Malnutrition screening and diagnosis tools: Implications for practice

Identifying nutrition risk in emergency patients: What is the most appropriate screening tool?

BACKGROUND

The emergency department (ED) is the most frequent access route to the hospital. Nutrition risk (NR) screening allows the early identification of patients at risk of malnutrition. This study aimed to evaluate the feasibility and predictive validity of five different tools in EDs: Nutritional Risk Screening 2002 (NRS-2002), Nutritional Risk Emergency 2017 (NRE-2017), Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT), Malnutrition Universal Screening (MUST), and Malnutrition Screening Tool (MST).

METHODS

Patients with scores ≥3 according to the NRS-2002, ≥1.5 according to the NRE-2017, and ≥2 according to the MUST, RFH-NPT, or MST were classified with NR. Prolonged length of stay (LOS) and 1-year mortality were evaluated.

RESULTS

431 patients were evaluated (57.31 ± 15.6 years of age; 54.4% women) in a public hospital in southern Brazil. The prevalence of NR was: 35% according to the NRS-2002, 43% according to the MST, 45% according to the NRE-2017 and MUST, and 49% according to the RFH-NPT. Patients with NR, had a greater risk of prolonged LOS (P < 0.001). The presence of NR was associated with an increased risk of 1-year mortality according to the NRS-2002 (hazard ratio [HR]: 4.04; 95% CI, 2.513-6.503), MST (HR: 2.60; 95% CI, 1.701-3.996), NRE-2017 (HR: 4.82; 95% CI, 2.753-8.443), MUST (HR: 4.00; 95% CI, 2.385-6.710), and RFH-NPT (HR: 5.43; 95% CI, 2.984-9.907).

CONCLUSIONS

NRE-2017 does not require objective data and presented predictive validity for all outcomes assessed, regardless of the severity of the disease, and thus appears to be the most appropriate tool for carrying out NR screening in the ED.

Prevalence and related assessment practices of adult hospital malnutrition in Africa: A scoping review

BACKGROUND AND AIMS

Globally, hospital malnutrition prevalence is estimated at 20-50%, with little known about the situation in African hospitals. The aim of this scoping review was to appraise the current evidence base regarding the prevalence of adult hospital malnutrition and related assessment practices in an African context.

METHODS

A comprehensive and exhaustive search strategy was undertaken to search seven electronic bibliographic databases (including Africa-specific databases) from inception until August 2022 for articles/resources reporting on the prevalence of adult hospital malnutrition in an African setting. Two reviewers independently reviewed abstracts and full-text articles and data extraction was undertaken in duplicate.

RESULTS

We screened the titles and abstracts of 7537 records and included 28 studies. Most of the included studies were conducted in the East African region (n = 12), with ten studies from South Africa. Most studies were single-centre studies (n = 22; 79%), including 23 to 2126 participants across all studies. A variety of study populations were investigated with most described as medical and surgical populations (n = 14; 50%). Malnutrition risk prevalence was reported to be between 23% and 74%, using a variety of nutritional screening tools (including MNA-SF/LF, NRS-2002, MUST, NRI, GNRI). Malnutrition prevalence was reported to be between 8% and 85%, using a variety of tools and parameters, including ASPEN and ESPEN guidelines, SGA, MNA-SF/LF, anthropometric and biochemical indices, with one study using the GLIM criteria to diagnose malnutrition.

CONCLUSIONS

Both malnutrition risk and malnutrition prevalence are alarmingly high in African adult hospitalised patients. The prevalence of malnutrition differs significantly among studies, owing in part to the variety of tools used and variability in cut-offs for measurements, underscoring the importance of adopting a standardised approach. Realities in the African context include limited nutritional screening and assessment, poor referral practices, and a unique disease burden. General awareness is needed, and routine nutritional screening practices with appropriate nutrition support action should be implemented as a matter of urgency in African hospitals.

