Apparent low frequency of undernutrition in Dublin hospital in-patients: should we review the anthropometric thresholds for clinical practice?

Prognostic Nutritional Index and Instant Nutritional Assessement Are Associated with Clinical Outcomes in a Geriatric Cohort of Acutely Inpatients

BACKGROUND

Among elderly inpatients, malnutrition is one of the most important predictive factors affecting length of stay (LOS), mortality, and risk of re-hospitalization.

METHODS

We conducted an observational, retrospective study on a cohort of 2206 acutely inpatients. Serum albumin and lymphocytes were evaluated. Instant Nutritional Assessment (INA) and the Prognostic Nutritional Index (PNI) were calculated to predict in-hospital mortality, LOS, and risk of rehospitalization.

RESULTS

An inverse relationship between LOS, serum albumin, and PNI were found. Deceased patients had lower albumin levels, lower PNI values, and third- and fourth-degree INA scores. An accurate predictor of mortality was PNI (AUC = 0.785) after ROC curve analysis; both lower PNI values (HR = 3.56) and third- and fourth-degree INA scores (HR = 3.12) could be independent risk factors for mortality during hospitalization after Cox regression analysis. Moreover, among 309 subjects with a lower PNI value or third- and fourth-class INA, hospitalization was re-hospitalization.

CONCLUSIONS

PNI and INA are two simple and quick-to-calculate tools that can help in classifying the condition of hospitalized elderly patients also based on their nutritional status, or in assessing their mortality risk. A poor nutritional status at the time of discharge may represent an important risk factor for rehospitalization in the following thirty days. This study confirms the importance of evaluating nutritional status at the time of hospitalization, especially in older patients. This study also confirms the importance for adequate training of doctors and nurses regarding the importance of maintaining a good nutritional status as an integral part of the therapeutic process of hospitalization in acute departments.

Trends in underweight and severe underweight disparities in Korean adults and older adults: a nationwide, repeated cross-sectional study

OBJECTIVES

Little is known about the disparities in underweight prevalence among the general population in high-income countries. We investigated the trends in underweight prevalence and disparities across sociodemographic groups among Korean adults and older adults.

SETTING AND PARTICIPANTS

A series of cross-sectional data on Korean national health checkups for adults aged ≥20 years were analyzed from 2005 to 2016.

MEASUREMENTS

Based on body mass index (kg/m2), underweight was graded as mild (17.0-18.49), moderate (16.0-16.9), and severe (<16.0). Underweight prevalence was compared across sociodemographic subgroups in 2015-2016. Trends in underweight disparities were examined from 2005-2006 to 2015-2016. Multivariable-adjusted odds ratios (ORs; 95% confidence intervals, CIs) were calculated using logistic regression.

RESULTS

Approximately 11-22 million adults were included in each wave. In 2015-2016, the overall prevalence of underweight was 3.6% (men 2.0%, women 5.2%); severe underweight was 0.2% (men 0.1%, women 0.3%). The prevalence of underweight varied by sex and age groups. In men, those aged ≥80 years had the highest prevalence (overall 7.33%, severe underweight 0.84%). In women, those aged 20-29 years had the highest prevalence of overall underweight (14.57%), whereas those aged ≥80 years had the highest prevalence of severe underweight (1.38%). Compared with individuals in the lowest income quartile, men in the highest income had lower ORs of overall (0.59, 95% CI 0.59-0.60) and severe underweight (0.46, 95% CI 0.44-0.48); women in the highest income quartile had a higher OR of overall (1.12, 95% CI 1.12-1.13) but a lower OR of severe underweight (0.89, 95% CI 0.86-0.92). From 2005-2006 to 2015-2016, severe underweight consistently declined in older men but remained constant in women aged ≥80 years, widening sex disparities among older adults. Severe underweight decreased or leveled off in the highest income quartile but steadily increased in the lowest quartile, worsening income disparities.

CONCLUSION

In this nationwide study, underweight was more prevalent among women, older adults aged ≥80 years, and low-income individuals. Disparities in severe underweight widened across sociodemographic subgroups over time.

Preoperative malnutrition is a risk factor for delayed recovery of mobilization after total hip arthroplasty

INTRODUCTION

Many studies have examined nutritional status and deteriorated postoperative outcomes in patients undergoing total hip arthroplasty. However, few studies have focused on nutritional status and postoperative mobility.

OBJECTIVE

To investigate the impact of preoperative nutritional status on mobility after total hip arthroplasty.

DESIGN

Retrospective single-institution cohort study.

SETTING

Orthopedic inpatient rehabilitation center.

PARTICIPANTS

A total of 503 patients who underwent unilateral primary total hip arthroplasty from 2015 through 2019 were included.

METHODS

Data were collected on patient demographics, comorbidities, preoperative nutritional status, and quadriceps strength. Nutritional status was assessed using the Controlling Nutritional Status (CONUT) score.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The primary outcome was postoperative mobility defined as the number of days from surgery to starting to walk independently.

RESULTS

Among 503 patients undergoing total hip arthroplasty, 18.9% were classified as malnourished. Patients with malnutrition had a one-day delay in achieving mobilization compared with patients with normal nutrition (6 vs. 5 days, P = .006). According to the Kaplan-Meier curves, patients with malnutrition had a significant delay in mobilization compared with those with normal nutrition (P < .001). All three Cox proportional hazards regression models showed that preoperative malnutrition was associated with a higher risk of delayed mobilization (hazard ratios 0.70-0.74).

CONCLUSIONS

Preoperative malnutrition as assessed by the CONUT is a significant risk factor for delayed recovery of mobilization after total hip arthroplasty.

Supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults

BACKGROUND

Supportive interventions such as serving meals in a dining room environment or the use of assistants to feed patients are frequently recommended for the management of nutritionally vulnerable groups. Such interventions are included in many policy and guideline documents and have implications for staff time but may incur additional costs, yet there appears to be a lack of evidence for their efficacy.

OBJECTIVES

To assess the effects of supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults.

SEARCH METHODS

We identified publications from comprehensive searches of the Cochrane Library, MEDLINE, Embase, AMED, British Nursing Index, CINAHL, SCOPUS, ISI Web of Science databases, scrutiny of the reference lists of included trials and related systematic reviews and handsearching the abstracts of relevant meetings. The date of the last search for all databases was 31 March 2013. Additional searches of CENTRAL, MEDLINE, ClinicalTrials.gov and WHO ICTRP were undertaken to September 2016. The date of the last search for these databases was 14 September 2016.

