Nutrition-Focused Care for Community-Living Adults: Healthcare Utilization and Economic Benefits

OBJECTIVES

We assessed the impact of a recently reported nutritional quality improvement program (QIP) on healthcare resource utilization and costs for older, community-living adults in Bogotá, Colombia.

METHODS

The study included 618 community-dwelling, older adults (> 60 years) who were at risk or malnourished and receiving outpatient clinical care. The intervention was a QIP that emphasized nutritional screening, dietary education, lifestyle counseling, 60-day consumption of oral nutritional supplements, and 90-day follow-up. For economic modeling, we performed 90-day budget impact and cost-effectiveness analyses from a Colombian third-party payer perspective. The base-case analysis quantified mean healthcare resource use in the QIP study population. Analysis was based on mean input values (deterministic) and distributions of input parameters (probabilistic). As the deterministic analysis provided a simple point estimate, the cost-effectiveness analysis focused on the probabilistic results informed by 1000 iterations of a Monte-Carlo simulation.

RESULTS

Results showed that the total use of healthcare resources over 90 days was significantly reduced by > 40% (hospitalizations were reduced by approximately 80%, emergency department visits by > 60%, and outpatient clinical visits by nearly 40%; P < .001). Based on economic modeling, total cost savings of $129 740 or per-patient cost savings of $210 over 90 days could be attributed to the use of nutritional QIP strategies. Total cost savings equated to nearly twice the initial investment for QIP intervention; that is, the per-dollar return on investment was $1.82.

CONCLUSIONS

For older adults living in the community in Colombia, the use of our nutritional QIP improved health outcomes while lowering costs of healthcare and was thus cost-effective.

A Nutritionally Complete Oral Nutritional Supplement Powder Improved Nutritional Outcomes in Free-Living Adults at Risk of Malnutrition: A Randomized Controlled Trial

BACKGROUND

This randomized controlled trial investigated the effectiveness of an oral nutritional supplement (ONS) on nutrition-related outcomes over 12 weeks in Chinese adults with or at risk of malnutrition.

METHODS

88 Chinese adults ≥18 years living independently in Hong Kong with Mini Nutritional Assessment-Short Form (MNA-SF) score ≤11 were randomly assigned to (1) 2 servings/day of nutritionally complete ONS powder made with water (Fresubin^® Powder (Fresubin Kabi Deutschland GmbH, Bad Homburg, Germany), 600 kcal, 22.4 g protein) for 12 weeks (intervention group) or (2) no treatment (control group). The primary outcome was increase in body weight (BW) over 12 weeks. Secondary outcomes included improvement in body mass index (BMI), mid-arm circumference (MAC), calf circumference, MNA-SF score, quality of life, self-rated health, frailty, and diet quality.

RESULTS

The intervention group showed a significantly higher mean increase in BW compared with the control group (1.381 kg, intervention vs control, p < 0.001). The intervention group also showed significantly higher mean increases in BMI, MAC, calf circumference, intake of energy, protein, vitamin D, and calcium compared with the control group. No group differences in the changes of other outcomes were observed.

CONCLUSIONS

For Chinese free-living adults at risk of malnutrition, daily consumption of a nutritionally complete ONS powder improved nutritional outcomes compared with the control group.

A questionnaire for physical findings of malnutrition when physical exams are not possible

BACKGROUND

When nutrition assessments must be performed virtually, such as during the coronavirus pandemic, it is difficult to fully assess patients for malnutrition without the ability to perform a nutrition-focused physical exam. Practitioners may ask patients about their physical appearance, but there is currently no validated set of questions whose answers correlate with nutrition-focused physical findings for the diagnosis of malnutrition in such situations. The aim of this study was to evaluate correlations between patients' responses to verbalized questions and physical signs of malnutrition.

METHODS

Questions related to the physical findings of malnutrition were developed and evaluated for content validity. Thirty patients receiving nutrition assessments at an acute care veterans' hospital were asked the questions prior to a nutrition-focused physical exam. Patients' responses were compared with a diagnosis of malnutrition and physical findings of muscle, fat, fluid accumulation, and handgrip strength.

RESULTS

Four questions significantly correlated with malnutrition: "Does the area around your eyes appear sunken in?" (P = 0.03), "Are you able to see your ribs?" (P = 0.05), "Do you feel you are unusually skinny for you?" (P = 0.001), and "Do you find yourself eating less due to swelling in your belly?" (P = 0.008).

CONCLUSION

There are relationships between patients' responses to certain verbalized questions and their physical status. Such questions can be used to identify physical signs of malnutrition when nutrition-focused physical exams cannot be performed. Further research is needed to validate these questions in other populations.

The importance of protein sources to support muscle anabolism in cancer: An expert group opinion

This opinion paper presents a short review of the potential impact of protein on muscle anabolism in cancer, which is associated with better patient outcomes. Protein source is a topic of interest for patients and clinicians, partly due to recent emphasis on the supposed non-beneficial effect of proteins; therefore, misconceptions involving animal-based (e.g., meat, fish, dairy) and plant-based (e.g., legumes) proteins in cancer are acknowledged and addressed. Although the optimal dietary amino acid composition to support muscle health in cancer is yet to be established, animal-based proteins have a composition that offers superior anabolic potential, compared to plant-derived proteins. Thus, animal-based foods should represent the majority (i.e., ≥65%) of protein intake during active cancer treatment. A diet rich in plant-derived proteins may support muscle anabolism in cancer, albeit requiring a larger quantity of protein to fulfill the optimal amino acid intake. We caution that translating dietary recommendations for cancer prevention to cancer treatment may be inadequate to support the pro-inflammatory and catabolic nature of the disease. We further caution against initiating an exclusively plant-based (i.e., vegan) diet upon a diagnosis of cancer, given the presence of elevated protein requirements and risk of inadequate protein intake to support muscle anabolism. Amino acid combination and the long-term sustainability of a dietary pattern void of animal-based foods requires careful and laborious management of protein intake for patients with cancer. Ultimately, a dietary amino acid composition that promotes muscle anabolism is optimally obtained through combination of animal- and plant-based protein sources.

