During Hospitalization, Older Patients at Risk for Malnutrition Consume <0.65 Grams of Protein per Kilogram Body Weight per Day

The effect of dose, frequency, and timing of protein supplementation on muscle mass in older adults: A systematic review and meta-analysis

Protein supplementation has shown to improve muscle mass in older adults. However, its effect may be influenced by supplementation dose, frequency and timing. This systematic review aimed to assess the effect of dose, frequency and timing of protein supplementation on muscle mass in older adults. Five databases were systematically searched from inception to 14 March 2023, for randomised controlled trials investigating the effect of protein supplementation on muscle mass in adults aged ≥65 years. Random effects meta-analyses were performed, stratified by population. Subgroups were created for dose (≥30 g, <30 g/day), frequency (once, twice, three times/day) and timing of supplementation (at breakfast, breakfast and lunch, breakfast and dinner, all meals, between meals). Heterogeneity within and between subgroups was assessed using I2 and Cochran Q statistics respectively. Thirty-eight articles were included describing community-dwelling (28 articles, n=3204, 74.6±3.4 years, 62.8 % female), hospitalised (8 articles, n=590, 77.0±3.7 years, 50.3 % female) and institutionalised populations (2 articles, n=156, 85.7±1.2 years, 71.2 % female). Protein supplementation showed a positive effect on muscle mass in community-dwelling older adults (standardised mean difference 0.116; 95 % confidence interval 0.032-0.200 kg, p=0.007, I2=15.3 %) but the effect did not differ between subgroups of dose, frequency and timing (Q=0.056, 0.569 and 3.084 respectively, p>0.05). Data including hospitalised and institutionalised populations were limited. Protein supplementation improves muscle mass in community-dwelling older adults, but its dose, frequency or timing does not significantly influence the effect.

Access to a pre-sleep protein snack increases daily energy and protein intake in surgical hospitalized patients

BACKGROUND & AIM

In hospitalized patients, daily protein intake remains far below WHO requirements for healthy adults (0.8 g·kg-1·d-1) as well as ESPEN guidelines for patients (1.2-1.5 g·kg-1·d-1). Providing access to a pre-sleep protein dense snack between dinner and going to bed may serve as a great opportunity to increase daily energy and protein intake in hospitalized patients. However, it remains to be assessed whether protein provision prior to sleep effectively increases protein intake, or may reduce food intake throughout the remainder of the day(s). The present study evaluated the impact of giving access to a pre-sleep snack on daily energy and protein intake in patients throughout their hospitalization.

METHODS

Patients admitted to the surgical wards of the Maastricht University Medical Centre+ were randomly allocated to usual care (n = 51) or given access to a pre-sleep snack (n = 50). The pre-sleep snack consisted of 103 g cheese cubes (30 g protein) provided between 7:30 and 9:30 PM, prior to sleep. All food provided and all food consumed was weighed and recorded throughout (2-7 days) hospitalization. Daily energy and protein intake and distribution were calculated. Data were analyzed by independent T-Tests with P < 0.05 considered as statistically significant.

RESULTS

Daily energy intake was higher in the pre-sleep group (1353 ± 424 kcal d-1) when compared to the usual care group (1190 ± 402 kcal·d-1; P = 0.049). Providing patients access to a pre-sleep snack resulted in a 17% (11 ± 9 g) higher daily protein intake (0.81 ± 0.29 g·kg-1·d-1) when compared to the usual care group (0.69 ± 0.28 g·kg-1·d-1; P = 0.045). Protein intake at breakfast, lunch, and dinner did not differ between the pre-sleep and usual care groups (all P > 0.05).

CONCLUSION

Providing access to a pre-sleep protein snack, in the form of protein dense food items such as cheese, represents an effective dietary strategy to increase daily energy and protein intake in hospitalized patients. Patients consuming pre-sleep protein snacks do not compensate by lowering energy or protein intake throughout the remainder of the days. Pre-sleep protein dense food provision should be implemented in hospital food logistics to improve the nutritional intake of patients.

TRIAL REGISTER NO

NL8507 (https://trialsearch.who.int/).

