Dietary advice and nutritional supplements in the management of illness-related malnutrition: systematic review

Efficacy of Postoperative Oral Nutritional Supplements in Geriatric Hip Fracture Patients Undergoing Total Hip Arthroplasty

Background/Objectives: Geriatric hip fracture patients have an increased risk of malnutrition. Proper nutritional supply in the perioperative period is very important for their recovery. Oral nutritional supplements (ONSs) are recommended in geriatric hip fracture patients to improve dietary intake and prevent complications. This study aimed to evaluate the efficacy of postoperative ONSs after total hip arthroplasty in geriatric hip fracture patients. Methods: A retrospective study of elderly patients who underwent total hip arthroplasty for hip fracture was conducted. Data from patients who received ONSs postoperatively until hospital discharge (ONS group, n = 69) were compared with patients who did not receive ONSs (control group, n = 168). Laboratory test results, including serum protein and albumin levels, length of hospital stay, and the incidence of postoperative medical complications of the two groups, were analyzed. Results: Preoperative serum protein and albumin levels were significantly higher in the control group (p = 0.002 and p = 0.010, respectively). However, the degree of decline for both protein and albumin levels was significantly less in the ONS group (p < 0.001 for both). Serum albumin levels were significantly higher in the ONS group at postoperative two-week follow-up (p = 0.006). The length of hospital stay was shorter in the ONS group (p < 0.001). The incidence of postoperative delirium was significantly higher in the control group (p = 0.007). Conclusions: In geriatric hip fracture patients, postoperative ONSs can improve postoperative nutritional status, shorten the length of hospital stay, and reduce the incidence of postoperative delirium.

Perioperative nutritional status thought to be important, but poorly understood

OBJECTIVES

Malnutrition has been shown to increase complications and leads to poor outcomes in surgical patients, but it has not been studied extensively in orthopedic trauma. This study's purpose is to determine the perspective and assessment of nutrition by orthopedic traumatologists.

METHODS

A survey was created and distributed via REDCap to orthopedic traumatologists at 60 U.S. trauma centers. Out of 183 distributed surveys, 130 surgeons completed the survey (71%). The survey focused on the importance of nutrition and practice patterns in orthopedic trauma.

RESULTS

Seventy-five percent of surgeons thought that nutritional status was "very important" to the final outcome of patients with orthopedic trauma injuries, 24% responded "somewhat important" and 1% responded "not important." Furthermore, 88% perform nutritional assessments; most surgeons (77%) utilize nutritional laboratory markers, with the most common markers being albumin, pre-albumin, transferrin and CRP. Additionally, 42% think trending the laboratory markers is important, and 50% are not sure if nutrition markers should be tested at multiple time points. Despite 75% of surgeons believing that nutrition is very important, only 8% discuss it with patients routinely. When asked what is more important for outcomes, nutrition or Vitamin D, almost three times as many surgeons thought nutrition was more important (29% vs 11%, respectively).

CONCLUSIONS

While orthopedic traumatologists believe nutrition is an important determinant of patient outcomes, this study shows a clear lack of consensus and variability in practice regarding nutrition among surgeons. Orthopedic trauma surgeons need specific guidelines on how to assess and treat malnutrition in trauma patients.

Association between the dental occlusion and perceived ability to eat foods of Taiwanese older adults

Tooth loss is a common problem among older adults that affects masticatory function (MF) and food selection. Financial burden is a reason that some older adults in Taiwan with this condition forgo dental restoration. To identify the number of posterior occlusal support areas (POSAs) associated with MF. Large-scale cross-sectional study included 1100 community-dwelling participants of Taiwan aged ≥65 years. Participants completed dental examination and questionnaires through personal interviews. Masticatory performance was evaluated using a colour-changeable chewing gum. Masticatory ability was evaluated on the basis of how many of 14 common foods the participants were able to eat. Participants were grouped into 10 categories (A1-A3, B1-B4 and C1-C3) according to the Eichner index (EI) of posterior occlusal contacts. Multivariable regression models were used to analyse the association between the EI groups and MF. More than 80% of the participants with two or more POSAs (those in groups A1-B2) could easily eat various foods. Compared with those in groups A1-B2, those in groups in B3, B4, C1, C2 and C3 exhibited a significantly different masticatory performance (all P < .001) and significantly higher difficulty in eating fruits and vegetables. A dose-response effect between POSAs and perceived masticatory ability to eat fruits and vegetables was observed (P < .05 for both trends). Preservation of at least two POSAs is essential for MF. Older adults with tooth loss can undergo the restoration of two POSAs to improve MF and increase food intake.

