Malnourished Inpatients Research Articles

Body mass index as a biomarker for the evaluation of the “Obesity Paradox” among inpatients

Overweight and obesity are, on the one hand, recognized as risk factors for many health-related disorders, and, on the other, as favorable prognostic factors in various patients treated for several different conditions; what is called the "obesity paradox". Until now, the existence of this phenomenon among a general population of consecutive inpatients has not been evaluated. We decided, therefore, to perform an evaluation. Historical prospective analysis of the medical documentation of 23603 hospitalizations during two consecutive years in one center was performed. The outcomes measured were as follows: length of stay, in-hospital all-cause mortality, and non-scheduled readmission in the 14-day, 30-day and one-year periods following discharge. Overweight and obese patients had a lower or similar prevalence of the measured outcomes than malnourished patients and those of normal weight. Adjustment of the standard WHO BMI ranges for patients aged ≥65y (normal weight BMI range 23-33kg/m2) made these differences more apparent. In logistic regression, the ratio of fat to fat-free body mass was a stronger and unfavorable risk factor compared with BMI for the measured outcomes. The greatest risk of all-cause in-hospital death and readmission concerned malnourished inpatients. Compared to patients with a normal BMI range, overweight and obesity had a lower or similar (but not greater) risk of the outcomes measured. However, due to several BMI limitations, our observations should be interpreted as suggesting a "BMI paradox", rather than an "obesity paradox".

Impact of kitchen organization on oral intake of malnourished inpatients: A two-center study

AimTo determine the impact of the type of hospital kitchen on the dietary intake of patients. MethodsA cross-sectional, two-centre study, of cooking in a traditional kitchen (TK) and in a chilled kitchen (CK). Subjective global assessment (SGA) was used for nutritional diagnosis. Before study start, a dietician performed a nutritional assessment of the menus of each hospital. All dishes were weighed upon arrival to the ward and at the end of the meal. Results201 and 41 patients from the centres with TK and CK respectively were evaluated. Prevalence of malnutrition risk was 50.2% at the hospital with TK and 48.8% at the hospital with CK (p=0.328). Forty-eight and 56 dishes were nutritionally evaluated at the hospitals with TK and CK respectively. Intake analysis consisted of 1993 and 846 evaluations in the hospitals with TK and CK respectively. Median food consumption was 76.83% at the hospital with TK (IQR 45.76%) and 83.43% (IQR 40.49%) at the hospital with CK (p<0.001). Based on the prevalence of malnutrition, a higher protein and energy intake was seen in malnourished patients from the CK as compared to the TK hospital, but differences were not significant after adjustment for other factors. ConclusionsCooking in a chilled kitchen, as compared to a traditional kitchen, may increase energy and protein intake in hospitalized patients, which is particularly beneficial for malnourished patients.

Impact of kitchen organization on oral intake of malnourished inpatients: A two-center study

AimTo determine the impact of the type of hospital kitchen on the dietary intake of patients. MethodsA cross-sectional, two-centre study, of cooking in a traditional kitchen (TK) and in a chilled kitchen (CK). Subjective global assessment (SGA) was used for nutritional diagnosis. Before study start, a dietician performed a nutritional assessment of the menus of each hospital. All dishes were weighed upon arrival to the ward and at the end of the meal. Results201 and 41 patients from the centres with TK and CK respectively were evaluated. Prevalence of malnutrition risk was 50.2% at the hospital with TK and 48.8% at the hospital with CK (p=0.328). Forty-eight and 56 dishes were nutritionally evaluated at the hospitals with TK and CK respectively. Intake analysis consisted of 1993 and 846 evaluations in the hospitals with TK and CK respectively. Median food consumption was 76.83% at the hospital with TK (IQR 45.76%) and 83.43% (IQR 40.49%) at the hospital with CK (p<0.001). Based on the prevalence of malnutrition, a higher protein and energy intake was seen in malnourished patients from the CK as compared to the TK hospital, but differences were not significant after adjustment for other factors. ConclusionsCooking in a chilled kitchen, as compared to a traditional kitchen, may increase energy and protein intake in hospitalized patients, which is particularly beneficial for malnourished patients.

