Complementarity of nutrition screening with Global Leadership Initiative on Malnutrition criteria for diagnosing malnutrition in critically ill patients: A comparison study of Nutritional Risk Screening 2002 and modified Nutrition Risk in the Critically Ill Score.

BACKGROUND AND AIM: Critical illness induces hypermetabolism and hypercatabolism, increasing nutrition risk (NR). Early NR identification is crucial for improving outcomes. We assessed four nutrition screening tools (NSTs) complementarity with the Global Leadership Initiative on Malnutrition (GLIM) criteria in critically ill patients. METHODS: We conducted a comparative study using data from a cohort involving five intensive care units (ICUs), screening patients for NR using NRS-2002 and modified-NUTRIC tools, with three cutoffs (≥3, ≥4, ≥5), and malnutrition diagnosed by GLIM criteria. Our outcomes of interest included ICU and in-hospital mortality, ICU and hospital length of stay (LOS), and ICU readmission. We examined accuracy metrics and complementarity between NSTs and GLIM criteria about clinical outcomes through logistic regression and Cox regression. We established a four-category independent variable: NR(-)/GLIM(-) as the reference, NR(-)/GLIM(+), NR(+)/GLIM(-), and NR(+)/GLIM(+). RESULTS: Of the 377 patients analyzed (median age 64 years [interquartile range: 54-71] and 53.8% male), NR prevalence varied from 87% to 40.6%, whereas 64% presented malnutrition (GLIM criteria). NRS-2002 (score ≥4) showed superior accuracy for GLIM-based malnutrition. Multivariate analysis revealed mNUTRIC(+)/GLIM(+) increased >2 times in the likelihood of ICU and in-hospital mortality, ICU and hospital LOS, and ICU readmission compared with the reference group. CONCLUSION: No NST exhibited satisfactory complementarity to the GLIM criteria in our study, emphasizing the necessity for comprehensive nutrition assessment for all patients, irrespective of NR status. We recommend using mNUTRIC if the ICU team opts for nutrition screening, as it demonstrated superior prognostic value compared with NRS-2002, and applying GLIM criteria in all patients.

Remote nutrition care during the first wave of COVID-19 pandemic: Did it impact nutrition therapy goals?

BACKGROUND AND AIMS: Nutrition societies recommended remote hospital nutrition care during the coronavirus disease 2019 (COVID-19) pandemic. However, the pandemic's impact on nutrition care quality is unknown. We aimed to evaluate the association between remote nutrition care during the first COVID-19 wave and the time to start and achieve the nutrition therapy (NT) goals of critically ill patients. METHODS: A cohort study was conducted in an intensive care unit (ICU) that assisted patients with COVID-19 between May 2020 and April 2021. The remote nutrition care lasted approximately 6 months, and dietitians prescribed the nutrition care based on medical records and daily telephone contact with nurses who were in direct contact with patients. Data were retrospectively collected, patients were grouped according to the nutrition care delivered (remote or in person), and we compared the time to start NT and achieve the nutrition goals. RESULTS: One hundred fifty-eight patients (61.5 ± 14.8 years, 57% male) were evaluated, and 54.4% received remote nutrition care. The median time to start NT was 1 (1-3) day and to achieve the nutrition goals was 4 (3-6) days for both groups. The percentage of energy and protein prescribed on day 7 of the ICU stay concerning the requirements did not differ between patients with remote and patients with in-person nutrition care [95.5% ± 20.4% × 92.1% ± 26.4% (energy) and 92.9% ± 21.9% × 86.9% ± 29.2% (protein); P > 0.05 for both analyses]. CONCLUSION: Remote nutrition care in patients critically ill with COVID-19 did not impact the time to start and achieve the NT goals.

Absence of association between low calf circumference, adjusted or not for adiposity, and ICU mortality in critically ill adults: A secondary analysis of a cohort study.

BACKGROUND: Despite its correlation with skeletal muscle mass and its predictive value for adverse outcomes in clinical settings, calf circumference is a metric underexplored in intensive care. We aimed to determine whether adjusting low calf circumference for adiposity provides prognostic value superior to its unadjusted measurement for intensive care unit (ICU) mortality and other clinical outcomes in critically ill patients. METHODS: In a secondary analysis of a cohort study across five ICUs, we assessed critically ill patients within 24 h of ICU admission. We adjusted calf circumference for body mass index (BMI) (25-29.9, 30-39.9, and ≥40) by subtracting 3, 7, or 12 cm from it, respectively. Values ≤34 cm for men and ≤33 cm for women identified low calf circumference. RESULTS: We analyzed 325 patients. In the primary risk-adjusted analysis, the ICU death risk was similar between the low and preserved calf circumference (BMI-adjusted) groups (hazard ratio, 0.90; 95% CI, 0.47-1.73). Low calf circumference (unadjusted) increased the odds of ICU readmission 2.91 times (95% CI, 1.40-6.05). Every 1-cm increase in calf circumference as a continuous variable reduced ICU readmission odds by 12%. Calf circumference showed no significant association with other clinical outcomes. CONCLUSION: BMI-adjusted calf circumference did not exhibit independent associations with ICU and in-hospital death, nor with ICU and in-hospital length of stay, compared with its unadjusted measurement. However, low calf circumference (unadjusted and BMI-adjusted) was independently associated with ICU readmission, mainly when analyzed as a continuous variable.

