Malnutrition and Clinical Outcomes: The Case for Medical Nutrition Therapy

Malnutrition is not a new or a rare problem. In studies involving more than 1,327 hospitalized adult patients, 40% to 55% were found to be either malnourished or at risk for malnutrition, and up to 12% were severely malnourished. Surgical patients with likelihood of malnutrition are two to three times more likely to have minor and major complications as well as increased mortality; and their length of stay can be extended by 90% compared with the stay of well-nourished patients. Hospital charges are reported to be from 35% to 75% higher for malnourished patients than for well-nourished patients. Obtaining data to assess the nutritional status of patients is essential to optimal patient care, especially for patients at high risk for malnutrition. Nutrition assessment can be done with readily available and relatively inexpensive methods. But it is not enough to assess and identify malnutrition. Outcomes are improved and costs are saved only when appropriate intervention follows. This article identifies many well-conducted, published studies that support the findings that health outcomes of malnourished patients can be improved and that overall use of resources can be reduced by nutrition counseling, oral diet and oral supplements, enteral formula delivered via tube, and parenteral nutrition support via central or peripheral line. Early nutrition assessment and appropriate nutrition intervention must be accepted as essential for the delivery of quality health care. Appropriately selected nutrition support can address the problem of malnutrition, improve clinical outcomes, and help reduce the costs of health care. J Am Diet Assoc. 1996; 96:361-366,369.     

Nutritional status on admission and hospital mortality of under-five year old children with infectious diseases in Ouagadougou,Burkina Faso

BACKGROUND: It is known that malnutrition in childhood interacting with infectious diseases contributes to increase mortality. In Burkina Faso, infectious pathologies and malnutrition are public health problems. We examined the impact of malnutrition status, using the Weight-for-age (WA) index, on mortality of children hospitalized for infectious diseases. METHODS: This retrospective study uses a systematic sample derived from the year 1999 hospital register. In total data of 1573 children from 0 to 59 months were analyzed. The association between mortality and dependent variables was measured by relative risks (RR) in univariate analysis. A logistic regression was realized and attributable risk percent (etiologic fraction among exposed) of death was calculated. RESULTS: The total intra-hospital lethality amounted to 15.3%. Age, diagnosis, type of care recourse and malnutrition (low WA index) on admission were associated to mortality. The logistic regression model confirmed the high risks of deaths for young children (0-11m), children in malnutrition (low WA index) and those with severe malaria. The attributable risk percent of death indicates that, 87% of deaths are statically attributable to severe malnutrition (WA Z-score<=-3) and 64.3% of deaths are statically attributable to moderate malnutrition (WA Z-score]-3, -2]). CONCLUSION: Nutritional status evaluation would allow to select children at risk and reduce mortality by including nutritional intervention in standard treatment of children hospitalized for infectious diseases.     

Stratégies de dépistage de la dénutrition chez l''enfant hospitalisé

Metabolic stress modifies homeostasis, therefore nutrient's metabolism and nutritional needs. Stress is a risk factor of malnutrition, which increases morbidity and short-term mortality, and, in the child, can threaten long-term growth. Nutritional assessment is difficult in critically ill children. Nutritional support must be undertaken early as possible, especially in malnourished children and with severe agression. Enteral nutrition must be privileged. Parenteral nutrition is indicated when enteral nutrition is impossible, badly supported or insufficient to satisfy needs. Monitoring must be rigorous because aggression increases the risk of metabolic complications.     

The impact of HIV on mortality during in-patient rehabilitation of severely malnourished children in Malawi

A prospective cohort study measured mortality during nutritional rehabilitation among HIV-infected and uninfected children, aged 6-59 months, with severe acute malnutrition (SAM). Children were tested for HIV and CD4% on admission to the nutrition rehabilitation unit (NRU). Mortality was assessed by following children to 4 months post discharge from the NRU or death if earlier. Overall mortality was 14.8% (67/454) and HIV prevalence was 17.4% (79/454). HIV-infected children were significantly more likely to die than uninfected children [35.4% (28/79) vs. 10.4% (39/375), P<0.001], and 85.7% of deaths occurred in children with a CD4% less than 20. Forty percent (18/45) of HIV-infected children with a CD4% <20 died, in contrast to 15% (3/20) of HIV-infected children with a CD4% >20 (P=0.05). Routine testing and treatment for HIV among all malnourished children is necessary to improve quality of care and reduce mortality among children with SAM.     

