Nutrition and Hydration Current Awareness Bulletin November 2020

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Report of the independent review of NHS hospital food This review, advised by chef and restaurateur Prue Leith, highlights the main challenges for NHS catering and makes recommendations on how NHS trusts can prioritise food safety and provide more nutritious meals to both staff and patients. The review covers: workforce; nutrition and hydration; food safety; facilities; technology; sustainability; enforcing standards; and the way forward to improving hospital food for patients, staff and visitors.

NHS hospital food survey Being offered a choice of meals is very important to inpatients, this survey of patients' experience of hospital catering has found. This survey, commissioned by the Department of Health and Social Care, was designed to complement, and feed into, the work of the NHS Hospital Food Review Panel. Patients who had spent one or more nights in hospital in the past six months were asked about their experiences of hospital catering. Title: The impact of acute changes of inflammation on appetite and food intake among older hospitalised patients. Citation: British Journal of Nutrition; Nov 2020; vol. 124 (no. 10); p. 1069-1075 Author(s): Pourhassan ; Sieske, Lars; Janssen, Gregor; Babel, Nina; Westhoff, Timm Henning; Wirth, Rainer Abstract: The present study aimed to investigate the effect of acute changes in serum C-reactive protein (CRP) on appetite and food intake among older hospitalised patients. A total of 200 patients (age range 65–94 years, 62·5 % women) participated in this prospective longitudinal observational study. Risk of malnutrition was measured according to the Mini Nutritional Assessment Short Form. The Simplified Nutritional Appetite Questionnaire (SNAQ) and Edmonton Symptom Assessment System (ESAS) were used to evaluate patients' appetite at the time of hospital admission (baseline) and after 7 d (follow-up). Food intake was measured according to the plate diagram and serum CRP was analysed at baseline and follow-up. At baseline, 30·5 % of the patients had moderate to severe inflammation, 31·0 % were malnourished and 48·0 % had food intake <75 % of the meals offered. Also, 32·5 and 23·5 % reported poor and very poor appetite or severe loss of appetite according to the SNAQ and ESAS, respectively. Of the patients, 40 % displayed a pronounced reduction in median CRP levels by −1·2 mg/dl and 19 % demonstrated an increase in median CRP levels by +1·2 mg/dl. Appetite significantly improved (P = 0·006) in patients with a decrease in CRP level and deteriorated in those with an increase in CRP level (P = 0·032). Changes in CRP levels did not show any significant impact on food intake. In a regression analysis, changes of inflammation were the major independent predictor for changes of patients' appetite. We conclude that inflammation has a significant impact on appetite and should therefore be considered in the diagnosis and treatment of malnutrition.

Title: Family member eating assistance and food intake in long-term care: A secondary data analysis of the M3 Study. Citation: Journal of Advanced Nursing (John Wiley & Sons, Inc.); Nov 2020; vol. 76 (no. 11); p. 2933-2944 Author(s): Wu ; Morrison-Koechl, Jill; Slaughter, Susan E.; Middleton, Laura E.; Carrier, Natalie; McAiney, Carrie; Lengyel, Christina; Keller, Heather

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Aim: To determine if protein and energy intake is significantly associated with a family member providing eating assistance to residents in long-term care homes as compared with staff providing this assistance, when adjusting for other covariates. Background: Who provides eating support has the potential to improve resident food intake. Little is known about family eating assistance and if this is associated with resident food intake in long-term care. Design: Cross-sectional, secondary data analysis. Methods: Between October and January 2016, multilevel data were collected from 32 long-term care homes across four Canadian provinces. Data included 3-day weighed/observed food intake, mealtime observations, physical dining room assessments, health record review, and staff report of care needs. Residents where family provided eating assistance were compared with residents who received staff-only assistance. Regression analysis determined the association of energy and protein intake with family eating assistance versus staff assistance while adjusting for covariates. Results: Of those residents who required any physical eating assistance (N = 147), 38% (N = 56) had family assistance during at least one of nine meals observed. Residents who received family assistance (N = 56) and those who did not (N = 91) were statistically different in several of their physiological eating abilities. When adjusting for covariates, family assistance was associated with significantly higher consumption of protein and energy intake. Conclusion: Energy and protein intake is significantly higher when family provides eating assistance. Family are encouraged to provide this direct care if it is required. Impact: Residents who struggle with independent eating can benefit from dedicated support during mealtimes. Findings from this study provide empirical evidence that family eating assistance is associated with improved resident food intake and provides strong justification to encourage families to be active partners in the care and well-being of their relatives. Home administrators and nursing staff should support the specialized care that families can provide at mealtimes.

