DOI: 10.1002/jpen.

2423

REVIEW‐SYMPOSIUM

Nutrition issues in the general medical ward patient: From

general screening to specific diagnosis and individualized
treatment

Carla Gressies MSc1 | Pascal Tribolet MSc1,2,3 | Philipp Schuetz MD, MPH1,4

1
Medical University Department, Division of
General Internal and Emergency Medicine, Abstract
Kantonsspital Aarau, Aarau, Switzerland
Disease‐related malnutrition in patients in the general medical ward remains a
2
Department of Health Professions, Bern
University of Applied Sciences, Bern,
complex syndrome, which contributes to high morbidity and mortality, and seriously
Switzerland interferes with recovery from acute illness. Recently, there have been important
3
Faculty of Life Science, University of Vienna, advances in the development of consensus diagnostic criteria for malnutrition, and
Vienna, Austria
4
through the recent completion of large‐scale trials, the understanding of
Department of Clinical Research, University
Hospital Basel, University of Basel, Basel, pathophysiological pathways and evidence‐based treatment algorithms to provide
Switzerland nutrition care to patients at risk for malnutrition in the hospital setting has advanced.

Correspondence
There is need to identify more specific clinical parameters and blood biomarkers,
Philipp Schuetz, MD, MPH, Medical University which allow a more personalized approach to the malnourished patients, because
Department, Division of General Internal and
not all patients show the same response to nutrition interventions. Recent studies
Emergency Medicine, Kantonsspital Aarau,
Tellstrasse, Aarau CH‐5001, Switzerland. have suggested that some nutrition biomarkers of inflammation, kidney function and
Email: [email protected]
muscle health, among others, predict treatment response to nutrition interventions
and may help to personalize treatments. In addition to advancing the science, there
is need for more education of students and treating teams in the hospital to improve
the screening of patients at hospital admission regarding nutrition risk with the start
of individualized nutrition support interventions, thereby bringing optimal nutrition
care to the bedside.

KEYWORDS
clinical outcomes, malnutrition, nutrition, nutrition support, screening

MAL N U TR I TI O N : P A T H O G E N E S IS , nutrients and includes undernutrition (eg, wasting, stunting, and

SCREENING, AND DIAGNOSTIC CRITERIA underweight), micronutrient‐related malnutrition, and overweight
(eg, obesity and diet‐related noncommunicable diseases).2 With
Malnutrition is common in the population of mostly elderly, important advances in medical treatments for chronic conditions
chronically ill medical inpatients and associated with detrimental and higher life expectancy in multimorbid patients, disease‐related
1,2
metabolic consequences, such as catabolism and muscle wasting. malnutrition has become a matter of growing concern. In fact,
We have known for a long time that malnutrition is associated with approximately one in four medical inpatients is malnourished on
high mortality and morbidity, increased risk for infection, and an hospital admission or becomes malnourished during the hospital stay
3,4
increased hospital length of stay. Malnutrition refers to deficien- because of illness‐related loss of appetite, drug‐related side effects,
cies, excesses, or imbalances in a person's intake of energy and/or fasting orders for diagnostic studies, diseases that impair the normal

© 2022 American Society for Parenteral and Enteral Nutrition.

S16 | wileyonlinelibrary.com/journal/jpen J Parenter Enteral Nutr. 2023;47:S16–S23.

 19412444, 2023, S1, Downloaded from https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/jpen.2423 by Cochrane Philippines, Wiley Online Library on [20/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
JOURNAL OF PARENTERAL AND ENTERAL NUTRITION | S17

