One Third of Hospital Inpatients Underfed

Troy Brown, RN

February 15, 2019

One in three hospitalized patients eat a quarter of their meals or less, putting them at risk for malnutrition and jeopardizing their recovery, a new study shows. Patients who eat none of their food despite being allowed to eat had a sixfold higher risk for in-hospital death compared with those who ate some of their food.

"The association with mortality was pretty striking...this is not necessarily causative — it's not a randomized trial...but the association is striking and lets us know that we've got to take special care of these patients and lets us know that they're at risk for death," Andrew Dunn, MD, chief of the Division of Hospital Medicine, Mt. Sinai Health System, New York City, and chair of the American College of Physicians' board of regents, told Medscape Medical News.

"Even if it's not causative, it is clearly a marker for mortality," said Dunn, who was not involved in the study.

The study, by Abby C. Sauer, MPH, RD, Abbott Nutrition, Columbus, Ohio, and colleagues, was published online January 22 in the Journal of Parenteral and Enteral Nutrition.

To assess inpatients' meal consumption and its effects, Sauer and colleagues analyzed data from the nutritionDay US database from 2009 through 2015. nutritionDay is an organization that leads a "1-day cross-sectional audit [of hospitals and nursing homes around the world] to collect their units' anonymous data on nutrition care processes and patients' anonymous data on their food intake and well-being," the authors explain. The program's goal is to combat malnutrition in healthcare facilities worldwide.

On nutritionDay (the day on which the audit occurred), patients completed the Malnutrition Screening Tool (MST), a validated predictor of the risk for malnutrition for hospitalized patients, regarding what was eaten for lunch or dinner. Scores of 2 or higher indicated malnutrition risk. The tool provided choices for indicating the amount eaten, which were expressed in words or by use of a plate symbol.

"[M]alnutrition in hospitalized individuals continues to be a concern. While the causes are multifactorial, including a combination of chronic or acute illness and socioeconomic factors, unaddressed prolonged inadequate food intakes in hospitalized people significantly contribute to negative outcomes, including increased length of stay, readmission, complications, and mortality," Cordialis Msora-Kasago, MA, RD, who is founder of the African Pot Nutrition and media spokesperson for the Academy of Nutrition and Dietetics, told Medscape Medical News. Msora-Kasago was not involved in the study.

Room for Improvement

Sauer and colleagues calculated MST scores for 9489 patients (95% of the total patient sample).

Of those, 51% ate half of their meal or less. Such consumption was associated with a trend for increased risk for in-hospital mortality (hazard ratio [HR], 1.27; 95% confidence interval [CI], 0.62 – 2.59; P = .5100), after adjustment for mobility, any intensive care unit stay, the lung as affected organ, having cancer, previously undergoing surgery, age, and length of stay before nutritionDay.

For those patients who ate a quarter of their meal or less despite being allowed to eat (25.2%), the HR for hospital mortality was 3.24 (95% CI, 1.73 – 6.07; P < .001).

Patients who ate none of their meal despite being allowed to eat (7.1%) were almost six times as likely to experience in-hospital mortality as those who ate all their food (HR, 5.99; 95% CI, 3.03 – 11.84; P = .0000). "This result appears stronger in the US population than the European population, where the corresponding mortality HR is 2.71 (CI, 1.88 – 3.91)," the researchers note.

A fairly high percentage of patients who participated in nutritionDay in the United States received a special diet, yet few received protein/energy supplements (PES), either alone or together with hospital food or a specially ordered diet.

Among patients eating nothing, 5.7% were given hospital food and PES, 5.3% were given a special diet and PES, and only 0.3% were given PES alone.

The patients who were not allowed to eat constituted the highest percentage of patients who received artificial nutrition (ie, enteral, parenteral, or combined enteral and parenteral nutrition).

Almost one third of patients (32.7%) were at risk for malnutrition, as evidenced by an MST score of at least 2. The highest prevalence of malnutrition was seen in infectious disease wards (46.1%) and long-term care wards (45.8%), whereas the lowest prevalence was found in orthopedic surgery wards (23.7%).

Team Approach, Innovative Food Delivery Systems May Help

For patients who have other urgent problems, nutrition may fly under the radar, Dunn said. "We often partner with our nutritionists to better identify patients who are malnourished or at risk for malnutrition. This is a call to pay close attention to their evaluation," Dunn added.

"Identification and treatment of malnutrition starts upon admission and continues throughout the course of the hospital stay," Msora-Kasago explained. "Through the use of validated tools such as the MST, at-risk individuals should be identified early and the registered dietitian nutritionist [RDN] consulted to conduct a comprehensive assessment, which may include a nutrition-focused physical examination to identify the presence and/or severity of malnutrition, as soon as possible after admission.

"Upon assessment, the RDN will develop an individualized nutrition plan of care aimed on maximizing nutrition through food, protein energy supplements, nutrition support, or a combination of feeding modalities," she continued.

Healthcare providers can do a number of things to improve their patients' nutrition. Opening a milk or juice container or helping a patient set up their food can help preserve their energy for eating.

"When you have someone you think is at risk...you need to make sure that you're doing whatever you can do to get them eating, and this is treating the underlying condition. It's also working with the patient for a diet that they will find the most palatable," Dunn explained. Sometimes special diets, such as low-potassium diets, can be adjusted to be more enjoyable for the patient.

Hospitals are changing the ways they deliver food to make them more user-friendly. "They are implementing innovative food-delivery systems, such as the 'room service' model, which allows patients to receive meals within 30 to 45 minutes of ordering. RDNs are collaborating with chefs to boost the nutritional content of foods served so that every meal consumed is the most nutrient dense," Msora-Kasago observed.

Teaming up with a dietary expert can help ensure patients have what they need to eat and drink in a way that they can consume it easily.

"Nutrition should be implemented as soon as the patient is stable, and interruptions through prolonged or unwarranted NPO [nil per os] orders kept to a minimum," Msora-Kasago said. "Clinicians should medically manage pain and gastrointestinal symptoms that impact potential to eat, such as nausea, vomiting, diarrhea, and dysgeusia. When appropriate, an appetite stimulant should be provided," Msora-Kasago continued.

"These results highlight the ongoing issues of poor oral intake and malnutrition risk in the hospital setting and the need for optimal nutrition care to improve outcomes, including mortality," the authors conclude.

Abbott Nutrition funded the study. Sauer and Goates are employees and stockholders of Abbott Nutrition. One author reports being a member on the advisory committees or review panels at Nestlé Health Science, Nutricia, and Smartfish and participating in speaking and teaching at Baxter and Abbott Nutrition. One author reports being a member on the advisory committees or review panels at Nestlé Health Science and Fresenius and participating in speaking and teaching at Nestlé Health Science, Fresenius, and Baxter. One author reports being a member of ThriveRx nutrition advisory board, a speaker for Baxter international conference for advancing nutrition, and a member of Pfizer's malnutrition advisory board. The remaining authors have disclosed no relevant financial relationships. Dunn and Msora-Kasago have disclosed no relevant financial relationships.

JPEN. Published online January 22, 2019. Abstract

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