Detection and treatment of medical inpatients with or at-risk of malnutrition: Suggested procedures based on validated guidelines.

OBJECTIVE: Despite the high prevalence of malnutrition in the general inpatient population, there is a lack of knowledge in regard to detecting disease-related malnutrition and implementing nutritional support. Our aim was to suggest practical procedures for screening and treating malnourished or at-risk patients hospitalized in medical wards, thereby fostering a straightforward implementation of nutritional therapy independent of the underlying disease and comorbidities. METHODS: A working group of experts in clinical nutrition selected and analyzed published disease-specific European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines relevant for our aim. Eight questions in population, intervention, control, outcome format were defined to cover topics such as screening, nutritional targets, and routes of feeding. Individual studies were extracted from the guidelines by applying inclusion and exclusion criteria targeting the heterogeneous population of medical inpatients with or at-risk of disease-related malnutrition. We used those studies as evidence, as well as recommendations from the selected ESPEN guidelines, to formulate answers to the questions. Final agreement with the statement was obtained by consensus of the whole working group. RESULTS: Procedures on how to provide integrated nutritional therapy (oral, enteral, and parenteral) to a heterogeneous patient population were suggested, including how to identify malnourished or at-risk patients, nutrient targets, choice of feeding route, monitoring, and assessment of patients. We also developed a simple algorithm to facilitate the implementation of a nutritional care plan for the general medical inpatient population. CONCLUSION: By compiling evidence and recommendations from disease-specific guidelines, we were able to suggest a nutritional strategy applicable to large and heterogeneous group of malnourished or at-risk patients admitted to hospitals. A large randomized controlled trial is currently investigating whether this strategy improves clinical outcomes of patients.

Preoperative nutritional screening by the specialist instead of the nutritional risk score might prevent excess nutrition: a multivariate analysis of nutritional risk factors.

BACKGROUND: The aim of the current study was to assess whether widely used nutritional parameters are correlated with the nutritional risk score (NRS-2002) to identify postoperative morbidity and to evaluate the role of nutritionists in nutritional assessment. METHODS: A randomized trial on preoperative nutritional interventions (NCT00512213) provided the study cohort of 152 patients at nutritional risk (NRS-2002 ≥3) with a comprehensive phenotyping including diverse nutritional parameters (n=17), elaborated by nutritional specialists, and potential demographic and surgical (n=5) confounders. Risk factors for overall, severe (Dindo-Clavien 3-5) and infectious complications were identified by univariate analysis; parameters with P<0.20 were then entered in a multiple logistic regression model. RESULTS: Final analysis included 140 patients with complete datasets. Of these, 61 patients (43.6%) were overweight, and 72 patients (51.4%) experienced at least one complication of any degree of severity. Univariate analysis identified a correlation between few (≤3) active co-morbidities (OR=4.94; 95% CI: 1.47-16.56, p=0.01) and overall complications. Patients screened as being malnourished by nutritional specialists presented less overall complications compared to the not malnourished (OR=0.47; 95% CI: 0.22-0.97, p=0.043). Severe postoperative complications occurred more often in patients with low lean body mass (OR=1.06; 95% CI: 1-1.12, p=0.028). Few (≤3) active co-morbidities (OR=8.8; 95% CI: 1.12-68.99, p=0.008) were related with postoperative infections. Patients screened as being malnourished by nutritional specialists presented less infectious complications (OR=0.28; 95% CI: 0.1-0.78), p=0.014) as compared to the not malnourished. Multivariate analysis identified few co-morbidities (OR=6.33; 95% CI: 1.75-22.84, p=0.005), low weight loss (OR=1.08; 95% CI: 1.02-1.14, p=0.006) and low hemoglobin concentration (OR=2.84; 95% CI: 1.22-6.59, p=0.021) as independent risk factors for overall postoperative complications. Compliance with nutritional supplements (OR=0.37; 95% CI: 0.14-0.97, p=0.041) and supplementation of malnourished patients as assessed by nutritional specialists (OR=0.24; 95% CI: 0.08-0.69, p=0.009) were independently associated with decreased infectious complications. CONCLUSIONS: Nutritional support based upon NRS-2002 screening might result in overnutrition, with potentially deleterious clinical consequences. We emphasize the importance of detailed assessment of the nutritional status by a dedicated specialist before deciding on early nutritional intervention for patients with an initial NRS-2002 score of ≥3.

