ESPEN guideline on hospital nutrition

Improved macronutrient composition of meals delivered to people with diabetes in hospital: a pre-post, mixed-methods observational study

BACKGROUND

Providing meals which meet diverse needs of hospital inpatients is complex, contributing to challenges in optimising glycaemia. We developed menus that improved the appropriateness of macronutrient composition of meals for inpatients with diabetes.

METHODS

Qualitative feedback from patients and healthcare professionals prompted the implementation of two new menus: 'diabetes lifestyle' and 'diabetes high energy'. Quantitative nutrition analysis of meals provided to inpatients using new menus was compared to the regular menu. Qualitative surveys were repeated after the implementation of the new menus.

RESULTS

Nutrition analysis demonstrated that meals ordered from the diabetes lifestyle menu (mean energy: 7.85 MJ) comprised less total fat (71 vs. 74 vs. 64 g, p < 0.001), saturated fat (34 vs. 36 vs. 31 g, p < 0.001), carbohydrate (246 vs. 249 vs. 217 g, p < 0.001) and sugar (125 vs. 121 vs. 102 g, p < 0.001) compared to the regular (mean energy: 8.46 MJ) and diabetes high energy menus (mean energy: 8.70 MJ). Meals ordered from the diabetes lifestyle menu provided greater protein (91 g) than the regular (85 g) and diabetes high energy (88 g) menus (p < 0.001) and equivalent fibre (33 vs. 31 vs. 33 g, respectively). After implementation of the new menus, more patients reported that meals met their nutritional needs (19 [95%] vs. 14 [70%], p = 0.04), and more healthcare professionals reported menus for inpatients with diabetes were appropriate (16 [100%] vs. 11 [41%], p < 0.001).

CONCLUSION

Using the diabetes lifestyle menu improved the macronutrient composition of meals for inpatients with diabetes not at risk of malnutrition.

Patient expectations and understanding of hospital food service provision when declaring a food allergy

BACKGROUND

Food allergies are increasingly common and so hospitals must promptly identify and manage these to maintain patient safety. The present study explored patient understanding and expectations of food allergy management in hospital food services.

METHODS

This exploratory descriptive study used mixed methods, including semi-structured interviews and surveys with hospital inpatients declaring food allergies, aiming to explore understanding, expectations and preferences for food allergy management in the hospital setting.

RESULTS

Twenty-four participants were interviewed, reporting between one and six food allergies across 25 different allergens. Three main themes were identified: "Shared responsibility for declaring and managing allergens in hospital", "Varied understanding and trust in hospital food service processes" and "Satisfactory hospital food service experience". In the latter, participants identified 13 key factors valued for hospital food, including appearance, food quality and flavour. Remarkably, being "free from" the food allergen was not amongst the most common factors. Generally, participants felt that declaring a food allergy had not negatively impacted their hospital admission, and overall satisfaction with food services did not differ between the food allergic study participants and the general hospital population.

CONCLUSIONS

Overall, the declaration of a food allergy did not negatively impact on hospital experience. However, further investigations are required to identify the most valued factors for hospital meals, aiming to enable a more targeted approach to better meet patient expectations.

Nutritional Support in the ICU

Critical illness is a complex condition that can have a devastating impact on health and quality of life. Nutritional support is a crucial component of critical care that aims to maintain or restore nutritional status and muscle function. A one-size-fits-all approach to the components of nutritional support has not proven beneficial. Recent randomized controlled trials challenge the conventional strategy and support the safety and potential benefits of below-usual calorie and protein intakes at the early, acute phase of critical illness. Further research is needed to define optimal nutritional support throughout the intensive care unit stay. Individualized nutritional strategies relying on risk assessment tools or biomarkers deserve further investigation in rigorously designed, large, multicenter, randomized, controlled trials. Importantly, although nutritional support is crucial, it might not be sufficient to enhance the recovery of critically ill patients. Thus, achieving the greatest efficacy may require individualized nutritional support combined with early, prolonged physical rehabilitation within a multimodal, holistic care program throughout the patient's recovery journey.

Persistent body-weight change on achalasia and peroral endoscopic myotomy: a multicenter cohort study

BACKGROUND

The distribution of body weight in patients with achalasia and after peroral endoscopic myotomy (POEM) has not been investigated. The role of body weight assessment after treatment remains unclear.

METHODS

Using the multicenter achalasia cohort, the frequency of underweight (body mass index [BMI] < 18.5 kg/m2) and overweight (BMI ≥ 25.0 kg/m2) and their associated clinical characteristics were analyzed. After POEM, risk factors for insufficient- (underweight persistently) and excessive- (responded to overweight) weight gainers were investigated. The correlation between BMI-increase rate and severity of esophageal symptoms post-POEM was evaluated.

RESULTS

Among 3,410 patients, 23.0% and 15.7% were underweight and overweight, respectively. Factors associated with underweight were higher age, female sex, severe symptoms, high lower esophageal sphincter (LES) pressure, and non-dilated esophagus (all p < 0.01). Longitudinal analyses revealed that weight gain post-POEM was achieved after a long duration (≥ 12 months; p < 0.01). In 528 patients post-POEM, the frequency of underweight reduced to 8.3% (p < 0.01). Risk factors for insufficient-weight gain (36.1% of underweight patients) included low BMI (p < 0.01) and high LES pressure (p = 0.03) and conversely for excessive-weight gain. Machine learning models based on patient characteristics successfully predicted insufficient- and excessive-weight gainers with an area under the curve value of 0.74 and 0.75, respectively. Esophageal symptoms post-POEM did not correlate with BMI increase.

CONCLUSION

Underweight is not solely a condition of advanced achalasia. After POEM, insufficient- or excessive-weight gainers are not rare and can be predicted preoperatively. Body weight change is an independent nutrition parameter rather than a part of the assessment of residual esophageal symptoms.

A liberalized diet does not improve caloric intake during neutropenia in patients undergoing hematopoietic stem cell transplants: A prospective randomized controlled trial

BACKGROUND

The neutropenic diet has been a long-standing approach to preventing infection in patients with hematopoietic stem cell transplants (HSCTs), although data on its efficacy are inconclusive and its restrictive nature might contribute to harm by reducing dietary intake in this patient population who typically experiences poor oral intake. The aim was to determine if a liberalized diet (LD), in comparison with a neutropenic hospital diet (ND), would improve energy intake and lessen weight loss during neutropenia in patients with HSCTs.

METHODS

A randomized controlled trial was conducted in a single-center HSCT/hematologic malignancy unit. The diet interventions were initiated when absolute neutrophil counts dropped to <500 cells/mm3; oral dietary intake was assessed during neutropenia until neutrophil recovery, which averaged 9.5 days.

RESULTS

Meal intake compliance (consuming at least 50% of meals/day) was not different between groups (LD, 47%; ND, 43%; P = 0.66). Of the 191 patients assessed (LD, n = 92; ND, n = 99), mean (SD) energy, 678 (349) vs 724 (393) kcal/d (P = 0.46), and protein, 30.3 (18.5) vs 30.4 (18.1) g/day (P = 0.89) did not differ between groups nor did weight change, 0.3 (2.5) vs 1.2 (4.1) kg (P = 0.22) during neutropenia. None vs higher than or equal to grade 1 mucositis, allogeneic vs autologous stem cell transplantation, and fewer days on intervention favored higher energy and protein intakes.

CONCLUSION

Energy intake during neutropenia did not improve with a LD encouraging fresh fruits and vegetables. Thus, alternative approaches to improving dietary intake, such as energy-dense and nutrient-dense foods with sensory characteristics acceptable to patients experiencing significant mucositis, require exploration.

Adequacy of oral intakes after cardiac surgery within an ERAS pathway: A prospective observational study

BACKGROUND

The 2019 Enhanced Recovery After Cardiac Surgery (ERACS) guidelines presented perioperative recommendations to optimize treatment for patients undergoing cardiac surgery (CS). However, the guidelines have not established postoperative nutrition recommendations. Limited studies have analyzed oral intakes after CS, but to our knowledge, none have done so in an ERACS pathway. The main objective of this study was to evaluate the adequacy of postoperative oral intakes, including adherence to oral nutrition supplements (ONSs).

METHODS

This was an observational prospective study. Postoperative oral intakes were analyzed from postoperative day (POD) 1 to 4, using direct observation of meal plates provided by the hospital. ONSs consumption was evaluated from POD2 to POD4. Adherence to other ERACS recommendations, including nutrition optimization before surgery, was recorded.

