Clinical and Economic Outcomes of Nutrition Interventions across the Continuum of Care

Journal Articles

Defining, recognizing, and measuring malnutrition

Cawood AL, Elia M, Sharp SK, Stratton RJ. Malnutrition self-screening by using MUST in hospital outpatients: validity, reliability, and ease of use. Am J Clin Nutr. 2012;96(5):1000-7.

Jensen GL, Mirtallo J, Compher C, et al. Adult starvation and disease-related malnutrition: a proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committee. JPEN J Parenter Enteral Nutr. 2010;34(2):156-9.

Kruizenga HM, Seidell JC, de Vet HC, et al. Development and validation of a hospital screening tool for malnutrition: the short nutritional assessment questionnaire (SNAQ). Clin Nutr. 2005;24(1):75-82.

Kyle UG, Kossovsky MP, Karsegard VL, Pichard C. Comparison of tools for nutritional assessment and screening at hospital admission: a population study. Clin Nutr. 2006;25(3):409-17.

Leistra E, Languis JA, Evers AM, et al. Validity of nutritional screening with MUST and SNAQ in hospital outpatients. Eur J Clin Nutr. 2013;67(7):738-42.

Leistra E, van Bokhorst-de van der Schueren NA, Visser M, et al. Systematic screening for undernutrition in hospitals: predictive factors for success. Clin Nutr. 2013;S0261-5614(13)00196-9.

Lim SL, Ang E, Foo YL, et al. Validity and reliability of nutrition screening administered by nurses. Nutr Clin Pract. 2013;28(6):730-6.

Lim SL, Ng SC, Lye J, et al. Improving the performance of nutrition screening through a series of quality improvement initiatives. Joint Commission Journal on Quality & Patient Safety. 2014;40(4):178-86(9).

Lim SL, Tong CY, Ang E, et al. Development and validation of 3-Minute Nutrition Screening (3-MinNS) tool for acute hospital patients in Singapore. Asia Pac J Clin Nutr. 2009;18(3):395-403.

Lochs H, Allison SP, Meier R, et al. Introductory to the ESPEN Guidelines on Enteral Nutrition: terminology, definitions and general topics. Clin Nutr. 2006;25(2):180-6.

McGurk P, Jackson JM, Elia M. Rapid and reliable self-screening for nutritional risk in hospital outpatients using an electronic system. Nutrition. 2013;29(4):693-6.

White JV, Guenter P, Jensen G, et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition. JPEN J Parenter Enteral Nutr. 2012;36(3):275-83.

Yang Y, Brown CJ, Burgio KL, et al. Undernutrition at baseline and health services utilization and mortality over a 1-year period in older adults receiving Medicare home health services. J Am Med Dir Assoc. 2011;12(4):287-94.

Prevalence of malnutrition around the world

Agarwal E, Ferguson M, Banks M, et al. Nutritional status and dietary intake of acute care patients: results from the Nutrition Care Day Survey 2010. Clin Nutr. 2012;31(1):41-7.

Barreto Peniè J, Cuban Group for the Study of Hospital Malnutrition. State of malnutrition in Cuban hospitals. Nutrition. 2005;21(4):487-97.

Imoberdorf R, Meier R, Krebs P, et al. Prevalence of undernutrition on admission to Swiss hospitals. Clin Nutr. 2010;29(1):38-41.

Kaiser MJ, Bauer JM, Rämsch C, et al. Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment. J Am Geriatr Soc. 2010;58(9):1734-8.

Meijers JM, Schols JM, van Bokhorst-de van der Schueren MA, et al. Malnutrition prevalence in The Netherlands: results of the annual Dutch national prevalence measurement of care problems. Br J Nutr. 2009;101(3):417-23.

Pirlich M, Schütz T, Norman K, et al. The German hospital malnutrition study. Clin Nutr. 2006;25(4):563-72.

Ramage-Morin PL, Garriguet D. Nutritional risk among older Canadians. Health Rep. 2013;24(3):3-13.

Vanderwee K, Clays E, Bocquaert I, et al. Malnutrition and associated factors in elderly hospital patients: a Belgian cross-sectional, multi-centre study. Clin Nutr. 2010;29(4):469-76.

Waitzberg DL, Caiaffa WT, Correia MI. Hospital malnutrition: the Brazilian national survey (IBRANUTRI): a study of 4000 patients. Nutrition. 2001;17(7-8):573-80.

Zhang L, Wang X, Huang Y, et al. NutritionDay 2010 audit in Jinling hospital of China. Asia Pac J Clin Nutr. 2013;22(2):206-13.

Adverse outcomes associated with malnutrition

Agarwal E, Ferguson M, Banks M, et al. Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: results from the Nutrition Care Day Survey 2010. Clin Nutr. 2013;32(5):737-45.

Allaudeen N, Vidyarthi A, Maselli J, Auerbach A. Redefining readmission risk factors for general medicine patients. J Hosp Med. 2011;6(2):54-60.

