Malnutrition is prevalent in hospitalized medical patients: are housestaff identifying the malnourished patient?

OBJECTIVE: Malnutrition is highly prevalent in hospitalized patients and is often not identified by the medical staff. Clinical nutrition and nutritional assessment are often neglected components of the curriculum of medical schools. The effect of instruction of nutritional assessment early in medical school on nutritional practice in clinical training is unknown. Four years after the introduction of nutritional assessment in the medical school curriculum, we assessed the knowledge of medical students and residents of nutritional assessment and the practice of this clinical skill in hospitalized medical patients. METHODS: We determined the nutritional status of 69 patients on a general medical ward within 10 d of their hospital admission. Hospital records were reviewed to determine the documentation of nutrition-related issues and practices. A questionnaire was then administered to the housestaff to determine their knowledge of assessment of nutritional status. RESULTS: Significant malnutrition was found in 69% of patients. Only one patient was identified as being malnourished by the housestaff. References to nutritional status were recorded in two patient charts. History of weight loss, appetite status, current oral intake, and functional status were recorded for fewer than 33% of patients. Although measurements of visceral protein stores (albumin and prealbumin) did not correlate with nutritional status, medical students and residents considered these to be the best markers of nutritional status. CONCLUSIONS: Malnutrition is common in hospitalized patients. Instruction of second-year medical students in assessment of nutritional status does not result in improved knowledge or practice of nutritional assessment in the clinical training years as medical housestaff. Additional instruction in nutritional assessment during clinical training needs to be emphasized. Hospitals need to develop standardized protocols for assessment of nutritional status.     

Implementation of a multidisciplinary nutritional assessment program

Depending on the severity of malnutrition, protein depletion is associated with general debilitation, inanition, slow healing of wounds, delayed convalescence, increased susceptibility to infection, and other pathophysiologic conditions. In an effort to decrease the incidence and severity of these complications, Hermann Hospital and the University of Texas Medical School at Houston have implemented a comprehensive nutritional assessment program to identify clinical and subclinical malnutrition and to implement aggressive, effective therapy. A multidisciplinary team approach to nutritional assessment, therapy, and research can lead to an increased awareness of the importance of nutritional support and optimal nutritional care for the hospitalized patient under all conditions at all times.     

The state of the provision of nutritional care to hospitalized patients--results from The Elan-Cuba Study

Current nutritional care provision to 1905 patients hospitalized in 12 Cuban hospitals is presented in this article, diagnosed after conducting the Hospital Nutrition Survey (HNS), as part of the activities comprising the Cuban Study of Hospital Malnutrition (Elan-Cuba). The obtained HNS results were contrasted with standards regarding the nutritional assessment of hospitalized patient, the diagnosis of nutritional disorders occurring in the patient, and the identification of patients in need of nutritional intervention. The Elan-Cuba Study returned a 41.2% malnutrition rate [Barreto Penié J, Cuban Group for the Study of Hospital Malnutrition. State of malnutrition in Cuban hospitals. Nutrition 2005;21:487-97]. However, malnutrition was recorded as an independent diagnosis in only 0.4% of the surveyed clinical charts. It could not be shown that medical care teams were systematically applying any of the techniques and procedures recommended for the assessment of the nutritional status of hospitalized patients. In the best of the cases, only 40.6% of the surveyed patients had their height and weight recorded in their clinical charts at admission, 9.0% of those with more than 15 days of hospitalization had a prospective value of weight, and less than 20.0% of them had their serum albumin levels and/or their counts of Lymphocytes annotated on their clinical charts. Although 10.9% of the surveyed patients (median of the subcategories values; range: 3.5-41.2%) fulfilled an indication for nutritional intervention, support (enteral and/or parenteral) was only provided to less than 15.0% of them, with the exception made of patients on NPO, of whom 32.3% received either of the two modes of artificial nutrition listed above. It is to be noticed that none of the patients with chronic organic failure were on nutritional support at the time of the survey. The current nutritional care provision to the hospitalized patient might explain the increased rates of hospital malnutrition documented in the Elan-Cuba Study, and should lead to the design and urgent implementation of nutritional and metabolic intervention programs in the surveyed hospitals, given the deleterious effects of nutritional disorders upon the ultimate results of the medical and surgical actions, and the quality and costs of medical care.     