Clinical observation and influence on nutritional status of intensive nutritional nursing combined with 3-day dietary diary intervention in peritoneal dialysis patients

BACKGROUND

Peritoneal dialysis is a commonly used treatment for chronic kidney failure patients. Studies have shown that long-term peritoneal dialysis can lead to various degrees of malnutrition. Therefore, it is of great significance to improve the nutritional conditions of patients with peritoneal dialysis. This retrospective cohort study aimed to evaluate the clinical effects of intensive nutritional nursing combined with a 3-day diet diary intervention on the nutritional condition of peritoneal dialysis patients.

METHODS

In total, 163 patients were included in this study and, after 6 months of intervention, their nutritional and biochemical indicators, body weight, body mass index (BMI) and intake of dietary ingredients were analysed.

RESULTS

After the intervention, patients' serum albumin, haemoglobin, prealbumin, body weight, BMI and cholesterol levels were significantly increased (p < 0.05). Also, the daily energy and protein intake were significantly increased, whereas phosphorus intake was decreased (p < 0.05). Of note, the effective rate of intervention was 63.8%, respectively. We also found that factors such as the patient's age, education degree, income level and peritoneal dialysis age were the risk factors associated with malnutrition. Moreover, patients younger than 55 years old, with dialysis age younger than 5 years, unmarried/divorced and high school graduates, had higher chances of effective intervention, whereas the possibility of effective intervention was lower when the per capita monthly household income was less than 4000 Yuan.

CONCLUSIONS

In conclusion, intensive nutritional nursing combined with a 3-day dietary diary intervention can significantly improve the nutritional condition and optimise the diet structure of peritoneal dialysis patients with malnutrition. These findings provide evidence for healthcare providers to develop personalised interventions to address malnutrition in this population.

Individualised nutritional treatment increases the positive effects of a novel á la carte hospital food service concept: Results of a quasi-experimental study

BACKGROUND & AIMS

One-third of hospitalised patients are at nutritional risk, and limited choice regarding meals and meal times, and inadequate nutritional support may contribute to inadequate nutritional intake during hospitalisation. The aim was to test the effect of a novel á la carte hospital food service concept as a stand-alone intervention and combined with individualised nutritional treatment.

METHODS

Medical inpatients at nutritional risk were recruited for this three-arm quasi-experimental study. The control group received meals from the traditional bulk trolley food service system. Intervention group 1 (IG1) received meals from a novel á la carte food service concept with an electronic ordering system, whereas intervention group 2 (IG2) in addition to this received individualised nutritional treatment by a clinical dietitian. Nutritional intake and length of stay was measured, and patient satisfaction was assessed with purpose-designed questionnaires.

RESULTS

206 patients were included: 67 in the control group, 68 in IG1, and 71 in IG2. The proportion of participants reaching ≥75 % of both their energy and protein requirement was higher in IG1 compared to the control group (34 % vs. 12 %, p = 0.002) and higher in IG2 compared to IG1 (53 % vs. 34 %, p = 0.035). Length of stay was shorter in IG2 compared to the control group (6.0 vs. 8.7 days, p = 0.005). It was important to participants to be able to choose when and what to eat, and this preference was met to a larger extent in the intervention groups.

CONCLUSION

The novel á la carte concept increases energy and protein intake in hospitalised patients, and the positive effects are increased, when the concept is used in combination with individualised nutritional treatment.

Management of disease-related malnutrition: a real-world experience with a novel concentrated high-protein energy-dense oral nutritional supplement

OBJECTIVE

Despite the availability of a wide range of oral nutritional supplements (ONS) offerings, individuals with malnutrition are still struggling to meet their nutritional targets. A new concentrated and high-protein energy-dense ONS (≥2.1 kcal/mL;32 g protein/200 mL) with high-quality protein (60% whey protein) has emerged as a pivotal formula to reach the patient's energy-protein requirements, enhance compliance, and maximize stimulation of muscle protein synthesis, key factors driving better nutritional, functional, and clinical outcomes. The purpose of this article is to provide our clinical experience using this new nutritionally concentrated ONS as a therapeutic strategy for patients with DRM.

METHODS

Three clinical cases have been examined using new assessment procedures and a new form of nutritional therapy, and their impact on the nutritional and functional outcomes in patients with moderate-to-severe DRM.