Banks MD, Graves N, Bauer JD, Ash S. The costs arising from pressure ulcers attributable to malnutrition. Clin Nutr. 2010;29(2):180-6.

Corkins MR, Geunter P, Dimaria-Ghalili RA, et al. Malnutrition diagnoses in hospitalized patients: United States, 2010. JPEN J Parenter Enteral Nutr. 2014;38(2):186-95.

Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr. 2003;22(3):235-9.

Fry DE, Pine M, Jones BL, Meimban RJ. Patient characteristics and the occurrence of never events. Arch Surg. 2010;145(2):148-51.

Gariballa S, Forster S. Malnutrition is an independent predictor of 1-year mortality following acute illness. Br J Nutr. 2007;98(2):332-6.

Hiesmayr M, Schindler K, Pernicka E, et al. Decreased food intake is a risk factor for mortality in hospitalized patients: the NutritionDay survey 2006. Clin Nutr. 2009;28(5):484-91.

Kagansky N, Berner Y, Koren-Morag N, et al. Poor nutritional habits are predictors of poor outcome in very old hospitalized patients. Am J Clin Nutr. 2005;82(4):784-91.

Krumholz HM. Post-hospital syndrome — an acquired, transient condition of generalized risk. N Engl J Med. 2013;368(2):100-2.

Li HJ, Cheng HS, Liang J, et al. Functional recovery of older people with hip fracture: does malnutrition make a difference? J Adv Nurs. 2013;69(8):1691-703.

Lim SL, Ong KC, Chan YH, et al. Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clin Nutr. 2012;31(3):345-50.

Mudge AM, Kasper K, Clair A, et al. Recurrent readmissions in medical patients: a prospective study. J Hosp Med. 2011;6(2):61-7.

Somanchi M, Tao X, Mullin GE. The facilitated early enteral and dietary management effectiveness trial in hospitalized patients with malnutrition. JPEN J Parenter Enteral Nutr. 2011;35(2):209-16.

Vivanti A, Ward N, Haines T. Nutritional status and associations with falls, balance, mobility and functionality during hospital readmission. J Nutr Health Aging. 2011;15(5):388-91.

Nutritional interventions and their impacts

Bandayrel K, Wong S. Systematic literature review of randomized control trials assessing the effectiveness of nutrition interventions in community-dwelling older adults. J Nutr Educ Behav. 2011;43(4):251-62.

Burke L, Lee AH, Jancey J, et al. Physical activity and nutrition behavioral outcomes of a home-based intervention program for seniors: a randomized controlled trial. Int J Behav Nutr Phys Act. 2013;10:14.

Cawood AL, Elia M, Stratton EJ. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Res Rev. 2012;11(2):278-96.

Gariballa S, Forster S, Walters S, Powers H. A randomized, double-blind, placebo-controlled trial of nutritional supplementation during acute illness. Am J Med. 2006;119(8):693-9.

Kruizenga HM, Van Tulder MW, Seidell JC, et al. Effectiveness and cost-effectiveness of early screening and treatment of malnourished patients. Am J Clin Nutr. 2005;82(5):1082-9.

Lammes E, Rydwik E, Akner G. Effects of nutritional intervention and physical training on energy intake, resting metabolic rate and body composition in frail elderly. A randomized, controlled pilot study. J Nutr Health Aging. 2012;16(2):162-7.

Lim SL, Lin X, Chan YH, et al. A pre-post evaluation of an ambulatory nutrition support service for malnourished patients post hospital discharge: a pilot study. Ann Acad Med Singapore. 2013;42(10):507-13.

Locher JL, Vickers KS, Buys DR, et al. A randomized controlled trial of a theoretically-based behavioral nutrition intervention for community elders: lessons learned from the Behavioral Nutrition Intervention for Community Elders Study. J Acad Nutr Diet. 2013;113(12):1675-82.

Malafarina V, Uriz-Otano F, Iniesta R, Gil-Guerrero L. Effectiveness of nutritional supplementation on muscle mass in treatment of sarcopenia in old age: a systematic review. J Am Med Dir Assoc. 2013;14(1):10-7.

Marshall S, Bauer J, Capra S, Isenring E. Are informal carers and community care workers effective in managing malnutrition in the older adult community? A systematic review of current evidence. J Nutr Health Aging. 2013;17(8):645-51.

Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev. 2009;(2):CD003288.

Neelemaat F, Bosmans JE, Thijs A, et al. Post-discharge nutritional support in malnourished elderly individuals improves functional limitations. J Am Med Dir Assoc. 2011;12(4):295-301.

Neelemaat F, Lips P, Bosmans JE, et al. Short-term oral nutritional intervention with protein and vitamin D decreases falls in malnourished older adults. J Am Geriatr Soc. 2012;60(4):691-9.

