Value of handgrip strength to predict clinical outcomes and therapeutic response in malnourished medical inpatients: Secondary analysis of a randomized controlled trial

Organization of nutritional care

The increasingly complex health care systems, the large and diverse population to whom nutritional therapy is addressed, and the need of specialized health care professionals implies an organizational strategy to be defined. The organization of nutritional care is a fundamental strategy to promote an optimal, quality and safety nutritional therapy. This is why, the organization of nutritional care should be based on 4 principles, including: Nutritional care should be considered as a process, a multidisciplinary approach is essential to a good nutritional care, the economic approach and the patient centered approach are essential to the organization of nutritional care. In this paper we will address the organization of nutritional care and its 4 principles.

Association of leucine and other branched chain amino acids with clinical outcomes in malnourished inpatients: a secondary analysis of the randomized clinical trial EFFORT

BACKGROUND

The essential branched-chain amino acids leucine, isoleucine and valine are considered anabolic and stimulate protein synthesis in the muscles as well in the liver. They also promote muscle recovery and contribute to glucose homeostasis. Recent studies in critically ill patients have demonstrated that depletion of plasma leucine is associated with increased mortality, but data in the non-critical care setting is lacking.

METHODS

This secondary analysis of the randomized controlled Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT), investigated the impact of leucine, isoleucine, and valine metabolism on clinical outcomes. The primary endpoint was 180-day all-cause mortality.

RESULTS

Among 238 polymorbid patients with available metabolite measurements, low serum leucin levels were associated with a doubled risk of 180-day all-cause mortality in a fully adjusted regression model (adjusted HR 2.20 [95% CI 1.46-3.30], p < 0.001). There was also an association with mortality for isoleucine (1.56 [95% CI 1.03-2.35], p = 0.035) and valine (1.69 [95% CI 1.13-2.53], p = 0.011). When comparing effects of nutritional support on mortality in patients with high and low levels of leucine, there was no evidence of significant differences in effectiveness of the intervention. The same was true for isoleucine and valine.

CONCLUSION

Our data suggest that depletion of leucine, isoleucine, and valine among malnourished polymorbid patients is associated with increases in long-term mortality. However, patients with low metabolite levels did not show a pronounced benefit from nutritional support. Further research should focus on the clinical effects of nutritional support in patients with depleted stores of essential branched-chain amino acids.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov as NCT02517476 (registered 7 August 2015).

Impact of Handgrip Strength on Survival in Hemodialysis Patients

Background: Hemodialysis patients face a high mortality risk, requiring effective clinical assessments. In these patients, muscle wasting due to protein-energy wasting (PEW) leads to increased frailty, which is strongly associated with worse outcomes, including higher mortality. As muscle mass declines, so does functional capacity, making regular assessment of both muscle mass and function critical for prognostic evaluation. Handgrip strength (HGS) offers a quick and reliable measure of muscle strength and functional capacity. In this study, we focused on the impact of HGS on survival in hemodialysis patients, analyzing its relationship with muscle mass and BMI. Methods: This retrospective cohort study included 408 dialysis patients (221 males, 187 females) who underwent bioimpedance spectroscopy (BIS) and HGS assessments between March 2021 and August 2023. Data collected included BIS profiles, HGS, dialysis status, age, complete blood count, blood chemistry, mortality, and CONUT scores. Results: Cox proportional hazards regression analysis revealed that lean tissue index (LTI) (HR 3.30, 95% CI 1.75-6.19), body mass index (BMI) (HR 2.65, 95% CI 1.17-6.01), and handgrip strength (HGS) (HR 4.22, 95% CI 2.05-8.70) were significant predictors of survival in the overall dialysis patient cohort. Gender-specific analysis showed that in males, both LTI (HR 4.81, 95% CI 1.89-12.23) and HGS (HR 5.45, 95% CI 2.18-13.61) significantly predicted survival. In females, HGS (HR 6.01, 95% CI 2.42-14.94) was a significant predictor, while LTI was also significant (HR 3.22, 95% CI 1.24-8.40, p = 0.017). In the multivariate Cox proportional hazards analysis, which adjusted for age, diabetes mellitus (DM), hypertension (HTN), BMI, fat tissue index (FTI), LTI, serum albumin, C-reactive protein (CRP), and CONUT score, HGS remained a significant predictor of survival in female dialysis patients (HR 2.77, 95% CI 1.00-7.65, p = 0.049). Conclusions: HGS has been identified as an important factor for survival in dialysis patients, particularly in female patients, independent of muscle mass and BMI.

Risk of sarcopenia, frailty and malnutrition as predictors of postoperative delirium in surgery

BACKGROUND

The risk factors for postoperative delirium are numerous and complex. One approach to identifying patients at risk is to evaluate their nutritional status. The aim of this prospective study is to better understand nutrition as a potential risk factor for postoperative delirium.

METHODS

A comprehensive preoperative assessment (Clinical Frailty Scale (CFS), the SARC-F questionnaire, Mini Nutritional Assessment-Short Form (MNA-SF)) were carried out as a prospective clinical study on 421 patients (70+) from 4 different surgical disciplines. Postoperatively, patients are examined daily for the presence of delirium using the 4AT screening tool (Arousal, Attention, Abbreviated Mental Test - 4, Acute change), the Nursing Delirium Screening Scale (NuDesc) and the Confusion Assessment Method (CAM) with its adaptation for the intensive care unit (CAM-ICU).

RESULTS

If there were indications of frailty or sarcopenia in the CFS or SARC-F, the association with delirium was increased 5.34-fold (OR of 5.34 [95% CI: 2.57;11.1]) and 5.56-fold (OR of 5.56 [95% CI: 2.97;10.4]) respectively. Delirium also occurred significantly more frequently with the risk of malnutrition or manifest malnutrition (MNA-SF) than with a normal nutritional status.

CONCLUSIONS

Patients' preoperative and nutritional status significantly impact the risk of developing postoperative delirium. Factors such as frailty, sarcopenia and possible malnutrition must be considered when implementing an effective and targeted preoperative assessment.

TRAIL REGISTRATION

German Clinical Trials Registry at https://www.drks.de/DRKS00028614 , Registered 25 March 2022.

Sex differences in clinical presentation, treatment response, and side effects of nutritional therapy among patients at nutritional risk: a secondary analysis of the randomized clinical trial EFFORT

BACKGROUND

Considering sex-specific factors has become an increasingly recognized area for research and practice, in the field of clinical nutrition, there is insufficient evidence regarding differences in clinical presentation, treatment response, and side effects of nutritional therapy among female and male patients.

OBJECTIVES

We hypothesized that the clinical presentation, response to nutritional therapy, and side effects from the intervention would differ in the two sexes.

METHODS

This secondary analysis investigated differences among female and male patients at risk for malnutrition regarding initial presentation, clinical outcomes, and treatment response in patients included in the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a randomized controlled trial comparing individualized nutritional support to usual care.

RESULTS

Of 2028 patients included in the trial, 964 were females and 1064 were males. The nutritional history and clinical presentation of female patients was different: they consumed less food and had a greater loss of appetite than the male population. Male patients had higher risk for mortality at 180 d [27% compared with 19%; adjusted hazards ratio (HR): 1.35; 95% CI: 1.12, 1.63] and further adverse clinical outcomes. However, there was no difference in the effect of nutritional support on mortality among female and male patients (HR: 0.76; 95% CI: 0.45, 1.27, compared with HR: 0.81; 95% CI: 0.54, 1.21, respectively; P-interaction = 0.939).

CONCLUSIONS

Results of this multicenter randomized trial suggest that multimorbid female inpatients have a different clinical presentation and are more prone to loss of appetite and reduced daily dietary intake than male inpatients. Importantly, the favorable response to nutritional interventions was similar in both sexes. This trial was registered at clinicaltrials.gov as NCT02517476.

Association of adipose tissue inflammation and physical fitness in older adults

An active lifestyle is of key importance for reduction of obesity and inflammation, as well as circulating levels of adipokines. Therefore, the aim of our study was to assess the relationship of physical fitness with chronic inflammatory status, and to evaluate biomarkers useful in the analysis of adipose tissue dysfunction. Sixty-three older adults (69.6 ± 5.1 years) were allocated to a high n = 31 (women n = 23 and men n = 8 male) or low physical fitness n = 32 (women n = 29 and men n = 3) group based on gait speed values (1.4-1.8 m/s or ≤ 1.3 m/s). The gait speed correlated with hand grip strength (rs = 0.493, p = 0.0001) and with leptin level (R = -0.372, p = 0.003), which shows the benefits of physical activity on muscle strength and circulating adipokines. In low physical fitness group, 58.1% individuals had adiponectin to leptin ratio (Adpn/Lep) < 0.5 revealing dysfunction of adipose tissue and high cardiometabolic risk; 20% of the group were obese with BMI ≥ 30 kg/m2. In high physical fitness group, 25.8% of individuals had Adpn/Lep ≥ 1.0 i.e., within the reference range. Markers of systemic inflammation were significantly related to physical fitness: CRP/gait speed (rs = -0.377) and HMGB-1/gait speed (rs = -0.264). The results of the ROC analysis for Adpn (AUC = 0.526), Lep (AUC = 0.745) and HMGB-1 (AUC = 0.689) indicated their diagnostic potential for clinical prognosis in older patients. The optimal threshold values corresponded to 1.2 μg/mL for Adpn (sensitivity 74.2%, specificity 41.9%, OR = 1.4, 95%Cl 0.488-3.902), 6.7 ng/mL for Lep (sensitivity 56.2%, specificity 93.5%, OR = 14.8, 95%Cl 3.574-112.229), 2.63 mg/L for CRP (sensitivity 51.6%, specificity 84.3%, OR = 4.4, 95% Cl 1.401- 16.063) and 34.2 ng/mL for HMGB-1 (sensitivity 62.0%, specificity 86.6%, OR = 12.0, 95%Cl 3.254-61.614). The highest sensitivity and specificity were observed for Leptin and HMGB-1. The study revealed changes in inflammatory status in older adults at various levels of physical fitness and demonstrated diagnostic usefulness of adipokines in the assessment of adipose tissue inflammation.

