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.

Physical performance and protein-energy wasting in patients treated with nocturnal haemodialysis compared to conventional haemodialysis: protocol of the DiapriFIT study

BACKGROUND

Poor physical performance and protein-energy wasting (PEW) are health issues of major concern in haemodialysis patients. The conventional haemodialysis (CHD) regime, three times per week 3-5 h, is subject of discussion because of high morbidity and mortality rates. When patients switch from CHD to longer dialysis sessions, i.e. nocturnal haemodialysis (NHD), improvement in protein intake and increase in body weight is seen. However, it is unclear whether physical performance and more important aspects of PEW, such as body composition, improve as well. Therefore, the aim of this study is to investigate whether physical performance improves and PEW decreases, when patients switch from CHD to NHD. A second aim is to assess the influence of NHD on the biomarkers fibroblast growth factor-23 and sclerostin which are thought to be associated with malnutrition and mortality in patients on haemodialysis.

METHODS

This study is a prospective multicentre cohort study with an inclusion aim of 50 patients: 25 patients in a control group (three times per week, 3-5 h CHD) and 25 patients in a nocturnal group (three times per week, 7-9 h NHD). Primary outcome is change in physical performance, measured by the Short Physical Performance Battery. Additional measurements are a 6-min walk test, handgrip strength, a physical activity questionnaire and physical activity monitoring. The secondary outcome of the study is PEW, which will be evaluated by body weight, dual-energy X-ray absorptiometry, bio-electrical impedance spectroscopy, mid-upper arm muscle circumference, subjective global assessment, visual analogue scale for appetite and dietary records. Laboratory measurements including fibroblast growth factor-23 and sclerostin, and quality of life assessed with the Kidney Disease Quality of Life-Short Form are also studied. In every patient, four repeated measurements will be performed during one year of follow-up.

DISCUSSION

This study will investigate whether physical performance improves and PEW decreases when patients switch from CHD to NHD, compared to a control group who continue treatment with CHD. Strengths of this study are the comparison with a conventional haemodialysis cohort, and the broad variety of objective measurements combined with patient-reported outcomes of physical performance and PEW.

TRIAL REGISTRATION

NTR4715 , Netherlands Trial Register. Registered 30 July 2014.

Survival in Malnourished Older Patients Receiving Post-Discharge Nutritional Support; Long-Term Results of a Randomized Controlled Trial

BACKGROUND

Previous analyses have shown that a post-discharge individualized nutritional intervention had positive effects on body weight, lean body mass, functional limitations and fall incidents in malnourished older patients. However, the impact of this intervention on survival has not yet been studied.

OBJECTIVE

The objective of this randomized controlled study was to examine the effect of a post-discharge individualized nutritional intervention on survival in malnourished older patients.

METHODS

Malnourished older patients, aged ≥ 60 years, were randomized during hospitalization to a three-months post-discharge nutritional intervention group (protein and energy enriched diet, oral nutritional supplements, vitamin D3/calcium supplement and telephone counseling by a dietitian) or to a usual care regimen (control group). Survival data were collected 4 years after enrollment. Survival analyses were performed using intention-to-treat analysis by Log-rank tests and Cox regression adjusted for confounders.

RESULTS

The study population consisted of 94 men (45%) and 116 women with a mean age of 74.5 (SD 9.5) years. There were no statistically significant differences in baseline characteristics. Survival data was available in 208 out of 210 patients. After 1 and 4 years of follow-up, survival rates were respectively 66% and 29% in the intervention group (n=104) and 73% and 30% in the control group (n=104). There were no statistically significant differences in survival between the two groups 1 year (HR= 0.933, 95% CI=0.675-1.289) and 4 years after enrollment (HR=0.928, 95% CI=0.671-1.283).

CONCLUSION

The current study failed to show an effect of a three-months post-discharge multi-component nutritional intervention in malnourished older patients on long-term survival, despite the positive effects on short-term outcome such as functional limitations and falls.

