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Cited by 268Clinical Nutrition and GastroenterologyNutrition and Health in AgingDietetics, Nutrition, and Education

Association of Nutritional Support With Clinical Outcomes Among Medical Inpatients Who Are Malnourished or at Nutritional Risk: An Updated Systematic Review and Meta-analysis

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Gomes, Filomena, Baumgartner, Annic, Bounoure, Lisa, Bally, Martina, Deutz, Nicolaas E., Greenwald, Jeffrey L., Stanga, Zeno, Mueller, Beat +1 more·2019·JAMA Network Open
DOI 10.1001/jamanetworkopen.2019.15138PMC PMC6902795
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Abstract

Importance: Malnutrition affects a considerable proportion of the medical inpatient population. There is uncertainty regarding whether use of nutritional support during hospitalization in these patients positively alters their clinical outcomes. Objective: To assess the association of nutritional support with clinical outcomes in medical inpatients who are malnourished or at nutritional risk. Data Sources: For this updated systematic review and meta-analysis, a search of the Cochrane Library, MEDLINE, and Embase was conducted from January 1, 2015, to April 30, 2019; the included studies were published between 1982 and 2019. Study Selection: A prespecified Cochrane protocol was followed to identify trials comparing oral and enteral nutritional support interventions with usual care and the association of these treatments with clinical outcomes in non-critically ill medical inpatients who were malnourished. Data Extraction and Synthesis: Two reviewers independently extracted data and assessed risk of bias; data were pooled using a random-effects model. Main Outcomes and Measures: The primary outcome was mortality. The secondary outcomes included nonelective hospital readmissions, length of hospital stay, infections, functional outcome, daily caloric and protein intake, and weight change. Results: A total of 27 trials (n = 6803 patients) were included, of which 5 (n = 3067 patients) were published between 2015 and 2019. Patients receiving nutritional support compared with patients in the control group had significantly lower rates of mortality (230 of 2758 [8.3%] vs 307 of 2787 [11.0%]; odds ratio [OR], 0.73; 95% CI, 0.56-0.97). A sensitivity analysis suggested a more pronounced reduction in the risk of mortality in recent trials (2015 or later) (OR, 0.47; 95% CI, 0.28-0.79) compared with that in older studies (OR, 0.94; 95% CI, 0.72-1.22), in patients with established malnutrition (OR, 0.52; 95% CI, 0.34-0.80) compared with that in patients at nutritional risk (OR, 0.85; 95% CI, 0.62-1.18), and in trials with high protocol adherence (OR, 0.67; 95% CI, 0.54-0.84) compared with that in trials with low protocol adherence (OR, 0.88; 95% CI, 0.44-1.76). Nutritional support was also associated with a reduction in nonelective hospital readmissions (14.7% vs 18.0%; risk ratio, 0.76; 95% CI, 0.60-0.96), higher energy intake (mean difference, 365 kcal; 95% CI, 272-458 kcal) and protein intake (mean difference, 17.7 g; 95% CI, 12.1-23.3 g), and weight increase (0.73 kg; 95% CI, 0.32-1.13 kg). No significant differences were observed in rates of infections (OR, 0.86; 95% CI, 0.64-1.16), functional outcome (mean difference, 0.32; 95% CI, -0.51 to 1.15), and length of hospital stay (mean difference, -0.24; 95% CI, -0.58 to 0.09). Conclusions and Relevance: This study's findings suggest that despite heterogeneity and varying methodological quality among trials, nutritional support was associated with improved survival and nonelective hospital readmission rates among medical inpatients who were malnourished and should therefore be considered when treating this population.

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  • In the meta-analysis by Gomes et al., analysis of 27 trials resulted in lower mortality rates in patients receiving nutritional care vs controls (230 of 2758 [8.3%] vs 307 of 2787 [11.0%]; OR 0.73; 95% CI 0.56 to 0.97).

    “Similarly, improved survival in medical inpatients receiving nutritional support was reported in the meta-analysis by Gomes et al.where the analysis of 27 trials resulted in lower mortality rates in patients receiving nutritional care vs. the controls (230 of 2758 [8.3%] vs. 307 of 2787 [11.0%];OR 0.73; 95% CI, 0.56e0.97)[35].”

    From ESPEN guideline on nutritional support for polymorbid medical inpatients (2023) · cites this paper as [35]

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  • Nutrition support was associated with lower non-elective hospitalizations (14.7% vs 18.0%; RR 0.76; 95% CI 0.60 to 0.96).

    “Nutrition support was also associated with lower non-elective hospitalizations 14.7% vs. 18.0%;RR 0.76; 95% CI 0.60 to 0.96) improved energy and protein intake (mean difference of 365 kcal, 95% CI 272e458 kcal for energy and mean difference of 17.7 g, 95% CI 12.1e23.3g for protein), and improvements in nutritional and functional status (Level of evidence 1þþ).”