Muscle matters: Prognostic implications of malnutrition and muscle health parameters in patients with cancer. A secondary analysis of a randomised trial

BACKGROUND

Low muscle mass and malnutrition are independently associated with an increased risk of adverse outcomes in patients with cancer. However, it is not yet clear which parameter is most indicative of these risks. This study investigates the prognostic significance of different parameters reflecting malnutrition and muscle health in a well-characterised oncology population at nutritional risk.

METHODS

This preplanned secondary analysis included patients with cancer from a Swiss-wide, randomised-controlled nutritional trial. We investigated associations among malnutrition markers (i.e., malnutrition diagnosis based on modified Global Leadership Initiative on Malnutrition (GLIM) criteria, albumin concentration) and muscle health markers (i.e., hand grip strength, computed tomography (CT)-based muscle mass and radiodensity) with 180-day all-cause mortality (primary outcome).

RESULTS

We included 269 patients with a main admission diagnosis of cancer and available CT scans. In a mutually adjusted model, four parameters contributed to risk assessment including modified malnutrition diagnosis (GLIM) (HR 1.78 (95%CI 1.17 to 2.69), p = 0.007, AUC 0.58), low albumin concentration (HR 1.58 (95%CI 1.08 to 2.31), p = 0.019, AUC 0.62), low handgrip strength (HR 2.05 (95%CI 1.43 to 2.93), p = 0.001, AUC 0.62) and low muscle radiodensity (HR 1.39 (95%CI 0.90 to 2.16), p = 0.139, AUC 0.63). Combining these parameters resulted in a model with high prognostic power regarding 180-day mortality (overall AUC 0.71).

CONCLUSIONS

In this study of inpatients with cancer at nutritional risk, several malnutrition and muscle health parameters emerged as independent prognostic indicators for mortality. The use of these parameters may improve risk stratification and guide nutritional interventions in this vulnerable population.

TRIAL REGISTRATION

ClinicalTrials.gov, number NCT02517476.

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.

Should handgrip strength be considered when choosing the administration mode of oral nutritional supplements in geriatric patients? A secondary analysis of the MEDPass Trial

OBJECTIVE

It is important to individualize nutrition therapy and to identify whether certain patient groups benefit from a specific intervention such as oral nutritional supplements (ONS). This study investigated whether patients with weak handgrip strength (HGS) benefit better from ONS administration in the Medication Pass Nutritional Supplement Program (MEDPass) mode regarding the individual coverage of energy and protein requirements throughout their hospitalization.

METHODS

A secondary analysis of the intention-to-treat data set of the randomized controlled MEDPass trial was conducted. Weak HGS was defined as <27 kg for men and <16 kg for women. Linear mixed-effect models adjusted for the stratification factors energy density of ONS and nutritional risk screening 2002 score were used to address the aim of the study.

RESULTS

We included 188 participants. Energy and protein coverage did not differ between the patients with weak or normal HGS depending on ONS administration mode (P = 0.084, P = 0.108). Patients with weak HGS and MEDPass administration mode tended to have the lowest energy and protein coverage (estimated mean, 77.2%; 95% confidence interval [CI], 69.3%-85% and estimated mean, 95.1%; 95% CI, 85.3%-105%, respectively). Patients with weak HGS and conventional ONS administration had the highest energy and protein coverage (estimated mean, 90%; 95% CI, 82.8%-97.2% and estimated mean, 110.2%; 95% CI, 101.3%-119%, respectively).

CONCLUSION

No clear recommendations regarding the mode of ONS administration depending on HGS can be made. In clinical practice, appetite and satiety in patients with weak HGS should be monitored, and the ONS administration mode should be adjusted accordingly.

Nutrition for the older adult - Current concepts. Report from an ESPEN symposium

BACKGROUND & AIMS

In view of the global demographic shift, a scientific symposium was organised by the European Society for Clinical Nutrition and Metabolism (ESPEN) to address nutrition-related challenges of the older population and provide an overview of the current state of knowledge.

METHODS

Eighteen nutrition-related issues of the ageing global society were presented by international experts during the symposium and summarised in this report.

RESULTS

Anorexia of ageing, dysphagia, malnutrition, frailty, sarcopenia, sarcopenic obesity, and the metabolic syndrome were highlighted as major nutrition-related geriatric syndromes. Great progress has been made in recent years through standardised definitions of some but not all syndromes. Regarding malnutrition, the GLIM approach has shown to be suitable also in older adults, justifying its continuous implementation. For anorexia of ageing, a consensus definition is still required. Intervention approaches should be integrated and person-centered with the aim of optimizing intrinsic capacity and maintaining functional capacity. Landmark studies like EFFORT and FINGER have impressively documented the potential of individualised and multifactorial interventions for functional and health benefits. Combining nutritional intervention with physical training seems particularly important whereas restrictive diets and drug treatment should generally be used with caution because of undesirable risks. Obesity management in older adults should take into account the risk of promoting sarcopenia.

CONCLUSIONS

In the future, even more individualised approaches like precision nutrition may enable better nutritional care. Meanwhile all stakeholders should focus on a better implementation of currently available strategies and work closely together to improve nutritional care for older adults.

Frailty in patients on dialysis

Frailty is a condition that is frequently observed among patients undergoing dialysis. Frailty is characterized by a decline in both physiological state and cognitive state, leading to a combination of symptoms, such as weight loss, exhaustion, low physical activity level, weakness, and slow walking speed. Frail patients not only experience a poor quality of life, but also are at higher risk of hospitalization, infection, cardiovascular events, dialysis-associated complications, and death. Frailty occurs as a result of a combination and interaction of various medical issues in patients who are on dialysis. Unfortunately, frailty has no cure. To address frailty, a multifaceted approach is necessary, involving coordinated efforts from nephrologists, geriatricians, nurses, allied health practitioners, and family members. Strategies such as optimizing nutrition and chronic kidney disease-related complications, reducing polypharmacy by deprescription, personalizing dialysis prescription, and considering home-based or assisted dialysis may help slow the decline of physical function over time in subjects with frailty. This review discusses the underlying causes of frailty in patients on dialysis and examines the methods and difficulties involved in managing frailty among this group.

Performance of anthropometry-based and bio-electrical impedance-based muscle-mass indicators in the Global Leadership Initiative on Malnutrition criteria for predicting prognosis in patients with cancer

BACKGROUND

Reduced muscle mass is a criterion for diagnosing malnutrition using the Global Leadership Initiative on Malnutrition (GLIM) criteria; however, the choice of muscle-mass indicators within the GLIM criteria remains contentious. This study aimed to establish muscle-measurement-based GLIM criteria using data from bio-electrical impedance analysis (BIA) and anthropometric evaluations and evaluate their ability to predict overall survival (OS), short-term outcomes, and healthcare burden in patients with cancer.

METHODS

This was a multicenter, prospective study that commenced in 2013 and enrolled participants from various clinical centers across China. We constructed GLIM criteria based on various muscle measurements, including fat-free mass index (FFMI), skeletal muscle index (SMI), calf circumference (CC), midarm circumference (MAC), midarm muscle circumference (MAMC), and midarm muscle area (MAMA). Survival was estimated using the Kaplan-Meier method and survival curves were compared using the log-rank test. Cox proportional hazards regression was used to assess the independent association between the GLIM criteria and OS. The discriminatory performance of different muscle-measurement-based GLIM criteria for mortality was evaluated using Harrell's concordance index (C-index). Logistic regression was used to evaluate the association of the GLIM criteria with short-term outcomes and healthcare burden.

