The 'obesity paradox' in chronic obstructive pulmonary disease

Poor nutritional status in chronic obstructive pulmonary disease (COPD) is associated with increased mortality independently of disease-severity (Collins et al).1 Epidemiological studies have suggested a protective role of obesity against mortality in COPD (Vestbo et al)2 which is contrary to data from the general population where obesity is associated with decreased life expectancy. This relationship has been referred to as the ‘obesity paradox’ and has been demonstrated in a number of chronic wasting conditions (Kalantar-Zadeh et al).3 This study investigated the existence of the obesity paradox in outpatients with COPD by examining the effect of body mass index (BMI) on 1-year healthcare use and clinical outcome in terms of hospital admission rates, length of hospital stay, outpatient appointments and mortality. BMI was assessed in 424 outpatients with COPD, with measurements performed by specialist respiratory nurses during outpatient clinics. 1-year healthcare use was retrospectively collected from the date of BMI measurement. Abstract S163 Table 1 Patients classified as overweight (25.0–29.9 kg/m2) or obese (>30 kg/m2) experienced significantly fewer emergency hospital admissions, as well as a reduced length of hospital stay, in comparison to normal weight (20.0–24.9 kg/m2) or underweight (<20 kg/m2) outpatients. There was a significant negative trend between BMI classification and mortality. This study supports the existence of the ‘obesity paradox’ in COPD, not only in relation to reduced 1 year mortality rates but also in terms of reduced emergency hospital admissions and reduced length of hospital stay.

Hospital to home outreach for malnourished elders (HHOME) : a feasibility pilot

Objectives: Malnutrition is common in older hospitalised patients, and barriers to adequate intake in hospital limit the effectiveness of hospital-based nutrition interventions. This pilot study was undertaken to determine whether nutrition-focussed care at discharge and in the early post-hospital period is feasible and acceptable to patients and carers, and improves nutritional status. Design: Prospective cohort study Setting: Internal medicine wards of a tertiary teaching hospital in Brisbane, Australia Participants: Patients aged 65 and older admitted for at least 3 days, identified as malnourished or at risk of malnutrition using Mini Nutritional Assessment (MNA). Interventions: An interdisciplinary discharge team (specialist discharge planning nurse and accredited practicing dietitian) provided nutrition-focussed education, advice, service coordination and follow-up (home visits and telephone) for 6 weeks following hospitalisation Measurements: Nutritional intake, weight, functional status and MNA were recorded 6 and 12 weeks after discharge. Service intensity and changes to care were noted, and hospital readmissions recorded. Service feedback from patients and carers was sought using a brief questionnaire. Results: 12 participants were enrolled during the 6 week pilot (mean age 82 years, 50% male). All received 1-2 home visits, and 3-8 telephone calls. Four participants had new community services arranged, 4 were commenced on oral nutritional supplements, and 7 were referred to community dietetics services for follow-up. Two participants had a decline in MNA score of more than 10% at 12 week follow-up, while the remainder improved by at least 10%. Individualised care including community service coordination was valued by participants. Conclusion: The proposed model of care for older adults was feasible, acceptable to patients and carers, and associated with improved nutritional status at 12 weeks for most participants. The pilot data will be useful for design of intervention trials.

Malnutrition screening tools : comparison against two validated nutrition assessment methods in older medical inpatients

Objective Although several validated nutritional screening tools have been developed to “triage” inpatients for malnutrition diagnosis and intervention, there continues to be debate in the literature as to which tool/tools clinicians should use in practice. This study compared the accuracy of seven validated screening tools in older medical inpatients against two validated nutritional assessment methods. Methods This was a prospective cohort study of medical inpatients at least 65 y old. Malnutrition screening was conducted using seven tools recommended in evidence-based guidelines. Nutritional status was assessed by an accredited practicing dietitian using the Subjective Global Assessment (SGA) and the Mini-Nutritional Assessment (MNA). Energy intake was observed on a single day during first week of hospitalization. Results In this sample of 134 participants (80 ± 8 y old, 50% women), there was fair agreement between the SGA and MNA (κ = 0.53), with MNA identifying more “at-risk” patients and the SGA better identifying existing malnutrition. Most tools were accurate in identifying patients with malnutrition as determined by the SGA, in particular the Malnutrition Screening Tool and the Nutritional Risk Screening 2002. The MNA Short Form was most accurate at identifying nutritional risk according to the MNA. No tool accurately predicted patients with inadequate energy intake in the hospital. Conclusion Because all tools generally performed well, clinicians should consider choosing a screening tool that best aligns with their chosen nutritional assessment and is easiest to implement in practice. This study confirmed the importance of rescreening and monitoring food intake to allow the early identification and prevention of nutritional decline in patients with a poor intake during hospitalization.

