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Cited by 106Clinical Nutrition and GastroenterologyNutrition and Health in AgingDietetics, Nutrition, and Education

ESPEN guideline on nutritional support for polymorbid medical inpatients

Open access
Wunderle, Carla, Gomes, Filomena, Schuetz, Philipp, Stumpf, Franziska, Austin, Peter, Ballesteros-Pomar, María D., Cederholm, Tommy, Fletcher, Jane +6 more·2023·Clinical Nutrition
DOI 10.1016/j.clnu.2023.06.023
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Abstract

BACKGROUND: Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and cost of care. AIM: As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards. METHODS: This update adheres to the standard operating procedures for ESPEN guidelines. We did a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g. published guidelines), until July 12th. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (incl. SIGN grading), which was followed by submission to Delphi voting. RESULTS: From a total of 3527 retrieved abstracts, 60 new relevant studies were analyzed and used to generate a guideline draft that proposed 32 recommendations (7x A, 11x B, 10x O and 4x GPP), which encompass different aspects of nutritional support including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. The results of the first online voting showed a strong consensus (agreement of >90%) on 100% of the recommendations. Therefore, no final consensus conference was needed. CONCLUSIONS: Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated guideline offers an evidence-based nutritional approach to the polymorbid medical inpatients and may improve their outcomes.

AI snapshot

Written from the paper’s full text.

TL;DR

This ESPEN guideline update provides 32 evidence-based recommendations on nutritional support for polymorbid medical inpatients, covering screening, assessment, energy/protein requirements, intervention, monitoring, and post-discharge continuation. It concludes that timely screening and individualized nutritional support can reduce morbidity and complications in this population.

Key findings

  • From 3527 screened abstracts, 60 new relevant studies were analyzed and a total of 100 studies were included; the guideline proposes 32 recommendations (7 A, 11 B, 10 O, 4 GPP), with >90% agreement on 100% of recommendations in the first online Delphi vote.
  • In a meta-analysis restricted to polymorbid patients using the guideline’s definition, nutritional support significantly reduced mortality (OR 0.68; 95% CI 0.51–0.91) and hospital readmissions (OR 0.64; 95% CI 0.45–0.90).
  • The EFFORT trial reported lower adverse clinical outcomes (adjusted OR 0.79, 95% CI 0.64–0.97) and lower 30-day mortality (adjusted OR 0.65, 95% CI 0.47–0.91) with individualized nutritional support targeting 1.2–1.5 g protein/kg/day, with per-patient cost savings of 199 € within 30 days.
  • Continued post-discharge nutritional support lowered mortality in a meta-analysis of 2438 patients (OR 0.63, 95% CI 0.48–0.84); in NOURISH, 90-day mortality was 4.8% vs 9.7% (RR 0.49, 95% CI 0.27–0.90, p=0.018).

Methods

  • Update of the 2018 ESPEN guideline following ESPEN standard operating procedures, conducted by a multidisciplinary team of 14 European specialists; it retained 12 PICO questions and addressed 3 non-PICO topics, with a new question on biomarkers predicting treatment response.
  • Systematic literature search for 15 clinical questions in Medline, Embase, and the Cochrane Library, plus secondary sources, with the primary-source update performed on 12 July 2022 since April 2016; abstracts were screened, full texts reviewed, and discrepancies resolved by consensus or a third reviewer.
  • Evidence was graded using SIGN, recommendations were drafted and submitted to online Delphi voting in April 2023; because of strong consensus on the first vote, no final consensus conference was held.

Limitations

  • The paper states that the rigorous methodological approach led to a lower number of included trials, that many published studies did not report multiple comorbidities or use typical key terms, and that there are no MeSH terms dedicated to multiple chronic conditions; authors were contacted for 16 papers, and for 11 unreachable papers the working group made consensus decisions (7 included, 4 excluded).
  • The paper states that some included studies were conducted in older populations, and that evidence for certain recommendations (e.g., recommendations 11, 22, and 23) is limited to the subgroup of polymorbid older patients; for some questions no studies were identified (e.g., comparing energy prediction equations with weight-based formulae, and multivitamin/multi-trace-element supplementation vs no supplements in exclusively orally fed polymorbid inpatients).
  • Evident from the text: many recommendations are graded O or GPP (10 O, 4 GPP), and several cited studies are small, non-randomized, underpowered for clinical outcomes, or at high risk of bias; the authors repeatedly call for further large-scale and head-to-head trials.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.clnu.2023.06.023

Cites

201 of 202 references verified0 citation errors · 1 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

105 of 263 cited sources checked · 42 supported · 5 flagged · accuracy not yet measured

  • Premisecitation

    In a study of 395 inpatients referred for nutritional support, no single prediction equation was accurate (within 90-110% of measured REE) in the majority of the population.

    “In this study the authors concluded that no single prediction equation was accurate (i.e.within 90e110% of measured REE) in the majority of the population.”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [63] Harris, 1918, A biometric study of human basal metabolism, Proc Natl Acad Sci USA source

      The Abstract identifies the study population as 136 men, 103 women, and 94 newborn infants who were presumably in good health—not 395 inpatients referred for nutritional support. It presents regression equations for predicting basal metabolism but does not report the claimed 90–110% accuracy assessment or conclusion. (LLM, conf=0.88)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
    • cites [64] Ireton-Jones, 1997, Comparison of the metabolic response to burn injury in obese and nonobese patients, J Burn Care Rehabil source
    • cites [69] Mifflin, 1990, A new predictive equation for resting energy expenditure in healthy individuals, Am J Clin Nutr source
  • Premisecitation

    In a subgroup analysis of EFFORT, patients with aging-related vulnerability receiving individualized early nutritional support compared with routine hospital food showed a >50% reduction in the risk of 30-day mortality (OR 0.48, 95% CI 0.31 to 0.76; p=0.002).

    “In a subgroup analysis of EFFORT, patients with aging-related vulnerability receiving individualized early nutritional support compared with routine hospital food showed a >50% reduction in the risk of 30-day mortality (OR 0.48 95% CI 0.31 to 0.76; p ¼ 0.002) [106].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [106] Baumgartner, 2020, Effect of nutritional support in patients with lower respiratory tract infection: secondary analysis of a randomized clinical trial, Clin Nutr source

      Split into 2 atoms — 0 confirmed, 1 partially supported, 1 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
  • Premisecitation

    In a secondary analysis of the EFFORT trial, an untargeted proteomics approach found that metabolites had only little prognostic and therapeutic potential for phenotyping the risk of malnutrition and response to nutritional therapy, due to high heterogeneity and small sample size.

    “They concluded, due to high heterogeneity and small sample size, that so far the metabolites had only little prognostic and therapeutic potential for phenotyping the risk of malnutrition and response to nutritional therapy [194] (Level of evidence 1þþ).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [194] Struja, 2021, Association of metabolomic markers and response to nutritional support: a secondary analysis of the EFFORT trial using an untargeted metabolomics approach, Clin Nutr source

      Split into 2 atoms — 1 confirmed, 0 partially supported, 1 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
  • Premisecitation

    Recent large randomized controlled trials over the last five years have provided important new evidence showing that nutritional support can reduce morbidity and other complications in polymorbid patients.

    “Yet, recent large randomized controlled trials (RCT) over the last five years have provided important new evidence showing that nutritional support can reduce morbidity and other complications in polymorbid patients, which may help us to answer these question and formulate evidence-based recommendations [8,9].”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [8] Schuetz, 2019, Individualised nutritional support in medical inpatients at nutritional risk: a randomised clinical trial, Lancet source
    • cites [9] Deutz, 2016, Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: a randomized clinical trial, Clin Nutr source

      The Discussion describes NOURISH as a large randomized trial in malnourished older adults hospitalized for several conditions. The Results (§3.3; page unavailable) report lower 90-day mortality with the specialized supplement, but no significant reduction in readmissions or the primary composite outcome. The Safety results (§3.5; page unavailable) also do not show fewer adverse events, so this trial does not establish the claimed reduction in morbidity and other complications across polymorbid patients. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
  • Premisecitation

    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].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [35] Gomes, 2019, Association of nutritional support with clinical outcomes among medical inpatients who are malnourished or at nutritional risk: an updated systematic review and meta-analysis, JAMA Netw Open source

      Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured
  • May combine two claims. 99
  • Classified as probably not a substantial claim. 43
  • The quote only partly states this claim. 4

  • May combine two claims.

    Premisecitation

    Compared to usual care, individualized nutrition with protein targets of 1.2-1.5 g/kg/day in polymorbid patients was associated with significantly lower odds for adverse outcomes (OR 0.79, 95% CI 0.64 to 0.97) and 30-day mortality (OR 0.65, 95% CI 0.47 to 0.91), while functional status via BI and QoL significantly increased.

    “Compared to the usual care CG, odds for adverse outcomes and 30-day mortality were significantly lower in patients receiving individualized nutrition with these protein targets (OR 0.79, 95% CI 0.64 to 0.97 and OR 0.65, 95% CI 0.47 to 0.91 respectively), while functional status via BI, and QoL significantly increased.”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [8] Schuetz, 2019, Individualised nutritional support in medical inpatients at nutritional risk: a randomised clinical trial, Lancet source
    • cites [37] Kaegi-Braun, 2021, Six-month outcomes after individualized nutritional support during the hospital stay in medical patients at nutritional risk: secondary analysis of a prospective randomized trial, Clin Nutr source

      Split into 2 atoms — 0 confirmed, 1 partially supported, 1 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
    • cites [46] Schuetz, 2020, Economic evaluation of individualized nutritional support in medical inpatients: secondary analysis of the EFFORT trial, Clin Nutr source

      Split into 2 atoms — 0 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Readmission rates were significantly reduced after six months of nutritional intervention in several trials but not all.

    “it was significantly reduced after six months of nutritional intervention in several trials (level of evidence: 1-) [116] (level of evidence: 1þ) [130] (level of evidence: 1þþ) [126] but not all (level of evidence: 1þ) [125].”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [116] Feldblum, 2011, Individualized nutritional intervention during and after hospitalization: the nutrition intervention study clinical trial, J Am Geriatr Soc source
    • cites [130] Yang, 2019, Effect of nutritional intervention programs on nutritional status and readmission rate in malnourished older adults with pneumonia: a randomized control trial, Int J Environ Res Publ Health source

      The citation to this paper is attached to “but not all,” implying that its trial did not find a significant reduction. In Results §3.6, the paper instead reports a significantly lower six-month pneumonia readmission rate in the nutritional-intervention group than in the standard-care group after adjustment for sex (p = 0.03). (LLM, conf=0.90)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
    • cites [126] Bonilla-Palomas, 2016, Nutritional intervention in malnourished hospitalized patients with heart failure, Arch Med Res source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    More than half of all people affected with polymorbidity are younger than 65 years.

    “Whilst the prevalence increases with age, more than half of all people affected with this problem are younger than 65 years [11].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [11] Barnett, 2012, Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study, Lancet source

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Clinicians struggle with the uncertainties of applying disease-specific guidelines to patients with multiple conditions and would benefit from tools to assist decision making for this population.

    “Fried et al. showed that clinicians struggle with the uncertainties of applying disease-specific guidelines to their patients with multiple conditions, and would therefore benefit from a number of tools to assist them in decision making for this population [12].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [12] Fried, 2011, Primary care clinicians' experiences with treatment decision making for older persons with multiple conditions, Arch Intern Med source

  • May combine two claims.

    Premisecitation

    The current single-disease healthcare approach has been challenged because clinical guidelines are largely created for individual diseases and rarely account for polymorbidity.

    “In this context, the current single-disease healthcare approach has been challenged, as clinical guidelines are largely created for individual diseases and rarely account for polymorbidity [11].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [11] Barnett, 2012, Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study, Lancet source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Polymorbidity is associated with higher mortality and healthcare burden.

    “Polymorbidity is highly prevalent, affecting more than 70% of the hospitalized adult population, and is associated with higher mortality and healthcare burden [10].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [10] Steiner, 2013, Hospital utilization, costs, and mortality for adults with multiple chronic conditions, Nationwide Inpatient Sample, 2009, Prev Chronic Dis source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The Charlson comorbidity index is the most extensively studied comorbidity index and is considered a valid and reliable method to measure comorbidity in clinical research.