利用简易营养评价法调查住院老年人的营养状况

目的 利用简易营养评价法(MNA)评价住院老年人的营养状况，了解MNA与传统营养指标的相关性。方法 利用MNA量表对144名住院老年人进行调查，同时收集人体测量指标、生化指标和其他资料。结果 住院老年人营养不良的患病率为36．1％，潜在营养不良为46．5％，营养正常占17．4％；年龄、牙齿状况和疾病状态是影响老年人营养的重要因素；MNA与多数传统营养指标之间有良好相关性。结论 住院老年人营养不良的患病率高，MNA是一种可靠、快捷、简便的老年人营养状况评价方法。     

Nutrition assessment in the elderly

The prevalence of malnutrition, which is relatively low in free-living elderly persons (5-10%), is considerably higher (30-60%) in hospitalized or institutionalized elderly persons. As a result, nutritional assessment should be part of routine clinical practice in elderly patients who are frail, sick or hospitalized. A comprehensive screening tool for assessment of nutritional status is needed that is clinically relevant and cost-effective to perform. A number of simple and rapid tests for detecting or diagnosing malnutrition in the elderly have recently been developed. If malnutrition is suggested by such screening tests, then they should be supplemented by conventional nutritional assessment before treatment is planned.     

Subjective vs objective nutritional assessment study in children: a cross-sectional study in the northwest of Iran

Different methods have been used to assess nutritional status in hospitalized pediatric patients, and there is no agreement on the finest index which reflects nutritional status. The aim of this study was to compare the subjective global assessment (SGA) and objective assessment of nutritional status in hospitalized pediatric patients. One hundred forty children with mean age of 6.43 ± 0.23 years hospitalized consecutively in Tabriz Pediatric Hospital from June to August in 2008 underwent a subjective assessment using the SGA questionnaire and objective assessment (anthropometric and biochemical measurements). An agreement between 2 assessment methods were analyzed by the κ statistic. According to the result of SGA method, the overall prevalence of malnutrition was higher than the objective assessment method. The agreement between the 2 methods were merely fair to moderate (κ = 0.336, P = .000). The linear relationship between 2 methods was also fair to moderate (r = 0.374, P < .05). Our findings indicated that the differences between two evaluated methods in assessing nutritional status of pediatric patients, and it can also detect the changing trend of nutritional status, which may be missed by one-time anthropometry and biochemical methods.     

Nutritional care in public hospitals of four Brazilian states: contributions of health evaluation to health surveillance services

Considering the importance of nutritional care for the quality of care provided to hospitalized patients, the study aims to assess health care in eight public hospitals that have received support from QualiSUS in four Brazilian states. There were semi-structured interviews with nutritionists, direct observation and review of 219 records of patients admitted to the medical clinics. The findings suggest weaknesses in the hospital nutritional care, poor integration between the production of food and nutritional care in the surveyed hospitals, in addition to structural deficiencies. We highlight problems related to the nutritional care process, including its documentation. In 93% of the records there were no records on the nutritional status on admission, or nutritional assessment of patients in nutritional therapy. It was observed that the assessment made by the health surveillance in routine inspections, focusing on the verification of compliance and structural aspects, does not include the detection of a possible nutritional risk for the patient. We suggest the inclusion of other criteria and strategies for surveillance, among them a review of open medical records.     

Hospital length of stay and nutritional status

PURPOSE OF REVIEW: This review looks at the recent medical literature on the association between hospital length of stay and nutritional status. RECENT FINDINGS: Simple anthropometric parameters underestimate the nutritional risk in hospitalized patients. The Malnutrition Universal Screening Tool and Nutritional Risk Screening are simple screening tools that identify patients who require further monitoring. Recent weight loss appears to be the most important single indicator of nutritional status. Body composition measurements identify patients with muscle mass depletion and excess body fat, both of which are significantly associated with increased length of stay. The Subjective Global Assessment is useful at detecting patients with established malnutrition and the Mini Nutritional Assessment for the elderly is useful at detecting patients who need preventive nutritional measures. The Nutritional Risk Index, which incorporates albumin and weight loss, appears to capture both nutritional risk and poor clinical outcome. SUMMARY: Nutritional risk is associated with the length of stay in hospital. The choice of nutritional screening and assessment tools depends on the type of institution (university hospital versus community hospital), the patient populations (acute care versus intermediary care; general hospital versus elderly population) and the resources available.     

Visceral protein status of patients hospitalized for alcoholism

The purpose of this study was to evaluate the nutritional status of patients hospitalized for alcoholic rehabilitation. It was hypothesized that thyroxine-binding prealbumin, due to its shorter half-life, would be more sensitive to poor nutritional status than other visceral proteins. Extensive biochemical, anthropometric, and nutrient intake data were obtained on hospital days 2, 7, and 14. No abnormalities in visceral protein status initially, or with time, were seen in this population. The principal conclusion is that severe nutritional deficiencies are not prevalent in this patient sample hospitalized for alcoholic rehabilitation.     