SELECTION CRITERIA

Randomised controlled trials of supportive interventions given with the aim of enhancing dietary intake in nutritionally vulnerable adults compared with usual care.

DATA COLLECTION AND ANALYSIS

Three review authors and for the final search, the editor, selected trials from titles and abstracts and independently assessed eligibility of selected trials. Two review authors independently extracted data and assessed risk of bias, as well as evaluating overall quality of the evidence utilising the GRADE instrument, and then agreed as they entered data into the review. The likelihood of clinical heterogeneity amongst trials was judged to be high as trials were in populations with widely different clinical backgrounds, conducted in different healthcare settings and despite some grouping of similar interventions, involved interventions that varied considerably. We were only able, therefore, to conduct meta-analyses for the outcome measures, 'all-cause mortality', 'hospitalisation' and 'nutritional status (weight change)'.

MAIN RESULTS

Forty-one trials (10,681 participants) met the inclusion criteria. Trials were grouped according to similar interventions (changes to organisation of nutritional care (N = 13; 3456 participants), changes to the feeding environment (N = 5; 351 participants), modification of meal profile or pattern (N = 12; 649 participants), additional supplementation of meals (N = 10; 6022 participants) and home meal delivery systems (N = 1; 203 participants). Follow-up ranged from 'duration of hospital stay' to 12 months.The overall quality of evidence was moderate to very low, with the majority of trials judged to be at an unclear risk of bias in several risk of bias domains. The risk ratio (RR) for all-cause mortality was 0.78 (95% confidence interval (CI) 0.66 to 0.92); P = 0.004; 12 trials; 6683 participants; moderate-quality evidence. This translates into 26 (95% CI 9 to 41) fewer cases of death per 1000 participants in favour of supportive interventions. The RR for number of participants with any medical complication ranged from 1.42 in favour of control compared with 0.59 in favour of supportive interventions (very low-quality evidence). Only five trials (4451 participants) investigated health-related quality of life showing no substantial differences between intervention and comparator groups. Information on patient satisfaction was unreliable. The effects of supportive interventions versus comparators on hospitalisation showed a mean difference (MD) of -0.5 days (95% CI -2.6 to 1.6); P = 0.65; 5 trials; 667 participants; very low-quality evidence. Only three of 41 included trials (4108 participants; very low-quality evidence) reported on adverse events, describing intolerance to the supplement (diarrhoea, vomiting; 5/34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567/2017 participants). Meta-analysis across 17 trials with adequate data on weight change revealed an overall improvement in weight in favour of supportive interventions versus control: MD 0.6 kg (95% CI 0.21 to 1.02); 2024 participants; moderate-quality evidence. A total of 27 trials investigated nutritional intake with a majority of trials not finding marked differences in energy intake between intervention and comparator groups. Only three trials (1152 participants) reported some data on economic costs but did not use accepted health economic methods (very low-quality evidence).

AUTHORS' CONCLUSIONS

There is evidence of moderate to very low quality to suggest that supportive interventions to improve nutritional care results in minimal weight gain. Most of the evidence for the lower risk of all-cause mortality for supportive interventions comes from hospital-based trials and more research is needed to confirm this effect. There is very low-quality evidence regarding adverse effects; therefore whilst some of these interventions are advocated at a national level clinicians should recognise the lack of clear evidence to support their role. This review highlights the importance of assessing patient-important outcomes in future research.

Patient Optimization-Strategies That Work: Malnutrition

BACKGROUND

Patient optimization is receiving increasing attention as outcomes monitoring and bundled payments have been introduced in joint arthroplasty. Optimization of nutrition is an important aspect of perioperative management.

METHODS

This manuscript is a review of previously published material related to nutrition and the impact of malnutrition on surgical outcomes, with guidance for surgeons preparing patients for elective joint arthroplasty.

RESULTS

Patients with optimized nutritional parameters have fewer complications, especially related to wound healing and infection.

CONCLUSION

Nutritional assessment and optimization should be a part of the perioperative management of patients undergoing lower extremity arthroplasty.

Body composition and morphological assessment of nutritional status in adults: a review of anthropometric variables

Evaluation of body composition is an important part of assessing nutritional status and provides prognostically useful data and an opportunity to monitor the effects of nutrition-related disease progression and nutritional intervention. The aim of this narrative review is to critically evaluate body composition methodology in adults, focusing on anthropometric variables. The variables considered include height, weight, body mass index and alternative indices, trunk measurements (waist and hip circumferences and sagittal abdominal diameter) and limb measurements (mid-upper arm and calf circumferences) and skinfold thickness. The importance of adhering to a defined measurement protocol, checking measurement error and the need to interpret measurements using appropriate population-specific cut-off values to identify health risks were highlighted. Selecting the optimum method for assessing body composition using anthropometry depends on the purpose (i.e. evaluating obesity or undernutrition) and requires practitioners to have a good understanding of both practical and theoretical limitations and to be able to interpret the results wisely.

Nutritional status among older residents with dementia in open versus special care units in municipal nursing homes: an observational study

Background

Undernutrition is widespread among institutionalised elderly, and people suffering from dementia are at particularly high risk. Many elderly with dementia live in open units or in special care units in nursing homes. It is not known whether special care units have an effect on the nutritional status of the residents. The aim of this study was therefore to examine the nutritional status of residents with dementia in both open units and in special care units.

Methods

Among Oslo’s 29 municipal nursing homes, 21 participated with 358 residents with dementia or cognitive impairment, of which 46% lived in special care units. Nutritional status was assessed using the Malnutrition Universal Screening Tool and anthropometry.

Results

We found no differences (p > 0.05) in risk of undernutrition, body mass index, mid-upper arm muscle circumference or triceps skinfold thickness between residents in open units and those in special care units. Residents in special care units were significantly younger and stronger when measured with a hand-grip test.

Conclusions

We found no difference in nutritional status between nursing home residents with dementia/cognitive impairment in open units versus in special care units.

Adherence to the National Institute of Clinical Excellence guidance on parenteral nutrition screening is not enough to improve outcomes

BACKGROUND & AIM

Majority of the National Institute of Clinical Excellence (NICE) nutrition guidance recommendations were based on Grade D evidence due to absence of randomised controlled trials. The aim was to assess outcomes of parenteral nutrition (PN) administration when the guidance was adhered to.

METHODS

The prospective study included patients referred for PN. Patients were divided into two groups: guidance compliant and guidance non-compliant. Primary outcome measures were duration of PN treatment, number of PN bags used per patient, length of hospital stay and mortality.

