set up optimum nutrition according to each individual situation, especially in case of need for artificial nutrition. The impact of NT intervention, in terms of patients’ outcome as well as financial benefits, has been shown for long.     

Place de l'impédancemétrie dans le dépistage de la dénutrition à l'hôpitalBio-impedance analysis: Screening of denutrition in hospitalized patients

The prevalence of malnutrition is high in patients and tends to worsen during the hospital stay. In the absence of one reliable method to evaluate patients, the assessment of nutritional status is based on a global approach. Body composition measurement by bio-impedance analysis (BIA) is one of these approaches. Body composition measurements can detect malnutrition or abnormal hydration. Fat free mass, fat mass, and total body water are the main body compartments that are evaluated. Determination of abnormal body composition can then guide nutritional support. The reliability of BIA depends on the equation used to predict body composition and the parameters included in the formula (weight, height, sex, age, race, etc.). These parameters allow to minimize measurement errors. Thus, formula developed for specific populations allow to evaluate the nutritional status with reasonable error rates. BIA has been found to be inaccurate with abnormal distribution of body compartments (ascites, dialysis, lypodystrophy, etc.) or extreme weights (cachexia, obesity). Multi-frequency or segmental BIA was developed to overcome hydration abnormalities and variations in body geometry. However, these techniques require further validation. The BIA seems to have some limitations. This review aims to assess the reliability of BIA to detect protein-calorie malnutrition at hospital admission or during nutritional follow-up of patients.     

Nutrition au cours des radiothérapies et chimiothérapiesNutritional support during cancer chemotherapy and radiotherapy

Nutritional support for cancer patients treated with radiotherapy and chemotherapy are strongly requested with regard to the frequent malnutrition at time of diagnosis. Furthermore, the malnutrition often progresses with adverse effects of therapy and disease progression. Nutritional screening and assessment are essential. Dietetic care is mandatory for patients with malnutrition or at risk of malnutrition when they are still able to eat. But this oral nutritional support is frequently unable to maintain sufficient nutritional intakes with regard to tumour effect or treatment toxicity. Enteral or parenteral nutrition must be provided to patients unable to absorb adequate quantity of nutrients for a prolonged period. The primary goal is to avoid, especially for malnourished patients, further nutritional degradation which can lead to treatment interruptions, complications or increased risk of death. Routine administration of artificial nutrition has been tested during radiotherapy and chemotherapy but results are conflicting and data are missing for severely malnourished patients. No benefits in terms of treatment toxicity, tumour response, risk of complications and finally mortality have been demonstrated for routine use of artificial nutrition. Most decisions for indication of nutritional support, route of administration and quality of artificial nutrition in this field can't rely today on evidence-based medicine. However, artificial nutrition can provide nutrients and hydration necessary to maintain comfort and to improve survival for patients unable to eat sufficient nutrition for a prolonged period.     

Modèles animaux pour les études métaboliques et nutritionnelles lors de la croissance tumoraleAnimal models of tumor growth for metabolic and nutritional studies

Diverse animal models have been used to model the complex metabolic changes involved in cancer-associate malnutrition. Transplantable tumors without anti-tumor therapy are useful to reveal catabolic mechanisms, if conducted within the limits of clinically relevant tumor burden. The few studies in which a treatment (surgery, chemotherapy) has been used suggest that malnutrition is the result of tumor-associated processes (capture of substrates; secretion of catabolic factors, alteration of the hormonal environment), of the anti-neoplastic treatments, or of interactions between these. Current approaches in nutritional intervention are focussed on the complex interplay between host and tumor, by the provision of specific amino acids (i.e., arginine, glutamine), as well as polyunsaturated n-3 fatty acids. Feeding route and diet formulation are critical elements of the research approach. Further evolved animal models representing the clinical diversity of cancer and treatments, and the key nutrients, will form a basis to develop the optimal nutritional support for the cancer patient.     

Prise en charge nutritionnelle à domicile des malades cancéreuxHome artificial nutrition in cancer patients

Cancer is the first indication for home artificial nutrition in France, with rising figures. Survival of cancer patients on home parenteral nutrition is lower than that of other patients on home parenteral nutrition, due to the evolution of the underlying disease, and cancer is also associated with lower survival figures in home enteral nutrition patients. More than half of cancer patients die within the first year of home artificial nutrition. Home artificial nutrition seems to improve health-related quality of life, and may improve life expectancy in some patients. It is prescribed in patients during treatment (supportive care) or with therapeutic sequels, the indications being comparable to those in the hospital setting. Home artificial nutrition as a palliative care is much more debated, as it has not proved to increase quality of life or survival. It should be banned for patients with a life expectancy lower than three months and a Karnofsky index lower than 50. There is no specific nutrition technique for cancer patients.     

Alimentation et soins nutritionnels dans les hôpitaux : une vision européenneFood and nutritional care in hospitals: an european view

Disease-related undernutrition is significant in European hospitals but is seldom treated. In 1999 the council of Europe decided to collect information regarding Nutrition programmes in hospitals and for this purpose a network consisting of national experts from 12 of the Partial Agreement member states was established. The aim was to review the current practice in Europe regarding hospital food provision, to highlight deficiencies and guidelines to improve the nutritional care and support of hospitalised patients. Five major problems seemed to be common in this context: (1) lack of clearly defined responsibilities; (2) lack of sufficient education; (3) lack of influence of the patients; (4) lack of co-operation among all staff groups; (5) lack of involvement from the hospital management. To solve the problems highlighted, a combined “team-effort” is needed from national authorities and all staff involved in the nutritional care and support, including support managers.