Malnutrition and falls risk in community-dwelling older adults

Background and Aims: Falls and fall-related injuries result in reduced functioning, loss of independence, premature nursing home admissions and mortality. Malnutrition is associated with falls in the acute setting, but little is known about malnutrition and falls risk in the community. The aim of this study was to assess the association between malnutrition risk, falls risk and falls over a one-year period in community-dwelling older adults. Methods: Two hundred and fifty four subjects >65 years of age were recruited to participate in a study in order to identify risk factors for falls. Malnutrition risk was determined using the Mini Nutritional Assessment–Short Form. Results: 28.6% had experienced a fall and according to the Mini Nutritional Assessment-Short Form 3.9% (n=10) of subjects were at risk of malnutrition. There were no associations between malnutrition risk, the risk of falls, nor actual falls in healthy older adults in the community setting. Conclusions: There was a low prevalence of malnutrition risk in this sample of community-dwelling older adults and no association between nutritional risk and falls. Screening as part of a falls prevention program should focus on the risk of developing malnutrition as this is associated with falls.

Relationships between appetite and quality of life in hemodialysis patients

The aim of this paper was to investigate the association between appetite and Kidney-Disease Specific Quality of Life in maintenance hemodialysis patients. Quality of Life (QoL) was measured using the Kidney Disease Quality Of Life survey. Appetite was measured using self-reported categories and a visual analog scale. Other nutritional parameters included Patient-Generated Subjective Global Assessment (PGSGA), dietary intake, body mass index and biochemical markers C-Reactive Protein and albumin. Even in this well nourished sample (n=62) of hemodialysis patients, PGSGA score (r=-0.629), subjective hunger sensations (r=0.420) and body mass index (r=-0.409) were all significantly associated with the Physical Health Domain of QoL. As self-reported appetite declined, QoL was significantly lower in nine domains which were mostly in the SF36 component and covered social functioning and physical domains. Appetite and other nutritional parameters were not as strongly associated with the Mental Health domain and Kidney Disease Component Summary Domains. Nutritional parameters, especially PGSGA score and appetite, appear to be important components of the physical health domain of QoL. As even small reductions in nutritional status were associated with significantly lower QoL scores, monitoring appetite and nutritional status is an important component of care for hemodialysis patients.

Prevalence of malnutrition in community-dwelling adults with Parkinson's disease

People with Parkinson’s disease (PD) have been reported to be at higher risk of malnutrition than an age-matched population due to PD motor and non-motor symptoms and pharmacotherapy side effects. The prevalence of malnutrition in PD has yet to be well-defined. Community-dwelling people with PD, aged > 18 years, were recruited (n = 97, 61 M, 36 F). The Patient-Generated Subjective Global Assessment (PGSGA) was used to assess nutritional status, the Parkinson’s Disease Questionnaire (PDQ-39) was used to assess quality of life, and the Beck’s Depression Inventory (BDI) was used to measure depression. Levodopa equivalent doses (LEDs) were calculated based on reported Parkinson’s disease medication. Weight, height, mid-arm circumference (MAC) and calf circumference were measured. Cognitive function was measured using the Addenbrooke’s Cognitive Examination. Average age was 70.0 (9.1, 35–92) years. Based on SGA, 16 (16.5%) were moderately malnourished (SGA B) while none were severely malnourished (SGA C). The well-nourished participants (SGA A) had a better quality of life, t(90) = −2.28, p < 0.05, and reported less depressive symptoms, t(94)= −2.68, p < 0.05 than malnourished participants. Age, years since diagnosis, cognitive function and LEDs did not signifi cantly differ between the groups. The well-nourished participants had lower PG-SGA scores, t(95) = −5.66, p = 0.00, higher BMIs, t(95) = 3.44, p < 0.05, larger MACs, t(95) = 3.54, p < 0.05 and larger calf circumferences, t(95) = 2.29, p < 0.05 than malnourished participants. Prevalence of malnutrition in community-dwelling adults with PD in this study is comparable to that in other studies with community-dwelling adults without PD and is higher than other PD studies where a nutritional status assessment tool was used. Further research is required to understand the primary risk factors for malnutrition in this group.