RESULTS

A tailored individualized nutritional interventions improved anthropometric, biochemical, and functional outcomes (Case 1,2, and 3) assessed using hand grip strength, bioimpedance and muscle ultrasound, and as well as good gastrointestinal tolerance (Case 1) and compliance to the ONS in patients with DRM (Case 1,2,3).

CONCLUSION

The use of this novel high-protein energy-dense formula with high-quality protein source (≥2.1 kcal/mL; 32 g protein/200 mL; 60% whey protein) overcome common practical challenges in the medical nutrition therapy of patients with DRM, either because these patients require a highly concentrated formulation to meet nutritional requirements due to loss of appetite, lack of interest in food, and high caloric-protein needs due to disease, and a large quantity and quality of protein to optimize muscle recovery due to sarcopenia, common in patients with moderate-severe malnutrition.

Dietary assessment methods for measurement of oral intake in acute care and critically ill hospitalised patients: a scoping review

Quantification of oral intake within the hospital setting is required to guide nutrition care. Multiple dietary assessment methods are available, yet details regarding their application in the acute care setting are scarce. This scoping review, conducted in accordance with JBI methodology, describes dietary assessment methods used to measure oral intake in acute and critical care hospital patients. The search was run across four databases to identify primary research conducted in adult acute or critical care settings from 1st of January 2000-15th March 2023 which quantified oral diet with any dietary assessment method. In total, 155 articles were included, predominantly from the acute care setting (n = 153, 99%). Studies were mainly single-centre (n = 138, 88%) and of observational design (n = 135, 87%). Estimated plate waste (n = 59, 38%) and food records (n = 43, 28%) were the most frequent assessment methods with energy and protein the main nutrients quantified (n = 81, 52%). Validation was completed in 23 (15%) studies, with the majority of these using a reference method reliant on estimation (n = 17, 74%). A quarter of studies (n = 39) quantified completion (either as complete versus incomplete or degree of completeness) and four studies (2.5%) explored factors influencing completion. Findings indicate a lack of high-quality evidence to guide selection and application of existing dietary assessment methods to quantify oral intake with a particular absence of evidence in the critical care setting. Further validation of existing tools and identification of factors influencing completion is needed to guide the optimal approach to quantification of oral intake in both research and clinical contexts.

The ability of the geriatric nutritional risk index to predict the risk of heart diseases in Korean adults: a Korean Genome and Epidemiology Study cohort

Introduction

The predictive ability of nutritional risk index on cardiovascular outcomes in middle-aged and non-hospitalized adults has not yet been reported. This study investigated whether the Geriatric Nutritional Risk Index (GNRI), an index for assessing the risk of developing malnutrition, could predict heart disease in middle-aged Korean adults.

Methods

The cohort used in this study consisted of 3,783 participants selected from 10,030 Korean adults who participated in the Ansan-Ansung cohort study as part of the Korean Genome and Epidemiology Study. The GNRI was determined based on serum albumin level, proportion of current weight, and ideal body weight. Participants were then divided into two groups: GNRI ≤98 and > 98, which corresponded to the risk of malnutrition and normal, respectively. The major outcome of this study was coronary artery disease (CAD) or congestive heart failure (CHF) during a 15-year-follow period.

Results

During the follow-up period spanning 2004-2018, 136 events of heart disease occurred. Using a Kaplan-Meier analysis, event-free rates were found to be associated with 90.5% on a GNRI ≤98 and 96.6% on a GNRI >98 (p < 0.0009). GNRI ≤98 showed a 3.2-fold (hazard ratio, 3.22; 95% credit interval, 1.49-6.96; p = 0.0029) increase in the incidence of heart disease, including CAD or CHF, compared with GNRI >98, after controlling for potential confounders.

Conclusion

Malnutrition risk confers a significantly increased risk for heart disease in middle-aged Koreans. Further studies with larger cohorts are needed to verify the efficacy of the GNRI in predicting disease risk in adults with pre-disease.

