Pulmonary rehabilitation: A cohort study assessing the effectiveness of a multi-professional nutrition intervention.

BACKGROUND: Limited benefit of pulmonary exercise rehabilitation has been associated with fulfilment of energy and protein requirements. OBJECTIVES: The aim was to enhance dietary intake towards requirements and to maintain changes after a pulmonary rehabilitation program. METHODS: This single arm intervention study included multidisciplinary focus on nutrition and three sessions of individual dietary counselling during a 10-week pulmonary exercise rehabilitation in five municipalities centers. Data were collected at baseline (P0), at the end of intervention (P1) and for two municipalities at three months post intervention (P2). RESULTS: Of the 111 included participants, (mean age 70.8 (±9)) 99 (89%) completed the rehabilitation including the three individual dietary counselling's. A very large variation in body composition including body mass index and exercise abilities was found. Protein intake improved from 64 (±22 g) (P0) to 88 (±25 g) (P1) (p < 0.001) and energy intake from 1676 (±505 kcal) (P0) to 1941 (±553 kcal) (p < 0.001) (P1) and Muscle Mass Index increased from 10.6 (±3.2) (P0) to 10.9 (±3.2) (P1) (p = 0.007); number of 30 s chair stand test improved from 10.9 (±2.8) repetitions (P0) to 14.1 (±4.3) repetitions (P1) (p < 0.001), distance in six-minut walking test improved from 377.2 (±131.2 m) (P0) to 404.1 (±128.6 m) (P1) (p < 0.001). Two municipalities completed the three months follow-up. For those, dietary improvements remained stable, including protein intake. CONCLUSION: Including three sessions of dietary counselling in a multi-professional effort was associated with improved individualized dietary intake, as well as physical function. Benefits remained almost unchanged after three months. Improvements in function could not be fully explained by improved intakes.

Implementation of nutritional care in hospitals: A qualitative study of barriers and facilitators using implementation theory.

BACKGROUND: Disease-related malnutrition is prevalent among hospitalised patients, but not all patients achieve the needed nutritional care. At a Danish University Hospital, focus has been on implementing nutritional practices based on clinical guidelines, but there is continuously variation between the wards regarding the quality of nutritional care. AIM: The aim of this study was to identify the potential barriers and facilitators for implementation of the clinical guidelines for nutritional practices and to recommend suggestions for development of nutritional practices, using a theoretical implementation strategy. METHOD: The design was a qualitative interview study of employees at a Danish University Hospital, using a semi-structured interview guide. The participants were nurses, nurse's assistant, nurse nutrition expert, head nurse and dieticians. We recruited 11 employees, representing eight different wards. FINDINGS: The analysis identified six themes: (1) clear allocation of responsibilities and committed management enhances nutrition practices, (2) leadership support is essential, (3) physical settings and tools affect possibilities for action, (4) selection of equivalent staff is core, (5) teaching promotes the knowledge and skills and (6) a dietitian in the ward facilitates implementation of nutritional care. Barriers and facilitators among the themes were identified and has led to suggestions to strengthen nutritional care, based on implementation theory. CONCLUSION: Various factors were identified as having impact on the implementation of nutrition practices and different suggestions have emerged to accommodate those factors, as well as to apply an implementation strategy to facilitate change in practice.

Measured versus estimated energy requirement in hospitalized patients.