Opportunities to Improve Quality Outcomes: Integrating Nutrition Care Into Medicare Advantage to Address Malnutrition and Support Social Determinants of Health

Medicare Advantage (MA) is a public–private healthcare program for older adults and individuals with disabilities in the United States (US). MA enrollees receive their benefits from private health plans and the percentage of Medicare beneficiaries in MA plans continues to increase. MA plan enrollees typically have more socioeconomic risk factors compared to traditional Medicare enrollees. The COVID-19 pandemic has highlighted the importance of MA plans’ flexibilities to address socioeconomic risk factors, or social determinants of health (SDOH), and to tailor benefits and services to meet individual MA enrollee needs. Poor nutrition—often termed malnutrition or protein calorie malnutrition—is a problem for many Medicare beneficiaries. Malnutrition can prolong recovery and increase medical complications and readmissions. Up to half of older Americans are at risk for malnutrition or are malnourished. Nutrition-related supplemental benefits offered by MA plans can most effectively help address malnutrition and impact SDOH and quality outcomes as part of multi-modal interventions. Multi-modal interventions integrate quality nutrition care throughout the MA care process. This Editorial explores the issue of older adult malnutrition and SDOH and the nutrition-related supplemental benefits currently offered by MA plans. It also identifies opportunities for further nutrition benefit development and impact, including through integration in MA outcome measurements and quality frameworks.

Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults

BACKGROUND

Disease-related malnutrition has been reported in 10% to 55% of people in hospital and the community and is associated with significant health and social-care costs. Dietary advice (DA) encouraging consumption of energy- and nutrient-rich foods rather than oral nutritional supplements (ONS) may be an initial treatment.

OBJECTIVES

To examine evidence that DA with/without ONS in adults with disease-related malnutrition improves survival, weight, anthropometry and quality of life (QoL).

SEARCH METHODS

We identified relevant publications from comprehensive electronic database searches and handsearching. Last search: 01 March 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of DA with/without ONS in adults with disease-related malnutrition in any healthcare setting compared with no advice, ONS or DA alone.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility, risk of bias, extracted data and graded evidence.

MAIN RESULTS

We included 94, mostly parallel, RCTs (102 comparisons; 10,284 adults) across many conditions possibly explaining the high heterogeneity.  Participants were mostly older people in hospital, residential care and the community, with limited reporting on their sex. Studies lasted from one month to 6.5 years.  DA versus no advice - 24 RCTs (3523 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.87 (95% confidence interval (CI) 0.26 to 2.96), or at later time points. We had no three-month data, but advice may make little or no difference to hospitalisations, or days in hospital after four to six months and up to 12 months. A similar effect was seen for complications at up to three months, MD 0.00 (95% CI -0.32 to 0.32) and between four and six months. Advice may improve weight after three months, MD 0.97 kg (95% CI 0.06 to 1.87) continuing at four to six months and up to 12 months; and may result in a greater gain in fat-free mass (FFM) after 12 months, but not earlier. It may also improve global QoL at up to three months, MD 3.30 (95% CI 1.47 to 5.13), but not later. DA versus ONS - 12 RCTs (852 participants) All outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.66 (95% CI 0.34 to 1.26), or at later time points. Either intervention may make little or no difference to hospitalisations at three months, RR 0.36 (95% CI 0.04 to 3.24), but ONS may reduce hospitalisations up to six months. There was little or no difference between groups in weight change at three months, MD -0.14 kg (95% CI -2.01 to 1.74), or between four to six months. Advice (one study) may lead to better global QoL scores but only after 12 months. No study reported days in hospital, complications or FFM. DA versus DA plus ONS - 22 RCTs (1286 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.92 (95% CI 0.47 to 1.80) or at later time points. At three months advice may lead to fewer hospitalisations, RR 1.70 (95% CI 1.04 to 2.77), but not at up to six months. There may be little or no effect on length of hospital stay at up to three months, MD -1.07 (95% CI -4.10 to 1.97). At three months DA plus ONS may lead to fewer complications, RR 0.75 (95% CI o.56 to 0.99); greater weight gain, MD 1.15 kg (95% CI 0.42 to 1.87); and better global QoL scores, MD 0.33 (95% CI 0.09 to 0.57), but this was not seen at other time points. There was no effect on FFM at three months. DA plus ONS if required versus no advice or ONS - 31 RCTs (3308 participants) Evidence was moderate- to low-certainty. There may be little or no effect on mortality at three months, RR 0.82 (95% CI 0.58 to 1.16) or at later time points. Similarly, little or no effect on hospitalisations at three months, RR 0.83 (95% CI 0.59 to 1.15), at four to six months and up to 12 months; on days in hospital at three months, MD -0.12 (95% CI -2.48 to 2.25) or for complications at any time point. At three months, advice plus ONS probably improve weight, MD 1.25 kg (95% CI 0.73 to 1.76) and may improve FFM, 0.82 (95% CI 0.35 to 1.29), but these effects were not seen later. There may be little or no effect of either intervention on global QoL scores at three months, but advice plus ONS may improve scores at up to 12 months. DA plus ONS versus no advice or ONS - 13 RCTs (1315 participants) Evidence was low- to very low-certainty. There may be little or no effect on mortality after three months, RR 0.91 (95% CI 0.55 to 1.52) or at later time points. No study reported hospitalisations and there may be little or no effect on days in hospital after three months, MD -1.81 (95% CI -3.65 to 0.04) or six months. Advice plus ONS may lead to fewer complications up to three months, MD 0.42 (95% CI 0.20 to 0.89) (one study). Interventions may make little or no difference to weight at three months, MD 1.08 kg (95% CI -0.17 to 2.33); however, advice plus ONS may improve weight at four to six months and up to 12 months. Interventions may make little or no difference in FFM or global QoL scores at any time point.

AUTHORS' CONCLUSIONS

We found no evidence of an effect of any intervention on mortality. There may be weight gain with DA and with DA plus ONS in the short term, but the benefits of DA when compared with ONS are uncertain. The size and direction of effect and the length of intervention and follow-up required for benefits to emerge were inconsistent for all other outcomes.  There were too few data for many outcomes to allow meaningful conclusions. Studies focusing on both patient-centred and healthcare outcomes are needed to address the questions in this review.

The economic cost of not coding disease-related malnutrition: A study in cancer inpatients

BACKGROUND & AIMS

Disease-related malnutrition (DRM) coding rate is usually low in hospitalised patients. The objective of our study was to estimate the percentage of correct DRM coding in cancer inpatients and to calculate the economic losses caused by such lack of coding.

METHODS

This was an observational, prospective study that was conducted in patients hospitalised in the Medical Oncology Unit of our hospital. A nutritional assessment was performed through subjective global assessment (SGA). The all patient refined-diagnosis related group (APR-DRG) weights were obtained at the moment of discharge; moreover, recalculation was done after including the diagnosis of malnutrition in the medical record of those patients in whom it had not been initially coded. The associated cost reimbursement were calculated based on the weight before and after revising the diagnosis of DRM.