functioning of the digestive system, and overall deficits in the not meet the GLIM criteria still showed some benefit from nutrition
management of inpatient nutrition.5–8 therapy.29 Thus, this study suggests that parameters that are more
Malnutrition may result from several factors, including starva- specific may be needed if these criteria are used for selecting patients
tion; disease‐associated factors, including polypharmacy with drug‐ regarding the initiation of nutrition support interventions. Also,
related side effects; and compromised intake or assimilation of similar to GLIM, there are other initiatives for consensus criteria
nutrients, as well as immobility, advanced ageing, and social regarding the diagnosis of malnutrition. The Academy of Nutrition
9
isolation. Importantly, inflammation has recently been discovered and Dietetics (AND) and the American Society for Parenteral and
as a main driver for malnutrition by negatively influencing appetite Enteral Nutrition (ASPEN) published a standardized set of diagnostic
and intake of food through several mechanisms. For example, several characteristics and an aetiology‐based malnutrition definition.30
cytokines affect brain circuits that control food intake, delay gastric A study from 2022 compared the AND‐ASPEN and the GLIM
emptying, and influence skeletal muscle catabolism. Another con- malnutrition diagnostic criteria and found them to have a high degree
tributing factor explaining the associations of illness and malnutrition of criterion validity and reliability for the identification of malnutrition
are changes in the endocrine systems, including an increase in cortisol in a hospital setting.31 Clearly, further studies are needed to
concentrations and a decrease in sex hormones, further advancing understand the best approach for the diagnosis of malnutrition in
catabolism.10,11 an individual patient.
Agreeing on malnutrition consensus criteria has been a challenge
for many years.12,13 However, malnutrition is not one specific and
well‐defined illness but a syndrome with several potential mecha- N U T R I T I O N SU P P O R T I N T E R V E N T I O N S T O
nisms. These include lack of intake or uptake of nutrition, inflamma- IM P ROVE CLI N I CAL OU TC OMES
tion, alterations in body composition with loss of fat‐free mass,
decreased physical and mental function, and impaired clinical While malnutrition is a well‐established risk factor for adverse
outcome from disease.14‐18 Recently, global experts have proposed clinical courses and mortality, several randomized controlled trials
specific variables for a consensus definition of malnutrition and have provided evidence that nutrition interventions reduce these
recommend that malnutrition is diagnosed in a two‐step approach.18 risks significantly. Actually, the field of nutrition care for medical
The first step consists of nutrition screening to identify patients at inpatients has raised significantly in recent years. Historically,
risk of malnutrition. Today, different easy‐to‐use malnutrition inadequate trial data regarding the best approach to addressing
screening tools exist to estimate the risk for malnutrition in patients malnutrition may explain the low level of attention that medical
admitted to the hospital.19‐21 Table 1 provides an overview of a staff often pay to the issue of malnutrition. Recently, several trials
selection of four different screening tools and one assessment studying the role of nutrition support in the medical inpatient have
instrument for adults, including an overview of their validity, changed our understanding. A 2019 systematic review and meta‐
agreement, and reliability.21‐27 A recent study additionally compared analysis, including 27 trials comprising 6803 patients, reported that
these tools and assessment instruments for their ability to predict nutrition support provided during hospitalization is associated with
1‐year mortality in medical patients.28 a 25% reduction in both mortality and non‐elective hospital
The second step for diagnosis of malnutrition is the use of more readmissions.32 Interestingly, the subgroup of trials using a high‐
specific criteria. Herein, the Global Leadership Initiative on Mal- protein diet and long‐term nutrition interventions showed best
nutrition (GLIM) has proposed three phenotypic criteria results regarding decrease in mortality, suggesting that these are
(unintentional weight loss, low body mass index, and reduced muscle key elements of nutrition care.33 Among these trials, EFFORT
mass) and two aetiological criteria (reduced food intake or assimila- (Effect of early nutritional support on Frailty, Functional Outcomes
tion and inflammation or disease burden), which should be assessed and Recovery of malnourished medical inpatients Trial), was the
by a nutrition specialist (Figure 1).15,16 At least one phenotypic largest trial, with >2000 patients, and compared the effects of
criterion and one aetiologic criterion must be present to reach a individualized nutrition support to reach energy and protein goals vs
diagnosis of malnutrition. This allows classification of malnutrition usual hospital food in eight Swiss hospitals.34 The primary end point
into four aetiology‐related diagnosis categories: from chronic disease of the trial was severe complications, a composite of mortality,
with no inflammation to acute disease with severe inflammation. admission to the intensive care unit, cardiovascular and gastro-
Phenotypic metrics are used to classify severity into stage 1 intestinal complications, functional decline and hospital
(moderate) and stage 2 (severe) malnutrition. While several studies readmission. In this trial, the nutrition support intervention was
have validated the GLIM criteria regarding their value to identify highly effective in lowering the risk for mortality, with a number
patients at higher medical risk, there is still need for further large‐ needed to treat (NNT) of 37. A similar effect on the risk of mortality
scale validation studies to understand whether these criteria are also (NNT = 20) was also found in the placebo‐controlled, 652‐patient
useful for the surgical patient and whether or not they help to predict NOURISH trial, which studied the effects of using a protein‐rich oral
treatment response to nutrition interventions. One recent analysis supplement on clinical outcomes in malnourished, medical inpa-
using data from a randomized trial found GLIM criteria to have a high tients in the United States.35 There are also a number of studies in
prognostic value, but patients identified as at nutrition risk who did other specific medical populations, such as patients with acute heart
 19412444, 2023, S1, Downloaded from https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/jpen.2423 by Cochrane Philippines, Wiley Online Library on [20/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
S18 | GRESSIES ET AL.