    “The Charlson comorbidity index is the most extensively studied comorbidity index and is considered a valid and reliable method to measure comorbidity that can be used in clinical research [6,14].”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [6] Charlson, 2022, Charlson comorbidity index: a critical review of clinimetric properties, Psychother Psychosom source

      The Conclusions state that the CCI is a reliable and valid index for assessing comorbidity in clinical research and practice. The Methods note extensive literature on the CCI, including more than 36,925 citations of its original version, but do not establish that it is the most extensively studied comorbidity index. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [14] de Groot, 2003, How to measure comorbidity: a critical review of available methods, J Clin Epidemiol source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The prevalence of polymorbidity increases with age.

    “Whilst the prevalence increases with age, more than half of all people affected with this problem are younger than 65 years [11].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [11] Barnett, 2012, Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study, Lancet source

  • May combine two claims.

    Premisecitation

    Polymorbidity is associated with increased health service utilization and poorer health outcomes.

    “Additionally polymorbidity is associated with increased health service utilization and poorer health outcomes [6,7], demonstrating the relevance of proper treatment for polymorbid patients.”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [6] Charlson, 2022, Charlson comorbidity index: a critical review of clinimetric properties, Psychother Psychosom source

      The Sensitivity section reports that mortality increased stepwise with increasing comorbidity, supporting the poorer-outcomes part of the claim. The Discussion says the review did not focus on multimorbidity or outcomes such as readmissions, length of stay, and cost. A References entry mentions health service use, but the paper's text does not establish the claimed increase in utilization. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [7] Huntley, 2012, Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide, Ann Fam Med source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Polymorbidity affects more than 70% of the hospitalized adult population.

    “Polymorbidity is highly prevalent, affecting more than 70% of the hospitalized adult population, and is associated with higher mortality and healthcare burden [10].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [10] Steiner, 2013, Hospital utilization, costs, and mortality for adults with multiple chronic conditions, Nationwide Inpatient Sample, 2009, Prev Chronic Dis source

      The Abstract Results report that 39% of adult discharges had 2–3 chronic conditions and 33% had 4 or more—72% combined—but exclude pregnancy- and maternity-related discharges. The Summary says nearly 66% of all adult discharges had two or more chronic conditions. Thus, the claim's unqualified figure of more than 70% for the hospitalized adult population overstates the paper's broader estimate; the paper also measures discharges rather than unique people. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    NRS 2002 and MNA-SF are rapid, easily undertaken and show a high degree of content validity and reliability, making them suitable in polymorbid medical inpatients including those with cognitive dysfunction.

    “Both of these tools are rapid, easily undertaken and show a high degree of content validity and reliability, thereby making them suitable in polymorbid medical inpatients including those patients with cognitive dysfunction [26,27].”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [26] Hengstermann, 2008, Which are the most efficient items of mini nutritional assessment in multimorbid patients?, J Nutr Health Aging source

      The Discussion (page not provided) says MNA-SF takes under five minutes and preserves diagnostic accuracy. It does not establish high content validity or reliability for MNA-SF, and its conclusion about suitability for patients with cognitive dysfunction concerns the different m-MNA. The paper does not address NRS 2002. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [27] Kondrup, 2003, ESPEN guidelines for nutrition screening 2002, Clin Nutr source

  • May combine two claims.

    Premisecitation

    In the EFFORT trial cost analysis, overall costs of care within 30 days of admission averaged 27,240 € per-patient in the intervention group versus 27,439 € in the control group, resulting in per-patient cost savings of 199 €.

    “Overall costs of care within 30 days of admission averaged 27,240 V per-patient in the IG versus 27,439 V in the CG resulting in per-patient cost savings of 199 V.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [46] Schuetz, 2020, Economic evaluation of individualized nutritional support in medical inpatients: secondary analysis of the EFFORT trial, Clin Nutr source

  • May combine two claims.

    Premisecitation

    The cost analysis of the multicenter, randomized clinical EFFORT trial showed that nutritional support for polymorbid medical inpatients is a highly cost-effective intervention to reduce risks for ICU admissions and hospital-associated complications, while improving patient survival.

    “The cost analysis of the multicenter, randomized clinical EFFORT trial showed that nutritional support for polymorbid medical inpatients is a highly cost-effective intervention to reduce risks for ICU admissions and hospital-associated complications, while improving patient survival.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [46] Schuetz, 2020, Economic evaluation of individualized nutritional support in medical inpatients: secondary analysis of the EFFORT trial, Clin Nutr source

  • May combine two claims.

    Premisecitation

    Early detection and intervention against disease-related malnutrition has been shown to improve nutritional status and reduce complications during hospital stay and non-elective readmissions.

    “Early detection and intervention against DRM has been shown to improve nutritional status and reduce complications during hospital stay and non-elective readmissions [9,43] (Level of Evidence 1þþ for both).”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [9] Deutz, 2016, Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: a randomized clinical trial, Clin Nutr source

      Section 3.4 (page unavailable) reports better nutritional status at day 90 with the supplement. But section 3.3 found no significant reduction in nonelective readmissions, and the paper does not show that early detection reduced complications during the hospital stay. The claim therefore extends beyond this trial’s findings. (LLM, conf=0.90)

      Experimental — accuracy not yet measured
    • cites [43] Gariballa, 2006, A randomized, double-blind, placebo-controlled trial of nutritional supplementation during acute illness, Am J Med source

      The Abstract reports improved nutritional status and fewer non-elective readmissions after supplementation in hospitalized patients aged 65–92. The Clinical Outcomes section reports no clinically important difference in infections or length of hospital stay, so this trial does not support the claimed reduction in complications during the hospital stay. It studied supplementation, not early detection of malnutrition. (LLM, conf=0.91)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    In the meta-analysis of Schuetz et al., overall costs of care within the model timeframe of 6 months averaged 63,227 $ per patient in the intervention group vs 66,045 $ in the control group, corresponding to per patient cost savings of 2818 $.

    “In the metaanalysis of Schuetz et al. the overall costs of care within the model timeframe of 6 months averaged 63,227 $ per patient in the IG vs. 66,045 $ in the CG, which correlate to per patient cost savings of 2818 $.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [47] Schuetz, 2021, Cost savings associated with nutritional support in medical inpatients: an economic model based on data from a systematic review of randomised trials, BMJ Open source

  • May combine two claims. The quote only partly states this claim.

    Premisecitation

    In the EFFORT trial cost analysis, economic benefits calculated to prevent adverse outcomes were 256 € for one severe complication, 2490 € for one day in ICU, and 7423 € for one death.

    “The economic benefits calculated to prevent adverse outcomes were 256 V for one severe complication, 2490 V for one day in ICU, and 7423 V for one death [46] (Level of Evidence 2þ).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [46] Schuetz, 2020, Economic evaluation of individualized nutritional support in medical inpatients: secondary analysis of the EFFORT trial, Clin Nutr source

      Section 3.2 reports exactly €256 per severe complication prevented, €2,490 per ICU day prevented, and €7,423 per death prevented. It describes these figures as costs to prevent adverse outcomes, however, not economic benefits or savings from preventing them. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    No single validated method for estimating energy requirements exists, and the evidence-base for all prediction methods currently in use is poor.

    “No single, validated method for estimating requirements exists, and the evidence-base for all prediction methods currently in use is poor [65].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [65] Reeves, 2003, Predicting energy requirements in the clinical setting: are current methods evidence based?, Nutr Rev source

  • May combine two claims.

    Premisecitation

    In pancreatitis, a meta-analysis of 11 trials (562 patients) found EN compared with PN was associated with decreased mortality (RR 0.43, 95% CI 0.23 to 0.78, p=0.006), lower risk of infection and complications (RR 0.53, 95% CI 0.39 to 0.71, p=0.000), and reduction in mean LOS (MD -2.93, 95% CI -4.52 to -1.34, p=0.000).

    “Similarly for pancreatitis, a metaanalysis including eleven trials and 562 patients found that compared with PN, EN was associated with decreased mortality (relative risk 0.43, 95% CI 0.23 to 0.78, p ¼ 0.006), a lower risk of infection and complications (RR 0.53, 95% CI 0.39 to 0.71, p ¼ 0.000) and a reduction in mean LOS (mean difference ¼ À2.93, 95% CI -4.52 to À1.34, p ¼ 0.000) [60].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [60] Wu, 2018, Efficacy comparisons of enteral nutrition and parenteral nutrition in patients with severe acute pancreatitis: a meta-analysis from randomized controlled trials, Biosci Rep source

      Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    The 2019 systematic review found significantly higher energy and protein intake, as well as beneficial effects on weight when comparing nutritional support (including counseling and oral and enteral feeding) to control group patients.

    “The review also found significantly higher energy and protein intake, as well as beneficial effects on weight when comparing nutritional support (including counseling and oral and enteral feeding) to CG patients.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [35] Gomes, 2019, Association of nutritional support with clinical outcomes among medical inpatients who are malnourished or at nutritional risk: an updated systematic review and meta-analysis, JAMA Netw Open source

  • May combine two claims.

    Premisecitation

    According to an economic evaluation of the NOURISH study by Zhong et al., provision of high protein bHMB ONS had an incremental cost-effectiveness ratio of 524 $/life years, concluding that this intervention was cost effective and positive in terms of survival for the patients.

    “According to this analysis the provision of high protein bHMB ONS had an incremental cost-effectiveness ratio (ICER) of 524 $/life years, concluding that this intervention was cost effective and positive in terms of survival for the patients [49] (Level of Evidence 1þþ).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [49] Zhong, 2017, The cost-effectiveness of oral nutrition supplementation for malnourished older hospital patients, Appl Health Econ Health Pol source

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationcitation

    Polymorbid medical inpatients requiring nutritional support shall receive 1.2-1.5 g protein/kg body weight per day as a cost-effective and highly efficient measure to prevent body weight loss, reduce complications, improve functional outcome and QoL.

    “Polymorbid medical inpatients requiring nutritional support shall receive 1.2e1.5 g protein/kg of body weight per day as a costeffective and highly efficient measure to prevent body weight loss, to reduce complications, to improve functional outcome and QoL.”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [8] Schuetz, 2019, Individualised nutritional support in medical inpatients at nutritional risk: a randomised clinical trial, Lancet source
    • cites [37] Kaegi-Braun, 2021, Six-month outcomes after individualized nutritional support during the hospital stay in medical patients at nutritional risk: secondary analysis of a prospective randomized trial, Clin Nutr source

      Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured
    • cites [46] Schuetz, 2020, Economic evaluation of individualized nutritional support in medical inpatients: secondary analysis of the EFFORT trial, Clin Nutr source

      Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Interpretationcitation

    Energy requirements in polymorbid medical inpatients can be estimated using indirect calorimetry, a published prediction equation or a weight-based formula, although the accuracy of prediction equations in this population is low.

    “Energy requirements in polymorbid medical inpatients can be estimated using indirect calorimetry (IC), a published prediction equation or a weight-based formula, although the accuracy of prediction equations in this population is low.”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [62] Branson, 2004, The measurement of energy expenditure, Nutr Clin Pract source
    • cites [65] Reeves, 2003, Predicting energy requirements in the clinical setting: are current methods evidence based?, Nutr Rev source

      The Introduction describes indirect calorimetry and prediction equations, General Estimates describes weight-based formulas, and Implication for Current Practice says current prediction methods do not determine energy requirements accurately. The review discusses clinical and hospitalized patients, but does not establish the accuracy of prediction equations specifically in polymorbid medical inpatients. Page numbers were not supplied in our copy. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [66] Boullata, 2007, Accurate determination of energy needs in hospitalized patients, J Am Diet Assoc source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    In critical care, EN compared to PN results in similar mortality but lower complication risk.

    “Albeit outside the scope of these guidelines, studies from critical care demonstrated that EN compared to PN results in similar mortality but lower complication risk.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [59] Elke, 2016, Enteral versus parenteral nutrition in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials, Crit Care source

  • May combine two claims.