Nutrition practices in hospitalized adults receiving noninvasive forms of respiratory support: A scoping review

The use of noninvasive respiratory support is increasing, with noninvasive ventilation (NIV) and high-flow nasal cannula providing unique barriers to nutrition support. Limited data related to nutrition management for these patients in the intensive care unit (ICU) exist; however, the literature in non-critically ill patients is not well described, and its improvement may help to inform practice within the ICU. Therefore, a scoping review was conducted of MEDLINE, EmCare, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases on August 18, 2022, to identify original publications that included adult patients receiving noninvasive respiratory support in a hospital setting with data related to nutrition management. Data were extracted on study design, population, details of respiratory support, and concepts relating to nutrition management (grouped into nutrition screening, assessment, delivery route, intake, and anthropometry). Eleven studies were included, most of which were small (<100 patients), single-center, observational trials in patients receiving NIV only. Five studies reported results related to route of nutrition and nutrition assessment, two on anthropometry, and one each on quantifying intake and nutrition screening; some studies reported multiple parameters. There was a lack of consensus regarding the ideal method for nutrition assessment and route of nutrition. Oral nutrition was the route most frequently reported, yet calorie and protein delivery via this route were inadequate, and barriers to intake included poor appetite, fatigue, and patient cognition. Future research should address barriers pertinent to this population and the impact of nutrition on outcomes.

Meta-analysis and moderator analysis of the prevalence of malnutrition and malnutrition risk among older adults with dementia

BACKGROUND

Aging and dementia are common and closely related health problems in older adults, affecting their ability to maintain a healthy diet and ultimately resulting in malnutrition.

OBJECTIVE

In this study, we estimated the global prevalence of malnutrition and malnutrition risk in older adults with dementia.

DESIGN

Meta-analysis.

DATA SOURCES

Embase, Ovid MEDLINE, PubMed, CINAHL, Scopus, and Web of Science were comprehensively searched for articles published from database inception to October 2022.

METHODS

Pooled prevalence analysis was conducted using a generalized linear mixed model and a random-effects model. I2 and Cochran's Q statistics were used for identifying heterogeneity. Publication bias was evaluated using Peters' regression test and a funnel plot. Moderator analyses were conducted to investigate variations in the prevalence estimates of the included studies. All statistical analyses were conducted using R software.

RESULTS

A total of 16 studies involving a total of 6513 older adults with dementia were included in the analysis. The results indicated that 32.52 % (95 % confidence interval: 19.55-45.49) of all included older adults with dementia had malnutrition, whereas 46.80 % (95 % confidence interval: 38.90-54.70) had a risk of malnutrition. The prevalence of malnutrition was found to be high among older patients living in institutionalized settings (46.59 %) and those with Alzheimer's disease (12.26 %). The factors moderating the prevalence of malnutrition included adequate vitamin B12 consumption, risk behaviors, medical comorbidities, and certain neuropsychiatric symptoms. The prevalence of malnutrition risk was high among women (29.84 %) and patients with Alzheimer's disease (26.29 %). The factors moderating the prevalence of malnutrition risk included total cholesterol level, vitamin B12 consumption, risk behaviors, medical comorbidities, and certain neuropsychiatric symptoms.

CONCLUSIONS

Approximately one-third of older adults with dementia are malnourished and nearly half of older adults are at a risk of malnutrition. Encouraging collaboration among health-care professionals and ensuring early assessment and effective management of malnutrition are crucial for maintaining a favorable nutritional status in older adults with dementia.

REGISTRATION

This study was registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42022369329).

TWEETABLE ABSTRACT

Globally, approximately 32.52 % of older adults with dementia are malnourished and approximately 46.80 % are at a risk of malnutrition.

Pre-Operative Malnutrition in Patients with Ovarian Cancer: What Are the Clinical Implications? Results of a Prospective Study

BACKGROUND

Malnutrition was associated with worse survival outcomes, impaired quality of life, and deteriorated performance status across various cancer types. We aimed to identify risk factors for malnutrition in patients with epithelial ovarian cancer (EOC) and impact on survival.