Norman K, Kirchner H, Freudenreich M, et al. Three month intervention with protein and energy rich supplements improve muscle function and quality of life in malnourished patients with non-neoplastic gastrointestinal disease — a randomized controlled trial. Clin Nutr. 2008;27(1):48-56.

Philipson TJ, Sniter JT, Lakdawalla DN, et al. Impact of oral nutrition supplementation on hospital outcomes. Am J Manag Care. 2013;19(2):121-8.

Roy MA, Payette H. Meals-on-wheels improves energy and nutrient intake in a frail free-living elderly population. J Nutr Health Aging. 2006;10(6):554-60.

Somanchi M, Tao X, Mullin GE. The facilitated early enteral and dietary management effectiveness trial in hospitalized patients with malnutrition. JPEN J Parenter Enteral Nutr. 2011;35(2):209-16.

Stratton RJ, Ek AC, Engfer M, et al. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Res Rev. 2005;4(3):422-50.

Stratton RJ, Green CT, Elia M. Disease-related Malnutrition: An Evidence Based Approach to Treatment. Wallingford, Oxon.: CABI Publishing; 2003.

Tappenden KA, Quatrara B, Parkhurst ML, et al. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. JPEN J Perenter Enteral Nutr. 2013;37(4):482-97.

Ukleja A, Freeman KL, Gilbert K, et al. Standards for nutrition support: adult hospitalized patients. Nutr Clin Pract. 2010;25(4):403-14.

Malnutrition and muscle depletion in cancer

Antoun S, Baracos VE, Birdsell L, et al. Low body mass index and sarcopenia associated with dose-limiting toxicity of sorafenib in patients with renal cell carcinoma. Ann Oncol. 2010;21(8):1594-8.

Baracos VE, Reiman T, Mourtzakis M, et al. Body composition in patients with non-small cell lung cancer: a contemporary view of cancer cachexia with the use of computed tomography image analysis. Am J Clin Nutr. 2010;91(4):1133S-1137S.

Baracos VE. Cancer-associated cachexia and underlying biological mechanisms. Annu Rev Nutr. 2006;26:435-61.

Fearon K, Strasser F, Anker SD, et al. Definition and classification of cancer cachexia: an international consensus. Lancet Oncol. 2011;12(5):489-95.

Lieffers JR, Bathe OF, Fassbender K, et al. Sarcopenia is associated with postoperative infection and delayed recovery from colorectal cancer resection surgery. Br J Cancer. 2012;107(6):931-6.

Martin L, Birdsell L, Macdonald N, et al. Cancer cachexia in the age of obesity: skeletal muscle depletion is a powerful prognostic factor, independent of body mass index. J Clin Oncol. 2013;31(12):1539-47.

Mourtzakis M, Bedbrook M. Muscle atrophy in cancer: a role for nutrition and exercise. Appl Physiol Nutr Metab. 2009;34(5):950-6.

Peng PD, van Vledder MG, Tsai S, et al. Sarcopenia negatively impacts short-term outcomes in patients undergoing hepatic resection for colorectal liver metastasis. HPB (Oxford). 2011;13(7):439-46.

Prado CM, Antoun S, Sawyer MB, Baracos VE. Two faces of drug therapy in cancer: drug-related lean tissue loss and its adverse consequences to survival and toxicity. Curr Opin Clin Nutr Metab Care. 2011;14(3):250-4.

Prado CM, Baracos VE, McCargar LJ, et al. Body composition as an independent determinant of 5-fluorouracil-based chemotherapy toxicity. Clin Cancer Res. 2007;13(11):3264-8.

Prado CM, Baracos VE, McCargar LJ, et al. Sarcopenia as a determinant of chemotherapy toxicity and time to tumor progression in metastatic breast cancer patients receiving capecitabine treatment. Clin Cancer Res. 2009;15(8):2920-6.

Prado CM, Birdsell LA, Baracos VE. The emerging role of computerized tomography in assessing cancer cachexia. Curr Opin Support Palliat Care. 2009;3(4):269-75.

Prado CM, Lieffers JR, McCargar LJ, et al. Prevalence and clinical implications of sarcopenic obesity in patients with solid tumors of the respiratory and gastrointestinal tracts: a population-based study. Lancet Oncol. 2008;9(7):629-35.

Prado CM, Lima IS, Baracos VE, et al. An exploratory study of body composition as a determinant of epirubicin pharmacokinetics and toxicity. Cancer Chemother Pharmacol. 2011;67(1):93-101.

Prado CM, Sawyer MB, Ghosh S, et al. Central tenet of cancer cachexia therapy: do patients with advanced cancer have exploitable anabolic potential? Am J Clin Nutr. 2013;98(4):1012-9.

Santarpia L, Contaldo F, Pasanisi F. Nutritional screening and early treatment of malnutrition in cancer patients. J Cachexia Sarcopenia Muscle. 2011;2(1):27-35.