The impact of malnutrition on morbidity,mortality, length of hospital stay and costs evaluated through a multivariate model analysis

Malnutrition has been identified as affecting patient outcome. The purpose of this study was to correlate the nutritional status of hospitalized patients with their morbidity, mortality, length of hospital stay and costs. The patients were nutritionally assessed within the first 72 h of hospital admission. The patients' charts were surveyed on the incidence of complications and mortality. Hospital costs were calculated based on economic tables used by insurance companies. Multivariate logistic regression analysis and the Cox regression model were used to identify possible confounding factors. A P<0.05 was considered statistically significant. The mean age was 50.6+/-17.3 years with 50.2% being male. The incidence of complications in the malnourished was 27.0% [Relative risk (RR)=1.60]. Mortality in the malnourished patients was 12.4% vs 4.7% in the well nourished (RR = 2.63). Malnourished patients stayed in the hospital for 16.7+/-24.5 days vs 10.1+/-11.7 days in the nourished. Hospital costs in malnourished patients were increased up to 308.9%. It was concluded that malnutrition, as analyzed by a multivariate logistic regression model, is an independent risk factor impacting on higher complications and increased mortality, length of hospital stay and costs.     

住院肝病病儿的营养风险筛查

目的 :营养不良是导致儿童肝病发病率和死亡率的主要因素。我们调查了肝病住院儿童营养不良和高营养风险的患病率以及住院营养支持率。方法 :选择在我院小儿肝病科住院治疗的共2 874例1~17岁肝病病儿为研究对象,用Z评分法(年龄别身高、身高别体重、年龄别体重Z评分)评价病儿的营养状况。采用STRONGkids营养筛查工具进行营养风险评分,分析不同营养风险评分对血液中的营养指标、营养支持率、住院时间的影响。结果 :总体营养不良发生率38.6%,近20.0%的病儿存在高度营养风险。高营养风险组与中营养风险组相比,营养不良的患病率明显增高(67.9%vs 31.3%)、血清白蛋白和前白蛋白在两组之间亦存在显著性差异(P0.001)。只有8.9%的高度营养风险病儿和3.5%的中度营养风险病儿在住院期间获得了营养支持。高营养风险病儿住院时间更长、住院费用更高(P0.001)。结论:肝病病儿营养不良率高,病儿在入院时即存在高营养风险。白蛋白和前白蛋白是区分不同营养风险的敏感指标。高度营养风险可致住院时间的延长和治疗费用的增加。肝病病儿的营养支持率仍偏低,临床营养治疗有待规范。     

Malnutrition as an underlying cause of childhood deaths associated with infectious diseases in developing countries

INTRODUCTION: Recent estimates suggest that malnutrition (measured as poor anthropometric status) is associated with about 50% of all deaths among children. Although the association between malnutrition and all-cause mortality is well documented, the malnutrition-related risk of death associated with specific diseases is less well described. We reviewed published literature to examine the evidence for a relation between malnutrition and child mortality from diarrhoea, acute respiratory illness, malaria and measles, conditions that account for over 50% of deaths in children worldwide. METHODS: MEDLINE was searched for suitable review articles and original reports of community-based and hospital-based studies. Findings from cohort studies and case-control studies were reviewed and summarized. RESULTS: The strongest and most consistent relation between malnutrition and an increased risk of death was observed for diarrhoea and acute respiratory infection. The evidence, although limited, also suggests a potentially increased risk for death from malaria. A less consistent association was observed between nutritional status and death from measles. Although some hospital-based studies and case-control studies reported an increased risk of mortality from measles, few community-based studies reported any association. DISCUSSION: The risk of malnutrition-related mortality seems to vary for different diseases. These findings have important implications for the evaluation of nutritional intervention programmes and child survival programmes being implemented in settings with different disease profiles.     