RESULTS

A total of 4769 patients were included in the analysis, of whom 1659 (34.8%) died during the study period. The Kaplan-Meier curves demonstrated that all muscle-measurement-based GLIM criteria significantly predicted survival in patients with cancer (all p < 0.001). The survival rate of malnourished patients was approximately 10% lower than that of non-malnourished patients. Cox proportional hazards regression showed that all the muscle-measurement-based GLIM could independently predict the OS of patients (all p < 0.001). The prognostic discrimination was as follows: MAMC (Chi-square: 79.61) > MAMA (Chi-square: 79.10) > MAC (Chi-square: 64.09) > FFMI (Chi-square: 62.33) > CC (Chi-square: 58.62) > ASMI (Chi-square: 57.29). In comparison to the FFMI-based GLIM criteria, the ASMI-based criteria (-0.002, 95% CI: -0.006 to 0.002, p = 0.334) and CC-based criteria (-0.003, 95% CI: -0.007 to 0.002, p = 0.227) did not exhibit a significant advantage. However, the MAC-based criteria (0.001, 95% CI: -0.003 to 0.004, p = 0.776), MAMA-based criteria (0.004, 95% CI: 0.000-0.007, p = 0.035), and MAMC-based criteria (0.005, 95% CI: 0.000-0.007, p = 0.030) outperformed the FFMI-based GLIM criteria. Logistic regression showed that muscle measurement-based GLIM criteria predicted short-term outcomes and length of hospital stay in patients with cancer.

CONCLUSION

All muscle measurement-based GLIM criteria can effectively predict OS, short-term outcomes, and healthcare burden in patients with cancer. Anthropometric measurement-based GLIM criteria have potential for clinical application as an alternative to BIA-based measurement.

Prognostic implications of the arginine metabolism in patients at nutritional risk: A secondary analysis of the randomized EFFORT trial

BACKGROUND

Arginine, a conditionally essential amino acid, is key component in metabolic pathways including immune regulation and protein synthesis. Depletion of arginine contributes to worse outcomes in severely ill and surgical patient populations. We assessed prognostic implications of arginine levels and its metabolites and ratios in polymorbid medical inpatients at nutritional risk regarding clinical outcomes and treatment response.

METHODS

Within this secondary analysis of the randomized controlled Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT), we investigated the association of arginine, its metabolites and ratios (i.e., ADMA and SDMA, ratios of arginine/ADMA, arginine/ornithine, and global arginine bioavailability ratio) measured on hospital admission with short-term and long-term mortality by means of regression analysis.

RESULTS

Among the 231 patients with available measurements, low arginine levels ≤90.05 μmol/l (n = 86; 37 %) were associated with higher all-cause mortality at 30 days (primary endpoint, adjusted HR 3.27, 95 % CI 1.86 to 5.75, p < 0.001) and at 5 years (adjusted HR 1.50, 95 % CI 1.07 to 2.12, p = 0.020). Arginine metabolites and ratios were also associated with adverse outcome, but had lower prognostic value. There was, however, no evidence that treatment response was influenced by admission arginine levels.

CONCLUSION

This secondary analysis focusing on medical inpatients at nutritional risk confirms a strong association of low plasma arginine levels and worse clinical courses. The potential effects of arginine-enriched nutritional supplements should be investigated in this population of patients.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov as NCT02517476 (registered 7 August 2015).

The influence of patients' nutritional risk, nutritional status, and energy density in MEDPass versus conventional administration of oral nutritional supplements - A secondary analysis of a randomized controlled trial

OBJECTIVES

The clinical influence of nutritional risk, nutritional status, and energy density of oral nutritional supplements (ONS) in MEDPass versus conventional administration of ONS is currently unknown. The aim of this analysis was to examine whether these variables have an impact on clinical outcomes.

METHODS

Secondary analysis of the intention to treat dataset of the randomized controlled MEDPass Trial in geriatric and medical inpatients. Patients in the intervention group received 4 × 50 ml ONS during the medication rounds (MEDPass mode), while those in the control group received ONS in a non-standardized manner. The examined endpoints included energy and protein coverage, ONS intake, handgrip strength (HGS), weight, appetite nausea and 30-day mortality. Three subgroup analyses for NRS 2002 total score (3, 4 or 5-7 points), NRS 2002 impaired nutritional status score (0, 1, 2 or 3 points) and energy density of the ONS (1.5 kcal/mL or 2 kcal/mL) were performed using linear and logistic regression with interaction and mixed effect models.

RESULTS

The data of 202 patients (103 women and 99 men) at nutritional risk (NRS total 2002 score ≥3), mean (SD) age 82.2 (6.5) years were included. There was no significant difference between the groups in the primary endpoint energy coverage in all three subgroup analyses. There were also no significant differences between the groups in the secondary endpoints of protein coverage, ONS intake, HGS, weight, appetite, nausea, and 30-day mortality.

CONCLUSION

The MEDPass mode of ONS administration was not superior to the conventional mode of administration in this study. ONS with high energy density (≥2 kcal/mL) should be offered since current evidence shows a tendency towards improved appetite, increased ONS and increased energy intake.

ESPEN practical guideline: Nutritional support for polymorbid medical inpatients

BACKGROUND

Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and healthcare costs.

AIM

As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.

METHODS

The 2023 update adheres to the standard operating procedures for ESPEN guidelines. We undertook a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g., published guidelines), until July 12th, 2022. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (including SIGN grading), which was followed by submission to Delphi voting. Here, the practical version of the guideline is presented which has been shortened and equipped with flow charts for patients care.

RESULTS

32 recommendations (7× A, 11× B, 10× O and 4× GPP), which encompass different aspects of nutritional support were included from the scientific guideline including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. Here, the practical version of the guideline is presented which has been shortened and equipped with flow charts for patients care.

CONCLUSIONS

Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated practical guideline offers an evidence-based nutritional approach to polymorbid medical inpatients and may improve their outcomes.

Red blood cell distribution width (RDW) - A new nutritional biomarker to assess nutritional risk and response to nutritional therapy?

BACKGROUND & AIMS

Red cell distribution width (RDW) has been proposed as a surrogate marker for acute and chronic diseases and may be influenced by nutritional deficits. We assessed the prognostic value of RDW regarding clinical outcomes and nutritional treatment response among medical inpatients at nutritional risk.

METHODS

This is a secondary analysis of EFFORT, a randomized, controlled, prospective, multicenter trial investigating the effects of nutritional support in patients at nutritional risk in eight Swiss hospitals. We examined the association between RDW and mortality in regression analysis.

RESULTS

Among 1,244 included patients (median age 75 years, 46.6 % female), high RDW (≥15 %) levels were found in 38 % of patients (n = 473) with a significant association of higher malnutrition risk [OR 1.48 (95%CI 1.1 to 1.98); p = 0.009]. Patients with high RDW had a more than doubling in short-term (30 days) mortality risk [adjusted HR 2.12 (95%CI 1.44 to 3.12); p < 0.001] and a signficant increase in long-term (5 years) mortality risk [adjusted HR 1.73 (95%CI 1.49 to 2.01); p < 0.001]. Among patients with high RDW, nutritional support reduced morality within 30 days [adjusted OR 0.56 (95%CI 0.33 to 0.96); p = 0.035], while the effect of the nutritional intervention in patients with low RDW was markedly smaller.

CONCLUSIONS

Among medical patients at nutritional risk, RDW correlated with several nutritional parameters and was a strong prognostic marker for adverse clinical outcomes at short- and long-term, respectively. Patients with high baseline RDW levels also showed a strong benefit from the nutritional intervention. Further research is needed to understand whether monitoring of RDW over time severs as a nutritional biomarker to assess effectiveness of nutritional treatment in the long run.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02517476.

Association of Glutamine and Glutamate Metabolism with Mortality among Patients at Nutritional Risk-A Secondary Analysis of the Randomized Clinical Trial EFFORT

Glutamine and its metabolite glutamate serve as the main energy substrates for immune cells, and their plasma levels drop during severe illness. Therefore, glutamine supplementation in the critical care setting has been advocated. However, little is known about glutamine metabolism in severely but not critically ill medical patients. We investigated the prognostic impact of glutamine metabolism in a secondary analysis of the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a randomized controlled trial comparing individualized nutritional support to usual care in patients at nutritional risk. Among 234 patients with available measurements, low plasma levels of glutamate were independently associated with 30-day mortality (adjusted HR 2.35 [95% CI 1.18-4.67, p = 0.015]). The impact on mortality remained consistent long-term for up to 5 years. No significant association was found for circulating glutamine levels and short- or long-term mortality. There was no association of glutamate nor glutamine with malnutrition parameters or with the effectiveness of nutritional support. This secondary analysis found glutamate to be independently prognostic among medical inpatients at nutritional risk but poorly associated with the effectiveness of nutritional support. In contrast to ICU studies, we found no association between glutamine and clinical outcome.

