MALNUTRITION
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Prevalence of malnutrition in general medical patients.
Bistrian BR, Blackburn GL, Vitale J, Cochran D, Naylor J.
JAMA 1976 Apr 12;235(15):1567-70.This study shows that in 1976, the prevalence of malnutrition in hospitalized patients of the general wards of an urban teaching hospital, was 44% or greater. Thirty-four percent of patients had levels of lymphopenia likely to be associated with reduced cellular immunity.
Incidence and recognition of malnutrition in hospital.
McWhirter JP, Pennington CR.
BMJ 1994 Apr 9;308(6934):945-8.This 1994 study shows that 40% of patients admitted to an acute teaching hospital were malnourished, and in 78% of them nutritional status further deteriorated during hospital stay. In addition, two thirds of all patients lost weight during hospital stay.
In 1995 a correlation between malnutrition and poor outcome in critically ill patients still exists.
Giner M, Laviano A, Meguid MM, Gleason JR.
Nutrition 1996 Jan;12(1):23-9.This study shows that 43% of 129 patients admitted to the intensive care unit of a hospital, were malnourished. Length of hospital stay, complications and number of deaths were greater in malnourished compared to well-nourished patients, and malnourished patients with less severe illnesses had worse clinical outcomes than sicker, well-nourished patients. The study also showed that malnutrition in patients who underwent surgery developed mainly during their preoperative stay in general medicine wards.
In-hospital malnutrition: indications of postoperative evolution.
FarrŽe Rovira R, Frasquet Pons I, Ibor Pica JF.
Nutr Hosp, 13(3):130-7 1998 May-Jun.This study shows that, after admission to the hospital, the number of patients with below- normal levels of serum albumin doubles, and the number of those with below-normal levels of body weight and body mass index, triplicates. Nutritional status worsens as length of hospital stay increases.
Protein-energy undernutrition among elderly hospitalized patients: a prospective study.
Sullivan DH, Sun S, Walls RC.
JAMA 1999 Jun 2;281(21):2013-9.This study evaluated whether hospitalized patients receive adequate nutritional intake during hospital stay and whether eventual nutritional deficits translate in increased mortality rates. The results of the study, conducted on 497 elderly patients during a 4-year period, showed that 21% of patients consumed less than 50% of their estimated maintenance energy requirements, and this was partly due to the fact that patients were frequently ordered to eat nothing by mouth but did not receive nutritional supplementation by other routes. Patients with low energy intake were 8 times more likely to die while being in the hospital and 3 times more likely to die within 90 days, compared to patients with normal energy intake. These findings indicate that during their hospital stay, elderly patients often receive largely inadequate nutrient intake -a practice that seems associated with a significant negative impact on their overall survival.
Malnutrition and clinical outcomes: the case for medical nutrition therapy.
Gallagher-Allred CR, Voss AC, Finn SC, McCamish MA.
J Am Diet Assoc 1996 Apr;96(4):361-6, 369.This article reports on the results of several studies conducted on over 1,327 patients, indicating that 40% to 55% of hospitalized patients are either malnourished or at risk for malnutrition, and 12% of them are severely malnourished. Postoperative complications and mortality occur 2-3 times more often, and hospital costs are 35% to 75% higher, in malnourished compared to well-nourished patients.
Prevalence of malnutrition in nonsurgical hospitalized patients and its association with disease complications.
Naber TH, et al.
Am J Clin Nutr 1997 Nov;66(5):1232-9.The results of this study, conducted on 155 patients admitted to the internal medicine ward of a hospital, show that the prevalence of malnutrition in this cohort, according to the Maastricht Index (which evaluates ideal weight together with prealbumin, albumin, and lymphocytes levels) was 62%. Rates of complications were 3 times higher in malnourished versus well-nourished patients.
The relationship between clinical assessments of nutritional status and adverse outcomes in older hospitalized medical patients.
Covinsky KE, Martin GE, Beyth RJ, Justice AC, Sehgal AR, Landefeld CS.
J Am Geriatr Soc 1999 May;47(5):532-8.This study evaluated the nutritional status of 369 patients aged 70 years or more admitted to a general ward of a tertiary care hospital, and found that 60% of them were well nourished, 25% were moderately malnourished, and 16% were severely malnourished. After controlling for severity of disease, presence of coexisting diseases, and functional status on admission, the researchers showed that severely malnourished patients were 2.8 times more likely to die and 3.2 times more likely to be admitted to a nursing home within a year of discharge, compared to well nourished patients.
