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Addressing malnutrition

Addressing malnutrition

Intervening upon admission with nutrition can contribute to patient stabilization and recovery and reduce hospital care costs. The benefits of nutrition intervention include:

  • A comprehensive nutrition plan may reduce hospital length of stay by an average of 2 days1,2
  • Oral nutritional supplementation results in a 25% reduction in risk of developing pressure ulcers3
  • Oral nutritional supplements reduced major complications by 60% in elderly orthopedic patients according to a study by Lawson et al4
  • Nutrition intervention helps reduce the risk of falls in malnourished patients. One study showed a 56% reduction in falls by intervening with high-energy, high-protein diets, 2 servings of oral nutrition supplements per day, calcium and vitamin D supplementation and nutrition counseling5

Read the research studies below to discover the effects of nutrition on patient outcomes and learn how nutrition can support faster healing.

The prevalence of disease-related malnutrition is common across health care settings, leading to detrimental effects on the patient and healthcare system. The use of high protein oral nutritional supplements (ONS) has been recommended in patients with disease-related malnutrition, even though there is a lack of systematically obtained evidence to support these recommendations. Therefore, this systematic review was undertaken to examine whether high protein ONS have beneficial effects in clinical practice and the extent to which these are associated with increased protein intake.

This systematic review included only randomized controlled trials and meta-analyses of adult populations receiving high protein ONS (>20% of energy as protein).

This systematic review included 36 RCTs that involved 3,790 patients (mean age 74 years; 83% of trials in patients >65 years).  The results demonstrated a range of effects across healthcare settings and patient groups in favor of the high protein ONS groups, including:
  • Reduced complications (odds ratio (OR) 0.68 (95%CI 0.55-0.83), p<0.001, 10 RCT, n=1830)
  • Reduced readmissions to hospital (OR 0.59 (95%CI 0.41-0.84), p=0.004, 2 RCT, n=546)
  • Improved grip strength (1.76 kg (95%CI 0.36-3.17), p<0.014, 4 RCT, n=219)
  • Increased intake of protein (p<0.001) and energy (p<0.001) with little reduction in normal food intake and improvements in weight (p<0.001)
  • There was inadequate information to compare standard ONS (<20% energy from protein) with high protein ONS (>20% energy from protein)

The systematic review and meta-analysis provides evidence that high protein supplements produce benefits to patients including reduced complications and readmissions, with economic implications. There are clinical, nutritional and functional benefits resulting from high protein ONS use and the available evidence suggests little suppression of normal food intake with the ONS being mostly additive to food intake.

Cawood A et al. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Research Reviews 2012; 11: 278-296.

In the US, nutrition screening is a Medicare Condition of Participation and therefore a requirement for accreditation or certification of healthcare facilities. Nutrition screening is also a primary mechanism for patients to be referred to a registered dietitian (RD) for further nutrition assessment, diagnosis, and intervention. Thus, valid and reliable nutrition screening tools are needed to ensure that referrals are appropriate. However, in many US hospitals, dietitians recommend lengthy nutrition screening tools, which have not been tested for reliability, validity, or accuracy. Alternatively, outside the US accurate, streamlined nutrition screening tools that have been validated against a complete nutrition assessment are widely used. In response to questions about tools for nutrition screening, an evidence analysis project was developed to identify the most valid and reliable nutrition screening tools for use in acute care and hospital-based ambulatory care settings.

An international workgroup of RDs with expertise in research, clinical nutrition management, and clinical practice was developed to provide oversight to the project. A trained analyst conducted structured searches of the literature for studies of nutrition screening tools according to predetermined criteria. Nutrition screening tools designed to detect undernutrition in patients in acute care and hospital-based ambulatory care were identified. Trained analysts evaluated articles for quality using criteria specified by the American Dietetic Association's Evidence Analysis Library. Members of the oversight group assigned quality grades to the tools (on a scale of I to IV, where I = good, II = fair, III = limited, IV = expert opinion, and V = grade not assignable) based on the quality of the supporting evidence, including reliability and validity data.

This workgroup evaluated 168 articles and 11 nutrition screening tools. The study results showed:
  • One tool, the NRS-2002, received a grade I
  • 4 tools, the Simple Two-Part Tool, the Mini-Nutritional Assessment-Short Form (MNA-SF), the Malnutrition Screening Tool (MST), and Malnutrition Universal Screening Tool (MUST), received a grade II
  • The MST was the only tool shown to be both valid and reliable for identifying undernutrition in the settings studied.

Validated nutrition screening tools that are simple and easy to use are available for application in acute care and hospital-based ambulatory care settings. Clinicians should focus on the selection of simple tools that are reliable and valid may improve compliance in completing nutrition screening and may also free up time that may be reallocated toward nutrition intervention.

Skipper A et al. Nutrition screening tools: an analysis of the evidence. J Parenter Enteral Nutr 2012; 36: 292-298.