RESULTS

A total of 266 patients were evaluated. From them, 220 (82.7%) suffered from DRM according to the SGA. In 137 (51.5%) of these patients, diagnosis was coded, as opposed to 83 (31.2%) cases (33 subjects with moderate and 50 with severe DRM) in whom it was not coded. The sum of the APR-DRG weights before revising the diagnosis of malnutrition was 343.4 points (mean: 1.29 ± 0.89). Whereas, after revising the diagnosis, it increased up to 384.3 (1.44 ± 0.96). The total cost reimbursement for the hospital before revising the diagnosis of malnutrition was 1,607,861.21€ and after revision it increased up to 1,799,199.69€, which means that 191,338.48€ were not reimbursed to the hospital due to the lack of coding of malnutrition. The cost reimbursement for each admission increased an average of 719.32€.

CONCLUSION

The prevalence of DRM in cancer inpatients is high. Nevertheless, the diagnosis is not coded in one third of patients, which results in important economic losses for the hospitals.

Innovating the Iowa Congregate Nutrition Program: A Needs and Preference Assessment

Participation in the Congregate Nutrition Program (CNP) is declining. This study examined CNP participation motivators, barriers, menu preferences, desired facility attributes, and educational programming to help identify strategies to increase participation. Four focus groups were held (3 = CNP participants only, n = 21; 1 = non-CNP participants, n = 11). They were audio-recorded, transcribed, and analyzed for common themes. All participants were White and food secure (93.8%). The majority were educated (75.8%), female (72.2%), and aged 71-80 years old (53.1%). CNP participation motivators were affordability, healthy meals, socialization, and location convenience. CNP participation barriers were limited awareness, the low perceived need for attending the CNP, and transportation. Ideal CNP characteristics were menu choice, variety of activities, and a welcoming ambiance. Preferred marketing strategies were print advertising and word of mouth. These findings provide insight as to how the CNP may be modified to be more appealing for the older adult population.

Prognostic impact of malnutrition in elderly patients with acute myocardial infarction

We aimed to investigate the prevalence and the prognostic impact of malnutrition using the geriatric nutritional risk index (GNRI) in elderly patients with acute myocardial infarction (AMI). We investigated 130 consecutive patients aged ≥ 75 years who were discharged following successful primary coronary intervention between March 2009 and December 2016. The mean age of the patients was 81.5 ± 5.0 years, and 55.4% of them were male. At discharge, the patients' nutritional statuses were evaluated using the GNRI, which were calculated as follows: 14.89 × serum albumin (g/dL) + 41.7 × body mass index/22. The patients were divided into two groups, a low GNRI group (GNRI < 92) with nutrition-related risk and a high GNRI group (GNRI ≥ 92) without nutrition-related risk. The mean GNRI score of all patients was 95.2 ± 11.0, and 46 patients (35.4%) had a low GNRI score. During the mean follow-up of 1030 ± 850 days, the all-cause mortality was significantly higher in the low GNRI group than in the high GNRI group (32.6% vs. 13.1%, p < 0.001), while the event rates of AMI recurrence and hospitalization due to heart failure did not differ significantly between the two groups. Multivariate Cox proportional analysis revealed that low GNRI was a modest but independent predictor of mortality (hazard ratio, 0.94; 95% confidence interval 0.90-0.98; p = 0.01). Among elderly patients with AMI, malnutrition assessed using the GNRI was often encountered and was an independent predictor of long-term mortality.

Item Generation in the Development of an Interactive Nutrition Specific Physical Exam Competency Tool (INSPECT): A Qualitative Study Utilizing Technology-Based Focus Groups in the United States

An alarming 30% to 50% prevalence rate of disease-related malnutrition among hospitalized patients compels the need for early diagnosis and treatment of malnutrition. Registered Dietitian Nutritionists (RDNs) can utilize the nutrition-focused physical examination (NFPE) as one of the nutrition assessment criteria to accurately diagnose malnutrition. Although RDNs are striving to employ NFPE in practice, a lack of experience and adequate training impedes full utilization of this technique. This results in wide skill variations requiring continuous evaluation of RDNs’ NFPE competency. However, a standardized, validated competency tool is not widely available and hence this study aims to develop a standardized, interactive nutrition-specific physical exam competency tool (INSPECT). As a first step in the development of INSPECT, a qualitative, technology-based focus group approach with 7 content and practice experts was utilized to generate appropriate tool items. A total of 70 NFPE items under 9 areas including 12 items for muscle loss, 4 items for subcutaneous fat loss, 31 items for micronutrient deficiencies, 1 item for fluid status, 2 items for handgrip strength, 5 items for initial preparation, 4 items for bedside manner, 8 items for swallowing, and 3 items for abdominal evaluation were generated. This study successfully utilized technology-based focus groups to generate appropriate NFPE items for the competency tool development. Using the items, an initial version of INSPECT has been developed, which is presently being investigated for content and face validity. The final version will undergo field tests and will be examined for reliability, validity, and item-level psychometric properties.

Real-World Evidence of Treatment, Tolerance, Healthcare Utilization, and Costs Among Postacute Care Adult Patients Receiving Enteral Peptide-Based Diets in the United States

Objective

Peptide ‐based (PB) enteral tube feeding (ETF) formulas have been shown to reduce gastrointestinal (GI) intolerance in patients receiving enteral nutrition. However, limited data exist in relation to their use in the postacute/home care setting. We sought to assess the real‐world GI tolerance, healthcare utilization, and resource use costs of 100% whey‐protein PB ETF in adults in a postacute care setting and describe their demographic, clinical, and treatment characteristics.

Method

Using medical claims data from the United States, we analyzed GI intolerance events occurring in adults receiving 100% whey‐protein PB ETF (Peptamen^® adult formulas) for one year before and after initiation of ETF. Resource use costs were subsequently estimated using a multivariate general linearized model and adjusted for age, gender, and Charlson Comorbidity Index score.

Results

The proportion of adults experiencing no GI intolerance events increased from 41% (418/1022) to 59% (601/1022) in the one‐year period after initiation of 100% whey PB ETF (P < .001). The proportion of patients with at least one hospital inpatient visit also decreased from 100% (1022/1022) to 72% (737/1022) over the same period, and the mean number of inpatient visits per patient decreased from 15.6 to 13.0. Cost modeling revealed that outpatient visits accounted for 42% ($1174/$2820) of total estimated healthcare resource costs in the first 30 days after 100% whey PB ETF initiation, with only 9% ($255/$2820) due to emergency room visits.