BACKGROUND & AIM: Failure to identify a patient's energy requirement has a variety of consequences both physiological and economical. Previous studies have shown that predictive formulas, including the Harris Benedict equation (HB), both over- and underestimates energy requirement in severely ill patients and healthy younger adults, compared to the golden standard, indirect calorimetry (IC). The comparison between measured and estimated energy requirements in hospitalized patients in regular wards is underreported. The aim of this study was to assess the agreement between measured energy requirements and requirements estimated by HB in the individual hospitalized patients, and to investigate whether those findings were associated with other specific patient characteristics. METHODS: IC (n = 86) was used to measure resting energy expenditure (REE) and bioimpedance analysis (BIA) (n = 67) was used for body composition in patients admitted to Aalborg University Hospital. Furthermore, height, weight, body mass index, calf circumference, while information regarding hospital ward, vital values, dieticians estimated energy requirements and blood samples were collected in the patients' electronic medical records. Bland-Altman plots, multiple linear regression analysis, and Chi2 tests were performed. RESULTS: On average a difference between IC compared with the HB (6.2%), dietitians' estimation (7.8%) and BIA (4.50%) was observed (p < 0.05). Association between REE and skeletal muscle mass (SMM) (R2 = 0.58, ß = 149.0 kJ), body fat mass (BFM) (R2 = 0.51, ß = 59.1 kJ), and weight (R2 = 0.62, ß = 45.6 kJ) were found (p < 0.05). A positive association between measured REE and HB were found in the following variables (p < 0.05): CRP, age, surgical patients, and respiratory rate. CONCLUSION: This study found a general underestimation of estimated energy expenditure compared to measured REE. A positive correlation between measured REE and SMM, BRM and weight was found. Lastly, the study found a greater association between CRP, age, surgical patients, and respiratory rate and a general greater than ±10% difference between measured and estimation of energy requirements.

Unintentional weight loss is reflected in worse one-year clinical outcomes among COPD outpatients.

RATIONALE: Unintentional weight loss (UWL) is prevalent among patients with chronic obstructive pulmonary disease (COPD). However, little research has been done on UWL as an independent variable in terms of clinical outcome. The aim of this study was to investigate the association between BMI, UWL, and clinical outcome in terms of hospitalization, length of stay, exacerbations, mortality, and quality of life (QoL) within six months and one year in a hospital outpatient setting. METHODS: A prospective single-center cohort study enrolled 200 patients from the COPD outpatient clinic between October 2020 and May 2021 at a Danish Hospital. At baseline, data was collected using patients' electronic journals and a quantitative questionnaire was gathered with a patient-reported UWL of 5% of body weight within three months. At six months and one-year follow-ups, data was collected using the patients' medical journals and a telephonic interview with the EQ-5D-5L and SARC-F questionnaire and the number of non-hospitalization exacerbations since inclusion. Data were analyzed using logistic and Cox hazard regression analysis. RESULTS: A total of 187 patients were eligible for follow-up (mean age 69.2 years, 43.9% males, median BMI 26.8 kg/m2), and the prevalence of UWL was 13.4%. UWL was associated with an almost trifold risk of >five days stay (OR = 2.94, p = 0.021). Additionally, UWL was associated with a worse QoL. A higher risk of exacerbation was found in the underweight patients (OR = 4.94, p = 0.014). No significant difference in mortality was found. CONCLUSION: UWL as a solitary factor is associated with increased hospital length of stay and a worse QoL. The results provide further evidence that implementation of regular screening for UWL in addition to BMI might be beneficial to include in international COPD guidelines for outpatient settings.

"More2Eat" in patients at nutritional risk during hospital stay lowers the risk of three-month mortality.