Pressure ulcers are common in certain patient populations and lead to negative patient and healthcare outcomes. Nutritional factors play a role in both the prevention and treatment of pressure ulcers. However, there have been few systematic reviews and no meta-analyses of the clinical benefits of nutritional support in patients with or at risk of developing pressure ulcers. The aim of this systematic review was to determine the effect of enteral nutritional support on pressure ulcer incidence, pressure ulcer healing and other relevant outcomes measures.

Fifteen studies (including eight randomized controlled trials (RCTs)) of oral nutritional supplements (ONS) or enteral tube feeding (ETF) identified using electronic databases (including Pub Med and Cochrane) and bibliography searches, were included in the systematic review. Outcomes including pressure ulcer incidence, pressure ulcer healing, quality of life, complications, mortality, anthropometry and dietary intake were recorded, with the aim of comparing nutritional support versus routine care (e.g. usual diet and pressure ulcer care) and nutritional formulas of different composition. Of these 15 studies, 5 RCTs comparing ONS (4 RCTs) and ETF (1 RCT) with routine care could be included in a meta-analysis of pressure ulcer incidence.

The study results showed:
  • ONS (250-500 kcal, 2-26 weeks) were associated with a significantly lower incidence of pressure ulcer development in at-risk patients compared to routine care (odds ratio 0.75, 95% CI 0.62-0.89, 4 RCTs, n=1224, elderly, post-surgical, chronically hospitalized patients)
  • Similar results were obtained when a combined meta-analysis of ONS (4 RCT) and ETF (1 RCT) trials was performed (OR 0.74, 95% CI 0.62-0.88, 5 RCTs, n=1325)
  • Individual studies showed a trend toward improved healing of existing pressure ulcers with disease-specific (including high protein) versus standard formulas, although robust RCTs are required to confirm this
  • Although some studies indicate that total nutritional intake is improved, data on other outcome measures (quality of life) are lacking.

This systematic review shows enteral nutritional support, particularly high protein ONS, can significantly reduce the risk of developing pressure ulcers (by 25%). Although studies suggest ONS and ETF may improve healing of PU, further research to confirm this trend is required.

Stratton RJ et al. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Research Reviews 2005; 4: 422-450.

The study tested whether nutritional support of older patients during acute illness leads to a clinical benefit.

A randomized, double-blind, placebo-controlled study, where 445 hospitalized patients aged 65 to 92 years were randomized to receive either a normal hospital diet plus 400 mL oral nutritional supplements (223 subjects) or a normal hospital diet plus a placebo (222 subjects) daily for six weeks. The composition of the supplement was such as to provide 995 kcal of energy and 100% of the Reference Nutrient Intakes for vitamins and minerals for a healthy older person. Patients had three assessments: at baseline, at 6 weeks, and at 6 months post-randomization. Outcome measures were 6 months of disability, non-elective readmission and length of hospital stay, discharge destination, morbidity, and mortality.

  • Over 6 months, 65 patients (29%) in the supplements group were readmitted to the hospital compared with 89 patients (40%) in the placebo group (adjusted hazard ratio 0.68 [95% confidence interval 0.49-0.94]).
  • The mean length of hospital stay was 9.4 days in the supplements group, compared with 10.1 days in the placebo group.
  • Thirty-two people (14%) died in the supplement group compared with 19 people (9%) in the placebo group at 6 months (adjusted hazard ratio 1.65 [95% confidence interval, 0.93-2.92]).

Oral nutritional supplementation of acutely ill patients improved nutritional status and led to a statistically significant reduction in the number of non-elective readmissions.

Gariballa S et al. A randomized, double-blind, placebo controlled trial of nutritional supplementation during acute illness.  Am J Med 2006; 119: 693-699.

Oral nutritional supplements (ONS) play a key role in the management of malnutrition. This systematic review examined patients' compliance with ONS across healthcare settings and the influence of patient and ONS-related factors.

A systematic review identified 46 studies (n = 4328) of was available.  Pooled mean % compliance was assessed overall and according to study design and healthcare setting. Inter-relationships between compliance and ONS-related and patient-related factors, and total energy intake were assessed.

  • Overall mean compliance with ONS was 78% (37%-100%; 67% hospital, 81% community; overall mean ONS intake 433 kcal/d).
  • Percentage compliance was similar in randomized (79%) and non-randomized (77%) trials, with little variation between diagnostic groups.
  • Compliance across a heterogeneous group of unmatched studies was positively associated with higher energy-density ONS and greater ONS and total energy intakes, negatively associated with age, and unrelated to amount or duration of ONS prescription.

This systematic review suggests that compliance to ONS is good, especially with higher energy-density ONS, resulting in improvements in patients' total energy intakes that have been linked with clinical benefits.

Hubbard GP et al. A systematic review of compliance to oral nutritional supplements. Clin Nutr 2012; 31 293-312.


1Brugler L et al.  J Qual Improv 1999; 25: 191-206
2Smith PE, et al. Healthcare Financial Management. 1997; 51:66-69
3Stratton RJ et al. Ageing Research Reviews 2005; 4: 422-450
4Lawson RM et al.  Clin Nutr 2003; 22: 39-46
5Neelemaat F et al. J Am Geriatr Soc 2012; 60: 691-699