    Premisecitation

    According to an analysis by Ballesteros-Pomar et al. from the perspective of the Spanish National Health System in patients included in the NOURISH study, the intervention proved to be cost effective, improved survival and marginally reduced cost of treatment.

    “According to their analysis the intervention proved to be cost effective, improved survival and marginally reduced cost of treatment [50] (Level of evidence 1þ).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [50] Ballesteros-Pomar, 2018, Cost-effectiveness of a specialized oral nutritional supplementation for malnourished older adult patients in Spain, Nutrients source

      Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    The authors calculated 820 $ to prevent a hospital-acquired infection and 733 $ to avoid a non-elective readmission.

    “The authors also calculated 820 $ to prevent a hospital-acquired infection and 733 $ to avoid a nonelective readmission [47].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [47] Schuetz, 2021, Cost savings associated with nutritional support in medical inpatients: an economic model based on data from a systematic review of randomised trials, BMJ Open source

  • May combine two claims.

    Premisecitation

    In that meta-analysis, EN compared to PN was associated with a significant reduction in infectious complications (RR 0.64, 95% CI 0.48 to 0.87, p=0.004) and ICU LOS (WMD -0.80, 95% CI -1.23 to -0.37, p=0.0003, I2=0%), with no significant differences in hospital LOS and mechanical ventilation.

    “In that meta-analysis, EN compared to PN was associated with a significant reduction in infectious complications (RR 0.64, 95% CI 0.48 to 0.87, p ¼ 0.004) and with a significant reduction in ICU LOS (weighted mean difference [WMD] À0.80, 95% CI -1.23 to À0.37, p ¼ 0.0003, I 2 ¼ 0%), while no significant differences in hospital LOS and mechanical ventilation were observed.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [59] Elke, 2016, Enteral versus parenteral nutrition in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials, Crit Care source

  • May combine two claims.

    Premisecitation

    An economic evaluation of EFFORT indicates that high-protein nutritional support was highly cost-effective with per-patient savings of 199 € of overall costs of care within 30 days of admission and 18 € in full cost analysis.

    “An economic evaluation of EFFORT indicates that the high-protein nutritional support was highly cost-effective with per-patients savings of 199 V of overall costs of care within 30 days of admission; and 18 V in full cost analysis (Level of Evidence 1þþ) [46].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [46] Schuetz, 2020, Economic evaluation of individualized nutritional support in medical inpatients: secondary analysis of the EFFORT trial, Clin Nutr source

      Section 3.2 reports savings of €199 per patient in the 30-day base-case analysis and €18.21 when dietitian costs were included; the summary calls the intervention highly cost-effective. But Section 2.3 describes individualized support aimed at both protein and energy goals, not a specifically high-protein intervention. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    In the Mexican budget-impact analysis, cost differences between groups were 2336 $ vs 3065 $ for hospital-associated costs (23.8% lower), 262 $ vs 780 $ for 30-day readmissions (66.4% lower) and 1348 $ for malnutrition-associated infections.

    “Cost differences between the groups were 2336 $ vs. 3065 $ for hospital-associated costs (23.8% lower), 262 $ vs. 780 $ for 30-day readmissions (66.4% lower) and 1348 $ for malnutrition-associated infections”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [111] Sulo, 2021, Hospital nutrition care informs potential cost-savings for healthcare: a budget impact analysis, Clinical Nutrition ESPEN source

  • Classified as probably not a substantial claim.

    Interpretationcitation

    For polymorbid medical inpatients at nutritional risk with impaired kidney function (eGFR <30 ml/min/1.73m2) who are not on kidney replacement therapy, a low amount of protein of 0.8 g protein/kg body weight/day should be targeted.

    “For polymorbid medical inpatients at nutritional risk with impaired kidney function (eGFR <30 ml/min/1.73m 2 ) who are not on kidney replacement therapy, a low amount of protein of 0.8 g protein/kg body weight/day should be targeted.”
    Quote in the paperSubstantial claim3 of 3 sources checked
    • cites [1] Gomes, 2018, ESPEN guidelines on nutritional support for polymorbid internal medicine patients, Clin Nutr source

      The Accepted Manuscript (p. 32) reports that renal-patient guidelines recommend 0.8–1 g/kg/day for at-risk or malnourished inpatients with renal failure who are not receiving renal replacement therapy. It does not specify an eGFR threshold or a fixed 0.8 g/kg/day target; it explicitly says a protein-intake recommendation cannot be made for polymorbid inpatients with a renal condition. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [88] Fiaccadori, 2021, ESPEN guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease, Clin Nutr (Edinb) source

      Recommendation 18 supports 0.8 g/kg body weight/day as the upper end of a 0.6–0.8 g/kg/day range for hospitalized patients with CKD without acute or critical illness. It does not set 0.8 g/kg/day as a target for all polymorbid inpatients at nutritional risk with eGFR <30 who are not on kidney replacement therapy; it recommends higher intakes for patients with acute or critical illness. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
    • cites [89] Bargetzi, 2021, Admission kidney function is a strong predictor for the response to nutritional support in patients at nutritional risk, Clin Nutr source

      The Study intervention section sets a target of 0.8 g/kg body weight for patients with eGFR <30, supporting the stated amount and threshold. But the Patient population section says patients on dialysis were included in the eGFR <15 group, so the paper does not limit that target to patients not receiving kidney replacement therapy. The Discussion also says the trial did not validate whether 0.8 g/kg was the optimal target. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationcitation

    Early nutritional support (provided in less than 48 h post hospital admission) compared to later nutritional support shall be performed in polymorbid medical inpatients, as mortality and adverse events are lower and lean body mass loss could be decreased and self-sufficiency could be improved.

    “Early nutritional support (i.e.provided in less than 48 h post hospital admission) compared to later nutritional support shall be performed in polymorbid medical inpatients, as mortality and adverse events are lower and lean body mass loss could be decreased and self-sufficiency could be improved.”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [8] Schuetz, 2019, Individualised nutritional support in medical inpatients at nutritional risk: a randomised clinical trial, Lancet source
    • cites [106] Baumgartner, 2020, Effect of nutritional support in patients with lower respiratory tract infection: secondary analysis of a randomized clinical trial, Clin Nutr source

      Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured
    • cites [107] Hersberger, 2021, Individualized nutritional support for hospitalized patients with chronic heart failure, J Am Coll Cardiol source

      Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured
    • Rests on an assumption: Polymorbid medical inpatients are at high risk of developing disease-related malnutrition (DRM).

  • Classified as probably not a substantial claim.

    Interpretationcitation

    In polymorbid medical inpatients with pressure ulcers, specific amino-acids (arginine and glutamine) and bHMB can be added to oral/enteral feeds to accelerate the healing of pressure ulcers.

    “In polymorbid medical inpatients with pressure ulcers, specific amino-acids (arginine and glutamine) and bHMB can be added to oral/enteral feeds to accelerate the healing of pressure ulcers.”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [100] Wong, 2014, The use of a specialised amino acid mixture for pressure ulcers: a placebo-controlled trial, J Wound Care source
    • cites [101] Miu, 2021, The use of an oral mixture of arginine, glutamine and β-Hydroxy-β-Methylbutyrate (hmb) for the treatment of high grade pressure ulcers: a randomized study, Aging Medicine and Healthcare source

      The indexed copy shows the article title, which identifies an oral arginine, glutamine and HMB mixture for treating high-grade pressure ulcers, but it does not expose the study text or results. Searches for accelerated healing, oral or enteral feeds, and the inpatient population returned only webpage material, so the claimed effect and setting cannot be checked against our copy. (LLM, conf=0.73)

      Experimental — accuracy not yet measured
    • Rests on an assumption: Pressure ulcers are responsible for protein loss, hypermetabolism and hypercatabolism, and are often associated with malnutrition, including nutrient deficiencies that are critical to the different phases of wound healing.

  • Classified as probably not a substantial claim.

    Interpretationcitation

    In severely underweight patients, the target of 30 kcal/kg actual body weight should be cautiously and slowly achieved because this population is at high risk of refeeding syndrome.

    “This target of 30 kcal/kg actual body weight in severely underweight patients should be cautiously and slowly achieved, as this is a population at high risk of refeeding syndrome.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [74] Cederholm, 2017, ESPEN guidelines on definitions and terminology of clinical nutrition, Clin Nutr source

      Section 3.2.6 (Refeeding syndrome; page unavailable) identifies severe chronic undernutrition as a high-risk condition and says refeeding syndrome can occur when feeding begins too aggressively. It does not specify a target of 30 kcal/kg actual body weight or say how slowly that target should be reached. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • Rests on an assumption: Severely underweight patients are at high risk of refeeding syndrome.

  • Classified as probably not a substantial claim.

    Interpretationcitation

    In polymorbid medical inpatients exclusively fed orally, an adequate intake of micronutrients (vitamins and trace elements) to meet daily estimated requirements should be ensured.

    “In polymorbid medical inpatients exclusively fed orally, an adequate intake of micronutrients (vitamins and trace elements) to meet daily estimated requirements should be ensured.”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [91] James, 2021, The role of nutrition in COVID-19 susceptibility and severity of disease: a systematic review, J Nutr source

      The Results, under “Nutritional support” (page unavailable), describe a protocol recommending multivitamin, multimineral, and trace-element supplements for hospitalized COVID-19 patients who may not meet nutritional needs through a normal diet. The passage does not specify polymorbid medical inpatients fed exclusively orally or say that supplementation should meet daily estimated micronutrient requirements. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [92] Kaegi-Braun, 2022, Effect of micronutrient supplementation in addition to nutritional therapy on clinical outcomes of medical inpatients: results of an updated systematic review and meta-analysis, Eur J Clin Nutr source
    • cites [93] Berger, 2022, ESPEN micronutrient guideline, Clin Nutr source

      Recommendation 1 (p. 8) calls for adequate trace elements and vitamins for patients receiving medical nutrition, and Recommendation 2 (p. 8) allows oral supplementation. But the guideline says it focuses primarily on enteral and parenteral nutrition (section 2.4, p. 8); these passages do not specifically establish daily estimated requirements for polymorbid inpatients fed exclusively orally. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • Rests on an assumption: Polymorbid medical inpatients may be at risk of micronutrient deficiency as a result of decreased intake or greater micronutrient utilization.

  • May combine two claims.

    Premisecitation

    Poor nutritional status contributes to post hospital syndrome, leading to higher morbidity and an increased rate of unplanned readmissions.

    “Poor nutritional status is acknowledged to contribute to the recently described post hospital syndrome that represents a 30-day “generalized transient vulnerability following hospital discharge” leading to higher morbidity and an increased rate of unplanned readmissions”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [112] Krumholz, 2013, Post-hospital syndrome — an acquired, transient condition of generalized risk, N Engl J Med source

  • May combine two claims.

    Premisecitation

    In a prospective RCT of 80 patients aged 75 years or more admitted for acute disease and at risk for malnutrition, a 60-day intervention with ONS started in hospital and continued at home or in the nursing home resulted in maintained body weight and improved MNA scores (3.01±2.65 vs 1.81±2.97, p=0.004), whereas control patients continued to lose weight.

    “Similarly, in a prospective RCT of 80 patients aged 75 years or more admitted for acute disease and at risk for malnutrition, a 60-day intervention with ONS which started in hospital and was continued at home or in the nursing home resulted in maintained body weight and improved MNA scores (3.01 ± 2.65 vs. 1.81 ± 2.97), p ¼ 0.004), whereas CG patients continued to lose weight”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [117] Gazzotti, 2003, Prevention of malnutrition in older people during and after hospitalisation: results from a randomised controlled clinical trial, Age Ageing source

      Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    A sub-analysis of the NOURISH study showed an increase in nutrient intake in intervention patients without decrease in dietary intake.

    “A sub-analysis of the NOURISH study showed an increase in nutrient intake in IG patients without decrease in dietary intake”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [98] Loman, 2019, Specialized high-protein oral nutrition supplement improves home nutrient intake of malnourished older adults without decreasing usual food intake, JPEN - J Parenter Enter Nutr source

  • May combine two claims.

    Premisecitation

    In most RCTs on intervention with ONS, sip feeds were given for at least three months, whereas individualized nutritional support was usually carried out for longer periods (e.g. four months in Persson et al., or six months in Feldblum et al., Casals et al., Bonilla-Palomas et al., and Yang et al.).