Critical Role of Nutrition in Improving Quality of Care

The current era of healthcare delivery, with its focus on providing high‐quality, affordable care, presents many challenges to hospital‐based health professionals. The prevention and treatment of hospital malnutrition offer a tremendous opportunity to optimize the overall quality of patient care, improve clinical outcomes, and reduce costs. Unfortunately, malnutrition continues to go unrecognized and untreated in many hospitalized patients. This article represents a call to action from the interdisciplinary Alliance to Advance Patient Nutrition to highlight the critical role of nutrition intervention in clinical care and to suggest practical ways to promptly diagnose and treat malnourished patients and those at risk for malnutrition. We underscore the importance of an interdisciplinary approach to addressing malnutrition both in the hospital and in the acute posthospital phase. It is well recognized that malnutrition is associated with adverse clinical outcomes. Although data vary across studies, available evidence shows that early nutrition intervention can reduce complication rates, length of hospital stay, readmission rates, mortality, and cost of care. The key is to systematically identify patients who are malnourished or at risk and to promptly intervene. We present a novel care model to drive improvement, emphasizing the following 6 principles: (1) create an institutional culture where all stakeholders value nutrition, (2) redefine clinicians’ roles to include nutrition care, (3) recognize and diagnose all malnourished patients and those at risk, (4) rapidly implement comprehensive nutrition interventions and continued monitoring, (5) communicate nutrition care plans, and (6) develop a comprehensive discharge nutrition care and education plan.     

Population-specific Mini Nutritional Assessment effectively predicts the nutritional state and follow-up mortality of institutionalized elderly Taiwanese regardless of cognitive status

The study was conducted to determine the effectiveness of a modified Mini Nutritional Assessment (MNA) for assessing the nutritional status and predicting follow-up mortality of institutionalized elderly Taiwanese. The study was conducted in a large long-term care centre in central Taiwan. Trained interviewers assisted by the caregivers elicited sociodemographic data, healthcare and disease history, and answers to the MNA screen from each subject. One researcher performed all subjects' anthropometric measurements. Plasma albumin and cholesterol concentrations were determined. Results showed that the MNA without BMI, modified according to population-specific mid-arm circumference and calf circumference cut-points, effectively predicted the nutritional risk status of the elderly regardless of cognitive status. Substituting caregiver's assessments for self-viewed nutrition and health status (questions O and P of MNA) improved the predicting power of the tool in cognition-normal subjects. Results showed that 21.9% of the elderly were malnourished, 59.2% were at risk of malnutrition and 18.9% were normal according to self-assessment whereas 14.2% were malnourished, 59.2% were at risk of malnutrition, and 26.6% were normal according to caregiver's evaluation. The tool was also effective in predicting 12- and 6-month follow-up mortality in cognition-normal and cognition-impaired elderly, respectively. Results indicate that a population-specific MNA can effectively predict the nutritional status and 6-month follow-up mortality of elderly Taiwanese regardless of cognitive condition. Easier and wider application of the tool will enable early detection of emerging nutritional problems and timely intervention to prevent the development of severe malnutrition in the elderly.     

Risk factors for acute respiratory infections in underfives in a rural community

The risk factors for acute respiratory infection (ARI) were investigated in a 6-month study of 366 children under 5 years of age from a rural zone of Delhi, India. Home visits were made to each child enrolled in the study every 2 weeks. 242 children (65.9%) had adequate nutritional status, 95 (26%) had mild malnutrition, and 30 (8.1%) had moderate to severe malnutrition. The annual ARI incidence was 3.27 episodes per child in the moderate to severely malnourished children, 2.82 episodes in mildly malnourished children, and 2.26 episodes in adequately nourished children. Lower respiratory infection was more affected by adverse nutritional status than upper respiratory infection. ARI incidence was also significantly lower among children living in well-ventilated homes (1.79 episodes/child/year) than those living in poorly ventilated homes (2.87 episodes/child/year). Since none of the mothers smoked and adequate breast feeding was practiced by 95% of mothers, the influence of these two risk factors on ARI was not relevant in this study.     

Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition

The current era of health care delivery, with its focus on providing high-quality, affordable care, presents many challenges to hospital-based health professionals. The prevention and treatment of hospital malnutrition offers a tremendous opportunity to optimize the overall quality of patient care, improve clinical outcomes, and reduce costs. Unfortunately, malnutrition continues to go unrecognized and untreated in many hospitalized patients. This article represents a call to action from the interdisciplinary Alliance to Advance Patient Nutrition to highlight the critical role of nutrition intervention in clinical care and to suggest practical ways to promptly diagnose and treat malnourished patients and those at risk for malnutrition. We underscore the importance of an interdisciplinary approach to addressing malnutrition both in the hospital and in the acute post-hospital phase. It is well recognized that malnutrition is associated with adverse clinical outcomes. Although data vary across studies, available evidence shows that early nutrition intervention can reduce complication rates, length of hospital stay, readmission rates, mortality, and cost of care. The key is to systematically identify patients who are malnourished or at risk and to promptly intervene. We present a novel care model to drive improvement, emphasizing the following six principles: (1) create an institutional culture where all stakeholders value nutrition; (2) redefine clinicians' roles to include nutrition care; (3) recognize and diagnose all malnourished patients and those at risk; (4) rapidly implement comprehensive nutrition interventions and continued monitoring; (5) communicate nutrition care plans; and (6) develop a comprehensive discharge nutrition care and education plan.     

GLIM-Defined Malnutrition in Patients with Head and Neck Cancer during the Qualification Visit for Home Enteral Nutrition

Patients with head and neck cancer (HNC) present multiple symptoms that increase the risk of malnutrition. Nutritional care, including enteral nutrition (EN), plays a crucial role in the management of this group of patients. The aim of the study was to determine the Global Leadership Initiative on Malnutrition (GLIM)-based stages of malnutrition and the relationship with selected biochemical parameters during the home enteral nutrition (HEN) qualification visit of patients with HNC. The retrospective analysis involved 224 patients with HNC referred for HEN. The following parameters were evaluated: body mass index (BMI), percent weight loss, and laboratory tests (serum albumin, total serum protein, C-reactive protein (CRP), and total lymphocyte count (TLC)). Malnutrition was defined using GLIM-based criteria. The prevalence of malnutrition based on GLIM criteria was 93.75% (15.18% moderately malnourished, 78.57% severely malnourished). There was a positive correlation between malnutrition based on GLIM criteria, serum albumin, and CRP. In the model assessing the odds of severe malnutrition according to the criteria of GLIM, TLC and CRP had a statistically significant effect on the chance in the probability of qualifying a patient to the severe malnutrition group, but the strength of the results was weak. The prevalence of malnutrition in HNC patients enrolled to HEN is high and most of them are severely malnourished. This suggests that it is important to identify more efficiently patients with risk of malnutrition at an earlier stage. GLIM criteria for malnutrition can be easily applied in this group of patients, but the definition of inflammation criteria should be clarified.     

The New European Society for Clinical Nutrition and Metabolism Definition of Malnutrition: Application for Nutrition Assessment and Prediction of Morbimortality in an Emergency Service

Background : Recently, the European Society for Clinical Nutrition and Metabolism (ESPEN) provided novel consensus criteria for malnutrition diagnosis. This study aimed to evaluate the applicability of this instrument in combination with different nutrition screening tools (1) to identify malnutrition and (2) to predict morbidity and mortality in hospitalized patients. Materials and Methods : Observational prospective study in 750 adults admitted to the emergency service of a tertiary public hospital. Subjective Global Assessment (SGA—reference method) and the new ESPEN criteria were used to assess nutrition status of patients, who were initially screened for nutrition risk using 4 different tools. Outcome measures included length of hospital stay, occurrence of infection, and incidence of death during hospitalization, analyzed by logistic regression. Results : There was a lack of agreement between the SGA and ESPEN definition of malnutrition, regardless of the nutrition screening tool applied previously (κ = ?0.050 to 0.09). However, when Malnutrition Screening Tool and Nutritional Risk Screening–2002 (NRS‐2002) were used as the screening tool, malnourished patients according to ESPEN criteria showed higher probability of infection (relative risk [RR], 1.54; 95% confidence interval [CI], 1.02–2.31 and RR, 2.06; 95% CI, 1.37–3.10, respectively), and when the NRS‐2002 was used, the risk for death was 2.7 times higher (hazard ratio, 2.69; 95% CI, 1.07–6.81) in malnourished patients than in well‐nourished patients. Conclusion : Although the new ESPEN criteria had a poor diagnostic value, it seems to be a prognostic tool among hospitalized patients, especially when used in combination with the NRS‐2002.     