Protein-energy undernutrition and the risk of mortality within six years of hospital discharge.
Sullivan DH, Walls RC.
J Am Coll Nutr 1998 Dec;17(6):571-8.The results of this study show that protein-energy malnutrition is the single strongest predictor of long-term mortality in elderly individuals discharged from the hospital. In the study, 322 elderly patients were followed for 6 years after being discharged from the hospital to evaluate the effects that nutritional status had on their long-term survival. Patients were defined as being at risk for malnutrition if they had serum albumin levels below 3.0 g/dL or body mass index below 19. Being at risk for malnutrition was the strongest predictor of death in the following 6 years. A diagnosis of congestive heart failure, being discharged to a health care facility, age and marital status were not as strongly associated with mortality as protein-energy malnutrition.
Economic impact of malnutrition: a model system for hospitalized patients.
Reilly JJ Jr, Hull SF, Albert N, Waller A, Bringardener S.
JPEN J Parenter Enteral Nutr 1988 Jul-Aug;12(4):371-6.This retrospective study, conducted on 771 individuals admitted to two acute care hospitals, shows that the rate of likelihood of malnutrition was 59% in medical wards and 48% in surgical wards. Rates of minor and major complications were 2.6 and 3.4 times higher, respectively, in patients with likelihood of malnutrition compared to those without it. Likelihood of malnutrition was associated with a 3.8-fold increased risk of death. Suspected malnutrition was also associated with increased length of hospital stay and increased excess average costs of $1738 to $3557 per patient. The impact of a nutritional intervention program could not be assessed, because too few patients had received it.
High-quality nutritional interventions reduce costs.
Smith PE, Smith AE.
Healthc Financ Manage 1997 Aug;51(8):66-9.This article reports on the results of a survey of 19 hospitals indicating that length of hospital stay decreases by approximately 2 days in patients who receive optimal nutritional care. The survey also revealed that only 7.5% of patients at risk for malnutrition receive optimal nutritional intervention, and this omission results in an increased cost of $1.064 per patient at risk of malnutrition.
Relationship of nutritional status to length of stay, hospital costs, and discharge status of patients hospitalized in the medicine service.
Chima CS, Barco K, Dewitt ML, Maeda M, Teran JC, Mullen KD.
J Am Diet Assoc 1997 Sep;97(9):975-8.This study, conducted on all 173 individuals admitted to three medicine units during a 1-month period, shows that those who, upon admission, were classified as being at risk for malnutrition, had, compared to patients not a risk of malnutrition, higher hospital length of stay (6 days vs. 4 days), higher hospitalization costs ($6,196 vs. $4,563), and higher home health care needs, even if 91% of them received nutrition intervention during hospitalization.
The five-year evolution of a malnutrition treatment program in a community hospital.
Brugler L, DiPrinzio MJ, Bernstein L.
Jt Comm J Qual Improv 1999 Apr;25(4):191-206.This study shows that implementation of a malnutrition treatment program in a 395-bed community hospital in Delaware, resulted in reduction of average patient length of stay from 10.8 to 8.2 days, in decrease of incidence of major complications from 75.3% to 17.5%, and in reduction of 30-day hospital re-admission rates from 16.5% to 7.15.
Effect of malnutrition after acute stroke on clinical outcome.
DŽavalos A, et al.
Stroke, 27(6):1028-32 1996 Jun.This study, conducted on a cohort of 104 patients with acute stroke, shows that the number of individuals with malnutrition increased from 16.3% at admission to 26.4% after a week in the hospital. Malnourished patients had increased incidence of infections and bedsores. In addition, patients with malnutrition after a week of hospitalization had a 3.5-fold increased risk of poor outcome, regardless of their age and nutritional status at admission.
Influence of nutritional status on clinical outcome after acute stroke.
Gariballa SE, Parker SG, Taub N, Castleden CM.
Am J Clin Nutr 1998 Aug;68(2):275-81.This study shows that the nutritional status of patients admitted to the hospital over a 15-month study period for acute stroke, deteriorated significantly during hospital stay. Malnutrition was significantly associated with increased risk of infections and poor functional outcome, and was a strong predictor of mortality in the 3 months after the stroke.