    “However, in most RCTs on intervention with ONS, the sip feeds were given for at least three months [9,120e124], whereas individualized nutritional support (which might include ONS where necessary) was usually carried out for longer periods (e.g.four months in the study by Persson et al. [119], or six months in the studies of Feldblum et al. [116], Casals et al. [118], Bonilla-Palomas et al. [126],”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [9] Deutz, 2016, Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: a randomized clinical trial, Clin Nutr source

      Split into 2 atoms — 1 confirmed, 0 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured
    • cites [120e124]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [119] Persson, 2007, Nutritional supplementation and dietary advice in geriatric patients at risk of malnutrition, Clin Nutr source

  • May combine two claims.

    Premisecitation

    Readmission rates were not reduced after three months in one of the largest trials, in geriatric patients, or in older patients.

    “While readmission rates as an indicator of clinical course e.g. were not reduced after three months in one of the largest trials to date (level of evidence: 1þþ) [9] in geriatric patients (level of evidence: 1þ) [131] or in older patients (level of evidence: 1-) [132]”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [9] Deutz, 2016, Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: a randomized clinical trial, Clin Nutr source
    • cites [131] Terp, 2018, A nutritional intervention program improves the nutritional status of geriatric patients at nutritional risk-a randomized controlled trial, Clin Rehabil source
    • cites [132] Sharma, 2017, Investigation of the benefits of early malnutrition screening with telehealth follow up in elderly acute medical admissions, QJM source

  • The quote only partly states this claim.

    Premisecitation

    In the NOURISH study, in-and post hospital continued nutritional support reported lower 90-day mortality in the intervention group receiving ONS twice a day for three months compared to placebo (4.8% vs 9.7%, p=0.018).

    “One of the largest RCTs to date (NOURISH study; n ¼ 652 patients aged 65 years or more with medical conditions) on in-and post hospital (¼continued) nutritional support reported lower 90-day mortality in the IG receiving ONS twice a day (one drink providing 350 kcal, 20 g protein, 1.5 g calcium-bHMB), 160 IU vitamin D and other essential micronutrients) for three months compared to the CG patients”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [9] Deutz, 2016, Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: a randomized clinical trial, Clin Nutr source

  • May combine two claims.

    Interpretationreasoning

    These findings may explain differences in results of nutritional trials depending on clinical setting, with several nutritional studies in ICU settings or in patients with advanced cancer not showing significant benefits from nutrition in regard to clinical outcomes.

    “These findings may also explain differences in results of nutritional trials, depending on the clinical setting with several nutritional studies in the ICU setting or in patients with advanced cancer not showing significant benefits form nutrition in regard to clinical outcomes [165,168].”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [165] Schuetz, 2021, Management of disease-related malnutrition for patients being treated in hospital, Lancet source
    • cites [168] Casaer, 2014, Nutrition in the acute phase of critical illness, N Engl J Med source

      Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Other conditions which may increase the effects of nutritional support are cancer and COPD.

    “Other conditions which may increase the effects of nutritional support are cancer [171], COPD [39] among others.”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [171] Bargetzi, 2021, Nutritional support during the hospital stay reduces mortality in patients with different types of cancers: secondary analysis of a prospective randomized trial, Ann Oncol source

      The Discussion (page unavailable) reports a strong benefit of nutritional support in hospitalized patients with cancer, including lower 30-day mortality. It does not establish that cancer increases the effect relative to patients without cancer. The COPD portion is attributed to a different citation and is not assessed here. (LLM, conf=0.78)

      Experimental — accuracy not yet measured
    • cites [39] Matheson, 2021, Specialized oral nutritional supplement (ONS) improves handgrip strength in hospitalized, malnourished older patients with cardiovascular and pulmonary disease: a randomized clinical trial, Clin Nutr source

  • May combine two claims.

    Premisecitation

    Kidney disease predicts response to nutritional treatment, with lower estimated glomerular filtration rates showing stronger clinical benefit.

    “A recent study by Bargetzi et al. found that kidney disease predicted response to nutritional treatment with lower estimated glomerular filtration rates [eGFR] showing stronger clinical benefit [89] (Level of evidence: 1þþ).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [89] Bargetzi, 2021, Admission kidney function is a strong predictor for the response to nutritional support in patients at nutritional risk, Clin Nutr source

  • May combine two claims.

    Premisecitation

    In that pilot controlled trial, energy and protein intake were higher in the intervention group (1725 vs 1863 kcal/day, p=0.21; 76 vs 80 g/day, p=0.59).

    “However, energy (1725 kcal/day vs. 1863 kcal/day, p ¼ 0.21) and protein (76 g/ day vs. 80 g/day, p ¼ 0.59) intake were higher in the IG.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [159] Collins, 2017, A foodservice approach to enhance energy intake of elderly subacute patients: a pilot study to assess impact on patient outcomes and cost, Age Ageing source

      The Results section reports higher energy and protein intake in the intervention group at day 14, with a significant difference after adjustment for weight. The available Table 2 text contains only its header, so our copy does not verify the quoted intake values or p-values; the Results passage does not give them. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Patients with chronic heart failure have shown strong benefit from nutritional support, including a survival benefit.

    “Similar results were also found within the NOURISH study with a significant survival benefit associated with nutritional support [9] (Level of evidence: 1þþ).”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [126] Bonilla-Palomas, 2016, Nutritional intervention in malnourished hospitalized patients with heart failure, Arch Med Res source
    • cites [107] Hersberger, 2021, Individualized nutritional support for hospitalized patients with chronic heart failure, J Am Coll Cardiol source

      The Results report significantly lower 30-day mortality with nutritional support in hospitalized patients with chronic heart failure, supporting the survival-benefit claim. However, the Methods identify the trial as EFFORT, not the NOURISH study named in the citing sentence. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [9] Deutz, 2016, Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: a randomized clinical trial, Clin Nutr source

  • May combine two claims.

    Premisecitation

    In a secondary analysis of the EFFORT trial, patients with CRP levels ≥100 mg/l no longer responded to nutritional therapy, while patients with lower levels had a significant mortality benefit from nutritional support.

    “A secondary analysis of the multicentre randomized-controlled EFFORT trial suggested that patients with CRP levels of !100 mg/l no longer responded to nutritional therapy, while patients with lower levels had a significant mortality benefit from nutritional support [147] (Level of evidence: 1þþ).”
    • Also stated in: § 3.32. Recommendation 32 · plain
      “In a secondary analysis of EFFORT, unlike patients with lower CRP concentrations ( 100 mg/L), patients with high inflammation (defined as CRP level >100 mg/L) did not respond to nutritional support [147] (Level of evidence 1þþ).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [147] Merker, 2020, Association of baseline inflammation with effectiveness of nutritional support among patients with disease-related malnutrition: a secondary analysis of a randomized clinical trial, JAMA Netw Open source

      The Results section (Effect of Nutritional Support on 30-Day Mortality According to Inflammation Groups; page unavailable) reports a significant 30-day mortality benefit in the low- and moderate-CRP groups, but no significant benefit in the high-CRP group. The claim broadens that outcome-specific finding to patients ‘no longer responding’ to nutritional therapy; the paper also defines the high group as CRP >100 mg/L, not ≥100 mg/L. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    In that pilot controlled trial, among patients with complete data, there was no difference between intervention and control in weight, handgrip strength, functional independence measure, or length of stay.

    “In those with complete data, there was no difference in patients' weight, HGS, functional independence measure or LOS.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [159] Collins, 2017, A foodservice approach to enhance energy intake of elderly subacute patients: a pilot study to assess impact on patient outcomes and cost, Age Ageing source

      The Results report no between-group difference in change in weight or handgrip strength from admission to day 14, and similar change in FIM score and length of stay. However, the Results specify that FIM and length-of-stay analyses included all participants, not only those with complete day-14 data. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Markers of inflammation (i.e., C-reactive protein) have been shown to correlate with disease-related anorexia, reduced food intake, and muscle catabolism, and to predict lack of response to nutritional treatment.

    “Markers of inflammation (i.e.C-reactive protein [CRP]) have been shown to correlate with disease-related anorexia, reduced food intake and muscle catabolism, and at the same predict lack of response to nutritional treatment [147,190,191].”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [147] Merker, 2020, Association of baseline inflammation with effectiveness of nutritional support among patients with disease-related malnutrition: a secondary analysis of a randomized clinical trial, JAMA Netw Open source

      The Introduction describes inflammation as a proposed driver of disease-related anorexia, reduced food intake, and muscle catabolism. The Discussion says patients with initially very high CRP may not respond to nutritional support. The paper does not establish that CRP itself correlates with all three conditions or that it reliably predicts lack of response; its Strengths and Limitations section calls the secondary-analysis findings hypothesis-generating. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [190] Morley, 2006, Cachexia: pathophysiology and clinical relevance, Am J Clin Nutr source

      The Chronic renal failure section and Table 4 associate elevated CRP in cachexia with increased protein catabolism and resistance to nutrition support. They do not show that CRP itself predicts treatment response, and Table 4 describes food intake in cachexia as low or normal, not consistently reduced. The section links cytokine excess—not specifically CRP—to anorexia. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [191] Braun, 2017, Obesity paradox in patients with community-acquired pneumonia: is inflammation the missing link?, Nutrition source

  • May combine two claims.

    Premisecitation

    Albumin and prealbumin levels have a strong prognostic value but little correlation with nutritional response.

    “Albumin and prealbumin levels also have a strong prognostic value, but little correlation with nutritional response [192,193] (both Level of evidence 1þþ).”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [192] Bretschera, 2022, Admission serum albumin concentrations and response to nutritional therapy in hospitalised patients at malnutrition risk: secondary analysis of a randomised clinical trial, EClinicalMedicine source

      The Discussion reports that admission albumin was a strong prognostic indicator and that response to nutritional support was independent of albumin concentration. It does not establish the same findings for prealbumin; the Discussion instead proposes studying prealbumin in future research. (LLM, conf=0.90)

      Experimental — accuracy not yet measured
    • cites [193] Bretscher, 2023, Association between prealbumin, all-cause mortality, and response to nutrition treatment in patients at nutrition risk. Secondary analysis of a randomized controlled trial, JPEN - J Parenter Enter Nutr source

  • May combine two claims.

    Premisecitation

    Sarcopenia is associated with a higher prevalence of polypharmacy (OR 1.65, 95% CI 1.23-2.20, p<0.01) and a higher number of medications (mean difference 1.39, 95% CI 0.59-2.19, I2=95%, p<0.01) compared with individuals without sarcopenia.

    “A recent metaanalysis from 2023, which included 29 studies, demonstrated that sarcopenia is associated with a higher prevalence of polypharmacy (OR: 1.65 [1.23, 2.20], p < 0.01) and higher number of medications (mean difference: 1.39, 95% CI 0.59 to 2.19, I 2 ¼ 95%, p < 0.01) compared with individuals without sarcopenia [176].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [176] Prokopidis, 2023, Sarcopenia is associated with a greater risk of polypharmacy and number of medications: a systematic review and meta-analysis, J Cachexia Sarcopenia Muscle source

  • May combine two claims.

    Study design and conductreasoning

    The rigorous methodical approach used led to a lower number of included trials and guarantees that the findings are valid for the population of polymorbid medical inpatients.

    “However, the rigorous methodical approach used came up with some limitations regarding selecting trials and has led to a lower number of included trials.Thus it guarantees that our findings are valid for the population of polymorbid medical inpatients.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given

    In cases of uncertainty about how comorbidities were reported, study authors were contacted; if they could not be reached, a blinded consensus decision within the guideline Working Group was taken about inclusion.

    “In cases of uncertainty about the way that comorbidities were reported, the study authors were contacted in order to obtain additional information.In the event that they could not be reached, a blinded consensus decision within the guideline WG was taken about whether or not to include the study.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The guideline update was conducted with a multidisciplinary team of 14 European specialists in nutritional support, twelve of whom were authors of the original 2018 paper, following the ESPEN SOP.