Investigation of the benefits of early malnutrition screening with telehealth follow up in elderly acute medical admissions.

The benefit of providing early nutrition intervention and its continuation post-discharge in older hospitalized patients is unclear. This study examined efficacy of such an intervention in older patients discharged from acute care. In this randomized controlled trial, 148 malnourished patients were randomized to receive either a nutrition intervention for 3 months or usual care. Intervention included an individualized nutrition care plan plus monthly post-discharge telehealth follow-up whereas control patients received intervention only upon referral by their treating clinicians. Nutrition status was determined by the Patient Generated Subjective Global Assessment (PG-SGA) tool. Clinical outcomes included changes in length of hospital stay, complications during hospitalization, Quality of life (QoL), mortality and re-admission rate. Fifty-four males and 94 females (mean age, 81.8 years) were included. Both groups significantly improved PG-SGA scores from baseline. There was no between-group differences in the change in PG-SGA scores and final PG-SGA scores were similar at 3 months 6.9 (95% CI 5.6-8.3) vs. 5.8 (95% CI 4.8-6.9) (P = 0.09), in control and intervention groups, respectively. Median total length of hospital stay was 6 days shorter in the intervention group (11.4 (IQR 16.6) vs. 5.4 (IQR 8.1) (P = 0.01). There was no significant difference in complication rate during hospitalization, QoL and mortality at 3-months or readmission rate at 1, 3 or 6 months following hospital discharge. In older malnourished inpatients, an early and extended nutrition intervention showed a trend towards improved nutrition status and significantly reduced length of hospital stay.

A Comprehensive Nutrition-Focused Quality Improvement Program Reduces 30-Day Readmissions and Length of Stay in Hospitalized Patients.

Although screening patients for malnutrition risk on hospital admission is standard of care, nutrition shortfalls are undertreated. Nutrition interventions can improve outcomes. We tested effects of a nutrition-focused quality improvement program (QIP) on hospital readmission and length of stay (LOS). QIP included malnutrition risk screening at admission, prompt initiation of oral nutrition supplements (ONS) for at-risk patients, and nutrition support. A 2-group, pre-post design of malnourished adults with any diagnosis was conducted at 4 hospitals: QIP-basic (QIPb) and QIP-enhanced (QIPe). Comparator patients had a malnutrition diagnosis and ONS orders. For QIPb, nurses screened all patients on admission using an electronic medical record (EMR)-cued Malnutrition Screening Tool (MST); ONS was provided to patients with MST scores ≥2 within 24-48 hours. QIPe had ONS within 24 hours, postdischarge nutrition instructions, telephone calls, and ONS coupons. Primary outcome was 30-day unplanned readmission. We used baseline (January 1-December 31, 2013) and validation cohorts (October 13, 2013-April 2, 2014) for comparison. Patients (n = 1269) were enrolled in QIPb (n = 769) and QIPe (n = 500). Analysis included baseline (n = 4611) and validation (n = 1319) comparator patients. Compared with a 20% baseline readmission rate, post-QIP relative reductions were 19.5% for all QIP, 18% for QIPb, and 22% for QIPe, respectively. Compared with a 22.1% validation readmission rate, relative reductions were 27.1%, 25.8%, and 29.4%, respectively. Similar reductions were noted for LOS. Thirty-day readmissions and LOS were significantly lowered for malnourished inpatients by use of an EMR-cued MST, prompt provision of ONS, patient/caregiver education, and sustained nutrition support.

Difficulties in recruiting frail older inpatients to intervention studies

AbstractAimTo describe difficulties experienced with recruitment of frail, malnourished inpatients aged 65+ years to a 12‐week multidisciplinary home‐based nutrition and physical activity intervention (SUSTAIN) and to identify factors associated with non‐participation.MethodsA multidisciplinary team approach to recruitment involved monthly team meetings, weekly clinician case conferences and strategic planning to accommodate patient needs (provision of transport, easy access to facilities, appropriate written/verbal information). Intensive recruitment occurred in eligible inpatients from a major acute tertiary and rehabilitation hospitals in a local health district over seven months.ResultsOf the 124 patients screened, 88 were not eligible, 32 declined, and 4 consented. Neither socio‐demographic nor clinical characteristics (age, gender, clinical diagnosis, birthplace, cognitive function, length of stay or nutritional status) explained non‐participation or ineligibility or refusals rates.ConclusionsThe advanced age and poor overall health status of this population necessitates alternative recruitment strategies to improve participation in clinical trials and improve generalisability for clinical practice.