Clinical significance of preoperative nutritional status in 215 noncancer patients.
Warnold I, Lundholm K.
Ann Surg 1984 Mar;199(3):299-305.The results of this study, conducted on 215 patients hospitalized for surgery, show that those with low nutritional status had a two-fold increase in rates of post-operative complications and in length of hospital stay, compared to those with normal nutritional status. The difference in rate of complications was particularly evident for major complications, which occurred in 31% of undernourished patients, compared to 9% of well-nourished subjects.
Outcomes of undernutrition in patients in the community with cancer or cardiovascular disease.
Edington J, Winter PD, Coles SJ, Gale CR, Martyn CN.
Proc Nutr Soc 1999 Aug;58(3):655-61.The results of this study indicate that even low levels of malnutrition are associated with significantly increased rates of morbidity and mortality in individuals with cancer or cardiovascular diseases. In the study, conducted on 10,128 individuals aged 18 and older with a diagnosis of cancer or cardiovascular disease, those with body mass index (BMI) levels below 20 kg/m2 had higher rates of physician consultations and higher rates of death, compared to those with higher levels of BMI. Poor nutritional status was strongly associated with increased risk of hospitalization in patients with cardiovascular disease.
Impact of body mass index and albumin on morbidity and mortality after cardiac surgery.
Engelman DT, et al.
J Thorac Cardiovasc Surg 1999 Nov;118(5):866-73.The results of this study indicate that patients with albumin levels below 2.5 g/dL and body mass index below 20 kg/m2 undergoing cardiac bypass surgery have significantly higher rates of post-operative morbidity and mortality, compared to those with normal values of both parameters.
Nutritional status is a prognostic factor for survival in ALS patients.
Desport JC, Preux PM, Truong TC, Vallat JM, Sautereau D, Couratier P.
Neurology 1999 Sep 22;53(5):1059-63.The results of this study show that patients with amyotrophic lateral sclerosis (ALS) with malnutrition have a 7.7-fold increased risk of death, compared to well-nourished patients, independently of neurological scores and type of ALS. The authors recommend increased surveillance of nutritional status in patients with this disease.
The impact of nutritional status on the outcome of lung volume reduction surgery: a prospective study.
Mazolewski P, Turner JF, Baker M, Kurtz T, Little AG.
Chest 1999 Sep;116(3):693-6.The results of this study indicate that patients with end stage emphysema and with below-normal levels of body mass index (BMI) undergoing lung surgery have significantly increased post-operative morbidity and length of hospital stay, compared to patients with normal levels of BMI. This study shows that body mass index value is a good indicator of nutritional status and a simple way to screen individuals at risk of nutritional deficiencies. The authors suggest that correction of nutritional deficiencies may translate in lower rates of hospital morbidity, length of stay, and health care costs in this group of patients.
Malnutrition in childhood lymphoblastic leukemia: a predictor of early mortality during the induction-to-remission phase of the treatment.
Mejia-Arangure JM, et al.
Arch Med Res 1999 Mar-Apr;30(2):150-3.The results of this study show that malnourished children undergoing chemotherapy for acute lymphoblastic leukemia (ALL) have a 2.6-fold increased risk of death, compared to well-nourished children. The risk of mortality increases with increased severity of nutritional deficit.
Disability is associated with malnutrition in institutionalized elderly people.
The I.R.A. Study. Istituto di Riposo per Anziani.
Romagnoni F, et al.
Aging (Milano) 1999 Jun;11(3):194-9.The results of this study indicate that disability in elderly patients is strongly associated with the presence of anthropometric and plasma measurements indicative of malnutrition. This association exists independently of age, gender, and presence of coexisting illness or other confounding factors. The authors highlight the importance of correcting nutritional imbalances in the management of elderly disabled patients.
Body mass index and mortality among older people living in the community.
Landi F, et al.
J Am Geriatr Soc 1999 Sep;47(9):1072-6.The results of this study show that elderly individuals living in the community who have body mass index (BMI) levels below 22 Kg/m2 (a sign of malnutrition) have a 20% increased risk of being dependent in one or more Activities of Daily Living and a 15% increased risk of death, compared to individuals with normal BMI levels.
Following is a series of study showing the effects of nutritional supplementation on morbidity and mortality.
Dietary supplementation in elderly patients with fractured neck of the femur.