Title: Malnutrition and Frailty Screening in Older Adults: Challenges and Opportunities for Dietetic Professionals. Citation: Nutrition Today; Sep 2020; vol. 55 (no. 5); p. 244-253 Author(s): Weiler ; Arensberg, Mary Beth; Paul, Marika H.; Gahche, Jaime J.; Comee, Laura; Krok-Schoen, Jessica L.; Dwyer, Johanna T. Abstract: We conducted a Web-based survey of Commission on Dietetic Registration members to identify opportunities and challenges related to malnutrition and frailty screening among older adults (≥65 years old). Of the 9279 surveys sent out in emails, 903 registered dietitian nutritionists (RDNs) returned the surveys (10% response rate), and of those who responded, 576 RDNs were working with adults 65 years or older. They reported greater familiarity with screening tools for malnutrition than for frailty and little use of any frailty screening tools. For malnutrition screening, RDNs were most familiar with the body mass index (99%), Subjective Global Assessment (79%), and Malnutrition Screening Tool (75%). The body mass index (86%) and Malnutrition Screening Tool (42%) were most commonly used for malnutrition screening. For frailty screening, virtually all of the respondents (90%) were unfamiliar with individual tools. Registered dietitian nutritionists were most familiar with the Frailty Index (9%) and Simple FRAIL Questionnaire (6%), and the Simple FRAIL Questionnaire (2%) and Frailty Index (2%) were most commonly used. Major risk factors RDNs considered when screening for malnutrition and frailty were weight loss (malnutrition,

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99%; frailty, 87%) and appetite loss (malnutrition, 95%; frailty, 45%), respectively. Although 70% of respondents reported their organizations had policies for malnutrition screening, only 6% did for frailty screening. Most RDNs (68%) agreed that dietetic professionals should play a role in frailty screening. To take a leading role in frailty screening and intervention, RDNs working with older adults need skills-based competency, education, and training.

Title: Home artificial nutrition in palliative care cancer patients: Impact on survival and performance status. Citation: Clinical Nutrition; Nov 2020; vol. 39 (no. 11); p. 3346-3353 Author(s): Ruggeri ; Giannantonio, Marilena; Agostini, Federica; Ostan, Rita; Pironi, Loris; Pannuti, Raffaella Abstract: The prevalence of malnutrition is over 70% in advanced cancer patients and impacts negatively on survival and quality of life. Artificial nutrition can be integrated into a home palliative care program. This observational study aims to describe the criteria for identifying the cancer patients that could benefit from home artificial nutrition (HAN) and to evaluate its impact on survival and performance status. The selection criteria for patient's eligibility to HAN were: Karnofsky Performance Status (KPS) ≥40, life expectancy ≥6 weeks, inadequate caloric intake ± malnutrition, suitable psycho-physical conditions and informed consent. The access route for nutritional therapy (home parenteral nutrition, HPN; home enteral nutrition, HEN) was chosen according to the ESPEN Guidelines. The parameters considered were: primary site of the tumor; oral food intake; nutritional status; stage of cachexia; fluid, energy and protein supplied by HAN; survival. From 1990 to 2019, 43,474 cancer patients were assisted at home in Bologna (Italy). HAN started in 969 patients (2.2% of total patients, 571 men and 398 women, mean age 65.7 ± 12.7 years): HPN in 629 patients (64.9%), with gastrointestinal obstruction as the main indication; HEN in 340 patients (35.1%), with dysphagia as the main indication. Considering the 890 deceased patients, the mean survival after the start of HAN was 18.3 weeks and 649 patients (72.9%) survived more than 6 weeks. The mean survival was higher in HEN (22.1 weeks) compared to HPN patients (16.1 weeks) (p <.001). After one month, KPS was unchanged in 649 (67.0%), increased in 232 (23.9%) and decreased in 88 patients (9.1%). The mean KPS increased in patients starting HAN in pre-cachexia and cachexia (p <.001). Cachexia and refractory cachexia at the entry were associated with a reduced survival [odds ratio: 1.5 and 2.3 respectively, p <.001 for both condition] respect to pre-cachexia. The selection criteria allow the identification of the patient who can take advantage of HAN. HAN can be effective in avoiding death from malnutrition in 73% of patients, and in maintaining or improving the KPS at one month in 90% of cases. The benefits provided by HAN on survival and performance status depend on the cachexia degree at the entry. Title: Nutritional care in relation to COVID-19. Citation: British Journal of Nursing; Oct 2020; vol. 29 (no. 19); p. 1096-1103 Author(s): Delaney, Emer Abstract: The following article was written after the initial wave of the COVID-19 pandemic in the UK. On reflection of clinical practice during this time, it was noted by the ICU team that the majority of ventilated patients appeared to have lost weight during their stay. Unfortunately, there was no ability to weigh patients during the pandemic, so this weight loss was a subjective observation. Regardless, this observation lead the ICU dietitian to retrospectively audit prescribed versus delivered feed. It was found that only 10% of