Oral Nutritional Supplements and Taste Adherence in Malnourished Adults Inpatients, Effect on Adhesion during Hospital Stance

Aim: The aim of our study was to evaluate a hypercaloric sweet milk-based oral nutrition supplement in a prospective 3-day study designed to assess the taste preferences of this oral nutritional supplement (ONS) in malnourished inpatients and the influence on adherence in daily intake. Methods: A total of 46 in patients with recent weight loss were included in this study. One flavor (chocolate, vanilla or strawberry) was administered each day in a random way to each patient during 3 consecutive days. In the first 3 days, patients were asked to fill 2 questionnaires intended for reflecting ONS tolerance and acceptance. Results: Sweet was better for chocolate flavor (3.9 ± 2.4 points) than for vanilla flavor (2.7 ± 2.3 points; p < 0.02) and strawberry flavor (3.1 ± 2.3 points; p < 0.01). Chocolate flavored ONSs were rated as having more aftertaste (3.4 ± 2.1 points) than vanilla (2.4 ± 2.1 points; p < 0.01) and strawberry (2.6 ± 1.5 points; p < 0.03). Patients who chose chocolate took a total of 20.7 ± 20.9 average bricks during hospitalization (1.95 ± 0.2 per day), patients who chose vanilla took 18.6 ± 21.0 bricks (1.90 ± 0.7 per day) and finally patients who chose strawberry took 14.5 ± 13.5 bricks during admission (1.78 ± 0.1 per day; p < 0.01). Conclusions: The taste preferences of all the ONSs are similar although the consumption is high in chocolate flavored ONS during hospitalization. Sweetness may have influenced this finding.

The effects of the administration of oral nutritional supplementation with medication rounds on the achievement of nutritional goals: A randomized controlled trial

Oral nutritional supplements (ONS) are often considered for hospitalized patients with acute severe malnutrition, however the compliance to the supplements is known to be variable. The aim of our study was to investigate whether providing a lower volume of ONS at a higher frequency during medication rounds would improve the intake of the supplements. In this randomized controlled trial, 234 malnourished inpatients (mean age 71.2 years, 55% male, median LOS 10 days) were randomized to receive ONS (300 kcal and 12 g Protein per 125 ml serving) in one of three different schemes. The usual care group (n = 88) was offered ONS 125 ml twice per day in between meals. This was compared to two intervention groups that were offered ONS during medication rounds: intervention group 1 (n = 66) received 125 ml of ONS twice per day, at 12 and 17 o'clock, and intervention group 2 (n = 80) received 62 ml of ONS four times a day, at 8, 12, 17 and 20 o'clock. Follow-up was performed until discharge or until ONS was no longer needed, with a maximum follow-up period of 30 days. The primary outcome measure was the percentage of patients who consumed at least 75% of the prescribed volume of ONS. No significant differences were observed between the control groups and intervention group 1 (risk difference of -16.0% (95% CI -33.2-1.2). However, the percentage of patients consuming at least 75% of the prescribed ONS was higher in intervention group 2, with a risk difference 23.4% (95% CI 7.8-39.0%) and a mean increased intake of 35 ml (84 kcal) per day, p < 0.001). Median time ONS were taken was 5 days (range 1-17). A higher frequency of a lower volume of ONS during medication rounds increased the compliance of patients needing ONS. Clinical trial registration number NTR2535; www.trialregister.nl.