RESULTS

Forty-three patients were included in this study. Nutrition optimization before CS was offered to three (7%) patients. Forty-one (95%) patients resumed oral intakes on POD1. Mean oral calorie and protein intakes from POD2 to POD4 were 1088 ± 437 kcal and 0.8 ± 0.3 g/kg, respectively; however, 17 (41%) patients had calorie and protein intakes ≥70% of their estimated requirements. On POD2, ONSs consumption contributed 35% ± 19% and 38% ± 20% of calorie and protein intake, respectively. There was a significant decrease in ONSs consumption starting on POD3.

CONCLUSION

Within an ERACS pathway and with the contribution of ONSs, 41% of patients achieved sufficient oral intakes within the first 4 days after CS. The optimization of ONSs adherence on postoperative oral intakes should be further studied.

Addressing Inflammaging and Disease-Related Malnutrition: Adequacy of Oral Nutritional Supplements in Clinical Care

BACKGROUND

Disease-related malnutrition, with or without inflammation, in older adults is currently emerging as a public health priority. The use of Foods for Special Medical Purposes, including Oral Nutritional Supplements, and supplements is crucial to support patients in achieving their nutritional needs. Therefore, this article aims to comprehensively provide an analysis of the adequacy of FSMPs in meeting the nutritional requirements of different age-related diseases and takes into account the emerging role of inflammation. Moreover, it provides an identikit of the ideal products, following the pathology-specific guidelines.

METHODS

Data on 132 products were gathered through face-to-face meetings with companies' consultants. Specifically, information on energy, macronutrient, and micronutrient contents were collected, as well as on texture and flavors, osmolarity, cost, and packaging.

RESULTS

Most FSMPs met the daily recommendations for energy and protein intake. Nonetheless, few products contained β-hydroxy-β-methylbutyrate, optimal Branched-Chain Amino Acids ratios, arginine, glutamine, and omega-3 fatty acids. Furthermore, a marked predominance of FSMPs with a high osmolarity (85.7%), sweet taste (72%), and only animal protein content (79.5%) was observed. Cost analysis of FSMPs revealed a mean cost of EUR 5.35/portion. Products were mostly adequate for cancer, neurodegenerative diseases, diabetes, inflammatory bowel disease, end-stage kidney disease, dysphagiam and chronic obstructive pulmonary disease. However, gaps have been found for sarcopenia and abdominal surgery.

CONCLUSION

In light of the current market landscape, there is a need for a comprehensive regulation that indicates the optimal composition of FSMPs and the production of such products to tackle disease-related malnutrition.

Accessing and Receiving Speech-Language Pathology Services at the Multidisciplinary Amyotrophic Lateral Sclerosis Clinic: An Exploratory Qualitative Study of Patient Experiences and Needs

PURPOSE

This study sought to explore how patients with amyotrophic lateral sclerosis (ALS) presenting with coexisting bulbar and cognitive impairments and their caregivers experienced the speech-language pathologist (SLP) services provided in multidisciplinary ALS clinics in Canada and identified their perceived needs for bulbar symptom management.

METHOD

This qualitative study was informed by interpretive description. Seven interviews were conducted with patients with severe bulbar dysfunction or severe bulbar and cognitive dysfunction due to ALS or ALS-frontotemporal dementia, respectively, and/or their caregivers. Purposive sampling was used to recruit individuals with severe bulbar or bulbar and cognitive disease. Thematic analysis was used to analyze interview data.

RESULTS

Patients and caregivers reported difficulties with accessing and receiving SLP services at the multidisciplinary ALS clinic. These difficulties were further exacerbated in those with severe cognitive disease. Participants expressed a need for more specific (i.e., disease and service-related) information and personalized care to address their changing needs and preferences. Engaging caregivers earlier in SLP appointments was perceived as vital to support care planning and provide in-time caregiver education.

CONCLUSIONS

This study highlighted the challenges experienced by patients and caregivers in accessing and receiving SLP services. There is a pressing need for a more person-centered approach to ALS care and a continuing need for education of SLPs on care provision in cases of complex multisymptom diseases within a multidisciplinary ALS clinic.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24069222.

Skeletal muscle size and quality in healthy kidney donors, normal range and clinical associations

The gold standard to estimate muscle mass and quality is computed tomography (CT) scan. Lower mass and density (intramuscular fat infiltration) of skeletal muscles are markers of sarcopenia, associated with increased mortality risk, impaired physical function, and poorer prognosis across various populations and medical conditions. We aimed to describe standard reference values in healthy population, prospective kidney donors, and correlate clinical parameters to muscle mass and density. Included in the cohort 384 consecutive kidney donors. Mean age was 44.6 ± 11.5 (range 18.4-74.2), 46% were female and mean BMI was 25.6 ± 3.8 kg/m2. Our quantified reference values for psoas cross -sectional area (CSA) index at L3 level (males/females respectively) were 6.3 ± 1.8 and 4.8 ± 1.9 cm2 /m2, and density was 46.1 ± 5 and 41 ± 5 HU at that level. Older age (standardized beta coefficient - 0.12, p = 0.04), sex (- 0.32, p < 0.001) and BMI (0.17, p = 0.002) were significantly associated with CSA index of psoas at L3. Density, however, was associated with triglycerides level (- 0.21, p < 0.001), in addition to age (- 0.22, p < 0.0001), sex (- 0.27, p < 0.001) and BMI (- 0.1, p = 0.05). Our study validates the normative values of psoas muscle mass and density in healthy individuals and suggests correlations with clinical parameters. We demonstrate the significance of measuring not only the mass of the muscle, but also its density, as it has a valid association with metabolic parameters, including BMI and lipid level, even in healthy individuals and in the normal range of the tests.

Higher protein intake may benefit in patients with prolonged mechanical ventilation

Background

Patients with prolonged mechanical ventilation (PMV) is usually associated with muscle wasting and diaphragm weakness, resulting in high medical costs and mortality. Adequate energy and protein intake were beneficial in sarcopenia patients. We aimed to investigate the impact of protein intake in weaning parameters in patients with PMV.

Materials and methods

We enrolled patients with PMV (mechanical ventilation ≥6 h/day for ≥21 days) from a respiratory care center (RCC) of a tertiary medical center from December 2020 to October 2022, and classified them into weaning success and weaning failure groups. The patients' characteristics, nutrition records, weaning parameters and outcomes were analyzed.

Results

A total of 289 patients were included (mean age 73.5 years). Of the 289 patients, 149 were weaned successfully and 140 were not. The average protein intake was higher in the weaning success group than in the weaning failure group (1.22 ± 0.320 versus 0.99 ± 0.332 g/kg/day, p < 0.001). No significant differences were noted in the average calorie intake and whey protein intake between the two groups. RSBI <90 breaths/min/L (OR = 2.38, p = 0.045), serum albumin at 4th week ≥3 g/dL (OR = 2.89, p = 0.027), daily protein intake ≥1.01 g/kg/day (OR = 8.10, p < 0.001), PaO2/FiO2 (PF) ratio ≥ 300 (OR = 2.56, p = 0.027) were independent predictors for weaning from ventilator. Weak positive correlations were found between average protein intake with PF ratio (r = 0.1576, p = 0.0227) and PaO2 (r = 0.13359, p = 0.0497).

Conclusion

Daily protein intake had positively correlated with PF ratio and had independently benefit for weaning in patients with PMV.

Research trends in nutritional interventions for stroke: a bibliometric analysis and literature review

Background

Over the past 23 years, there has been a thorough analysis of literature concerning nutritional interventions, nutrients, and feeding approaches related to stroke. Furthermore, a scientific knowledge map was established, elucidating the current state of research, examining its development and trends, and offering new research viewpoints for the future. This study aimed to investigate global and emerging research trends in nutritional interventions for stroke from 2000 to 2023 through bibliometric analysis.

Methods

A bibliometric analysis of literature from the Core Collection of Scientific Networks for the years 2000-2022 was conducted. CiteSpace, VOSviewer, and bibliometric graphical software were used to identify major contributors to publications, including authors, countries, institutions, journals, references, and keywords.

Results

The bibliometric analysis yielded a total of 464 publications. This is a gradually increasing number in terms of the number of publications during the study period. China had the highest number of publications. Clinical Nutrition" was the journal with the highest number of relevant publications, and the most commonly used keywords were "stroke," "nutrition" and "malnutrition."