A Comparative Study of Spatial Distribution of Gastrointestinal Cancers in Poverty and Affluent Strata (Kermanshah Metropolis, Iran)

INTRODUCTION

The trend of cancers has witnessed a twofold rise in the last three decades, which is expected to be fivefold by 2030. On the other hand, gastrointestinal cancers have turned into one of the health issues in many societies. Given the presence of gastrointestinal cancer hot spots and evidence of health inequalities across Kermanshah Metropolis and the results of studies signaling the association between gastrointestinal cancers and socioeconomic status of individuals as well as evidence of unequal socioeconomic opportunities in this metropolis, the present study aimed to investigate the spatial distribution of gastrointestinal cancers in the poverty and affluent strata of Kermanshah Metropolis, Iran.

MATERIALS AND METHODS

In this descriptive-analytical study, the recorded data of patients, suffering from gastrointestinal cancers, in Kermanshah-based Pathology Centers and Vice Chancellery of Kermanshah University of Medical Sciences (2007-2012) were used. Moreover, to examine the status of gastrointestinal cancers in socioeconomic classes based on the census data collected during 2007-2012, 33 social, cultural, and structural indexes were extracted from the statistical blocks. Additionally, for data analysis and factor analysis, Kruskal-Wallis Test in the environment of SPSS and kernel density estimation (KDE) and Moran's I tests in the GIS environment were employed.

FINDINGS

The results of the present study revealed that the distribution of poverty (Z score = 48.916518, p value = 0.000000) and affluent strata (Z score = 14.345028, p value = 0.000000) followed clustered patterns (p < 0.01). Additionally, the results indicated that the spatial distribution pattern of the upper gastrointestinal cancer was clustered (Z score = 1.896996, p value = 0.007828), whereas the spatial distribution pattern of the lower gastrointestinal cancer was inclined to a randomized clustered pattern (Z score = 1.338121, p value = 0.000857) (p < 0.01). Finally, seven main hot spots were identified from the poverty stratum in Kermanshah, which perfectly overlapped the hot spots of upper gastrointestinal cancer. Similarly, four main hot spots were identified from the affluent stratum in Kermanshah, which overlapped the hot spots of lower gastrointestinal cancer. The results of the Kruskal-Wallis Test demonstrated that the poverty and affluent strata were significantly different from each other in terms of gastrointestinal cancer: upper gastrointestinal cancer (p < 0.05 and X²=10.064) and lower gastrointestinal cancer (p < 0.05 and X²=10.253).

CONCLUSION

The results of the present study showed that the ratio of patients with lower gastrointestinal cancers was higher than the incidence of upper gastrointestinal cancers over the 5-year period under study. Moreover, in Kermanshah Metropolis, there was a significant difference between the upper gastrointestinal cancer in the poverty stratum and the lower gastrointestinal cancer in the affluent stratum. Hence, it is suggested that GIS be applied as a tool for identifying the patterns of effective factors of this type of cancer in each social class, and it is recommended that some effective policies be presented and adopted by health managers according to the role and importance of socioeconomic, environmental, and nutritional factors in the poverty and affluent strata of society, and people at risk be equipped with preventive training programs in this respect.

Nutritional status of patients hospitalized in the intensive care unit: A comprehensive report from Iranian hospitals, 2018

INTRODUCTION AND AIM

Malnutrition is a complication of hospitalization in critically ill patients. This event is occurred because of disease and therapeutic processes for curing the patients. Determination of nutritional status helps physicians and clinical nutritionists decide on the best regimen which should be prescribed for a patient. In the current study, we aimed to report the nutritional status ofpatientshospitalizedin the intensive care unit (ICU).