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admissions received the prescribed daily volume of feed within the first 7 days of admission. A further 6% of admissions were within 10% of achieving daily prescribed target volumes. The main reasons for this were proning patients, high gastric residual volumes and the overwhelming nature of the pandemic. Three areas of practice have been highlighted that will improve feed delivery should a second wave occur. 1. A nasojejunal team comprising 20 members of the ICU multidiciplinary team will be established to insert bedside nasojejunal tubes in all ICU patients on admission. 2. All proned patients will be enterally fed and practice adjusted as per British Dietetic Association recommendations. 3. The international enteral feeding guidelines regarding hypocaloric feeding for the first 7 days will not be followed due to minimal clinical evidence for the ICU COVID-19 demographic.

Title: Malnutrition and its effects in severely injured trauma patients. Citation: European Journal of Trauma & Emergency Surgery; Oct 2020; vol. 46 (no. 5); p. 993-1004 Author(s): Dijkink ; Meier, Karien; Krijnen, Pieta; Yeh, D. Dante; Velmahos, George C.; Schipper, Inger B. Purpose: In hospitalized patients, malnutrition is associated with adverse outcomes. However, the consequences of malnutrition in trauma patients are still poorly understood. This study aims to review the current knowledge about the pathophysiology, prevalence, and effects of malnutrition in severely injured patients. Methods: A systematic literature review in PubMed and Embase was conducted according to PRISMA-guidelines. Results: Nine review articles discussed the hypermetabolic state in severely injured patients in relation to malnutrition. In these patients, malnutrition negatively influenced the metabolic response, and vice versa, thereby rendering them susceptible to adverse outcomes and further deterioration of nutritional status. Thirteen cohort studies reported on prevalences of malnutrition in severely injured patients; ten reported clinical outcomes. In severely injured patients, the prevalence of malnutrition ranged from 7 to 76%, depending upon setting, population, and nutritional assessment tool used. In the geriatric trauma population, 7–62.5% were malnourished at admission and 35.6–60% were at risk for malnutrition. Malnutrition was an independent risk factor for complications, mortality, prolonged hospital length of stay, and declined quality of life. Conclusions: Despite widespread belief about the importance of nutrition in severely injured patients, the quantity and quality of available evidence is surprisingly sparse, frequently of low-quality, and outdated. Based on the malnutrition-associated adverse outcomes, the nutritional status of trauma patients should be routinely and carefully monitored. Trials are required to better define the optimal nutritional treatment of trauma patients, but a standardized data dictionary and reasonable outcome measures are required for meaningful interpretation and application of results.

Title: Nutritional Risk Screening Tools for Older Adults with COVID-19: A Systematic Review. Citation: Nutrients; Oct 2020; vol. 12 (no. 10); p. 2956-2956 Author(s): Silva ; Lima, Severina Carla Vieira Cunha; Sena-Evangelista, Karine Cavalcanti Mauricio; Marchioni, Dirce Maria; Cobucci, Ricardo Ney; Andrade, Fábia Barbosa de