BACKGROUND & AIMS: Malnutrition is a common problem among hospitalized patients due to increased nutrient requirements and reduced food intake or uptake of nutrients. The aim of this prospective cohort study was to investigate the association of nutritional risk status (at or not at risk by NRS-2002) as well as energy and protein intake, use of oral nutritional supplements (ONS) and snack meals in at risk patients during hospitalization and adverse outcomes (length of stay (LOS), readmissions and mortality) at three-months follow-up. METHODS: Data were collected at baseline and at three-months follow-up in patients hospitalized at 31 units at a Danish University Hospital. Diet records were performed at baseline by using the nurses' quartile nutrition recording methods. Data about disease and clinical outcomes were collected from electronic medical records at baseline and three-months follow-up. RESULTS: A total of 318 patients were included. Patients at nutritional risk (n = 149, 47%) had higher risk of longer LOS (≥20 days (OR = 4.24 [1.81;9.95] and ≥30 days OR = 2.50 [1.22;5.14])), having one readmission (OR = 1.86 [1.15;3.01]) and death (OR = 2.56 [1.27;5.20]) compared to patients not at nutritional risk (n = 169, 53%). A longer LOS was associated with patients who achieved ≥75% of energy and protein requirements, consumed snack meals incl. and excl. oral nutritional supplements. Readmissions in patients at nutritional risk during the three-months were not associated with food intake during the index hospitalization. Mortality was observed in 43 of the 318 (13.5%) hospitalized patients. A lower mortality was associated with increased energy and protein intake in patients at nutritional risk. CONCLUSIONS: The results of this study indicate a longer LOS, higher readmission rate and increased mortality in patients at nutritional risk compared to patients not at risk. Patients at nutritional risk had lower risk of three-month mortality and longer LOS during index hospitalization with increased energy and protein intake. Readmissions in patients at nutritional risk were not affected by food intake. The association of nutritional risk with poorer outcomes indicates that good nutritional care including constant attention to food-intake during hospitalization can be beneficial regarding mortality.

Are nutritional sufficiency of ≥75% energy and protein requirements relevant targets in patients at nutritional risk? - A one month follow-up study.

BACKGROUND & AIM: Nutrient intake in patients at nutritional risk was recorded with the aim of reaching at least 75% of estimated requirements for energy and protein. However, the cutoff at 75% has only been sparsely investigated. The aim of this study was to re-evaluate the 75% cutoff of estimated energy and protein requirements among patients at or not at nutritional risk in relation to 30-day mortality and readmissions. METHODS: A 30-day follow-up study was performed among hospitalized patients in 31 units at a Danish University Hospital. Data was collected using the nurses' quartile nutrition registration method and electronic patient journals. All patients were screened using the NRS-2002 and classified as either at nutritional risk (NRS-2002, score ≥3) or not at nutritional risk (NRS-2002, score <3). Energy and protein requirements were estimated using weighted Harris-Benedict equation and 1.3 g/kg/day, respectively. RESULTS: In total, 318 patients were included in this study. Patients at nutritional risk were older, lower BMI, male, more comorbidities and a longer primary length of stay compared to patients not at nutritional risk (p < 0.05). After 30-day follow-up, mortality was higher among patients at risk (9.5% vs. 2.0%, p < 0.05). Patients at nutritional risk showed increased risk of mortality if they did not achieve 75% of estimated requirements (energy: OR = 8.08 [1.78; 36.79]; protein: OR = 3.40 [0.74; 15:53]). Furthermore, predicted probability of mortality decreased with increased energy and protein intakes. No significant associations were found for readmissions achieving 75% of estimated energy or protein requirements. A cutoff of 76-81% for energy and 58-62% for protein was equivalent with accepting a 6-8% mortality rate. CONCLUSION: The results of this study indicate that an energy intake ≥75% of estimated requirement among patients at nutritional risk has a preventative effect regarding mortality within one month, but not for readmissions.

A 1-year follow-up study in patients with idiopathic pulmonary fibrosis regarding adverse outcomes to unintended weight loss.

OBJECTIVES: Malnutrition in pulmonary fibrosis may influence clinical outcomes negatively. This project aimed to investigate if weight, unintended weight loss (UWL) at baseline and weight development, and signs of sarcopenia measured by the strength, assistance with the walking, rising from a chair, climbing stairs, and falls questionnaire (SARC-F) are associated with hospital admissions and mortality for idiopathic pulmonary fibrosis outpatients in ≤1 y as well as referral to pulmonary rehabilitation. METHODS: At baseline, prevalence of weight and UWL were sought in a cross-sectional questionnaire study, consecutively, including 100 patients in an outpatient clinic. Medical records were sought for time from diagnosis and comorbidities. One year after inclusion weight, UWL and SARC-F were collected by phone interviews, and medical records were revisited for clinical outcomes. RESULTS: Of the 100 patients, two patients died and seven were lost to follow-up. The prevalence of UWL increased within the year (10-13%), and the amount of UWL increased (9.1-11.8 kg). Patients with a UWL at baseline had a significantly higher risk of mortality (odds ratio = 29.8; P = 0.037). UWL at baseline was associated with risk of hospital admissions (odds ratio = 14.7; P = 0.009). Based on the results from SARC-F, 20.9% have signs of sarcopenia. UWL at follow-up was associated with the risk of sarcopenia by SARC-F. Patients with risk of sarcopenia and those with body mass index ≥30 kg/m2 were to a higher degree offered pulmonary rehabilitation; however, participation was low. CONCLUSIONS: UWL at baseline was significantly associated with risk of hospital admissions and mortality in ≤1 y in idiopathic pulmonary fibrosis outpatients. Patients with signs of sarcopenia and body mass index ≥30 kg/m2 were most often referred to pulmonary rehabilitation.

