Role of nutritional care in hospitals in the prevention of disease-related malnutrition

The prevalence of undernutrition is about 30% at admission to hospitals, and in many cases the nutritional risk is not recognized and significantly increases in patients during hospitalisation in Hungary. Undernutrition and acute rapid weight loss of as little as 2-3 kg (cc. 5%) in combination with disease increases the risk of complications, lowers resistance to infection, impairs physical and mental functioning and delays recovery. Undernourished patients are at greater risk for adverse medical outcomes than well-nourished ones. In most hospitals the nutritional risk of patients is not determined and nutritional treatment plan isn't developed; fewer than 10 Nutritional Support Teams are established in hospitals. Nutritional care of ill patients is considered as a part of clinical treatment in very few hospitals in Hungary. There is no adequate recognition of the problem of undernutrition. The simplest and safest way to provide nutritional support is the adequate energy rich oral nutrition. If the oral nutrition fails or is inappropriate then artificial nutritional support becomes necessary. Nutrition is the most cost effective measure to prevent the complications of diseases. To improve the intolerable situation it would be necessary to increase the nutritional knowledge and the awareness of health care teams of the real importance of nutritional status in illnesses, and improve the quality of hospital food and eating conditions and environment.     

A Qualitative Exploration of Nutrition Screening,Assessment and Oral Support Used in Patients Undergoing Cancer Surgery in Low- and Middle-Income Countries

Preoperative undernutrition is a prognostic indicator for postoperative mortality and morbidity. Evidence suggests that treating undernutrition can improve surgical outcomes. This study explored the provision of nutritional screening, assessment and support on surgical cancer wards in low- and middle-income countries (LMICs). This was a qualitative study and participants took part in one focus group or one individual interview. Data were analysed thematically. There were 34 participants from Ghana, India, the Philippines and Zambia: 24 healthcare professionals (HCPs) and 10 patients. Results showed that knowledge levels and enthusiasm were high in HCPs. Barriers to adequate nutritional support were a lack of provision of ward and kitchen equipment, food and sustainable nutritional supplements. There was variation across countries towards nutritional screening and assessment which seemed to be driven by resources. Many hospitals where resources were scarce focused on the care of individual patients in favour of an integrated systems approach to identify and manage undernutrition. In conclusion, there is scope to improve the efficiency of nutritional management of surgical cancer patients in LMICs through the integration of nutrition assessment and support into routine hospital policies and procedures, moving from case management undertaken by interested personnel to a system-based approach including the whole multidisciplinary team.     

肾脏内科住院患者营养风险、营养不足及营养干预状况

目的 调查广州市部分医院肾脏内科住院患者的营养风险、营养不足发生率以及营养干预状况,为指导肾脏病患者营养治疗提供依据.方法 采用营养风险筛查2002（NRS 2002）工具,对广州市部分医院378例肾脏内科住院患者进行营养风险筛查,以NRS 2002评分≥3分为有营养风险,体重指数（BMI）＜18.5 kg/m^2（或白蛋白＜30 g/L）为营养不足,并调查营养干预情况,分析营养风险与营养干预之间的关系.结果 378例肾脏内科患者营养不足和营养风险的发生率分别为21.7%和41.3%,其中慢性肾功能不全患者营养不足和营养风险发生率最高,分别为24.3%和60.7%;糖尿病肾病患者的营养风险发生率为42.3%.378例患者中,102例（27.0%）接受了营养支持,其中有营养风险患者的营养支持率为50.0%（78/156）,无营养风险患者的营养支持率为10.8%（24/222）.结论 广州部分医院肾脏内科住院患者中营养风险或营养不足的发生率较高,营养干预存在不合理性,应引起关注并规范营养干预指南以改善此状况.     