Follow-up of children with moderate or severe malnutrition in the peripheral population (Brazil)]

What happens to children who develop moderate or severe malnutrition? What is done for them? Keeping in mind these questions, the present research was undertaken with the following objectives: to assess the nutritional status of children who develop moderate or severe malnutrition before the age of 5 years, after a period from 2 to 4 years after diagnosis; to assess the nutritional status of the under 5-year old siblings of these children; to study the influence of nutritional programs available in the community for the improvement of the nutritional status of the malnourished children; and to identify factors interfering with nutrition of these children during the study period. After a period of 2 to 4 years from the time of diagnosis of moderate or severe malnutrition the authors tried to locate the families of 61 malnourished children of Porto Alegre, RS (Brazil). The mothers their substitutes were interviewed and the children and siblings under 5 years of age were weighed and measured. Thirty-nine children were located. Of these, 4 (10%) died and 22 (56%) presented an increase of at least 10% in weight for age. Of the 35 children who survived, 29 (82%) still presented some degree of malnutrition (weight/age < or = 90% of the standard), 25 (71%) were stunted (height/age < or = 95%), and 5 (14%) were wasted (weight/height < or = 90%). The nutritional status of the 5-year old siblings was similar to that of the malnourished children.(ABSTRACT TRUNCATED AT 250 WORDS)     

Malnutrition Identified by the Nutritional Risk Index and Poor Prognosis in Advanced Epithelial Ovarian Carcinoma

Ovarian cancer is a chronic disease with a risk of malnutrition. Nutritional Risk Index (NRI) has been reported as a simple and accurate tool to assess the nutritional status. We sought to explore the prevalence of malnutrition and its association with survival in ovarian cancer. A retrospective study was conducted in 213 advanced ovarian cancer patients. NRI was calculated before and at the end of treatment using patients’ body weight and serum albumin level. Overall survival (OS) and progression-free survival (PFS) were estimated by Kaplan-Meier method, and associations were assessed using a Cox proportional hazards analysis adjusted for known prognostic variables. Moderate to severely malnourished patients had lower 5-yr OS (45.3%) compared to normal to mild group (64.0%), respectively (P?=?0.024). Adjusted for covariates, the relative risk of death was 5.8 times higher in moderate/severely malnourished group identified at the last course of chemotherapy (HR?=?5.896, 95% CI?=?2.723-12.764, P?P?=?0.011). Malnutrition is prevalent among ovarian cancer patients and is found to be a significant predictor for mortality.     

The facilitated early enteral and dietary management effectiveness trial in hospitalized patients with malnutrition

Background: The prevalence of malnutrition in the hospitalized setting is 30% to 55%. Previous studies reported an association of malnutrition with an increased hospital length of stay (LOS), morbidity, and mortality of patients. This study evaluated the role of early nutrition intervention on LOS, diagnosis coding of malnutrition cases, calculating case mix index, and reducing delays in implementing nutrition support to patients. Methods: Demographic data, anthropometric measurements, LOS, and serum albumin levels were collected from 400 patients in 2 medical wards to determine the prevalence of malnutrition and potential delays in nutrition consultation. Based on these results, a nutrition intervention study was conducted in 1 ward; the other ward served as a control. Patients were classified as normally nourished or malnourished. Multivariate general linear regressions were used to reveal the impact of intervention on the change in LOS, controlling for other potential confounding factors on the cohort and a subset with severe malnutrition. Results: Of the 400 patients assessed, 53% had malnutrition. Multiple general linear regressions showed that nutrition intervention reduced LOS an average of 1.93 days in the cohort group and 3.2 days in the severe malnourished group. Case mix index and female gender were positively associated with LOS in the malnourished group. Nutrition intervention reduced the delays in implementing nutrition support to patients by 47%. Conclusions: Results highlight the positive impact of nutrition intervention in terms of reduced LOS in malnourished hospital patients. Reduction in LOS with diagnosis coding of malnutrition cases yielded substantial economic benefits.     