Delmi M, Rapin CH, Bengoa JM, Delmas PD, Vasey H, Bonjour JP.
Lancet 1990 Apr 28;335(8696):1013-6.The results of this study show that elderly patients hospitalized with a fracture of the neck of the femur who underwent nutritional supplementation had approximately half the rates of complications and death, compared to those who did not receive dietary supplementation. The study was conducted on 59 elderly patients who were randomly assigned to receive daily for an average of 32 days an oral nutritional supplement (27 patients), or no supplementation (32 patients). Most patients had nutritional deficiencies upon admission. Outcome was favorable in 56% of supplemented patients, compared to 13% of those not supplemented. In the supplemented group, 44% of patients experienced complications or death, compared to 87% of patients in the non-supplemented group. These differences persisted 6 months after the occurrence of the fracture. Average length of hospital stay was 24 days in the supplemented group, and 40 days in the non-supplemented group. These findings indicate that daily oral supplementation cuts length of hospital stay and rates of complications and death by half, in elderly patients with fractured neck of the femur.
Effect of vitamin and trace-element supplementation on immune responses and infection in elderly subjects.
Chandra RK.
Lancet 1992 Nov 7;340(8828):1124-7.The results of this study show that supplementation with modest physiological amounts of nutrients improves immune status and significantly reduces rates of infections in elderly individuals. The study was conducted on 96 healthy elderly subjects who were randomized to receive a nutritional supplement containing vitamins and trace elements or a placebo pill. After 12 months, immune function was improved, compared to baseline values, in individuals who had received nutritional supplementation, but not in those receiving placebo. In addition, those who received the supplement, spent considerable less time being ill from infectious diseases, compared to control subjects who received placebo (23 days versus 48 day per year). These findings indicate that a simple nutritional supplement is efficacious in improving immune status and significantly decreasing rates of infections in elderly individuals.
Vitamin C depletion and pressure sores in elderly patients with femoral neck fracture.
Goode HF, Burns E, Walker BE.
BMJ 1992 Oct 17;305(6859):925-7.The results of this study show that vitamin C concentration in elderly patients hospitalized with fractured neck of the femur who developed pressure ulcers is approximately half that of patients who did not develop this complication, indicating that vitamin C depletion may be an important factor in the etiology of pressure ulcers in the elderly.
Impact of trace elements and vitamin supplementation on immunity and infections in institutionalized elderly patients: a randomized controlled trial.
MIN. VIT. AOX. geriatric network.
Girodon F, et al.
Arch Intern Med 1999 Apr 12;159(7):748-54.The results of this double-blind, placebo-controlled study conducted on 725 institutionalized patients aged 65 and older, show that supplementation with zinc and selenium is associated with a significant reduction of the incidence of respiratory tract infections.
The clinical effects of vitamin C supplementation in elderly hospitalised patients with acute respiratory infections.
Hunt C, Chakravorty NK, Annan G, Habibzadeh N, Schorah CJ.
Int J Vitam Nutr Res 1994;64(3):212-9.The results of this randomized, double-blind, placebo controlled trial show that elderly patients admitted to the hospital for acute respiratory infections who receive daily supplementation of 200 mg of vitamin C, had significantly improved disease course, compared to those who received placebo. The positive effects of vitamin C supplementation were particularly evident in patients who were most severely ill, and who often had very low levels of the vitamin on admission.
Routine protein energy supplementation in adults: systematic review.
Potter, J et al.
BMJ 1998;317:495-501.This study reviewed 30 randomized trial conducted on 2,062 patients, evaluating the impact of routine oral and enteral nutritional supplementation on survival in adult hospitalized patients. Patients who received nutritional supplementation showed significant improvements in body weight and mid-arm muscle circumference, and had an overall 36% increased rate of survival, compared to untreated patients. These findings indicate that protein calorie supplementation improves nutritional status in adults and significantly lowers fatality rates.
Care of dying patients in hospital.
Mills M, Davies HT, Macrae WA.
BMJ 1994 Sep 3;309(6954):583-6.This study assessed the level of care received by dying patients in 13 wards of four large university hospitals in Scotland and concluded that patients basic needs before dying were left unmet: thirst remained unquenched, oral hygiene was poor, eating was not encouraged. Contact with patients by nurses and doctors was minimal and patient isolation increased as death advanced. Over half of the patients remained conscious until shortly before death.
