Predictors for achieving protein and energy requirements in undernourished hospital patients

doi:10.1016/j.clnu.2011.01.008

Clinical Nutrition

Volume 30, Issue 4, August 2011, Pages 484-489

https://doi.org/10.1016/j.clnu.2011.01.008 Get rights and content

Summary

Background & aims

Providing sufficient protein an energy is considered crucial in the treatment of undernutrition. Still, the majority of undernourished hospital patients have a suboptimal protein and energy intake. The aim of this study was to investigate predictors for achieving protein and energy requirements on the fourth day of admission in undernourished hospitalized patients.

Methods

830 adult undernourished patients (SNAQ ≥ 3) were retrospectively included. Intake requirements were defined as ≥1.2 g protein per kg bodyweight and ≥100% of the energy requirement based on calculated resting energy expenditure according to Harris & Benedict + 30%. Logistic regression analyses were performed to investigate predictors for achieving the requirements.

Results

Protein and energy intake had been recorded for 610 patients, of whom 25.6% had sufficient protein and energy intake. Protein requirements were less commonly met than energy requirements. Complete case analyses (n = 575) showed that negative predictors for achieving the protein and energy requirements were: nausea (OR = 0.18; 95%CI = 0.06–0.53), cancer (0.57; 0.35–0.93), acute infections (0.63; 0.37–1.01) and higher BMI (0.84; 0.79–0.89). Positive predictors were: a higher age (1.01; 1.00–1.03), chronic lung disease (3.76; 2.33–6.07) and receiving tube feeding (3.89; 1.56–9.73).

Conclusion

Only one in four undernourished hospital patients meets the predefined protein and energy requirements on the fourth day of admission. Nausea, cancer, acute infections, BMI, age, chronic lung disease and tube feeding were identified as predictors for achieving protein and energy intake.

Introduction

Disease related undernutrition is a common problem in hospitalized patients, with a prevalence rating between 25 and 40%.1, 2, 3, 4, 5, 6, 7 Causes for disease related undernutrition are reduced intake, changes in metabolism, or abnormal losses due to malabsorption, leading to a deficiency or imbalance of protein, energy and other nutrients.6, 8 Undernutrition is associated with increased morbidity and mortality in acute and chronic diseases, impairment of recovery, prolonged length of stay, and increased treatment costs.6, 9, 10

The standard treatment of undernutrition is aimed at achieving optimal protein and energy intake, according to a patient’s requirements, in order to reduce the effects of catabolism and minimize the loss of body protein mass.¹¹ The adequate level of protein intake for hospitalized patients is currently defined as 1.2–1.7 g/kg bodyweight per day.11, 12, 13 The adequate level of energy intake is generally assessed by using the estimated resting energy expenditure (REE) of Harris and Benedict¹⁴ with an additional factor of 30% for either activity or disease.11, 15

Data on nutritional intake of undernourished patients are scarce. A study of Dupertuis et al. (2003) showed that 43% of hospitalized patients, independent of nutritional status, did not achieve their minimal protein and energy needs (defined as 0.8 g/kg bodyweight per day and Harris & Benedict¹⁶) and that 70% did not reach their recommended needs (defined as 1.2 or 1.0 g/kg day (for patients ≤ or > 65 years) and Harris & Benedict¹⁶ + 10%).¹⁷ First results of the multinational Nutrition Day survey showed that 60% of all patients admitted to the hospital did not eat their full regular meals on the measurement day, and that these patients were considered to be at increased risk of acquiring a significant protein-energy deficit within a few days.¹⁸

It is still unknown which factors influence the chance of sufficient protein and energy intake. Therefore, the objective of this study was to investigate predictors for achieving protein and energy requirements in undernourished hospital patients.

Section snippets

Subjects

This study was conducted in the Franciscus Hospital, a general hospital in Roosendaal, The Netherlands. At admission to the hospital, patients were routinely screened with the Short Nutritional Assessment Questionnaire (SNAQ).¹⁹ All patients admitted to the hospital in 2008 who were screened as undernourished (SNAQ score ≥ 3) at hospital admission were retrospectively included in this study. Patients below the age of 18 years or with a hospital stay of less than four days were excluded.

