Nutritional status in older persons according to healthcare setting: A systematic review and meta-analysis of prevalence data using MNA®.

BACKGROUND & AIMS: Old persons are more likely to suffer from malnutrition, which may result in higher dependency in activities of daily living. We aimed to provide a quantitative synthesis of prevalence data on malnutrition and its risk as assessed by the Mini Nutritional Assessment across different healthcare settings. The association between nutritional status and setting-related level of dependence was also investigated. METHODS: Non-interventional studies published as full-text articles in English up to 31th December 2014 were searched for in PubMed and by reviewing references of eligible articles. Meta-analysis and meta-regression of potential sources of heterogeneity were conducted. RESULTS: A total of 240 studies/795 citations - providing 258 setting-specific prevalence estimates (113,967 subjects) - fulfilled inclusion criteria for meta-analysis. Prevalence of malnutrition differed significantly across the healthcare settings considered: community, 3.1% (95%CI, 2.3-3.8); outpatients, 6.0% (95%CI, 4.6-7.5); home-care services, 8.7% (95%CI, 5.8-11.7); hospital, 22.0% (95%CI, 18.9-22.5); nursing homes, 17.5% (95%CI, 14.3-20.6); long-term care, 28.7% (95%CI, 21.4-36.0); rehabilitation/sub-acute care, 29.4% (95%CI, 21.7-36.9). For every setting significant heterogeneity in individual study results was observed (I2 ≥80%, P < 0.001) and meta-regression showed that study quality was the most important determinant. Finally, meta-regression of all the studies included showed that both malnutrition and its risk were directly associated with the setting-related level of dependence (P < 0.001). However, despite multiple adjustments, residual heterogeneity remained high. CONCLUSION: We provided updated estimates of malnutrition and its risk in different healthcare settings. Although the level of dependence appears to be an important determinant, heterogeneity in individual study results remained substantially unexplained. The cause-effect relationship between nutritional status and level of dependence deserves further investigation.

Serum prealbumin is an independent predictor of mortality in systemic sclerosis outpatients.

OBJECTIVE: Serum prealbumin is a recognized marker of malnutrition, but its role in the prognosis of patients with SSc has not yet been investigated. The aim of the present multicentre prospective study was to investigate the association between prealbumin and mortality, independent of clinical features, in a cohort of SSc outpatients. METHODS: Patients were followed up according to standard clinical guidelines with visits at least every 6 months. Data collected included records of skin and internal organ involvement, survival and causes of death. RESULTS: During a median follow-up of 48 months [interquartile range (IQR) 25-58], 34/299 patients (11%) died. In univariable survival analysis, age; male sex; lung, gastrointestinal or multiple visceral organ involvement (two or more); co-morbidities (two or more) and low serum prealbumin were significant predictors of mortality. In bivariable Cox models, alternatively adjusted for significant predictors, prealbumin was independently and significantly associated with the outcome. Mortality rates were particularly influenced by low prealbumin in patients without significant co-morbidities or multiple organ involvement. CONCLUSION: In SSc patients, low serum prealbumin is an independent predictor of mortality, particularly in those without significant internal organ involvement. Further research on this nutritional marker is warranted.

Nutritional counseling improves quality of life and preserves body weight in systemic immunoglobulin light-chain (AL) amyloidosis.

OBJECTIVE: Malnutrition is associated with mortality and impaired quality of life (QoL) in systemic immunoglobulin light-chain (AL) amyloidosis. The aim of this study was to determine whether nutritional counseling is beneficial to patients with AL. METHODS: In this intervention study (ClinicalTrials.gov Identifier: NCT02055534), 144 treatment-naïve outpatients with AL were randomized to usual care (UC; n = 72) and nutritional counseling (NC; n = 72). RESULTS: In the randomized population, although patients in the NC group maintained a stable body weight (weight loss [WL] = 0.6 kg; 95% confidence interval [CI], -1.0 to 2.1; P = 0.214), those in the UC group demonstrated a significant decrease (WL = 2.1 kg; 95% CI, 0.2-4.1; P = 0.003). However, the difference in weight between groups was not significant (mean WL difference = 1.6 kg; 95% CI, -0.7 to 3.9; P = 0.179). Patients in the NC group demonstrated more satisfactory energy intake (≥75% of estimated requirements, odds ratio, 2.18; 95% CI, 1.04-4.57; P = 0.048) and a significant increase in the mental component summary of QoL (Short form-36) at 12 mo (mean difference, 8.1; 95% CI, 2.3-13.9; P = 0.007), which was restored to a mean score of 53 (95% CI, 50-53), over the healthy population norms. NC was also associated with better survival (crude hazard ratio, 0.57; 95% CI, 0.35-0.94; P = 0.028). CONCLUSIONS: In outpatients with AL, NC was helpful in preserving body weight, effective in improving mental QoL, and associated with better survival.