Websites

The Alliance to Advance Patient Nutrition
The Alliance to Advance Patient Nutrition is an interdisciplinary consortium dedicated to championing effective patient nutrition practices. Launched in 2013, it is comprised of leaders from the Academy of Medical-Surgical Nurses, the Academy of Nutrition and Dietetics, the Society of Hospital Medicine, and Abbott Nutrition.

The Canadian Malnutrition Task Force
CMTF is a group of clinicians and investigators who are part of the Canadian Nutrition Society (CNS). The group aspires to create a knowledge base and close the gaps between research and practice in the prevention, detection, and treatment of malnutrition in Canadians throughout the continuum of care.

Fight Malnutrition: The Dutch Malnutrition Steering Group
Over the last five years, the combined Dutch efforts to fight malnutrition have led to gradually decreasing malnutrition prevalence in all health care settings in the Netherlands. The Fight Malnutrition website gives a short overview of the combined activities of the Dutch Malnutrition Steering Group (DMG), the Dutch Annual Measurement of Care Problems (LPZ), the Dutch Ministry of Health, and the Dutch Society for Clinical Nutrition and Metabolism (NESPEN).

UK National Institute for Health Care Excellence: Quality Standards, QS24
QS24 outlines quality standards for nutrition support in adults from the UK's National Institute for Health and Clinical Excellence.

Sponsors

Keynote Speaker:
Kelly Tappenden, University of Illinois

Malnutrition in the 21st century

Malnutrition can be broadly defined as an imbalance in energy, protein, or other nutrients that has an adverse effect on health. Although it is often associated with famine in regions beset by poverty, conflict, or natural disasters, malnutrition can occur in any individual of any age, weight, or income level and can be caused by inadequate diet, increased nutrient requirements, or difficulty absorbing or metabolizing nutrients from food.

Because of its multiplicity, malnutrition has long been difficult to define precisely. Keynote speaker Kelly Tappenden from the University of Illinois opened the conference by highlighting a recently published definition that recognizes the well-known, starvation-related form of malnutrition as well as two additional disease-related types: one associated with chronic diseases, such as cancer, and characterized by the presence of mild to moderate inflammation; the other related to acute diseases or injuries, such as infections or burns, and characterized by the presence of severe inflammation. Inflammation alters energy metabolism and nutrient requirements and may therefore influence the effectiveness of nutritional interventions.

Recognizing these different forms of malnutrition, the Academy of Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition developed a set of criteria for the diagnosis of malnutrition in adults in clinical settings. According to the guidelines, patients with two or more of the following characteristics might be malnourished: insufficient energy intake, weight loss, reduced muscle mass, loss of subcutaneous fat, fluid accumulation, and decreased handgrip strength.

One-quarter to one-half of hospitalized patients in the U.S. are malnourished upon admission, and 38% of patients who are well-nourished upon admission become malnourished during their hospital stay, according to a 2013 estimate. The occurrence of malnutrition in hospitals ranges from 20% to 50% worldwide. "These are very high numbers, indicating that the prevalence of malnutrition in our hospitals is much greater than many people realize," Tappenden said.

Several additional studies suggest that malnutrition can worsen health and clinical outcomes in hospitalized patients and increase health care costs as a result. Tappenden noted a 2013 study showing that loss of lean body mass can delay recovery from illness or injury and impede rehabilitation. She also presented data from several studies that have linked malnutrition in elderly hospitalized patients with reduced mobility as well as an increased risk for infection and other complications following surgery. In a 2013 study comparing malnourished and adequately nourished hospitalized patients in Australia and New Zealand (controlling for disease severity and other non-nutritional factors such as age, gender, disease type, and quality of life), malnourished patients had longer hospital stays, were readmitted to hospital more frequently, and were twice as likely to die while hospitalized. "These people were equally as sick as their non-malnourished counterparts," Tappenden noted, but they had poorer health outcomes.

These findings are supported by studies showing that nutritional interventions can improve health outcomes among malnourished hospitalized patients, resulting in fewer medical complications, fewer avoidable hospital readmissions, shorter hospital stays, lower health care costs, and increased handgrip strength, body weight, and muscle mass. Interventions include energy- or protein-enriched diets, nutrient supplements, and nutritional education and counseling.

However, malnutrition remains unrecognized and untreated in many hospitalized patients. Successful management of malnutrition in hospitals will require an interdisciplinary approach involving dietitians, nurses, physicians, and administrators. Tappenden is on the steering committee for the Alliance to Advance Patient Nutrition, established by the Academy of Medical-Surgical Nurses, the Academy of Nutrition and Dietetics, the Society of Hospital Medicine, and Abbott Nutrition. The alliance aims to increase awareness of malnutrition and recently issued a call to action encouraging hospitals to create an institutional culture that prioritizes nutrition across all stages of care.