普外科患者术前营养不足、营养风险及营养支持状况分析

目的调查分析普通外科住院患者术前营养不足、营养风险及营养支持状况。方法采用营养风险筛查2002（NRS2002）直接查询和阅读病历记录方式,对北京市某三级甲等医院普通外科1个月内所有217例新入院患者进行调查。结果术前患者营养不足和营养风险发生率分别为7．4％和15．7％,以胃肠道疾病和恶性疾病患者多见。分别有18．8％有营养不足者和14．7％有营养风险者,以及3．0％无营养不足者和2．2％无营养风险者接受了营养支持。肠内和肠外营养应用比例为1：2。结论建议在普外科推广NRS2002,以提高临床营养支持的合理性。     

Undernutrition Risk and Undernutrition in Pulmonology Department Inpatients: A Systematic Review and Meta-Analysis

Pulmonology patients are predisposed to be undernourished and a wide variability in the estimates of frequency of undernutrition risk and undernutrition is found in the literature. The aim of this systematic review and meta-analysis was to investigate the prevalence of undernutrition risk and undernutrition on hospital admission in pulmonology department inpatients. We also intend to take into account the different methodologies used to evaluate undernutrition risk and undernutrition in this population.

Pubmed, ISI-Web of Science, and Scopus were searched until January 2015. The evidence regarding the prevalence of undernutrition risk and undernutrition was summarized.

Twenty-two studies were included in the qualitative analysis and 21 in meta-analysis. The overall prevalence of undernutrition risk (32.73%; 95% confidence interval [CI], 31.29%–34.17%, I² = 97.6%) was lower than undernutrition prevalence (36.95%; 95% CI, 34.80%–39.10%, I² = 99.7%). The subtotal prevalence of undernutrition risk was similar using the Malnutrition Universal Screening Tool and Nutritional Risk Screening–2002. The studies using only anthropometric parameters for the assessment of undernutrition reported lower prevalence of undernutrition than the studies that used Subjective Global Assessment. Cross-sectional studies reported higher prevalence of undernutrition risk and undernutrition than cohort studies. Studies including larger samples reported a prevalence estimate similar to the overall prevalence for undernutrition risk and undernutrition. Studies conducted in non-pulmonology departments showed lower prevalence of undernutrition risk than those from pulmonology departments, contrary to the estimates for undernutrition prevalence.

Undernutrition risk and undernutrition prevalence at hospital admission are high among pulmonology inpatients, but the heterogeneity between the studies illustrates the lack of standardized methods to assess nutritional status in this population. The assessment of undernutrition must always be preceded by nutritional screening, according to guidelines, which did not take place in some analyzed studies.

Teaching Points

? Undernutrition risk and undernutrition prevalence are high among pulmonology inpatients.

? The heterogeneity between the analyzed studies reveals that there is no standard pattern in the choice of methods for nutritional status assessment in these patients.

? Timely screening and identification of undernutrition is of the utmost relevance in earlier nutritional interventions and implementation of nutritional support.

? The assessment of undernutrition must always be preceded by nutritional screening, in accordance with guidelines, which did not occur in some of the analyzed studies.     

应用营养风险筛查2002方法对天津市三级甲等医院住院患者营养风险、营养不足筛查、营养支持情况调查

目的调查天津三级甲等医院部分科室住院患者营养风险筛查（NRS）2002方法适用率、营养风险发生率以及接受营养支持的情况,为合理应用肠外肠内营养提供依据。方法2005年3月至2006年3月对天津南开医院及天津胸科医院6个科室住院患者采用连续定点抽样调查,应用NRS2002方法进行营养风险筛查,并调查营养支持情况。结果共完成1200例住院患者的营养筛查,NRS2002方法在1200例住院患者的营养筛查适用率为93．0％,总的营养不足和营养风险发生率分别为9．8％和42．8％。有营养风险者接受营养支持为241例（46．4％）,无营养风险者接受营养支持为244（35．9％）。结论NRS2002方法对住院患者营养风险筛查有较高的适用率。住院患者存在一定的营养风险或营养不足,不同地区、不同医院的各科室医生对于营养风险、营养不足了解和关注存在着一定的差距,临床可能存在着营养支持某些不合理性。     