Conclusion

These 100% whey‐protein PB ETF formulas are a valuable nutrition treatment option for patients with or at risk of malnutrition who show intolerance to standard ETF formulas and may reduce hospital inpatient visits and associated costs.

Associations between early parenteral nutrition and in-hospital outcomes in underweight patients with gastrointestinal surgery

BACKGROUND & AIMS

Guidelines recommend early parenteral nutrition for malnourished patients. However, the effectiveness of early parenteral nutrition in underweight patients has not been established. This study aimed to determine whether in-hospital outcomes were associated with early parenteral nutrition in underweight gastrointestinal surgery patients with short-term contraindications to early enteral nutrition.

METHODS

We identified underweight adult gastrointestinal surgery patients with short-term contraindications to early enteral nutrition using the Japanese Diagnosis Procedure Combination database from July 2010 to March 2018. We performed propensity-score overlap weighting to compare in-hospital outcomes between patients with and without early parenteral nutrition. The primary outcome was length of hospital stay. The secondary outcomes were total hospitalization cost, hospital-acquired pneumonia, hospital-acquired urinary tract infection, central line-associated bloodstream infection, and all-cause 28-day in-hospital mortality.

RESULTS

We identified 31,898 eligible patients. Early parenteral nutrition was associated with longer hospital stay (19.2 vs. 18.4 days; difference, 0.7 days; 95% CI, 0.1 to 1.4). There were no differences between the patients with and without early parenteral nutrition in total hospitalization cost (difference, US$60; 95% CI, -277 to 397), hospital-acquired pneumonia (risk difference, -0.11%; 95% CI, -0.78 to 0.55), hospital-acquired urinary tract infection (risk difference, 0.03%; 95% CI, -0.08 to 0.14), central line-associated bloodstream infection (risk difference, 0.08%; 95% CI, -0.02 to 0.18), and all-cause 28-day in-hospital mortality (risk difference, 0.31%; 95% CI, -0.07 to 0.69).

CONCLUSIONS

Early parenteral nutrition for underweight gastrointestinal surgery patients with short-term contraindications to early enteral nutrition was associated with longer hospital stay.

Prevalence and Economic Burden of Malnutrition Diagnosis Among Patients Presenting to United States Emergency Departments

BACKGROUND

Malnutrition is a potentially remediable condition that when untreated contributes to poor health and economic outcomes. While assessment of malnutrition risk is improving, its identification rate and economic burden in emergency departments (EDs) is largely unknown. We sought to determine prevalence and economic burden of diagnosed malnutrition among patients presenting to U.S. EDs.

METHODS

This is a retrospective analysis of Healthcare Cost and Utilization Project Nationwide Emergency Department Sample data. Malnutrition prevalence was confirmed via International Classification of Diseases, 9th Edition, diagnosis codes. The economic burden was assessed by comparing probability of hospitalization and the average total charges between propensity-score matched visits with and without a malnutrition diagnosis.

RESULTS

Data from 238 million ED visits between 2006 and 2014 were analyzed. Over this period, the prevalence of diagnosed malnutrition increased for all demographic categories assessed. For older adults (≥65 years), the prevalence increased from 2.5% (2006) to 3.6% (2014). Older age, high-income community residence, Western region, urban areas, and Medicare coverage were associated with higher diagnosis prevalence. Malnutrition diagnosis was associated with a 4.23 (95% confidence interval [CI] = 3.93 to 4.55) times higher odds of hospitalization and $21,892 higher mean total charges (95% CI = $19,593 to $24,192).

CONCLUSIONS

While malnutrition is currently diagnosed at a low rate in U.S. EDs, the economic burden of malnutrition is substantial in this care setting. Given the potential for systematic malnutrition screening and treatment protocols to alleviate this burden, future research is warranted.

Implementation of malnutrition quality improvement reveals opportunities for better nutrition care delivery for hospitalized patients

BACKGROUND

Gaps in hospital-based nutrition care practices and opportunities to improve care of patients at risk of malnutrition or malnourished have been demonstrated by several US hospitals implementing quality improvement (QI) projects. This study examined the impact of nutrition care process improvements focused on better documentation of identification and diagnosis of malnutrition in 5 hospital services and differences between nutritionally targeted vs nontargeted services.

METHODS

Data on malnutrition risk screening, nutrition assessment, malnutrition diagnosis, and nutrition care plan delivery were collected from 32,723 hospital encounters for patients admitted to the intensive care unit, pulmonology, oncology, urology, and general medicine services (targeted) as well as the rest of the nontargeted hospital services between 2017 and 2019.

RESULTS

Higher rates of morbidity in targeted service patients compared with those in the patient population admitted in the nontargeted services were observed, including higher rates of malnutrition risk (37.43% vs 19.16%, P < .001), higher rates of moderate and severe malnutrition first identified by a registered dietitian nutritionist (20.27% vs 9.67%, P < .001), and malnutrition diagnosis confirmed by an admitting physician (16.72% vs 6.74%, P < .001).

CONCLUSIONS

The findings suggest sustained improvements in confirmed rates of malnutrition identification and diagnosis are achievable. Targeting malnutrition QI efforts to hospital services with higher patient morbidity is an effective method for improving malnutrition diagnosis, in particular in hospitals with limited resources, which in turn can result in improved nutrition care delivery.

Quality of the Evidence Supporting the Role of Oral Nutritional Supplements in the Management of Malnutrition: An Overview of Systematic Reviews and Meta-Analyses

There is considerable heterogeneity across the findings of systematic reviews of oral nutritional supplement (ONS) interventions, presenting difficulties for healthcare decision-makers and patients alike. It is not known whether heterogeneity arises from differences in patient populations or relates to methodological rigor. This overview aimed to collate and compare findings from systematic reviews of ONSs compared with routine care in adult patients who were malnourished or at risk of malnutrition with any clinical condition and to examine their methodological quality. Three electronic databases were searched to July 2019, supplemented with hand-searching. Data on all outcomes were extracted and review methodological quality assessed using A MeaSurement Tool for Assessment of systematic Reviews (AMSTAR). Twenty-two reviews were included, 11 in groups from mixed clinical backgrounds and 11 in specific clinical conditions. Ninety-one meta-analyses were identified for 12 different outcomes but there was discordance between results. Significant benefits of ONSs were reported in 4 of 4 analyses of energy intake, 7 of 11 analyses of body weight, 7 of 22 analyses of mortality, 10 of 17 analyses of complications (total and infectious), 1 of 3 analyses of muscle strength, 4 of 9 analyses of body composition/nutritional status, 2 of 14 analyses of length of stay, and 2 of 5 analyses of hospital readmissions. Ten reviews were high quality (AMSTAR scores 8-11), 9 moderate (AMSTAR scores 3-8), and 3 poor (AMSTAR scores 0-3). Methodological deficiencies were limitations to searches, poor reporting of heterogeneity, and failure to incorporate quality of evidence into any recommendations. Discordance between reviews was not markedly reduced when only high-quality reviews were considered. Evidence for the effects of ONS in malnourished patients or those who are at risk of malnutrition is uncertain, and discordance in results can arise from differences in clinical background of patients or the etiological basis of malnutrition.