Six key principles for advancing patient nutrition. (Image courtesy of Kelly Tappenden)

Tappenden concluded with data published in 2014 showing that the rate of malnutrition diagnoses among patients discharged from U.S. hospitals tripled from 1993 to 2010—to 3.2%. Although this trend is encouraging, because it indicates a heightened awareness of malnutrition, in 2010 the percentage of patients who had received a diagnosis of malnutrition was still very low. "That is a very big problem," Tappenden said. "If we have multiple surveys showing us that our malnutrition rate is anywhere between thirty to fifty percent, yet 3.2% of [patients] are actually diagnosed with malnutrition, there is much work for us to do—not only [to] improve patient outcomes but [to] decrease costs."

Speakers:
Leah Gramlich, University of Alberta, Canada
Lim Su Lin, National University Hospital, Singapore
Marian de van der Schueren, VU University Medical Center Amsterdam, Netherlands
Carla Prado, Florida State University

Highlights

• Nutritional care should be integrated into hospital protocols through mandatory malnutrition screening for patients and education about malnutrition care for providers.
• Clinical questionnaires and rating scales used to screen for malnutrition must be validated.
• An initiative in the Netherlands to improve nutritional screening and intervention has reduced the prevalence of malnutrition in all health care settings.
• Malnutrition and loss of muscle mass are common in cancer patients and can impact patient outcomes.

Malnutrition in Canadian hospitals

Leah Gramlich from the University of Alberta presented a study on malnutrition in Canadian hospitals. Initiated in 2010 and spearheaded by the Canadian Malnutrition Task Force (CMTF), it assessed malnutrition during and after hospitalization in more than 1000 patients with an average age of 66. Forty five percent of patients were malnourished upon admission, and three-quarters of those patients had elevated inflammatory markers associated with chronic disease-related malnutrition.

Malnourished patients were six times more likely to die and 1.6 times more likely to be readmitted compared to well-nourished patients. Hospital stays were shorter for well-nourished patients and those who ate more than half of the food offered during the first week of hospitalization. The majority of participants reported satisfaction with hospital food, but some had difficulties opening food packages, reaching meals, and getting into a suitable position for eating.

Surveys of doctors and nurses revealed discrepancies in their knowledge of nutrition, in the perceived importance of malnutrition, and in current practices. Most physicians said patients should be assessed for malnutrition at admission, yet only one-third of doctors reported performing such assessments and only 30% had protocols available to identify malnutrition. In contrast, most nurses said malnutrition is not a problem. As Gramlich pointed out, the "perception and knowledge in nursing [is] different from what we see among physicians."

Her team identified priorities for improving nutritional care in Canadian hospitals, including mandatory malnutrition screening upon admission; education for administrators and health care providers; and interventions such as patient-focused mealtimes, provision of quality food with adequate nutrients, care delivered by multidisciplinary teams, and therapies such as oral nutritional supplements and feeding tubes.

Gramlich reported that the CMTF study empowered her to advance a malnutrition agenda in her own province of Alberta, especially because it included local patients. "It was important and relevant to have local data that could mobilize our own troops," she concluded.

Hospital nutritional care process. (Image courtesy of Leah Gramlich)

Clinical and economic outcomes in Singapore

Research demonstrates a link between malnutrition and adverse clinical outcomes, but few studies have controlled for the confounding effects of disease. Lim Su Lin, a clinical dietitian at the National University Hospital in Singapore, shared results from a study at her hospital, where malnutrition affects 30% of patients. After controlling for the potentially confounding effects of underlying illness by comparing patients with related diagnoses, the study found that malnourished patients had longer hospital stays, were more likely to be readmitted after discharge, incurred higher costs, and had a higher risk of death compared to well-nourished patients. "This study demonstrates that the adverse outcomes of malnutrition are not just the consequence of the underlying disease process itself," she said.

Lim also shared strategies the hospital has adopted to manage malnutrition, such as screening within 24 hours of admission, assessment of malnourished or at-risk patients, nutritional interventions, and patient follow-up after discharge to reassess the nutritional care plan and monitor responses to treatment.

Screening tools have been devised to diagnose malnutrition, including clinical questionnaires and rating scales that assess a patient's height, weight, and history of weight loss. Lim emphasized that it is important to use a screening tool that has been validated as sensitive and specific for identifying malnutrition; studies show that commonly used screening tools, such as the Malnutrition Universal Screening Tool (MUST) and the Nutritional Risk Screening 2002 (NRS-2002), are used incorrectly 30%–97% of the time.

In her hospital, Lim discovered in 2008 that roughly 33% of nutritional screening tests were incomplete or had errors, and 10% of patients found to be at risk of malnutrition were not referred to dietitians. These problems stemmed from lack of awareness among nurses of screening mistakes and a lengthy dietitian referral time. Interventions have since improved compliance to nutritional screening. A feedback system that informs nurses of screening errors reduced error rates from 33% in 2008 to 5% in 2013; and a new procedure empowering nurses to refer patients directly to dietitians, skipping the intermediary doctor referral, shortened the average referral time from 4 days to 0.3 days.