METHODS

In our prospective observational monocentric study, we included the patients with primary and recurrent EOC, tubal or peritoneal cancer conducted. We assessed serum laboratory parameters, body mass index, nutritional risk index, nutritional risk screening score (NRS-2002), and bio-electrical impedance analysis.

RESULTS

We recruited a total of 152 patients. Patients > 65 years-old, with ascites of >500 mL, or with platinum-resistant EOC showed statistically significant increased risk of malnutrition when evaluated using NRS-2002 (p-values= 0.014, 0.001, and 0.007, respectively). NRS-2002 < 3 was an independent predictive factor for complete tumor resectability (p = 0.009). The patients with NRS-2002 ≥ 3 had a median overall survival (OS) of seven months (95% CI = 0-24 months), as compared to the patients with NRS-2002 < 3, where median OS was forty-six months (p = 0.001). A phase angle (PhAα) ≤ 4.5 was the strongest predictor of OS.

CONCLUSIONS

In our study, we found malnutrition to be an independent predictor of incomplete cytoreduction and independent prognostic factor for poor OS. Preoperative nutritional assessment is an effective tool in the identification of high-risk EOC groups characterized by poor clinical outcome.

Targeting malnutrition in patients with COPD in the community

The number of individuals living with chronic obstructive pulmonary disease (COPD) is increasing, but nutritional care can be inconsistent, especially in those with stable COPD. Historically, poor appetite and weight loss have been considered the norm during the progression of COPD into the later stage. However, it is imperative that nutritional assessment, support and management is undertaken from diagnosis, because malnutrition can lead to exacerbations of COPD and increased hospitalisation. Poor nutrition in individuals with COPD has been shown to predict an increase in mortality and with the care of patients taking place principally in the community, the nutritional aspects of care should be assessed, monitored and managed, in accordance with the latest guidance. The lack of a nutritional Quality Outcome Framework indicator for COPD can leave nutrition overlooked, but evidence shows that screening, assessment and planning can have an overall positive impact.

Malnutrition in solid organ transplant patients: A review of the literature

Screening for malnutrition is of vital importance for solid organ transplant candidates to optimize nutrition status before transplant, to improve clinical outcomes and to inform selection committees of nutritional contraindications and risks. There are multiple criteria and screening tools available for determining malnutrition diagnosis and risk. Registered Dietitian Nutritionists use these tools for nutrition assessments to quantify the severity of malnutrition, provide patient-centered interventions, and monitor progression. Many transplant centers in the United States utilize the American Society of Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics' Adult Malnutrition Criteria, though there is limited research using these criteria specifically in the transplant population. Malnutrition, utilizing other diagnostic and screening tools, has been associated with important complications, including longer length of hospital stay, increased mortality, decreased quality of life, worsened end-stage organ progression, and decreased functional status. Malnutrition typically results from sarcopenia and cachexia, and can ultimately lead to frailty, causing further negative impacts on transplant outcomes. This literature review summarizes the current research on malnutrition in solid organ transplant candidates and provides recommendations for future research and current practice implications.

Assessing Nutrition Status in an Outpatient Wound Center: A Feasibility Study

OBJECTIVE

To explore the feasibility of using the Patient-Generated Subjective Global Assessment (PG-SGA) to assess the nutrition status of patients with chronic wounds receiving care in an outpatient wound clinic.

METHODS

The PG-SGA was administered to a single cohort convenience sample of adults with chronic wounds who presented to an outpatient wound clinic. The authors performed univariate descriptive analyses and calculated interrater reliability.

RESULTS

Nutrition assessments were completed with 15 clinic patients. Patients required an average of 6.5 minutes (range, 3.5-10 minutes) to complete their component of the PG-SGA, exceeding the target goal of 5 minutes or fewer. Dietitians required an average of 2 minutes per patient to complete the professional component of the PG-SGA (physical examination). The nutrition assessment process was rated highly favorable. Resources to conduct the study at the site were available 100% of the time.