    “We conducted the update of the guideline with a multidisciplinary team of 14 European specialist in nutritional support from which twelve have already been authors of the original paper from 2018 following the SOP for the development of ESPEN guidelines [2].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [2] Bischoff, 2015, Standard operating procedures for ESPEN guidelines and consensus papers, Clin Nutr source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Other consequences of polymorbidity include disability, functional decline, poor quality of life and higher healthcare costs.

    “Other consequences of polymorbidity include disability, functional decline, poor quality of life (QoL) and higher healthcare costs [5].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [5] Marengoni, 2011, Aging with multimorbidity: a systematic review of the literature, Ageing Res Rev source

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductown data

    From 3527 retrieved abstracts, 60 new relevant studies were analyzed and used to generate a guideline draft proposing 32 recommendations.

    “From a total of 3527 retrieved abstracts, 60 new relevant studies were analyzed and used to generate a guideline draft that proposed 32 recommendations (7x A, 11x B, 10x O and 4x GPP), which encompass different aspects of nutritional support including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisenone given

    Disease-related malnutrition in polymorbid medical inpatients is associated with increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and cost of care.

    “Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short-and long-term mortality, impaired recovery from illness, and cost of care.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Retrieved abstracts were screened to identify relevant studies used to develop recommendations, followed by SIGN grading and Delphi voting.

    “Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (incl.SIGN grading), which was followed by submission to Delphi voting.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The first online voting showed strong consensus (agreement of >90%) on 100% of the recommendations.

    “The results of the first online voting showed a strong consensus (agreement of >90%) on 100% of the recommendations.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    A systematic literature search was conducted for 15 clinical questions in Medline, Embase, the Cochrane Library, and secondary sources until July 12th.

    “We did a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g.published guidelines), until July 12th.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    This update adheres to the standard operating procedures for ESPEN guidelines.

    “This update adheres to the standard operating procedures for ESPEN guidelines.”
    • Also stated in: § 1. Introduction · plain
      “The present guideline represents an update of the original guideline on polymorbid patients from 2018 [1] and follows the Standard Operating Procedures (SOP) from European Society for Clinical Nutrition and Metabolism (ESPEN) [2].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [2] Bischoff, 2015, Standard operating procedures for ESPEN guidelines and consensus papers, Clin Nutr source

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    The classification of the literature into levels of evidence and grades of recommendation was performed according to the SIGN grading system.

    “The classification of the literature into levels of evidence and grades of recommendation were performed according to the SIGN grading system [15], as exemplified in Tables 2 and 3.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [15] 2014

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    On the 12th of July the primary source search update was conducted by the same author in Medline, Embase and the Cochrane Library since April 2016.

    “On the 12th of July the primary source search update was conducted by the same author in three databases (Medline, Embase and the Cochrane Library) since April 2016.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The search update in July 2022 identified 4234 additional possible eligible abstracts; after removing duplicates, 3527 abstracts were screened.

    “The search update in July 2022 identified 4234 additional possible eligible abstracts; after removing the duplicates, a number of 3527 abstracts were screened.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    For 16 papers, the authors were contacted and requested to provide more information.

    “Many studies required the assessment of the full paper to ascertain whether it met all of the inclusion criteria, and for a proportion of the papers (n ¼ 16), the authors were contacted and requested to provide more information, which was usually to clarify whether their study population suffered from multiple”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Each Working Group member was allocated one or two clinical questions and was responsible for validation of the literature, quality assessment, assignment of level of evidence, and generation of the first draft of recommendations.

    “Each WG member was allocated with one or two clinical questions and was responsible for: validation of the literature, quality assessment and assignment of level of evidence for each paper relevant for the recommendations (e.g. using SIGN checklists), generation of first draft of recommendations, including the supporting text and grade of recommendation.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The results of the online voting were a strong consensus (agreement of >90%) in 100% of recommendations.

    “The results of this online voting were a strong consensus (agreement of >90%) in 100% of recommendations, which is so far unique in ESPEN guideline development.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The Working Group generated a guideline draft with 32 recommendations, approved by the Working Group and the ESPEN Guidelines Editorial Board, followed by Delphi online voting in April 2023.

    “The WG generated a guideline draft with a total of 32 recommendations (approved by the WG and the ESPEN Guidelines Editorial Board office, which was followed by the start of the consensus procedure, by sending that draft to the members of the ESPEN guideline project, ESPEN members and other experts in clinical nutrition for online voting (Delphi method) in April 2023.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Abstracts were screened by either one of two Working Group members in a standardized and systematic way, full texts were reviewed by both members, and discrepancies were resolved through consensus or recourse to a third review author.

    “The abstracts were screened by either one of two WG members in a standardized and systematic way e potential studies (full texts) were then reviewed by both members.Discrepancies were resolved through consensus or recourse to a third review author.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The Hegerov a el al. supplementation resulted in significant preservation of independence (the difference in Barthel Index values between admission and three months showed a statistically significant decline in the control group (p<0.01) vs a non-significant decline in the intervention group).

    “This supplementation resulted in significant preservation of muscle mass (lean body mass difference between admission and three months after discharge was À3.5 kg in CG patients, and þ1.3 in the IG) and independence (the difference in the Barthel Index (BI) values between admission and three months showed a statistically significant decline in the CG (p < 0.01) vs. a non-significant decline in the”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [33] Hegerová, 2015, Early nutritional support and physiotherapy improved long-term self-sufficiency in acutely ill older patients, Nutrition source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    For studies whose authors could not be reached (n=11), seven were included and four excluded according to the Working Group consensus decision.

    “For those studies whose authors could not be reached (n ¼ 11), seven were included and four excluded, according to the WG consensus decision.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The same search strategies used in the original guidelines were used in the literature searches in 2022.

    “The same search strategies used in the original guidelines were used in the literature searches in 2022.”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Premisecitation

    In the Jie et al. study, these effects were robust after multivariate adjustment.

    “These effects were robust after multivariate adjustment.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [17] Jie, 2010, Impact of nutritional support on clinical outcome in patients at nutritional risk: a multicenter, prospective cohort study in Baltimore and Beijing teaching hospitals, Nutrition source

  • May combine two claims.

    Premisecitation

    Observational studies have shown the frequency of complications in untreated at-risk patients to be three times higher than in patients not at-risk, and length of hospital stay is 50% longer.

    “Observational studies have shown the frequency of complications in untreated at-risk patients to be three times higher than in patients not at-risk, and furthermore length of hospital stay (LOS) is 50% longer, which has a negative influence on clinical outcomes [18].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [18] Sorensen, 2008, EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome, Clin Nutr source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    A systematic literature search was conducted first in secondary sources and then in primary sources.

    “Similar to the original guideline, a systematic literature search was conducted, first in secondary sources by searching published guidelines and systematic reviews potentially relevant for each question, followed by a search in primary sources.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    As a result of the update and the conversion of the statements to recommendations, a total of 100 studies are now included.

    “As a result of the update and the conversion of the statements to recommendations, a total of 100 studies are now included.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In a controlled trial, Rypkema et al. demonstrated that a standardized, early nutritional intervention in older polymorbid medical inpatients at nutritional risk, determined by MNA-SF, is effective and does not significantly increase hospital costs.

    “In a controlled trial, Rypkema et al. demonstrated that a standardized, early nutritional intervention in older polymorbid medical inpatients at nutritional risk, determined by the MNA-SF, is effective and does not significantly increase hospital costs.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    SGA and MNA-SF showed the strongest association with 1-year mortality, with adjusted odds ratios of 3.17 (95% CI 2.18 to 4.61, p<0.001) and 3.45 (95% CI 2.28 to 5.22, p<0.001).

    “While high nutritional risk was associated with higher mortality in all tools, SGA and MNA-SF showed the strongest association with adjusted odds ratios of 3.17 (95% CI, 2.18 to 4.61, p < 0.001) and 3.45 (95% CI, 2.28 to 5.22, p < 0.001).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [31] Stalder, 2022, Prospective validation of five malnutrition screening and assessment instruments among medical inpatients: secondary analysis of a randomized clinical trial, Clin Nutr source

  • May combine two claims.

    Premisecitation

    Hegerov a el al. conducted a prospective RCT in 200 inpatients from an internal medicine department and found that provision of ONS combined with physiotherapy increased overall nutritional intake, mainly energy (1954 ± 429 kcal in the intervention group vs 1401 ± 364 kcal, p<0.001) and protein (76.3 ±16.1 in the intervention group vs 55.5 ±13.7 in the control group, p<0.001), without negatively影响

    “Hegerov a el al. conducted a prospective RCT in 200 inpatients from an internal medicine department and found that the provision of ONS (combined with physiotherapy) increased the overall nutritional intake, mainly energy (1954 ± 429 kcal in the IG vs. 1401 ± 364 kcal, p < 0.001) and protein (76.3 in the IG ±16.1 vs. 55.5 in the CG ±13.7, p < 0.001), without negatively affecting the hospital food”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [33] Hegerová, 2015, Early nutritional support and physiotherapy improved long-term self-sufficiency in acutely ill older patients, Nutrition source

  • Classified as probably not a substantial claim.

    Interpretationcitation

    The importance of providing nutritional support to those most in need is stressed.

    “This stresses the importance of providing nutritional support to those most in need [45] (Level of Evidence 1þþ).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [45] 2005, Routine oral nutritional supplementation for stroke patients in hospital (FOOD): a multicentre randomised controlled trial, Lancet source

  • May combine two claims.

    Premisecitation

    The ONS containing 995 kcal from macronutrients and covering 100% of the RDA for healthy older adults in vitamins and minerals had a significant positive effect on self-reported quality of life (treatment effect in QoL scores using the SF-36 form at 6 months was 7.0, 95% CI 0.5 to 13.6, p=0.04 for physical function, 10.2, 95% CI 0.1 to 20.2, p=0.047 for role physical, and 7.8, 95% CI 0.0 to 15.5,

    “with a significant positive effect on their self-reported QoL (i.e. the treatment effect in QoL scores using the SF-36 form at 6 months was 7.0, 95% CI 0.5 to 13.6, p ¼ 0.04 for physical function, 10.2, 95% CI 0.1 to 20.2, p ¼ 0.047 for role physical, and 7.8, 95% CI 0.0 to 15.5, p ¼ 0.05 for social function domains, compared to placebo) [40,41] (Level of evidence 1þþ for both).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [40] Gariballa, 2007, Dietary supplementation and quality of life of older patients: a randomized, double-blind, placebo-controlled trial, J Am Geriatr Soc source
    • cites [41] Gariballa, 2007, Effects of dietary supplements on depressive symptoms in older patients: a randomised double-blind placebo-controlled trial, Clin Nutr source

  • May combine two claims.

    Premisecitation

    The Gressies et al. 2022 meta-analysis included trials exclusively conducted within the population of polymorbid patients using the exact same definition as used in this guideline.

    “A meta-analysis by Gressies et al. conducted in 2022 that was an update and re-analysis of Gomes et al. included trials exclusively conducted within the population of polymorbid patients using the exact same definition as used in this guideline.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [36] Gressies, 2022, Letter to the Editor: is nutritional support effective in malnourished polymorbid medical inpatients?, Clin Nutr source

  • May combine two claims.

    Interpretationcitation

    In the absence of IC, TEE for polymorbid older patients (aged ≥65 years) can be estimated at approximately 27 kcal/kg actual body weight/day, and REE can be estimated at 18-20 kcal/kg actual body weight/day with addition of activity or stress factors to estimate TEE.

    “In the absence of IC, TEE for polymorbid older patients (aged !65 years) can be estimated at approximately 27 kcal/kg actual body weight/day.REE can be estimated at 18e20 kcal/kg actual body weight/day with the addition of activity or stress factors to estimate TEE.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [71] Gaillard, 2007, Energy requirements in frail elderly people: a review of the literature, Clin Nutr source

  • May combine two claims.

    Premisecitation

    Both published prediction equations and weight-based formulae provide valid estimates of energy requirements for groups of patients, but both are subject to significant bias and imprecision when applied to individuals.

    “While both published prediction equations and weight-based formulae provide valid estimates of energy requirements for groups of patients, both methods are subject to significant bias and imprecision when applied to individuals [66,67].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [66] Boullata, 2007, Accurate determination of energy needs in hospitalized patients, J Am Diet Assoc source
    • cites [67] Miles, 2006, Energy expenditure in hospitalized patients: implications for nutritional support, Mayo Clin Proc source

  • May combine two claims.