Predicting COVID-19 Using Retrospective Data: Impact of Obesity on Outcomes of Adult Patients With Viral Pneumonia

Background

Community-acquired pneumonia due to viral pathogens is an under-recognized cause of healthcare-associated mortality and morbidity worldwide. We aimed to compare mortality rates and outcome measures of disease severity in obese vs non-obese patients admitted with viral pneumonia.

Methods

Adult patients admitted with viral pneumonia were selected from the Nationwide Inpatient Sample of 2016 and 2017. The arms were stratified based on the presence of a secondary discharge diagnosis of obesity. The primary outcome was inpatient mortality. Secondary outcomes included sepsis, acute respiratory failure, acute respiratory distress syndrome, acute kidney injury, and pulmonary embolism.

Results and interpretation

In total, 89,650 patients admitted with viral pneumonia were analyzed, and 17% had obesity. There was no significant difference in mortality between obese and non-obese patients (aOR: 0.98, 95% CI: 0.705 - 1.362, p < 0.001). Compared to non-obese patients, obese patients had higher adjusted odds of developing acute hypoxic respiratory failure (aOR: 1.37, 95% CI: 1.255 - 1.513, p < 0.001), acute respiratory distress syndrome (aOR: 2.29, 95% CI: 1.554 - 3.381, p < 0.001), need for mechanical ventilation (aOR: 1.50, 95% CI: 1.236 - 1.819, p < 0.001), and pulmonary embolism (aOR: 1.69, 95% CI: 1.024 - 2.788, p = 0.040).

Conclusions

Obesity was not found to be an independent predictor of inpatient mortality in patients admitted with viral pneumonia. However, obesity is associated with worse clinical outcomes and disease severity as defined by the presence of complications, greater incidence of acute respiratory failure (ARF), acute respiratory distress syndrome (ARDS), need for mechanical ventilation, acute kidney injury (AKI), pulmonary embolism (PE), stroke, and sepsis.

Simulations for Teaching and Evaluating Nutrition-Focused Physical Exam Skills

OBJECTIVE

To develop, implement, and evaluate a patient simulation to assess Nutrition-Focused Physical Exam (NFPE) skills among dietetics students.

METHODS

Three student cohorts (n = 47) in a combined internship and master's program participated. Curricula included: (1) formal instruction with practice resources, (2) baseline NFPE evaluation performed on a classmate, and (3) final NFPE evaluation performed on a standardized patient. Trained observers evaluated students using the NFPE Skills Assessment tool. Self-rated performance was assessed by the 8-item survey completed at baseline and after the final evaluation. Paired t tests analyzed differences in observed NFPE skill, and 1-tailed Wilcoxon signed-rank test analyzed differences in survey responses.

RESULTS

Nutrition-Focused Physical Exam skill improvements were observed for each cohort (P < .05). Surveys demonstrated increased comfort touching patients (P < .001), and improved self-rated abilities to assess subcutaneous fat, muscle stores, fluid accumulation, and micronutrient deficiency (P < .001).

CONCLUSIONS AND IMPLICATIONS

Simulations were an effective method for increasing observed and perceived NFPE skills among dietetics students. These findings justify the investigation of these methods within a larger sample of students from multiple programs with rigorous study design.

The Underappreciated Role of Low Muscle Mass in the Management of Malnutrition

Preserving muscle is not only crucial for maintaining proper physical movement, but also for its many metabolic and homeostatic roles. Low muscle mass has been shown to adversely affect health outcomes in a variety of disease states (eg, chronic obstructive pulmonary disease, cancer, cardiovascular disease) and leads to an increased risk for readmission and mortality in hospitalized patients. Low muscle mass is now included in the most recent diagnostic criteria for malnutrition. Current management strategies for malnutrition may not prioritize the maintenance and restoration of muscle mass. This likely reflects the challenge of identifying and measuring this body composition compartment in clinical practice and the lack of awareness by health care professionals of the importance that muscle plays in patient health outcomes. As such, we provide a review of current approaches and make recommendations for managing low muscle mass and preventing muscle loss in clinical practice. Recommendations to assist the clinician in the optimal management of patients at risk of low muscle mass include the following: (1) place muscle mass at the core of nutritional assessment and management strategies; (2) identify and assess low muscle mass; (3) develop a management pathway for patients at risk of low muscle mass; (4) optimize nutrition to focus on muscle mass gain versus weight gain alone; and (5) promote exercise and/or rehabilitation therapy to help maintain and build muscle mass. The need to raise awareness of the importance of screening and managing 'at risk' patients so it becomes routine is imperative for change to occur. Health systems need to drive clinicians to treat patients with this focused approach, and the economic benefits need to be communicated to payers. Lastly, further focused research in the area of managing patients with low muscle mass is warranted.

The malnutrition in polytrauma patients (MaPP) study: Research protocol

BACKGROUND

Polytrauma patients are at risk of considerable harm from malnutrition due to the metabolic response to trauma. However, there is little knowledge of (the risk of) malnutrition and its consequences in these patients. Recognition of sub-optimally nourished polytrauma patients and their nutritional needs is crucial to prevent complications and optimize their clinical outcomes.

AIM

The primary objective is to investigate whether polytrauma patients admitted to the Intensive Care Unit (ICU) who have or develop malnutrition have a higher complication rate than patients who are and remain well nourished. Secondary objectives are to determine the prevalence of pre-existent and in-hospital acquired malnutrition in these patients, to assess the association between malnutrition and long-term outcomes, and to determine the association between serum biomarkers (albumin and pre-albumin) and malnutrition.

METHODS

This international observational prospective cohort study will be performed at three Level-1 trauma centers in the United States and two Level-1 centers in the Netherlands. Adult polytrauma patients (Injury Severity Score ≥16) admitted to the ICU of one of the participating centers directly from the Emergency Department are eligible for inclusion. Nutritional status and risk of malnutrition will be assessed using the Subjective Global Assessment (SGA) scale and Nutritional Risk in Critically Ill (NUTRIC) score, respectively. Nutritional intake, biomarkers and complications will be collected daily. Patients will be followed up to one year after discharge for long-term outcomes.