TABLE 1 Characteristics of major nutrition screening tools and assessment instruments for adults (a selection)
Nutrition screening tool Parameters assessed Possible outcomes Recommended setting
21
Nutrition Risk Screening 2002 Weight loss Nutrition risk (≥3 points) Adults admitted to hospital

Recent food intake No nutrition risk

(<3 points)
BMI and impaired general condition

Severity of disease

Age

Malnutrition Universal Screening Weight loss Low risk of malnutrition Community‐dwelling adults
Tool22
BMI Medium risk of Adults admitted to hospital and
malnutrition other care settings

Reduced food intake for ≥5 days (acute High risk of malnutrition

disease)

Mini Nutritional Assessment Reduced food intake Normal nutrition status Older adults living in institutional
Short‐Form23 settings

Weight loss At risk of malnutrition Community‐dwelling older adults

Mobility Malnourished

Psychological stress/acute disease

Neuropsychological problems

BMI or calf circumference

Malnutrition Screening Tool24 Weight loss Low risk of malnutrition Older adults living in institutional
settings

Reduced food intake Medium risk of Adults admitted to hospital

malnutrition

High risk of malnutrition

Short Nutritional Assessment Weight loss No intervention Adults admitted to hospital

Questionnaire25
Decreased appetite Moderately malnourished

Use of supplemental drinks or tube feeding Severely malnourished

26
Subjective Global Assessment Weight loss Well nourished Adults admitted to hospital

Reduced food intake Mildly/moderately Community‐dwelling adults

malnourished

Gastrointestinal symptoms Severely malnourished

Functional capacity

Comorbid illness and its relation to

nutrition requirements

Brief physical examination

Abbreviation: BMI, body mass index.

failure36 and patients with pneumonia, which show beneficial step. Exclusion of medication side effects and specific medical
effects of nutrition support on mortality and other clinical illnesses that cause loss of appetite, difficulties in feeding, or
outcomes.37 malabsorption is mandatory. Second, defining nutrition goals for an
Although these trials had varying approaches to nutrition individual patient is important.5,39 These include energy and protein
support intervention, overall concepts and ideas were somewhat goals but also fluid, micronutrient, and vitamin goals. Energy goals
similar and largely in line with recent recommendations from the can be estimated using indirect calorimetry, which provides one of
5
European Society for Clinical Nutrition and Metabolism (ESPEN) and the most sensitive, accurate, and non‐invasive measurements of
ASPEN.38 Initially, screening for risk of malnutrition, followed by a energy expenditure in an individual.40 Alternatively, validated
thorough assessment of nutrition status by multidisciplinary teams to formulas, such as the adapted Harris‐Benedict equation41 or more
identify patients with disease‐related malnutrition, is the first key simple weight‐based formulas (eg, 25–30 kcal/kg body weight per
 19412444, 2023, S1, Downloaded from https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/jpen.2423 by Cochrane Philippines, Wiley Online Library on [20/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
JOURNAL OF PARENTERAL AND ENTERAL NUTRITION | S19