RESULTS

There were 262 patients, aged 54(42-67) [median (IQR)] years. The guidance compliant and the non-compliant groups consisted of 143 and 119 patients respectively. In the guidance compliant group all patients were screened on admission compared to 40% in the non-compliant group (p < 0.001). Among those malnourished/at risk of malnutrition all were referred for early dietetic assessment in the compliant group but only 14% in the non-compliant group (p < 0.001). There was no difference in any of the outcome measures between the groups.

CONCLUSION

Compliance with the nutritional guidance in the UK was not enough to improve outcomes in patients requiring PN in our cohort. Evidence based changes to PN practice are required to optimise care.

Length of stay in surgical patients: nutritional predictive parameters revisited

Nutritional evaluation may predict clinical outcomes, such as hospital length of stay (LOS). We aimed to assess the value of nutritional risk and status methods, and to test standard anthropometry percentilesv.the 50th percentile threshold in predicting LOS, and to determine nutritional status changes during hospitalisation and their relation with LOS. In this longitudinal prospective study, 298 surgical patients were evaluated at admission and discharge. At admission, nutritional risk was assessed by Nutritional Risk Screening-2002 (NRS-2002), Malnutrition Universal Screening Tool (MUST) and nutritional status by Subjective Global Assessment (SGA), involuntary % weight loss in the previous 6 months and anthropometric parameters; % weight loss and anthropometry were reassessed at discharge. At admission, risk/undernutrition results by NRS-2002 (P< 0·001), MUST (P< 0·001), % weight loss (P< 0·001) and SGA (P< 0·001) were predictive of longer LOS. A mid-arm circumference (MAC) or a mid-arm muscle circumference (MAMA) under the 15th and the 50th percentile, which was considered indicative of undernutrition, did predict longer LOS (P< 0·001); conversely, there was no association between depleted triceps skinfold (TSF) and longer LOS. In-hospital, there was a high prevalence of weight, muscle and fat losses, associated with longer LOS. At discharge, patients with a simultaneous negative variation in TSF+MAC+MAMA (n158, 53 %) had longer LOS than patients with a TSF+MAC+MAMA positive variation (11 (8–15)v.8 (7–12) d,P< 0·001). We concluded that at risk or undernutrition evaluated by all methods, except TSF and BMI, predicted a longer LOS. Moreover, MAC and MAMA measurements and their classification according to the 50th percentile threshold seem reliable undernutrition indicators.

Weakness of expiratory muscles and pulmonary complications in malnourished patients undergoing upper abdominal surgery

BACKGROUND AND OBJECTIVE

Malnutrition is prevalent in hospitalized patients and causes systemic damage including effects on the respiratory and immune systems, as well as predisposing to infection and increasing postoperative complications and mortality. This study aimed to assess the impact of malnutrition on the rate of postoperative pulmonary complications, respiratory muscle strength and chest wall expansion in patients undergoing elective upper abdominal surgery.

METHODS

Seventy-five consecutive candidates for upper abdominal surgery (39 in the malnourished group (MNG) and 36 in the control group (CG)) were enrolled in this prospective controlled cohort study. All patients were evaluated for nutritional status, respiratory muscle strength, chest wall expansion and lung function before surgery. Postoperative pulmonary complications (pneumonia, tracheobronchitis, atelectasis and acute respiratory failure) before discharge from hospital were also evaluated.

RESULTS

The MNG showed expiratory muscle weakness (MNG 65 ± 24 vs CG 82 ± 22 cm H(2) O; P < 0.001) and decreased chest wall expansion (P < 0.001), whereas inspiratory muscle strength and lung function were preserved (P > 0.05). The MNG also had a higher incidence of postoperative pulmonary complications compared with the CG (31% and 11%, respectively; P = 0.05). In addition, expiratory muscle weakness was correlated with BMI in the MNG (r = 0.43; P < 0.01). The association between malnutrition and expiratory muscle weakness increased the likelihood of postoperative pulmonary complications after upper abdominal surgery (P = 0.02).

CONCLUSIONS

These results show that malnutrition is associated with weakness of the expiratory muscles, decreased chest wall expansion and increased incidence of pulmonary complications in patients undergoing elective upper abdominal surgery.

Standardized phase angle indicates nutritional status in hospitalized preoperative patients

There is currently no criterion standard to assess nutritional status, and different methods have been used in hospitalized patients. The aim of this study was to investigate the agreement and the association between bioelectrical impedance analysis derived by standardized phase angle (SPA) and other methods used for the nutritional assessment of body composition, metabolic status, and functional status in surgical patients. The hypothesis was that the SPA is effective for evaluating nutritional status in surgical patients; therefore, it could be used when the application of other assessment methods is not possible. The sample consisted of 125 patients (20-94 years of age) before elective gastrointestinal or hernia repair. The participants were from the Surgical Clinic 1 at the University Hospital of the Federal University of Santa Catarina, Florianópolis, SC, Brazil. Nutritional status was evaluated during the preoperative period based on the triceps skinfold thickness, mid-arm circumference, body mass index, percent weight loss, nutritional risk screening 2002 (NRS 2002), subjective global assessment (SGA), and SPA. The agreement between the SPA and the other methods was assessed with the k coefficient. The agreement between the SPA and the methods of nutritional assessment that were investigated for diagnosing malnutrition was moderate for NRS 2002 and SGA, weak for percent weight loss, and poor for triceps skinfold thickness, mid-arm circumference, and body mass index. There was a significant association between SPA and both NRS 2002 and SGA (P < .001). Our results suggest that SPA is able to indicate the risk of nutritional deficiency in the patients assessed. However, good agreement between SPA and the methods investigated was not observed.

Influence of adherence to the national guidance on nutrition screening and dietitian referral on clinical outcomes of those requiring parenteral nutrition

BACKGROUND

National guidance in the UK on nutrition support suggests that all patients should be screened on initial admission to hospital and, where appropriate, be referred to a healthcare professional. The present study aimed to investigate whether initial nutrition screening influenced the outcome of patients who received parenteral nutrition (PN).

METHODS

Data were prospectively evaluated on 100 consecutive patients referred to the multidisciplinary PN team in a teaching hospital. Information was obtained from medical notes, electronic patient records, completed PN prescription charts, dietetic record cards and nursing care plans. Patients who were treatable by nutritional supplements or enteral nutrition were not included. Patients were divided into two groups: guidance compliant and guidance noncompliant, in order to compare outcome measures such as the duration of PN treatment, total number of PN bags used per patient and length of hospital stay. Comparison of data between the two groups was carried out using either the independent samples t-test or the Mann-Whitney U-test.