Resting energy expenditure in malnourished older patients at hospital admission and three months after discharge: predictive equations versus measurements

BACKGROUND

Predicting resting energy expenditure (REE) in malnourished hospitalized older patients is important for establishing optimal goals for nutritional intake. Measuring REE by indirect calorimetry is hardly feasible in most clinical settings.

OBJECTIVE

To study the most accurate and precise REE predictive equation for malnourished older patients at hospital admission and again three months after discharge.

DESIGN

Twenty-three equations based on weight, height, gender, age, fat free mass (FFM) and/or fat mass (FM) and eleven fixed factors of kcal/kg were compared to measured REE. REE was measured by indirect calorimetry. Accuracy of REE equations was evaluated by the percentage patients predicted within 10% of REE measured, the mean percentage difference between predicted and measured values (bias) and the Root Mean Squared prediction Error (RMSE).

RESULTS

REE was measured in 194 patients at hospital admission (mean 1473 kcal/d) and again three months after hospital discharge in 107 patients (mean 1448 kcal/d). The best equations predicted 40% accuracy at hospital admission (Lazzer, FAO/WHO-wh and Owen) and 63% three months after discharge (FAO/WHO-wh). Equations combined with FFM, height or illness factor predicted slightly better. Fixed factors produce large RMSE's. All predictive equations showed proportional bias, with overestimation of low REE values and underestimation of high REE values. Correction by regression analysis did not improve results.

CONCLUSIONS

The REE predictive equations are not adequate to predict REE in malnourished hospitalized older patients. There is an urgent need for either a new accurate REE predictive equation, or accurate easy-to-use equipment to measure REE in clinical practice.

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

Background

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

Methods

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

Conclusion

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

Trial registration

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

Prevalence of undernutrition in Dutch hospital outpatients

BACKGROUND

The prevalence of undernutrition in hospital inpatients is high. Earlier detection and treatment in the hospital outpatient clinic may help to reduce these numbers. The purpose of this study was to assess the prevalence of undernutrition in hospital outpatients in the Netherlands, to determine high risk departments, and to determine the percentage of patients receiving dietetic treatment.

METHODS

This cross-sectional multicenter study was conducted in nine hospitals. Patients who visited the outpatient clinic on one of the screening days in the period March-May 2008 received a short questionnaire and were weighed. Patients were classified as severely undernourished, moderately undernourished or not undernourished.

RESULTS

2288 patients were included in the study, of which 5% were severely undernourished and 2% were moderately undernourished. The prevalence of severe undernutrition was highest in the outpatient departments of oral maxillofacial surgery (17%), oncology (10%), rehabilitation (8%), gastroenterology (7%) and pulmonology (7%). Only 17% of all severely undernourished and 4% of all moderately undernourished patients reported to receive dietetic treatment.

CONCLUSION

The prevalence of undernutrition in hospital outpatients is generally low but largely undertreated. Future screening should focus on high risk departments.

Are malnourished patients complex patients? Health status and care complexity of malnourished patients detected by the Short Nutritional Assessment Questionnaire (SNAQ)

BACKGROUND

This article describes the characteristics of patients identified as malnourished using the Short Nutritional Assessment Questionnaire (SNAQ) in terms of health status (quality of life, functional capacity, and body composition) and care complexity. We expected that by using the quick and easy SNAQ method of screening on malnutrition, inferences could be made about general health status and care complexity. This information can be used for optimal multi-disciplinary treatment of the malnourished patient.

METHODS

The research population consisted of a group of 588 patients admitted to internal medicine and surgery wards of the VU university medical center. Patients with a SNAQ score of at least 3 points were considered malnourished. The SNAQ score was compared to the health status, which was determined by serum albumin, hand grip strength, quality of life, body composition, and estimated care complexity.

RESULTS

At admission, 172 patients (29%) had a SNAQ score of at least 3 points. These patients had a significantly poorer quality of life, poorer physical functioning, a lower fat free mass index, and higher care complexity.

CONCLUSION

These findings confirm our assumption that a considerable proportion of malnourished patients should be considered as complex patients and that malnutrition is an important aspect and indicator of overall health status of the patients. The SNAQ is a simple malnutrition screening tool, applicable in the current complex hospital situation, to identify these complex, malnourished patients.