Association of reduced BMI, length of hospital stay, mortality, and malnutrition diagnosis in patients with acute exacerbation COPD: A secondary analysis of a cohort study.

BACKGROUND: Body mass index (BMI) presents prognostic value in chronic obstructive pulmonary disease (COPD), and despite its limitations in capturing malnutrition, its use is common to assess nutritional status. We aimed to confirm the association between BMI and in-hospital outcomes in acute exacerbation of COPD (AECOPD) and its inaccuracy in diagnosing malnutrition. METHODS: We diagnosed malnutrition using the Subjective global assessment (SGA), Academy of Nutrition and Dietetics-American Society for Parenteral and Enteral Nutrition (AND-ASPEN), and two cutoff values for reduced BMI (age-related and ≤ 21.0). BMI accuracy was assessed using the area under the receiver operating characteristic (AUC-ROC) curve and SGA and AND-ASPEN as references. We evaluated in-hospital mortality and hospital stay outcomes and constructed logistic regression models. RESULTS: The median hospital stay was 11 (7-18) days, and 7.5% of patients died. Malnutrition prevalence according to BMI, SGA, and AND-ASPEN was 21.4% (mean of both cutoff values), 50%, and 54%, respectively. Reduced BMI presented low agreement (κ = 0.315-0.383) and unsatisfactory accuracy (AUC-ROC curve = 0.333-0.679) with reference methods for malnutrition diagnosis. Age-related reduced BMI (odds ratio [OR] = 2.11; 95% CI, 1.10-4.04) and BMI ≤ 21.0 (OR = 2.25; 95% CI, 1.13-4.48) were associated with hospital stays longer than the median in adjusted models, but not in-hospital mortality. CONCLUSION: BMI was inaccurate in identifying malnutrition in hospitalized patients with AECOPD and was associated with hospital stays longer than ten days.

A scoping review on the GLIM criteria for malnutrition diagnosis: Understanding how and for which purpose it has been applied in studies on hospital settings.

AIMS: This scoping review aimed to identify and map the literature on malnutrition diagnosis made using the GLIM criteria in hospitalized patients. METHODS: The scoping review was conducted using the Joanna Briggs Institute's methodology. We searched PubMed, Embase, Scopus, and Web of Science (until 16 April 2022) to identify studies based on the 'population' (adults or elderly patients), 'concept' (malnutrition diagnosis by the GLIM criteria), and 'context' (hospital settings) framework. Titles/abstracts were screened, and two independent reviewers extracted data from eligible studies. RESULTS: Ninety-six studies were eligible (35.4% from China, 30.2% involving oncological patients, and 30.5% with prospective data collection), 32 followed the two-step GLIM approach, and 50 applied all the criteria. All the studies evaluated body mass index (BMI), while 92.7% evaluated weight loss; 77.1%, muscle mass; 93.8%, inflammation; and 70.8%, energy intake. A lack of details on the methods adopted for criterion evaluation was observed in five (muscle mass evaluation) to 40 studies (energy intake evaluation). The frequency of the use of the GLIM criteria ranged from 22.2% (frequency of low BMI) to 84.7% (frequency of inflammation), and the malnutrition prevalence ranged from 0.96% to 87.9%. Less than 30% of studies aimed to assess the GLIM criterion validity, eight studies cited the guidance on validation of the GLIM criteria, and a minority implemented it. CONCLUSIONS: This map of studies on the GLIM criteria in hospital settings demonstrated that they are applied in a heterogeneous manner, with a wide range of malnutrition prevalence. Almost 50% of the studies applied all the criteria, while one-third followed the straightforward two-step approach. The recommendations of the guidance on validation of the criteria were scarcely adhered to. The gaps that need to be explored in future studies have been highlighted.

Complementarity of nutritional screening tools to GLIM criteria on malnutrition diagnosis in hospitalised patients: A secondary analysis of a longitudinal study.