RESULTS

There was no difference in outcome measures between the guidance compliant and noncompliant groups. Patients in the guidance noncompliant group were more likely to be in general (77%) than critical wards (23%). Patients who were in the guidance compliant group received nutrition support earlier.

CONCLUSIONS

Compliance with the national guidance in the UK on screening did not improve outcomes in patients requiring parenteral nutrition in this cohort. Initial nutrition screening prior to PN administration warrants further investigation to ensure value is added to patient care.

Undernutrition in hospitalized older adults: patterns and correlates, outcomes, and opportunities for intervention with a focus on processes of care

Undernutrition in hospitalized older adults is increasingly being recognized as a serious problem with implications for both patient care and outcomes and health service utilization and costs. This article presents an overview of research that has been conducted examining undernutrition in hospitalized older adults. First, findings from observational studies examining patterns and predictors of undernutrition in hospitalized older adults will be described, with a focus on methodological challenges. Second, clinical outcomes and costs associated with undernutrition in hospitalized older adults will be presented, both while in the hospital and subsequent to discharge. Third, a description of interventions that have already been implemented in hospitalized older adults will be described. Finally, future areas of inquiry and opportunities for evidence-based nutritional interventions targeted at older adults during and following hospitalization will be suggested. The emphasis of the discussion on interventions will focus on processes of care and the hospital environment.

A hospital-based multidisciplinary approach improves nutritional status of the elderly living in long-term care facilities in middle Taiwan

Improvement in nutritional status using two different care models was assessed in 374 elderly people (mean +/- S.D. age = 78.8+/-7.2 years) living in eight long-term care facilities in middle Taiwan. The subjects were divided into two groups using randomized block design; a hospital-based multidisciplinary team was responsible for the care of the intervention group, and the control group received usual care for 6 months. A structured questionnaire, anthropometric measurements, and biomedical markers were checked for each subject before and after the intervention. No significant differences were observed in age, height, weight, body mass index, hemoglobin, and albumin between the intervention (n = 125) and control (n = 249) groups at baseline. After 6 months of intervention, 83 subjects in the intervention group and 182 subjects in the control group had completed the study. The change in albumin level was greater in the intervention group (1.58 g/l) than in the control group (0.15 g/l, p < 0.05). The prevalence of hypoalbuminemia (albumin < 35 g/l) decreased from 69.2% to 52.9% in the intervention group and from 70.3% to 67.0% in the control group. In conclusion, a hospital-based multidisciplinary care effectively improved the nutritional status of elderly patients living in long-term care facilities in middle Taiwan.

Protein and energy supplementation in elderly people at risk from malnutrition

BACKGROUND

Evidence for the effectiveness of nutritional supplements containing protein and energy, often prescribed for older people, is limited. Malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition.

OBJECTIVES

This review examined trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually as commercial 'sip-feeds'.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of oral protein and energy supplementation in older people, with the exception of groups recovering from cancer treatment or in critical care.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary.

MAIN RESULTS

Sixty-two trials with 10,187 randomised participants have been included in the review. Maximum duration of intervention was 18 months. Most included trials had poor study quality. The pooled weighted mean difference (WMD) for percentage weight change showed a benefit of supplementation of 2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42 trials. There was no significant reduction in mortality in the supplemented compared with control groups (relative risk (RR) 0.92, CI 0.81 to 1.04) from 42 trials. Mortality results were statistically significant when limited to trials in which participants (N = 2461) were defined as undernourished (RR 0.79, 95% CI 0.64 to 0.97).The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75 to 0.99). Few trials were able to suggest any functional benefit from supplementation. The WMD for length of stay from 12 trials also showed no statistically significant effect (-0.8 days, 95% CI -2.8 to 1.3). Adverse effects included nausea or diarrhoea.

AUTHORS' CONCLUSIONS

Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.

Subjective and objective nutritional assessment methods: what do they really assess?

PURPOSE OF REVIEW

Objective and subjective methods are used to assess nutritional status. They are used as diagnostic, prognostic and response tools. It is still controversial which of them is more suitable for each situation and what they are really assessing. The most recent findings about these methods will be discussed in this review.

RECENT FINDINGS

Malnutrition still has a high prevalence all over the world. Anthropometric measurements are best useful to assess chronic malnutrition, and albumin and other visceral protein should no longer be considered as nutritional markers, but inflammatory response markers. Subjective global assessment enables comparison among different populations, and its scored version may be useful in other clinical situations besides cancer. Functional methods and bioelectrical impedance analysis may become possible to identify malnutrition in an early stage. Nitrogen balance seems to be the only way to assess the response to nutritional interventions.

SUMMARY

Malnutrition should be understood as a continuum. Nutritional assessment should not be an expensive and time-consuming process, and simple methods such as subjective global assessment may be enough to identify those patients who need nutritional intervention. Future studies may show which method is more suitable to evaluate the response to this treatment.

How important is malnutrition? A prospective study in internal medicine

BACKGROUND/OBJECTIVE

Data about the prevalence of malnutrition on hospital admission vary and follow-up data are scarce. We assessed the nutritional status of unselected patients on admission and discharge.

SUBJECTS/METHODS

A total of 430 consecutively admitted patients were assessed and 168 patients hospitalized > or =6 days were reassessed on discharge. Assessment was carried out by the Mini Nutritional Assessment (MNA), weight and anthropometric measurements, bioelectrical impedance analysis, biochemical markers and a subjective clinical assessment by the physicians in charge.

RESULTS

On admission, 47% of all patients were overweight (body mass index, BMI >25 kg m(-2)) and 8% underweight (BMI<18.5 kg m(-2)). In terms of the MNA 70% were adequately nourished, 20% were at risk for malnutrition and 10% were malnourished. By clinical judgment alone 18 (4.3%) malnourished patients according to MNA were missed. The 44 malnourished patients according to the MNA had significantly lower values for BMI, fat-free mass, fat mass, waist circumference, triceps skinfold thickness, hemoglobin, albumin, prealbumin, total cholesterol but higher values for C-reactive protein. Of the 168 patients staying > or =6 days in hospital, 57% lost and 39% gained weight. Only 1.9% of all patients (8 of 430) were malnourished and lost further weight during hospitalization.