Data collection

Data was

Patient characteristics

In 2008, 7960 (71%) of all 11231 patients admitted to the Franciscus Hospital were screened with the SNAQ. A total of 1180 (15%) were found to be undernourished. Of these, 830 patients with a hospital stay of four days or more were included in the study. Mean age was 69.0 (±14.4) years and 50% of the patients were male. Of all patients, 320 (38.6%) had a malignant disease, 215 (25.9%) had an acute infection, and 161 (19.4%) had a chronic lung disease (primarily COPD). Older patients (≥65 years)

Discussion

The aim of this study was to investigate predictors for achieving protein and energy requirements in undernourished hospitalized patients. Of all patients with known intake, only one in four had a protein and energy intake meeting their requirements at the fourth day of admission. Moreover, we observed that protein requirements were less commonly met than energy requirements. This emphasizes the specific attention that should be paid to protein intake in the treatment of undernutrition.

The

Conclusions

The present study shows that only one out of four undernourished hospital patients meets the predefined protein and energy requirements on the fourth day of admission. A major finding was the result that protein requirements were less commonly met than energy requirements, emphasizing the importance of focusing on adequate protein intake in the treatment of undernutrition. Although this study has some methodological shortcomings, results suggest that nausea, cancer, acute infections, higher

Role of funding source

This project received no external funds.

Statement of authorship

Author contributions to the manuscript are as follows: EL and HMK were responsible for the study design. EL was responsible for data collection, data analysis and writing the manuscript. FW participated in most of the data collection and writing the manuscript. AH and JO participated significantly in the data collection. MAEvB, MV, PJMW, AME and HMK participated in writing the manuscript. All authors read and approved the final manuscript.

Conflict of interest

The authors declare no conflict of interest.

Acknowledgments

With gratitude to Kim Franse, who cooperated in the data collection, and to all cooperating dieticians of the Franciscus Hospital in Roosendaal.

