Evaluation of the Validity and Feasibility of the GLIM Criteria Compared with PG-SGA to Diagnose Malnutrition in Relation to One-Year Mortality in Hospitalized Patients.

BACKGROUND: The Global Leadership Initiative on Malnutrition (GLIM) approach to diagnose malnutrition was published in 2018. An important next step is to use the GLIM criteria in clinical investigations to assess their validity and feasibility. OBJECTIVE: To compare the validity and feasibility of the GLIM criteria with Patient-Generated Subjective Global Assessment (PG-SGA) in hospitalized patients and to assess the association between malnutrition and 1-year mortality. DESIGN: Post hoc analysis of a prospective cohort study. PARTICIPANTS/SETTING: Hospitalized patients (n = 574) from the Departments of Gastroenterology, Gynecology, Urology, and Orthopedics at the Radboudumc academic facility in Nijmegen, The Netherlands, were enrolled from July 2015 through December 2016. MAIN OUTCOME MEASURES: The GLIM criteria and PG-SGA were applied to identify malnourished patients. Mortality rates were collected from electronic patient records. Feasibility was assessed by evaluating the amount of and reasons for missing data. STATISTICAL ANALYSES PERFORMED: Concurrent validity was evaluated by assessing the sensitivity, specificity, and Cohen's kappa coefficient for the GLIM criteria compared with PG-SGA. Cox regression analysis was used for the association between the GLIM criteria and PG-SGA and mortality. RESULTS: Of 574 patients, 160 (28%) were classified as malnourished according to the GLIM criteria and 172 (30.0%) according to PG-SGA (κ = 0.22, low agreement). When compared with PG-SGA, the GLIM criteria had a sensitivity of 43% and a specificity of 79%. Mortality of malnourished patients was more than two times higher than for non-malnourished patients according to the GLIM criteria (hazard ratio [HR], 2.68; confidence interval [CI], 1.33-5.41). Data on muscle mass was missing in 454 of 574 (79%) patients because of practical problems with the assessment using bioimpedance analysis (BIA). CONCLUSIONS: Agreement between GLIM criteria and PG-SGA was low when diagnosing malnutrition, indicating that the two methods do not identify the same patients. This is supported by the GLIM criteria showing predictive power for 1-year mortality in hospitalized patients in contrast to PG-SGA. The assessment of muscle mass using BIA was difficult to perform in this clinical population.

Experiences of patients with cancer with information and support for psychosocial consequences of reduced ability to eat: a qualitative interview study.

PURPOSE: Patients with cancer may experience emotions such as anger or sadness due to tumour- or treatment-related reduced ability to eat. These emotions can be provoked by patients' own struggle with eating, by misunderstanding of their struggle by others, or by less pleasure in social activities. Literature indicates that patients with cancer may experience a lack of information and support regarding psychosocial consequences of reduced ability to eat. The aim of this qualitative study is to gain insights into experiences with this information and support. METHOD: Transcripts of semi-structured interviews with 24 patients with cancer who experience(d) psychosocial consequences of reduced ability to eat were thematically analysed. Interviews were recorded, transcribed verbatim, and analysed using Atlas.ti. RESULTS: Patients expressed positive experiences with information and support for psychosocial consequences of reduced ability to eat while receiving multidisciplinary recognition and personalised care. Patients expressed negative experiences when healthcare professionals only assessed topics within their own expertise, or when healthcare professionals mainly focused on their nutritional intake. Informal support for reduced ability to eat was positively evaluated when informal caregivers tried to understand their situation. Evaluation of informal practical support varied among patients. CONCLUSION: Patients with cancer who experience psychosocial consequences of reduced ability to eat both need professional and informal support. Recognition of these consequences from healthcare professionals is important, as well as understanding from informal caregivers.

High Frequency Protein-Rich Meal Service to Promote Protein Distribution to Stimulate Muscle Function in Preoperative Patients.