CONCLUSIONS

The PG-SGA demonstrates promise for use in the chronic wound population and could be incorporated into clinical care in settings equipped with appropriate and adequate resources. The complexities of workforce stability and resource availability, in addition to the ongoing need to be responsive to patient challenges, must be acknowledged in the planning of future studies.

Optimizing Nutritional Status of Patients Prior to Major Surgical Intervention

In patients undergoing elective cardiovascular and thoracic surgery, malnutrition and the deterioration of nutritional status are associated with negative outcomes. Recognition of the contributory factors and the complications stemming from surgical stress is important for the prevention and management of these patients. We have reviewed the literature available and focused on the nutritional and metabolic aspects affecting surgical patients, with emphasis on the recommendations of enhanced recovery protocols. The implementation of enhanced recovery protocols and nutritional support guidelines focusing on the surgical patient as part of a multidisciplinary approach would improve the nutritional status of surgical patients at risk for negative outcomes.

Malnutrition screening tool and malnutrition universal screening tool as a predictors of prolonged hospital stay and hospital mortality: A cohort study

BACKGROUND & AIMS

Different nutrition screening tools have been proposed to screen inpatients, although, there is still no consensus regarding the reference method for identifying patients at nutritional risk. This retrospective cohort study aimed to evaluate the concurrent and predictive validity of the Malnutrition Screening Tool (MST) and Malnutrition Universal Screening Tool (MUST) to identify inpatients at nutritional risk.

METHODS

Data from electronic medical records were collected from adult and elderly inpatients in wards of a public tertiary hospital (Hospital de Clínicas de Porto Alegre, Brazil) over one year. Only the first nutritional evaluation was considered for each patient. GLIM criteria was used for malnutrition status (concurrent validity) and hospital stay length and mortality were outcomes to predictive validity.

RESULTS

A total of 5270 patients were included in this study. The mean patient age was 59 ± 16 years old, and 50.7% were males. More than 60% of the patients (65.8%) were admitted to a surgical unit, 63.8% had mild disease-related metabolic stress, 50.7% experienced prolonged hospital stays (more than ten days), and 1.9% of the patients died. Considering the availability of nutritional data, it was possible to perform nutritional screening of 98.1% of patients by MST and 96.7% of patients by MUST. A higher proportion of patients at risk were identified by MUST (53.6%) as compared to MST (21.3%; P < 0.001). MST had 89.9% of Specificity, 60.4% of PPV, 94.6% of NPV, and a moderate agreement with malnutrition by GLIM criteria (κ = 0.591; P < 0.001). A prolonged hospital stay was positively associated with the classification of nutritional risk based on both screening tools. Death was positively associated with nutritional risk by MST (hazard ratio [HR] 2.09; 95% confidence interval [CI] 1.37-3.16) and by MUST (HR 1.79; 95% CI 1.00-3.18) after adjustment based on sex, age, admission type (surgical or clinical), and disease-related metabolic stress.

CONCLUSIONS

MST may be good concurrent validity to malnutrition by GLIM criteria as compared to MUST. However, both risk nutritional tools were positively associated with predicting a prolonged hospital stay and mortality.

Perioperative nutrition for gastrointestinal surgery: On the cutting edge

Evidence on perioperative nutrition interventions in gastrointestinal surgery is rapidly evolving. We conducted a narrative review of various aspects of nutrition support, including formula choice and route of administration, as well as duration and timing of nutrition support therapy. Studies have demonstrated that nutrition support is associated with improved clinical outcomes in malnourished patients and those at nutrition risk, emphasizing the importance of nutrition assessment, for which several validated nutrition risk assessment tools exist. The assessment of serum albumin levels has fallen out of favor, as it is an unreliable marker of nutrition status, whereas imaging evidence of sarcopenia has prognostic value and may emerge as a standard component of nutrition assessment. Preoperatively, evidence supports limiting fasting to reduce insulin resistance and improve oral tolerance. Benefits to preoperative carbohydrate loading remain unclear, whereas literature suggests preoperative parenteral nutrition (PN) may reduce postoperative complications in high-risk patients with malnutrition or sarcopenia. Postoperatively, early oral feeding is safe with benefits in time to return of bowel function and reduced hospital stay. There is a signal for potential benefit to early postoperative PN in critically ill patients, though evidence is sparse. There has also been a recent emergence in randomized studies evaluating the use of ω-3 fatty acids, amino acids, and immunonutrition. Meta-analyses have reported favorable outcomes for these supplements, though individual studies are small and with significant methodological limitations and risk of bias, emphasizing the need for high-quality randomized studies to guide clinical practice.