Conclusion

These analyses reveal research trends in nutritional therapy for stroke from 2000 to 2023 and point to prospective research frontiers. This study provides a deeper understanding of what nutritional treatment of stroke entails and provides guidance and support for future research in this area.

The neutropenic diet and its impacts on clinical, nutritional, and lifestyle outcomes for people with cancer: a scoping review

The neutropenic diet (ND) is often recommended to people with cancer to reduce infection risk despite recommendations of clinical guidelines advising against its use. While recent literature suggests the ND does not reduce infection risk, other outcomes related to health, nutrition, and lifestyle are unknown. The aim of this review is to systematically scope the literature on the ND in people with cancer for all outcomes related to clinical health, nutrition, and lifestyle. Scientific databases were systematically searched. Eligible studies were in English, people with any cancer type, consuming an ND, any age group, date, or setting. Eligible study types were randomised control trials, observational studies, systematic reviews, and meta-analyses. Twenty-one studies met the inclusion criteria. Outcomes of interest found were infection rates, fever, mortality, antibiotic use, gastrointestinal side effects, comorbidities, biochemistry, hospitalisation, nutritional status, quality of life (QoL), well-being, and financial costs. Most research has focused on infection and mortality rates with few assessing hospitalisation rates, nutritional status, financial costs, and QoL. Most included studies found no significant differences between ND and comparator diet for mortality, antibiotics use, comorbidities, and QoL; however, several studies reported the ND significantly increased the risk of infection. Gaps in the literature included effect of ND on QoL in an adult population, microbiome, lifestyle changes, and financial burden. Further research is needed regarding how the ND affects the microbiome and QoL of its consumers, but in the interim, it is important for hospitals providing an ND to their patients to liberalise the ND wherever possible.

Optical Microscopy as a Tool for Assessing Parenteral Nutrition Solution Stability: A Proof of Concept

Background/Objectives: Parenteral nutrition (PN) is used when enteral feeding is not possible. It is a complex mixture of nutrients that must meet a patient's needs but can face stability issues, such as lipid emulsion destabilisation and precipitate formation. Stability studies are complex, and the methodologies used are very varied in the literature. In addition, many studies are outdated and use outdated components. This study conducts a stability analysis of PN solutions using optical microscopy. Methods: Samples were prepared according to clinical practice standards and previous studies. We used a counting chamber for optical microscopic observations and different storage conditions (RT, 4 °C 1-14 days). Results: Precipitates larger than 5 µm were found in 8 out of 14 samples after 14 days of storage at room temperature, and none were observed in refrigerated samples. More lipid globules larger than 5 µm were detected in samples stored at room temperature than in those stored in a refrigerator after 14 days. Additionally, the number of large globules generally increased from day 1 to day 14 in most samples. Conclusions: The observed precipitates were probably calcium oxalate crystals, the formation of which is possible in PN but is not expected under the usual storage conditions in a hospital environment. Prolonged storage time and storage at room temperature increases the formation of these precipitates. These findings highlight the importance of using filters during both the preparation and administration of PN to prevent large particles from reaching patients.

Self-Determination, Optimism, Social Support, Knowledge, and Skills Have a Positive Influence on the Oral Intake of Long-Stay Acute Patients: A Qualitative Study

BACKGROUND

Although previous research has attempted to understand the barriers and enablers of oral intake in hospitalized patients, these studies have mainly focused on short-stay inpatients and lacked a theory-driven examination of the determinants that influence dietary behavior in the hospital.

OBJECTIVE

To explore and compare the factors influencing adequate and poor oral intake in long-stay acute patients (admitted >14 days).

DESIGN

A qualitative descriptive study with semistructured interviews.

PARTICIPANTS/SETTING

Twenty-one adult inpatients (13 men, 8 women) admitted to 2 medical and 2 surgical wards at a tertiary hospital in Brisbane, Australia, during 2022, stratified by the Subjective Global Assessment. Analysis performed Transcripts were initially deductively analyzed against the Theoretical Domains Framework, and a reflexive thematic approach was used to create overall themes.

RESULTS

Of the 21 included patients (median age = 68.0 years, IQR 34 years), 11 had adequate/improved intake and 10 poor/decreased intake. Six themes were identified to have influenced oral intake in long-stay patients: self-determination to eat; nutrition impact symptoms; foodservice characteristics and processes; nutrition-related knowledge and skills; social support; and optimism, emotions, and emotion regulation. Patients with adequate/improved oral intake were characterized by an autonomous motivation to eat. They had increased awareness about their nutritional status, knowledge, and skills about food for recovery, were more optimistic, and social support was an important enabler to eating. In contrast, patients with poor/decreased oral intake perceived nutrition impact symptoms and dislike of meals as the main barriers to eating in the hospital; however, they also expressed more negative emotions, reduced coping strategies, and decreased knowledge, skills, intrinsic motivation, and capabilities to eat. Social support was present but did not enable oral intake in this patient group.

CONCLUSIONS

This study provides novel insights into the factors that influenced oral intake in long-stay acute patients, highlighting the importance of patient-centered nutrition care, encompassing motivational interviewing techniques and collaboration from the multidisciplinary team to create a supportive environment that fosters autonomy and empowers patients to actively participate in their own nutrition and recovery.

Personalization in mitigating food waste and costs in hospitalization

BACKGROUND

Organization of food services within hospitals has been identified as a determinant of hospitalized patients' nutritional intake and associated food waste. Whereas hospital food service systems in the Netherlands traditionally consist of 3 fixed mealtimes each day, we recently implemented a new 3-channel concept that provides patients the opportunity to order extra meals or snacks in-between their 3 main mealtimes or even have dinner with their visitors in a bistro located on their ward.

AIM

This study investigates the impact of transitioning from a traditional paper-based to a patient-centered, digital hospital food service system on food waste production patterns and its associated financial implications.

METHODS

Plate waste (served but uneaten food) measurements were performed at baseline for all served meals during a one-week period within the traditional system and follow-up measurements were conducted annually after implementation of the new system during 3 consecutive years. Measurements were conducted at two hospital floors, each comprising four wards. Average grams of plate waste per served meal, daily meal frequency per patient and the associated production and disposal costs of the collected waste were calculated and compared between the two systems.

RESULTS

A total of 4361 meals served within the traditional system were compared with 7815 meals served within the new digital system. Meal frequency increased from an average of 2.5 meals per patient per day in the old system to an average varying between 3 and 3.3 meals per patient per day in the consecutive years. Within the traditional system, average plate waste was 81 grams per served meal, whilst it ranged between 33 and 49 grams per served meal during the following years, with the 3-channel concept in place (p < 0.001, p = 0.010). Dinner demonstrated the largest reduction in plate waste at all measurement points. Following this reduction of plate waste, estimated associated costs of plate waste production and disposal decreased in a similar pattern.

CONCLUSION

Transitioning from a traditional, paper based to a patient-centered and digital hospital catering system results in significantly higher daily meal frequency and less food waste per served meal.

Association between energy intake and activities of daily living in patients with acute stroke at hospital discharge: a retrospective cohort study

OBJECTIVE

This study aimed to investigate the effects of energy intake on activities of daily living (ADL) in patients with acute stroke, with a focus on the differences between obese and non-obese patients.

METHODS

This retrospective observational study was conducted in a neurological hospital and included patients hospitalized for acute stroke. During the acute phase (1 week after admission), energy intake was assessed, and the main outcome was defined as the Functional Independence Measure in the motor domain (FIM-M) at discharge. All subjects were divided into two groups based on their body mass index (BMI) at admission, with BMI ≥ 25 defining the obese stroke group and BMI < 25 defining the non-obese stroke group. Linear regression analysis was performed to examine the relationship between energy intake and FIM-M in each group.

RESULTS

A total of 307 patients with acute stroke (median age: 72 years) were included in this study, with 118 patients (39%) in the obese stroke group. In the non-obese stroke group, a significant and independent relationship was observed between FIM-M and energy intake (β = 0.103, p = 0.031, adjusted R2 = 0.687). However, in the obese stroke group, no significant relationship was found between FIM-M and energy intake (β = 0.076, p = 0.302).

CONCLUSION

In patients with acute stroke, energy intake positively affects functional outcomes in non-obese patients but not in obese patients. This study highlights the importance of considering obesity as a potential factor in determining energy intake in patients with acute stroke.