Apart from meeting daily protein requirements, an even distribution of protein consumption is proposed instrumental to optimizing protein muscle synthesis and preserving muscle mass. We assessed whether a high frequency protein-rich meal service for three weeks contributes to an even daily protein distribution and a higher muscle function in pre-operative patients. This study was a post-hoc analysis of a randomized controlled trial (RCT) in 102 patients. The intervention comprised six protein-rich dishes per day. Daily protein distribution was evaluated by a three-day food diary and muscle function by handgrip strength before and after the intervention. Protein intake was significantly higher in the intervention group at the in-between meals in the morning (7 ± 2 grams (g) vs. 2 ± 3 g, p < 0.05) and afternoon (8 ± 3 g vs. 2 ± 3 g, p < 0.05). Participants who consumed 20 g protein for at least two meals had a significantly higher handgrip strength compared to participants who did not. A high frequency protein-rich meal service is an effective strategy to optimize an even protein distribution across meals throughout the day. Home-delivered meal services can be optimized by offering more protein-rich options such as dairy or protein supplementation at breakfast, lunch and prior to sleep for a better protein distribution.

Lessons learned from a randomized controlled trial on a home delivered meal service in advanced cancer patients undergoing chemotherapy: a pilot study.

BACKGROUND: Performing a randomized controlled trial (RCT) in the field of nutrition is challenging and success highly depends on understanding the factors that influence recruitment and dropout of participants. Our aim was to assess the feasibility of a RCT that evaluated a home delivered meal service in advanced cancer patients while receiving chemotherapy. METHODS: This pilot RCT aimed to enroll 20 participants who were randomized into the home delivered meal service group or usual care group. Study procedures took place before chemotherapy (T0), 3 weeks after T0 (T1), 6 weeks after T0 (T2) and 3 months after T2 (T3). All information regarding recruitment, dropout and study procedures was recorded. Patient satisfaction was assessed by in-depth interviews. RESULTS: Over 7 months, 20 of 41 approached patients (49%) were included, followed by a dropout rate of 35%. At baseline, hand grip strength (n = 8/16), the Short Physical Performance Battery (n = 12/16) and nutritional intake (n = 8/16) had the highest rate of missing values. Study procedures were not experienced as burdensome and planning of these procedures in line with fixed hospital appointments contributed to this low burden. Keeping the symptom diary was mentioned as being burdensome. CONCLUSIONS: It is feasible to conduct a RCT on a home delivered meal service in advanced cancer patients during chemotherapy, although recruitment is challenging. Close contact of patients with recruiting personnel is essential to sustain motivation. To increase compliance with the study protocol it is important to carefully instruct participants on how to complete questionnaires and to emphasize to use these in the communication with their practitioners. TRIAL REGISTRATION: ClinicalTrials.gov NCT03382171 .

Protein Intake at the First Day of Full-Oral Intake During Hospitalization Is Associated With Complications and Hospital Length of Stay.

BACKGROUND: Malnutrition at admission is associated with complication-related readmission and prolonged hospital stay. This underscores the importance of an adequate intake - more particular, protein intake - to prevent further deterioration and treat malnutrition during hospitalization. Our objective was to assess whether protein intake relative to requirements at the first day of full oral intake is associated with complications and hospital length of stay (LOS) in medical and surgical patients. METHODS: This was a post hoc analysis of a prospective cohort study in patients on the wards of gastroenterology, orthopedics, urology, and gynecology. Protein intake was measured by subtracting the weight of each dish at the end of each mealtime from the weight at serving time. Complications and LOS were reported using patients' medical records. RESULTS: In total, complications were observed in 92 of 637 (14.4%) patients, with a median LOS of 5 days (3.0-7.0). An absolute increase of 10% protein intake relative to requirements reduced the relative complication risk by 10% (odds ratio, 0.900; 95% CI, 0.83-0.97; P < .05). Also, LOS was shortened by 0.23 days for each increase of 10% in protein intake relative to requirements (95% CI, -0.3 to -0.2; P < .05). CONCLUSION: Protein intake relative to requirements at the first day of full-oral intake is associated with the risk of complications and hospital LOS. This analysis bolsters the evidence for the importance of any hospital meal service that increases protein intake.

Effect of a Preoperative Home-Delivered, Protein-Rich Meal Service to Improve Protein Intake in Surgical Patients: A Randomized Controlled Trial.