BACKGROUND & AIMS: The Global Leadership Initiative on Malnutrition (GLIM) proposed a two-step approach for the malnutrition diagnosis: screening to identify "at risk" patients by any validated nutritional screening tool (NST), followed by a detailed nutritional assessment for diagnosis and grading the severity of malnutrition. Since there are several validated NST, this study aimed to evaluate the complementarity of five NST to GLIM criteria for malnutrition diagnosis in a sample of hospitalized patients. METHODS: A secondary analysis of a longitudinal study. Data collection occurred within 48 h of hospital admission and included clinical, sociodemographic and nutritional data. We applied five tools for nutritional risk (NR) screening: Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), Nutritional Risk in Emergency-2017 (NRE-2017), Nutritional Risk Screening - 2002 (NRS-2002), and Short Nutritional Assessment Questionnaire (SNAQ). GLIM criteria were applied to malnutrition diagnosis considering all five criteria. Patients were followed up until discharge to assess hospital length of stay (LOS) and in-hospital mortality and contacted six months post-discharge to assess hospital readmission and death. We calculated the sensitivity, specificity, predictive positive and negative values (PPV and NPV), and kappa. We grouped patients according to NR and malnutrition status in four categories [i.e. NR(+)/GLIM(+)] and investigated their associations with the clinical outcomes in regression models adjusted to the Charlson Comorbidity Index. RESULTS: Among the 601 patients included (55.8 ± 14.8 years, 51.4% males), 41.6% were malnourished by GLIM criteria. The frequency of NR ranged from 24.0% (NRE-2017) to 35.8% (NRS-2002). MUST had the highest sensitivity (73.6%), NPV (83.6%) and PPV (93.4%). All NST presented specificity higher than 90%, except NRS-2002. The accuracy of NST ranged from 76.3% (SNAQ) to 86.8% (MUST). NR (+)/GLIM (+) by NRE-2017, MST, and MUST increased the risk of in-hospital mortality (HR ranged from 5.34 to 10.10). NR (+)/GLIM (+) increased the odds of LOS ≥10 days (RR between 2.11 and 3.01), readmission (RR between 1.51 and 1.80), and mortality six months after discharge (RR between 3.91 and 5.12), regardless of the NST applied. CONCLUSION: MUST presented the highest metrics of accuracy in comparison to GLIM criteria and was an independent predictor of worse clinical outcomes when nutritional risk was combined to malnutrition diagnosis. So, risk screening by MUST is suggested as the first step of the GLIM approach.

Increased energy and/or protein intake improves anthropometry and muscle strength in chronic obstructive pulmonary disease patients: a systematic review with meta-analysis on randomised controlled clinical trials.

Compromised nutritional status is associated with a poor prognosis in chronic obstructive pulmonary disease (COPD) patients. However, the impact of nutritional support in this group of patients is controversial. The present study systematically reviewed the effect of energy and or protein supplements or food fortification on anthropometry and muscle strength of COPD patients. We searched MEDLINE (PubMed), EMBASE, Cochrane Library and Scopus for all published randomised clinical trials without language restriction up to May 2021. Three reviewers performed study selection and data extraction independently. We judged the risk of bias by RoB 2 and the certainty of evidence by the GRADE approach. We included thirty-two randomised controlled trials and compiled thirty-one of them (1414 participants) in the random-effects model meta-analyses. Interventions were energy and/or protein oral nutritional supplements or food fortification added to the diet for at least one week. Pooled analysis revealed that nutritional interventions increased body weight (muscle circumference (MD) = 1·44 kg, 95 % CI 0·81, 2·08, I2 = 73 %), lean body mass (standardised mean difference (SMD) = 0·37; 95 % CI 0·15, 0·59, I2 = 46 %), midarm muscle circumference (MD = 0·29 mm2, 95 % CI 0·02, 0·57, I2 = 0 %), triceps skinfold (MD = 1·09 mm, 95 % CI 0·01, 2·16, I2 = 0 %) and handgrip strength (SMD = 0·39, 95 % CI 0·07, 0·71, I2 = 62 %) compared with control diets. Certainty of evidence ranged from very low to low, and most studies were judged with some concerns or at high risk of bias. This meta-analysis revealed, with limited evidence, that increased protein and/or energy intake positively impacts anthropometric measures and handgrip strength of COPD patients.

Markers of respiratory function response to high-carbohydrate and high-fat intake in patients with lung diseases: a systematic review with meta-analysis of randomized clinical trials.

