Nutritional Support Linked to Better Survival Among Inpatients

Veronica Hackethal, MD

November 20, 2019

Roughly one third of patients hospitalized on general medicine wards are malnourished, and they may reap clinically significant benefits from nutritional support, according to a systematic review and meta-analysis.

Among individuals who were malnourished or at risk for malnourishment, the odds of death were significantly lower for those who received nutritional support. Most of these individuals received intermittent high-protein feeds by mouth, rather than continuous feeding by tube or intravenous (IV) line, which is commonly used for patients in intensive care units (ICUs).

"This analysis supports the current practice guidelines issued by the European Society for Clinical Nutrition and Metabolism (ESPEN) and the American Society for Parenteral and Enteral Nutrition (ASPEN), advocating a proactive, screening-based approach for initiating nutritional support during the hospital stay of medical inpatients who are malnourished or at nutritional risk," write Filomena Gomes, PhD, of the New York Academy of Sciences, New York City, and colleagues.

"Malnutrition starts in the community (the patient is identified as being malnourished on admission to the hospital) and does not end at the hospital discharge; therefore, the causes of malnutrition in the community need to be explored, and nutritional support should be continued after hospital discharge," they add.

The research was published online November 20 in JAMA Network Open.

Until now, not much evidence has supported guidelines calling for nutritional support of hospitalized medical patients. At least two meta-analyses failed to find significant associations between nutritional support and improved outcomes. But those analyses included mostly small, poor-quality studies published before 2014. They also included ICU patients, whose nutritional needs may differ from those of general medical inpatients.

Since then, two large, high-quality, randomized controlled trials (EFFORT and NOURISH) have been published. The new meta-analysis includes data from five new trials, which nearly doubles the total number of patients in the analysis. The authors also limited the analysis to general medical ward inpatients.

They searched three databases for studies that compared the clinical impact of any kind of nutritional support delivered by mouth or through a tube to the stomach or small intestine (enteral feeds) with usual care. They excluded patients who received nutrition through an IV (parenteral feeds).

The analysis included 27 trials published in any language between 1982 and 2019. The studies included 6803 non–critically ill individuals who were malnourished or at risk for malnourishment while hospitalized on general medical wards. Of these, about half (n = 3067) were included in studies published between 2015 and 2019.

For inpatients who received nutritional support, rates of death were significantly lower (8.3%; 230/2758) compared with rates for those who received usual care (11%; 307/2787).

Nutritional support was also linked to 27% lower odds of death than usual care (odds ratio [OR], 0.73; P = .03).

Further analyses that were confined to trials published since 2015 showed an even greater impact for nutritional support. Risk for death was 53% lower with nutritional support compared with usual care for recent trials but was just 6% lower for trials published before 2015 (OR, 0.47, vs OR, 0.94).

The authors point out that a 2016 meta-analysis found a difference in mortality of 0.5% favoring nutritional support over usual care. But the absolute mortality benefit rose to 2.8% in the current analysis, which included recent research. That translates into a number needed to treat of 36 to prevent one death.

Nutritional support had a greater impact for those with established malnutrition, for whom the odds of death were 48% lower than for those who received usual care (OR, 0.52). Among those at risk for malnourishment, the risk for death was 15% lower than for those who received usual care (OR, 0.85).

Other benefits of nutritional support included a decrease in nonelective hospital readmissions (14.7% vs 18.0%; risk ratio, 0.76), higher calorie intake (mean difference, 365 kcal), higher protein intake (mean difference, 17.7 g), and a weight gain of approximately 1.6 pounds (0.73 kg).

Nutritional support had no significant impact on rates of infection (OR, 0.86), functional outcome (mean difference, 0.32), and length of hospital stay (mean difference, −0.24).

The authors note several limitations. The included studies varied in their type of nutritional support and design. Some were placebo-controlled, whereas others were not, which could have affected results.

These findings are "important" but may not apply to critically ill patients, Paul Marik, MD, of Eastern Virginia Medical School in Norfolk, writes in an invited commentary.

The findings "suggest that all hospital inpatients should undergo screening using a validated nutrition-screening tool. Those patients at nutritional risk should receive individualized nutritional support including the provision of a high-quality ONS [oral nutritional supplements]," he writes.

A number of recent high-quality trials have failed to support the benefits of early nutritional assistance in critically ill patients, who may actually experience harm from it, he writes. He notes that some studies have linked nutritional intake to reduced clearance of pathogens and damaged cells, which could harm patients with infections. Also, most ICU patients receive continuous nutrition via tubes or IV infusion, which is not how humans evolved to receive nutrition and could interfere with protein synthesis.

"The optimal 'whey' to feed critically ill patients in the ICU has yet to be determined; however, less may be more," he concludes.

The study was supported by grants from the Swiss National Science Foundation (SNSF) and the Forschungsrat of the Kantonsspital Aarau, Switzerland. One or more authors report receiving grants, institutional support, and/or personal fees from the SNSF, the Forschungsrat of the Kantonsspital Aarau, Neste Health Science, Abbott Nutrition, and/or Fresenius Kabi. Marik has disclosed no relevant financial relationships.

JAMA Netw Open. Published online November 20, 2019. Full text, Commentary

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