    Premisecitation

    In a review of 33 studies (2450 subjects) measuring REE by IC in subjects aged ≥65, the weighted mean REE for the whole group was 20.4 kcal/kg actual body weight, and the weighted mean for the polymorbid hospitalized older group was 18.5 kcal/kg body weight.

    “The weighted mean for the whole group was 20.4 kcal/kg actual body weight whereas the weighted mean for the polymorbid hospitalized older group was lower at 18.5 kcal/kg body weight.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [71] Gaillard, 2007, Energy requirements in frail elderly people: a review of the literature, Clin Nutr source

  • May combine two claims. The quote only partly states this claim.

    Study design and conductown data

    The review's results should be interpreted with caution because relatively few data were available in sick older individuals (n=248) compared with healthy older individuals (n=1970), and the methods failed to comply fully with guidelines for systematic reviews (only MEDLINE searched, only English studies).

    “The results of this review should be interpreted with caution since relatively few data were available in the sick older individuals (n ¼ 248) compared with the healthy older individuals (n ¼ 1970).Furthermore the methods described in the paper failed to comply fully with guidelines for the conduct of systematic reviews [72].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [72] Higgins, 2011

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    In that review, mean TEE in sick older individuals was 27 ± 1.8 kcal/kg body weight and weighted physical activity level was 1.36 ± 0.03.

    “The mean TEE in sick older individuals was 27 ± 1.8 kcal/kg body weight and the weighted physical activity level in these patients was 1.36 ± 0.03 reflecting the relative physical inactivity of this population.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [71] Gaillard, 2007, Energy requirements in frail elderly people: a review of the literature, Clin Nutr source

  • May combine two claims.

    Study design and conductcitation

    The study's results should be interpreted with caution because the sample size was very small and patients received continuous EN or PN during IC, so measured energy expenditure included diet-induced thermogenesis.

    “These results should be interpreted with caution since the sample size was very small.Furthermore, patients received continuous EN or PN during IC and thus measured energy expenditure included not only REE but also diet-induced thermogenesis.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [73] Ahmad, 1999, An evaluation of resting energy expenditure in hospitalized, severely underweight patients, Nutrition source

  • Classified as probably not a substantial claim.

    Interpretationcitation

    In the absence of IC, REE for severely underweight patients can be estimated at 30 kcal/kg actual body weight.

    “In the absence of IC, REE for severely underweight patients can be estimated at 30 kcal/kg actual body weight.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [73] Ahmad, 1999, An evaluation of resting energy expenditure in hospitalized, severely underweight patients, Nutrition source

  • May combine two claims.

    Premisecitation

    More than 200 prediction equations have been published, with accuracy rates ranging from 36% to 75% when compared with IC, and no single equation is most accurate in polymorbid medical inpatients.

    “More than 200 prediction equations have been published in the literature, with accuracy rates ranging from 36% to 75% when compared with IC and no single equation emerges as being the most accurate in polymorbid medical inpatients [66].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [66] Boullata, 2007, Accurate determination of energy needs in hospitalized patients, J Am Diet Assoc source

  • May combine two claims.

    Premisecitation

    In a meta-analysis of RCTs on hospitalized patients at high risk of developing pressure ulcers, by Tuffaha et al., provision of nutritional support resulted in a cost saving of 425 $ per patient and a marginal improvement of quality adjusted life years of 0.005, compared to usual care.

    “Positive results were also reported in a meta-analysis of RCTs on hospitalized patients at high risk of developing pressure ulcers, by Tuffaha et al.Provision of nutritional support resulted in a cost saving of 425 $ per patient and a marginal improvement of quality adjusted life years of 0.005, compared to the usual care [48] (Level of evidence 1þþ).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [48] Tuffaha, 2016, Cost-effectiveness analysis of nutritional support for the prevention of pressure ulcers in high-risk hospitalized patients, Adv Skin Wound Care source

  • May combine two claims.

    Premisecitation

    In a study of 14 severely underweight hospitalized patients, mean REE by IC was 1300 ± 160 kcal/day, equating to 31.4 kcal/kg body weight.

    “In this study mean REE by IC was 1300 ± 160 kcal/day equating to 31.4 kcal/kg body weight.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [73] Ahmad, 1999, An evaluation of resting energy expenditure in hospitalized, severely underweight patients, Nutrition source

  • May combine two claims.

    Premisecitation

    In the EFFORT trial, by 30 days, patients in the intervention group (therapy initiated within 48h) experienced 21% less adverse clinical outcomes and 35% lower mortality (adjusted OR 0.65 [0.47 to 0.91], p=0.011).

    “The previous described large EFFORT trial [8] addressed this question as the IG got their therapy initiated within 48h.By 30 days, patients in the IG experienced 21% less adverse clinical outcomes and 35% lower mortality (adjusted OR 0.65 [0.47 to 0$91], p ¼ 0.011) (Level of evidence 1þþ).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [8] Schuetz, 2019, Individualised nutritional support in medical inpatients at nutritional risk: a randomised clinical trial, Lancet source

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    Recommendation 17 was downgraded from grade B to 0 due to the limited number of available studies in identified polymorbid medical inpatients.

    “Recommendation 17 was downgraded from grade of recommendation B to 0, due to the limited number of available studies in identified polymorbid medical inpatients.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationcitation

    In polymorbid medical older inpatients requiring EN, EN formulas enriched in a mixture of soluble and insoluble fibers can be used to improve bowel function.

    “In polymorbid medical older inpatients requiring EN, EN formulas enriched in a mixture of soluble and insoluble fibers can be used to improve bowel function.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [104] Vandewoude, 2004, Fibre-supplemented tube feeding in the hospitalised elderly, Age Ageing source
    • Rests on an assumption: Diarrhea and constipation are the most frequent complications of EN in hospitalized patients.

  • May combine two claims.

    Premisecitation

    A 2021 meta-analysis demonstrated that high protein intake was one of the strongest predictors for beneficial mortality effects of nutritional interventions: trials using high-protein strategies in medical inpatients at nutritional risk had significantly stronger effects on mortality compared to trials with low-protein interventions (OR 0.57, 95% CI 0.44 to 0.74 vs. 0.93, 95% CI 0.73 to 1.19).

    “The results of a recent meta-analysis from 2021 demonstrated that high protein intake was one of the strongest predictors for beneficial mortality effects of nutritional interventions: trials using high-protein strategies in medical inpatients at nutritional risk, had significantly stronger effects on mortality compared to trials with low-protein interventions (OR 0.57, 95% CI 0.44 to 0.74 vs. 0.9”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [78] Kaegi-Braun, 2021, Nutritional trials using high protein strategies and long duration of support show strongest clinical effects on mortality.: results of an updated systematic review and meta-analysis, Clin Nutr ESPEN source

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    We cannot recommend the use of other disease-specific nutritional supplementation in polymorbid medical inpatients.

    “We cannot recommend the use of other disease-specific nutritional supplementation in polymorbid medical inpatients.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [105] Ogasawara, 2018, Effect of eicosapentaenoic acid on prevention of lean body mass depletion in patients with exacerbation of chronic obstructive pulmonary disease: a prospective randomized controlled trial, Clin Nutr ESPEN source

  • May combine two claims.

    Premisecitation

    A Belgian study of 145 older patients receiving enteral feeding found positive effects of a formula enriched with 30 g fiber including 33% insoluble and 67% soluble fiber vs. the control group receiving the same EN with no fiber: frequency of stools was lower (4.1 ± 2.6 vs. 6.3 ± 4.7 per week; p<0.001) and stool consistency higher in the IG (31% solid vs. 21%, and 2% liquid-watery vs. 13%, p<0.001

    “A Belgian study of 145 older patients receiving enteral feeding [104] found positive effects of a formula enriched with 30 g fiber including 33% insoluble (cellulose and hemicellulose A) and 67% soluble (pectin, hemicellulose B, inulin) fiber (IG) vs. the CG, which received the same EN with no fiber (level of evidence 1þþ).The frequency of stools was lower (4.1 ± 2.6 per week versus 6.3 ± 4.7 per”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [104] Vandewoude, 2004, Fibre-supplemented tube feeding in the hospitalised elderly, Age Ageing source

  • May combine two claims.

    Study design and conductreasoning

    In the Zheng et al. RCT, patients were admitted to the stroke unit in the intervention group and to the regular ward in the control group, entailing a high risk of bias.

    “However, patients were admitted to the stroke unit in the IG and to the regular ward in the CG, which entails a high risk of bias”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [108] Zheng, 2015, Impact of early enteral nutrition on short term prognosis after acute stroke, J Clin Neurosci source

  • May combine two claims.

    Premisecitation

    Self-sufficiency measured by BI diminished during annual monitoring in both groups, but the decline was sharper in the control group.

    “Regarding self-sufficiency (measured by independency in the activities of daily living through the BI, it diminished during the course of annual monitoring in both groups of patients, but the decline was sharper in the CG”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [33] Hegerová, 2015, Early nutritional support and physiotherapy improved long-term self-sufficiency in acutely ill older patients, Nutrition source

  • Classified as probably not a substantial claim.

    Interpretationcitation

    In polymorbid medical inpatients exclusively fed orally, documented or suspected micronutrient deficiencies should be repleted.

    “In polymorbid medical inpatients exclusively fed orally, documented or suspected micronutrient deficiencies should be repleted.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [94] Joosten, 1993, Metabolic evidence that deficiencies of vitamin B-12 (cobalamin), folate, and vitamin B-6 occur commonly in elderly people, Am J Clin Nutr source
    • cites [95] Kilonzo, 2007, A cost-utility analysis of multivitamin and multimineral supplements in men and women aged 65 years and over, Clin Nutr source
    • cites [96] Graat, 2002, Effect of daily vitamin E and multivitamin-mineral supplementation on acute respiratory tract infections in elderly persons: a randomized controlled trial, JAMA source
    • Rests on an assumption: Polymorbid medical inpatients may be at risk of micronutrient deficiency as a result of decreased intake or greater micronutrient utilization.

  • May combine two claims.

    Premisecitation

    A meta-analysis of mixed study populations found that additional micronutrient supplementation to a therapeutic diet already supplemented in micronutrients did not reduce mortality and may have increased length of stay by approximately one day (borderline statistical significance).

    “For example, a meta-analysis of mixed study populations found additional micronutrient supplementation to a therapeutic diet [74] already supplemented in micronutrients did not reduce mortality and may have increased LOS by approximately one day (albeit with borderline statistical significance) [92].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [92] Kaegi-Braun, 2022, Effect of micronutrient supplementation in addition to nutritional therapy on clinical outcomes of medical inpatients: results of an updated systematic review and meta-analysis, Eur J Clin Nutr source

  • May combine two claims.

    Premisecitation

    Lean body mass did not reach its original value even twelve months post-discharge in the control group, but it did in the intervention group.

    “Lean body mass did not reach its original value even twelve months post-discharge in the CG, but it did in the IG.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [33] Hegerová, 2015, Early nutritional support and physiotherapy improved long-term self-sufficiency in acutely ill older patients, Nutrition source

  • May combine two claims.

    Premisecitation

    Three months postdischarge, lean body mass was 3.5 kg lower in the control group but only 0.4 kg lower in the treated group.

    “Three months postdischarge, lean body mass was 3.5 kg lower in the CG but only 0.4 kg lower in the treated group.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [33] Hegerová, 2015, Early nutritional support and physiotherapy improved long-term self-sufficiency in acutely ill older patients, Nutrition source

  • May combine two claims.

    Premisecitation

    In a nationwide inpatient database of 432,620 patients hospitalized for acute heart failure after propensity score matching, delayed initiation of feeding later than two days after admission was associated with higher in-hospital mortality (OR 1.32, 95% CI 1.26 to 1.39), longer LOS and higher incidence of pneumonia and sepsis compared to earlier initiation.