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Abstract: Coronavirus disease 2019 (COVID-19) is associated with high risk of malnutrition, primarily in older people; assessing nutritional risk using appropriate screening tools is critical. This systematic review identified applicable tools and assessed their measurement properties. Literature was searched in the MEDLINE, Embase, and LILACS databases. Four studies conducted in China met the eligibility criteria. Sample sizes ranged from six to 182, and participants' ages from 65 to 87 years. Seven nutritional screening and assessment tools were used: the Nutritional Risk Screening 2002 (NRS-2002), the Mini Nutritional Assessment (MNA), the MNA-short form (MNA-sf), the Malnutrition Universal Screening Tool (MUST), the Nutritional Risk Index (NRI), the Geriatric NRI (GNRI), and modified Nutrition Risk in the Critically ill (mNUTRIC) score. Nutritional risk was identified in 27.5% to 100% of participants. The NRS-2002, MNA, MNA-sf, NRI, and MUST demonstrated high sensitivity; the MUST had better specificity. The MNA and MUST demonstrated better criterion validity. The MNA-sf demonstrated better predictive validity for poor appetite and weight loss; the NRS-2002 demonstrated better predictive validity for prolonged hospitalization. mNUTRIC score demonstrated good predictive validity for hospital mortality. Most instruments demonstrate high sensitivity for identifying nutritional risk, but none are acknowledged as the best for nutritional screening in older adults with COVID-19.

Title: Fingerfoods: a feasibility study to enhance fruit and vegetable consumption in Dutch patients with dementia in a nursing home. Citation: BMC geriatrics; Oct 2020; vol. 20 (no. 1); p. 423 Author(s): Visscher, Annemijn; Battjes-Fries, Marieke C E; van de Rest, Ondine; Patijn, Olga N; van der Lee, Mascha; Wijma-Idsinga, Nienke; Pot, Gerda K; Voshol, Peter Background: Eating problems are highly prevalent in older patients with dementia and as a consequence, these patients are at greater risk of becoming malnourished. Fingerfoods, snacks that can be picked with thumb and forefinger, could be used to counteract malnutrition in patients with dementia. The aim of this feasibility study was to evaluate whether providing fruit and vegetable rich fingerfoods in the form of recognizable and familiar snacks on top of the normal intake was feasible for both patients with dementia and caregivers as a means to increase patients' nutritional status. Methods: Institutionalised patients with dementia (N = 15, 93% female, mean age = 85 years) were included in this feasibility study in the Netherlands. The residents received their regular diet supplemented with fingerfoods, comprising quiches and cakes rich in fruit or vegetables, for 6 weeks. Daily fingerfood consumption together with compensation behaviour at dinner of residents was administered with a checklist and food diaries at the start and end of the intervention as dose delivered. Furthermore, caregivers were asked to fill out a feedback form at the end of the intervention to measure fidelity and appreciation of the intervention. Results: Patients consumed on average 1.4 pieces (70 g) of fingerfoods daily, containing 41 g of fruit and/or vegetables. Fruit and vegetable consumption increased during the provision of the fingerfoods and the residents seemed not to compensate this intake during the rest of the day. The intervention was generally positively received by the majority of caregivers, depending on the type of fingerfood and state of the resident. Conclusion: This feasibility study showed that providing recognizable fruit and vegetable rich fingerfoods to patients with dementia seems feasible for both patients and caregivers and could provide a pragmatic approach to enhance fruit and vegetable consumption and total food intake in institutionalized elderly. In an up-scaled study, effects of fingerfoods on nutritional status and quality of life should be investigated.

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Title: A Review of Nutrition Support Guidelines for Individuals with or Recovering from COVID-19 in the Community. Citation: Nutrients; Oct 2020; vol. 12 (no. 11) Author(s): Cawood, Abbie L; Walters, Emily R; Smith, Trevor R; Sipaul, Rachel H; Stratton, Rebecca J Abstract: COVID-19 negatively impacts nutritional status and as such identification of nutritional risk and consideration of the need for nutrition support should be fundamental in this patient group. In recent months, clinical nutrition professional organisations across the world have published nutrition support recommendations for health care professionals. This review summarises key themes of those publications linked to nutrition support of adults with or recovering from COVID-19 outside of hospital. Using our search criteria, 15 publications were identified from electronic databases and websites of clinical nutrition professional organisations, worldwide up to 19th June 2020. The key themes across these publications included the importance in the community setting of: (i) screening for malnutrition, which can be achieved by remote consultation; (ii) care plans with appropriate nutrition support, which may include food based strategies, oral nutritional supplements and referral to a dietitian; (iii) continuity of nutritional care between settings including rapid communication at discharge of malnutrition risk and requirements for ongoing nutrition support. These themes, and indeed the importance of nutritional care, are fundamental and should be integrated into pathways for the rehabilitation of patients recovering from COVID-19.