METHOD OF STUDY

We used three standard tolls, including Subjective global assessment (SGA), Nutrition Risk in the Critically Ill (NUTRIC) Score and nutrition risk screening (NRS) questionnaires via a multi-stage sampling for different ICU wards of 32 university hospitals in Iran. Frequencies and rates of nutritional scores, comparative studies, and determined agreement of scoring systems and nutritional status in any ward of hospitals were evaluated.

RESULTS

There were 771 males and 540 female Cancer and trauma patients had the best and worst nutritional scores, respectively. Using NRS and NUTRIC, the low-risk scores were more frequent than thehigh-riskscores among ICU patients. SGA showed that most patients were in grades A (well nutritional status) or B (moderate nutritional status), andfew caseswere in grade C (poor nutritional status).The high-risk nutritional score wasobtained for older patients. NUTRIC and NRS had better agreement for diagnosis and differentiation of malnutrition than NUTRIC-SGA or NRS-SGA pairs. However, there was no strong agreement between the mentioned pairs.

CONCLUSION

Nutritional status of patients hospitalized in ICU wards in Iran wassomewhat better than other countries that this could be due to the highly observed guidelines of patient's care in Iran. Anyway,it is suggested that a more precise tool of nutritional scoresto be validated for patients hospitalized in ICU·In addition, better medical care needs a well evaluation of nutritional insufficiencies and what is necessary for compensation using complementary regimens.

Improving Nutrition Care, Delivery, and Intakes Among Hospitalised Patients: A Mixed Methods, Integrated Knowledge Translation Study

Malnutrition is a common and complex problem in hospitals. This study used an integrated knowledge translation approach to develop, implement, and evaluate a multifaceted, tailored intervention to improve nutrition care, delivery, and intake among acute medical inpatients. This observational, pre-post study was conducted in a medical ward at a public hospital in Australia. The intervention was co-developed with key stakeholders and targeted three levels: individuals (nutrition intake magnets at patient bedsides), the ward (multidisciplinary hospital staff training), and the organisation (foodservice system changes). Observational data were collected pre- and post-intervention on patient demographics, food intakes, and the mealtime environment. Data were entered into SPSS and analysed using descriptive and inferential statistics. Ethical approval was gained through the hospital and university ethics committees. A total of 207 patients were observed; 116 pre- and 91 post-intervention. After intervention implementation, patients' mean energy and protein intakes (in proportion to their estimated requirements) were significantly higher and the number of patients eating adequately doubled (p < 0.05). In summary, a multifaceted, pragmatic intervention, tailored to the study context and developed and implemented alongside hospital staff and patients, seemed to be effective in improving nutrition practices and patient nutrition intakes on an acute medical ward.

Nutritional assessment and factors associated with malnutrition among the elderly population of Nepal: a cross-sectional study

Objectives

This study aimed at assessing the nutritional status among the elderly population and factors associated with malnutrition in the community setting in rural Nepal.

Results

Out of 339 participants, 24.8% (95% CI 20.21–29.30) fell into the normal nutritional status range; 49.6% (95% CI 44.29–54.91) were at risk for malnutrition while 24.8% (95% CI 20.21–29.30) were in the malnourished range, based on Mini Nutritional Assessment scores. Our findings revealed that belonging to a Dalit community, being unemployed, having experience of any form of mistreatment, lack of physical exercise, experiencing problems with concentration in past 30 days and taking medication for more than one co-morbidity was significantly associated with the malnutrition status of the elderly.

Glycine Does Not Add to the Beneficial Effects of Perioperative Oral Immune-Enhancing Nutrition Supplements in High-Risk Cardiac Surgery Patients

BACKGROUND

Elderly patients and patients with a poor cardiac function have increased morbidity rates when undergoing cardiac surgery. The aim of this study was to determine whether addition of glycine to a standard preoperative oral immune-enhancing nutrition supplement (OIENS) improves outcome. Glycine-enriched OIENS was compared with 2 formulas: standard OIENS and control.