    “Using a nationwide inpatient database with 432,620 eligible patients hospitalized for acute heart failure after propensity score matching, Kaneko et al. showed that delayed initiation of feeding (later than two days after admission) was associated with higher in-hospital mortality (OR 1.32, 95% CI1.26 to 1.39), longer LOS and higher incidence of pneumonia and sepsis when compared to earlier init”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [109] Kaneko, 2021, Early initiation of feeding and in-hospital outcomes in patients hospitalized for acute heart failure, Am J Cardiol source

  • May combine two claims.

    Premisecitation

    In a secondary budget-impact analysis applied to a Colombian population, average total costs over 60 days were 3770 $ for delayed nutrition therapy vs 2419 $ for early nutrition therapy started within 24-48 h of hospital admission, a savings of 1351 $ (35.8% decrease) per nutrition-treated patient.

    “Buitrago et al. in a secondary analysis applied to a Colombian population, found that average total costs over 60 days were 3770 $ for patients with delayed nutrition therapy vs. 2419 $ for patients with early nutrition therapy (started within 24e48 h of hospital admission) À a savings of 1351 $ (35.8% decrease) per nutrition-treated patient”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [110] Buitrago, 2020, Targeting malnutrition: nutrition programs yield cost savings for hospitalized patients, Clin Nutr source

  • May combine two claims.

    Premisecitation

    In the PICNIC study, both mortality (HR 0.37, 95% CI 0.19-0.72, p=0.003) and readmission rates were lower in the intervention group (10.2 vs 36.1%, p=0.001).

    “Both mortality (HR 0.37, 95% CI 0.19e0.72,p ¼ 0.003) and readmission rates were lower in the IG patients (10.2 vs. 36.1%,p ¼ 0.001)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [126] Bonilla-Palomas, 2016, Nutritional intervention in malnourished hospitalized patients with heart failure, Arch Med Res source

  • May combine two claims.

    Premiseown data

    Improvements in physical function were significantly higher in the intervention group (Δ4.2±4.4 vs Δ2.2±2.5, p=0.008) but clinically relevant in both groups.

    “The improvements in physical function were significantly higher in the IG (D 4.2 ± 4.4 vs. D 2.2 ± 2.5), p ¼ 0.008) but clinically relevant in both groups.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In the PICNIC study, benefits persisted at 24 months, as the primary endpoint occurred more frequently in control patients (73.8%) compared to intervention patients (47.5%) (HR 0.45, 95% CI 0.28-0.72; p=0.001).

    “The benefits of the nutritional intervention persisted at 24 months, as the primary endpoint occurred more frequently in of the CG patients (73.8%) compared to in 47.5% of IG patients (HR 0.45, 95% CI 0.28e0.72;p ¼ 0.001).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [127] Bonilla-Palomas, 2018, Does nutritional intervention maintain its prognostic benefit in the long term for malnourished patients hospitalised for heart failure?, Rev Clin Esp source

  • May combine two claims.

    Premisecitation

    HGS and peak expiratory flow increased after three months only in intervention patients (grip strength improved from 26.1±11.3 to 31.5±10.1 kg, p<0.0001; peak flow from 329.2±124.0 to 388.9±108.4 l/min, p=0.004).

    “HGS and peak expiratory flow increased after three months only in the intervention patients (grip strength improved from 26.1 ± 11.3 to 31.5 ± 10.1 kg, p < 0.0001; and peak flow from 329.2 ± 124.0 to 388.9 ± 108.4 l/ min, p ¼ 0.004)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [124] Norman, 2008, Three month intervention with protein and energy rich supplements improve muscle function and quality of life in malnourished patients with non-neoplastic gastrointestinal disease—a randomized controlled trial, Clin Nutr source

  • May combine two claims.

    Premiseown data

    The Q-5D-3L VAS-score was higher in the intervention group at the end of the study compared to the control group (61.6±16.2 vs 53.3±19.3, p=0.011) with a significantly higher increase in the intervention group (Δ14.3±15.5 vs Δ5.6±17.2, p=0.002).

    “Regarding QoL, the Q-5D-3L VAS-score was higher in IG at the end of the study compared to the CG (IG: 61.6 ± 16.2 vs. CG: 53.3 ± 19.3, p ¼ 0.011) with a significantly higher increase in the IG (D 14.3 ± 15.5 vs. D 5.6 ± 17.2, p ¼ 0.002).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In the study by Persson et al., older patients at risk of malnutrition (85±6 years) treated with liquid supplements and dietary advice for four months had improvement of Katz's activities of daily living index (p<0.001; p=0.05 between groups), but not in QoL assessed by SF-36.

    “In the study by Persson et al., which included older patients at risk of malnutrition (85 ± 6 years), treatment with complete or incomplete liquid supplements (providing an average intake of 60 kcals and 11.25 g protein per day) and dietary advice for four months resulted in an improvement of Katz's activities of daily living index (p < 0.001; p ¼ 0.05 between groups), but not in QoL assessed by”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [119] Persson, 2007, Nutritional supplementation and dietary advice in geriatric patients at risk of malnutrition, Clin Nutr source

  • May combine two claims.

    Study design and conductcitation

    Trial quality in the meta-analysis was deemed moderate, highlighting the need for further large-scale studies.

    “However, trial quality was deemed moderate, highlighting the need for further large-scale studies”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [115] Kaegi-Braun, 2022, Nutritional support after hospital discharge improves long-term mortality in malnourished adult medical patients: systematic review and meta-analysis, Clin Nutr source

  • May combine two claims.

    Premisecitation

    In a RCT by Casals et al., continued nutritional counseling by case manager nurses for six months increased body weight (4.750±5.12 kg in IG vs -0.903±6.12 kg in CG, p<0.001) and improved the MUST score (-2.457±1.39 in IG vs -1.170±1.67 in CG, p<0.001).

    “the intervention resulted in increased body weight (4.750 ± 5.12 kg in the IG vs. À0.903± 6.12) kg in the CG, p < 0.001) and improved the MUST score (À2.457 ± 1.39 in the IG vs. À1.170± 1.67) in the CG, p < 0.001) after six months of continued nutritional counseling by case manager nurses”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [118] Casals, 2015, Randomized clinical trial of nutritional counseling for malnourished hospital patients, Rev Clin Esp source

  • May combine two claims.

    Premisecitation

    In a RCT of malnourished patients aged 85±6 years, individualized nutritional support for four months after discharge maintained body weight in the intention-to-treat analysis (difference in mean weight from baseline to 4-month followup was 0.6 kg in IG vs -1.5 kg in CG, p<0.001), although a high dropout rate was reported.

    “in a RCT of malnourished patients (according to the MNA-SF) aged 85 ± 6 years, individualized nutritional support for four months after discharge maintained body weight in the intention-to-treat analysis (difference in mean weight from baseline to 4-month followup was 0.6 kg in the IG vs. À1.5 kg in the CG, p < 0.001), although a high dropout rate was reported”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [119] Persson, 2007, Nutritional supplementation and dietary advice in geriatric patients at risk of malnutrition, Clin Nutr source

  • May combine two claims.

    Premisecitation

    Systematic reviews found evidence for improved body weight and nutritional status in older patients after discharge either with individualized nutritional support or intervention with ONS.

    “Systematic reviews found evidence for improved body weight and nutritional status in older patients after discharge either with individualized nutritional support [113] or intervention with ONS [114].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [113] Munk, 2016, Individualised dietary counselling for nutritionally at-risk older patients following discharge from acute hospital to home: a systematic review and meta-analysis, J Hum Nutr Diet source
    • cites [114] Beck, 2013, Oral nutritional support of older (65 years+) medical and surgical patients after discharge from hospital: systematic review and meta-analysis of randomized controlled trials, Clin Rehabil source

  • May combine two claims.

    Premisecitation

    Type of underlying disease, severity of disease, and extent of the acute-phase reaction have an impact on the effect of nutrition therapy.

    “There is growing evidence that type of underlying disease, severity of disease and extend of the acute-phase reaction have an impact on the effect of nutrition therapy [165].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [165] Schuetz, 2021, Management of disease-related malnutrition for patients being treated in hospital, Lancet source

  • May combine two claims.

    Premisecitation

    Inflammation is a key factor with several important metabolic effects at a cellular level (e.g., increasing insulin resistance and inhibiting nutrition entering cells) and on organs such as the brain, intestines, and muscle (e.g., causing disease-related anorexia, reduced food intake, catabolism, and sarcopenia).

    “Thereby, inflammation is a key factor with several important metabolic effects on a cellular level (e.g., increase in insulin resistance leading to an inhibition of nutrition entering cells) and on different organs such as the brain (e.g., causing disease-related anorexia and reduced food intake), the intestines and on muscle (e.g., causing catabolism and sarcopenia).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [165] Schuetz, 2021, Management of disease-related malnutrition for patients being treated in hospital, Lancet source

  • May combine two claims.

    Premisecitation

    Patients with high inflammation do not show a positive response to nutritional interventions, while patients with lower levels of inflammation do.

    “There are also studies showing that patients with high inflammation do not show a positive response to nutritional interventions while patients with lower levels of inflammation did.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    In that single-blinded RCT, mean protein intake was significantly increased in the intervention group, with 27/41 versus 12/40 in the control group meeting ≥75% protein requirements (p=0.001).

    “However, mean protein intake was significantly increased in the IG; with 27/41 compared to 12/40 in the CG meeting !75% protein requirements (p ¼ 0.001).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [148] Munk, 2014, Positive effect of protein-supplemented hospital food on protein intake in patients at nutritional risk: a randomised controlled trial, J Hum Nutr Diet source

  • May combine two claims.

    Premisecitation

    In that prospective controlled trial, there was no statistically significant difference between groups in development of pressure ulcers or length of stay.

    “There was no statistically significant difference in the development of pressure ulcers or LOS (Level of Evidence 2þ).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [160] Rypkema, 2004, Cost-effectiveness of an interdisciplinary intervention in geriatric inpatients to prevent malnutrition, J Nutr Health Aging

  • May combine two claims.

    Premiseown data

    Predictors for the success of nutritional support were high protein supplementation (OR 0.57 vs 0.93, I2=86.3%, p for heterogeneity=0.007) and long-term nutritional interventions (OR 0.53 vs 0.85, I2=76.2%, p for heterogeneity=0.040).

    “Among the predictors for the success of nutritional support were high protein supplementation (OR 0.57 vs. 0.93, I 2 ¼ 86.3%, p for heterogeneity ¼ 0.007) and long-term nutritional interventions (OR 0.53 vs. 0.85, I 2 ¼ 76.2%, p for heterogeneity ¼ 0.040).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    The evidence shows that organizational changes in nutritional support provision can improve energy and protein intake and reduce the risk of adverse outcomes in polymorbid medical inpatients.

    “Thus, the evidence shows that organizational changes in nutritional support provision can improve energy and protein intake and reduce the risk of adverse outcomes in polymorbid medical inpatients.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    In that single-blinded RCT, there was no significant difference between the protein-fortified menu group and control in energy intake, length of stay, or handgrip strength.

    “There was no significant difference in energy intake, LOS or HGS between groups.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [148] Munk, 2014, Positive effect of protein-supplemented hospital food on protein intake in patients at nutritional risk: a randomised controlled trial, J Hum Nutr Diet source

  • May combine two claims.

    Premisecitation

    Markers of chronic kidney dysfunction (i.e., creatinine) are associated with renal cachexia and weight loss, but patients with reduced kidney function show a particularly stronger response to nutritional treatment.

    “Similarly, markers of chronic kidney dysfunction (i.e., creatinine) are associated with renal cachexia and weight loss, but patients with reduced kidney function show a particularly stronger response to nutritional treatment [8] (Level of evidence 1þþ).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [8] Schuetz, 2019, Individualised nutritional support in medical inpatients at nutritional risk: a randomised clinical trial, Lancet source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Many healthcare professionals are familiar with the physical binding of drugs such as tetracyclines to divalent and trivalent cations found in milk or antacid preparations or in many ONS and enteral formulas, which limits absorption from the gastrointestinal tract.