Albumin concentration determined by the modified bromocresol purple method is superior to that by the bromocresol green method for assessing nutritional status in malnourished patients with inflammation

The controlling nutritional status (CONUT) score (CS), a simple score for assessing nutritional status, is calculated using laboratory data, including serum albumin concentration. Although dye-binding assays such as the bromocresol green (BCG) and modified bromocresol purple (mBCP) methods are widely used for albumin measurement, acute-phase proteins interfere with the BCG method. We aimed to determine whether the choice of albumin assay affects assessment of nutritional status using CONUT scores (CSs). We measured serum albumin concentrations by the BCG (ALBBCG) and mBCP (ALBmBCP) methods in 44 malnourished inpatients, 27 of whom underwent nutritional intervention, and compared them to 30 age-matched healthy volunteers. In treated patients, CSs were calculated by ALBBCG (CS-BCG) and ALBmBCP (CS-mBCP). C-reactive protein (CRP) concentrations were positively correlated with the difference between ALBBCG and ALBmBCP in malnourished inpatients (r = 0.59, p < 0.001). CS-BCG was always lower than CS-mBCP (lower CS indicates superior nutritional status) in treated patients with persistently high CRP levels. However, in patients whose CRP decreased gradually, this difference diminished over the clinical course. CS-BCG and CS-mBCP were similar throughout their courses in patients with normal CRP concentrations. Adding haptoglobin to the human albumin solutions increased ALBBCG in a dose-dependent manner. The choice of albumin assay affected the assessment of nutritional status using CSs in patients with inflammation. We recommend that the modified BCP assay be used to assess nutritional status, particularly in patients with inflammation.

Mortality, length of hospital stay, and nutritional status improvement in severely malnourished children with HIV infection in a tertiary center

Background Severe malnutrition contributes to child mortalityrates, especially in children under five HIV infection further increases the risk of death.Objective To evaluate the impact of HIV infection on mortality,length of hospital stay and improvement of nutritional status inseverely malnourished inpatients under five Methods This retrospective study included children aged less than5 years and admitted to a terti ary hospital for severe malnutrition.We excluded those with incomplete data, as well as thosetransferred to other hospitals or discharged against medical advice.Outcome measures were live/death status, length of hospital stayand improvement of nutritional status (weight gain and improvedweight􀁀for􀁀height Z score).Results Of 104 eligible patients, 97 were included as studysubjects. Their mean ages were 25.8 (SD 17.3) months forHIY-infected children and 16.3 (SD 15.3) months for HIYuninfectedchildren. Death occurred in 31.8% and 18.7% ofHIV􀁀infected and uninfected subjects, respectively. Medianlength of hospital stay was 14.5 (range 5􀁀51) days and 11(range 1􀁀99) days, respectively. There were no statisticallysignificant differences in between the two groups. Weight􀁀for􀁀height Z scores (WHZ) onadmission and discharge in HIV􀁀infected children were lowerthan those of uninfected children, but the weight gain (medianweight gain of 0.45 (-0.26 to 1.9) kg vs 0.38 (-0.81 to 2.2) kgin HIV􀁀infected and uninfected children, respectively) andimprovement of WHZ [1 (SD 1.1) vs 0.9 (SD 1), respectively]were similar.Conc l usion Severely malnourished children with HIVinfection had higher mortality rate, and longer hospitalizationsthan the uninfected group, although the differences were notstatistically signific ant. They also had lower mean WHZ scoresat admission and discharge, butnutritionalimprovement wassimilar to those who were HIV􀁀negative. [Paediatr Indones.2012;52:362-6].

Mortality, length of hospital stay, and nutritional status improvement in severely malnourished children with HIV infection in a tertiary center