METHODS

In this double-blind, 3-armed study, patients scheduled to undergo cardiac surgery with the use of extracorporeal circulation received either the glycine-enriched OIENS (OIENS + glyc, n = 24), standard OIENS (OIENS, n = 25), or control formula (Control, n = 25) for minimally 5 preoperative days. Patients were included if they were aged 70 years or older, had a compromised left ventricular function, or were planned for mitral valve surgery. Main outcome measures were postoperative infectious morbidity, organ function, and postoperative recovery.

RESULTS

Infectious morbidity was significantly lower in both treatment groups compared with the control group (p = .02). An infection was diagnosed in 5 and 4 patients in the OIENS + glyc and OIENS groups, respectively, and in 12 control patients. Less supportive therapy was necessary to stabilize circulation in both treatment groups compared with the control group. Median length of hospital stay was 7.0, 6.5, and 8.0 days in the OIENS + glyc, OIENS, and control groups, respectively. Inflammatory responses, as measured by systemic levels of proinflammatory cytokines and surface markers on polymorphonuclear cells, were comparable for all groups.

CONCLUSIONS

Preoperative OIENS reduces postoperative infectious morbidity and results in a more stable circulation; the addition of glycine does not result in any beneficial effect over standard OIENS.

Malnutrition in Acutely Unwell Hospitalized Elderly - "The Skeletons Are Still Rattling in the Hospital Closet"

INTRODUCTION

Malnutrition is common in hospitalized patients with prevalence rates of up to 30% in Australian hospitals with adverse consequences for both the patients and health care services. Despite formulation of nutritional screening protocols, not all hospitalized patients get nutritional screening. Real life screening rates of hospitalized elderly patients are unknown.

AIM

The present study explored nutrition screening rate in acutely unwell elderly patients admitted in a large tertiary hospital and how these patients fared depending upon their nutrition status.

METHODS

A prospective cross-sectional study involving 205 general medical patients ≥60years recruited between November 2014 and November 2015. The number of patients who missed nutrition screening were noted and all patients underwent nutritional assessment by a qualified dietitian using PG-SGA and quality of life was measured using EQ-5D 5L. A survival curve was plotted and multivariate cox proportional hazard model was used to adjust for confounders.

RESULTS

Only 99 (49.7%) patients underwent nutritional screening. One hundred and six (53.5%) patients were confirmed as malnourished by PG-SGA. Malnourished patients had significantly longer length of hospital stay and had worse quality of life. Mortality was significantly higher in malnourished patients at one year (23 (21.7%) vs 4 (4.3%); p<0.001) and cox proportional hazard model suggests that malnutrition significantly affects survival even after adjustment for confounders like age, sex, Charlson index and polypharmacy.

CONCLUSION

This study confirms that nutrition screening is still suboptimal in elderly hospitalized patients with adverse consequences and suggests need for review of policies to improve screening practices.

Nutrition Screening Tools and the Prediction of Clinical Outcomes among Chinese Hospitalized Gastrointestinal Disease Patients

Nutrition risk Screening 2002 (NRS-2002) and Subjective Global Assessment (SGA) are widely used screening tools but have not been compared in a Chinese population. We conducted secondary data analysis of a cross-sectional study which included 332 hospitalized gastrointestinal disease patients, collected by the Gastrointestinal department of Peking Union Medical College Hospital (PUMCH) in 2008. Results of NRS-2002 and SGA screening tools, complications, length of stay (LOS), cost, and death were measured. The agreement between the tools was assessed via Kappa (κ) statistics. The performance of NRS-2002 and SGA in predicting LOS and cost was assessed via linear regression. The complications and death prediction of tools was assessed using receiver operating characteristic (ROC) curves. NRS-2002 and SGA identified nutrition risk at 59.0% and 45.2% respectively. Moderate agreement (κ >0.50) between the two tools was found among all age groups except individuals aged ≤ 20, which only slight agreement was found (κ = 0.087). NRS-2002 (R square 0.130) and SGA (R square 0.140) did not perform differently in LOS prediction. The cost prediction of NRS-2002 (R square 0.198) and SGA (R square 0.190) were not significantly different. There was no difference between NRS-2002 (infectious complications: area under ROC (AUROC) = 0.615, death: AUROC = 0.810) and SGA (infectious complications: AUROC = 0.600, death: AUROC = 0.846) in predicting infectious complication and death, but NRS-2002 (0.738) seemed to perform better than SGA (0.552) in predicting non-infectious complications. The risk of malnutrition among patients was high. NRS-2002 and SGA have similar capacity to predict LOS, cost, infectious complications and death, but NRS-2002 performed better in predicting non-infectious complications.