Nutritional status at submission for dietetic services and screening for malnutrition at admission to hospital.

This paper presents two studies in a quality management project that aims to diminish malnutrition among hospitalized patients. The objective of study 1 was to investigate what information was available on the nutritional status of patients submitted for dietetic services for reasons other than obesity (n= 167) and of study 2 to evaluate a nine-question screening sheet for malnutrition in patients (n= 115) within 48 h of admission to the hospital. In study 1 sufficient data to evaluate nutritional status was found for 17% of the patients submitted for dietetic services. In study 2 the screening sheet identified 21% of the patients as malnourished and a full nutritional assessment of seven anthropometrical and biochemical measurements 20%. The screening sheet could be simplified to six questions and then had a sensitivity of 0.69, a specificity of 0.91 and a positive predictive value of 0.65. It is concluded that evaluation of nutritional status in hospitalized patients has been disregarded and a simple screening sheet can be used to identify patients in need of further nutritional assessment and treatment.     

Epidemiological study of malnutrition in elderly patients in acute, sub-acute and long-term care using the MNA

MNA is a simple and accurate way to assess the nutritional status in routine practice, and is suitable for systematic use and large epidemiologic studies. The purpose of this study was to evaluate the difference in the nutritional status of elderly patients hospitalized in different types of care in the same hospital, and to evaluate its relationship with risk factors. Nutritional status was evaluated in 918 elderly patients hospitalized in acute care (AC) (n=299), sub-acute care (SAC) (n=196) or long-term care (LTC) (n=423), using the MNA (Mini-Nutritional Assessment), a nutritional assessment tool including 18 items grouped in 4 domains, within the first 48 h after admission (all subjects) and at the end of hospitalization (AC, SAC). More patients were rated in the "malnourished" class in SAC (32.5%) than in AC (24.5%) and LTC (24. 7%). Retrospective analysis showed that the initial nutritional status was linked to the type of care and the nature of underlying pathology. The nutritional status on arrival was worse in patients in SAC, and better in those in LTC (p = 0.005). This is probably due to a difference in the kind of patients hospitalized. The nutritional status was worse in patients suffering from infectious disease, stroke, dementia and traumatic injuries, and, conversely, better in patients suffering from cardiopathy, metabolic and gastro-intestinal (except cancerous) diseases (p < 0.0001). Prospective analysis showed that duration of hospitalization was the only variable found to be linked to an improvement of nutritional status. The MNA is a rapid, effective and cheap tool for the assessment of nutritional status and moreover for evaluation of the mortality risk of patients admitted into AC and SAC.     

Anthropometric parameters of nutritional assessment as predictive factors of the MINI nutritional assessment (MNA) of hospitalized elderly patients

Objective  

The objective of this study was to identify nutritional indicators that predict MNA (mini nutritional assessment) classification in hospitalized elderly patients.     

Comparison of two nutrition assessment techniques in hospitalized patients

OBJECTIVE: Different methods have been used to assess nutritional status in hospitalized patients, and there is no agreement as to which index best reflects nutritional status. The aim of this study was to determine the prevalence of malnutrition and compare the Subjective Global Assessment, Nutrition Risk Index, and non-nutritional factors in hospitalized patients. METHODS: This prospective study was done in the teaching hospital of Pamukkale University Medical School, Denizli, Turkey. Two hundred fifty-one consecutive patients hospitalized in medical and surgical wards were studied. On admission, the Subjective Global Assessment, Nutrition Risk Index, anthropometric measurements, and laboratory data were assessed. Differences between independent groups were assessed with Student's t test and one-way analysis of variance. Spearman's rank correlation coefficients were calculated for associations between scores and variables. Agreement between two assessment methods was analyzed by the K statistic. RESULTS: On admission, 30% of patients were malnourished according to the Subjective Global Assessment and 36% according to the Nutrition Risk Index. Body weight, albumin, lymphocyte, total cholesterol, and anthropometric data were lower in the malnourished patients according to both assessments (P < 0.01). Body weight loss and length of stay were higher in the malnourished patients according to both assessments (P < 0.01). Body weight, anthropometric data, albumin, and total cholesterol correlated inversely with nutritional status according to both techniques. Concordance was observed in 203 of the 251 (81%) patients with both assessments (K = 0.57, P = 0.000). CONCLUSIONS: Both tests correlated with each other with respect to age, length of stay, and anthropometric and laboratory data in hospitalized patients. Therefore, these two techniques can be used for nutritional assessment in hospitalized patients.     