Background Severe malnutrition contributes to child mortalityrates, especially in children under five HIV infection further increases the risk of death.Objective To evaluate the impact of HIV infection on mortality,length of hospital stay and improvement of nutritional status inseverely malnourished inpatients under five Methods This retrospective study included children aged less than5 years and admitted to a terti ary hospital for severe malnutrition.We excluded those with incomplete data, as well as thosetransferred to other hospitals or discharged against medical advice.Outcome measures were live/death status, length of hospital stayand improvement of nutritional status (weight gain and improvedweightô€€forô€€height Z score).Results Of 104 eligible patients, 97 were included as studysubjects. Their mean ages were 25.8 (SD 17.3) months forHIY-infected children and 16.3 (SD 15.3) months for HIYuninfectedchildren. Death occurred in 31.8% and 18.7% ofHIVô€€infected and uninfected subjects, respectively. Medianlength of hospital stay was 14.5 (range 5ô€€51) days and 11(range 1ô€€99) days, respectively. There were no statisticallysignificant differences in between the two groups. Weightô€€forô€€height Z scores (WHZ) onadmission and discharge in HIVô€€infected children were lowerthan those of uninfected children, but the weight gain (medianweight gain of 0.45 (-0.26 to 1.9) kg vs 0.38 (-0.81 to 2.2) kgin HIVô€€infected and uninfected children, respectively) andimprovement of WHZ [1 (SD 1.1) vs 0.9 (SD 1), respectively]were similar.Conc l usion Severely malnourished children with HIVinfection had higher mortality rate, and longer hospitalizationsthan the uninfected group, although the differences were notstatistically signific ant. They also had lower mean WHZ scoresat admission and discharge, butnutritionalimprovement was

Does Aggressive Refeeding in Hospitalized Adolescents With Anorexia Nervosa Result in Increased Hypophosphatemia?

Concerns about refeeding syndrome have led to relatively conservative nutritional rehabilitation in malnourished inpatients with anorexia nervosa (AN), which delays weight gain. Compared to other programs, we aggressively refed hospitalized adolescents. We sought to determine the incidence of hypophosphatemia (HP) in 12-18-year-old inpatients in order to inform nutritional guidelines in this group. A 1-year retrospective chart review was undertaken of 46 admissions (29 adolescents) with AN admitted to the adolescent ward of a tertiary children's hospital. Data collected over the initial 2 weeks included number of past admissions, nutritional intake, weight, height, body mass index, and weight change at 2 weeks. Serum phosphorus levels and oral phosphate supplementation was recorded. The mean (SD) age was 15.7 years (1.4). The mean (SD) ideal body weight was 72.9% (9.1). Sixty-one percent of admissions were commenced on 1,900 kcal (8,000 kJ), and 28% on 2,200 kcal (9,300 kJ). Four patients were deemed at high risk of refeeding syndrome; of these patients, three were commenced on rehydration therapy and one on 1,400 kcal (6,000 kJ). All patients were graded up to 2,700 kcal (11,400 kJ) with further increments of 300 kcal (1,260 kJ) as required. Thirty-seven percent developed mild HP; no patient developed moderate or severe HP. Percent ideal body weight at admission was significantly associated with the subsequent development of HP (p = .007). These data support more aggressive approaches to nutritional rehabilitation for hospitalized adolescents with AN compared to current recommendations and practice.

Does Aggressive Refeeding in Hospitalised Adolescents with Anorexia Nervosa Result in Increased Hypophosphataemia?

Purpose: Concerns about refeeding syndrome (RS) have led to relatively conservative nutritional rehabilitation in malnourished inpatients with anorexia nervosa (AN) which delays weight gain. Compared to other programs, we aggressively refeed hospitalized adolescents, graduating this according to perceived risk of RS. We aimed to determine the incidence and degree of hypophosphatemia in 12-18 year old inpatients in order to inform nutritional guideline development in adolescents with AN.

Oral nutritional supplements and taste preferences: 545 days of clinical testing in malnourished in-patients

Acceptability and intake of oral nutritional supplements are often suboptimal, partly because patients dislike flavour, texture or smell. We assessed the taste preferences about milk-based and fruit-juice typed supplements in malnourished in-patients. One hundred and nine in-patients requiring oral nutritional support were assigned to consume four given supplements on four consecutive days, to answer a questionnaire based on a 10-point visual analogue scale (VAS) on acceptance/tolerance, and to choose their preferred product for the fifth day. Overall pleasantness was significantly better for milk-based supplements than for sweet and salty fruit-juice typed products (on VAS: 6.2+/-3.1 versus 4.4+/-3.9, p<0.01 and 3.5+/-3.4, p<0.0001, respectively, when 1 meant "not at all" and 10 "very much"), whereas digestive tolerance was comparable. When offered together on day 5, milk-based products were more frequently preferred (81.6%) than fruit-juice typed supplements (18.4%, p<0.001). Among milk-based products, vanilla, coffee and strawberry had comparable good results, whereas chocolate was less chosen and neutral never. For fruit-juice typed products, tomato obtained better results than orange or apple. Oral nutritional supplements are globally well-accepted and tolerated, but with variations according to categories and flavours that must be considered to improve compliance.