Hand grip strength as a proposed new vital sign of health: a narrative review of evidences

Hand grip strength (HGS) serves as a fundamental metric in assessing muscle function and overall physical capability and is particularly relevant to the ageing population. HGS holds an important connection to the concept of sarcopenia, which encompasses the age-related decline in muscle mass, strength, and function. It has also been reported to indicate the health of an individual. We reviewed the interplay between HGS and various health parameters, including morbidity and mortality, by carrying out a literature search on PubMed, Scopus and Google Scholar between 10 and 30 August 2023, to identify the relevant papers on the relationship between health and HGS. We used several keywords like 'hand grip strength', 'muscle strength, 'sarcopenia', 'osteosarcopenia', 'health biomarker', 'osteoporosis', and 'frailty', to derive the appropriate literature for this review. This review has shown that the HGS can be measured reliably with a hand-held dynamometer. The cut-off values are different in various populations. It is lower in Asians, women, less educated and privileged, and those involved in sedentary work. Several diseases have shown a correlation with low HGS, e.g., Type 2 diabetes, cardiovascular disease, stroke, chronic kidney and liver disease, some cancers, sarcopenia and fragility fractures. The low HSG is also associated with increased hospitalization, nutritional status, overall mortality and quality of life. We believe that there is adequate evidence to show that HGS stands as an important biomarker of health. Its utility extends to the identification of diverse health issues and its potential as a new vital sign throughout the lifespan.

Influence of the Results of Control of Intakes, Proteins and Anthropometry Nutritional Screening, Sarcopenia and Body Composition on the Clinical Evolution of Hospitalized Patients

(1) Background: Hospital malnutrition and sarcopenia are common in inpatients and are associated with worse prognosis. Our objective is to determine the association of the positivity of CIPA (Control of Intakes, Proteins and Anthropometry) nutrition screening tool and sarcopenia and evaluate its prognostic implications (length of stay, readmissions and mortality) as well as different components of body composition. (2) Methodology: Cross-sectional single-center study and prospective six months follow-up for prognostic variables. On admission, CIPA and EWGSOP2 criteria were assessed. (3) Results: Four hundred inpatients, a median of 65.71 years old and 83.6% with high comorbidity, were evaluated. In total, 34.8% had positive CIPA and 19.3% sarcopenia. Positive CIPA and sarcopenia had worse results in body composition (fat mass (FM), fat-free mass (FFM) and appendicular skeletal muscle mass index (ASMI)) and dynamometry. Positive CIPA is significantly associated with worse prognosis (mortality (OR = 1.99), readmissions (OR = 1.86) and length of stay (B = 0.19)). Positive CIPA and sarcopenia combined are associated with a tendency to higher mortality (OR = 2.1, p = 0.088). Low hand grip strength (HGS) is significantly related to a higher length of stay (B = -0.12). (4) Conclusions: In hospitalized patients, malnutrition independently and combined with sarcopenia is associated with a worse prognosis but not body composition. Low HGS is related to a higher length of stay.

Association of admission cortisol levels with outcomes and treatment response in patients at nutritional risk : A secondary analysis of a randomized clinical trial

INTRODUCTION

Cortisol is a metabolically active stress hormone that may play a role in the pathogenesis of malnutrition. We studied the association between admission cortisol levels and nutritional parameters, disease severity, and response to nutritional support among medical inpatients at nutritional risk.

METHODS

Admission cortisol was measured in a subset of 764 patients participating in the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a multicentre, randomized-controlled trial that compared individualized nutritional support with usual nutritional care.

RESULTS

Overall, mean cortisol levels were 570 (± 293) nmol/L and significantly higher in patients with high nutritional risk (NRS ≥ 5) and in patients reporting loss of appetite. Cortisol levels in the highest quartile (> 723 nmol/l) were associated with adverse outcomes including mortality at 30 days and 5 years (adjusted HR 2.31, [95%CI 1.47 to 3.62], p = 0.001 and 1.51, [95%CI 1.23 to 1.87], p < 0.001). Nutritional treatment tended to be more effective regarding mortality reduction in patients with high vs. low cortisol levels (adjusted OR of nutritional support 0.54, [95%CI 0.24 to 1.24] vs. OR 1.11, [95%CI 0.6 to 2.04], p for interaction = 0.134). This effect was most pronounced in the subgroup of patients with severe malnutrition (NRS 2002 ≥ 5, p for interaction = 0.047).

CONCLUSION

This secondary analysis of a randomized nutritional trial suggests that cortisol levels are linked to nutritional and clinical outcome among multimorbid medical patients at nutritional risk and may help to improve risk assessment, as well as response to nutritional treatment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02517476.

Impact of diabetes, malnutrition and sarcopenia on the prognosis of patients admitted to internal medicine

OBJECTIVE

To describe patients hospitalized in internal medicine in terms of malnutrition and sarcopenia, depending on the presence or absence of type 2 diabetes mellitus (DM2), as well as to evaluate short- and long-term mortality related to both.

METHODS

Cross-sectional, single-center study, which included consecutive patients admitted to internal medicine in May and October 2021. Malnutrition was determined using the Mini Nutritional Assessment-Short Form (MNA-SF) and sarcopenia using SARC-F and handgrip strength. Patients hospitalized for more than 48 h are excluded.

RESULTS

511 patients were analyzed, 49.1% male, mean age 75.2 +/- 15 years, 210 (41.1%) DM2. 6 groups (2 × 3 design) are generated based on the presence of DM2 and the nutritional status according to the result of the MNA-SF: 12-14 points, without risk; MNA-SF 8-12 points, high risk; MNA-SF 0-7 points, malnourished. Malnourished patients with DM2 had significantly higher sarcopenia, comorbidity, inflammation, and pressure ulcers. The main determinants of in-hospital mortality were sarcopenia (OR 1.27, 95%CI 1.06-1.54, p = 0.01), comorbidity (OR 1.27, 95%CI 1,08-1,49, p = 0.003) and inflammation (OR 1.01, 95%CI 1.00-1.02, p = 0.02). The 120-day prognosis was worse among malnourished patients (p = 0.042).

CONCLUSION

Patients admitted with DM2 have a similar degree of malnutrition than the rest, but with greater sarcopenia. This sarcopenia, together with inflammation and comorbidity determine a worse prognosis. The active and early identification of malnutrition and sarcopenia and their subsequent approach could improve the prognosis of patients.

Changes in serum albumin concentrations over 7 days in medical inpatients with and without nutritional support. A secondary post-hoc analysis of a randomized clinical trial

BACKGROUND

Serum albumin concentrations are frequently used to monitor nutritional therapy in the hospital setting but supporting studies are largely lacking. Within this secondary analysis of a randomized nutritional trial (EFFORT), we assessed whether nutritional support affects short-term changes in serum albumin concentrations and whether an increase in albumin concentration has prognostic implications regarding clinical outcome and response to treatment.

METHODS

We analyzed patients with available serum albumin concentrations at baseline and day 7 included in EFFORT, a Swiss-wide multicenter randomized clinical trial that compared individualized nutritional therapy with usual hospital food (control group).

RESULTS

Albumin concentrations increased in 320 of 763 (41.9%) included patients (mean age 73.3 years (SD ± 12.9), 53.6% males) with no difference between patients receiving nutritional support and controls. Compared with patients that showed a decrease in albumin concentrations over 7 days, those with an increase had a lower 180-day mortality [74/320 (23.1%) vs. 158/443 (35.7%); adjusted odds ratio 0.63, 95% CI 0.44 to 0.90; p = 0.012] and a shorter length of hospital stay [11.2 ± 7.3 vs. 8.8 ± 5.6 days, adjusted difference -2.2 days (95%CI -3.1 to -1.2)]. Patients with and without a decrease over 7 days had a similar response to nutritional support.

CONCLUSION

Results from this secondary analysis indicate that nutritional support did not increase short-term concentrations of albumin over 7 days, and changes in albumin did not correlate with response to nutritional interventions. However, an increase in albumin concentrations possibly mirroring resolution of inflammation was associated with better clinical outcomes. Repeated in-hospital albumin measurements in the short-term is, thus, not indicated for monitoring of patients receiving nutritional support but provides prognostic information.

TRAIL REGISTRATION

ClinicalTrials.gov Identifier: NCT02517476.

ESPEN guideline on nutritional support for polymorbid medical inpatients

BACKGROUND

Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and cost of care.

AIM

As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.

METHODS

This update adheres to the standard operating procedures for ESPEN guidelines. We did a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g. published guidelines), until July 12th. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (incl. SIGN grading), which was followed by submission to Delphi voting.

RESULTS

From a total of 3527 retrieved abstracts, 60 new relevant studies were analyzed and used to generate a guideline draft that proposed 32 recommendations (7x A, 11x B, 10x O and 4x GPP), which encompass different aspects of nutritional support including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. The results of the first online voting showed a strong consensus (agreement of >90%) on 100% of the recommendations. Therefore, no final consensus conference was needed.

CONCLUSIONS

Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated guideline offers an evidence-based nutritional approach to the polymorbid medical inpatients and may improve their outcomes.