    From ESPEN guideline on nutritional support for polymorbid medical inpatients (2023) · cites this paper as [35]

    The Results (Secondary Outcomes) report the stated rates and risk ratio for nonelective hospital readmissions. The claim calls these nonelective hospitalizations, which is broader than the readmissions measured in the source. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • Nutrition support was associated with improvements in nutritional and functional status.

    “Nutrition support was also associated with lower non-elective hospitalizations 14.7% vs. 18.0%;RR 0.76; 95% CI 0.60 to 0.96) improved energy and protein intake (mean difference of 365 kcal, 95% CI 272e458 kcal for energy and mean difference of 17.7 g, 95% CI 12.1e23.3g for protein), and improvements in nutritional and functional status (Level of evidence 1þþ).”

    From ESPEN guideline on nutritional support for polymorbid medical inpatients (2023) · cites this paper as [35]

    The Results (Secondary Outcomes) report higher energy and protein intake and a significant increase in body weight with nutritional support. They report no overall difference in functional outcome at follow-up (Barthel index mean difference, 0.32 points; 95% CI, −0.51 to 1.15). The Discussion likewise says improved functional outcomes were not observed in the overall analysis. (LLM, conf=0.92)

    Experimental — accuracy not yet measured

  • The 2019 systematic review reported a 27% reduction in mortality and non-elective hospital readmissions.

    “The review included 27 RCTs from several countries comprising 6803 medical inpatients, and reported a 27% reduction in mortality and non-elective hospital readmissions [35].”

    From ESPEN guideline on nutritional support for polymorbid medical inpatients (2023) · cites this paper as [35]

    The Discussion describes an updated review of 27 studies comprising 6,803 patients. Results > Primary Outcome reports lower mortality with nutritional support (OR 0.73, or 27% lower odds), but Results > Secondary Outcomes reports nonelective readmissions at RR 0.76, or 24% lower risk—not 27%. (LLM, conf=0.93)

    Experimental — accuracy not yet measured

  • Nutrition support was associated with improved energy and protein intake (mean difference of 365 kcal, 95% CI 272 to 458 kcal for energy and mean difference of 17.7 g, 95% CI 12.1 to 23.3 g for protein).

    “Nutrition support was also associated with lower non-elective hospitalizations 14.7% vs. 18.0%;RR 0.76; 95% CI 0.60 to 0.96) improved energy and protein intake (mean difference of 365 kcal, 95% CI 272e458 kcal for energy and mean difference of 17.7 g, 95% CI 12.1e23.3g for protein), and improvements in nutritional and functional status (Level of evidence 1þþ).”

    From ESPEN guideline on nutritional support for polymorbid medical inpatients (2023) · cites this paper as [35]

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Authors
Gomes, F., Baumgartner, A., Bounoure, L., Bally, M., Deutz, N. E., Greenwald, J. L., Stanga, Z., Mueller, B., & Schuetz, P.
Affiliations
  • New York Academy of Sciences (US)
  • University of Basel (CH)
  • Texas A&M University (US)
  • Massachusetts General Hospital (US)
  • University of Bern (CH)
  • University Department of Medicine, Clinic for Endocrinology, Diabetology, and Metabolism, Kantonsspital Aarau, Aarau, Switzerland and Medical Faculty of the University of Basel, Basel, Switzerland
ORCID
Venue
JAMA Network Open
Publisher
American Medical Association (AMA)
Published
2019-11-20
Volume
2
Issue
11
Pages
e1915138
ISSN
2574-3805 (ISSN-L)
DOI
10.1001/jamanetworkopen.2019.15138
PMC
PMC6902795
OpenAlex
W2990441532
Cited by
268
References
5
Citations by year
2026: 26 · 2025: 40 · 2024: 44 · 2023: 42 · 2022: 46 · 2021: 40 · 2020: 27 · 2019: 3
FWCI
3.94
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • JAMA Network Open (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Bern Open Repository and Information System (University of Bern) (submittedVersion, cc-by)
  • Open Access CRIS of the University of Bern
Funders
  • National Science Foundation
  • Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung (150531)
Topics
  • Health Sciences › Nursing › Nutrition and Dietetics › Clinical Nutrition and Gastroenterology
  • Health Sciences › Medicine › Physiology › Nutrition and Health in Aging
  • Health Sciences › Health Professions › Health Information Management › Dietetics, Nutrition, and Education
Keywords
nutritional support, malnutrition, nutritional risk, medical inpatients, enteral nutrition, oral nutritional supplementation, mortality, hospital readmission, length of hospital stay, infection, functional outcome, weight change, non-critically ill patients
MeSH terms
Adult, Hospitalization, Humans, Inpatients, Nutritional Status, Quality of Health Care, Outcome Assessment, Health Care, Malnutrition, Nutrition Therapy

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