The hospital also developed a program to continue to monitor malnourished patients after discharge. It involves regular telephone calls, outpatient appointments, and home visits, and has led to measurable improvements in nutritional status, weight, strength, and quality of life among patients.

Malnutrition screening and patient outcomes in the Netherlands

In the past decade, malnutrition in the Netherlands has fallen from approximately 30% across all health care settings to 17% in home care settings and 22% in hospital care settings. Marian de van der Schueren from the VU University Medical Center in Amsterdam described the strategies used to achieve this outcome. She is a member of the Dutch Malnutrition Steering Group, which collaborates with the Dutch Annual Measurement of Care Problems (LPZ), the Dutch Ministry of Health, and the Dutch Society for Clinical Nutrition and Metabolism to collect data on the prevalence of malnutrition. The Dutch have implemented a malnutrition screening and treatment program in all health care settings, based primarily on the Short Nutritional Assessment Questionnaire (SNAQ) screening tools, which are quick and easy to use and tied to a treatment plan.

The Dutch approach to fighting malnutrition. (Image courtesy of Marian de van der Schueren)

In 2012, more than 80% of patients were screened for malnutrition at hospital admission; this success can partly be attributed to the Dutch Ministry of Health mandate, implemented in 2007, requiring all hospitals to collect and report data about malnutrition screening and treatment. These data are part of a set of performance indicators that all hospitals in the Netherlands are required to report annually as a measure of hospital quality. As of 2013, hospitals must also report on malnutrition screening for outpatients.

De van der Schueren noted that the steering group has performed studies to validate the screening tools and to investigate the cost-effectiveness of screening and treatment in hospitals. Nutritional interventions reduced the length of hospital stays for malnourished patients by 3.5 days in 2005, and although the interventions required an investment of 76 euros per day saved, the steering group concluded that implementation would save money, based on the 400 euro per day cost of hospitalization. Data such as these helped to convince the Dutch Ministry of Health to partner in the effort to tackle malnutrition.

The steering group has implemented its nutritional screening strategy across clinical care settings in the Netherlands, including hospitals, nursing homes, home care settings, general practice, rehabilitation clinics, and most recently, hospital outpatient clinics. "We're well aware that malnutrition does not start in hospital," de van der Schueren said. "It starts at home, and it needs to be solved after discharge." She emphasized that one of the strengths of the strategy is its multidisciplinary approach at each institution. The group has also made information about malnutrition available to the public online and developed downloadable screening tools. "We want to share our knowledge and experience across the world," she concluded.

Malnutrition and cancer treatment

Malnutrition affects 15%–80% of cancer patients. Loss of appetite and abnormal metabolism are common, and in some patients malnutrition can progress to cancer-associated cachexia, which is characterized by skeletal muscle depletion and severe weight loss. But these conditions can be difficult to diagnose, explained Carla Prado from Florida State University. Furthermore, although body weight and body mass index (BMI, based on height and weight measurements) have long been important in diagnosis, these measures do not provide information about the type of body mass—lean or adipose tissue—that is lost, which is critical to clinical outcomes and survival. To assess body composition, Prado and other researchers have turned to techniques such as computerized tomography (CT) cross-sectional images of the lower vertebrae that show the proportions of adipose and muscle tissues throughout the body.

Prado and others have found that muscle and adipose tissue composition can vary widely in cancer patients, regardless of body weight or BMI. Studies also suggest that severe muscle depletion is associated with an increased incidence of toxic side effects of chemotherapy, major complications following surgery, longer hospital stays, and lower rates of survival.

Interventions that slow or reverse muscle loss in cancer patients might improve patient outcomes and reduce the need for health care. To determine whether cancer patients have the ability to build muscle, Prado and colleagues examined the progression of tissue loss in late-stage disease. As expected, most patients progressively lost both muscle and adipose tissue in the final nine months of life. But up until the final three months of life some patients gained muscle tissue, suggesting an "anabolic window" when some patients may be able to add muscle. Therefore, therapies that promote muscle accumulation "should be diverted from patients in the terminal stage and applied during parts of the disease course when the window to anabolism is open," Prado concluded.

Speakers:
Tomas Philipson, University of Chicago
Marinos Elia, University of Southampton, UK
Hélène Payette, Université de Sherbrooke, Canada
Michael Johnson, Bayada Home Health Care

Highlights

• Oral nutritional supplements may shorten hospital stays, prevent readmissions, and reduce the cost of care among malnourished adults.
• Standardized nutritional screening, assessment, and treatment in all health care settings will require substantial financial investment, but such interventions are likely to reduce health care costs in the long term.
• Nutritional interventions for elderly adults living in community settings must target the causes and consequences of malnutrition.
• Nutritional screening, education, and treatment may prevent hospital readmission among individuals receiving home health care services.