Effects of Nutritional Interventions in Older Adults with Malnutrition or at Risk of Malnutrition on Muscle Strength and Mortality: Results of Pooled Analyses of Individual Participant Data from Nine RCTs

Nutritional intervention studies in older adults with malnutrition aim to improve nutritional status. Although these studies show a significant gain in body weight, there is inconsistent evidence of clinical effectiveness on muscle strength and mortality. This study aimed to examine the effects of nutritional interventions on muscle strength and risk of mortality in older adults (malnourished or at risk) and explore whether these effects are influenced by participant characteristics. Individual participant data were used from nine RCTs (community setting, hospital and long-term care; duration 12-24 weeks and included oral nutritional supplements, dietary counseling, or both). Handgrip strength (HGS) was measured in seven RCTs and six RCTs obtained mortality data. A ≥3 kg increase in HGS was considered clinically relevant. Logistic generalized estimating equations analyses (GEE) were used to test intervention effectiveness. GEE showed no overall treatment effect (OR 1.11, 95% CI 0.78-1.59) on HGS. A greater, but not statistically significant, effect on HGS was observed for older (>80 years) versus younger participants. No significant treatment effect was observed for mortality (OR 0.78, 95% CI 0.42-1.46). The treatment effect on mortality was greater but remained non-significant for women and those with higher baseline energy or protein intake. In conclusion, no effects of nutritional interventions were observed on HGS and mortality in older adults (malnourished or at risk). While the treatment effect was modified by some baseline participant characteristics, the treatment also lacked an effect in most subgroups.

Association between prealbumin, all-cause mortality, and response to nutrition treatment in patients at nutrition risk: Secondary analysis of a randomized controlled trial

BACKGROUND

Because of the shorter half-life as compared with albumin, serum prealbumin concentrations have been proposed to be useful nutrition biomarkers for the assessment of patients at nutrition risk. In a post hoc analysis of patients at nutrition risk from a randomized controlled nutrition trial, we tested the hypothesis that (1) prealbumin is associated with higher all-cause 180-day mortality rates and that (2) individualized nutrition support compared with usual-care nutrition more effectively improves survival at 30 days in patients with low prealbumin levels compared with patients with normal prealbumin levels.

METHODS

We performed a prespecified cohort study in patients included in the pragmatic, Swiss, multicenter randomized controlled EFFORT trial comparing the effects of individualized nutrition support with usual care. We studied low prealbumin concentrations (<0.17 g/L) in a subgroup of 517 patients from one participating center.

RESULTS

A total of 306 (59.2%) patients (mean age 71.9 years, 53.6% men) had low admission prealbumin levels (<0.17 g/L). There was a significant association between low prealbumin levels and mortality at 180 days (115/306 [37.6%] vs 47/211 [22.3%], fully adjusted hazard ratio [HR]=1.59, 95% CI 1.11-2.28; P = 0.011). Prealbumin levels significantly improved the prognostic value of the Nutritional Risk Screening total score regarding mortality prediction at short- and long-term. The difference in mortality between patients receiving individualized nutrition support and usual-care nutrition was similar for patients with low prealbumin levels compared with patients with normal prealbumin levels (HR=0.90 [95% CI=0.51-1.59] vs HR=0.88 [95% CI=0.35-2.23]) with no evidence for interaction (P = 0.823).

CONCLUSION

Among medical inpatients at nutrition risk, low admission prealbumin levels correlated with different nutrition markers and higher mortality risk, but patients with low or high prealbumin levels had a similar benefit from nutrition support. Further studies should identify nutrition markers that help further personalize nutrition interventions.

Incorporating handgrip strength examination into dietetic practice: A quality improvement project

Protein-energy malnutrition is both prevalent and costly within the inpatient rehabilitation population. Registered dietitians play a key role in identifying, diagnosing, and treating protein-energy malnutrition. Handgrip strength has been shown to correlate with clinical outcomes, including malnutrition. Reduced handgrip strength is included as a criterion in national and international consensus guidelines of malnutrition diagnoses for functional changes. However, limited research and quality improvement projects have reported on its actual use in the clinical setting. The purpose of this quality improvement project was to (1) implement handgrip strength testing into dietitian care on three inpatient rehabilitation units to allow dietitians to identify and treat nutrition-related muscle function losses and (2) evaluate the feasibility, clinical utility, and clinical impact of this project. This quality improvement educational intervention demonstrated that handgrip strength is feasible, does not impact dietitian efficiency, and is clinically useful. Dietitians reported three areas in which handgrip strength provided value: assessing nutrition status, motivating patients, and monitoring responses to nutrition interventions. Specifically, they were able to shift away from focusing solely on change in weight to focusing on functional ability and strength. Although outcome measures demonstrated favorable outcomes, the results must be interpreted cautiously because of the small sample and pre-post uncontrolled design. Further high-quality research is required to provide more in-depth information on the utility and limitations of handgrip strength as an assessment, motivational, and monitoring tool for clinical dietetics.

Inflammation and Nutrition: Friend or Foe?

The importance of the interplay between inflammation and nutrition has generated much interest in recent times. Inflammation has been identified as a key driver for disease-related malnutrition, leading to anorexia, reduced food intake, muscle catabolism, and insulin resistance, which are stimulating a catabolic state. Interesting recent data suggest that inflammation also modulates the response to nutritional treatment. Studies have demonstrated that patients with high inflammation show no response to nutritional interventions, while patients with lower levels of inflammation do. This may explain the contradictory results of nutritional trials to date. Several studies of heterogeneous patient populations, or in the critically ill or advanced cancer patients, have not found significant benefits on clinical outcome. Vice versa, several dietary patterns and nutrients with pro- or anti-inflammatory properties have been identified, demonstrating that nutrition influences inflammation. Within this review, we summarize and discuss recent advances in both the role of inflammation in malnutrition and the effect of nutrition on inflammation.

Association of Thoracic Skeletal Muscle Index with Clinical Outcome and Response to Nutritional Interventions in Patients at Risk of Malnutrition-Secondary Analysis of a Randomized Trial

BACKGROUND

Measurement of skeletal muscle index (SMI) in computed tomography has been suggested to improve the objective assessment of muscle mass. While most studies have focused on lumbar vertebrae, we examine the association of SMI at the thoracic level with nutritional and clinical outcomes and response to nutritional intervention.

METHODS

We conducted a secondary analysis of EFFORT, a Swiss-wide, multicenter, randomized trial. We investigated the association of low SMI at the 12th thoracic vertebra (T12) with adverse outcome within 30 days after hospital admission (primary endpoint).

RESULTS

663 of 2028 patients from the EFFORT trial had available CT scans for T12, and 519 among them also had available L3 scans. Mean SMI at T12 was 22.4 ± 5.8 cm²/m² and 19.6 ± 5.5 cm²/m² in male and female patients, respectively, and correlated well with nutritional parameters, including nutritional risk based on NRS 2002 (adjusted coefficient -0.63, 95%CI -1.25 to -0.01, p = 0.047), BMI (adjusted coefficient 0.74, 95%CI 0.66 to 0.82, p < 0.001) and handgrip strength (adjusted coefficient 0.15, 95%CI 0.11 to 0.2, p < 0.001). In multivariate regression analyses, low SMI was not a significant predictor for either clinical outcome or for treatment response. Results for SMI measured at L3 were similar, with only little prognostic value.

CONCLUSIONS

Within medical patients at risk for malnutrition, SMI at thoracic vertebra provided low prognostic information regarding clinical outcomes and nutritional treatment response.

Nutrition issues in the general medical ward patient: From general screening to specific diagnosis and individualized treatment

Disease-related malnutrition in patients in the general medical ward remains a complex syndrome, which contributes to high morbidity and mortality, and seriously interferes with recovery from acute illness. Recently, there have been important advances in the development of consensus diagnostic criteria for malnutrition, and through the recent completion of large-scale trials, the understanding of pathophysiological pathways and evidence-based treatment algorithms to provide nutrition care to patients at risk for malnutrition in the hospital setting has advanced. There is need to identify more specific clinical parameters and blood biomarkers, which allow a more personalized approach to the malnourished patients, because not all patients show the same response to nutrition interventions. Recent studies have suggested that some nutrition biomarkers of inflammation, kidney function and muscle health, among others, predict treatment response to nutrition interventions and may help to personalize treatments. In addition to advancing the science, there is need for more education of students and treating teams in the hospital to improve the screening of patients at hospital admission regarding nutrition risk with the start of individualized nutrition support interventions, thereby bringing optimal nutrition care to the bedside.

Association of CT-based diagnosis of sarcopenia with prognosis and treatment response in patients at risk of malnutrition - A secondary analysis of the Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) trial

BACKGROUND & AIM

CT-derived measures of muscle mass may help to identify patients with sarcopenia. We investigated the prognostic significance of CT-derived sarcopenia and muscle attenuation with nutritional markers, clinical outcomes and response to nutritional support in medical in-patients at nutritional risk.

METHOD

Within this secondary analysis of the randomized-controlled Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) comparing individualized nutritional support with usual care nutrition in medical inpatients, we investigated associations of CT-based sarcopenia and muscle attenuation at the level L3 with different nutritional and clinical outcomes, and the response to the nutritional intervention. The primary composite endpoint was adverse clinical outcome within 30 days of hospital admission.

RESULTS

We included 573 of 2028 EFFORT patients with available CT scans, of which 68.4% met the CT-based definition of sarcopenia and 72.9% had low muscle attenuation. In multivariate analysis, low skeletal muscle index was associated with higher nutritional risk (coefficient per NRS class -0.94 (95%CI -1.87 to -0.01) p = 0.049) and higher risk for adverse clinical outcomes (adjusted odds ratio 1.59 (95% CI 1.06 to 2.38), p = 0.024). Low muscle attenuation was also associated with adverse clinical outcome (adjusted odds ratio 1.67 (95%CI 1.08 to 2.58), p = 0.02). Nutritional support tended to be more effective in reducing mortality in non-sarcopenic patients compared to patients with CT-based sarcopenia (p for interaction 0.058).