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Access to a pre-sleep protein snack increases daily energy and protein intake in surgical hospitalized patients
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In hospitalized patients, daily protein intake remains far below WHO requirements for healthy adults (0.8 g·kg⁻¹·d⁻¹) as well as ESPEN guidelines for patients (1.2–1.5 g·kg⁻¹·d⁻¹). Providing access to a pre-sleep protein dense snack between dinner and going to bed may serve as a great opportunity to increase daily energy and protein intake in hospitalized patients. However, it remains to be assessed whether protein provision prior to sleep effectively increases protein intake, or may reduce food intake throughout the remainder of the day(s). The present study evaluated the impact of giving access to a pre-sleep snack on daily energy and protein intake in patients throughout their hospitalization.
Patients admitted to the surgical wards of the Maastricht University Medical Centre+ were randomly allocated to usual care (n = 51) or given access to a pre-sleep snack (n = 50). The pre-sleep snack consisted of 103 g cheese cubes (30 g protein) provided between 7:30 and 9:30 PM, prior to sleep. All food provided and all food consumed was weighed and recorded throughout (2–7 days) hospitalization. Daily energy and protein intake and distribution were calculated. Data were analyzed by independent T-Tests with P < 0.05 considered as statistically significant.
Daily energy intake was higher in the pre-sleep group (1353 ± 424 kcal d⁻¹) when compared to the usual care group (1190 ± 402 kcal·d⁻¹; P = 0.049). Providing patients access to a pre-sleep snack resulted in a 17% (11 ± 9 g) higher daily protein intake (0.81 ± 0.29 g·kg⁻¹·d⁻¹) when compared to the usual care group (0.69 ± 0.28 g·kg⁻¹·d⁻¹; P = 0.045). Protein intake at breakfast, lunch, and dinner did not differ between the pre-sleep and usual care groups (all P > 0.05).
Providing access to a pre-sleep protein snack, in the form of protein dense food items such as cheese, represents an effective dietary strategy to increase daily energy and protein intake in hospitalized patients. Patients consuming pre-sleep protein snacks do not compensate by lowering energy or protein intake throughout the remainder of the days. Pre-sleep protein dense food provision should be implemented in hospital food logistics to improve the nutritional intake of patients.
NL8507 (https://trialsearch.who.int/)
Protein and Exercise to Reverse Frailty in Older Men and Women Undergoing Transcatheter Aortic Valve Replacement: Design of the PERFORM-TAVR Trial
2024, Canadian Journal of Cardiology
Despite the high procedural success of transcatheter aortic valve replacement (TAVR), 2 out of 5 older adults report poor physical performance and health-related quality of life (HRQOL) in the ensuing months, particularly those with frailty. There has yet to be a trial examining the synergistic effects of exercise and protein supplementation to counteract frailty and improve patient-centred outcomes following TAVR. The PERFORM-TAVR trial is a multicentre parallel-group randomised clinical trial that is enrolling 200 frail older adults ≥ 70 years of age undergoing TAVR. Patients will be randomly allocated to 1 of 2 treatment groups: standard-of-care lifestyle education (control group) or protein-rich oral nutritional supplement for 4 weeks before TAVR with the addition of home-based supervised exercise sessions for 12 weeks after TAVR (intervention group). The primary outcome will be physical performance as measured by a blinded observer using the Short Physical Performance Battery at 3 months. Secondary outcomes at 3, 6, and 12 months will include HRQOL, as measured by the Short-Form 36 Physical and Mental Component summary scores, and a composite safety end point. The PERFORM-TAVR trial is testing a novel frailty intervention in older adults undergoing TAVR to optimise recovery and downstream HRQOL. This represents a potential paradigm shift that highlights the value of assessing and treating patients’ frailty in parallel with their underlying heart valve disease.
URL: https://www.clinicaltrials.gov. Unique identifier: NCT03522454.
En dépit du taux élevé de réussite remplacement valvulaire aortique par cathéter (RVAC), 2 personnes âgées sur 5 signalent une détérioration de leurs capacités physiques et de la qualité de vie liée à la santé dans les mois qui suivent l’intervention, particulièrement les patients fragiles. Aucun essai n’a encore été mené sur les effets synergiques de l’activité physique et de la supplémentation protéique pour contrer la fragilité et améliorer le devenir des patients après un RVAC. L’essai PERFORM-TAVR est un essai clinique multicentrique à répartition aléatoire mené avec groupes parallèles auquel participent 200 personnes fragiles âgées de 70 ans et plus qui subissent un RVAC. Les patients seront répartis aléatoirement dans l’un des deux groupes de traitements : éducation standard sur les habitudes de vie (groupe témoin) ou prise de supplément alimentaire riche en protéines par voie orale pendant 4 semaines avant le RVAC à laquelle s’ajoutent des séances d’exercices supervisées à domicile pendant 12 semaines après le RVAC (groupe d’intervention). Le principal critère d’évaluation sera la performance physique mesurée à l’insu par un observateur au moyen du SPPB (Short Physical Performance Battery) après 3 mois. Les critères d’évaluation secondaires à 3 mois, à 6 mois et à 12 mois comprendront la qualité de vie liée à la santé, mesurée par les scores sommaires des composantes physique et mentale du questionnaire SF-36 (Short-Form 36) et un paramètre composé de l’innocuité. L’essai PERFORM-TAVR vise à évaluer une nouvelle intervention en présence de fragilité chez les personnes âgées qui subissent un RVAC afin d’optimiser le rétablissement et la qualité de vie liée à la santé en aval. Cela représente un changement de paradigme possible qui met en lumière la valeur de l’évaluation et du traitement de la fragilité des patients en parallèle avec leur valvulopathie sous-jacente.