CONCLUSIONS

This international prospective cohort study aims to gain more insight into the effect and consequences of malnutrition in polytrauma patients admitted to the ICU.

Clinical and Economic Value of Nutrition in Healthcare: A Nurse's Perspective

In the US healthcare system, malnutrition is a common condition, yet it remains underreported and underdiagnosed. The financial costs of disease-associated malnutrition are substantial; hospital-acquired conditions, readmissions, and prolonged lengths of stay are reported to cost as much as $150 billion per year. By contrast, nutrition-focused quality improvement programs for inpatients can help reduce the negative impact of disease-associated malnutrition. Such programs include systematic screening for malnutrition risk on admission, timely malnutrition diagnoses, and prompt nutrition interventions, which have been shown to lower rates of hospital-acquired infections, shorten lengths of stay, reduce readmissions, and lessen costs of care. Nurses are ideally positioned to play critical roles in nutrition-related care-screening for malnutrition on admission, monitoring for and addressing conditions that impede nutrition intake, and ensuring that prescribed nutrition interventions are delivered and administered or consumed. Such nursing support of multidisciplinary nutrition care contributes to better patient outcomes at lower costs.

Malnutrition-Related Health Care Cost in Japan: An Analysis of Health Insurance Claims Data

The objective of our study is to evaluate the prevalence and health care cost of malnutrition in Japan. Using the health insurance data, we defined 2 types of malnutrition, strictly diagnosed malnutrition (SDM) and disease-associated malnutrition (DAM) by International Classification of Diseases 10th Revision. We also analyzed the health care costs by body mass index (BMI) data from medical checkups. The nationwide prevalence of SDM was estimated 0.8%, and that of SDM plus DAM was 2.9%. The total annual health care cost for SDM patients in Japan was $14.5 billion, representing 4.3% of the national health expenditures in 2014; the excess cost for patients with SDM was estimated to be $9.7 billion. The health care costs became high among the patients with either low BMI or high BMI. Because of the rapidly aging population, actions are urgently needed to avoid increasing the current high health care costs of malnutrition.

Perspective: The Public Health Case for Modernizing the Definition of Protein Quality

Prevailing definitions of protein quality are predicated on considerations of biochemistry and metabolism rather than the net effects on human health or the environment of specific food sources of protein. In the vernacular, higher "quality" equates to desirability. This implication is compounded by sequential, societal trends in which first dietary fat and then dietary carbohydrate were vilified during recent decades, leaving dietary protein under an implied halo. The popular concept that protein is "good" and that the more the better, coupled with a protein quality definition that favors meat, fosters the impression that eating more meat, as well as eggs and dairy, is desirable and preferable. This message, however, is directly opposed to current Dietary Guidelines for Americans, which encourage consumption of more plant foods and less meat, and at odds with the literature on the environmental impacts of foods, from carbon emissions to water utilization, which decisively favor plant protein sources. Thus, the message conveyed by the current definitions of protein quality is at odds with imperatives of public and planetary health alike. We review the relevant literature in this context and make the case that the definition of protein quality is both misleading and antiquated. We propose a modernized definition that incorporates the quality of health and environmental outcomes associated with specific food sources of protein. We demonstrate how such an approach can be adapted into a metric and applied to the food supply.

Identifying malnutrition: From acute care to discharge and beyond

Nutrition assessment and intervention significantly contribute to the well-being of patients. NPs should advocate that patients be appropriately evaluated and implement recommendations as part of a comprehensive care plan to avoid malnutrition in patients while they are in the hospital and when they return home.

Healthcare utilization, medical costs and mortality associated with malnutrition in patients with chronic obstructive pulmonary disease: a matched cohort study

Objective: Although disease-related malnutrition has prognostic implications for patients with chronic obstructive pulmonary disease (COPD), its health-economic impact and clinical burdens are uncertain. We conducted a population-level study to investigate these questions. Methods: We excerpted data relevant to malnutrition, prolonged mechanical ventilation and medications from claims by 1,197,098 patients which were consistent with COPD and registered by the Taiwan National Health Insurance Administration between 2009 and 2013. These patients were separated into cohorts with or without respiratory failure requiring long-term mechanical ventilation, and each cohort was divided to compare cases who developed malnutrition after their first diagnosis consistent with COPD, versus non-malnourished propensity-score matched controls. Results: The prevalence of malnutrition was 3.8% overall (10,259/287,000 non-ventilator-dependent; 1198/15,829 ventilator-dependent). Propensity-score matched non-ventilator-dependent patients who became malnourished (N = 10,242) had comparatively more hospitalizations, emergency room and outpatient visits, longer hospitalization (all p < .01), and higher mortality (HR = 2.26, 95% CI 2.18-2.34) than non-malnourished controls (N = 40,968). Malnourished ventilator-dependent patients (N = 1197) had higher rates of hospitalization, emergency room and outpatient visits, but shorter hospitalization (all p < .001) and lower mortality (HR = 0.85, 95% CI 0.80-0.93) than matched non-malnourished controls (N = 4788). Total medical expenditure on malnourished non-ventilator-dependent COPD patients was 75% higher than controls (p < .001), whereas malnourished ventilator-dependent patients had total costs 7% lower than controls (p < .001). Conclusions: Malnourishment among COPD patients who were not dependent on mechanical ventilation was associated with greater healthcare resource utilization and higher aggregate medical costs.

Identifying Geriatric Patients at Risk for Malnutrition: A Quality Improvement Project

Malnourishment leads to poor outcomes in the geriatric surgical population and national guidelines recommend preoperative nutrition screening. However, care practices do not reflect current recommendations. As a quality-improvement project, a validated nutritional screening tool, the Mini Nutritional Assessment-Short Form (MNA-SF), was implemented in the preoperative clinic of a large academic health center to identify patients at-risk for malnutrition prior to elective surgery. Patients were screened during the nursing intake process and categorized as no nutritional risk; at-risk for malnourishment; or severely malnourished. During the four-week screening period, 413 patients met inclusion criteria with 67.8% (n = 280) screened. No nutritional risk was identified in 77.5% (n = 215) of patients, 18.2% (n = 51) were at-risk, and 4.3% (n = 12) were malnourished. This project will inform and guide a prehabilitation plan for nutrition optimization to improve healthcare quality, outcomes, and costs in the geriatric surgical population.