Chronic obstructive pulmonary disease outpatients bear risks of both unplanned weight loss and obesity.

BACKGROUND & AIMS: Malnutrition is commonly seen in chronic obstructive pulmonary disease (COPD) and has been associated with negative outcomes. The objective of this study was to examine unintended weight loss (UWL) within three months, as a primary indicator for disease related malnutrition among COPD outpatients, to evaluate the prevalence of UWL, and to identify possible characteristics for UWL. METHODS: A cross-sectional study including a patient questionnaire and medical record data extraction was made with all patients visiting a Danish COPD outpatient clinic. RESULTS: Among the 200 included patients (68.7 ± 11.2 years of age), UWL was seen in 21.5%, with a median weight loss of 3.5 (2-16) kg. Underweight (BMI<18.5 kg/m2) was recognized in 13.5%, while 34.5% were obese (BMI>30 kg/m2). Reduced food intake (RFI) within the past week was experienced among 22.0% of the patients. The most common nutrition impact symptoms (NIS) were shortness of breath, reduced appetite and nausea. NIS, RFI and BMI<18.5 kg/m2 were associated to UWL, while co-morbidities, hospitalization within three months and resent exacerbations showed no association to UWL. CONCLUSIONS: A high prevalence of UWL was found in COPD outpatients, and NIS and RFI as characteristics associated with UWL. Shortness of breath, reduced appetite and nausea were the most common NIS. This study found 13.5% of patients underweight, 23.5 overweight and 34.5% obese. Underweight as well as obesity may have negative consequences for the patient and the community.

Malnutrition measured by unintended weight loss among patients in general practice.

OBJECTIVE: Disease-related malnutrition should be managed before negative consequences occur. The aim of this study was to investigate the prevalence of unintended weight loss and reduced food intake among patients ≥18 y of age attending a general practice. METHODS: All patients visiting five general practices in Denmark, for 4 d in each place, were invited to participate in this questionnaire-based cross-sectional study. The questionnaire consisted of eight questions including unintended weight loss within the previous 2 mo, reduced food intake within the previous week, and symptoms that affected nutrition. Descriptive statistics, χ2 tests, and simple and multivariable logistic regression analysis were performed. The study included 1087 patients with an 88.7% response rate. RESULTS: Unintended weight loss was found in 14.2% and 12.9% had reduced food intake. Of the patients with unintended weight loss, 62.3% also had reduced food intake. Patients 18 to 39 and >80 y of age; underweight patients; and patients visiting general practice for chronic pain, mental discomfort, and suspicion of serious illness had significantly higher odds for unintended weight loss and reduced food intake. Patients with reduced food intake had higher odds for unintended weight loss, and those visiting the general practice due to fatigue had higher odds for reduced food intake. Patients in obesity class 1 to 3 and patients who had come for a general health checkup had lower odds. Patients visiting for follow-up on chronic physical illness had higher odds of having unintended weight loss and reduced food intake combined. CONCLUSION: Overall, 14.2% of the patients had unintended weight loss, 12.9% had reduced food intake, and 62.3% had both, indicating a high prevalence of unintended weight loss among patients in general practice. Unintended weight loss seems relevant and feasible to use as an initial indicator for the need for further nutritional screening in general practice. Studies are needed to investigate the effect of interventions and outcomes.