Title: The prevalence of malnutrition and impact on patient outcomes among older adults presenting at an Irish emergency department: a secondary analysis of the OPTI-MEND trial. Citation: BMC geriatrics; Nov 2020; vol. 20 (no. 1); p. 455 Author(s): Griffin, Anne; O'Neill, Aoife; O'Connor, Margaret; Ryan, Damien; Tierney, Audrey; Galvin, Rose Background: Malnutrition is common among older adults and is associated with adverse outcomes but remains undiagnosed on healthcare admissions. Older adults use emergency departments (EDs) more than any other age group. This study aimed to determine the prevalence and factors associated with malnutrition on admission and with adverse outcomes post-admission among older adults attending an Irish ED. Methods: Secondary analysis of data collected from a randomised controlled trial exploring the impact of a dedicated team of health and social care professionals on the care of older adults in the ED. Nutritional status was determined using the Mini Nutritional Assessment- short form. Patient parameters and outcomes included health related quality of life, functional ability, risk of adverse health outcomes, frailty, hospital admissions, falls history and clinical outcomes at index visit, 30-day and 6-month follow up. Aggregate anonymised participant data linked from index visit to 30-days and 6-month follow-up were used for statistical analysis. Results: Among 353 older adults (mean age 79.6 years (SD = 7.0); 59.2% (n = 209) female) the prevalence of malnutrition was 7.6% (n = 27) and 'risk of malnutrition' was 28% (n = 99). At baseline, those who were malnourished had poorer quality of life scores, functional ability, were more frail, more likely to have been hospitalised or had a fall recently, had longer waiting times and were more likely to be discharged home from the ED than those who had normal nutrition status. At 30-days, those who were malnourished were more likely to have

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reported another hospital admission, a nursing home admission, reduced quality of life and functional decline than older adults who had normal nutrition status at the baseline ED visit. Differences between the MNA SF and 6-month outcomes were similar but not statistically significant. Conclusion: Over one-third of older adults admitted to an Irish ED are either malnourished or at risk of malnourishment. Malnutrition was associated with a longer stay in the ED, functional decline, poorer quality of life, increased risk of hospital admissions and a greater likelihood of admission to a nursing home at 30 days. Trial Registration: Protocol registered in ClinicalTrials.gov, ID: NCT03739515 , first posted November 13, 2018.

Title: Relationship between markers of malnutrition and clinical outcomes in older adults with cancer: systematic review, narrative synthesis and meta-analysis. Citation: European journal of clinical nutrition; Nov 2020; vol. 74 (no. 11); p. 1519-1535 Author(s): Bullock, Alex F; Greenley, Sarah L; McKenzie, Gordon A G; Paton, Lewis W; Johnson, Miriam J Abstract: Malnutrition predicts poorer clinical outcomes for people with cancer. Older adults with cancer are a complex, growing population at high risk of weight-losing conditions. A number of malnutrition screening tools exist, however the best screening tool for this group is unknown. The aim was to systematically review the published evidence regarding markers and measures of nutritional status in older adults with cancer (age ≥ 70). A systematic search was performed in Ovid Medline, EMBASE, Web of Science, CINAHL, British Nursing Database and Cochrane CENTRAL; search terms related to malnutrition, cancer, older adults. Titles, abstracts and papers were screened and quality-appraised. Data evaluating ability of markers of nutritional status to predict patient outcomes were subjected to meta-analysis or narrative synthesis. Forty-two studies, describing 15 markers were included. Meta-analysis found decreased food intake was associated with mortality (OR 2.15 [2.03-4.20] p = < 0.00001) in univariate analysis. Prognostic Nutritional Index (PNI) was associated with overall survival (HR 1.89 [1.03-3.48] p = 0.04). PNI markers (albumin, total lymphocyte count) could be seen as markers of inflammation rather than nutrition. There a suggested relationship between very low body mass index (BMI) (<18 kg/m2) and clinical outcomes. No tool was identified as appropriate to screen for malnutrition, as distinct from inflammatory causes of weight-loss. Risk of cancer-cachexia and sarcopenia in older adults with cancer limits the tools analysed. Measures of food intake predicted mortality and should be included in clinical enquiry. A screening tool that distinguishes between malnutrition, cachexia and sarcopenia in older adults with cancer is needed.