Oral nutritional supplements, hospital costs, and patient outcomes

Recent randomized controlled clinical trials (RCTs) suggest that oral nutritional supplements (ONS) can reduce adverse outcomes associated with malnutrition in hospitalized patients. RCTs are considered the gold standard for studying the effectiveness of medical interventions; however, these trials have several important limitations in the context of nutrition, including small patient populations, short-term outcomes monitoring, and study environments that do not mimic real-world conditions. These limitations can lead to artificially high levels of adherence to the therapy under investigation.

As an alternative, Tomas Philipson from the University of Chicago investigated the effects of ONS on patient outcomes in a real-world setting using a natural experiment model, in which individuals receive a treatment or not based on a naturally occurring, chance event. The study included 700 000 hospitalized adults in the U.S. and evaluated their length of hospital stay, probability of hospital readmission within 30 days of discharge, and hospitalization costs. To minimize bias due to confounding variables, the study controlled for differences in observable characteristics, including age, gender, and disease status. It then compared pairs of patients who differed only in the use of ONS, and matched pairs when this difference could be ascribed to the differing propensities of their hospitals to prescribe ONS.

ONS use shortened the length of hospital stays by about 2.3 days, or 21%, and reduced the likelihood of readmission by nearly 7%. It also reduced costs per hospitalization by more than $4700. In fact, the analysis suggested that every dollar spent on ONS saved $52 in hospital costs. "That's almost unheard of returns on investment in health care," Philipson noted.

Cost savings and nutritional interventions

Marinos Elia from the University of Southampton continued the discussion of the economic outcomes of interventions for malnutrition, reporting on a study in the UK's National Health Service (NHS). In 2012, the UK National Institute for Health and Care Excellence (NICE)—a health authority that formulates standards and guidelines for health care practices in hospital, community, and care home settings—released updated guidelines on caring for malnourished adults, calling for the expansion of systematic screening, assessment, and treatment of malnourished patients in all health care settings.

An analysis comparing the cost of care using either existing practices or the new guidelines found that substantial investment would be required to expand nutritional care; however, it also found that the changes would result in lower rates of heath care use, saving £72 000 (about $113 800 in 2012 currency) per 100 000 people in the general population. Elia noted that these net savings rank third among the costs savings associated with NICE guidelines and standards in England.

However, Elia pointed to several limitations of the model used in the NICE analysis. Although it purported to examine the impact of the NICE guidelines on nutritional support in adults, the model incorporated data derived from children. In addition, it did not account for uncertainties about what proportion of the malnourished population should be treated, and some potential cost savings were not explored. In response, Elia and his colleagues conducted an independent economic analysis of nutritional support interventions, devising a new model that accounts for some of the uncertainties. Their analysis revealed higher net savings than were reported by NICE, resulting in large part from an expansion in the proportion of patients treated for malnutrition.

Cost impact analysis of implementing the NICE guidelines for nutritional care. (Image courtesy of Marinos Elia)

By further varying the parameters of their model, Elia's team demonstrated a growth in net cost savings with increasing rates of hospital admission and malnutrition prevalence. Shorter nutrition screenings also yielded substantial cost benefits. The largest net savings arose from increased use of oral nutritional supplementation (which is known to shorten hospital stays). Elia concluded by noting that the economic models could be strengthened by studies investigating the impact of ONS or other interventions, such as changes in diet, on the length of hospital stays and on health care use in malnourished patients.

Malnutrition in older adults living in community settings

Studies report that 20%–30% of elderly people who reside in community settings have a moderate risk for malnutrition. Older adults are particularly vulnerable to malnutrition: age-related changes in health, physical fitness, and sense of smell and/or taste can influence dietary needs and may limit their ability to consume a nutritious diet. Inadequate food or nutrient consumption can rapidly lead to fatigue, reduced mobility, decreased resistance to stress and infections, muscle loss, and other adverse health outcomes. "This is a vicious cycle that is put in place very easily and very rapidly in older people," said Hélène Payette from the University of Sherbrooke. Therefore, nutritional interventions in this community will require a multifaceted approach that targets the causes and consequences of malnutrition.

Payette reviewed the evidence for several nutritional interventions aimed at treating malnutrition or preventing the deterioration of nutritional status among the free-living elderly population. A 2011 systematic review in this population suggested that nutritional counseling and education can increase intake of healthy foods and that ONS can improve serum levels of specific nutrients. But it is unclear whether these interventions can improve functional outcomes, such as cognition or muscle strength, because the available studies provide inconclusive or contradictory results.

Payette noted that it is difficult to demonstrate the effectiveness of nutritional interventions in such a heterogeneous population, which includes everyone from fit and active octogenarians to frail individuals who require regular assistance. She suggested that future studies should more carefully select study subjects and outcome measures; increase the duration and intensity of the intervention being tested; and use personalized approaches, such as combinations of nutritional and exercise therapies.