    “For example, many healthcare professionals are familiar with the physical binding of drugs such as tetracyclines to the divalent and trivalent cations found in milk or antacid preparations [181] or in many of the ONS and enteral formulas, which limits absorption from the gastrointestinal tract.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [181] Neuvonen, 1976, Interactions with the absorption of tetracyclines, Drugs source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Simvastatin has no specific requirement to be taken with or without food but has the potential to be toxic when taken concurrently with grapefruit juice.

    “This is because whilst drugs such as simvastatin have no specific requirement to be taken with or without food it has the potential to be toxic when taken concurrently with grapefruit juice [186].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [186] Dreier, 2004, Statin-associated rhabdomyolysis triggered by grapefruit consumption, Neurology source

  • May combine two claims.

    Premisereasoning

    As the number of medicines required increases, the risk of drug-drug and drug-nutrient interactions and the risk of potential effects on nutritional status increase.

    “Indeed, as the number of medicines required increases so does the risk of these interactions as well as the risk of potential effects on nutritional status.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Polymorbid medical inpatients often require multiple medicines to manage their comorbidities.
    • Rests on an assumption: The use of multiple medicines is often essential.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Ceftriaxone has the potential for physical binding to calcium salts when each is given intravenously.

    “Fewer are likely to be familiar with the potential for physical binding of ceftriaxone to calcium salts when each is given intravenously [182] or that hydration status, which is for example commonly impaired in acute medical admissions [183], can affect drug enrichment [184].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [182] Donnelly, 2017, Ceftriaxone-associated biliary and cardiopulmonary adverse events in neonates: a systematic review of the literature, Pediatr Drugs source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Adverse effects from medicines on body systems could affect the status of specific types of nutrients.

    “Such adverse effects from medicines on body systems could affect the status of specific types of nutrients.”
    Quote in the paperNot a substantial claim
128 of 128

  • The paper relies on this without support.

    The health and nutrition implications of suffering from more than one disease at the same time differ from the corresponding interactions between disease and aging.

    “The health and nutrition implications of suffering from more than one disease at the same time differ from the corresponding interactions between disease and aging.”

  • The paper relies on this without support.

    We did not know if the screening, assessment and treatment of disease-related malnutrition in polymorbid medical inpatients should differ from the approach used in patients with a single disease.

    “In fact, we did not know if the screening, assessment and treatment of disease-related malnutrition (DRM) in polymorbid medical inpatients should differ from the approach used in patients with a single disease.”

  • The paper relies on this without support.

    To date, it is unknown whether there is a synergistic negative effect of several diseases on nutritional status, or on clinical outcome.

    “To date, it is unknown whether there is a synergistic negative effect of several diseases on nutritional status, or on clinical outcome.”

  • The paper relies on this without support.

    The greater the number of medications, the higher the risk of weight loss and manifest malnutrition, which suggests that polypharmacy has a potentially negative effect on nutritional status.

    “Additionally, it has been shown that the greater the number of medications, the higher the risk of weight loss and manifest malnutrition, which suggests that polypharmacy has a potentially negative effect on nutritional status.”

  • The paper relies on this without support.

    Reaching energy goals in medical inpatients is important to prevent weight loss and the loss of muscle mass that may lead to poorer functional outcomes.

    “Reaching energy goals in medical inpatients is important to prevent weight loss and the loss of muscle mass that may lead to poorer functional outcomes.”

  • The paper relies on this without support.

    In the acute care setting many obstacles may prevent patients from meeting their nutritional requirements orally.

    “However, in the acute care setting many obstacles may prevent patients from meeting their nutritional requirements orally.”

  • The paper relies on this without support.

    Obstacles to meeting nutritional requirements orally include loss of appetite due to acute illness, delayed gastric emptying causing nausea and early satiety, inability to swallow, and vomiting.

    “These obstacles include loss of appetite due to acute illness, delayed gastric emptying causing both nausea and early satiety, inability to swallow, and vomiting, among others.”

  • The paper relies on this without support.

    Limited, if any, accounting for polymorbidity applies to current nutritional guidelines that focus on single diseases or on patient groups.

    “Limited, if any, accounting for polymorbidity applies to current nutritional guidelines that focus on single diseases (e.g.nutritional support in renal failure) or on patient groups (e.g.older adults).”

  • The paper relies on this without support.

    Severely underweight patients are at high risk of refeeding syndrome.

    “This target of 30 kcal/kg actual body weight in severely underweight patients should be cautiously and slowly achieved, as this is a population at high risk of refeeding syndrome.”
    “The target of approximately 30 kcal/kg body weight in severely underweight patients may need to be achieved with caution, as this is a population at high risk of refeeding syndrome.”

  • The paper relies on this without support.

    Polymorbid medical inpatients are at high risk of developing disease-related malnutrition (DRM).

    “Polymorbid medical inpatients are at high risk of developing DRM, so it is possible that this population could benefit from early nutritional support during hospital admission to avoid worsening of DRM with subsequent negative outcomes.”

  • The paper relies on this without support.

    Diarrhea and constipation are the most frequent complications of EN in hospitalized patients.

    “Diarrhea and constipation are the most frequent complications of EN in hospitalized patients.”

  • The paper relies on this without support.

    Pressure ulcers are responsible for protein loss, hypermetabolism and hypercatabolism, and are often associated with malnutrition, including nutrient deficiencies that are critical to the different phases of wound healing.

    “Pressure ulcers are responsible for protein loss, hypermetabolism and hypercatabolism, and are often associated with malnutrition, including nutrient deficiencies that are critical to the different phases of wound healing (conditionally essential amino acids and antioxidant micronutrients).”

  • The paper relies on this without support.

    Polymorbid medical inpatients may be at risk of micronutrient deficiency as a result of decreased intake or greater micronutrient utilization.

    “Polymorbid medical inpatients may be at risk of micronutrient deficiency as a result of decreased intake or greater micronutrient utilization, which can compromise health as well as recovery from illness or disease.”

  • The paper relies on this without support.

    Polymorbid medical inpatients are commonly malnourished and their nutritional status frequently does not improve but instead deteriorates during hospital stay.

    “Polymorbid medical inpatients are commonly malnourished and frequently nutritional status does not improve but instead deteriorates during their hospital stay.”

  • The paper relies on this without support.

    Many patients leave the hospital malnourished, or more malnourished, which increases the risk for functional decline, loss of independence and greater morbidity.

    “As a result, many patients leave the hospital malnourished, or more malnourished, which increases the risk for functional decline, loss of independence and greater morbidity.”

  • The paper relies on this without support.

    Very few studies have directly compared nutritional intervention in and after hospital discharge versus nutritional support in hospital alone.

    “Very few studies have, however, directly compared nutritional intervention in and after hospital discharge vs. nutritional support in hospital alone.”

  • The paper relies on this without support.

    The effect of nutritional intervention with ONS on mortality has not been frequently studied in sufficiently sized patient cohorts.

    “The effect of nutritional intervention with ONS on mortality has not been frequently studied in sufficiently sized patient cohorts.”

  • The paper relies on this without support.

    Only one study has studied the impact of nutritional support on long-term mortality (> one year).

    “Only one study studied the impact of nutritional support on long-term mortality (> one year).”

  • The paper relies on this without support.

    Most trials assessing the impact of nutritional support in polymorbid inpatients used nutritional and functional status as outcome rather than as monitoring tools of the efficacy of nutrition intervention in improving other outcomes.

    “Most trials assessing the impact of nutritional support in polymorbid inpatient used nutritional and functional status as outcome rather than as monitoring tools of the efficacy of nutrition intervention in improving other outcomes.”

  • The paper relies on this without support.

    Reduced food intake has several commonly occurring determinants, including anorexia, dysphagia and oral and dental problems.

    “Reduced food intake has several commonly occurring determinants, including anorexia, dysphagia and oral and dental problems.”

  • The paper relies on this without support.

    Numerous studies indicate that reduced food intake is associated with increased mortality and with complications like infections in medical patients.

    “There are numerous studies indicating that reduced food intake is associated with increased mortality and with complications like infections in medical patients.”

  • The paper relies on this without support.

    Provision of nutritional support via ONS is often discontinued or not well tolerated by hospitalized patients.

    “Another important aspect is that provision of nutritional support via ONS is often discontinued or not well tolerated by hospitalized patients.”

  • The paper relies on this without support.

    Polymorbid medical inpatients often require multiple medicines to manage their comorbidities.

    “Polymorbid medical inpatients will often require the prescription of multiple medicines in order to manage their comorbidities.”

  • The paper relies on this without support.

    The use of multiple medicines is often essential.

    “Whilst the use of multiple medicines is often essential, it can present a number of risks that include potential 'drugedrug' and/or 'drug-nutrient' interactions.”

  • The paper relies on this without support.

    Many published studies did not report data on the presence of multiple comorbidities or did not use typical key terms for this purpose.

    “many of the published studies did not report data on the presence of multiple comorbidities or did not use typical key terms for this purpose.”
25 of 25

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Same trial has conflicting findings for energy intake

    Major

    The discussion of the protein-fortified menu trial says the intervention significantly improved energy intake, but a later discussion of the same trial [148] says there was no significant difference in energy intake between groups.

  • Conflicting three-month muscle-mass changes in the same trial

    Minor

    Two accounts of the Hegerová trial give the intervention group's change in lean body mass from admission to three months after discharge as +1.3 kg and −0.4 kg, respectively.

  • Cited publication predates the stated study period

    Minor

    The cost-effectiveness discussion describes a retrospective study using data through 2010, but its cited reference [44] is dated 2003.

3 of 3

Cites

Flagged first, then by citations

Research works printed but not linked: 2

  1. Schuetz, 2019, Individualised nutritional support in medical inpatients at nutritional risk: a randomised clinical trial, Lancet (London, England), 393, 2312, 10.1016/s0140-6736(18)32776-4 · DOI · Paper page
  2. Crespi-Lofton, 2016, Managing clinically significant drug interactions in patients with HIV and comorbid conditions, Pharm Today, 64

Cited by

Sorted by citations

Related

Authors
Wunderle, C., Gomes, F., Schuetz, P., Stumpf, F., Austin, P., Ballesteros-Pomar, M. D., Cederholm, T., Fletcher, J., Laviano, A., Norman, K., Poulia, K.-A., Schneider, S. M., Stanga, Z., & Bischoff, S. C.
Affiliations
  • University of Basel (CH)
  • University of Hohenheim (DE)
  • University of Oxford (GB)
  • Complejo Asistencial Universitario de León (ES)
  • Uppsala University (SE)
  • Queen Elizabeth Hospital Birmingham (GB)
  • Sapienza University of Rome (IT)
  • Berlin Institute of Health at Charité - Universitätsmedizin Berlin (DE)
  • Agricultural University of Athens (GR)
  • Université Côte d'Azur (FR)
  • University of Bern (CH)
ORCID
Venue
Clinical Nutrition
Publisher
Elsevier BV
Published
2023-09
Volume
42
Issue
9
Pages
1545-1568
ISSN
0261-5614 (ISSN-L)
DOI
10.1016/j.clnu.2023.06.023
OpenAlex
W4383646138
Semantic Scholar
d9cd21518d53a2153b8c52078abdecf840e6035c
Cited by
105
References
190
Citations by year
2026: 34 · 2025: 37 · 2024: 32 · 2023: 2
FWCI
15.06
Type
journal article
Language
en
Open access
Licence
Locations
  • Clinical Nutrition (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • Uppsala University Publications (Uppsala University) (submittedVersion, cc-by-nc-nd)
  • New University of Lisbon's Repository (New University of Lisbon) (submittedVersion)
  • BORIS (University Library Bern) (submittedVersion, cc-by-nc-nd)
  • IRIS Research product catalog (Sapienza University of Rome) (submittedVersion)
  • Open Access CRIS of the University of Bern
Funders
  • Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung (PP00 P3_150531/1)
  • European Society for Clinical Nutrition and Metabolism
  • Forschungsrat des Kantonsspitals Aarau (1410.000.044)
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, disease-related malnutrition, multimorbidity, medical inpatients, energy and protein requirements, micronutrient requirements, enteral nutrition, parenteral nutrition, nutritional monitoring, Delphi consensus
MeSH terms
Hospitalization, Hospitals, Humans, Inpatients, Practice Guidelines as Topic, Nutritional Support, Malnutrition

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-23.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-23.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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