CONCLUSIONS

We found a low prevalence (10%) of malnourished patients on admission. Clinical judgment and to some extent anthropometrical measurement were helpful for assessing the nutritional status, laboratory values were not.

Role of visceral proteins in detecting malnutrition in the elderly

OBJECTIVE

In the clinical practice, visceral proteins are used as indirect markers of protein energy malnutrition (PEM), but their reliability could be reduced with advancing age. The aim of this work is to investigate the reliability of albumin, prealbumin, retinol-binding protein (RBP) and transferrin in evaluating nutritional status in old patients and their relationship with fat-free mass (FFM).

DESIGN

Cross-sectional study.

SETTING

Padua, Italy.

SUBJECTS

In 44 underweight (body mass index < 20 kg/m(2)) (66-97 years) and 69 normal weight or overweight elderly subjects (62-98 years), albumin, prealbumin, transferrin and RBP were determined in the plasma. Body composition and particularly FFM was obtained by dual X-ray absorptiometry. FFM was also expressed as FFM index (FFMI) calculated as FFM divided by height squared. Subjects affected by acute illnesses and inflammatory states were excluded.

RESULTS

Albumin, prealbumin and RBP mean values were significantly lower in underweight subjects. No differences between two groups were found for transferrin. Albumin prealbumin and RBP resulted under the normal range in 55, 25 and 54% of underweight subjects, respectively. Transferrin's values were low in about 40% of underweight and normal weight subjects, respectively. In all subjects, FFMI shows a significant correlation with albumin (r: 0.52), prealbumin (r: 0.64) and RBP (r: 0.57). No correlation between FFMI and transferrin was found.

CONCLUSIONS

Visceral proteins, except for transferrin, seem to be useful indexes in detecting malnutrition in the elderly; low values still in the normal range should also be carefully evaluated because they could suggest a poor nutritional status.

Cost savings of an adult hospital nutrition support team

OBJECTIVES

A hospital-based nutrition support team (NST) may need to demonstrate cost savings and quality benefits. The primary aim of this study was to determine whether an NST could show tangible cost savings (equipment, investigations, and medication costs) from managing patients considered for parenteral nutrition (PN). Secondary aims related to the quality issues of placement of PN catheters, catheter-related sepsis (CRS), duration of parenteral nutrition, and mortality.

METHODS

An NST was formed in 1999 and worked in all adult areas of a university hospital (Leicester Royal Infirmary). Comparative data about all patients given PN were collected for 2 consecutive years (a retrospective pre-NST year and a prospective NST year).

RESULTS

In the pre-NST year there were 82 PN episodes (54 patients), 665 PN days, and a CRS rate of 71% (seven infections/100 PN days). In the NST year, there were 133 referrals for PN but only 78 PN episodes (75 patients, 59% of referrals), 752 PN days, and a decreased overall CRS rate of 29% (three infections/100 PN days, P < 0.05) but a rate of 7% (0.6 infection/100 PN days) in the final 3 mo of the NST year. Tangible cost savings for the NST year were derived from 55 avoided PN episodes (42741 pounds sterlings) and 35 avoided CRS episodes (7974 pounds sterlings). Thirty-nine percent of PN catheters were inserted by the NST with no insertion-related complications. Competency-based training of ward nursing staff decreased the CRS rate. Mean duration of PN increased from 8 to 10 d (P not significant). In-hospital mortality for patients who had PN was 23 of 54 (43%) in the pre-NST year compared with 18 of 75 (24%) in the NST year (P < 0.05).

CONCLUSIONS

Although the number of PN days increased with an NST, tangible cost savings of 50715 pounds sterlings were demonstrated within the NST year by avoided PN episodes and a decreased incidence of CRS. These savings justify the salaries of a nutrition nurse specialist and a senior dietitian.

An adequate threshold for body mass index to detect underweight condition in elderly persons: the Italian Longitudinal Study on Aging (ILSA)

BACKGROUND

The present study aims at defining a body mass index (BMI) threshold for risk of being underweight in elderly persons on the basis of the BMI distribution in a large Italian population-based sample and on its ability to predict short-term mortality.

METHODS

At baseline (1992), BMI was obtained for 3110 (1663 males and 1447 females) persons aged 65-84 participating in the Italian Longitudinal Study on Aging (ILSA). BMI and risk factors (age, sex, education, smoking status, disability, and disease status) have been considered for their potential association with 4-year all-cause mortality. Information on vital status at 1995 was obtained for 2551 participants.

RESULTS

The fifth centile of BMI was well approximated by a value of 20 for both sexes. Also in both sexes, at a BMI value of 24 the a posteriori probability of death started to increase, doubling at a value of 22 for men and 20 for women. Crude mortality was 14.6% for men and 9.8% for women. The hazard ratios and confidence intervals (CIs) comparing mortality for each BMI two-unit class to the 26-28 class, after adjusting for confounding variables, showed significantly higher rates only for BMI values below 20 (2.9; 95% CI, 1.2-7.0), although a consistent increase in hazard ratio (1.6; 95% CI, 0.9-3.0) already appeared for the 20-22 BMI group.

CONCLUSIONS

Our study confirms that low BMI is an independent predictive factor of short-term mortality in elderly persons. A BMI value of 20 kg/m2 seems to be a reliable threshold for defining underweight elderly persons at high risk. Nevertheless, more careful clinical and nutritional management should also be applied to elderly persons with higher BMI values.

Profile of the malnourished patient

OBJECTIVE

To characterize malnutrition in a nonspecific group of newly admitted hospital patients.

DESIGN

A prospective, descriptive study aiming to identify typical symptoms of malnutrition in a heterogeneous population of newly admitted patients to the wards of internal medicine.

SETTING

The wards of internal medicine of the VU University Medical Center.

SUBJECTS

A total of 106 patients were included in the study, 70 patients underwent the full interview. Next to nutritional status, the sociodemographics, underlying disease, estimated care complexity, care situation before admission, journey through the care system, nutritional intervention and nutritional follow-up after discharge were described for each patient.

RESULTS

Of 70 patients 24 (34%) were malnourished. Malnourished patients suffered two chronic diseases vs one for well-nourished patients (P = 0.05). They also had a higher estimated care complexity (P = 0.035) and a trend towards longer length of hospital stay (P = 0.09). Malnourished patients did not differ from well-nourished patients in age, sex, partner status and care received at home. In all, 54% of the malnourished patients were identified correctly by the medical staff. The reasons for admission to the hospital were diverse in only four out of 24 patients malnutrition was the primary reason for admission. Discharge letters to the general practitioner (GP) contained only fragmentary information about the patients' nutritional status. At 3 months after discharge, most of the GPs were scarcely aware of any nutritional problems of their patients.