Improving nutritional screening of hospitalized patients: the role of prealbumin

BACKGROUND: Limited resources prevent hospitals from having all patients formally evaluated by a nutrition expert. Thus, hospitals rely on nutrition-screening tools to identify malnourished patients. The purpose of this study was to determine the effectiveness of a nutrition-screening protocol, prealbumin (PAB), retinol binding protein (RBP), and albumin (ALB) in identifying malnourished hospitalized patients. METHODS: A nutrition screening protocol was prospectively used in medical and surgical patients and consisted of a nurse administering a questionnaire to patients and requesting formal evaluation by a registered dietitian (RD) only if nutritional issues were identified. Patients also had ALB, PAB, and RBP drawn, which were used to both screen and identify the malnourished. PAB, RBP, and ALB were compared as predictors of RD classification of patient nutritional status. RESULTS: The nutrition-screening protocol classified 104 of 320 patients (33%) as malnourished. However, 43% of the patients were not deemed at nutritional risk according to this protocol and therefore did not receive RD assessment. PAB was a significant predictor of RD-determined nutritional status (p < .05), whereas RBP and ALB were not. PAB screening/assessment identified 50% (162/320) of the patients as being malnourished. Notably, 50% of the patients (71 of 142) who were not evaluated by an RD were identified as malnourished using PAB criteria. The nutrition-screening protocol took 1.2 days longer to determine malnourishment compared with PAB (p = .0021). CONCLUSIONS: Use of screening questionnaires may miss or delay identification of malnourished patients. PAB screening/assessment may improve identification of those patients requiring nutrition intervention and thus enhance the care of hospitalized individuals.     

Impact of declines in nutritional status on outcomes in adult patients hospitalized for more than 7 days

OBJECTIVE: To assess the association between changes in nutritional status in hospitalized patients and the occurrence of infections, complications, length of stay in hospital, and hospital charges. DESIGN: A prospective observational study with a retrospective component was conducted over a 7-month interval at a university hospital. SUBJECTS: A total of 404 adults (> or = 18 years old) admitted to the inpatient service for more than 7 days who were not pregnant or lactating and not a psychiatric patient were included. MAIN OUTCOME MEASURES: Major outcome variables included changes in nutritional status as assessed by subjective global assessment (SGA) at hospital admission and discharge, length of stay, hospital charges, complications, and infections. STATISTICAL ANALYSIS PERFORMED: Analysis of variance with a Tukey adjustment for multiple comparisons was used to examine the impact of changes in nutritional status between nutrition change categories for continuous variables (charges and length of stay). Discrete variables were assessed using chi 2 analysis. Logistic regression was used to calculate odds ratios with 95% confidence intervals for the development of complications and infections when compared with the reference group. RESULTS: Compared with the reference group (normally nourished at admission and discharge), patients who declined nutritionally, regardless of nutritional status at admission, had significantly higher hospital charges ($28,631 +/- 1,835 vs $45,762 +/- 4,021). Odds of complications were significantly greater for patients who declined nutritionally, regardless of nutritional status at admission, compared with the reference group. APPLICATIONS/CONCLUSIONS: Declines in patients' nutritional status while they are hospitalized, regardless of their nutritional status at admission, were associated with significantly higher hospital charges and a higher likelihood of complications. Practicing clinicians should make reducing declines in patients' nutritional status a priority regardless of patients' nutritional status at admission.     

NRS 2002筛查COPD病人营养风险及与检查指标的相关性

目的 :用NRS 2002对住院COPD病人进行营养风险筛查,探讨NRS 2002营养风险筛查结果与体格检查指标和生化指标的相关性。方法 :随机抽取2015年1月~2015年12月入院住院的COPD病人218例,用NRS 2002进行营养风险筛查,同时进行体格检查,计算对应指标,测定血生化指标,分析NRS 2002营养风险筛查结果与体格检查指标和生化指标的相关性。结果 :218例住院COPD病人中存在营养风险者(NRS 2002≥3分)69例,发生率31.7%,不同年龄段和不同肺功能分级病人间营养风险发生率差异有统计学意义(P0.05)。NRS 2002营养风险筛查结果与2个体格检查指标(BMI和FFMI)和2个生化指标(ALB和PA)存在关联性(P0.05)。结论 :住院COPD病人营养风险发生率较高,老年病人尤甚。NRS 2002适合作为住院COPD病人营养风险筛查工具,但在临床应用中应结合体格检查指标和生化指标进行全面综合营养评估。     