Update on Nutritional Advice Post-Heart Transplant: A Cross-Sectional Study across French-Speaking European Centers

INTRODUCTION

Heart transplantation is the standard treatment for severe heart failure. Graft preservation and infectious risk secondary to immunosuppressive drugs lead healthcare teams to offer nutritional advice to patients upon discharge from the hospital. However, no consensus or recommendation is available.

METHOD

We conducted a study to review the practices in all 26 centers providing heart transplantation in French-speaking Europe. We requested and analyzed the written documents these centers provided to their patients. The same two dieticians categorized the highlighted pieces of advice into distinct, autonomous categories.

RESULTS

We identified 116 pieces of advice, categorized into three areas: dietary restrictions for immunosuppressant/food interaction; environmental and food preparation guidelines and prevention of foodborne infections; and healthy and active lifestyle recommendations. Except for advice on immunosuppressant/food interaction, over one-third of the centers suggest discontinuing advice within 2 years post-transplant. General dietary advice covers lipids, carbohydrates, protein, calcium, sodium, and fiber but offers limited guidance on fatty acids despite their importance in cardiovascular risk prevention.

CONCLUSION

This study represents a pioneering exploration of the nutritional advice provided to patients following cardiac transplantation. It underscores the critical necessity of establishing consensus-based clinical guidelines in this domain.

Nutritional support in hospitalised patients with diabetes and risk for malnutrition: a secondary analysis of an investigator-initiated, Swiss, randomised controlled multicentre trial

OBJECTIVES

The main objective of this study was to investigate the effects of nutritional support on mortality in hospitalised patients with diabetes and nutritional risk participating in the Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) trial.

DESIGN

Secondary analysis of a Swiss-wide multicentre, randomised controlled trial.

PARTICIPANTS

Patients with diabetes and risk for malnutrition.

INTERVENTIONS

Individualised nutritional support versus usual care.

PRIMARY OUTCOME MEASURE

30-day all-cause mortality.

RESULTS

Of the 2028 patients included in the original trial, 445 patients were diagnosed with diabetes and included in this analysis. In terms of efficacy of nutritional therapy, there was a 25% lower risk for mortality in patients with diabetes receiving nutritional support compared with controls (7% vs 10%, adjusted HR 0.75 (95% CI 0.39 to 1.43)), a finding that was not statistically significant but similar to the overall trial effects with no evidence of interaction (p=0.92). Regarding safety of nutritional therapy, there was no increase in diabetes-specific complications associated with nutritional support, particularly there was no increase in risk for hyperglycaemia (adjusted OR 0.97, 95% CI 0.56 to 1.67 p=0.90).

CONCLUSION

Patients with diabetes and malnutrition in the hospital setting have a particularly high risk for adverse outcomes and mortality. Individualised nutritional support reduced mortality in this secondary analysis of a randomized trial, but this effect was not significant calling for further large-scale trials in this vhighly ulnerable patient population.

TRIAL REGISTRATION NUMBER

NCT02517476.

Summary of the best evidence for the management of dysphagia in elderly patients

OBJECTIVE

To search for and summarize the best evidence for themanagement of elderly patients with dysphagia.

METHODS

Clinical decisions, recommended practices, evidence summaries, clinical practice guidelines, expert consensus, and systematic reviews on the management of dysphagia among elderly patients were systematically reviewed from domestic and foreign guideline websites, association websites, and Chinese and English databases according to the 6S model of evidence-based resources. The search period was between January 1, 2010 and November 1, 2023. Two researchers evaluated the quality of the included literature respectively and extracted evidence.

RESULTS

A total of 14 literatures were identified, including 2 guidelines, 2 clinical decisions, 5 evidence summaries, 3 expert consensus statements, and 2 systematic reviews. Twenty-four pieces of evidence from 7 aspects were summarized, including assessment, treatment and rehabilitation, medication care, nutrition management, oral care, complication management, and psychological care.

CONCLUSION

The best evidence-based recommendations for the management of dysphagia in elderly patients is summarized, it is suggested that the best evidence should be selected according to the actual situation of patients, and a personalized management plan should be formulated to improve the quality of life of patients and achieve high-quality nursing.

Managing blood glucose levels with a hybrid closed-loop system in a patient with type 1 diabetes mellitus on enteral nutrition: A case report

The achievement of glycemic management is challenging in patients with diabetes on enteral nutrition, limited literature exists on hybrid closed-loop systems' efficacy in such a situation. We described the case of a patient with type 1 diabetes treated by advanced hybrid closed loop on enteral nutrition with satisfactory glycemic management.

A Novel Machine-Learning Algorithm to Predict the Early Termination of Nutrition Support Team Follow-Up in Hospitalized Adults: A Retrospective Cohort Study

BACKGROUND

For hospitalized adults, it is important to initiate the early reintroduction of oral food in accordance with nutrition support team guidelines. The aim of this study was to develop and validate a machine learning-based algorithm that predicts the early termination of medical nutritional therapy (the transition to oral feeding).

METHODS

This retrospective cohort study included consecutive adult patients admitted to the Hacettepe hospital (from 1 January 2018 to 31 December 2022). The outcome of the study was the prediction of an early transition to adequate oral feeding before discharge. The dataset was randomly (70/30) divided into training and test datasets. We used six ML algorithms with multiple features to construct prediction models. ML model performance was measured according to the accuracy, area under the receiver operating characteristic curve, and F1 score. We used the Boruta Method to determine the important features and interpret the selected features.

RESULTS

A total of 2298 adult inpatients who were followed by a nutrition support team for medical nutritional therapy were included. Patients received parenteral nutrition (1471/2298, 64.01%), enteral nutrition (717/2298, 31.2%), or supplemental parenteral nutrition (110/2298, 4.79%). The median (interquartile range) Nutritional Risk Screening (NRS-2002) score was 5 (1). Six prediction algorithms were used, and the artificial neural network and elastic net models achieved the greatest area under the ROC in all outcomes (AUC = 0.770). Ranked by z-value, the 10 most important features in predicting an early transition to oral feeding in the artificial neural network and elastic net algorithms were parenteral nutrition, surgical wards, surgical outcomes, enteral nutrition, age, supplemental parenteral nutrition, digestive system diseases, gastrointestinal complications, NRS-2002, and impaired consciousness.

CONCLUSIONS

We developed machine learning models for the prediction of an early transition to oral feeding before discharge. Overall, there was no discernible superiority among the models. Nevertheless, the artificial neural network and elastic net methods provided the highest AUC values. Since the machine learning model is interpretable, it can enable clinicians to better comprehend the features underlying the outcomes. Our study could support personalized treatment and nutritional follow-up strategies in clinical decision making for the prediction of an early transition to oral feeding in hospitalized adult patients.

Does enteral nutrition require continuity of management: a randomized controlled study

Objective

To explore a set of enteral nutrition therapy continuity management programs for intensive care unit patients based on the theoretical study of circadian rhythm mechanism.

Methods

The control group followed routine nursing management. Patients in the experimental group were implemented with an enteral nutrition continuity management program, and their eating behavior was adjusted 3 days before the end of tube feeding. Food intake was intermittent at 2, 3, and 4 h on the first day, the second day, and the third day of intervention, respectively, and all patients stopped eating at night. Abdominal distension assessment, appetite assessment, application of gastric motility drugs, and patient satisfaction were compared between the two groups after tube feeding.

Results

Three days after the end of tube feeding, abdominal distention assessment, bowel sound auscultation, and appetite assessment were statistically different (P<0.05) between the two groups. There were differences in the first day (15 vs. 6, P<0.05), the second day (9 vs. 3, P<0.05), and the cumulative number (17 vs. 7, P<0.05) of gastrointestinal drugs, but no differences in the third day (2 vs. 1, P>0.05). There was a statistical difference in nursing intervention (6.0 vs. 7.0, P<0.05) and psychological nursing (6.0 vs. 7.0, P<0.05), but no statistical difference in health education, medical environment, and nursing attitude (P>0.05).

Conclusion

Enteral nutrition continuity management program has a good preventive effect on the gastrointestinal symptoms of intensive care unit patients after the end of tube feeding.

ESPEN guideline on nutrition and hydration in dementia - Update 2024

BACKGROUND & AIMS

Dementia is accompanied by a variety of changes that result in an increased risk of malnutrition and low-intake dehydration. This guideline update aims to give evidence-based recommendations for nutritional care of persons with dementia in order to prevent and treat these syndromes.

METHODS

The previous guideline version was reviewed and expanded in accordance with the standard operating procedure for ESPEN guidelines. Based on a systematic search in three databases, strength of evidence of appropriate literature was graded by use of the SIGN system. The original recommendations were reviewed and reformulated, and new recommendations were added, which all then underwent a consensus process.