BACKGROUND: The preoperative period likely provides an important opportunity to improve postoperative recovery, as suggested by the finding that low nutrition status is a predictor of increased postoperative complications and longer length of stay (LOS). It was investigated whether a home-delivered, protein-rich meal service improves protein intake relative to requirements within 3 weeks prior to surgery compared to usual care (UC). METHODS: This randomized controlled trial included adults (n = 126) with planned surgery performed at the orthopedics, urology, gynecology, or general surgery departments. The intervention group received 6 protein-rich dishes per day for 3 weeks, and the control group sustained their usual diet. Dietary intake, nutrition status, hand grip strength, physical performance, and quality of life were assessed at baseline and after 3 weeks. Patient satisfaction was reported after 3 weeks, and data on complications and LOS were reported 30 days after surgery. RESULTS: Protein intake relative to requirements significantly improved by 16%, and energy intake relative to requirements increased by 19% for the meal service, as compared with UC. The intervention group experienced significantly less stress with preparing meals and were more satisfied with the presentation of the meals than the control group. No significant effects of the intervention were detected on other secondary outcomes. CONCLUSION: The home-delivered, protein-rich meal service was successfully implemented before surgery and improved protein and energy intake relative to requirements within 3 weeks while patient satisfaction maintained. The preoperative period serves as a window of opportunity to prepare patients before hospitalization.

Effective elements of home-delivered meal services to improve energy and protein intake: A systematic review.

Home-delivered meal services are an example of a nutritional intervention in the home setting developed to enhance dietary intake and contribute to the independence of especially older adults. There is a lack of evidence about the contribution of specific elements of any home-delivered meal service on the improved outcomes. Therefore, a systematic review was performed to evaluate which elements of home-delivered meal services are effective to improve energy and protein intake, nutritional status, functional outcomes and satisfaction in adults. Pubmed, Embase and Web of Science databases were searched for studies assessing energy and protein intake, nutritional or functional status, or satisfaction of these services. The quality of the studies was assessed using the Quality Criteria Checklist for Primary Research. Of 138 studies meeting the search criteria, 19 were included, none of which met the criteria to be rated as high quality. These studies show that various elements of home-delivered meal services such as Meals on Wheels providing protein-enriched bread or snacks in addition to meals or providing meals and snacks for whole days can improve outcomes such as energy and protein intake and satisfaction. A distinction can be made between services focusing on supporting homebound, essentially healthy, older adults and services aiming at the optimal, nutritional, transmural care for patients at risk for malnutrition. This review shows that various elements of these meal services can improve key outcomes. Following the rising interest and importance of these interventions, there is an urgent need to optimize such services to improve nutritional care at home regarding the increasingly limited time frame of admission in hospitals.

Strategies to increase protein intake at mealtimes through a novel high-frequency food service in hospitalized patients.

BACKGROUND/OBJECTIVES: Additional strategies should be applied to optimize hospital food services, in order to increase the number of patients with adequate protein intake at mealtimes. Therefore, we aim to specify the differences in protein intake per mealtime between the traditional three meals a day food service (TMS) and a novel six times a day food service containing protein-rich food items, FoodforCare (FfC). SUBJECTS/METHODS: This was a post-hoc analysis of a prospective cohort study comparing the TMS (July 2015 - May 2016; n = 326) to FfC (January 2016 - December 2016; n = 311) in adult hospitalized patients. RESULTS: Protein intake (g) was higher with FfC at all mealtimes (p < 0.05) except for dinner (median [IQR] at breakfast: 17 [6.5-25.7] vs. 10 [3.8-17]; 10:00 a.m.: 3.3 [0.3-5.3] vs. 1 [0-2.2]; lunch: 17.6 [8.4-25.8] vs. 13 [7-19.4]; 2:30 p.m.: 5.4 [0.8-7.5] vs. 0 [0-1.8]; 7:00 p.m.: 1 [0-3.5] vs. 0 [0-1.7]; 9:00 p.m.: 0 [0-0.1] vs. 0 [0-0]). At dinner, protein intake was highest for both food services (20.9 g [8.4-24.1] vs. 20.5 g [10.5-27.8]). CONCLUSIONS: Implementation of a high-frequency food service can improve protein intake at mealtimes during the day and might be a strategy to increase the number of patients with adequate protein intake.