URL: https://www.clinicaltrials.gov. Unique identifier: NCT03522454.
Protein intake during hospital admission; Dutch national data on protein intake in 339,720 malnourished patients from 2009–2019
2022, Clinical Nutrition Open Science
To stimulate early recognition and treatment of malnutrition, the Dutch Healthcare Inspectorate obliged all hospitals from 2008–2019 to report the number of malnourished patients with an adequate protein intake on the fourth day of hospital admission. In this article we present results over the past 11 years and discuss success factors and barriers for adequate treatment of malnourished patients in hospitals.
The annual reports of hospitals on the numbers of patients with a screening result ‘malnourished’ and an adequate protein intake on the fourth day of admission were analysed. Hospitals were categorized based on the percentage of malnourished patients with an adequate protein intake on the fourth day of admission as ‘poor’ (<40% of patients in a hospital achieve an adequate protein intake), ‘moderate’ 40–60% of patients in a hospital achieve an adequate protein intake), and ‘good’ (>60% of patients in a hospital achieve an adequate protein intake). To identify success factors and barriers for adequate treatment and registration of malnourished patients in hospitals, three focus groups were held in June and July 2020. Participants were dietitians and quality employees or nurses who were involved in data collection for malnutrition indicators in their hospitals.
Between 2008–2019, data were reported of 339,720 malnourished patients. The relative number of patients with adequate intake of protein on the fourth day in hospital ranges from 44%-53% between 2011 and 2019. Before 2013, the number of hospitals that reported data was too small to draw conclusions about results of treatment of malnutrition. Data from 2013 to 2019, show a decline in the number of hospitals with a ‘poor’ score. The number of hospitals with a moderate score increased between 2015 and 2019 and the number of hospitals with a good score remained more or less stable, except for 2018 where more hospitals reached a ‘good’ score. Sixteen professionals from ten different hospitals participated in the focus groups and revealed several determinants of adequate treatment of malnourished patients in hospitals such as awareness, feeling responsible and the need of clear instructions and good collaboration.
This inventory of the protein intake of 339,720 hospital malnourished patients over 11 years shows that in one out of five Dutch hospitals >60% of malnourished patients had an adequate protein intake on the fourth day of admission. This shows that meeting protein requirements remains a difficult challenge. Early recognition of malnutrition, optimal multidisciplinary treatment and continuous evaluation is necessary to provide optimal nutritional care in the hospital and beyond.
Malnutrition and nutrition support in COVID-19: The results of a nutrition support protocol
2021, Endocrinologia, Diabetes y Nutricion
COVID-19 is characterized by various clinical manifestations, mainly respiratory involvement. Disease-related malnutrition is associated with impaired respiratory function and increased all-cause morbidity and mortality. Patients with COVID-19 infection carry a high nutritional risk. After designing a specific nutritional support protocol for this disease, we carried out a retrospective study on malnutrition and on the use of nutritional support in patients with COVID-19.
We performed a retrospective study to determine whether nutritional support positively affected hospital stay, clinical complications, and mortality in patients with COVID-19. We compared the results with those of standard nutritional management. Our secondary objectives were to determine the prevalence of malnutrition in patients with COVID-19 and the value of nutritional support in the hospital where the study was performed.
At least 60% of patients with COVID-19 experience malnutrition (up to 78.66% presented at least 1 of the parameters studied). The specialized nutritional support protocol was indicated in only 21 patients (28%) and was started early in only 12 patients (16%). Hospital stay was significantly shorter in patients managed with the early protocol (5.09 days, 95% CI, 1.338–8.853, p < 0.01). Similarly, in this group, respiratory distress was less severe and less frequent (41% vs 82.5%, p < 0.007), and statistically significantly fewer complications were recorded (9/12 vs 91/63; p < 0.001).
COVID-19 is associated with high rates of disease-related malnutrition. Early implementation of a specialized nutritional support plan can improve the prognosis of these patients by reducing hospital stay, the possibility of more severe respiratory distress, and complications in general.
La COVID-19 se caracteriza por diversas manifestaciones clínicas, principalmente afectación respiratoria. La desnutrición relacionada con la enfermedad se asocia con deterioro de la función respiratoria y aumento de la morbilidad y la mortalidad globales. Los pacientes con COVID-19 tienen un riesgo nutricional alto. Tras diseñar un protocolo de apoyo nutricional específico para esta enfermedad, se emprendió un estudio retrospectivo sobre desnutrición y uso de soporte nutricional en pacientes con COVID-19.
Se realizó un estudio retrospectivo para determinar si el apoyo nutricional tenía efectos positivos en la estancia hospitalaria, las complicaciones clínicas y la mortalidad de los pacientes con COVID-19. Se compararon los resultados con los del manejo nutricional habitual. Los objetivos secundarios eran determinar la prevalencia de desnutrición en los pacientes con COVID-19 y la utilidad del apoyo nutricional en el hospital en el que se realizó el estudio.