Minimising undernutrition in the older inpatient

Background Malnutrition among elderly hospitalised patients is widespread and has been shown to lead to adverse health outcomes. The effectiveness of interventions to minimise undernutrition in elderly inpatients is not well documented. Objectives To identify the best available practices, in the hospital setting, that minimise undernutrition or the risk of undernutrition, in the acute care patient especially for the older patient. The review will assesses the effectiveness of a range of interventions designed to promote adequate nutritional intake in the acute care setting, with the aim of determining what practices minimise malnutrition in the elderly inpatients. Search strategy English language articles from 1980 onwards were sought using Medline, Premedline, Cinahl, Austrom-Australasian Medical Index and AustHealth, Embase and Science Citations Index. Selection criteria For inclusion the study had to include an intervention aiming to minimise undernutrition in hospitalised elderly patients aged 65?years or older. All study designs were included. Data collection and analysis Two independent reviewers assessed the eligibility of each study for inclusion into the review, critically appraised the study quality and extracted data using standardised tools. For each outcome measure results were tabulated by intervention type and discussed in a narrative summary. Results from randomised controlled trials were pooled in meta-analyses where appropriate. Main results Twenty-nine studies met the inclusion criteria, with a total of 4021 participants. The focus of 15 interventions was the supplying of oral supplements to the participants, six focused on enteral nutrition therapy, four interventions made changes to the foods provided as part of the hospital diet, one included the services of an additional staff member and three incorporated the implementation of evidence-based guidelines. Ten meta-analyses were conducted from which the main findings were: significant improvements in weight status and arm muscle circumferences with an oral supplement intervention, P?相似文献   

Nutrition guidance in The Netherlands: the role of the GP in the translation from population strategy to individual approach

An important pitfall of nutritional guidance in medical practice is how to deal with the prevention paradox: a nutritional advice that is good for the population as a whole is not necessarily proven effective for the individual patient. Evidence-based guidelines are needed to support GPs to translate these advices to the individual patient. We illustrate this with two examples: obesity and undernutrition. The Dutch Ministry of Health started a national partnership on overweight. The role of the Dutch College of GPs (NHG) in this process is to insert the GP's perspective and to 'translate' the multidisciplinary guideline into a practice guideline for GPs. A systematic review on nutritional deficiency in general practice in The Netherlands showed a prevalence ranging from 0% to 13%. The 'National Steering Committee Undernutrition' stimulates GPs to pay more attention to undernutrition, in collaboration with the Dutch College of GPs. The Cochrane Primary Health Care Field (Nijmegen) accommodates the Cochrane Diet and Nutrition Sub Field involving the inclusion of evidence from non-randomized studies, which are generally not included in Cochrane Reviews, but which form an important part of the evidence for the role of nutrition. From this international initiative, a national collaboration in The Netherlands between universities, researchers and the Dutch College was founded, which aims to support the foundation of practice-based nutrition counselling in the consulting room.     

Nutritional concerns in American Indian and Alaska Native children: transitions and future directions

The nutritional health of American Indian and Alaska Native children has changed dramatically over the past 30 years. The prevention and treatment of malnutrition (primarily undernutrition) was a major health issue until the mid to late 1970s. Now, a generation later, obesity in American Indian and Alaska Native children is a major health threat. In 1969, the National Institutes of Health sponsored a conference to review the nutritional status of North American Indian children and to set a national agenda to improve the nutritional health of Indian children. Subsequently, increased food availability; food assistance programs; and improved sanitation, transportation, and health care have eliminated undernutrition as a major health issue. However, the substantial reduction in undernutrition has been accompanied by a rapid increase in childhood obesity. The current epidemic of child and adult obesity and associated obesity-related morbidities, such as type 2 diabetes mellitus and other chronic diseases, has implications for the immediate and long-term health of young American Indians. This article reviews the current nutritional health of American Indian and Alaska Native children, the changes that have occurred the past 30 years, and the nutrition transition to increasing obesity and subsequent diabetes that is being seen in American Indians. Future directions to improve the health of American Indian and Alaska Native children are discussed, as is the urgent need for obesity prevention programs that are culturally oriented, family centered, and community- and school-based and that target healthful eating and physical activity beginning in childhood.     