Pioglitazone improves fat distribution, the adipokine profile and hepatic insulin sensitivity in non-diabetic end-stage renal disease subjects on maintenance dialysis: a randomized cross-over pilot study.

BACKGROUND: Fat redistribution, increased inflammation and insulin resistance are prevalent in non-diabetic subjects treated with maintenance dialysis. The aim of this study was to test whether pioglitazone, a powerful insulin sensitizer, alters body fat distribution and adipokine secretion in these subjects and whether it is associated with improved insulin sensitivity. TRIAL DESIGN: This was a double blind cross-over study with 16 weeks of pioglitazone 45 mg vs placebo involving 12 subjects. METHODS: At the end of each phase, body composition (anthropometric measurements, dual energy X-ray absorptometry (DEXA), abdominal CT), hepatic and muscle insulin sensitivity (2-step hyperinsulinemic euglycemic clamp with 2H2-glucose) were measured and fasting blood adipokines and cardiometabolic risk markers were monitored. RESULTS: Four months treatment with pioglitazone had no effect on total body weight or total fat but decreased the visceral/sub-cutaneous adipose tissue ratio by 16% and decreased the leptin/adiponectin (L/A) ratio from 3.63 × 10(-3) to 0.76 × 10(-3). This was associated with a 20% increase in hepatic insulin sensitivity without changes in muscle insulin sensitivity, a 12% increase in HDL cholesterol and a 50% decrease in CRP. CONCLUSIONS/LIMITATIONS: Pioglitazone significantly changes the visceral-subcutaneous fat distribution and plasma L/A ratio in non diabetic subjects on maintenance dialysis. This was associated with improved hepatic insulin sensitivity and a reduction of cardio-metabolic risk markers. Whether these effects may improve the outcome of non diabetic end-stage renal disease subjects on maintenance dialysis still needs further evaluation. TRIAL REGISTRATION: ClinicalTrial.gov NCT01253928.

Comparison of the interobserver variability of 2 different methods of dietary assessment in a geriatric ward: a pilot study.

BACKGROUND: Protein-energy malnutrition is highly prevalent in aged populations. Associated clinical, economic, and social burden is important. A valid screening method that would be robust and precise, but also easy, simple, and rapid to apply, is essential for adequate therapeutic management. OBJECTIVES: To compare the interobserver variability of 2 methods measuring food intake: semiquantitative visual estimations made by nurses versus calorie measurements performed by dieticians on the basis of standardized color digital photographs of servings before and after consumption. DESIGN: Observational monocentric pilot study. SETTING/PARTICIPANTS: A geriatric ward. The meals were randomly chosen from the meal tray. The choice was anonymous with respect to the patients who consumed them. MEASUREMENTS: The test method consisted of the estimation of calorie consumption by dieticians on the basis of standardized color digital photographs of servings before and after consumption. The reference method was based on direct visual estimations of the meals by nurses. Food intake was expressed in the form of a percentage of the serving consumed and calorie intake was then calculated by a dietician based on these percentages. The methods were applied with no previous training of the observers. Analysis of variance was performed to compare their interobserver variability. RESULTS: Of 15 meals consumed and initially examined, 6 were assessed with each method. Servings not consumed at all (0% consumption) or entirely consumed by the patient (100% consumption) were not included in the analysis so as to avoid systematic error. The digital photography method showed higher interobserver variability in calorie intake estimations. The difference between the compared methods was statistically significant (P < .03). CONCLUSIONS: Calorie intake measures for geriatric patients are more concordant when estimated in a semiquantitative way. Digital photography for food intake estimation without previous specific training of dieticians should not be considered as a reference method in geriatric settings, as it shows no advantages in terms of interobserver variability.