F I G U R E 1 GLIM diagnostic scheme for screening, assessment, diagnosis, and grading of malnutrition and future considerations: personalized
nutrition support. BIA, bioelectrical impedance analysis; CT, computer tomography; DXA, dual‐energy X‐ray absorptiometry; GLIM, Global
Leadership Initiative on Malnutrition; MRI, magnetic resonance imaging
 19412444, 2023, S1, Downloaded from https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/jpen.2423 by Cochrane Philippines, Wiley Online Library on [20/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
S20 | GRESSIES ET AL.

day) are helpful in estimating energy needs.1 A protein intake of nutrition status and to predict functional decline during hospital-
1.2–1.5 g/kg/day has been shown to improve clinical outcomes in ization and postdischarge.48–50 Although the prognostic value of
34,35
medical and older adult patients in EFFORT. However, in HGS has been demonstrated in several studies, a new study
patients with kidney failure, lower targets of 0.8 g/kg/day should demonstrated that individualized nutrition support was most
be used.34 Electrolyte‐free fluid requirements are generally in the effective in reducing mortality in patients with low HGS (ie,
range of 1500–2000 ml or 25–30 ml/kg body weight per day for ≤8 kg for female patients and ≤16 kg for male patients).51 HGS may
42
routine maintenance of fluid balance in adults. Finally, multivitamin thus help to identify sarcopenic patients with most benefit from
and/or multimineral supplements are important to correct micro- nutrition support.
nutrient deficiencies and protect against refeeding syndrome.5,39 Yet there are other markers that have not proven to enhance the
Once set, a nutrition plan to achieve these goals must be established identification of patients most likely benefiting from treatment.
within the treating team. Starting with oral nutrition, including Historically, circulating serum albumin levels on hospital admission have
optimization of the oral diet according to patient preferences,39 with been considered useful biochemical markers for the nutrition assess-
a possible escalation to enteral and parenteral nutrition if goals ment. However, a recent study suggested that a low serum albumin
cannot be achieved is important. Figure 2 shows a pragmatic level on admission in hospitalized patients at nutrition risk has
treatment algorithm for malnutrition in the inpatient setting that prognostic implications and indicates higher mortality risk but is not
was based on a consensus conference39 and a later validation trial.34 helpful in selecting patients regarding nutrition treatment interven-
tions.52 These results are in line with a recent consensus article and a
meta‐analysis concluding that serum albumin levels should be used in
MAL N U TR I TI O N B IO M A R K E R S A N D the evaluation of severity of disease but not in the assessment of
PREDICTO RS FOR “ P E R S O N A L I Z E D nutrition status or to diagnose malnutrition.18,53,54 This may be
NUTRITION”? explained by albumin serum concentrations being affected by a variety
of nonnutrition factors, mostly reflecting acute disease or inflammation
To improve nutrition care of patients, it is not only the question of but not available plasma proteins or nutrition status.55 The visceral
whether nutrition support is effective in reducing long‐term protein albumin is a negative acute‐phase protein and serum albumin
malnutrition‐associated risks, and in the mechanisms underlying these levels are inversely correlated to CRP levels.54 Normalization of serum
effects, but also the question of whether we can identify parameters to albumin levels may therefore not depend on nutrition treatment or
better individualize nutrition support to the specific needs of patients albumin treatment but rather on the resolution of inflammation.56
(“personalized nutrition”). Published personalized nutrition studies In addition, as of yet there are no convincing data demonstrating
utilizing biomarkers, proteomics, and metabolomics show promise.43,44 that the addition of proteonomic or metabolomic data would improve
Inflammatory markers are associated with response to nutrition the phenotyping of patients regarding malnutrition and response to
treatment44 and may in part explain why many critical illness trials are treatment.57 Gut microbiota or nutrigenetics are other tools that
neutral. Inflammation is a well‐known key driver of low appetite and could possibly be used to advance the concept of personalized
anorexia, leading to low food intake and catabolism.44–46 In fact, a nutrition. But again, there is a lack of studies proving their benefit for
recent analysis within the EFFORT cohort found that patients with a the management of patients.
C‐reactive protein (CRP) > 100 mg/L did not respond to nutrition
support concerning mortality reduction, as compared with patients
with CRP concentrations of ≤100 mg/L.44 These effects were O U T L O O K A N D FU T U R E C O N S I D E R A T I O N S
independent of infection and severity of disease and suggest that
highly inflamed patients may need another nutrition approach Nutrition is essential for survival and function in health and disease,
compared with patients with lower inflammation. The approach to and observational data show that malnutrition is a major risk factor
highly inflamed patients is not clear yet. for mortality and decline in functional outcomes among medical
Similarly, an analysis looking at the degree of kidney function at the patients. Yet high‐quality evidence regarding the efficacy, safety, and
time of hospital admission, found a strong association of benefit from cost‐effectiveness in acutely ill patients was, until recently, sparse.
nutrition with worsening kidney function.47 Again, these data suggest Furthermore, there is still a lack of knowledge about useful
that worsening kidney function could help to identify patients that need biomarkers and other approaches to build up personalized nutrition
special nutrition attention when patients are acutely ill. For these and include them in treating algorithms. With the publication of
patients, there are some more nutrition aspects to have in mind in the recent large‐scale trials, we have recently learned that nutrition
role of accumulation of nitrogen‐containing products, such as special- interventions are effective in reducing adverse outcomes associated
ized goals of minerals (eg, potassium and phosphates).2 with malnutrition in the medical inpatient. Also, some nutrition
Another parameter that predicts treatment response and may biomarkers of inflammation, kidney function and muscle health,
help to personalize nutrition therapy is handgrip strength (HGS). In among others, are helpful in predicting treatment response to
fact, HGS has been proposed as an easy‐to‐use, noninvasive, nutrition interventions and may help to further personalize treat-
objective, and inexpensive tool to detect and monitor changes in ments. In addition to advancing the science, there is need for more
 19412444, 2023, S1, Downloaded from https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/jpen.2423 by Cochrane Philippines, Wiley Online Library on [20/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
JOURNAL OF PARENTERAL AND ENTERAL NUTRITION | S21