RESULTS

40 recommendations for nutritional care of older persons with dementia were developed and agreed, seven at institutional level and 33 at individual level. As a prerequisite for good nutritional care, organizations caring for persons with dementia are recommended to employ sufficient qualified staff and offer attractive food and drinks with choice in a functional and appealing environment. Nutritional care should be based on a written care concept with standardized operating procedures. At the individual level, routine screening for malnutrition and dehydration, nutritional assessment and close monitoring are unquestionable. Oral nutrition may be supported by eliminating potential causes of malnutrition and dehydration, and adequate social and nursing support (including assistance, utensils, training and oral care). Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Routine use of dementia-specific ONS, ketogenic diet, omega-3 fatty acid supplementation and appetite stimulating agents is not recommended. Enteral and parenteral nutrition and hydration are temporary options in patients with mild or moderate dementia, but not in severe dementia or in the terminal phase of life. In all stages of the disease, supporting food and drink intake and maintaining or improving nutrition and hydration status requires an individualized, comprehensive approach. Due to a lack of appropriate studies, most recommendations are good practice points.

CONCLUSION

Nutritional care should be an integral part of dementia management. Numerous interventions are available that should be implemented in daily practice. Future high-quality studies are needed to clarify the evidence.

Impact of gibberellin-regulated protein allergy on quality of life

The purpose of this study was to investigate possible allergens that cause gibberellin-regulated protein allergy. For this purpose, a thorough search of relevant information in the databases Embase, PubMed, Scopus, and Web of Science, presented for 2018-2023, was carried out. The study showed that about 4% of the world’s population suffers from food allergies. The main manifestations of allergic reactions and the degree of resistance to allergens depend on the age group of patients. The study identified the following food allergens in gibberellin-regulated protein allergy: Pru p7 (peach), Pru m7 (Japanese apricot), Cit s7 (orange), Pun g7 (pomegranate), Pru av7 (sweet cherry), Cap a7 (bell pepper), Fra a3 (strawberry), Cup s7 (cypress pollen). Gibberellin-regulated protein allergy is characterised by a predominantly adolescent and young adult population. The symptoms of this allergy usually manifest themselves in the form of oral syndrome, facial swelling (including eyelids), anaphylactic reactions and are aggravated by the action of cofactors. Such manifestations substantially impair the quality of life of patients, causing a social, psychological, and economic burden.

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/).

Incidence and outcomes of in-hospital nutritional decline: A prospective observational cohort study in adult patients

BACKGROUND AND AIMS

Hospital malnutrition is associated with higher healthcare costs and worse outcomes. Only a few prospective studies have evaluated trends in nutritional status during an acute stay, but these studies were limited by the short timeframe between nutrition assessments. The aim of this study was to investigate changes in nutritional status, incidence of hospital-acquired malnutrition (HAM), and the associated risk factors and outcomes in acute adult patients admitted for >14 days.

METHODS

A prospective observational cohort study was conducted in two medical and two surgical wards in a tertiary hospital in Brisbane, Australia. Nutrition assessments were performed using the Subjective Global Assessment at baseline (day eight) and weekly until discharge. Nutritional decline was defined as a change from well-nourished to moderate/severe malnutrition (HAM) or from moderate to severe malnutrition (further decline) >14 days after admission.

RESULTS

One hundred and thirty patients were included in this study (58.5% male; median age 67.0 years (IQR 24.4), median length of stay 23.5 days (IQR 14)). At baseline, 70.8% (92/130) of patients were well-nourished. Nutritional decline occurred in 23.8% (31/130), with 28.3% (26/92) experiencing HAM. Of the patients with moderate malnutrition on admission (n = 30), 16% (5/30) continued to decline to severe malnutrition. Improvement in nutritional status from moderate and severe malnutrition to well-nourished was 18.4% (7/38). Not being prescribed the correct nutrition care plan within the first week of admission was an independent predictor of in-hospital nutritional decline or remaining malnourished (OR 2.3 (95% CI 1.0-5.1), p = 0.039). In-hospital nutritional decline was significantly associated with other hospital-acquired complications (OR 3.07 (95% CI 1.1-8.9), p = 0.04) and longer length of stay (HR 0.63 (95% CI 0.4-0.9), p = 0.044).

CONCLUSION

This study found a high rate of nutritional decline in acute patients, highlighting the importance of repeated nutrition screening and assessments during hospital admission and proactive interdisciplinary nutrition care to treat or prevent further nutritional decline.

Physicochemical Stability of Hospital Parenteral Nutrition Solutions: Effect of Changes in Composition and Storage Protocol

(1) Background: Parenteral nutrition (PN) is a technique used for the administration of nutrients to patients for whom traditional routes cannot be used. It is performed using solutions with extremely complex compositions, which can give rise to a large number of interactions. These interactions can impact their stability and put the patient's life at risk. The aim of this study is to determine how changes in composition and storage protocol affect the stability of NP solutions. (2) Methods: Twenty-three samples were prepared according to routine clinical practice, with modifications to the concentration of some components. The samples were stored at room temperature (RT) and refrigerated (4 °C). Measurements of the droplet diameter, pH, density and viscosity were performed for both storage protocols on days 1, 3, 10 and 14. (3) Results: The samples with the lowest concentration of lipids (PN13-17) and proteins (PN18-22) showed a larger droplet diameter than the rest of the samples throughout the experiments. The USP limits were exceeded for some of the measurements of these sample groups. The pH density and viscosity remained relatively constant under the conditions studied. (4) Conclusions: The PN samples were considered stable and safe for administration under real-world conditions, but the samples with the lowest concentrations of lipids and proteins showed a tendency towards emulsion instability.

[Comprehensive nutrition therapy in hospitals - Wishful thinking or reality? A survey-based cross-sectional study of the nutritional therapy in hospitals of Baden-Württemberg]

INTRODUCTION

Malnutrition is widespread in German hospitals, has a negative impact on therapeutic success and quality of life, and it leads to increasing costs. An individualized nutritional support by nutritional professionals in accordance with current guidelines was shown to reduce mortality of malnourished inpatients. Ideally, nutritional support is conducted by an interdisciplinary nutrition support team. Current data on the nutritional therapy in German hospitals is missing.

METHODS

In order to ascertain the current status of nutritional support in hospitals in the federal state of Baden-Württemberg, clinic managements of all hospitals in Baden-Württemberg received an online questionnaire. Affiliated hospitals, specialist hospitals, as well as hospitals with less than 50 beds were excluded from the analysis.

RESULTS

The response rate was 84% (n = 94). The presence of a nutrition support team was reported by 34% of the hospitals. Twelve percent of the hospitals meet the structural characteristic of the OPS Code 8-98j Ernährungsmedizinische Komplexbehandlung, which means that their nutrition support team includes a physician. A validated nutritional risk screening is performed in 72% of the hospitals. Only 40% of the hospitals report that this is performed throughout every department. Nutrition support teams are more often concerned with malnutrition, enteral and parenteral nutrition as compared to nutritionists who are not organized in a team. Moreover, nutrition support teams have a wider range of tasks and more often a physician as a team member. Also, nutritional risk screenings are more often applied in hospitals with nutrition support teams.

DISCUSSION

Compared with a nationwide survey from 2004, there are markedly more nutrition support teams available in hospitals in Baden-Württemberg. When compared internationally, however, the rate of nutrition support teams is still low. In addition, there is no comprehensive nutritional care available. High-quality nutritional support is more often found in hospitals with nutrition support teams.

CONCLUSION

There is still a great potential of improving clinical nutritional care in hospitals in Baden-Württemberg. Moreover, an increase in nutrition support teams, also comprising medical members, should be achieved. Therefore, legal regulations and a sufficient refinancing are indispensable.

