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Evidence-based management of nutritional deficiency

Malnutrition

As estimated by the the NRS, 20 – 30% of hospitalised medical patients are malnourished or are at high risk of protein-energy malnutrition. 2 Malnourished patients have a higher rate of complications, longer duration of hospitalisation, poorer quality of life and higher mortality as compared to those who are well-nourished. 3 Malnutrition is often the result of other medical diseases but can be managed with a targeted therapy. The therapeutic algorithm presented here is based on ESPEN guidelines for polymorbid medical patients as well as on the EFFORT study. 4-5

Goals of nutritional deficiency management

Improved early identification of patients at risk of malnutrition and initiation of appropriate individual therapy for improvement/maintenance of functionality and quality of life as well as significant reduction of complications and mortality. Management of malnutrition is a team effort and can only be undertaken in close cooperation between nurses, dieticians and doctors.

Nutritional calculator

Individual nutritional goals may be easily calculated on-line with the available nutritional calculator. The displayed results are based on the formulae used in the EFFORT study.

  • Energy requirement: Harris Benedict equation REE x (AF + DF – 1); REE with adjusted weight.
  • Protein requirement 1.2 - 1.5 g per kg body weight (0.8 g in severe renal failure without dialysis (GFR < 30 ml/min/1.73 m2))

The EFFORT study demonstrates clinical benefit5

The EFFORT study, supported by the Swiss National Fund and published in the Lancet in April 2019, clearly demonstrates the benefit of adequate, individualised nutritional therapy:

  • The protein and energy balance improves significantly which in turn has a positive effect on the course of the disease.

  • Consistent management of nutritional deficiency reduces the risk of complications and mortality.
  • The quality of life improves and leads to fewer functional losses.
  • These results apply to patients in Internal Medicine in general, independent of the involved organ.

References

  1. Kondrup J, et al. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr. 2003;22(3):321-36.

  2. Imoberdorf R, et al. Prevalence of undernutrition on admission to Swiss hospitals. Clin Nutr 2010; 29: 38–41.
  3. Felder S, et al. Association of nutritional risk and adverse medical outcomes across different medical inpatient populations. Nutrition 2015; 31: 1385–93.
  4. Gomes F, et al. ESPEN guidelines on nutritional support for polymorbid internal medicine patients. Clin Nutr. 2018;37(1):336-53.
  5. Schuetz P, et al. Individualised nutritional support in medical inpatients at nutritional risk: a randomised clinical trial. Lancet 2019; 393(10188), 2312-2321

List of abbreviations

AF Activity factor
DF Disease factor
EFFORT Effect of Early Nutritional Therapy on Frailty, Functional Outcomes and Recovery of Undernourished Medical Inpatients Trial
GFR Glomerular filtration rate
NRS Nutritional risk screening
RDA Recommended daily allowance
REE Resting energy expenditure