Economic burden of hospital malnutrition and the cost-benefit of supplemental parenteral nutrition in critically ill patients in Latin America

AIM

Disease-related malnutrition (DRM) is a prevalent condition that significantly increases the risk of adverse outcomes in hospitalized patients, particularly those with critical illness. Limited data is available on the economic burden of DRM and the cost-benefit of nutrition therapy in high-risk populations in Latin America. The aims of the present study were to estimate the economic burden of DRM and evaluate the cost-benefit of supplemental parenteral nutrition (SPN) in critically ill patients who fail to receive adequate nutrient intake from enteral nutrition (EN) in Latin America.

METHODS

Country-specific cost and prevalence data from eight Latin American countries and clinical data from studies evaluating outcomes in patients with DRM were used to estimate the costs associated with DRM in public hospitals. A deterministic decision model based on clinical outcomes from a randomized controlled study and country-specific cost data were developed to examine the cost-benefit of administering SPN to critically ill adults who fail to reach ≥60% of the calculated energy target with EN.

RESULTS

The estimated annual economic burden of DRM in public hospitals in Latin America is $10.19 billion (range, $8.44 billion-$11.72 billion). Critically ill patients account for a disproportionate share of the costs, with a 6.5-fold higher average cost per patient compared with those in the ward ($5488.35 vs. $839.76). Model-derived estimates for clinical outcomes and resource utilization showed that administration of SPN to critically ill patients who fail to receive the targeted energy delivery with EN would result in an annual cost reduction of $10.2 million compared with continued administration of EN alone.

LIMITATIONS

The cost calculation was limited to the average daily cost of stay and antibiotic use. The costs associated with other common complications of DRM, such as prolonged duration of mechanical ventilation or more frequent readmission, are unknown.

CONCLUSIONS

DRM imposes a substantial economic burden on Latin American countries, with critically ill patients accounting for a disproportionate share of costs. Cost-benefit analysis suggests that both improved clinical outcomes and significant cost savings can be achieved through the adoption of SPN as a therapeutic strategy in critically ill patients who fail to receive adequate nutrient intake from EN.

Hidden Hunger: Solutions for America's Aging Populations

The global population, including the United States, is experiencing a demographic shift with the proportion of older adults (aged ≥ 65 years) growing faster than any other age group. This demographic group is at higher risk for developing nutrition-related chronic conditions such as heart disease and diabetes as well as infections such as influenza and pneumonia. As a result, an emphasis on nutrition is instrumental for disease risk reduction. Unfortunately, inadequate nutrient status or deficiency, often termed hidden hunger, disproportionately affects older adults because of systematic healthcare, environmental, and biological challenges. This report summarizes the unique nutrition challenges facing the aging population and identifies strategies, interventions, and policies to address hidden hunger among the older adults, discussed at the scientific symposium "Hidden Hunger: Solutions for America's Aging Population", on March 23, 2018.

Cost-effectiveness of food, supplement and environmental interventions to address malnutrition in residential aged care: a systematic review

Background

observational studies have shown that nutritional strategies to manage malnutrition may be cost-effective in aged care; but more robust economic data is needed to support and encourage translation to practice. Therefore, the aim of this systematic review is to compare the cost-effectiveness of implementing nutrition interventions targeting malnutrition in aged care homes versus usual care.

Setting

residential aged care homes.

Methods

systematic literature review of studies published between January 2000 and August 2017 across 10 electronic databases. Cochrane Risk of Bias tool and GRADE were used to evaluate the quality of the studies.

Results

eight included studies (3,098 studies initially screened) reported on 11 intervention groups, evaluating the effect of modifications to dining environment (n = 1), supplements (n = 5) and food-based interventions (n = 5). Interventions had a low cost of implementation (<£2.30/resident/day) and provided clinical improvement for a range of outcomes including weight, nutritional status and dietary intake. Supplements and food-based interventions further demonstrated a low cost per quality adjusted life year or unit of physical function improvement. GRADE assessment revealed the quality of the body of evidence that introducing malnutrition interventions, whether they be environmental, supplements or food-based, are cost-effective in aged care homes was low.

Conclusion

this review suggests supplements and food-based nutrition interventions in the aged care setting are clinically effective, have a low cost of implementation and may be cost-effective at improving clinical outcomes associated with malnutrition. More studies using well-defined frameworks for economic analysis, stronger study designs with improved quality, along with validated malnutrition measures are needed to confirm and increase confidence with these findings.

Association Between Malnutrition and Depression Among Community-Dwelling Older Chinese Adults

Malnutrition and depression are of important concern among older adults. We investigated the association between malnutrition and depression among community-dwelling older Chinese adults and how both affect health care costs. Data from 4916 older adults (age ≥60 years) collected as part of 2013-Wave II China Health and Retirement Longitudinal Study (CHARLS) survey were analyzed. Measures of body mass index and weight loss were used as indicators of malnutrition. Malnourished subjects were 31% more likely to be depressed than their non-malnourished counterparts (odds ratio = 1.311, P < .1). Health care–related cost was ¥591.8 higher for malnourished older adult per year compared to a non-malnourished counterpart ( P < .1), thus confirming that incidence of depression coupled with malnutrition significantly increases health care–related costs. These results highlight the importance of malnutrition and depression screening and treatment for older Chinese community-dwelling adults, and the importance of community-based nutrition-specific programs that could address the needs of the affected populations.

Malnutrition and Malnutrition Risk Can Be Associated with Systolic Orthostatic Hypotension in Older Adults

BACKGROUND

Malnutrition and orthostatic hypotension(OH) are the two important geriatric syndromes, which have similar negative outcomes such as falls. The aim of the study is to detect whether there is any relation between malnutrition and OH.

METHODS

862 geriatric patients, who had undergone comprehensive geriatric assessment (CGA),were included in the retrospective study. OH was identified as 20 and/or 10 mmHg dropped for systolic and/or diastolic blood pressures with the active standing test when patients got up from supine to standing position. Nutritional status was checked according to Mini Nutritional Assesment-Short Form(MNA-SF).

RESULTS

The mean age of the patients was 74±8.05, and %66.3 of them were female. The prevalence of malnutrition, malnutrition-risk and OH were detected as 7.7%, 26.9 % and 21.2%, respectively. When OH, systolic OH, diastolic OH and control group were compared with CGA parameters and the effects of age and gender were removed, the frequency of falls and Timed-Up and Go Test were higher, activity daily living indexes and TINETTI-Balance scores were lower in systolic OH than without it (p<0.05).Systolic OH was more frequent in malnutrition-risk and malnutrition group than control group (p<0.002 and p<0.05, respectively). Diastolic OH was not associated with nutritional status (p>0.05).OH was only higher in malnutrition-risk group than robust (p<0.05).