Al menos el 60% de los pacientes con COVID-19 sufre desnutrición (hasta el 78,66% presentaba al menos uno de los parámetros estudiados). El protocolo de apoyo nutricional especializado estaba indicado en sólo 21 pacientes (28%) y se inició de forma temprana en sólo 12 pacientes (16%). La estancia hospitalaria fue significativamente menor en los pacientes sometidos al protocolo temprano (5,09 días, IC 95%, 1.338-8.853, p < 0,01). Este grupo mostró asimismo un sufrimiento respiratorio menos intenso y frecuente (41 y 82,5%, respectivamente, p < 0,007), y un número significativamente menor de complicaciones (9/12 frente a 91/63; p < 0,001).
La COVID-19 se asocia con tasas elevadas de desnutrición relacionada con la enfermedad. La implantación precoz de un plan de apoyo nutricional especializado puede mejorar el pronóstico de estos pacientes al reducir la estancia hospitalaria, la posibilidad de sufrimiento respiratorio más intenso y las complicaciones en general.
Frailty, Sarcopenia, and Malnutrition Frequently (Co-)occur in Hospitalized Older Adults: A Systematic Review and Meta-analysis
2020, Journal of the American Medical Directors Association
The purpose of this systematic review and meta-analysis was to summarize the prevalence of, and association between, physical frailty or sarcopenia and malnutrition in older hospitalized adults.
A systematic literature search was performed in 10 databases.
Articles were selected that evaluated physical frailty or sarcopenia and malnutrition according to predefined criteria and cutoffs in older hospitalized patients.
Data were pooled in a meta-analysis to evaluate the prevalence of prefrailty and frailty [together (pre-)frailty], sarcopenia, and risk of malnutrition and malnutrition [together (risk of) malnutrition], and the association between either (pre-)frailty or sarcopenia and (risk of) malnutrition.
Forty-seven articles with 18,039 patients (55% female) were included in the systematic review, and 39 articles (8868 patients, 62% female) were eligible for the meta-analysis. Pooling 11 studies (2725 patients) revealed that 84% [95% confidence interval (CI): 77%, 91%, I² = 98.4%] of patients were physically (pre-)frail. Pooling 15 studies (4014 patients) revealed that 37% (95% CI: 26%, 48%, I² = 98.6%) of patients had sarcopenia. Pooling 28 studies (7256 patients) revealed a prevalence of 66% (95% CI: 58%, 73%, I² = 98.6%) (risk of) malnutrition. Pooling 10 studies (2427 patients) revealed a high association [odds ratio (OR): 5.77 (95% CI: 3.88, 8.58), P < .0001, I² = 42.3%] and considerable overlap (49.7%) between physical (pre-)frailty and (risk of) malnutrition. Pooling 7 studies (2506 patients) revealed a high association [OR: 4.06 (95% CI: 2.43, 6.80), P < .0001, I² = 71.4%] and considerable overlap (41.6%) between sarcopenia and (risk of) malnutrition.
The association between and prevalence of (pre-)frailty or sarcopenia and (risk of) malnutrition in older hospitalized adults is substantial. About half of the hospitalized older adults suffer from 2 and perhaps 3 of these debilitating conditions. Therefore, standardized screening for these conditions at hospital admission is highly warranted to guide targeted nutritional and physical interventions.
Dietary protein intake in older adults undergoing cardiac surgery
2019, Nutrition, Metabolism and Cardiovascular Diseases
Citation Excerpt :
Older adults require 25–50% more dietary protein intake than younger adults to overcome the age-related decline in muscle protein synthesis and resulting risk of sarcopenia [1,2]. However, a majority of older adults do not consume the recommended protein intake in their daily diet [3]. During periods of physiological stress from critical illness, such as cardiac surgery, metabolic demands and muscle breakdown are accelerated and compounded by bedrest and poor oral intake resulting in substantial loss of muscle mass [4].
Older adults undergoing major surgery have increased protein requirements in the postoperative period, but there are limited data describing actual protein intake following cardiac surgery.
We performed a prospective sub-study within a registry of older adults ≥60 years of age undergoing cardiac surgery at a tertiary care centre. A dietician administered a food frequency questionnaire before surgery and 1–4 months after surgery. In-hospital food intake was recorded by direct observation for 3 days in the early postoperative period. Food intake was analyzed to calculate the protein intake per kilogram of body weight per day (g/kg/d) during the three phases of care, compared to the dietary reference intake. Frailty was measured by a questionnaire and physical performance tests before surgery. There were 22 patients (8 females, 14 males; 59% frail) enrolled in the study with a mean age of 72.0 ± 7.8 years. The mean protein intake was 1.3 ± 0.5 g/kg/d, 0.7 ± 0.3 g/kg/d, and 1.3 ± 0.6 g/kg/d in the preoperative, early postoperative, and postdischarge periods, respectively (P < 0.0001 for early postoperative compared to other periods). Compared to the targeted dietary reference intake of 1.5 g/kg/d, there was a mean protein deficit of 0.8 g/kg/d in the early postoperative period. Only one patient (5%) met the protein dietary reference intake in the early postoperative period.
In older adults undergoing cardiac surgery, dietary protein intake was substantially lower than the recommended target in the early postoperative period. Strategies to improve protein intake, particularly in frail older patients, may be considered as a therapeutic target.

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Original ArticlePredictors for achieving protein and energy requirements in undernourished hospital patients

Summary

Background & aims

Methods

Results

Conclusion

Introduction

Section snippets

Subjects

Data collection

Patient characteristics

Discussion

Conclusions

Role of funding source

Statement of authorship

Conflict of interest

Acknowledgments

Clin Nutr

Clin Nutr

Clin Nutr

Nutrition

Clin Nutr

Clin Nutr

Am J Clin Nutr

Clin Nutr

Clin Nutr

Clin Nutr

Clin Nutr

Eur J Oncol Nurs

Arch Bronconeumol

Nutrition

Eur J Oncol Nurs

Eur J Intern Med

Clin Nutr

Original Article
Predictors for achieving protein and energy requirements in undernourished hospital patients