Title: Medical Nutrition Therapy in Hospitalized Patients With SARS-CoV-2 (COVID-19) Infection in a Non-critical Care Setting: Knowledge in Progress. Citation: Current nutrition reports; Oct 2020 Author(s): Cervantes-Pérez, Enrique; Cervantes-Guevara, Gabino; Martínez-Soto Holguín, Martha C; Cervantes-Pérez, Lorena A; Cervantes-Pérez, Gabino; Cervantes-Cardona, Guillermo Alonso; González-Ojeda, Alejandro; Fuentes-Orozco, Clotilde; Ramírez-Ochoa, Sol Purpose Of Review: As of 13 September 2020, almost 28 million confirmed cases of COVID-19 including more than 920,000 deaths have been reported to the World Health

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Organization. The SARS-CoV-2 pandemic represents a potential threat to patients and healthcare systems worldwide. Patients with the worst outcomes and higher mortality are reported to include older adults, polymorbid individuals, and malnourished people in general. The purpose of this review is to provide concise guidance for the nutritional management of individuals with COVID-19 based on the current literature and focused on those in the non-ICU setting or with an older age and polymorbidity, which are independently associated with malnutrition and its negative impact on mortality. Recent Findings: Prolonged hospital stays are reported to be required for individuals with COVID-19, and longer acute setting stays may directly worsen or cause malnutrition, with severe loss of skeletal muscle mass and function, which may lead to poor quality of life and additional morbidity. Nutritional therapy is among the mainstay of therapeutic principles and one of the core contents of comprehensive treatment measures. The current COVID-19 pandemic is unprecedented. The prevention, diagnosis, and treatment of malnutrition should therefore be routinely included in the management of individuals with COVID-19.

Title: Nutritional Status and Its Contributing Factors among Older Adults with Cancer Receiving Chemotherapy Citation: Clinical Nursing Research; Nov 2020; vol. 29 (no. 8); p. 650 Author(s): Abd Allah Eman Shokry; Gad Hanan Mohammed Mohammed; Abdel-Aziz, Hassanat Ramadan Abstract: The study aimed to assess nutritional status and its contributing factors among older adults with cancer receiving chemotherapy so, a descriptive study design was used. The study was conducted at Zagazig University Hospitals, Egypt. The study’s sample was selected purposively which composed of 194 older adults. Nutritional status was measured by the Arabic version of the Mini-Nutritional Assessment (MNA). Contributing factors were identified by examining the relationship of nutritional status with demographic and clinical variables. Study results revealed that 33% of the older patients were malnourished and 51.5% were at risk for malnutrition. Statistically significant relations were found between nutritional status and advanced age, illiteracy, insufficient monthly income, comorbidities, cancer stage four at diagnosis, and receiving ≥4 chemotherapy cycles. High prevalence of malnutrition and many contributing factors were identified among older patients with cancer receiving chemotherapy. So, continuous malnutrition screening along chemotherapy courses with special concern for contributing factors assessed in this study is recommended.

Title: Nutrition interventions to improve the appetite of adults undergoing cancer treatment: a systematic review. Citation: Supportive Care in Cancer; Oct 2020; vol. 28 (no. 10); p. 4575-4583 Author(s): Ukovic ; Porter, Judi Purpose: Loss of appetite is a common side effect of cancer and cancer treatments resulting in risk of malnutrition and cancer cachexia. This review aimed to systematically determine nutrition interventions that improve appetite and nutrition-related outcomes of adults with cancer undergoing cancer treatments, and to identify appetite assessment tools used to measure appetite. Methods: Inclusion criteria included randomised controlled trials of adults with cancer undergoing chemotherapy, radiotherapy or immunotherapy treatments, nutrition interventions and appetite assessed by an appetite assessment tool or quality of life tool.

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The search strategy was applied to four databases and two researchers systematically assessed for eligibility. Following data extraction, quality of the included library was assessed using the Quality Criteria Checklist: Primary Research. A narrative synthesis of results was undertaken. Results: After title/abstract screening, 24 full texts were assessed for eligibility; five trials of n = 472 participants were included in the final library. Nutrition interventions that improved appetite were oral nutrition supplements, fish oil supplements and dietary counselling. Appetite was assessed via visual analogue scales (n = 1) and EORTC QLQ C30 questionnaire (n = 4). Quality was assessed as neutral in 2 studies and positive in 3 studies. Conclusion: The use of oral nutrition supplements and dietary counselling and increases in EPA from fish oil supplementation improved the appetite and nutrition outcomes of patients with cancer undergoing cancer treatments. Validated assessment tools in the oncology setting are needed to determine which nutrition interventions positively influence appetite outcomes.