Phase angle and handgrip strength are sensitive early markers of energy intake in hypophagic, non-surgical patients at nutritional risk, with contraindications to enteral nutrition.

The assessment of nutritional intakes during hospitalization is crucial, as it is known that nutritional status tends to worsen during the hospital stay, and this can lead to the negative consequences of malnutrition. International guidelines recommend the use of parenteral nutrition (PN) in hypophagic, non-surgical patients at nutritional risk, with contraindications to enteral nutrition. However, to date, there are no published data regarding either energy intake or objective measurements associated with it in this patient population. The aim of the present exploratory methodological study was to evaluate whether phase angle (PhA) and handgrip strength normalized for skeletal muscle mass (HG/SMM) are sensitive early markers of energy intake in hypophagic, non-surgical patients at nutritional risk, with contraindications to enteral nutrition. We evaluated 30 eligible patients, who were treated with personalized dietary modifications and supplemental PN for at least one week during hospitalization. In a liner regression model adjusted for age, gender, basal protein intake and the basal value of each variable, a trend toward improvement of PhA and preservation of HG/SMM was observed in patients satisfying the estimated calorie requirements (N = 20), while a significant deterioration of these parameters occurred in those who were not able to reach the target (N = 10). The mean adjusted difference and 95% CI were +1.4° (0.5-2.3) (p = 0.005) for PhA and +0.23 (0.20-0.43) (p = 0.033) for HG/SMM. A significant correlation between PhA and HG/SMM variations was also observed (r = 0.56 (95% CI, 0.23-0.77); p = 0.0023). PhA and HG/SMM were able to distinguish between hypophagic, non-surgical patients at nutritional risk who satisfied their estimated caloric requirements and those who did not after a one-week personalized nutritional support. Clinical studies are warranted, in order to verify these preliminary observations and to validate the role of PhA variations as early markers of anabolic/catabolic fluctuations.

The Geriatric Nutritional Risk Index predicts hospital length of stay and in-hospital weight loss in elderly patients.

BACKGROUND & AIMS: Nutritional derangements are common in elderly patients, but how nutritional risk affects outcome in this subset of hospital inpatients deserves further investigation. We evaluated the impact of nutritional risk on length of stay (LOS) and in-hospital weight loss (WL) in elderly patients (>65 yrs). METHODS: Nutritional risk was assessed by the Geriatric Nutritional Risk Index (GNRI) in a prospective multicentre hospital-based cohort study. The outcomes were LOS and in-hospital WL. RESULTS: In the whole sample (N = 667), the prevalence of high (GNRI < 92) and mild (GNRI: 92-98) nutritional risk were 33% and 25%, respectively. Patients with a high nutritional risk were more likely (OR = 1.89; 95%CI: 1.22-2.92) to stay longer in hospital (fourth quartile, LOS ≥ 20 days) compared to those without. Other factors associated with prolonged LOS were cancer diagnosis (OR = 2.52; 95%CI: 1.69-3.75), the presence of comorbidities (OR = 1.24; 95%CI: 1.11-1.40) and surgical setting (OR = 1.65; 95%CI: 1.10-2.47). In-hospital WL ≥ 5% was recorded in 75 ambulant patients from a representative subgroup (N = 583). It was independently associated with prolonged LOS (OR = 1.80; 95%CI: 1.03-3.06) and was more frequent among cancer patients (OR = 1.88; 95%CI: 1.09-3.24), in patients with a high nutritional risk (OR = 2.23; 95%CI: 1.20-4.14) or those admitted to surgical units (OR = 1.77; 95%CI: 1.02-3.05). CONCLUSIONS: Nutritional risk assessed by the GNRI on admission, predicts LOS and in-hospital WL in elderly patients.

Malnutrition at diagnosis predicts mortality in patients with systemic immunoglobulin light-chain amyloidosis independently of cardiac stage and response to treatment.