Healthcare professionals' experiences with practice for managing disease-related malnutrition in general practice and proposals for improvement: A qualitative study.

BACKGROUND & AIM: Disease-related malnutrition is prevalent in all healthcare settings, including general practice, and is associated with negative consequences for the individual and the community. The aim of this study was to investigate general practitioners and general practice nurses' perceptions of how they manage disease-related malnutrition, and their view on introducing an early intervention against disease-related malnutrition. METHODS: Content analysis was used to analyse individual semi-structured interviews with the general practitioners (n = 9) and five focus group interviews with the general practice nurses (n = 21) from five general practices in Denmark. RESULTS: General practice has no tradition for detection of disease-related malnutrition and find that they rarely see patients with unintended weight loss. Nutritional guidance is to a low degree and only randomly performed. Furthermore, most of the health professionals do not have access to nutritional guidance material for patients and lack information about patients' nutrition, when patients when patients receive treatment in the hospital. Suggestions for improvement were handouts with pictures and including nutritional status as a standard in the communication from hospital to general practice. An early intervention against unintended weight loss in specific groups was found feasible. Barriers and facilitators were seen as lack of time, lack of educational opportunities and skills. A financial incentive from the health authorities, and interventions adapted to the individual general practice were among suggested facilitators. CONCLUSION: Disease-related malnutrition was rarely recognised and managed in general practice. The health professionals found they lacked means to perform nutritional guidance to patients with unintended weight loss. However, the health professionals had suggestions for improvement for an early intervention including handouts for patients. Further research on implementation of early intervention against unintended weight loss in general practice is needed.

Different GLIM criteria combinations change prevalence of malnutrition in patients with intestinal insufficiency or intestinal failure.

BACKGROUND & AIM: Due to lack of global consensus in diagnosing malnutrition, Global Leadership Initiative on Malnutrition (GLIM) has suggested the GLIM criteria based on etiological and phenotypical criteria. The aim of this study was to investigate the prevalence of malnutrition in patients with intestinal insufficiency (INS) or intestinal failure (IF) based on the different GLIM criteria combinations to diagnose malnutrition. Furthermore, the aim was to investigate the severity of malnutrition in the two patient groups. METHODS: A cross-sectional study with INS patients on enteral nutrition and IF patients on home parenteral nutrition. We recorded age, gender, weight, height, fat free mass index (FFMI) by bioelectrical impedance analysis, handgrip strength (HGS), arm muscle circumference (AMC) and biochemical parameters: plasma albumin (p-alb) and plasma C-reactive protein (p-CRP). Further, we calculated Glasgow prognostic score (GPS) and body mass index (BMI). STATISTICS: T-test, Chi-square test and simple logistic regression analysis. Significance level: p < 0.05. RESULTS: In total 277 INS and IF patients were included (age 59.5 ± 15.2 years, male 43,7%, BMI 22.1 ± 4.3 kg/m2). Groups were comparable according to number, age and gender but more IF patients had decreased BMI, p-alb, HGS and FFMI and increased CRP and GPS 1 or 2. Prevalence of malnutrition using GPS 1 or 2 combined with BMI, FFMI or HGS was 22.6%, 23.4%, 26.3% for INS, respectively (p = 0.756) and 40.7%, 40.0%, 59.3% for IF, respectively (p = 0.001). Agreement between the criteria combinations were: 8.0% for INS and 25.7% for IF. Significantly more with IF was diagnosed with severe malnutrition as compared to no malnutrition (43 vs. 26, p = 0.012, OR 2.1 [CI95% 1.2-3.8]), but only a tendency in the group with moderate malnutrition as compared to no malnutrition (27 vs. 22, p = 0.180, OR 1.6 [CI95% 0.8-3.0]) CONCLUSION: We found both prevalence and severity of malnutrition to be higher in IF than INS patients. GLIM-criteria were able to identify approximately same prevalence of malnutrition in INS but not in IF, when combining GPS 1 or 2 with BMI, FFMI and HGS. However, the agreement was poor in both groups. Consequently, further validation of GLIM is needed - including association to clinical outcome in lack of a gold standard.