Title: Predictors of Dietitian Referrals in Hospitals. Citation: Nutrients; Sep 2020; vol. 12 (no. 9); p. 2863-2863 Author(s): Eglseer ; Bauer, Silvia Abstract: Dietitian involvement has considerable benefits for hospitalized patients, resulting in better health outcomes and improved quality of life. However, dietitian referral routines are often inappropriate in hospitals. The aim of this study was to identify predictors for dietitian referrals in hospitalized patients. This study was performed on data collected in an annually conducted cross-sectional study (in the years 2017, 2018, 2019). A standardized questionnaire was used to collect data, and logistic regression and a generalized estimating equation (GEE) model were used to calculate the associations between the patient characteristics and dietitian referrals. In the final GEE model, the following predictors for dietitian referrals remained significant: diabetes diagnosis (OR 1.80), cancer diagnosis (OR 1.76), digestive disease diagnosis (OR 2.03), presence of a pressure injury (OR 1.58), risk of malnutrition based on body mass index (BMI) and weight loss (OR 1.72), risk of malnutrition based on the malnutrition universal screening tool (MUST) (2.55), and the application of any malnutrition screening at admission to hospital (2.20). Total dietitian referral rate was 16.8%. The highest rate of dietitian referrals was found in patients with a risk of malnutrition (37%). This study included a large sample of hospitalized adult patients and revealed a low dietitian referral rate among these patients. These results indicate that dietitian involvement in hospitalized patients with nutrition-related conditions urgently needs to be improved.

Title: Nutrition Education on the Wards: A Self-Study Module for Improving Medical Student Knowledge of Nutrition Assessment and Interventions Citation: MedEdPORTAL : the journal of teaching and learning resources; Oct 2020; vol. 16 ; p. 10968 Author(s): Dutra B.; Lissauer M.; Rashid H. Introduction: Nutrition plays a key role in the prevention and treatment of disease. Hospitalized patients are often malnourished, which is a major contributor to medical complications, decreased quality of life, lengthened medical stay, increased health care costs, and mortality. However, medical students continue to have inadequate education in

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nutrition and report feeling poorly trained in nutrition. We proposed an online module that could be used by medical students as a self-study activity to learn about key signs for the diagnosis of malnutrition and the nutrition interventions available in the hospital setting. Method(s): Third- and fourth-year medical students at Rutgers Robert Wood Johnson Medical School in medicine, surgery, and critical care clerkships were given access to an online nutrition education module discussing the signs of malnutrition in hospitalized patients and the interventions available in the inpatient setting. A premodule and postmodule survey was given via email at the beginning and at the end of the clerkship. A one-sample t test was used to assess the relationship between the mean scores of the pre- and postmodule surveys. Result(s): One hundred nine out of 255 students responded to the premodule survey. Thirty-two students completed the module and postmodule survey. There was a significant difference in mean scores between students who completed the module and postmodule survey compared to the overall student population prior to having access to the module. Discussion(s): Medical students have limited training in nutrition education, and our findings show that a self-study online module can improve students' knowledge. Copyright © 2020 Dutra et al.