CONCLUSIONS

Malnutrition is difficult to recognize in a nonspecific hospital population. Patients do not present with unique symptoms indicating malnutrition. To be able to correctly identify all malnourished patients, screening of the nutritional status of all newly admitted patients seems to be necessary.

Évolution périopératoire du statut nutritionnel en chirurgie carcinologique des voies aérodigestives supérieures. Étude prospective et descriptive

AIM OF THE STUDY

To assess the perioperative evolution of the nutritional status of head and neck surgical patients.

DESIGN

Prospective, descriptive case series.

PATIENTS AND METHODS

Fifty-four patients candidates for total or partial laryngectomy for malignancy of the neck tract without a past of neck surgery. The nutritional status of all patients hospitalized for total pharyngolaryngectomy, total or partial laryngectomy was assessed by 1) clinical parameters including weight (W), weight variation (WV, percentage of loss), Body Mass Index (BMI), triceps skin fold measurement (T), midarm circumference (M), and 2) biological parameters such as serum albumin (SA), transthyretin (TTR), lymphocytes (Ly). These parameters were noted at the time of diagnostic laryngoscopy (T1), the day before surgery (T2), and 10 days afterward (T3) when patients were authorized to eat normally. All patients had enteral nutrition (EN) support (35 kcal/kg/day) starting at D1 and for 10 days afterward. Only complete data per patient were analyzed.

RESULTS

24 patients were excluded. During the 21 days [7-53] preoperative period (T1-T2), WV was (6.6% [-8,1-+20.0] [T2] vs. 4.7% [-12,9-+20.0] [T1], p<0.05) without difference in T and M. In the postoperative period (T2-T3), all parameters worsened, except T, with: WV (8.2% [-8,1-+20.0] [T3], p<0.05 vs T2), M (27.4 cm [20.0-37.0] [T3] vs 28.3 cm [20.5-39.0] [T2], p<0.05) et TTR (0.21 mg/l [0.09-0.36] [T3] vs. 0.27 mg/l [0.08-0.45] [T2], p<0.05). BMI was 22.9 [15.2-36.7] (T1) vs 22.9 [15.2-35.3] (T2), NS and 22.1 [15.0-34.9] (T3), p<0.05 vs (T2).

CONCLUSION

The nutritional status in malignancy head and neck surgical patients seems to be best assessed by loss weight. It worsened mainly during the postoperative period even if a well-conducted EN was performed as defined by the French consensus conference.

The Subjective Global Assessment reliably identifies malnutrition-related muscle dysfunction

BACKGROUND

Muscle dysfunction is a common finding in malnourished patients and is associated with poor outcome. We investigated whether the Subjective Global Assessment (SGA) is a valuable tool for identifying malnutrition-related muscle dysfunction.

METHODS

Two hundred eighty seven consecutive patients were assessed on admission to hospital according to the SGA, anthropometric measurements, and to the results of bioelectrical impedance analysis. The SGA was used as the main criterion for the classification of malnutrition. Muscle function was assessed by handgrip strength.

RESULTS

Maximal voluntary handgrip strength was significantly lower in malnourished than in well-nourished male and female patients (45.22 (13.51-67.7)kg versus 30.82(11-48) kg in men; 23.81 (5.60-56.5) kg versus 18.5 (5.90-48.8) kg in women). Handgrip strength tended to decline with age. Handgrip strength was positively correlated to body cell mass (BCM) (r=0.72, P<0.001 in men and: r=0.56, P<0.001 in women) and to body mass index (r=0.271, P=0.03 in men and r=0.183, P=0.02 in women). BCM was identified as a powerful contributor to the variation in handgrip strength (delta r2=0.645, P<0.001).

CONCLUSION

The SGA appears to be a reliable bedside assessment tool for malnutrition and malnutrition-related dysfunction. Patients classified malnourished according to the SGA have an impaired functional status. Every effort should be made to provide both nutritional and physical therapy in order to improve the patients' outcome.

Protein and energy supplementation in elderly people at risk from malnutrition

BACKGROUND

Evidence for the effectiveness of nutritional supplements containing protein and energy, which are often prescribed for older people, is limited. Furthermore malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition.

OBJECTIVES

This review examined the evidence from trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually in the form of commercial 'sip-feeds'.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers. Date of most recent search: March 2004.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised controlled trials of oral protein and energy supplementation in older people with the exception of groups recovering from cancer treatment or in critical care.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary.

MAIN RESULTS

Forty-nine trials with 4790 randomised participants have been included in the review. Most included trials had poor study quality. The pooled weighted mean difference [WMD] for percentage weight change showed a benefit of supplementation of 2.3% (95% confidence interval (CI) 1.9 to 2.7) from 34 trials. There was a reduced mortality in the supplemented compared with control groups (relative risk (RR) 0.74, CI 0.59 to 0.92) from 32 trials. The risk of complications from 14 trials showed no significant difference (RR 0.95, 95% CI 0.81 to 1.11). Few trials were able to suggest any functional benefit from supplementation. The pooled weighted mean difference (WMD) for length of stay from 10 trials also showed no statistically significant effect (WMD -1.98 days, 95% CI -5.20 to 1.24).

AUTHORS' CONCLUSIONS

Supplementation produces a small but consistent weight gain in older people. There may also be a beneficial effect on mortality. However, there was no evidence of improvement in clinical outcome, functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.

Effect of nutritional support on clinical outcome in patients at nutritional risk

BACKGROUND & AIMS

Undernourished patients have an increased risk of complications and a prolonged hospital stay, compared to those who are not undernourished. The aim of this study was to evaluate the effect of nutritional intervention in a random sample of hospitalized patients at nutritional risk.

METHODS

A randomized, controlled trial of nutritional intervention in 212 patients. Intervention consisted of a specialized nutritional team (nurse and dietician) who attended patients and staff for motivation, detailed a nutritional plan, assured delivery of prescribed food and gave advice on enteral or parenteral nutrition when appropriate. The control group received the standard regime used in the department. The primary endpoint was the part of the length of stay (LOS) that was considered to be sensitive to nutritional support, designated LOSNDI. The nutritional discharge index (NDI) consists of three objective criteria: (1) the patient is able to manage toilet visits without assistance, reflecting mobilization; (2) the patient is without fever (tp < 38 degrees C), reflecting absence of infection; and (3) the patient has no intravenous access, reflecting absence of complications in general. On the day when all three criteria were fulfilled, hospital stay was no longer considered to be sensitive to nutritional support. Actual LOS is also reported. Incidence and severity of complications were recorded to explain LOSNDI findings. As a secondary endpoint, quality of life was evaluated by the Short Form 36 (SF-36) questionnaire.