相位角预测手术病人营养风险及住院时间

目的:探讨生物电阻抗相位角(phase angle,PA)与胸外手术病人营养风险、住院时间(hospital length of stay,LOS)的关系。方法:60例胸部手术病人,应用营养风险筛查2002(NRS2002)、主观全面评定(Subjective Global Assessment,SGA)、白蛋白、人体成分分析、PA评价其营养风险及LOS。结果 :与对照组比较,手术病人PA偏低,男(6.0±1.0)vs(3.85±1.0),女(5.4±0.9)vs(4.9±0.6),P0.01。与正常PA比较,低PA者营养风险相对危险度,用NRS2002。无风险(RR 2.8,95%CI=1.2~6.9),中度风险(RR 3.9,95%CI=1.8~8.6),重度风险(RR4.2,95%CI=2.0~8.7);用SGA。营养良好(RR 2.5,95%CI=0.9~6.9),中度营养不良(RR 4.4,95%CI=2.1~9.4),重度营养不良(RR 3.9,95%CI=1.9~8.0),与NRS2002相似;与正常PA比较,低PA者住院时间倾向于延长(LOS≥21 d,RR=4.4,95%CI=2.2~8.8)。结论 :低PA与手术病人营养风险、LOS延长密切关联。PA测量有助于快速明确病人的营养风险对于确定病人营养干预和判断疾病转归提供了客观依据。     

Infections associated with severe malnutrition among hospitalised children in East Africa

Severe protein-energy malnutrition (PEM) predisposes affected children to various infections, which either worsens their nutritional status or causes malnutrition, hence complicating their management and outcome. This study was carried out to determine the infections associated with severe malnutrition among children admitted at Kilifi District Hospital (KDH) in Kenya and Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania. Data was collected from hospital register books and online system database. A total of 1121 children with severe malnutrition were admitted during a period of one year (2004-2005) (MNH = 781; KDH = 340). The proportion of male children with malnutrition was higher than that of female children. Non-oedematous malnutrition was more prevalent at MNH (N = 504; 64%) than KDH (N = 130; 38%). Conversely, oedematous was more prevalence than non-oedematous malnutrition among children admitted at KDH (N = 2 10; 61.7%). More than 75% of all patients with severe PEM were children < 2 years old. Thirty-six per cent of all severe PEM cases had malaria in both hospitals. Forty-five per cent of all admitted patients with severe PEM at KDH had diarrhoea. Two hundred twenty two (28%) and 64 (19%) of the children with severe malnutrition died at MNH and KDH, respectively. Oedematous PEM was associated with a higher case fatality rate than non-oedematous one (P < 0.05). At MNH, 86% of the patients who died with severe malnutrition had other co-morbidities. More (46%) oedematous malnourished patients with co-infections died at MNH than non-oedematous malnourished patients (19%). At KDH, septicaemia was the leading cause of death (55%) among severely malnourished patients. In conclusion, coinfections complicate the management of severe malnutrition and are associated with higher death rate. Management of such infections is of paramount importance to reduce case fatality rates.     

Nutritional status of adults participating in ambulatory rehabilitation

AIMS: To assess the overall nutritional status of older adults participating in ambulatory rehabilitation and determine its association with relevant outcomes including physical function and quality of life. DESIGN: Cross-sectional. SETTING: Ambulatory rehabilitation service in the Southern region of Adelaide, Australia. SUBJECTS: A total of 229 participants recruited as part of a RCT between June 2005 and June 2006, stroke (n=83), elective orthopedic procedure (n=44) and other medical condition (n=102). METHODS: Nutritional status was measured using Mini Nutritional Assessment (MNA), Simplified Nutrition Appetite Questionnaire (SNAQ) and Body Mass Index. Functional performance was assessed using the Modified Barthel Index (MBI) and quality of life was measured using the Short Form-36 (SF-36). RESULTS: Sixty-three percent of participants were malnourished or at risk of malnutrition according to the MNA and a third had a risk of >or= 5% weight loss in the subsequent six months, according to the SNAQ. Participants with a diagnosis other than stroke or elective orthopedic procedure were the most vulnerable, with 53% (n=74/140) classified as at risk of malnutrition or malnourished and a longer length of stay in hospital. Functional performance was no different for participants assessed as at risk of malnutrition or malnourished compared to the well nourished, but the SF-36 mental component score was significantly higher for those who were well nourished (p=0.003). CONCLUSION: Findings emphasise the magnitude of the malnutrition problem in ambulatory rehabilitation settings. Further research is required to evaluate the resource implications against expected benefits of providing nutrition interventions at this point.