Relationship Between Prognostic Nutrition Index and New York Heart Association Classification in Patients with Coronary Heart Disease: A RCSCD-TCM Study

Aim

This study aimed to elucidate the relationship between the prognostic nutrition index (PNI) of patients with coronary heart disease (CHD) and the New York Heart Association (NYHA) classification and the complex relationship between PNI combined body mass index (BMI) and NYHA classification.

Methods

The PNI was applied to 17,413 consecutive patients with CHD. Patients were divided into three groups according to PNI: normal nutrition (PNI ≥ 38), moderate malnutrition (35 < PNI < 38), and severe malnutrition (PNI ≤ 35). A total of 2,052 CHD patients with BMI were selected and stratified by combined subgroups of nutritional status and BMI. Logistic regression analysis was used to evaluate the relationship between the PNI and NYHA classification and to adjust for confounding factors.

Results

The prevalence of malnutrition among the 17,413participants with CHD was 4.2%. Moderate and severe malnutrition were significantly related to NYHA class III and V, and the strongest relationship was observed in NYHA class V (odd ratio [OR]: 6.564; 95% confidence interval [CI]: 4.043–10.658). Malnourished-underweight patients and malnourished-overweight patients were significantly associated with higher NYHA classification, and malnourished-underweight patients (OR: 8.038; 95% CI: 2.091–30.892) were significantly more than malnourished-overweight patients (OR: 3.580; 95% CI: 1.286–9.966).

Conclusion

There were differences in the NYHA classification of CHD patients with different nutritional statuses. The lower the PNI, the worse the NYHA classification of CHD patients. Malnourished-underweight patients had a worse NYHA classification than malnourished-overweight patients.

Development of Formulas for Calculating L3 Skeletal Muscle Mass Index and Visceral Fat Area Based on Anthropometric Parameters

Background

The anthropometric index is not accurate but shows a great advantage in accessibility. Simple body composition formulas should be investigated before proceeding with the universal nutrition screening.

Materials and Methods

Clinical data of patients with a malignant tumor of the digestive system were collected. SliceOmatic 5.0 software (TOMOVISION, Canada) was used to analyze abdominal CT images and taken as references. A linear regression analysis was adopted to establish the formula for calculating skeletal muscle index (SMI) and visceral fat area (VFA). In addition, the relweights function was adopted to measure the contribution of each variable.

Results

In total, 344 patients were divided into the training set and 134 patients into the validation set. The selected formulas were SMI.pre = 0.540 × weight (kg) – 0.559 × height (cm) – 13.877 × sex (male = 1, female = 2) + 123.583, and VFA.pre = 5.146 × weight (kg) – 2.666 × height (cm) + 1.436 × age (year) + 134.096, of which the adjusted R² were 0.597 and 0.581, respectively. The “weight” explained more than 80% of R² in the prediction of VFA. In addition, “sex” occupied approximately 40% of R² in the prediction of SMI. The paired t-test showed no significant difference between the real measured indices and the predicting ones (p = 0.123 for SMI and p = 0.299 for VFA). The logistic regression analysis exhibited similar diagnostic efficacy of the real measured parameters and formulas.

Conclusion

The SMI and VFA formulas were developed through basic indices, such as weight, height, sex, and age. According to the contribution of each variable, weight should always be focused on preserving appropriate muscle and adipose tissue.