RESULTS

Intervention led to an intake of > or = 75% of requirements in 62% of the intervention patients, as compared to 36% of the control patients. Rates of complications, mean LOSNDI and LOS were not significantly different between the two study groups. However, among patients with complications a difference in LOSNDI between intervention patients (14 +/- 2 days, mean +/- SE) and control patients (20 +/- 2 days) was statistically significant (P = 0.015). In the same patients, LOS was 17 +/- 2 days in the intervention group and 22 +/- 2 days in the control group (P = 0.028). The SF-36 questionnaire did not show a significant effect of treatment.

CONCLUSIONS

Protein and energy intake of nutritionally at-risk patients was increased which resulted in shortening of the part of the length of stay that was considered to be sensitive to nutritional support (LOSNDI) and shorter length of stay (LOS) among patients with complications.

Comparison of nutritional risk screening tools in patients on admission to hospital

BACKGROUND AND AIMS

Under nutrition has been frequently reported in patients on admission to hospital. Because this is not always detected promptly, screening for nutritional risk on admission has been widely advocated. Although there is no universally accepted 'gold standard' for defining undernutrition, the definition used by McWhirter, J.P. & Pennington, C.R. [(1994) Br. Med. J.308, 945] has been widely used by clinical nutrition specialists. This study aimed to compare the efficacy of two frequently used nutritional risk screening tools in detecting undernutrition according to this definition.

METHODS

Both the Nutrition Risk Index [Veterans Affairs Total Parenteral Nutrition Co-operative Study Group (1991) N. Engl. J. Med.325, 525] and the Nutrition Risk Score [Reilly H.M. et al. (1995) Clin. Nutr.14, 269] were used to screen for undernutrition in 359 admissions to two acute teaching hospitals in Dublin. Undernutrition was defined as a Body Mass Index below 20 kg m(-2) and a triceps skinfold thickness or mid-arm muscle circumference below the 15th percentile. Comparison of stratification of nutritional risk by the two screening tools was carried out.

RESULTS

Both screening tools identified over 40% (Nutrition Risk Index, 44%; Nutrition Risk Score, 46%) of all patients assessed as at nutritional risk on admission. However, one-third of the undernourished patients were classified as at no nutrition risk by the Nutrition Risk Index, while almost one-fifth of those undernourished were classified as at low risk by the Nutrition Risk Score. The degree of nutritional risk differed with the screening tool used, the Nutrition Risk Score classifying 29% of all patients as high risk while the Nutrition Risk Index classified only 5% as in the high risk category.

CONCLUSIONS

Although a large proportion of patients on admission were classified as being at nutritional risk, the degree of risk was significantly different depending on the screening tool used. Both nutritional risk screening tools evaluated in this study failed to recognize many cases of undernutrition. Evaluation of the efficacy of nutritional screening tools should be promoted as seriously as the development of such tools.

Are we wasting our money on food supplements in elder care wards?

BACKGROUND

It is reported that undernutrition in older hospitalized patients is commonly found, but estimates of its prevalence vary. It is also not clear which treatment approaches are best because poor methodology prevents comparison of outcomes between different studies.

RATIONALE

The rationale of this observational study was to look at typical elder care wards in order to determine what food supplements were being prescribed. We wished to determine whether serum albumin and/or body mass index (BMI) were appropriately related to the prescription of sip feeds and also to determine the palatability of supplements provided.

METHOD

We monitored the wastage of sip feeds over a 24-hour period and extrapolated an estimated cost. Ninety-six patients were studied, including 23 patients with a BMI of less than 20, of whom 30% were on supplementary feeds.

RESULTS

Seventy percentage of prescribed sip feeds were being given to people with a BMI of 20 or more. The mean wastage in this 24-hour period was 63% ( pound 79.56) in four wards containing 96 older patients.

CONCLUSION

We concluded that there was no relationship between the numbers of patients with a low albumin and BMI and the prescription of sip feeds. We found compliance to be low (37%) because of poor palatability, with a large number of patients who appeared to require sip feeds not being prescribed them and those who received them wasting more than they drank.

Assessment of nutritional status on hospital admission: nutritional scores

Malnutrition is still a largely unrecognized problem in hospitals. Malnutrition in hospitalized patients is generally related to increasing morbidity and mortality, and costs and length of stay. The aim of this study was to assess the nutritional status of patients on admission to a general hospital using different nutritional scores and to test the sensitivity and specificity of these scores. Sample population included 60 patients (55% male; 45% female) selected (aged 65.6+/-15.9 y) at random by using a computer software program. The nutritional state assessment was performed within 48 h of admission, using different nutritional indices (Subjective Global Assessment (SGA), Nutritional Risk Index (NRI), Gassull classification, Instant Nutritional Assessment (INA) and a combined index). About 78.3% of patients were found to be malnourished on admission. The frequency of malnutrition degree varied from 63.3% as assessed by the SGA to 90% with the NRI. Malnutrition severity was not related to the diagnosis. However, an elderly population was associated with a higher prevalence of malnutrition. INA was the best single score to identify patients who are malnourished or at risk of malnutrition and who may benefit from nutrition support.

Anthropometric measurements from a cross-sectional survey of Irish free-living elderly subjects with smoothed centile curves

Anthropometric screening has been recommended for the detection of undernutrition as it is simple, inexpensive and non-invasive. However, a recent study estimating the prevalence of undernutrition on admission to hospital in Dublin, Republic of Ireland, highlighted that the anthropometric reference data currently available in the UK and Republic of Ireland are inadequate to accurately determine nutritional status. In order to provide current anthropometric data, we carried out a cross-sectional study of 874 free-living, apparently healthy Irish-born elderly individuals aged over 65 years. Height, weight, triceps skinfold thickness, mid-arm and calf circumference were measured, values for BMI, mid-arm muscle circumference and arm muscle area were calculated and smoothed centile data derived for each variable. One-third of these elderly individuals had a BMI between 20-25 kg/m2, approximately two-thirds (68.5 % of males and 61 % of females) were classified as overweight or obese, almost one-fifth having a BMI over 30 kg/m2 (17 % of men and 20 % of women). Very few were underweight, only 3 % having a BMI below 20 kg/m2. Height, weight, BMI and muscle reserves decreased with increasing age. The reduction in muscle size was associated with lower handgrip strength. Fat reserves declined with age in females only. Just over half of elderly Irish women reported participating in active leisure of 20 min duration four or more times/week, although 13 % reported having no involvement in active leisure. These data for the Irish elderly extend the data generated from a recent countrywide survey of Irish adults aged 18-64 years, thus providing suitable reference standards for nutritional assessment of elderly Irish individuals.