Title: Comparison of nutritional screening and diagnostic tools in diagnosis of severe malnutrition in critically ill patients. Citation: Clinical nutrition (Edinburgh, Scotland); Nov 2020; vol. 39 (no. 11); p. 3419-3425 Author(s): Rattanachaiwong, Sornwichate; Zribi, Benjamin; Kagan, Ilya; Theilla, Miriam; Heching, Moshe; Singer, Pierre Rationale: While various nutritional assessment tools have been proposed, consensus is lacking with respect to the most effective tool to identify severe malnutrition in critically ill patients. Methods: We conducted a retrospective study in an adult general intensive care unit (ICU) comparing four nutritional assessment tools: Nutrition Risk Screening (NRS), Nutrition Risk in Critically Ill (NUTRIC), and malnutrition criteria proposed by European Society of Clinical Nutrition and Metabolism (ESPEN) and American Society for Parenteral and Enteral Nutrition (ASPEN). These criteria were tested for their sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) in diagnosis of severe malnutrition, defined as Subjective Global Assessment (SGA) C. Results: Hospitalization records for 120 critically ill patients were analyzed. 60 (50%), 17 (14.2%) and 43 (35.8%) patients were classified as SGA A, B, and C, respectively. The sensitivity in diagnosis of severe malnutrition was 79.1%, 58.1%, 65.1%, and 65.1%, and specificity was 94.8%, 74.0%, 94.8%, and 98.7% for NRS, NUTRIC, ESPEN, and ASPEN, respectively. NRS, ESPEN, and ASPEN had higher PPV (89.5%, 87.5%, and 87.5%, respectively) and NPV (89%, 83%, and 83.5%, respectively) than NUTRIC (PPV 55.6% and NPV 76%). NUTRIC showed the highest correlation with mortality, but none of the tools retained their correlation with mortality after adjustment for potential confounding factors. Conclusions: NRS showed the highest sensitivity and high specificity, PPV, and NPV. NUTRIC had least effective overall performance in diagnosis of severe malnutrition in an ICU setting. A larger population may be required to explore the association between mortality and these nutritional assessment tools.

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Title: Economic evaluation of individualized nutritional support in medical inpatients: Secondary analysis of the EFFORT trial. Citation: Clinical nutrition (Edinburgh, Scotland); Nov 2020; vol. 39 (no. 11); p. 3361-3368 Author(s): Schuetz, Philipp; Sulo, Suela; Walzer, Stefan; Vollmer, Lutz; Stanga, Zeno; Gomes, Filomena; Rueda, Ricardo; Mueller, Beat; Partridge, Jamie; EFFORT trial collaborators Background and Aims: Existing guidelines support the importance of nutritional interventions for medical inpatients at malnutrition risk to alleviate the impact of malnutrition on outcomes. While recent studies have reported positive effects of nutritional support on health outcomes, limited evidence exists on whether in-hospital nutritional support also results in economic advantages. We report the results of the economic evaluation of EFFORT-a pragmatic, investigator-initiated, open-label, multicenter trial. Methods: A total of 2028 medical inpatients at nutritional risk were randomly assigned to receive individualized nutritional support to reach protein and energy goals (intervention group; n = 1015) or standard hospital food (control group; n = 1013). To calculate the economic impact of nutritional support, a Markov model was developed with relevant health states. Costs were estimated for days in normal hospital ward and in the Intensive Care Unit (ICU), hospital-acquired complications, and nutritional support. We used a Euro conversion rate of 0.93216 Euro for 1 Swiss Franc (CHF). Results: The estimated per-patient cost was CHF90 (83.78 €) for the in-hospital nutritional support and CHF283.85 (264.23 €) when also considering dietitian consultation time. Overall costs of care within 30 days of admission averaged CHF29,263 (27,240 €) per-patient in the intervention group versus CHF29,477 (27,439 €) in the control group resulting in per-patient cost savings of CHF214 (199 €). Per-patient cost savings was CHF19.56 (18.21 €) when also accounting for dietician costs (full cost analysis). These cost savings were mainly due to reduced ICU length of stay and fewer complications. We also calculated costs to prevent adverse outcomes, which were CHF276 (256 €) for one severe complication, CHF2,675 (2490 €) for one day in ICU, and CHF7,975 (7423 €) for one death. For the full cost analysis, these numbers were CHF872 (811 €), CHF8,459 (7874 €) and CHF25,219 (23,475 €). Sensitivity analyses confirmed the original findings. Conclusions: Our evaluation demonstrates that in-hospital nutritional support for medical inpatients is a highly cost-effective intervention to reduce risks for ICU admissions and hospital-associated complications, while improving patient survival. The positive clinical and economic benefits of nutritional support in at-risk medical inpatients calls for comprehensive nutrition programs, including malnutrition screening, consultation, and nutritional support. Trial Registration: ClinicalTrials.gov number, NCT02517476. Sources Used: The following databases are used in the creation of this bulletin: Amed, British Nursing Index, Cinahl & Medline. Disclaimer: The results of your literature search are based on the request that you made, and consist of a list of references, some with abstracts. Royal United Hospital Bath Healthcare Library will endeavour to use the best, most appropriate and most recent sources available to it, but accepts no liability for the information retrieved, which is subject to the content and accuracy of databases, and the limitations of the search process. The library assumes no liability for the interpretation or application of these results, which are not intended to provide advice or recommendations on patient care.