The Association of Body Mass Index on Falls Risk and Mortality in Hospitalized Patients of Different Old-Age Categories Requiring Nutritional Support

Malnutrition affect clinical outcomes in hospitalized old age patients, but the data on the related outcomes on the basis of different age categories are still limited. We aimed to investigate the interplay of associations among body mass index (BMI), falls risk, and mortality rate in different older adult patient age categories. This retrospective study included hospitalized patients aged ≥ 65 years who received artificial nutrition. Demographic, biochemical, and survival data were collected. BMI was evaluated using the World Health Organization BMI cutoffs for Asians, and patients were classified into high (≥ 23.0 kg/m2), normal (18.5-22.9 kg/m2), and low (< 18.5 kg/m2) BMI groups. The Morse Fall Scale was used to assess falls risk. By age categories, all patients (n = 4,642) were divided into the 65-74 (n = 2,649) and ≥ 75 (n = 1,993) years age groups. We found that the proportion of low-BMI and high risk of falls increased with age. Further, low-BMI was associated with increased falls risk in both age groups. Overall survival rate tended to be lower in the low-BMI and ≥ 75 years group than that in other patient groups, but did not differ significantly compared with the low-BMI and 65-74 years group. Low-BMI was associated with increased falls risk and mortality; however, the association depended on specific patient age groups.

Development of an electronic food ordering system and a la carte menu: Enhancing patient involvement in nutritional care

BACKGROUND

Malnutrition is a significant issue in hospitals, leading to weight loss and reduced quality of life for patients. Hospital food plays a crucial role in preventing malnutrition, especially for patients with high nutritional risk or malnourishment. However, barriers to providing adequate nutritional care include a lack of tools to record patients' nutritional intake and a limited understanding of energy and protein content in hospital menus.

OBJECTIVE

The study aimed to develop an electronic patient-centered food ordering system and an à la carte menu to improve patients' nutritional care and involvement in their dietary choices.

METHODS

The study was conducted in two parts. Part 1 involved a questionnaire survey among hospitalized patients to determine their food preferences, self-assessed ability to use an electronic food ordering system, and preferences for different types of cuisine. The survey also investigated patients' meal choices for a full day, including portion sizes. Part 2 comprised usability tests of the electronic food ordering system prototype, conducted on hospitalized patients to identify interface issues and assess overall satisfaction.

RESULTS

A total of 99 patients participated in the questionnaire survey. The majority (78.7 %) found the selection of dishes appropriate. Patients' preferences were used to adjust the à la carte menu to reflect their meal choices. In the usability tests, the electronic food ordering system prototype showed positive results, and the System Usability Score was above the threshold for minor adjustments.

CONCLUSION

The study successfully developed an electronic patient-centered food ordering system and an à la carte menu that aligned with patients' preferences and needs. The system demonstrated usability and potential to improve patients' nutritional care and involvement in their dietary decisions. By addressing the barriers to nutritional care, this system offers a feasible solution to prevent and treat malnutrition in hospitalized patients.

Prevalence of the use of oral nutritional supplements among acute inpatients at risk of malnutrition and associated patient characteristics

AIM

To provide a snapshot of the current use of oral nutritional supplements, its association with inpatient characteristics, and with a focus on the role of nursing monitoring of food intake and implementing nutritional interventions for patients with low intake.

DESIGN

Retrospective cohort study.

METHODS

The study collected data from a hospital database regarding oral nutritional supplement initiation and variables of patients hospitalised in internal medicine departments, who did not receive enteral or parenteral nutrition.

RESULTS

Of the 5155 admissions, 1087 fulfilled the inclusion criteria (47% female; mean age, 72.4 ± 14.6 years; mean length of stay, 14.6 ± 11.4 days). Sufficient food intake reporting was noted in 74.6% of the patients; of these 17% had decreased intake. Oral nutritional supplements and non-oral nutritional supplements groups did not differ in terms of sex, age, length of stay, Charlson Comorbidity Index, proportion of nursing reports, and absence of intake monitoring. Oral nutritional supplements were initiated in 31.9% of patients with a Malnutrition Universal Screening Tool score ≥2 and in 34.6% with decreased food intake. On multivariable analysis, hypoalbuminemia (adjusted odds ratio, 3.70), decreased food intake (adjusted odds ratio, 3.38), Malnutrition Universal Screening Tool score ≥2 (adjusted odds ratio, 2.10), and age <70 years (adjusted odds ratio, 1.56) were significantly associated with oral nutritional supplements use.

CONCLUSION

The prevalence of oral nutritional intervention was suboptimal in patients at risk of malnutrition during acute hospitalisation, although decreased food intake and Malnutrition Universal Screening Tool score ≥2 independently increased the probability of oral nutritional supplements initiation.

RELEVANCE IN CLINICAL PRACTICE

Understanding the clinical practice and nursing impact of care management in relation to nutritional intervention can assist in reviewing and improving patient care. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE IMPACT (ADDRESSING): This study informs clinical management and influences nursing practice standards related to assessing, monitoring, and managing malnutrition risk.

IMPACT

The study impacts the quality of care for patients at risk of malnutrition.

REPORTING METHOD

We adhered to the STROBE Checklist for cohort studies.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Dietary Provision, GLIM-Defined Malnutrition and Their Association with Clinical Outcome: Results from the First Decade of nutritionDay in China

Malnutrition is a common and serious issue that worsens patient outcomes. The effects of dietary provision on the clinical outcomes of patients of different nutritional status needs to be verified. This study aimed to identify dietary provision in patients with eaten quantities of meal consumption and investigate the effects of dietary provision and different nutritional statuses defined by the GLIM criteria on clinical outcomes based on data from the nutritionDay surveys in China. A total of 5821 adult in-patients from 2010 to 2020 were included in this study's descriptive and Cox regression analyses. Rehabilitation and home discharge of 30-day outcomes were considered a good outcome. The prevalence of malnutrition defined by the GLIM criteria was 22.8%. On nutritionDay, 51.8% of all patients received dietary provisions, including hospital food and a special diet. In multivariable models adjusting for other variables, the patients receiving dietary provision had a nearly 1.5 higher chance of a good 30-day outcome than those who did not. Malnourished patients receiving dietary provision had a 1.58 (95% CI [1.36-1.83], p < 0.001) higher chance of having a good 30-day outcome and had a shortened length of hospital stay after nutritionDay (median: 7 days, 95% CI [6-8]) compared to those not receiving dietary provision (median: 11 days, 95% CI [10-13]). These results highlight the potential impacts of the dietary provision and nutritional status of in-patients on follow-up outcomes and provide knowledge on implementing targeted nutrition care.

Early nutritional risk detection and intervention in COVID-19 hospitalized patients through the implementation of electronic automatized alarms

INTRODUCTION

Hospitalized COVID-19 patients may present acute malnutrition which could influence morbidity and mortality. In the first wave of the pandemic severe weight loss was observed in many hospitalized patients. This pilot study evaluates the usefulness of an electronic automatized alarm for the early quantification of a low food intake as a predictor of the risk of malnutrition using COVID-19 disease as a model of severe illness.

METHODS

Observational prospective nutritional screening with a daily automatized warning message to the Endocrinology and Nutrition Service provided by the Information Systems. All adult patients admitted for COVID-19 from November 2020 to February 2021 were included. When diet intake was <50% during consecutive 48h, an automated message was generated identifying the patient as "at nutritional risk (NR)" and additional specialist nutritional evaluation and therapy was performed within the next 24h.

RESULTS

205 patients out of 1176 (17.4%) were detected by automatized alarm and were considered as presenting high NR; 100% were concordant by the validated nutritional screening SNAQ. Nutritional support after detection was: 77.6% dietary adaptation+oral supplements; 9.3% enteral nutrition (EN); 1.5% parenteral nutrition (PN); 1% EN+PN and 10.7% no intervention is performed due to an end-of-life situation. Median weight loss during admission was 2.5kg (p25 0.25-p75: 6kg). Global mortality was 6.7% while in those detected by automatized alarm was 31.5%.

CONCLUSIONS

The implementation of an electronic NR screening tool was feasible and allowed the early nutritional assessment and intervention in COVID-19 hospitalized patients and can be useful in patients hospitalized for other pathologies.

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.

Characterizing food environments of hospitals and long-term care facilities in the Netherlands: a mixed methods approach

BACKGROUND

Hospitals and long-term care facilities, which are key institutions to serve health and well-being, have an important exemplary role in providing supportive food environments to encourage healthy and sustainable food choices. The objective of this study is to characterize the physical, socio-cultural, political and economic dimensions of the food environment for health care receivers, health workforce and visitors in healthcare settings, and make comparisons between the food environment of hospitals and long-term care facilities.

METHODS

To characterize the food environment in healthcare settings, two sub-studies were conducted. In sub-study 1, semi-structured interviews were held with staff members (n = 46) representing 11 hospitals and 26 long-term care facilities (rehabilitation centres, nursing homes, institutions for people with intellectual disabilities and mental healthcare institutions). In sub-study 2, staff members audited the food environment in hospitals (n = 28) and long-term care facilities (n = 36) using a predefined checklist.