Nutritional status of elective gastrointestinal surgery patients pre- and post-operatively

BACKGROUND AND AIMS

Studies have indicated that undernutrition is common on admission to hospital but there is limited data on change in nutritional parameters during the hospital stay. We assessed the nutritional status of elective gastrointestinal surgery patients on admission and documented change in nutritional indices during hospitalisation.

METHODS

Two hundred patients aged 18-80 years undergoing elective open gastrointestinal surgery were nutritionally assessed on admission and 150 were reassessed on commencement of oral diet post-surgery. Data were collected on height, weight, upper arm anthropometry and hand-grip dynamometry.

RESULTS

On admission BMI <20, 20-24.9 and >25, respectively, were found in 9%, 34% and 57% of patients. Post-surgery, 34% of patients experienced a clinically significant weight loss. Males lost significantly more weight (3.7% vs 1.6%, P<0.001) and tended to lose muscle mass while females preferentially lost subcutaneous fat.

CONCLUSIONS

The incidence of undernutrition on admission appears to be lower than previously reported. However, clinically significant weight loss was common and this study highlighted gender differences in the changes in nutritional parameters experienced by gastrointestinal surgery patients. This differential influence of gender warrants further investigation and may have implications for the nutritional management of such patients.

Influence of fat-free mass and functional status on resting energy expenditure in underweight elders

BACKGROUND

In underweight elders, resting energy expenditure (REE) and its relationship with fat-free mass (FFM) could be modified by sarcopenia, physical activity, and functional limitation. The aims of this study were to investigate REE and its relationship with quantity and metabolic activity of FFM and to evaluate the influence of functional status on REE in underweight elderly subjects.

METHODS

Forty-eight underweight elders (BMI < 20) and 54 normal weight elderly subjects (BMI 20-30) as a control group were selected. Body composition was determined by dual energy x-ray absorptiometry (DEXA). REE was measured by indirect calorimetry. Ability in activities of daily living (ADLs) was assessed by the Katz index.

RESULTS

Underweight elders had significantly lower FFM, FFM index (FFM/height(2)), and REE than healthy subjects. REE adjusted for FFM with analysis of covariance remained significantly lower in the underweight group (1287 +/- 85 vs 1715 +/- 139 kcal/day in men, and 1124 +/- 63 vs 1366 +/- 91 kcal/day in women). Katz index in the underweight group was inversely correlated with REE (r = -0.68; p <.001) even after removal of FFM, FM, and gender, by multiple regression analysis. In this model, FFM and Katz index together explained approximately 54% of REE variability.

CONCLUSIONS

Underweight elderly subjects show a hypometabolism due to a reduction of both FFM quantity and its metabolic activity. Functional status in ADLs comes out as an important predictor of REE independently from FFM. The limited physical activity might be the underlying determinant of this hypometabolism, but further investigations are necessary to confirm this issue.

Anthropometric measurements in the elderly: age and gender differences

In clinical practice and epidemiological surveys, anthropometric measurements represent an important component of nutritional assessment in the elderly. The anthropometric standards derived from adult populations may not be appropriate for the elderly because of body composition changes occurring during ageing. Specific anthropometric reference data for the elderly are necessary. In the present study we investigated anthropometric characteristics and their relationship to gender and age in a cross-sectional sample of 3,356 subjects, randomly selected from an elderly Italian population. In both sexes, weight and height significantly decreased with age while knee height did not. The BMI was significantly higher in women than in men (27.6 SD 5.7 v. 26.4 SD 3.7; P<0.001) and it was lower in the oldest than in the youngest subjects (P<0.05) of both genders. The 75th year of age was a turning point for BMI as for other anthropometric measurements. According to BMI values, the prevalence of malnutrition was lower than 5 % in both genders, whereas obesity was shown to have a higher prevalence in women than in men (28% v. 16%; P<0.001). Waist circumference and waist: hip ratio values were higher for the youngest men than for the oldest men (P<0.05), whereas in women the waist: hip ratio values were higher in the oldest women, suggesting that visceral redistribution in old age predominantly affects females. In conclusion, in the elderly the oldest subjects showed a thinner body frame than the youngest of both genders, and there was a more marked fat redistribution in women.

Nutrition in the elderly

Malnutrition is more common in elderly persons than in younger adults. Ageing itself, however, neither leads to malabsorption nor to malnutrition with the exception of a higher frequency of atrophic gastritis in older persons. Malnutrition in elderly people is therefore a consequence of somatic, psychic or social problems. Typical causes are chewing or swallowing disorders, cardiac insufficiency, depression, social deprivation and loneliness. Undernutrition is associated with a worse prognosis and is an independent risk factor for morbidity and mortality. Awareness of this problem is therefore important. For the evaluation of nutritional status, it must be remembered that most normal values are derived from younger adults and may not necessarily be suitable for elderly persons. Suitable tools for evaluating the nutritional status of elderly persons are e.g. the body mass index, weight loss within the last 6 months, the Mini Nutritional Assessment (MNA) or the Subjective Global Assessment (SGA). An improvement in the nutritional status can be achieved by simple methods such as the preparation of an adequate diet, hand feeding, additional sip feeding or enteral nutrition.

Organizational aspects of starting and running an effective nutritional support service

Setting up and running a Clinical Nutritional Support Team can be challenging and is time consuming. Team members have to be motivated, committed and persistent. High quality working relationships are fundamentally important within the team, between teams and with other healthcare professionals. Good communication, careful planning, sensitive implementation and robust monitoring are the cornerstones of a successful service. Looking forward as well as back will help the team to maintain and improve its position in an ever-changing environment. While nutritional support is everyone's business, an effective multiprofessional Clinical Nutritional Support Team is the best way to ensure that patients receive appropriate and timely treatment. It is also wise to remember that a successful Clinical Nutritional Support Team will be as committed to its own development as it is to the care of the patients referred to it.