Effects on Weight, Blood Lipids, Serum Fatty Acid Profile and Coagulation by an Energy-Dense Formula to Older Care Residents: A Randomized Controlled Crossover Trial

OBJECTIVES

Dietary intake in frail old adults is often lower than estimated needs. The aim of this study was to evaluate the effects of an energy-dense oral supplement on nutritional status, food intake, and physical function in residents living in care residential homes.

DESIGN

Randomized controlled intervention trial with a crossover design.

SETTING

Five care residential homes in the southern Stockholm area.

PARTICIPANTS

Older people living at care residential homes: age 65 or older, malnourished or at risk of malnutrition according to Mini Nutritional Assessment-Short Form (MNA-SF).

INTERVENTION

Energy-dense formula (oleic and linoleic acid emulsion enriched with protein and micronutrients) (Calogen Extra, Nutricia) 30 mL distributed 3 times daily for 6 weeks.

MEASUREMENTS

Body weight, 3-day food and fluid record, appetite rating, and physical function (ie, Short Physical Performance Battery, grip strength, and peak expiratory flow). Biochemical indicators of nutritional status, blood lipids, and serum phospholipid fatty acid (FA) profile.

RESULTS

Twenty-eight participants completed the 2 phases of the crossover study; group A (n = 14, 87 ± 6 years, 50% women) and group B (n = 14, 82 ± 8 years, 71% women). The intervention periods combined resulted in significantly (P < .05) increased energy intake (238 ± 544 kcal), weight gain (1.4 ± 3.7 kg), improved appetite, relative reduction of saturated FA and increase in polyunsaturated FA, increased apoliporotein A, and reduced serum fibrinogen (-0.9 ± 1.5 g/L).

CONCLUSION

Distribution of an oleic and linoleic acid based fat emulsion enriched with protein and micronutrients (Calogen Extra) 3 times daily to old people in care residential homes improved nutritional status, had positive effects on fatty acid profile and blood lipids, and a potential antithrombotic effect. CLINICALTRIALS.

GOV IDENTIFIER

NCT01259999.

The effects of the administration of oral nutritional supplementation with medication rounds on the achievement of nutritional goals: a randomized controlled trial

BACKGROUND & AIMS

Oral nutritional supplements (ONS) are often considered for hospitalized patients with acute severe malnutrition, however the compliance to the supplements is known to be variable. The aim of our study was to investigate whether providing a lower volume of ONS at a higher frequency during medication rounds would improve the intake of the supplements.

METHODS

In this randomized controlled trial, 234 malnourished inpatients (mean age 71.2 years, 55% male, median LOS 10 days) were randomized to receive ONS (300 kcal and 12 g Protein per 125 ml serving) in one of three different schemes. The usual care group (n = 88) was offered ONS 125 ml twice per day in between meals. This was compared to two intervention groups that were offered ONS during medication rounds: intervention group 1 (n = 66) received 125 ml of ONS twice per day, at 12 and 17 o'clock, and intervention group 2 (n = 80) received 62 ml of ONS four times a day, at 8, 12, 17 and 20 o'clock. Follow-up was performed until discharge or until ONS was no longer needed, with a maximum follow-up period of 30 days. The primary outcome measure was the percentage of patients who consumed at least 75% of the prescribed volume of ONS.

RESULTS

No significant differences were observed between the control groups and intervention group 1 (risk difference of -16.0% (95% CI -33.2-1.2). However, the percentage of patients consuming at least 75% of the prescribed ONS was higher in intervention group 2, with a risk difference 23.4% (95% CI 7.8-39.0%) and a mean increased intake of 35 ml (84 kcal) per day, p < 0.001). Median time ONS were taken was 5 days (range 1-17).

CONCLUSION

A higher frequency of a lower volume of ONS during medication rounds increased the compliance of patients needing ONS. Clinical trial registration number NTR2535; www.trialregister.nl.