F I G U R E 2 Treatment algorithm for malnutrition in the inpatient setting. GLP‐1, glucagon‐like‐peptide‐1; SGLT2, sodium‐glucose co‐
transporter‐2

education of students and treating teams in the hospital to improve A UT H O R C O N T R I B U TI O NS

the screening of patients at hospital admission regarding nutrition Carla Gressies, Pascal Tribolet, and Philipp Schuetz equally con-
risk with the start of individualized nutrition support interventions, tributed to the conception and design of the manuscript. All authors
thereby bringing optimal nutrition care to the bedside. drafted the manuscript, critically revised the manuscript, agree to be
 19412444, 2023, S1, Downloaded from https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/jpen.2423 by Cochrane Philippines, Wiley Online Library on [20/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
S22 | GRESSIES ET AL.

fully accountable for ensuring the integrity and accuracy of the work, 12. Jensen GL, Mirtallo J, Compher C, et al. Adult starvation and disease‐
and read and approved the final manuscript. related malnutrition: a proposal for etiology‐based diagnosis in the
clinical practice setting from the International Consensus Guideline
Committee. JPEN J Parenter Enteral Nutr. 2010;34(2):156‐159.
CO NFL I CT OF INTERES T S doi:10.1177/0148607110361910
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Foundation (SNSF Professorship, PP00P3_150531) and the Research Wounds. 2017;16(4):230‐237. doi:10.1177/1534734617733902
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unrestricted grant money from Nestlé Health Science and Abbott tion and documentation of adult malnutrition (undernutrition). J Acad
Nutrition. All other authors report no conflict of interests within the last Nutr Diet. 2012;112(5):730‐738. doi:10.1016/j.jand.2012.03.012
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36 months. The content of this article was presented during the course,
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