BACKGROUND: Nutrition status was shown to be a prognostic factor in patients with immunoglobulin light-chain amyloidosis (AL). However, malnutrition was associated with cardiac involvement, thus suggesting potential interactions. This study aim was to clarify the association among nutrition status, cardiac stage, and mortality in AL. METHODS: One hundred twenty-eight consecutive newly diagnosed, treatment-naïve patients with histologically confirmed AL were enrolled. Anthropometric, biochemical, and clinical variables were assessed. RESULTS: At multivariable Cox proportional hazard analysis, body mass index (BMI) < 22 kg/m(2) (HR = 1.98, 95% CI = 1.09-3.56) and unintentional 6-month weight loss (WL) ≥ 10% (HR = 1.94, 95% CI = 1.00-3.74) resulted in independent predictors of survival after controlling for hematologic response to treatment (HR = 0.27, 95% CI = 0.14-0.53) and cardiac stage (Mayo Clinic stage III, HR = 4.42, 95% CI = 2.61-7.51). There was no effect modification of malnutrition on mortality by cardiac stage (P for interaction = .27). Moderate and severe malnutrition (prevalence: 21.9% and 7.8%, respectively) similarly increased the risk of death (HR = 3.09, 95% CI = 1.75-5.46; 2.88, 95% CI = 1.23-6.72, respectively). CONCLUSIONS: In AL, malnutrition at diagnosis is a frequent comorbidity that affects the prognosis independently of hematologic response to treatment and cardiac stage. Nutrition status should be systematically considered in future intervention trials in AL. Nutrition support trials are warranted.

Disease-related nutritional risk and mortality in systemic sclerosis.

BACKGROUND & AIMS: To evaluate the relationship between mortality and nutritional risk associated with disease activity in Systemic Sclerosis (SSc). METHODS: A single-centre prospective cohort study involving 160 SSc outpatients (median age, 62 years [25th-75th, 54-68]). Nutritional risk was assessed by the Malnutrition Universal Screening Tool (MUST), a screening tool that combines anthropometric parameters of nutritional status (body mass index [BMI] and percentage of unintentional weight loss [WL]) with the presence of an "acute disease" (as defined by a disease activity score ≥3 according to Valentini's criteria). RESULTS: Prevalence of high nutritional risk (MUST score ≥2) was 24.4% [95%CI, 17.4-31.3]. A low nutritional risk (MUST = 1) was detected in 30% of our study sample. In hazard analysis (median follow-up duration = 46 months [25th-75th percentile, 31-54]), high nutritional risk was significantly associated with mortality (HR = 8.3 [95%CI, 2.1-32.1]). The performance of the model based on nutritional risk including disease activity (Harrell's c = 0.74 [95%CI, 0.59-0.89]) was superior to that based on active disease alone (HR = 6.3 [95%CI, 1.8-21.7]; Harrell's c = 0.68 [95%CI, 0.53-0.84]). Risk scored only by anthropometric parameters (prevalence, 9.4% [95%CI, 4.6-14.2]) was not associated with mortality: HR = 2.8 [95%CI, 0.6-13.2]. CONCLUSIONS: In SSc outpatients MUST significantly predicts mortality. The combined assessment of nutritional parameters and disease activity significantly improves the evaluation of mortality risk. Disease-related nutritional risk screening should be systematically included in the clinical workup of every SSc patient.

Serum prealbumin: an independent marker of short-term energy intake in the presence of multiple-organ disease involvement.

OBJECTIVE: Serum prealbumin has a prognostic value in several diseases, but its serum levels can be influenced by different factors. However, a multivariable analysis to test the independent effect of each has not yet, to our knowledge, been performed. The aim of this cross-sectional study was to investigate the association between prealbumin and several factors possibly affecting its serum levels to test the potential of using prealbumin as an indicator of nutritional status and short-term energy intake in patients newly diagnosed with immunoglobulin light-chain amyloidosis. METHODS: Multivariable general linear regression models of non-collinear variables were fitted to assess the association of demographic (sex, age), nutritional (short-term energy intake, unintentional weight loss, body mass index), and clinical (cardiac and liver involvement, kidney function, C-reactive protein) parameters with serum prealbumin levels in 187 patients newly diagnosed with immunoglobulin light-chain amyloidosis. RESULTS: Serum prealbumin levels were associated with C-reactive protein and short-term energy intake (P < 0.001 for both). A significant association was also detected with age (P = 0.023), serum creatinine (P = 0.017), liver involvement (P = 0.002), and peripheral edema (P = 0.032). In a prespecified subgroup analysis (n = 140) in patients with normal C-reactive protein level (<0.5 mg/dL), all other associations were confirmed. A significant relation was also observed with sex (P = 0.022) and body mass index (P = 0.041). CONCLUSIONS: Serum prealbumin is associated with short-term energy intake independently of the presence of multiple-organ involvement and inflammation. Its serum levels should be always interpreted in light of its influencing factors, among which inflammation and liver and kidney functions appear predominant.

Disease-related malnutrition in outpatients with systemic sclerosis.