Application of a score system to evaluate the risk of malnutrition in a multiple hospital setting

BACKGROUND

An increased but unpredictable risk of malnutrition is associated with hospitalization, especially in children with chronic diseases. We investigated the applicability of Screening Tool for Risk of Impaired Nutritional Status and Growth (STRONGkids), an instrument proposed to estimate the risk of malnutrition in hospitalized children. We also evaluated the role of age and co-morbidities as risk for malnutrition.

METHODS

The STRONGkids consists of 4 items providing a score that classifies a patient in low, moderate, high risk for malnutrition. A prospective observational multi-centre study was performed in 12 Italian hospitals. Children 1-18 years consecutively admitted and otherwise unselected were enrolled. Their STRONGkids score was obtained and compared with the actual nutritional status expressed as BMI and Height for Age SD-score.

RESULTS

Of 144 children (75 males, mean age 6.5 ± 4.5 years), 52 (36%) had an underlying chronic disease. According to STRONGkids, 46 (32%) children were at low risk, 76 (53%) at moderate risk and 22 (15%) at high risk for malnutrition. The latter had significantly lower Height for Age values (mean SD value -1.07 ± 2.08; p = 0.008) and BMI values (mean SD-values -0.79 ± 2.09; p = 0.0021) in comparison to other groups. However, only 29 children were actually malnourished.

CONCLUSIONS

The STRONGkids is easy to administer. It is highly sensitive but not specific. It may be used as a very preliminary screening tool to be integrated with other clinical data in order to reliably predict the risk of malnutrition.

Randomized study of clinical effect of enteral nutrition support during neoadjuvant chemotherapy on chemotherapy-related toxicity in patients with esophageal cancer

BACKGROUND & AIMS

Enteral nutrition (EN) is provided for patients with cancer. However, Little is known about the clinical efficacy of EN support during chemotherapy in patients with cancer.

METHODS

Ninety-one patients who received neoadjuvant chemotherapy (5-fluorouracil, cisplatin and adriamycin) for esophageal cancer were enrolled to receive either EN (n = 47) or PN (n = 44) at random. The primary endpoint was the incidence of chemotherapy-related toxicities during chemotherapy.

RESULTS

Total and dietary intake calories during chemotherapy were equal in the two groups. There were no significant differences in serum albumin level and body weight change after chemotherapy between the two groups. There was no significant difference in tumor response to chemotherapy between the two groups (EN: 51%, PN: 55%, p = 0.886). Leukopenia and neutropenia of grade 3 or 4, defined according to the Common Toxicities Criteria of the National Cancer Institute, were significantly less frequent in the EN group than PN group (leukopenia: 17% vs 41%, p = 0.011, neutropenia: 36% vs 66%, p = 0.005). Lymphopenia and thrombocytopenia tended to be less frequent in the EN group, albeit insignificantly.

CONCLUSIONS

Compared with PN support, EN support during neoadjuvant chemotherapy reduced the incidence of chemotherapy-related hematological toxicities in patients with esophageal cancers.

Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system

Malnutrition is a debilitating and highly prevalent condition in the acute hospital setting, with Australian and international studies reporting rates of approximately 40%. Malnutrition is associated with many adverse outcomes including depression of the immune system, impaired wound healing, muscle wasting, longer lengths of hospital stay, higher treatment costs and increased mortality. Referral rates for dietetic assessment and treatment of malnourished patients have proven to be suboptimal, thereby increasing the likelihood of developing such aforementioned complications. Nutrition risk screening using a validated tool is a simple technique to rapidly identify patients at risk of malnutrition, and provides a basis for prompt dietetic referrals. In Australia, nutrition screening upon hospital admission is not mandatory, which is of concern knowing that malnutrition remains under-reported and often poorly documented. Unidentified malnutrition not only heightens the risk of adverse complications for patients, but can potentially result in foregone reimbursements to the hospital through casemix-based funding schemes. It is strongly recommended that mandatory nutrition screening be widely adopted in line with published best-practice guidelines to effectively target and reduce the incidence of hospital malnutrition.