Effect of intradialytic resistance band exercise on physical function in patients on maintenance hemodialysis: a pilot study.

Although physical activity is recommended in patients on maintenance hemodialysis (MHD), randomized controlled trials testing the effects of exercise in this population have given conflicting results. In general, aerobic exercises mostly failed to produce improvements in physical function, whereas resistance exercises, although less studied, appeared to be more promising. The use of sophisticated materials such as leg press and free weights may preclude widespread application of resistance training in patients on MHD. Simple and cheap elastic bands may thus be an attractive alternative. We tested the feasibility of a supervised intradialytic resistance band exercise training program, and its effects on physical function, in patients on MHD. A total of 11 unselected adult patients on MHD from our center, aged 70 ± 10.7 (mean ± standard deviation) years, including 8 men and 3 women, accepted to follow the program under the supervision of qualified physiotherapists. Thirty-six exercise sessions of moderate intensity (twice a week, mean duration 40 minutes each, during 4.5 to 6 months), mainly involving leg muscles against an elastic resistance, were performed. The exercise program was well tolerated and all patients completed it. Statistically significant improvements were observed in the following tests: Tinetti test, 23.9 ± 3.9 points before versus 25.7 ± 3.5 points after the program (P = .022); the Timed Up and Go test, 12.1 ± 6.6 versus 10 ± 5.8 seconds (P = .0156). Improvements in the 6-minute walk distance and in the one-leg balance tests just failed to reach statistical significance. In this single-center pilot study, an intradialytic resistance band exercise program was feasible, well tolerated, and showed encouraging results on physical function.

[Anorexia and malnutrition]. / Anorexie et dénutrition.

Anorexia is a frequent and complex symptom occurring physiologically in older persons and during acute or chronic pathology. It's an adaptable physiological response to stress. It must be respected as such, as long as it's quickly reversible. The study of anorexia requires evaluation of oral intakes, causal aetiology and nutritional repercussion on body composition, different systems function and quality of life. Early artificial nutrition is recommended for adult patient who severely diminished oral intakes for 7 to 10 days after the beginning of acute pathology. Artificial nutrition is also indicated with chronic pathology associated with a significant weight loss. Faced to the impossibility of treating anorexia and its all causes, we have to treat at least anorexia repercussions and prevent undernutrition with an adequate artificial nutrition.

Preoperative nutritional support at home in head and neck cancer patients: from nutritional benefits to the prevention of the alcohol withdrawal syndrome.

PURPOSE OF REVIEW: Preoperative nutritional support in severely malnourished patients decreases complications after major surgery. This review summarizes previous studies on head and neck cancer patients undergoing surgery, and offers recommendations on preoperative nutritional support based on the literature and our experience. RECENT FINDINGS: Head and neck cancer has a large impact on the patient's quality of life and a high mortality rate. Aggressive surgical resection followed by soft-tissue and osseous reconstruction is the gold standard of treatment. The incidence of postoperative complications is high at 20-50%. Malnutrition and alcohol withdrawal syndrome are often present, and are considered risk factors for developing wound infection after head and neck cancer surgery. Proactive intervention by preoperative nutritional support may correct nutrient deficiencies, minimize malnutrition-related morbidity and mortality, reduce the length and cost of hospitalization, and may prevent alcohol withdrawal syndrome. Nutritional support given preoperatively for 7-10 days decreases postoperative complications by approximately 10% in malnourished patients with weight loss of 10% or more. Oral liquid supplements and enteral nutrition are useful to support head and neck cancer patients preoperatively. Enteral nutrition is safer, more physiological, less expensive and practicable at home compared with parenteral nutrition, which is not usually indicated in these patients. SUMMARY: Enteral nutrition is efficient in preoperative phase to prevent postoperative complications. However evidence is insufficient to conclude that preoperative immune-enhancing enteral feeding provides any supplementary benefit by comparison with a standard diet. Our experience with the preoperative approach in head and neck cancer patients is reported in this paper.