Elsevier

Clinical Nutrition

Volume 27, Issue 1, February 2008, Pages 48-56
Clinical Nutrition

ORIGINAL ARTICLE
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

https://doi.org/10.1016/j.clnu.2007.08.011Get rights and content

Summary

Background

Malnutrition is a common problem in patients with digestive disease and is associated with impaired outcome.

Objective

We investigated the effect of a three-month post-hospital nutritional intervention with high protein and energy supplements on body composition, muscle function and quality of life (QoL) in malnourished GI patients.

Patients and intervention

Eighty malnourished patients with benign digestive disease were randomized to receive either oral nutritional supplements (ONS) for three months in addition to dietary counselling (DC) (ONS patients) or only dietary counselling (DC patients).

Methods

Nutritional status was determined with the subjective global assessment, body composition by bioelectrical impedance and anthropometry, muscle function with hand-grip strength and peak flow. QoL was assessed by the 36-item short-form questionnaire.

Results

Age, body cell mass (BCM), muscle function, gender distribution and QoL did not differ between ONS patients (n=38) and DC patients (n=42) at baseline. Body weight and BCM improved significantly in both groups after three months. However, hand-grip strength (26.1±11.3–31.5±10.1 kg, p<0.0001) and peak flow (329.2±124.0–388.9±108.4 l/min, p=0.004) improved only in the ONS patients and remained unchanged in the DC patients. Similarly, all eight scales of the QoL improved in the ONS patients compared with merely three in the DC patients. DC patients experienced significantly more readmissions (n=20) than ONS patients (n=10) during the study period (p=0.041).

Conclusion

A three month intervention with high protein oral supplements improves outcome in malnourished patients with digestive disease in terms of functional status, QoL and rehospitalization.

Introduction

Malnutrition is still a common problem occurring in up to 50% of hospitalized patients with digestive disease.1, 2 Frequently, disease-related malnutrition is already present on admission, and nutritional status deteriorates further during hospitalization due to progression of disease, lack of awareness of the attending staff or simply adverse clinical routines.3 Patients are, therefore, often discharged in rather worse than better nutritional or functional status than when admitted to hospital. This undeniably has great implications for the patient's outcome: malnourished patients experience more in-hospital complications, non-elective readmissions and have a significantly higher in-hospital and post-hospital mortality than well-nourished patients with the same disease.2, 4 Also, patients with any amount of weight loss and no improvement in albumin concentrations during the first month after hospitalization have been shown to be at a much higher risk of readmission.5, 6

We have recently shown that malnutrition in patients with benign gastrointestinal disease is associated with both reduced muscle function and impaired quality of life when compared with well-nourished patients.7 Decreased hand-grip strength is a superior prognostic parameter to other nutritional parameters8, 9, 10 and if present on admission to hospital is a risk factor for general loss of functionality.11 This is particularly evident in elderly patients in whom loss of functionality before admission is associated with increased mortality12 and malnutrition on discharge is a strong independent risk factor for mortality.6

Since the average hospital stay is rather short, the time for nutritional repletion during hospitalization is limited. This raises the concern that patients with chronic disease are not able to fully reverse their nutritional depletion and its related dysfunctions. There is only limited information on nutritional status in patients with benign gastrointestinal disease following hospital discharge.

Several studies have demonstrated improvement of nutritional status and short-term outcome e.g. in post-surgical patients by oral nutritional supplements (ONS). However, it is not clear whether nutritional intake can be improved by dietary counselling (DC) alone or whether a therapy with nutritional supplementation has further benefits.

This study was therefore designed to compare the effect of a three-month post-hospital oral high-protein supplementation on functional status and body composition with DC. Simultaneously, we wanted to determine whether nutritional therapy with oral supplements leads to a concomitant increase in subjective quality of life, functionality and a decrease in hospital readmissions.

Section snippets

Study protocol

The study was conducted with the approval of the Ethics Committee of the Charité University Medicine Berlin. All patients signed written informed consent. This was a randomized, controlled study conducted over three months.

Patients classified malnourished according to the Subjective Global Assessment13 (SGA B or C) suffering from a benign gastrointestinal disease admitted to our department were randomized to either DC alone (DC patients) or ONS in addition to DC for three months after hospital

Screening and recruitment

Of the 384 consecutively admitted patients 114 were classified malnourished during the study recruitment period (March 2004 till October 2005). Thirteen patients declined to participate in the study and 101 patients were initially included. Nine patients originally assigned to the ONS group withdrew before the start of the study since they came to the opinion that they no longer needed nutritional therapy. One patient with liver cirrhosis declined to start the study due to increasing severity

Discussion

With this randomized controlled study we have demonstrated that nutritional therapy with an oral high-energy and protein supplement for three months following hospitalization is beneficial in malnourished patients with non-neoplastic gastrointestinal disease. Nutritional supplementation in contrast to DC led to an increase in functional capacity and a decrease in hospital readmissions. Both hand-grip strength and peak expiratory flow improved which was reflected by a simultaneous increase in

Conclusion

Malnourished patients with benign gastrointestinal disease frequently suffer from impaired muscle function and quality of life. Medical therapy together with DC fails to improve these parameters. Energy and protein rich oral supplements were, however, beneficial in malnourished patients with non-neoplastic disease as both muscle function and quality of life were improved. Moreover, the number of hospital re-admissions was significantly lower in the patients receiving nutritional supplements.

Acknowledgments

We are very grateful to the physicians and nurses in our clinic for their cooperation. Moreover, we are deeply indebted to Thomas Kahlert, Mathias von Ostrowski and Kerstin Schindler for their invaluable logistical support. We also thank Christine Smoliner, Judith Reiss, Dina Schubert and Katharina Werkstetter for their participation in data collection and entry.

This study was financially supported by a grant from Fresenius Kabi, Bad Homburg, Germany.

Conflict of interest


None declared.

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