BACKGROUND & AIM: Disease-related malnutrition is known to negatively affect clinical outcomes. The aim of the present study was to evaluate the prevalence of malnutrition in a cohort of outpatients affected by Systemic Sclerosis (SSc) and its association with clinical variables. METHODS: One hundred sixty SSc patients were consecutively evaluated. The following clinical variables were assessed: disease duration, activity and severity, treatments, functional status, gastrointestinal involvement. Nutritional assessment included: body mass index (BMI), weight loss (WL) history, nutritional intakes and serum prealbumin. Malnutrition was defined as BMI <20 kg/m² and/or previous 6-month WL ≥ 10%. RESULTS: Prevalence of malnutrition was 15% (10-21%). Logistic regression showed that malnutrition was independently associated with disease activity (OR 3.72; p < 0.001) and low serum prealbumin (OR 8.58; p < 0.001). The association with gastrointestinal involvement was not statistically significant, although a trend was detected (OR 1.88). CONCLUSION: Malnutrition is common in SSc outpatients. It appears associated with disease activity and not influenced by nutritional intakes; gastrointestinal involvement might contribute to its development over time. Serum prealbumin could be an early marker of malnutrition in SSc, whose role should be confirmed by further longitudinal investigations. Prospective studies are also required to clarify the clinical significance of the association between malnutrition and disease activity in SSc.

Nutritional status independently affects quality of life of patients with systemic immunoglobulin light-chain (AL) amyloidosis.

Nutritional status is an independent prognostic factor in immunoglobulin light-chain amyloidosis (AL), but its influence on quality of life (QoL) is unknown. The aim of this cross-sectional study was to investigate the association between nutritional status and QoL in AL patients at diagnosis. One hundred and fifty consecutive patients with biopsy-proven AL were assessed for nutritional status by anthropometry [body mass index, unintentional weight loss (WL) in the previous 6 months and mid-arm muscle circumference (MAMC)], biochemistry (serum prealbumin), and semiquantitative food intake at referral. QoL was assessed by the Medical Outcomes Study 36-item Short Form General Health Survey. The composite physical component summary (PCS) and the mental component summary (MCS) for AL outpatients were 36.2 ± 10.1 and 44.9 ± 11.3, respectively (p < 0.001 for both vs the population norms of 50). In multivariate linear regression models adjusted for gender, age, Eastern Cooperative Oncology Group performance status, the number of organs involved, the severity of cardiac damage, C-reactive protein, energy intake, and WL, PCS was significantly lower for serum prealbumin <200 mg/L and MAMC <10th percentile (adjusted difference 3.8, 95% CI 0.18-7.5, p = 0.040 and 5.3, 95% CI 2.0-8.7, p = 0.002, respectively). MCS was decreased by 0.47 (95% CI 0.18-0.75, p = 0.002) for each kilogram of body weight lost in the previous 6 months. Nutritional status independently affects QoL in AL patients since diagnosis. Nutritional evaluation should be integral part of the clinical assessment of AL patients. Nutritional support intervention trials are warranted in such patients' population.

Nutritional parameters associated with prolonged hospital stay among ambulatory adult patients.

BACKGROUND: Comprehensive evaluations of the nutritional parameters associated with length of hospital stay are lacking. We investigated the association between malnutrition and length of hospital stay in a cohort of ambulatory adult patients. METHODS: From September 2006 to June 2009, we systematically evaluated 1274 ambulatory adult patients admitted to hospital for medical or surgical treatment. We evaluated the associations between malnutrition and prolonged hospital stay (> 17 days [> 75th percentile of distribution]) using multivariable log-linear models adjusted for several potential nutritional and clinical confounders recorded at admission and collected during and at the end of the hospital stay. RESULTS: Nutritional factors associated with a prolonged hospital stay were a Nutritional Risk Index score of less than 97.5 (relative risk [RR] 1.64, 95% confidence interval [CI] 1.31-2.06) and an in-hospital weight loss of 5% or greater (RR 1.60, 95% CI 1.30-1.97). Sensitivity analysis of data for patients discharged alive and who had a length of stay of at least three days (n = 1073) produced similar findings (adjusted RR 1.51, 95% CI 1.20-1.89, for Nutritional Risk Index score < 97.5). A significant association was also found with in-hospital starvation of three or more days (RR 1.14, 95% CI 1.01-1.28). INTERPRETATION: Nutritional risk at admission was strongly associated with a prolonged hospital stay among ambulatory adult patients. Another factor associated with length of stay was worsening nutritional status during the hospital stay, whose cause-effect relationship with length of stay should be clarified in intervention trials. Clinicians need to be aware of the impact of malnutrition and of the potential role of worsening nutritional status in prolonging hospital stay.