RESULTS

The food environment in Dutch healthcare settings varies substantially between locations although noticeable differences between hospitals and long-term care facilities were identified. Hospitals and larger long-term care facilities featured more often restaurants and utilized central spaces for preparation of meals, while smaller long-term care facilities often operated as household-like settings. Type of healthcare shaped the socio-cultural food environment, with hospitals primarily emphasizing nutrition for fast recovery, while long-term care facilities more often as an instrument (i.e., to structure the day). Participants highlighted the importance of food policies and broad organizational support for realizing and regulating improvement of the food environment. Yet, long-term care facilities were less familiar with national guidelines for food environments compared to hospitals. Several economical aspects, like profit motives, strict budgets and contracts with external parties affected and shaped the food available within all healthcare settings.

CONCLUSIONS

This study characterized the food environment in Dutch healthcare settings. Disclosed differences between hospitals and long-term care facilities should be incorporated in strategies for a transition of the food environment. Future research should investigate the underlying mechanisms of the healthcare food environment attaining all healthcare stakeholders - health care receivers, staff and visitors - while prioritizing sustainability alongside healthiness.

Improving enteral nutrition tolerance and protein intake maybe beneficial to intensive care unit patients

Enteral nutrition (EN) is important for critically ill patients. This study investigated the current situation of EN treatment in SHANGHAI intensive care units (ICUs). We hypothesized that improving EN practice in SHANGHAI may benefit the prognosis of ICU patients. Clinical information on EN use was collected using clinic information forms in 2019. The collected data included the patient's general clinical information, EN prescription status, EN tolerance status, and clinical outcomes. The observation time points were days 1, 3, and 7 after starting EN. A total of 491 patients were included. The proportion of EN intolerance (defined as < 20 kcal/kg/day) decreased, with rates of intolerance of 100%, 82.07%, 70.61%, and 52.23% at 1, 3, 7, and 14 days, respectively. Age, mNutric score, and protein intake < 0.5 g/kg/day on day 7 were risk factors for 28-day mortality.The EN tolerance on day 7 and protein intake > 0.5 g/kg/day on day 3 or day 7 might affect the 28-day mortality. Risk factors with EN tolerance on day 7 by logistic regression showed that the AGI grade on day 1 was a major factor against EN tolerance. The proportion of EN tolerance in SHANGHAI ICU patients was low. Achieving tolerance on day 7 after the start of EN is a protective factor for 28-day survival. Improving EN tolerance and protein intake maybe beneficial for ICU patients.

A Predictive Tool Based on DNA Methylation Data for Personalized Weight Loss through Different Dietary Strategies: A Pilot Study

BACKGROUND AND AIMS

Obesity is a public health problem. The usual treatment is a reduction in calorie intake and an increase in energy expenditure, but not all individuals respond equally to these treatments. Epigenetics could be a factor that contributes to this heterogeneity. The aim of this research was to determine the association between DNA methylation at baseline and the percentage of BMI loss (%BMIL) after two dietary interventions, in order to design a prediction model to evaluate %BMIL based on methylation data.

METHODS AND RESULTS

Spanish participants with overweight or obesity (n = 306) were randomly assigned to two lifestyle interventions with hypocaloric diets: one moderately high in protein (MHP) and the other low in fat (LF) for 4 months (Obekit study; ClinicalTrials.gov ID: NCT02737267). Basal DNA methylation was analyzed in white blood cells using the Infinium MethylationEPIC array. After identifying those methylation sites associated with %BMIL (p < 0.05 and SD > 0.1), two weighted methylation sub-scores were constructed for each diet: 15 CpGs were used for the MHP diet and 11 CpGs for the LF diet. Afterwards, a total methylation score was made by subtracting the previous sub-scores. These data were used to design a prediction model for %BMIL through a linear mixed effect model with the interaction between diet and total score.

CONCLUSION

Overall, DNA methylation predicts the %BMIL of two 4-month hypocaloric diets and was able to determine which type of diet is the most appropriate for each individual. The results of this pioneer study confirm that epigenetic biomarkers may be further used for precision nutrition and the design of personalized dietary strategies against obesity.

Quality appraisal of clinical practice guidelines for the management of Dysphagia after acute stroke

Objectives

Dysphagia is a common complication in stroke patients, widely affecting recovery and quality of life after stroke. The objective of this systematic review is to identify the gaps that between evidence and practice by critically assessing the quality of clinical practice guidelines (CPGs) for management of dysphagia in stroke.

Methods

We systematically searched academic databases and guideline repositories between January 1, 2014, and August 1, 2023. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was used by two authors to independently assess CPG quality.

Results

In a total of 14 CPGs included, we identified that three CPGs obtained a final evaluation of "high quality," nine CPGs achieved "moderate quality" and two CPGs received "low quality." The domain of "scope and purpose" achieved the highest mean score (91.1%) and the highest median (IQR) of 91.7% (86.1, 94.4%), while the domain of "applicability" received the lowest mean score (55.8%) and the lowest median (IQR) of 55.4% (43.2, 75.5%).

Conclusion

The CPG development group should pay more attention to improving the methodological quality according to the AGREE II instrument, especially in the domain of "applicability" and "stakeholder involvement;" and each item should be refined as much as possible.

A Comparative Evaluation of the Caloric Intake and Economic Efficiency of Two Types of Homogenized Diets in a Hospital Setting

The prevalence of malnutrition is increasing globally due to factors such as age-related pathological conditions and diseases that impact food and beverage intake. In hospital settings, older adult patients often require homogenised diets, which can lead to malnutrition due to poor palatability and limited variety. This study compared the Standard Homogenised Diet (HSD) and a Modified Homogenized Diet (HMD) proposed in a tertiary hospital in Northern Italy. A retrospective and observational design was used to analyse data from 86 adult patients with various conditions requiring a homogenised diet. The primary goal was to compare food intake, rheological characteristics, and palatability of the two diets. The secondary objective was to evaluate the economic impact by comparing costs and quantifying food waste from unused meals. Patients on HMD had a median daily caloric intake of 852 kcal (IQR 787-926 kcal) compared to 631 kcal (IQR 506-797 kcal) in the HSD group. Taste, texture, palatability, and ease of intake for HMD outperformed HSD with scores such as 3.7 ± 0.6 vs. 2.5 ± 0.4 for taste. Economically, HMD was EUR 0.53 less expensive per day than HSD, and food wastage costs were significantly lower for HMD (EUR 2.66 ± 0.81) than HSD (EUR 4.66 ± 1.27). Overall, HMD presented substantial benefits in patient satisfaction and cost-efficiency. This insight may aid diverse care settings to enhance meal acceptance and nutritional intake for patients needing homogenised diets.

Nutrition Care after Hospital Discharge in Singapore: Evidence-Based Best-Practice Recommendations

The nutritional status of hospitalised patients is often at risk or compromised and predisposed to further deterioration after discharge, leading to poor clinical outcomes, high healthcare costs, and poor quality of life. This paper aims to provide evidence-based best-practice recommendations to address this, supported by a national survey of healthcare professionals in Singapore and reviewed by a multidisciplinary expert panel under the Sarcopenia Interest Group of Society of Parenteral and Enteral Nutrition Singapore (SingSPEN). We advocate screening all patients with a validated tool which includes a disease activity/burden component, an easily accessible dietitian referral pathway for patients at risk of malnutrition, and an individualised nutrition care plan formulated and delivered using a multidisciplinary team approach for patients at risk or with malnutrition. A comprehensive team would include not only dietitians but also physicians, nurses, physiotherapists, speech therapists, and medical social workers working together towards a common goal. Information on why nutrition is important for good health and how it can be achieved should also be provided to all patients and their caregivers before and after hospital discharge. With the above recommendations, we seek to improve upon the current nutrition care processes at discharge for healthcare institutions in Singapore.

Implementation of the ESPEN guideline on clinical nutrition in the intensive care unit (ICU): It is time to move forward!: A position paper from the 'nutrition in the ICU' ESPEN special interest group

Nutritional assessment and provision of nutritional therapy are a core part of intensive care unit (ICU) patient treatment. The ESPEN guideline on clinical nutrition in the ICU was published in 2019. However, uncertainty and difficulties remain regarding its full implementation in daily practice. This position paper is intended to help ICU healthcare professionals facilitate the implementation of ESPEN nutrition guidelines to ensure the best care for their patients. We have aimed to emphasize the guideline recommendations that need to be implemented in the ICU, are advised, or are optional, and to give practical directives to improve the guideline recommendations in daily practice. These statements were written by the members of the ICU nutrition ESPEN special interest group (SIG), based on a survey aimed at identifying current practices relating to key issues in ICU nutrition. The ultimate goal is to improve the ICU patients quality of care.