北京某二甲医院非终末期晚期肿瘤患者营养风险、营养不足及营养支持情况前瞻性描述性研究

目的 前瞻性调查北京某二甲医院肿瘤内科非终末期晚期住院患者的营养风险、营养不足发生情况及营养支持应用现状,为今后营养支持改善临床结局研究奠定基础.方法 采用连续抽样方法对2011年10月至2013年4月北京某二甲医院肿瘤内科入院患者展开调查.对符合入选标准的患者,于入院次日采用营养风险筛查2002 （NRS2002）进行营养风险筛查和营养不足评估,并记录患者住院期间的营养支持情况.对没有营养风险患者每周重复筛查.出院后根据患者的临床及病理资料,将其分为早、中期（Ⅰ、Ⅱ、Ⅲa期）、非终末期晚期（Ⅲb、Ⅳ期）及终末期（预计生存期短于3个月）3组.本研究仅对非终末期晚期肿瘤患者的营养风险、营养不足发生率及营养支持应用情况进行统计学分析,所有数据进入EDC系统并经核查无误.结果 调查期间人院患者305例,排除不符合标准的患者后,共224例患者接受了营养风险筛查.其中,对非终末期晚期患者171例进行统计分析,结果营养风险发生率为67.8％ （116/171）,不同肿瘤类型患者营养风险发生率依次为肺癌45.7％ （21/46）,消化道肿瘤89.4％ （42/47）,肝、胆、胰腺肿瘤81.3％ （26/32）,头颈部肿瘤83.3％ （5/6）.以体质量指数（BMI） ＜18.5 kg/m2计算营养不足发生率为12.3％ （21/171）;以NRS2002营养受损部分评分达到3分汁算营养不足的发生率为19.9％ （34/171）.有营养风险的116例患者中,71例接受了营养支持,占61.2％;肠外与肠内营养的应用例数比为68∶3 （23∶1）;能量摄入为（56.78±8.20） kJ/（kg·d）,氮摄入为（0.06±0.01） g/（kg·d）.55例无营养风险患者中,5例接受了营养支持（9.1％）.结论 非终末期晚期肿瘤患者营养风险、营养不足的发生率较高,且与肿瘤类型相关.非终末期晚期肿瘤患者的营养支持亦存在不合理之处,以有营养风险患者的营养支持率偏低为主.对于有营养风险的患者,营养支持能否改善其临床结局,是今后需要进行研究的课题.     

The aetiology and impact of malnutrition in paediatric inflammatory bowel disease

Disease‐associated undernutrition of all types is very common in paediatric inflammatory bowel disease (IBD). Recent weight loss remains one of the triad of clinical manifestations and a cornerstone for the diagnosis of Crohn’s disease (CD), although significantly fewer patients now present as being underweight. Recent evidence suggests that the introduction of medical treatment will quickly restore body weight, although this does not reflect concomitant changes in body composition. CD children present with features of nutritional cachexia with normal fat stores but depleted lean mass. Poor bone health, delayed puberty and growth failure are additional features that further complicate clinical management. Suboptimal nutritional intake is a main determinant of undernutrition, although activation of the immune system and secretion of pro‐inflammatory cytokines exert additional independent effects. Biochemically low concentrations of plasma micronutrients are commonly reported in IBD patients, although their interpretation is difficult in the presence of an acute phase response and other indices of body stores adequacy are needed. Anaemia is a common extraintestinal manifestation of the IBD child. Iron‐deficient anaemia is the predominant type, with anaemia of chronic disease second. Decreased dietary intake, as a result of decreased appetite and food aversion, is the major cause of undernutrition in paediatric IBD. Altered energy and nutrient requirements, malabsorption and increased gastrointestinal losses are additional factors, although their contribution to undernutrition in paediatric CD needs to be studied further.     