Unintended weight loss in hematology outpatients - Work to do.

BACKGROUND: Malnutrition frequently occurs in hematology diseases and may threaten the course of treatment and patient outcomes. While screening for nutritional risk is often done in hospitalized patients, it is rarely described in the outpatient setting. Hematology patients are often followed in outpatient settings before hospitalization and for a longer time after. AIMS: The primary aim of this study was to investigate the prevalence of nutritional risk measured by unintended weight loss within three months and reduced food intake within one week among patients in a hematology outpatient clinic. The second purpose was to investigate the two variables as a quick initial screening tool. METHODS: All patients visiting the outpatient clinic within one week were invited to participate in this study, designed as a questionnaire-based cross-sectional study, consisting of nine questions. Descriptive statistical analyses, chi2 test and simple logistic regression analyses were performed. RESULTS: Of the 219 included patients, 23.7% had an unintended weight loss of mean 13.7% of body weight within the last three months and 13.2% had eaten less than usual within the past week. Patients who had significantly increased odds for unintended weight loss were >80 years of age [CI95%: 1274; 6084], patients visiting for examinations [CI95%: 1.105; 7.227], patients visiting for treatment [CI95%: 1.383; 6598] and patients visiting as part of a course of investigations [CI95%: 1.112; 34.184] as well as patients who had eaten less [CI95%: 2.731; 14.224]. Patients visiting the outpatient clinic for examination had significantly increased odds of having eaten less [CI95%: 1.783; 14.629]. CONCLUSIONS: Based on the statistical analyses, almost one fourth of the patients had a significant unintended weight loss, about 15% had reduced food intake and only 7.8% had both unintended weight loss and reduced food intake. These results indicate that unintended weight loss can be used as a quick screening tool to identify and detect patients at risk of malnutrition and that guidelines should be drawn up for managing patients at nutritional risk in hematology outpatient clinics.

High risk of disease-related malnutrition in gastroenterology outpatients.

OBJECTIVE: Disease-related malnutrition (DRM) in hospitalized patients is known to have significant negative impact on clinical outcomes. Meanwhile, DRM in gastroenterology outpatients is scarcely investigated. The aim of this study was to investigate the prevalence of unintentional weight loss (UWL) and reduced food intake (RFI) as contributors to the risk of DRM in outpatients. Furthermore, the aim was to investigate if UWL may be used as initial screening for DRM, based on the correlation between UWL and RFI. METHODS: All outpatients visiting the clinics for Medical and Surgery Gastroenterology, Aalborg University Hospital, Denmark, during 1 wk in September 2018, were invited to participate. Data regarding UWL within the past 3 mo, RFI the past week, and nutritional impact symptoms (NIS) were collected in this questionnaire-based cross-sectional study. Descriptive analysis, χ2 test, and multiple logistic regression analysis were used for statistics. RESULTS: Out of 348 eligible patients, 346 were included at the medical clinic (n = 170) and surgery clinic (n = 176). UWL occurred in 26%, with a mean weight loss of 7.1 kg (standard deviation [SD] 5.2), and 24% had RFI. A significantly increased risk of UWL was identified in patients with body mass index <18.5 kg/m2 (odds ratio 6.1; confidence interval 2.0-18.7; P = 0.003). NIS were more common in the medical clinic. The main self-reported reasons for NIS affecting UWL were lack of appetite (15% versus 12%), pain (14% versus 8%), and nausea (12% versus 3%). CONCLUSIONS: One in four outpatients experienced UWL to an extent that may have a significant negative impact on clinical outcome. A firm correlation was found between UWL and RFI. Thus, based on this superficial study, UWL may be used as initial screening for protein-energy malnutrition in the medical and surgery gastroenterology outpatient setting. The impact on clinical outcome and of early nutritional intervention in these settings need to be investigated.