Study protocol: cost-effectiveness of transmural nutritional support in malnourished elderly patients in comparison with usual care

Background

Malnutrition is a common consequence of disease in older patients. Both in hospital setting and in community setting oral nutritional support has proven to be effective. However, cost-effectiveness studies are scarce. Therefore, the aim of our study is to investigate the effectiveness and cost-effectiveness of transmural nutritional support in malnourished elderly patients, starting at hospital admission until three months after discharge.

Methods

This study is a randomized controlled trial. Patients are included at hospital admission and followed until three months after discharge. Patients are eligible to be included when they are ≥ 60 years old and malnourished according to the following objective standards: Body Mass Index (BMI in kg/m²) < 20 and/or ≥ 5% unintentional weight loss in the previous month and/or ≥ 10% unintentional weight loss in the previous six months. We will compare usual nutritional care with transmural nutritional support (energy and protein enriched diet, two additional servings of an oral nutritional supplement, vitamin D and calcium supplementation, and consultations by a dietitian). Each study arm will consist of 100 patients. The primary outcome parameters will be changes in activities of daily living (determined as functional limitations and physical activity) between intervention and control group. Secondary outcomes will be changes in body weight, body composition, quality of life, and muscle strength. An economic evaluation from a societal perspective will be conducted alongside the randomised trial to evaluate the cost-effectiveness of the intervention in comparison with usual care.

Conclusion

In this randomized controlled trial we will evaluate the effect of transmural nutritional support in malnourished elderly patients after hospital discharge, compared to usual care. Primary endpoints of the study are changes in activities of daily living, body weight, body composition, quality of life, and muscle strength. An economic evaluation will be performed to evaluate the cost-effectiveness of the intervention in comparison with usual care.

Trial registration

Netherlands Trial Register (ISRCTN29617677, registered 14-Sep-2005)

Should food or supplements be used in the community for the treatment of disease-related malnutrition?

Strategies are needed for community-based treatment of disease-related malnutrition (DRM), which is a common debilitating condition that in the UK is estimated to cost >£7×109annually. Whilst dietary fortification and counselling are often used as a first-line treatment for malnutrition, the numbers of dietitians available to undertake and oversee such practices are currently insufficient to address the extent of DRM in primary care. Although dietary fortification and counselling can improve nutritional (primarily energy) intake, the evidence base for this practice is weak and it needs addressing with well-designed trials that assess clinically-relevant outcome measures and costs. Liquid oral nutritional supplements (ONS) are increasingly used in the community, often in combination with dietary counselling. The larger evidence base of trials that have assessed ONS suggests that nutritional intake and some functional outcomes can be improved in some patient groups in the community. Although meta-analysis indicates significant reductions in mortality (odds ratio 0.59 (95% CI 0.48, 0.72),n3258) and complication rates (odds ratio 0.41 (95% CI 0.31, 0.53),n1710) with ONSv. routine care, few of these studies are community based. Thus, the impact of ONS on clinical outcome, healthcare use and costs requires further assessment. Similarly, the clinical and cost efficacy of other strategies (e.g. sensory enhancement, music, behavioural therapy), alone or in combination with other treatments, requires greater investigation in order to meet the challenge of treating DRM more effectively and cheaply in the future.

ESPEN Guidelines on Enteral Nutrition: Non-surgical oncology

Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility of increasing or ensuring nutrient intake in cases where normal food intake is inadequate. These guidelines are intended to give evidence-based recommendations for the use of ONS and TF in cancer patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards, are based on all relevant publications since 1985 and were discussed and accepted in a consensus conference. Undernutrition and cachexia occur frequently in cancer patients and are indicators of poor prognosis. EN should be started if undernutrition already exists or if food intake is markedly reduced for more than 7-10 days. Standard formulae are recommended for EN. Nutritional needs generally are comparable to non-cancer subjects. In cachectic patients metabolic modulators such as progestins, steroids and possibly eicosapentaenoic acid may help to improve nutritional status. EN is indicated preoperatively for 5-7 days in cancer patients undergoing major abdominal surgery. During radiotherapy of head/neck and gastrointestinal regions dietary counselling and ONS prevent weight loss and interruption of radiotherapy. Routine EN is not indicated during (high-dose) chemotherapy.