Malnutrition in older adults receiving home care

Malnutrition affects 13%–21% of patients who receive home health care services, and about 50% are thought to be at risk. Nearly a quarter of home care patients have age-related muscle loss, or sarcopenia, which can compromise strength, immunity, healing, and digestion, and can lead to difficulties performing everyday activities, such as eating, using the bathroom, and walking around. Some evidence suggests that ONS may help rebuild lost muscle tissue, improve strength, and enhance quality of life.

Michael Johnson and his colleagues at Bayada Home Health Care are investigating whether a combination of screening, education, and access to ONS could help prevent hospitalization among home care clients. Conducted in collaboration with Abbott Nutrition, the initiative began in 2011 by screening nearly 1300 clients at seven Bayada offices around the country and providing free samples of ONS along with educational literature about the benefits of the supplement for those found to be at risk.

About one in four clients had a moderate to high risk of malnutrition, and of those clients 77% received nutritional education and 60% received ONS samples. At offices participating in the intervention, only 8.7% of clients were hospitalized in 2011, compared to 24% of the company's clients nationwide.

The program's initial success prompted Bayada to mandate nutritional screening and assessment. As of 2013, more than 21 000 clients had been screened, with more than 70% found to be at risk for malnutrition. "This really opened our eyes," Johnson said. "It confirmed to us that taking the time and effort to do this was worthwhile."

Johnson concluded by emphasizing the importance of malnutrition screening and intervention as part of a holistic approach to improving health and health care and reducing costs. He noted that dietitians and other nutrition advocates are integral to community-based health care and argued that providers should work together to improve population health.

Moderator:
Kelly Tappenden, University of Illinois

Highlights

• It is important to coordinate care to maintain nutritional support for individuals as they transition from one health care setting to another.
• Systems should be implemented to ensure that clinicians routinely carry out nutritional screening and intervention.
• Inflammation is important in disease-related malnutrition, but it is unclear how or whether inflammation affects malnutrition treatment.

Panel discussion

In the panel discussion, moderated by Kelly Tappenden, the speakers discussed strategies to maintain nutritional care when patients transition from one health care setting to another. Lim mentioned a program at the National University Hospital in Singapore called Hospital to Home, which includes nutritional support for individuals who have been readmitted more than three times in one year, as well as support from dietitians who call and visit patients at home. The hospital also has a documentation and auditing system for use by dietitians when patients transition between the hospital and a nursing home or home care. Johnson reported that Bayada also works with clinicians to ensure that nutritional supplements, education, exercises, and other information are transferred home with patients. One potential barrier to coordinated care, according to Elia, is the fragmented approaches to treatment and communication used by health care providers.

The discussion also touched on nutritional knowledge deficits among health care providers, and several speakers acknowledged the need to educate clinicians about malnutrition diagnosis and the complexities of nutritional adequacy. Johnson agreed that education is important but suggested we also need structured systems that remind clinicians to routinely perform nutritional screening. Elia concurred, noting, "If you have an enabling environment that demands that you put what you've learned into practice, then it's much more likely to be successful."

Because inflammation is thought to be an important component of disease-related malnutrition, the discussion turned briefly to potential therapeutic uses of nutrients that influence inflammation. Gramlich mentioned that nutrients with anti-inflammatory properties include omega-3 fatty acids, antioxidants, and vitamin D, but said more research is needed on the role of inflammation in the development and treatment of malnutrition. Prado noted that omega-3 fatty acids may reduce inflammation in cancer patients and help build skeletal muscle mass.

On behalf of Jamie Partridge, Rob Miller of Abbott Nutrition closed the meeting by reviewing its three key messages. First, health care providers need to focus on patients and concern themselves with patient care in all settings. Second, it is important to disseminate information about nutritional care throughout institutions. Finally, we need to understand who the stakeholders are—including health care providers, patients, patients' families, payers, and policy makers. "Know who they are and speak their language," Miller said, "because then you recruit them into helping you."

Why is malnutrition underappreciated, and why does it continue to go undiagnosed and untreated?

Why do patients become malnourished while they are hospitalized?

What are the best approaches for tackling malnutrition in each health care setting?

When are interventions for malnutrition best targeted? Should we focus on hospitalized patients or target individuals before admission or after discharge?

What proportion of malnourished patients should receive treatment?

Which patients should receive oral nutritional therapies, and which should receive tube feeding?

What are the potential cost savings associated with enteral tube feeding and parenteral feeding?

What effects do dietary counseling and diet have on health care use in malnourished patients?

How can we effectively and efficiently target nutritional interventions?

How can we determine which elements of an intervention program are successful?

How should we design studies to investigate nutritional interventions in community-living elderly adults who are malnourished or at risk of malnutrition?

How can we build political awareness of the problem of malnutrition?

How can researchers obtain funding to study malnutrition?

What are the economic costs of malnutrition and nutritional interventions, and what are the economic returns of successful interventions?

How do energy and nutritional requirements vary with differences in body composition?

Can severely muscle-depleted cancer patients add muscle tissue, and when should nutritional interventions to slow or stop muscle wasting be applied?