Use of Nutritional Scores to Predict Clinical Outcomes in Chronic Diseases

Many hospitalized patients are malnourished, and the relationship between malnutrition and patient outcome is well established. To determine which patients are at nutritional risks, clinical scores are probably more accurate than using a single nutritional parameter. Among the numerous scores published, both the Prognostic Nutritional Index and the Subjective Global Assessment were prospectively validated. One is based on objective measurements, whereas the second is based on medical history and physical examination. The Nutritional Risk lndex has been used in many studies including the "Veterans Study'. The Mini Nutritional Assessment is a promising score for evaluating malnutrition in the elderly. The development of nutritional scores for use by nurses may facilitate screening of a large number of hospitalized patients.     

Glycemic management in the inpatient setting

Hyperglycemia occurs frequently in hospitalized patients and affects patient outcomes, including mortality, inpatient complications, hospital length of stay, and overall hospital costs. Various degrees of glycemic control have been studied and consensus statements from the American Diabetes Association/American Association of Clinical Endocrinologists and The Endocrine Society recommend a target blood glucose range of 140 to 180 mg/dL in most hospitalized patients. Insulin is the preferred modality for treating all hospitalized patients with hyperglycemia, as it is adaptable to changing patient physiology over the course of hospitalization. Critically ill patients should receive intravenous insulin infusion, and all noncritically ill patients with hyperglycemia (individuals with and without diabetes) should be managed using a subcutaneous insulin algorithm with basal, nutritional, and correctional dose components. Hypoglycemia remains a limiting factor to achieving optimal glycemic targets. Similar to hyperglycemia, hypoglycemia is an independent risk factor for poor outcomes in hospitalized patients. Improvement in glycemic control throughout the hospital includes efforts from all health care providers. Institutions can encourage safe insulin use by using insulin algorithms, preprinted order sets, and hypoglycemia protocols, as well as by supporting patient and health care provider education.     

Usefulness of oral mucosal epithelial cell apoptosis rate in nutritional assessment

OBJECTIVE: This preliminary study was designed to explore a new method for nutritional assessment by measuring oral mucosal cell apoptosis or proliferation. METHODS: Forty-two consecutive patients with gastrointestinal malignant tumors were hospitalized on the surgical wards and studied prospectively. Patient-Generated Subjective Global Assessment was used to identify malnourished patients. Anthropometric measurements including weight, body mass index, triceps skinfold thickness, and midarm muscle circumference were recorded. The serum proteins measured were retinol-binding protein (RBP), transferrin, prealbumin (PA), and albumin. Simultaneously, the rates of oral epithelial cell apoptosis and proliferation were measured by flow cytometry. Of the 20 malnourished patients, 14 were followed up in a serial study with a 3-d nutritional support therapy. Nutritional indices and oral epithelial cell apoptosis rate were measured after 3 d of nutritional support. RESULTS: Malnutrition was diagnosed in 20 of 42 patients (47.6%). Oral epithelial apoptosis and proliferation rates were significantly decreased (P < 0.01 and P < 0.05, respectively) in malnourished compared with non-malnourished patients, although there were no significant differences between their anthropometric data. Malnourished patients had lower serum levels of RBP, albumin, and PA and rates of oral epithelial cell apoptosis and proliferation. The rate of oral epithelial cell apoptosis positively correlated with serum RBP (R = 0.32, P < 0.05) and PA (R = 0.33, P < 0.05). The rate of oral epithelial cell apoptosis and serum RBP and PA increased significantly in the malnourished patients who received nutritional support for 3 days. CONCLUSIONS: Measuring the rate of oral epithelial cell apoptosis may be another non-invasive technique to determine nutritional assessment and is worthy of further exploration.     

Malnutrition in pediatric hospital patients: Current issues

Malnutrition in hospitalized children is still very prevalent, especially in children with underlying disease and clinical conditions. The purpose of this review is to describe current issues that have to be taken into account when interpreting prevalence data. Weight-for-height and height-for-age standard deviation scores are used for classification for acute and chronic malnutrition, respectively. Body mass index for age can also be used for the definition of acute malnutrition but has a few advantages in the general pediatric population. The new World Health Organization child-growth charts can be used as reference but there is a risk of over- and underestimation of malnutrition rates compared with country-specific growth references. For children with specific medical conditions and syndromes, specific growth references should be used for appropriate interpretation of nutritional status. New screening tools are available to identify children at risk for developing malnutrition during admission. Because of the diversity of medical conditions and syndromes in hospitalized children, assessment of nutritional status and interpretation of anthropometric data need a tailored approach.