Neurosurgical perioperative management of frail elderly patients

With the rapid increase in global aging, the prevalence of frailty is increasing and frailty has emerged as an emerging public health burden. Frail elderly patients suffer from reduced homeostatic reserve capacity, which is associated with a disproportionate decline in physical status after exposure to stress and an increased risk of adverse events. Frailty is closely associated with changes in the volume of the white and gray matter of the brain. Sarcopenia has been suggested to be an important component of frailty, and reductions in muscle strength and muscle mass lead to reductions in physical function and independence, which are critical factors contributing to poor prognosis. Approximately 10-32% of patients undergoing neurological surgery are frail, and the risk of frailty increases with age, which is significantly associated with the occurrence of adverse postoperative events (major complications, total duration of hospitalization, and need for discharge to a nursing facility). The postoperative mortality rate in severely frail patients is 9-11 times higher than that in non-frail individuals. Therefore, due attention must be paid to neurosurgical frailty and muscle assessment in elderly patients. Specialized interventions in the perioperative period of neurosurgery in frail elderly patients may improve their postoperative prognosis.

Assessment of Nutrient Levels Provided by General Hospital Patient Menus: A Cross-Sectional Study Carried Out in the Region of Murcia (Spain)

Disease-related malnutrition remains a health problem with a high prevalence that increases the risk of poor patient outcomes, in addition to an elevation of healthcare costs. The aim of this study was to evaluate the nutritional quality of the menus at Ribera Molina Hospital, including their adequacy regarding recommended daily nutrient intakes and the agreement with the theoretical nutrition information provided by catering. The mean levels of energy, macronutrients, vitamins, and minerals provided by the basal, diabetic, and soft diets were calculated through the weighing of plated food served throughout the first 14 days of February 2020. A nutritional overestimation was seen in the nutrition information provided by the catering compared to the values derived from weighing foods (p < 0.01). Despite this, the nutritional content calculated by weighing satisfied the energy and protein requirements of 203 hospitalized patients previously studied in the internal medicine area of the hospital. The mean age of these patients was 62 years, and the main causes of admission were lung, cardiovascular, renal, and digestive diseases. There seems to be an insufficient amount of vitamins E and D, as well as magnesium, on all the menus. A possible insufficient amount of calcium, potassium, zinc, and copper was observed in some of the menus studied. It is necessary to update the hospital prescription manual so the nutritional contents of the diets are accurate and based on the weighted and calculated values to improve the adequacy of diets prescribed to patients.

n-3 Polyunsaturated Fatty Acid Supplementation Affects Oxidative Stress Marker Levels in Patients with Type II Intestinal Failure: A Randomized Double Blind Trial

Type II intestinal failure (IF-II) is a condition in which the gastrointestinal tract is compromised. Liver complications may occur because of the pathology and/or prolonged use of parenteral nutrition (PN); oxidative stress has been implicated as one of the causes. Lipid emulsions containing n-3 polyunsaturated fatty acids (PUFAs) have been proposed for the treatment. We aimed to evaluate the effect of 7-day n-3 PUFA supplementation on oxidative stress in IF-II patients receiving PN. This was a randomized, controlled, double-blinded, pilot trial of adult patients with IF-II, receiving either conventional PN (control) or PN enriched with n-3 PUFAs (intervention). Twenty patients were included (14 men, 49 ± 16.9 years), with the ANCOVA analysis the glucose (p = 0.003), and direct bilirubin (p = 0.001) levels reduced; whereas the high-density lipoprotein cholesterol (HDL-C) increased (p = 0.017). In the random-effect linear regression analysis, a reduction (p < 0.0001) in the malondialdehyde (MDA) level was found in the intervention group when the covariables age, HDL-C level, and alanine aminotransferase activity were considered. After 1 week of PN supplementation with n-3 PUFAs, the marker levels of some oxidative stress, blood lipids, and hepatic biomarkers improved in patients with IF-II.

Predictive Value of Malnutrition, Identified via Different Nutritional Screening or Assessment Tools, for Functional Outcomes in Patients with Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

Malnutrition affects more than half of patients with stroke. Although malnutrition leads to more deaths, a longer hospital stay, and higher costs, there is still a lack of consensus regarding the impact of malnutrition on physical functional outcomes in patients with stroke, and there are large differences in the diagnostic effects of nutritional screening or assessment tools for malnutrition. This study aimed to explore the impact of malnutrition in patients with stroke and assess the significance of current nutritional screening and assessment tools for these patients.

METHODS

Six databases were systematically searched until October 2022. Cohort studies meeting the eligibility criteria were included. Pooled effects were calculated using random-effects models.

RESULTS

Twenty-six studies with 21,115 participants were included. The pooled effects of malnutrition on poor functional outcome, FIM points, and dysphagia were OR = 2.72 (95% CI = 1.84-4.06), WMD = -19.42(95% CI = -32.87--5.96), and OR = 2.80 (95% CI = 1.67-4.67), respectively.

CONCLUSION

Malnutrition adversely affects the recovery of physical and swallowing functions in patients with stroke. Nutritional assessments consistently predict the outcomes of physical function in patients with stroke.

How processed is the hospital menu? An analysis based on NOVA food scoring system

BACKGROUND AND AIMS

Having healthier, less processed hospital menus is an emerging issue. Diets high in ultra-processed foods (UPF) have lower nutrient density, but the incidence of UPF in hospital menus has not been previously addressed. The present study determined the presence of UPF, minimally processed foods (MPF) and processed culinary ingredients (PCI) and their correlations with provided energy and nutrients.

METHODS

We recorded the hospital diet for 14 consecutive days and analyzed it with the USDA database, and published NOVA values.

RESULTS

The NOVA score of the menu was 1.90, 1.80-1.93, while the energy from UPF was 25.2%, 23.2%-29.9% (medians, interquartile ranges). Energy from UPF was positively related to beta-cryptoxanthin and negatively associated with dietary cholesterol and manganese. In contrast, the energy from MPF and PCI was positively associated with energy, protein, zinc, selenium, iron and B₁₂.

CONCLUSIONS

In conclusion, MPF and PCI in hospital diets relate to higher energy, protein and several micronutrients, which is essential to combat hospital malnutrition.

Assessment of Food Intake Assisted by Photography in Older People Living in a Nursing Home: Maintenance over Time and Performance for Diagnosis of Malnutrition

Malnutrition is related to poor outcomes. Food intake semi-quantitative assessment is helpful for malnutrition screening. Aims: to assess maintenance over one month of one-day semi-quantitative assessment of food intake (primary aim) and its performance in diagnosing malnutrition (secondary aim) in older people living in a nursing home. Food portions consumed at lunch and dinner were measured during 20 days by the Simple Evaluation of Food Intake (SEFI)® assisted by photography (SEFI®-AP) in 70 residents. Nutritional status was assessed in each patient during the first week of food intake monitoring according to Global Leadership Initiative on Malnutrition criteria. Food intake was decreased, i.e., SEFI®-AP < 7, in 39% (n = 27/73) of patients. According to the methods, 36 to 48% (n = 25 to 33/73) of patients had malnutrition, and 6 to 37% (n = 4 to 25/73) sarcopenia. According to a generalized linear model on ranks with repeated measures, the SEFI®-AP medians of lunch (p = 0.11) and means of lunch and dinner (p = 0.15) did not vary over time. Day 3 SEFI®-AP anticipated decreased food intake from days 4 to 20, with a sensitivity of 78% (95% confidence interval (CI), 62-94), a specificity of 30% [95%CI, 17-44] and positive and negative predictive values of 41% [95%CI, 28-55] and 68% [95%CI, 48-89]. The performance of SEFI®-AP for diagnosis of malnutrition using calf circumference <31 cm as a phenotypic criterion was correct: area under the curve = 0.71 [95%CI, 0.59-0.83]. SEFI®-AP sensitivity was better if ≤9.5 than <7, and inversely for specificity. The food intake of older people living in nursing homes is stable over one month. One-day SEFI®-AP correctly anticipates food intake during the following month and predicts diagnosis of malnutrition. Any decrease in food intake should lead to suspect malnutrition.