Micronutrient needs of malnourished children

PURPOSE OF REVIEW: In addition to overt manifestations of undernutrition such as stunting, wasting and underweight, micronutrient deficiencies are also recognized as important components of the spectrum of malnutrition. This review focuses on recent advances in our understanding of undernutrition and micronutrient deficiencies during childhood from a review of the literature over the last 18 months (August 2006-January 2008). RECENT FINDINGS: There is considerable advance in our understanding of the epidemiology and burden of childhood undernutrition and micronutrient deficiencies. Based on recent surveys, an estimated 32% (178 million) of children under 5 years of age were stunted. The corresponding global estimate of wasting is 10% (55 million children), of which 3.5% (19 million children) are severely wasted. It is estimated that nearly 11% of all children under 5 years of age, die due to four micronutrient deficiencies (vitamin A, zinc, iron and iodine). There is evidence from recent reviews of evidence-based interventions that administering single or multiple micronutrients can make a significant difference to health outcomes. However, delivery strategies may differ and recent data suggest that fortification may be a more efficient strategy to deliver multiple micronutrients. SUMMARY: These findings support the scaling up of evidence-based interventions to prevent and treat such deficiencies and to integrate these within health systems.     

山东地区部分医院住院患者营养风险筛查和营养支持应用状况

目的 调查山东省部分地区不同规模医院住院患者营养风险、营养不良（不足）发生率及营养支持应用状况及相关并发症发生率.方法 以山东地区部分大、中、小医院2792例新住院患者为研究对象,进行营养风险筛查2002（NRS 2002）,记录患者营养支持应用情况、住院时间、感染性及非感染性并发症发生率.以NRS 2002≥3分为有营养风险,体重指数＜18.5 kg/m^2并结合患者临床情况判定为营养不足.结果 大、中、小医院新住院患者营养不足发生率分别为5.6%、1.6%、2.7%,差异有统计学意义（P=0.000）;营养风险发生率分别为27.3%、15.4%、18.3%,差异有统计学意义（P=0.000）;存在营养风险患者营养支持的应用率分别为51.5%、30.8%、20.9%,差异有统计学意义（P=0.000）;营养支持以肠外营养应用最多,大、中、小医院分别为72.9%、95.1%、100%,差异有统计学意义（P=0.000）.大医院483例新人院患者中无营养风险者并发症的发生率明显低于有营养风险的患者（P=0.000）;在有营养风险的患者中,接受营养支持患者的感染性并发症发生率明显低于无营养支持者（P=0.043）;在无营养风险的患者中,接受营养支持患者与无营养支持患者之间总并发症发生率差异无统计学意义（P＞0.05）.结论 采用NRS 2002对我国住院患者进行营养风险筛查是可行的,营养支持可以减少有营养风险患者并发症的发生.     

Maternal Underweight and Its Association with Composite Index of Anthropometric Failure among Children under Two Years of Age with Diarrhea in Bangladesh

Malnutrition in women has been a long-standing public health concern, with serious effects on child survival and development. Maternal body mass index (BMI) is an important maternal nutritional indicator. There are few published studies although child anthropometric failures do not occur in isolation and identifying children with single versus several co-occurring failures can better capture cases of growth failure in combination: stunting, wasting, and underweight. In the context of multiple anthropometric failures, traditional markers used to assess children’s nutritional status tend to underestimate overall undernutrition. Using the composite index of anthropometric failure (CIAF), we aimed to assess the association between maternal undernutrition and child undernutrition among children with diarrhea under the age of two and to investigate the correlates. Using 1431 mother-child dyads from the Antibiotic for Children with Diarrhea (ABCD) trial, we extracted children’s data at enrollment and on day 90 and day 180 follow-ups. ABCD was a randomized, multi-country, multi-site, double-blind, placebo-controlled clinical trial. The Bangladesh site collected data from July 2017 to July 2019. The outcome variable, CIAF, allows combinations of height-for-age, height-for-weight, and weight-for-age to determine the overall prevalence of undernutrition. The generalized estimating equation was used to explore the correlates of CIAF. After adjusting all the potential covariates, maternal undernutrition status was found to be strongly associated with child undernutrition using the CIAF [aOR: 1.4 (95% CI: 1.0, 1.9), p-value = 0.043] among the children with diarrhea under 2 years old. Maternal higher education had a protective effect on CIAF [aOR: 0.7 (95% CI: 0.5, 0.9), p-value = 0.033]. Our study findings highlight the importance of an integrated approach focusing on maternal nutrition and maternal education could affect a reduction in child undernutrition based on CIAF.     