Short-Term Effects of Dietary Protein Supplementation on Physical Recovery in Older Patients at Risk of Malnutrition during Inpatient Rehabilitation: A Pilot, Randomized, Controlled Trial

It is estimated that about 50% of geriatric rehabilitation patients suffer from sarcopenia. Thereby, malnutrition is frequently associated with sarcopenia, and dietary intake is the main modifiable risk factor. During hospitalization, older adults are recommended to consume more dietary protein than the current recommended dietary allowance of 0.8 g/kg body weight per day to optimize the recovery of muscular strength and physical function. This prospective pilot study examined the feasibility and preliminary efficacy of short-term protein supplementation with protein-enriched foods and drinks on the hand-grip strength, nutritional status, and physical function of older patients at risk of malnutrition during a three-week inpatient orthopedic rehabilitation stay. The Mini Nutritional Assessment (MNA) tool was used to assess malnutrition. Patients with an MNA score ≤ 23.5 points were randomly assigned to an intervention group (goal: to consume 1.2-1.5 g protein/kg body weight per day) or a control group (standard care). Both groups carried out the same rehabilitation program. Physical recovery parameters were determined at admission and discharge. A trend was recognized for participants in the intervention group to consume more protein than the control group (p = 0.058): 95.3 (SD 13.2) g/day as compared to 77.2 (SD 24.2) g/day, which corresponds to a mean protein intake of 1.6 (SD 0.3) g/kg/day vs. 1.3 (SD 0.5) g/kg/day. Dietary protein supplementation increased body weight by an average of 0.9 (SD 1.1) kg and fat mass by an average of 0.9 (SD 1.2) kg as compared to the baseline (p = 0.039 and p = 0.050, respectively). No significant change in hand-grip strength, body composition, or physical function was observed. In conclusion, short-term intervention with protein-enriched foods and drinks enabled older patients at risk of malnutrition to increase their protein intake to levels that are higher than their required intake. In these older individuals with appropriate protein intake, dietary protein supplementation did not result in a greater improvement in physical recovery outcomes during short-term inpatient rehabilitation. The intervention improved dietary protein intake, but further research (e.g., a full-scale, randomized, controlled trial with sufficient power) is required to determine the effects on physical function outcomes.

Nutrition Intervention Informed by Indirect Calorimetry Compared to Predictive Equations to Achieve Weight Goals in Geriatric Rehabilitation Inpatients: The NEED Study

OBJECTIVES

To assess if nutritional interventions informed by indirect calorimetry (IC), compared to predictive equations, show greater improvements in achieving weight goals, muscle mass, strength, physical and functional performance.

DESIGN

Quasi-experimental study.

SETTING AND PARTICIPANTS

Geriatric rehabilitation inpatients referred to dietitian.

INTERVENTION AND MEASUREMENTS

Patients were allocated based on admission ward to either the IC or equation (EQ) group. Measured resting metabolic rate (RMR) by IC was communicated to the treating dietitian for the IC group but concealed for the EQ group. Achieving weight goals was determined by comparing individualised weight goals with weight changes from inclusion to discharge (weight gain/loss: >2% change, maintenance: ≤2%). Muscle mass, strength, physical and functional performance were assessed at admission and discharge. Food intake was assessed twice over three-days at inclusion and before discharge using plate waste observation.

RESULTS

Fifty-three patients were included (IC n=22; EQ n=31; age: 84.3±8.4 years). The measured RMR was lower than the estimated RMR within both groups [mean difference IC -282 (95%CI -490;-203), EQ -273 (-381;-42) kcal/day)] and comparable between-groups (median IC 1271 [interquartile range 1111;1446] versus EQ 1302 [1135;1397] kcal/day, p=0.800). Energy targets in the IC group were lower than the EQ group [mean difference -317 (95%CI -479;-155) kcal/day]. There were no between-group differences in energy intake, achieving weight goals, changes in muscle mass, strength, physical and functional performance.

CONCLUSIONS

In geriatric rehabilitation inpatients, nutritional interventions informed by IC compared to predictive equations showed no greater improvement in achieving weight goals, muscle mass, strength, physical and functional performance. IC facilitates more accurate determination of energy targets in this population. However, evidence for the potential benefits of its use in nutrition interventions was limited by a lack of agreement between patients' energy intake and energy targets.