Food intake of a typical Brazilian diet among hospitalized malnourished patients

Aim: To verify whether malnourished inpatients receiving a typical Brazilian diet meet their food requirements.Methods: Thirty-five consecutive surgical and medical hospitalized adults, able to feed themselves, received rice and beans based diets for 3 consecutive days. All served food was weighed before and after the meals. Nutrient intake was determined and results compared to American Recommended Dietary Allowances (RDA). Malnutrition was defined by the presence of at least one of these criteria: body mass index ≦ 18.5 kg/m2; height-creatinine index ⪡ 70%; or albumin level ⪡ 3.5 g/dl.Results: Malnourished and non-malnourished patients were paired in relation to age, gender, diagnoses and clinical parameters. Despite showing distinct anthropometric parameters and laboratory data, malnourished patients ingested enough quantities of food and met or exceeded RDA for energy and other nutrients.Conclusions: Clinically-stable malnourished inpatients, supplied with rice- and beans based diets have adequate energy and nutrient intake, the same occurring for non-malnourished ones.

Malnourished inpatients: overlooked and undertreated.

On several occasions this year, we have discussed illnesses made worse by obesity and urged weight loss as part of the management of patients with gastrointestinal reflux, osteoarthritis and coronary heart disease. In this article, we turn to problems associated with being underweight. In a recent study, 40% of adults admitted to a UK general hospital were undernourished and in a quarter of these their undernutrition was probably severe enough to threaten life. Here we discuss how undernourished patients can be recognised and review ways in which undernourishment can be tackled, concentrating on gross undernutrition rather specific deficiencies of, for instance, single vitamins or essential fatty acids.

Bacterial contamination and growth in two defined formula diets of different pH

We inoculated partially hydrolysed protein feed of low pH and an intact protein feed of neutral pH with various pathogenic bacteria, and showed that the low pH feed restricted bacterial growth. To study this effect in a clinical setting, 20 malnourished in-patients were randomised prospectively to receive one or other of these feeds. Both formulae were given as a continuous feed via a nasogastric tube, 1,000 ml over 12 h twice daily, using routine hygienic measures. On two occasions significant contamination was demonstrated ( Erwinia herbicola and Acinetobacter Iwoffi), both occurring in the intact protein diet. When the bacteria were isolated and transferred to the hydrolysed protein diet, their growth was inhibited. The contamination did not cause clinical complications. The study demonstrates inhibition of microbial growth in a partially hydrolysed protein formula of low pH. This effect may reduce the risk of contamination, and limit infectious complications.

The Effects of Refeeding on Peripheral and Respiratory Muscle Function in Malnourished Chronic Obstructive Pulmonary Disease Patients

We carried out a prospective randomized controlled trial to investigate the effects of short-term refeeding (16 days) in 10 malnourished inpatients with chronic obstructive pulmonary disease (COPD). Six patients were randomized to receive sufficient nasoenterically administered calories to provide a total caloric intake equal to 1,000 kcal above their usual intake. The other four patients were sham fed, receiving only 100 kcal more. Measurements of nutritional status, respiratory muscle strength and endurance, adductor pollicis function, and pulmonary function were performed initially and at study end. The refed group gained significantly more weight and showed significant increases in maximal expiratory pressure and mean sustained inspiratory pressure. There were no significant changes in the maximal inspiratory pressure or in adductor pollicis function. In malnourished inpatients with COPD, short-term refeeding leads to improvement in respiratory muscle endurance and in some parameters of respiratory muscle strength in the absence of demonstrable changes in peripheral muscle function.