BACKGROUND: Macronutrients can differently affect respiratory function markers such as VO2 , VCO2 , PaO2 , PaCO2 , and respiratory quotients (RQs), but systematic appraisal of the evidence on randomized clinical trials (RCTs) is lacking. OBJECTIVE: The objective of this work is to compare the response of respiratory function markers with high-carbohydrate and high-fat intake in patients with lung diseases. METHODS: Systematic review conducted according to Cochrane Collaboration recommendations, reported following Preferred Reporting Items for Systematic Reviews and Meta-Analysis for pairwise systematic reviews of interventions 2020. PubMed, EMBASE, Scopus, and Cochrane CENTRAL were searched up to July 2021. Two reviewers selected the RCTs and extracted the data. Risk of bias and the certainty of evidence were assessed by RoB 2 and Grading of Recommendations Assessment, Development, and Evaluation System criteria, respectively. Statistical and graphical data guided the publication bias investigation. Meta-analyses were conducted. RESULTS: We included 14 RCTs (362 participants), four of which were parallel. Most studies included patients with chronic obstructive pulmonary disease. High-fat intake decreased VCO2 (mean difference [MD] = -35.89 ml/min [95% confidence interval (CI), -45.24 to -26.21]); I² = 0%), VO2 (MD = -29.30 ml/min [95% CI, -40.94 to -17.66]; I² = 0%), PaCO2 mm Hg (MD = -4.62 [95% CI, -7.67 to -1.58]; I² = 84%), and RQ (MD = -0.08 [95% CI, -0.09 to -0.06]; I² = 0%) in the subset of parallel RCTs. In crossover RCTs, there was generally no evidence of effect except for a greater decrease in RQ (MD = -0.09 [95% CI, -0.12 to -0.02]; I² = 96%) in favor of high-fat intake. CONCLUSION: High-fat intake resulted in greater reductions of VCO2 , VO2 , PaCO2 , and RQ in adult patients with lung diseases. The certainty of the evidence is very low/low, and it precludes a specific recommendation on macronutrients contribution to energy intake of these patients.

Reduced calf circumference is an independent predictor of worse quality of life, severity of disease, frequent exacerbation, and death in patients with chronic obstructive pulmonary disease admitted to a pulmonary rehabilitation program: A historic cohort study.

BACKGROUND: Muscle wasting is associated with worse outcomes in chronic obstructive pulmonary disease (COPD) patients. We assessed the association of calf circumference (CC) measurements with clinical outcomes in COPD patients referred to an outpatient pulmonary rehabilitation program (PRP). METHODS: In this single-center, retrospective study, we analyzed demographic and clinical data ( spirometry tests, comorbidities, COPD exacerbations, dyspnea scoring, exercise capacity, quality-of-life scores, BMI, CC measurements, and all-cause deaths [for 2 years]) from COPD patients PRP medical records. Patients were grouped according to CC into reduced CC (male, ≤34 cm; female, ≤33 cm) or adequate CC groups. RESULTS: We evaluated 144 patients (aged 64.6 ± 8.5 years; mostly males; forced expiratory volume in 1 s, 40.3% ± 15.8%, predicted). Eighteen patients (12.5%) died during the 2 years of follow-up. Logistic regression showed that patients with reduced CC were more likely to present worse outcomes compared with COPD patients with adequate CC: more advanced disease severity (odds ratio [OR] = 5.09; 95% CI, 2.00-12.96), COPD frequent exacerbators (OR = 2.34; 95% CI, 1.11-4.91), worse total quality-of-life score (OR = 2.70, 95% CI, 1.22-6.00), and higher mortality (OR = 3.69; 95% CI, 1.06-12.87). CONCLUSION: Reduced CC in COPD patients under initial assessment for PRP admission was associated with disease severity, frequent exacerbation, poor health status, and higher mortality in 2 years of follow-up. Considering its clinical applicability, CC measurement should be introduced in the nutrition assessment of COPD patients admitted to the PRP.

Stages of change for fruit and vegetable intake among patients with atherosclerotic disease.

This paper describes the stages of change in fruit and vegetable intake among patients with atherosclerotic disease, identifying demographic, socioeconomic, and health predictive factors for each stage of change. It is a cross-sectional study of 290 consecutive patients with atherosclerotic disease submitted to endovascular procedures in two referral hospitals. The staging algorithm included intentional and behavioral criteria, and patients were categorized into "pre-action" (pre-contemplation, contemplation, and preparation), or "action" (action, non-reflective action, and maintenance). Most of the patients were in action for the fruits intake (67.9%) and pre-action for the vegetables intake (69.1%). The logistic regression analysis for the stages of action change for fruits intake has identified as predictive factors, the higher level of education and consultation with a cardiologist. For the stages of action change for vegetable intake, absence of abdominal obesity, previous cardiac surgery, and consultation with dietitian have shown significant association. This study has shown differences in the distribution of stages of change for the fruits and vegetable intake among the patients with atherosclerotic disease. The different predictive factors for the stage of changes for fruits and vegetables suggest that approaches of nutritional orientation of the individuals must be distinct for each eating behavior.