CONCLUSIONS

Within a population of medical patients at nutritional risk, CT-based sarcopenia and muscle attenuation were associated with several nutritional parameters and predicted adverse clinical outcomes. Information from CT scans, thus may help to better characterize these patients, and may be helpful in guiding therapeutic interventions.

Expert Consensus on Morphofunctional Assessment in Disease-Related Malnutrition. Grade Review and Delphi Study

Disease-related malnutrition (DRM) affects approximately a third of hospitalized patients and is associated with an increased risk of morbimortality. However, DRM is often underdiagnosed and undertreated. Our aim is to evaluate the prognostic value of morphofunctional tools and tests for nutritional assessment in clinical practice. A systematic literature review was conducted to identify studies relating to the morphofunctional assessment of nutritional status and mortality or complications. Evidence was evaluated using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) method. Twelve GRADE recommendations were made and divided into seven topics: food intake and nutrient assimilation, anthropometry, biochemical analysis, hand grip strength, phase angle, muscle imaging, and functional status and quality of life. From these recommendations, 37 statements were developed and scored in a two-survey Delphi method by 183 experts. A consensus was reached on accepting 26/37 statements. Surveys had high internal consistency and high inter-rater reliability. In conclusion, evidence-based recommendations were made on the prognostic value of morphofunctional assessment tools and tests to assess malnutrition, most of which were found to be feasible in routine clinical practice, according to expert opinions.

Effects of Beta-Hydroxy-Beta-Methylbutyrate Supplementation on Older Adults with Sarcopenia: A Randomized, Double-Blind, Placebo-Controlled Study

OBJECTIVES

Sarcopenia is recognized as a major public health concern because of its association with several adverse health events. Beta-hydroxy-beta-methylbutyrate (HMB) supplementation reportedly delays the loss of muscle mass and function; however, the effect of HMB on sarcopenia remains inconclusive. We aimed to evaluate the impact of HMB intervention on muscle strength, physical performance, body compositions, and inflammatory factors in older adults with sarcopenia.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING AND PARTICIPANTS

This study included subjects aged ≥60 years with sarcopenia which were assigned to the HMB group (HMBG, n=18) and the placebo group (PG, n=16).

INTERVENTION

The HMBG and PG were supplied with HMB and placebo products twice daily for 12 weeks, and both received resistance exercise training twice a week in 12 weeks.

MEASUREMENTS

Hand grip strength was selected as the primary outcome; gait speed, five-time chair stand test, body composition and inflammatory indicators were selected as the secondary outcomes. The differences in changes from baseline between the two groups were analyzed using the analysis of covariance(ANCOVA).

RESULTS

After the 12-week intervention, the HMBG demonstrated significantly greater improvements in handgrip strength (4.61(95%CI:2.93,6.28) kg, P<0.001), gait speed (0.11(95%CI:0.02,0.20)m/s, P=0.014), five-time chair stand test (-3.65 (95%CI:-5.72, -1.58)s, P=0.001), muscle quality (2.47(95%CI:1.15,3.80),kg.kg-1 P=0.001) and tumor necrosis factor-like weak inducer of apoptosis (-15.23(95%CI:-29.80,-0.66)pmol/mL, P=0.041) compared with the PG; no significant differences in skeletal muscle mass, skeletal muscle index, and other body composition parameters were found between the two groups.

CONCLUSION

In older adults with sarcopenia, HMB significantly enhance the effect of resistance exercise training on muscle strength, physical performance, muscle quality, and reduced inflammatory factors. Therefore, HMB supplementation could be an effective treatment for sarcorpenia. The trial protocol was registered at http://www.chictr.org.cn/showproj.aspx?proj=47571 as ChiCTR2000028778.

[Malnutrition management of hospitalized patients with diabetes/hyperglycemia and heart failure]

Introduction

Heart failure (HF) is one of the leading causes of morbidity and mortality among older people, making it a major public health problem. Cardiovascular diseases in general, and HF in particular, are common comorbidities in people with type 2 diabetes (DM2). The concurrence of DM2 and HF is associated with more severe clinical symptoms and signs, and poorer quality of life and prognosis. Furthermore, due to the hypercatabolic state and nutrient absorption disorders, malnutrition is present in many HF cases. This article describes the results of the expert consensus and the responses of the panelists on the nutritional management in routine clinical practice of patients with diabetes/hyperglycemia hospitalized (non-critically ill) with HF.

Low T3 syndrome upon admission and response to nutritional support in malnourished medical inpatients

INTRODUCTION

During illness, deiodination of thyroxine (T4) to triiodothyronine (T3) is down regulated. This is called "low T3 syndrome", an adaptive metabolic mechanism to reduce energy expenditure and prevent catabolism. We investigated the prognostic role of low T3 syndrome in patients at nutritional risk regarding mortality, clinical outcomes and response to nutritional support.

METHODS

This is a secondary analysis of the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a randomized-controlled Swiss multicenter trial comparing effects of individualized nutritional support with usual care in adult medical inpatients at nutritional risk. The primary endpoint was all-cause mortality over 30-,180-days and 5-years.

RESULTS

We had complete data including fT3 concentration of 801/2028 (39.5%) patients from the initial trial. Of these 492 (61.4%) had low T3 syndrome (fT3 < 3.2 pmol/l). Low T3 syndrome was associated with higher mortality over 30 days (adjusted hazard ratio 1.97 [95%CI 1.17 to 3.31], p 0.011) and other adverse clinical outcomes. Nutritional support only lowered mortality in the group of patients with but not in those without low T3 syndrome (adjusted odds ratio of nutritional support of 0.82 [95%CI 0.47 to 1.41] vs. 1.47 [95%CI 0.55 to 3.94]). This finding, however, was not significant in interaction analysis (p for interaction = 0.401).

CONCLUSIONS

Our secondary analysis of a randomized trial suggests that medical inpatients at nutritional risk with low T3 syndrome have a substantial increase in mortality and may show a more pronounced beneficial response to nutritional support interventions.

Mid-Arm Muscle Circumference or Body Weight-Standardized Hand Grip Strength in the GLIM Superiorly Predicts Survival in Chinese Colorectal Cancer Patients

Our objective was to identify the optimal method to assess reduced muscle mass (RMM) using the Global Leadership Initiative on Malnutrition (GLIM) approach and investigate the roles of the GLIM approach in nutrition assessment and survival prediction in colorectal cancer (CRC) patients. During a median follow-up period of 4.2 (4.0, 4.4) years, a development cohort of 3612 CRC patients with a mean age of 64.09 ± 12.45 years was observed, as well as an external validation cohort of 875 CRC patients. Kaplan−Meier curves and multivariate Cox regression were adopted to analyze the association between GLIM-diagnosed malnutrition and the overall survival (OS) of CRC patients. A nomogram predicting individualized survival was constructed based on independent prognostic predictors. The concordance index, calibration curve, and decision curve were applied to appraise the discrimination, accuracy, and clinical efficacy of the nomogram, respectively. Patients diagnosed with severe malnutrition based on either the mid-arm muscle circumference (MAMC) or body weight-standardized hand grip strength (HGS/W) method had the highest mortality hazard ratio (HR, 1.51; 95% CI, 1.34−1.70; p < 0.001). GLIM-defined malnutrition was diagnosed in 47.6% of patients. Severe malnutrition was an independent mortality risk factor for OS (HR, 1.25; 95% CI, 1.10−1.42; p < 0.001). The GLIM nomogram showed good performance in predicting the survival of CRC patients and was clinically beneficial. Our findings support the effectiveness of GLIM in diagnosing malnutrition and predicting OS in CRC patients.

Approaching person-centered clinical practice: A cluster analysis of older inpatients utilizing the measurements of intrinsic capacity

Background

Maintaining the intrinsic capacity (IC) of older inpatients is a novel view in providing person-centered treatments in clinical practice. Uncertainty remains regarding the primary nature of IC among older hospitalized patients.

Objectives

We aimed to understand the status of IC among older inpatients by a cluster analysis based on IC measurements.

Methods

This is a cross-sectional study conducted in the geriatric department of Beijing Hospital in China. Older inpatients who were older than 60 years and who underwent comprehensive geriatric assessments were included. The inpatients were classified into subgroups based on 13 measurements of IC according to unsupervised methods (K-means cluster analysis and t-SNE). Subgroup differences were investigated for domains of IC, age, sex, frailty, activities of daily living, and falls.