Practices in relation to nutritional care and support--report from the Council of Europe

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 to issue recommendations in improve the nutritional care and support of hospitalised patients. The data collection regarding the nutritional care providers and their practices of nutritional care and support showed that the use of nutritional risk screening and assessment, and of nutritional support and counselling was sparse and inconsistent, and that the responsibilities in these contexts were unclear. Besides, the educational level with regard to nutritional care and support was limited at all levels. All patients have the right to expect that their nutritional needs will be fulfilled during a hospitalisation. Optimal supply of food is a prerequisite for an optimal effect of the specific treatment offered to patients. Hence, the responsibilities of staff categories and the hospital management with respect to procuring nutritional care and support should be clearly assigned. Also, a general improvement in the educational level of all staff groups is needed.     

吉林省五家中小医院胃肠病住院患者营养风险和营养不足发生率及营养支持状况

目的调查吉林省3个地区5家中小医院胃癌、结直肠癌（病组I）及胃肠溃疡、肠梗阻、克罗恩病（病组1／）两病组住院患者营养风险和营养不足发生率及营养支持状况。方法采用连续抽样方法选取吉林省长春地区、松原地区、白城地区等5家中小医院2010年5月至2013年3月普外科住院患者4330例,排除年龄〈18岁或〉80岁、住院时间不足24h或次日8时前手术、神志不清、拒绝参加本研究、不符合预定诊断的、符合预定诊断且未手术的病例后,筛选出诊断为胃结直肠癌、胃溃疡、肠梗阻、克罗恩病等患者687例,其中病组Ⅰ140例、病组Ⅱ547例,被纳入的患者入院后24h内利用营养风险筛查2002进行营养风险筛查,调查营养不足发生率并记录住院期间营养支持应用情况。结果两病组存在营养风险的患者为167例,营养风险发生率为24．3％;两病组存在营养风险的患者接受营养支持的占73．7％,未接受营养支持的占26．3％;无营养风险的患者为520例,接受营养支持的占8．8％,未接受营养支持的占91．2％。病组Ⅰ患者营养风险发生率占64．3％,病组Ⅱ营养风险发生率占14．1％,两组比较差异具有统计学意义（P=0．000）。687例患者中以体重指数〈18．5kg／m^2计算营养不足发生率为3．2％,而以营养状况评分≥3分计算营养不足发生率为8．3％,两组比较差异具有统计学意义（P=0．000）。结论5家中小医院符合纳人标准的患者营养风险总发生率为24．3％,营养不足的发生率为3．2％-8．3％,低于大医院的营养不足发生率。5家中小医院均应用肠外营养支持,尚未应用肠内营养和肠内肠外联合营养支持。     

Nutritional support in oncologic patients: where we are and where we are going

The use of nutritional support in cancer patients has evolved since its introduction in the clinical practice 40 years ago. Both parenteral and enteral nutrition are now increasingly integrated within the main oncologic strategy with the aim of making surgery, chemotherapy and radiation therapy more safe and effective. This requires a better awareness of the inherent risk of starvation and undernutrition by the surgeons, medical oncologists and radiologists, the ability to implement a policy of nutritional screening of cancer patients and to propose them the nutritional support in a single bundle together with the oncologic drugs. Four different areas of nutritional intervention are now recognized which parallel the evolutionary trajectory of patients with tumour: the perioperative nutrition in surgical patients, the permissive nutrition in patients receiving chemotherapy and/or radiation therapy and the home parenteral nutrition which may be total (in aphagic-obstructed-incurable patients) or supplemental (in advanced weight-losing anorectic patients). Since cancer is a common disease and the continuous progress in medical therapy is changing its natural history, with more and more patients entering in a chronic and finally incurable phase where nutrition is determinant for survival, we can expect an increased demand for nutritional support in the next future.