Impact of Exercise Intervention-Based Changes on Physical Function Biomarkers in Older Adults After Hospital Discharge: A Systematic Review with Meta-Analysis of Randomized Clinical Trials

BACKGROUND

This systematic review with meta-analysis aimed to compare the changes caused by exercise interventions with those provoked by usual care on physical function biomarkers in older adults immediately after hospital discharge.

METHODS

Two independent authors performed a systematic search (PubMed, Scopus, Web of Science, and SciELO) of studies published from database inception until August 2021. Randomized clinical trials investigating the effects of an exercise intervention compared to usual care were included. The Cochrane Collaboration assessment tool was used to analyze the risk of bias. The comparisons included handgrip strength, the short physical performance battery scale, six-minute walking test, and 10-m gait speed.

RESULTS

Overall, the exercise intervention led to significantly greater changes compared to usual care in physical function biomarkers [standard mean difference = 0.89, 95% CI = 0.39, 1.42; P = 0.001]. However, considering the very few studies investigating each variable separately, our sub-analysis did not reveal a significant effect of the exercise intervention on handgrip strength, the short physical performance battery, six minutes walking test, and 10-m gait speed.

CONCLUSIONS

This systematic review with meta-analysis of randomized clinical trials suggests that exercise interventions after hospital discharge induce greater physical function biomarker alterations in older adults after hospitalization than usual care including physical activity guidance. Future trials comparing the effects of these intervention groups on physical function biomarkers in this population are needed to confirm our results.

Malnutrition in Hospitalized Old Patients: Screening and Diagnosis, Clinical Outcomes, and Management

Malnutrition in hospitalized patients heavily affects several clinical outcomes. The prevalence of malnutrition increases with age, comorbidities, and intensity of care in up to 90% of old populations. However, malnutrition frequently remains underdiagnosed and undertreated in the hospital. Thus, an accurate screening to identify patients at risk of malnutrition or malnourishment is determinant to elaborate a personal nutritional intervention. Several definitions of malnutrition were proposed in the last years, affecting the real frequency of nutritional disorders and the timing of intervention. Diagnosis of malnutrition needs a complete nutritional assessment, which is often challenging to perform during a hospital stay. For this purpose, various screening tools were proposed, allowing patients to be stratified according to the risk of malnutrition. The present review aims to summarize the actual evidence in terms of diagnosis, association with clinical outcomes, and management of malnutrition in a hospital setting.

The Acute Effects of Breakfast Drinks with Varying Protein and Energy Contents on Appetite and Free-Living Energy Intake in UK Older Adults

Proposed strategies for preventing protein deficiencies in older patients include increasing protein intake at breakfast. However, protein is highly satiating and the effects of very high protein intakes at breakfast on subsequent appetite and free-living energy intake (EI) in older adults are unclear. This study compared the acute effects of two breakfast drinks varying in protein and energy contents on appetite and free-living EI in healthy older adults using a randomized 2 × 2 crossover design. Participants (n = 48 (20 men, 28 women); mean ± SD age: 69 ± 3 years; BMI: 22.2 ± 2.0 kg·m⁻²; fat-free mass: 45.5 ± 8.0 kg) consumed two drinks for breakfast (high-protein (30.4 ± 5.3 g), low-energy (211.2 ± 37.1 kcal) content (HPLE) and very high-protein (61.8 ± 9.9 g), fed to energy requirements (428.0 ± 68.9 kcal) (VHPER)) one week apart. Appetite perceptions were assessed for 3 h post-drink and free-living EI was measured for the remainder of the day. Appetite was lower in VHPER than HPLE from 30 min onwards (p < 0.01). Free-living energy and protein intake did not differ between conditions (p = 0.814). However, 24 h EI (breakfast drink intake + free-living intake) was greater in VHPER than HPLE (1937 ± 568 kcal vs. 1705 ± 490 kcal; p = 0.001), as was 24 h protein intake (123.0 ± 26.0 g vs. 88.6 ± 20.9 g; p < 0.001). Consuming a very high-protein breakfast drink acutely suppressed appetite more than a low-energy, high-protein drink in older adults, though free-living EI was unaffected. The long-term effects of adopting such a breakfast strategy in older adults at high risk of energy and protein malnutrition warrants exploration.