Results

A total of 909 inpatients with a mean age of 76.6 years were included. Almost 98% of the inpatients showed IC impairment. Locomotion impairment was the most prevalent problem (91.1%), followed by sensory impairment (61.4%), psychological impairment (57.3%), cognition decline (30.7%), and vitality problem (29.2%). A total of five clusters were obtained by classification: Cluster 1 (56.6% of the participants) showed high IC with fair impairment of locomotion and vision; clusters 2 and 3 (37.8 % of the participants) had additional impairment of sleep in the psychological domain; clusters 4 and 5 (5.6% of the participants) represented a severe loss of all the IC domains; and clusters 1-5 showed a gradual decline in the IC score and were significantly associated with increased age, frailty, decreased activities of daily living, and falls. Significant correlations among the domains were observed; the locomotion domain showed the strongest links to the others in network analysis.

Conclusions

Great declines in IC and disparities between IC domains were found in older inpatients. IC-based primary assessment and classification enabled us to identify the variation of functional abilities among the older inpatients, which is pivotal for designing integrated treatment or care models in clinical practice.

Unresolved issues in perioperative nutrition: A narrative review

Surgical patients are at an increased risk of negative outcomes if they are malnourished or at risk of malnutrition preoperatively. Optimisation of nutritional status should be a focus throughout the perioperative continuum to promote improved surgical outcomes. Enhanced Recovery after Surgery (ERAS) protocols are increasingly applied in the surgical setting but are not yet widespread. This narrative review focused on areas of perioperative nutrition that are perceived as controversial or are lacking in agreement. A search for available literature was conducted on 1 March 2022 and relevant high-quality articles published since 2015 were considered for inclusion. Most malnutrition screening tools are not specific to the surgical population except for the Perioperative Nutrition Screen (PONS) although more large-scale initiatives are needed to improve the prevalence of preoperative nutrition screening. Poor muscle health is common in patients with malnutrition and further exacerbates negative health outcomes indicating that prevention, detection and treatment is of high importance in this population. Although a lack of consensus remains for who should receive preoperative nutritional therapy, evidence suggests a positive impact on muscle health. Additionally, postoperative nutritional support benefits surgical outcomes, with some patients requiring enteral and/or parenteral feeding routes and showing benefit from immunonutrition. The importance of nutrition extends beyond the time in hospital and should remain a priority post-discharge. The impact of individual or personalised nutrition based on select patient characteristics remains to be further investigated. Overall, the importance of perioperative nutrition is evident in the literature despite select ongoing areas of contention.

Handgrip Strength Values Depend on Tumor Entity and Predict 180-Day Mortality in Malnourished Cancer Patients

BACKGROUND

Cancer-related malnutrition is a prevalent condition associated with a loss of muscle mass and impaired functional status, leading to immunodeficiency, impaired quality of life and adverse clinical outcomes. Handgrip strength (HGS) is a practical measure to assess muscle strength in individual patients during clinical practice. However, HGS reference values refer to populations of healthy people, and population-specific values, such as those in the population of cancer patients, still need to be defined.

METHODS

Within a secondary analysis of a previous randomized controlled nutritional trial focusing on hospitalized cancer patients at risk for malnutrition, we investigated sex-specific HGS values stratified by age and tumor entity. Additionally, we examined the association between HGS and 180-day all-cause mortality.

RESULTS

We included data from 628 cancer patients, which were collected from eight hospitals in Switzerland. Depending on the age of patients, HGS varied among female patients from 7 kg to 26 kg and among male patients from 20.5 kg to 44 kg. An incremental decrease in handgrip strength by 10 kg resulted in a 50% increase in 180-day all-cause mortality (odds ratio 1.52 (95%CI 1.19 to 1.94), p = 0.001).

CONCLUSION

Our data provide evidence of the prognostic implications of HGS measurement in cancer patients and validate the prognostic value of handgrip strength in regard to long-term mortality. In addition, our results provide expected HGS values in the population of hospitalized malnourished cancer patients, which may allow better interpretation of values in individual patients.

Defining and assessing intrinsic capacity in older people: A systematic review and a proposed scoring system

INTRODUCTION

The World Health Organization has introduced the term 'intrinsic capacity' (IC) as a marker of healthy ageing. However, controversy exists on the definition and assessment of IC. We aimed to review the definitions and methods used for the assessment of IC in older adults. In addition, we proposed a new IC scoring method.

METHODS

A systematic search was performed in PubMed, Web of Science, Cochrane Library, Scopus and SPORTDiscus (up to February 10th, 2022) for studies assesing IC in older adults (>60 years).

RESULTS

Thirty-three studies were included. There is overall consensus on the definition of IC as well as on its different dimensions, that is: locomotion, vitality, sensory, cognition and psychological. However, the methods for assessing each of these five dimensions differ substantially across studies and there is no consensus on the best method to compute an eventual global compound score to evaluate IC taking into account all its different dimensions.

CONCLUSIONS

The IC represents a highly relevant clinical concept that has been unfortunately underutilized. We propose a standardization for the assessment of each dimension of IC, with a global 0 (worst) to 10 (highest) score.

Phase Angle Is a Stronger Predictor of Hospital Outcome than Subjective Global Assessment-Results from the Prospective Dessau Hospital Malnutrition Study

This prospective cohort study of 16,943 consecutive patients compared phase angle (PhA, foot-to-hand at 50 kHz) and subjective global assessment (SGA) to predict outcomes length of hospital stay (LOS) and in-hospital mortality in patients at risk of malnutrition (NRS-2002 ≥ 3). In 1505 patients, the independent effects on LOS were determined by competing risk analysis and on mortality by logistic regression. In model I, including influence factors age, sex, BMI, and diagnoses, malnourished (SGA B and C) patients had a lower chance for a regular discharge (HR 0.74; 95%CI 0.69−0.79) and an increased risk of mortality (OR 2.87; 95%CI 1.38−5.94). The association of SGA and outcomes regular discharge and mortality was completely abrogated when PhA was added (model II). Low PhA reduced the chance of a regular discharge by 53% in patients with a PhA ≤ 3° (HR 0.47; 95%CI 0.39−0.56) as compared to PhA > 5°. Mortality was reduced by 56% for each 1° of PhA (OR 0.44; 95%CI 0.32−0.61). Even when CRP was added in model III, PhA ≤ 3° was associated with a 41% lower chance for a regular discharge (HR 0.59; 95%CI 0.48−0.72). In patients at risk of malnutrition, the objective measure PhA was a stronger predictor of LOS and mortality than SGA.

Current Practice of Assessing and Monitoring Muscle Strength, Muscle Mass and Muscle Function during Nutritional Care by Dietitians in Switzerland-An Online Survey

Muscle parameters are recommended as diagnostic criteria for malnutrition and sarcopenia in various guidelines. However, little is known about the application of muscle parameters in daily practice of nutritional care. The aim of this study was to investigate the current practice of the application of muscle parameters, along with its promoting factors and barriers by dietitians in Switzerland. A 29-item literature-based online survey was developed and distributed via the Swiss professional association of dietitians. The data were analyzed descriptively, and relationships between demographic data and usage were examined. Dietitians (n = 117) from all three language regions completed the survey and were included in the analysis. Musculature was classified as important for the assessment of nutritional status. Body weight (89.7%), handgrip strength (87.2%), bioimpedance analysis (BIA) (87.1%) and Body Mass Index (66.7%) were considered as most significant for evaluation of nutritional status. Seventy-point nine percent (70.9%) of dietitians include at least one muscle parameter in their assessment; BIA was the parameter most often included (73.5%). However, the frequency of use of muscle parameter in daily practice was rather low. Only 23.1% applied BIA on a weekly basis. Lack of knowledge (78.6%), practical experience (71.8%) and lack of equipment (77.8%) were most frequently stated as barriers for usage. The general application of muscle parameters in nutritional care is still lacking. There is an opportunity to further strengthen diagnosis and patient monitoring via a stronger application of muscle parameters in daily practice. Practical training and education could help promote their application.

Validation of modified GLIM criteria to predict adverse clinical outcome and response to nutritional treatment: A secondary analysis of a randomized clinical trial

BACKGROUND & AIMS

The Global Leadership Initiative on Malnutrition (GLIM) recently suggested specific criteria to standardize the diagnosis of malnutrition. There is need for validation of these criteria regarding response to nutrition treatment. Our aim was to validate modified GLIM (mGLIM) criteria among medical inpatients at risk of disease related malnutrition for prediction of outcome and response to nutritional therapy.

METHODS

This is a secondary analysis of the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a multicenter randomized controlled trial conducted between April 2014 and February 2018. Adult medical inpatients at nutritional risk (Nutrition Risk Score 2002 ≥ 3 points) were randomly assigned to receive nutritional therapy according to an algorithm based on individualized nutritional requirements (intervention group) or standard hospital food (control group). We included all participants with available information regarding mGLIM criteria. The primary outcome was adverse clinical outcome, which was a composite of 30-day all-cause mortality, ICU-admission, rehospitalization rate, major complications and decline in functional status.