CONCLUSION

Our findings suggest that not only malnutrition but also malnutrition-risk may be associated with systolic OH, which leads to many negative outcomes in older adults. Because malnutrition/ malnutrition risk is preventable and reversible, nutritional status should be checked during the evaluation of OH patients.

Assessment of adult malnutrition and prognosis with bioelectrical impedance analysis: phase angle and impedance ratio

PURPOSE OF REVIEW

Malnutrition affects prognosis in many groups of patients. Although screening tools are available to identify adults at risk for poor nutritional status, a need exists to improve the assessment of malnutrition by identifying the loss of functional tissues that can lead to frailty, compromised physical function, and increased risk of morbidity and mortality, particularly among hospitalized and ill patients and older adults. Bioimpedance analysis (BIA) offers a practical approach to identify malnutrition and prognosis by assessing whole-body cell membrane quality and depicting fluid distribution for an individual.

RECENT FINDINGS

Two novel applications of BIA afford opportunities to safely, rapidly, and noninvasively assess nutritional status and prognosis. One method utilizes single-frequency phase-sensitive measurements to determine phase angle, evaluate nutritional status, and relate it to prognosis, mortality, and functional outcomes. Another approach uses the ratio of multifrequency impedance values to indicate altered fluid distribution and predict prognosis.

SUMMARY

Use of basic BIA measurements, independent of use of regression prediction models and assumptions of constant chemical composition of the fat-free body, enables new options for practical assessment and clinical evaluation of impaired nutritional status and prognosis among hospitalized patients and elders that potentially can contribute to improved patient care and clinical outcomes. However, these novel applications have some technical and physiological limitations that should be considered.

Risk Factors for Malnutrition among Older Adults in the Emergency Department: A Multicenter Study

BACKGROUND

Among older adults, malnutrition is common, often missed by healthcare providers, and influences recovery from illness or injury.

OBJECTIVE

To identify modifiable risk factors associated with malnutrition in older patients.

DESIGN

Prospective cross-sectional multicenter study.

SETTING

3 EDs in the South, Northeast, and Midwest.

PARTICIPANTS

Non-critically ill, English-speaking adults aged ≥65 years.

MEASUREMENTS

Random time block sampling was used to enroll patients. The ED interview assessed malnutrition using the Mini Nutritional Assessment Short-Form. Food insecurity and poor oral health were assessed using validated measures. Other risk factors examined included depressive symptoms, limited mobility, lack of transportation, loneliness, and medication side effects, qualified by whether the patient reported the risk factor affected their diet. The population attributable risk proportion (PARP) for malnutrition was estimated for each risk factor.

RESULTS

In our sample (n = 252), the prevalence of malnutrition was 12%. Patient characteristics associated with malnutrition included not having a college degree, being admitted to the hospital, and residence in an assisted living facility. Of the risk factors examined, the PARPs for malnutrition were highest for poor oral health (54%; 95% CI 16%, 78%), food insecurity (14%; 95% CI 3%, 31%), and lack of transportation affecting diet (12%; 95% CI 3%, 28%).

CONCLUSION

Results of this observational study identify multiple modifiable factors associated with the problem of malnutrition in older adults.

Economic Burden of Disease-Associated Malnutrition at the State Level

Background

Disease-associated malnutrition has been identified as a prevalent condition, particularly for the elderly, which has often been overlooked in the U.S. healthcare system. The state-level burden of community-based disease-associated malnutrition is unknown and there have been limited efforts by state policy makers to identify, quantify, and address malnutrition. The objective of this study was to examine and quantify the state-level economic burden of disease-associated malnutrition.

Methods

Direct medical costs of disease-associated malnutrition were calculated for 8 diseases: Stroke, Chronic Obstructive Pulmonary Disease, Coronary Heart Failure, Breast Cancer, Dementia, Musculoskeletal Disorders, Depression, and Colorectal Cancer. National disease and malnutrition prevalence rates were estimated for subgroups defined by age, race, and sex using the National Health and Nutrition Examination Survey and the National Health Interview Survey. State prevalence of disease-associated malnutrition was estimated by combining national prevalence estimates with states’ demographic data from the U.S. Census. Direct medical cost for each state was estimated as the increased expenditures incurred as a result of malnutrition.

Principal Findings

Direct medical costs attributable to disease-associated malnutrition vary among states from an annual cost of $36 per capita in Utah to $65 per capita in Washington, D.C. Nationally the annual cost of disease-associated malnutrition is over $15.5 billion. The elderly bear a disproportionate share of this cost on both the state and national level.

Conclusions

Additional action is needed to reduce the economic impact of disease-associated malnutrition, particularly at the state level. Nutrition may be a cost-effective way to help address high health care costs.

Influence of undernutrition at admission on clinical outcomes in patients with acute myocardial infarction

BACKGROUND

Although the effect of overweight or obesity on clinical outcomes in patients with acute myocardial infarction (MI) has been reported, the effect of undernutrition is not as well understood. Therefore, we investigated whether acute MI patients frequently present with undernutrition, and whether this influences poor clinical outcomes.

METHODS AND RESULTS

Using the Korea Acute Myocardial Infarction Registry database, we screened initial data on acute MI patients admitted within 48h of symptom onset to a tertiary university hospital between November 1, 2011 and May 31, 2015. We then assessed nutritional status at admission, using the Geriatric Nutritional Risk Index (GNRI). Of a total of 2251 patients, there were 1585 (70.4%) men, and mean age was 65.0±12.8 years. Based on GNRI score, undernutrition at admission was present in 409 (18.2%) patients. Multiple logistic regression analysis found undernutrition to be an independent factor influencing post-MI complications [odds ratio (OR), 2.13; 95% confidence interval (CI), 1.61-2.84; p<0.001], after adjusting for age, sex, hypertension, diabetes, hyperlipidemia, previous stroke, smoking, diagnosis, number of involved vessel lesions, Killip class, atrial fibrillation, baseline blood pressure, hemoglobin, creatine kinase-MB, creatinine, performance of percutaneous coronary intervention, reperfusion time, recanalization, and use of antithrombotics. Undernutrition was also an important factor influencing in-hospital death (OR, 2.48; 95% CI, 1.55-3.95; p<0.001), after adjusting for all potential factors by univariate analysis.

CONCLUSIONS

Nutritional status is a significant prognostic factor in clinical outcomes after MI during hospitalization. Therefore, nutritional assessment and intervention, especially for undernourished MI patients, should be considered.