Sepsis-Induced Myopathy and Gut Microbiome Dysbiosis: Mechanistic Links and Therapeutic Targets

ABSTRACT

Sepsis is currently defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. The skeletal muscle system is among the host organ systems compromised by sepsis. The resulting neuromuscular dysfunction and impaired regenerative capacity defines sepsis-induced myopathy and manifests as atrophy, loss of strength, and hindered regeneration after injury. These outcomes delay recovery from critical illness and confer increased vulnerability to morbidity and mortality. The mechanisms underlying sepsis-induced myopathy, including the potential contribution of peripheral organs, remain largely unexplored. The gut microbiome is an immunological and homeostatic entity that interacts with and controls end-organ function, including the skeletal muscle system. Sepsis induces alterations in the gut microbiota composition, which is globally termed a state of "dysbiosis" for the host compared to baseline microbiota composition. In this review, we critically evaluate existing evidence and potential mechanisms linking sepsis-induced myopathy with gut microbiota dysbiosis.

Guidance for Healthy and More Climate-Friendly Diets in Nursing Homes-Scenario Analysis Based on a Municipality's Food Procurement

Reducing the climate impact of food provided for residents in nursing homes is challenging, as the diets for older, frail adults must be high in protein content and energy density while at the same time ensuring that the meals are palatable and recognizable. This study aimed at providing guidance on healthy and more climate-friendly diets for nursing homes in the City of Copenhagen. The goal was to decrease greenhouse gas emissions (GHGE) by at least 25% while at the same time providing nutritionally adequate and recognizable menus. First, food purchase data were compiled with datasets matching each food item to a proxy food item and then to databases containing GHGE and nutrient information. Secondly, two diet scenarios were modelled based on current procurement practices, i.e., an energy- and protein-dense diet and a standard protein-dense diet, and converted into guidelines for menu planning. The diets contained less total meat, especially beef, and significantly more pulses, nuts and seeds in order to increase protein content according to recommendations for older adults. Finally, a combined scenario was calculated to reflect the joint climate impact reduction. This kind of innovation in food procurement is required in order to achieve the necessary transition to a sustainable food system.

Omega-3 fatty acids and human skeletal muscle

PURPOSE OF REVIEW

To examine recent findings related to the influence of omega-3 (ω-3) fatty acid supplementation on skeletal muscle anabolism with a particular focus on situations of skeletal muscle disuse.

RECENT FINDINGS

Skeletal muscle disuse results in a reduction in fed and fasted rates of skeletal muscle protein synthesis leading to the loss of skeletal muscle mass. Recent evidence has suggested that supplementation with ω-3 fatty acids during a period of skeletal muscle disuse increases the ω-3 fatty acid composition of skeletal muscle membranes, heightens rates of skeletal muscle protein synthesis, and protects against skeletal muscle loss. The protective effects of ω-3 fatty acids towards skeletal muscle during disuse appear to be related to changes in mitochondrial bioenergetics suggesting crosstalk between mitochondria and the regulation of skeletal muscle protein synthesis.

SUMMARY

ω-3 fatty acid ingestion is a potential preventive therapy to combat skeletal muscle-disuse atrophy but additional, appropriately powered randomized controlled trials are now needed in a range of populations before firm conclusions can be made.

Effects of protein supplementation on muscle wasting disorders: A brief update of the evidence

OBJECTIVE

To examine the effects of protein supplementation on muscle mass, strength and function in individuals at risk of muscle wasting disorders.

METHODS

A narrative overview of the literature based on a PubMed search.

RESULTS

Increasing protein intake beyond the recommended dietary intake may prevent or attenuate muscle loss in people at risk of muscle wasting disorders; however, there is inconsistent evidence for any benefits on muscle strength or physical function. This is likely due to the significant heterogeneity and bias regarding baseline demographics, basal protein/energy intakes and protein supplement type, dose, timing and compliance.

CONCLUSION

Protein supplementation attenuates muscle loss in some populations at increased risk of muscle wasting, but there is no consistent evidence to support benefits on muscle strength or physical function. Further randomised controlled trials are needed that focus on whether there is an optimal type, dose and timing of protein intake, and potential interaction with other nutrients.