RESULTS

Of 1917 eligible participants at nutritional risk, 1181 (61.6%) met the diagnosis of malnutrition based on mGLIM criteria. The incidence of adverse clinical outcome was significantly higher in mGLIM-positive participants compared with mGLIM-negative participants [330/1181 (27.9%) versus 140/736 (19.0%); multivariable adjusted odds ratio [OR] 1.53; 95% CI 1.22-1.93; p < 0.001]. Regarding the effect of nutritional therapy, the reduction in adverse clinical outcomes was higher in mGLIM-positive participants [180/581 (31.0%) vs. 150/600 (25.0%), OR 0.69; 95% CI 0.53-0.9, p = 0.007], compared with mGLIM-negative participants [75/379 (19.8%) versus 65/357 (18.2%), OR 0.95; 95% CI 0.65-1.40, p = 0.797], a finding that was, however, not significant in interaction analysis (p for interaction = 0.217).

CONCLUSION

Data from this secondary analysis of a multicenter randomized trial involving medical inpatients at nutritional risk validate the strong prognostic value of mGLIM criteria regarding adverse clinical outcomes and other long-term outcomes. However, further research is needed to improve the ability of GLIM criteria to predict therapeutic response to nutritional interventions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02517476.

Admission serum albumin concentrations and response to nutritional therapy in hospitalised patients at malnutrition risk: Secondary analysis of a randomised clinical trial

BACKGROUND

Historically, admission serum albumin concentrations have been considered useful biochemical markers for nutrition assessment. However, there is a lack of randomised trial data investigating whether low albumin concentrations are helpful for identifying patients benefitting from nutritional support.

METHODS

This study was a secondary analysis of the EFFORT trial, a Swiss-wide multicentre, randomised controlled trial comparing individualised nutritional support with usual care nutrition in medical inpatients from April 1, 2014, to February 1, 2018. 1389 of 2028 patients at nutritional risk with available albumin concentrations on admission were included. The primary endpoint was all-cause mortality within 30 and 180 days. Patients were stratified into groups of low or normal albumin based on the albumin cut-off of 30 g/L. ClinicalTrials.gov number, NCT02517476.

FINDINGS

1389 patients (mean age, 73.1 (SD 3.5) years; 747 (53.8%) men) were included and 676 (48.7%) had low serum albumin concentrations at admission (<30 g/L). Mortality at 180 days was significantly increased in the low albumin group compared with patients with normal albumin concentrations (219/676 (32.4%) vs. 162/713 (22.7%), fully adjusted HR 1.4, 95%CI 1.11 to 1.77, p = 0.005]. Effects of nutritional support on 30-day mortality were similar for patients with low compared to patients with normal albumin concentrations (HR 0.68, 95%CI 0.44 to 1.05 vs. HR 0.70, 95%CI 0.41 to 1.20), with no evidence for a subgroup effect (p for interaction=0.97).

INTERPRETATION

Based on this secondary analysis of a randomised trial, low admission serum albumin concentrations in hospitalised, non-critically ill, medical patients at nutritional risk had prognostic implications and indicated higher mortality risk but were not helpful in selecting patients for nutritional interventions.

FUNDING

The Swiss National Science Foundation (SNSF) (PP00P3_150531) and the Research Council of the Kantonsspital Aarau (1410.000.058 and 1410.000.044) provided funding for the EFFORT trial.

Distribution of oral nutritional supplements with medication: Is there a benefit? A systematic review

OBJECTIVES

Disease-related malnutrition remains a major burden for patients and health care systems. The Medication Pass Nutritional Supplement Program (MEDPass) involves providing patients with oral nutritional supplements (ONS) in unusually small amounts three to four times per day during medication rounds. This systematic review aims to evaluate the impact of MEDPass ONS administration on compliance, total energy and protein intake, food intake, body weight and handgrip strength in hospitalized adults and nursing-home residents.

METHODS

We conducted a systematic literature search in the databases MEDLINE, Embase, ScienceDirect, and the Cochrane Library and included randomized controlled trials (RCTs), non-RCTs, and before-after studies. Validated tools specific to the study design were used to assess the included studies.

RESULTS

Ten studies were identified, including two RCTs, three non-RCTs, and five before-after trials. Compliance increased by 23.4% to 66% with MEDPass administration, resulting in compliance rates of 72.7% to 96%. With MEDPass administration, body weight increased by 1% to 6.8% or remained stable. The assessed evidence on total energy intake is ambiguous for protein, with a trend toward an increased intake. Trials on energy intake from food show mixed results as well. One study suggested a slight increase in handgrip strength. The included studies predominantly raise concerns for bias.

CONCLUSIONS

We conclude that MEDPass ONS administration increases compliance in hospitalized adults and nursing-home residents. For all other outcomes, robust and well-powered trials are necessary.

Management of disease-related malnutrition for patients being treated in hospital

Disease-related malnutrition in adult patients who have been admitted to hospital is a syndrome associated with substantially increased morbidity, disability, short-term and long-term mortality, impaired recovery from illness, and cost of care. There is uncertainty regarding optimal diagnostic criteria, definitions for malnutrition, and how to identify patients who would benefit from nutritional intervention. Malnutrition has become the focus of research aimed at translating current knowledge of its pathophysiology into improved diagnosis and treatment. Researchers are particularly interested in developing nutritional interventions that reverse the negative effects of disease-related malnutrition in the hospital setting. High-quality randomised trials have provided evidence that nutritional therapy can reduce morbidity and other complications associated with malnutrition in some patients. Screening of patients for risk of malnutrition at hospital admission, followed by nutritional assessment and individualised nutritional interventions for malnourished patients, should become part of routine clinical care and multimodal treatment in hospitals worldwide.

Association of metabolomic markers and response to nutritional support: A secondary analysis of the EFFORT trial using an untargeted metabolomics approach

BACKGROUND & AIMS

The EFFORT trial reported a substantial risk reduction for adverse events and mortality in medical in-patients receiving a nutritional support intervention. With the use of an untargeted metabolomics approach, we investigated the prognostic and therapeutic potential of metabolomic markers to understand, whether there are distinct metabolic patterns associated with malnutrition risk as assessed by the Nutritional Risk screening (NRS 2002) score, the risk of 30-day mortality and the response to nutritional support, respectively.

METHODS

Out of the 2088 samples we randomly selected 120 blood samples drawn on day 1 after hospital admission and before treatment initiation. Samples were stratified by NRS 2002, treatment allocation (intervention vs. control), and mortality at 30 days, but not on the type of medical illness. We performed untargeted analysis by liquid chromatography mass spectrometry (LC-MS/MS).

RESULTS

We measured 1389 metabolites in 120 patients of which 81 (67.5%) survived until day 30. After filtering, 371 metabolites remained, and 200 were matched to one or more Human Metabolome Data Base (HMDB) entries. Between group analysis showed a slight distinction between the treatment groups for patients with a NRS 3, but not for those with NRS 4 and ≥ 5. C-statistic between those who died and survived at day 30 ranged from 0.49 (95% confidence interval 0.35-0.68) for a combination of 5 metabolites/predictors to 0.66 (95% confidence interval 0.53-0.79) for a combination of 100 metabolites. Pathway analysis found significant enrichment in the pathways for nitrogen, vitamin B3 (nicotinate and nicotinamide), leukotriene, and arachidonic acid metabolisms in nutritional support responders compared to non-responders.

CONCLUSION

In our heterogenous population of medical inpatients with different illnesses and comorbidities, metabolomic markers showed little prognostic and therapeutic potential for better phenotyping malnutrition and response to nutritional therapy. Future studies should focus on more selected patient populations to understand whether a metabolomic approach can advance the nutritional care of patients.

Disease-Related Malnutrition and Sarcopenia Predict Worse Outcome in Medical Inpatients: A Cohort Study

(1) Background: Both sarcopenia and disease-related malnutrition (DRM) are unfortunately underdiagnosed and undertreated in our Western hospitals, which could lead to worse clinical outcomes. Our objectives included to determine the impact of low muscle mass (MM) and strength, and also DRM and sarcopenia, on clinical outcomes (length of stay, death, readmissions at three months, and quality of life). (2) Methodology: Prospective cohort study in medical inpatients. On admission, MM and hand grip strength (HGS) were assessed. The Global Leadership Initiative on Malnutrition (GLIM) criteria were used to diagnose DRM and EWGSOP2 for sarcopenia. Assessment was repeated after one week and at discharge. Quality of life (EuroQoL-5D), length of stay (LoS), readmissions and mortality are reported. (3) Results: Two hundred medical inpatients, median 76.0 years-old and 68% with high comorbidity. 27.5% met GLIM criteria and 33% sarcopenia on admission, increasing to 38.1% and 52.3% on discharge. Both DRM and sarcopenia were associated with worse QoL. 6.5% died and 32% readmission in 3 months. The odds ratio (OR) of mortality for DRM was 4.36 and for sarcopenia 8.16. Readmissions were significantly associated with sarcopenia (OR = 2.25) but not with DRM. A higher HGS, but not MM, was related to better QoL, less readmissions (OR = 0.947) and lower mortality (OR = 0.848) after adjusting for age, sex, and comorbidity. (4) Conclusions: In medical inpatients, mostly polymorbid, both DRM but specially sarcopenia are associated with poorer quality of life, more readmissions, and higher mortality. Low HGS proved to be a stronger predictor of worse outcomes than MM.