Risk factors for malnutrition in community-dwelling people with Parkinson’s disease

In the elderly, the risks for protein-energy malnutrition from older age, dementia, depression and living alone have been well-documented. Other risk factors including anorexia, gastrointestinal dysfunction, loss of olfactory and taste senses and early satiety have also been suggested to contribute to poor nutritional status. In Parkinson’s disease (PD), it has been suggested that the disease symptoms may predispose people with PD to malnutrition. However, the risks for malnutrition in this population are not well-understood. The current study’s aim was to determine malnutrition risk factors in community-dwelling adults with PD. Nutritional status was assessed using the Patient-Generated Subjective Global Assessment (PG-SGA). Data about age, time since diagnosis, medications and living situation were collected. Levodopa equivalent doses (LDED) and LDED per kg body weight (mg/kg) were calculated. Depression and anxiety were measured using the Beck’s Depression Inventory (BDI) and Spielberger Trait Anxiety questionnaire, respectively. Cognitive function was assessed using the Addenbrooke’s Cognitive Examination (ACE-R). Non-motor symptoms were assessed using the Scales for Outcomes in Parkinson's disease-Autonomic (SCOPA-AUT) and Modified Constipation Assessment Scale (MCAS). A total of 125 community-dwelling people with PD were included, average age of 70.2±9.3(35-92) years and average time since diagnosis of 7.3±5.9(0–31) years. Average body mass index (BMI) was 26.0±5.5kg/m2. Of these, 15% (n=19) were malnourished (SGA-B). Multivariate logistic regression analysis revealed that older age (OR=1.16, CI=1.02-1.31), more depressive symptoms (OR=1.26, CI=1.07-1.48), lower levels of anxiety (OR=.90, CI=.82-.99), and higher LDED per kg body weight (OR=1.57, CI=1.14-2.15) significantly increased malnutrition risk. Cognitive function, living situation, number of prescription medications, LDED, years since diagnosis and the severity of non-motor symptoms did not significantly influence malnutrition risk. Malnutrition results in poorer health outcomes. Proactively addressing the risk factors can help prevent declines in nutritional status. In the current study, older people with PD with depression and greater amounts of levodopa per body weight were at increased malnutrition risk.

Malnutrition in a sample of community-dwelling people with Parkinson’s disease

Objective: Malnutrition results in poor health outcomes, and people with Parkinson’s disease may be more at risk of malnutrition. However, the prevalence of malnutrition in Parkinson’s disease is not yet well defined. The aim of this study is to provide an estimate of the extent of malnutrition in community-dwelling people with Parkinson’s disease. Methods: This is a cross-sectional study of people with Parkinson’s disease residing within a 2 hour driving radius of Brisbane, Australia. The Subjective Global Assessment (SGA) and scored Patient Generated Subjective Global Assessment (PG-SGA) were used to assess nutritional status. Body weight, standing or knee height, mid-arm circumference and waist circumference were measured. Results: Nineteen (15%) of the participants were moderately malnourished (SGA-B). The median PG-SGA score of the SGA-B group was 8 (4 – 15), significantly higher than the SGA-A group, U=1860.5,p<.05. The symptoms most influencing intake were loss of appetite, constipation, early satiety and problems swallowing. Conclusions: As with other populations, malnutrition remains under-recognised and undiagnosed in people with Parkinson’s disease. Regular screening of nutritional status in people with Parkinson’s disease by health professionals with whom they have regular contact should occur to identify those who may benefit from further nutrition assessment and intervention.

Comparison of two methods to assess malnutrition in community-dwelling people with Parkinson's disease

Nutritional status in people with Parkinson’s disease (PD) has previously been assessed in a number of ways including BMI, % weight loss and the Mini-Nutritional Assessment(MNA). The symptoms of the disease and the side effects of medication used to manage them result in a number of nutrition impact symptoms that can negatively influence intake. These include chewing and swallowing difficulties, lack of appetite, nausea, and taste and smell changes, among others. Community-dwelling people with PD, aged >18 years, were recruited (n=97, 61 M, 36 F). The Patient-Generated Subjective Global Assessment(PG-SGA) and (MNA) were used to assess nutritional status. Weight, height, mid-arm circumference(MAC) and calf circumference were measured. Based on SGA, 16(16.5%) were moderately malnourished (SGA B) while none were severely malnourished (SGA C). The MNA identified 2(2.0%) as malnourished and 22(22.7%) as at risk of malnutrition. Mean MNA scores were different between the three groups,F(2,37)=7.30,p<.05 but not different between SGA B (21.0(2.9)) and MNA at risk (21.8(1.4)) participants. MAC and calf circumference were also different between the three groups,F(2,37)=5.51,p<.05 and F(2,37)=15.33,p<.05 but not between the SGA B (26.2(4.2), 33.3(2.8)) and MNA at risk (28.4(5.6), 36.4(4.7)) participants. The MNA results are similar to other PD studies using MNA where prevalence of malnutrition was between 0-2% with 20-33% at risk of malnutrition. In this population, the PG-SGA may be more sensitive to assessing malnutrition where nutrition impact symptoms influence intake. With society’s increasing body size, it might also be more appropriate as it does not rely on MAC and calf circumference measures.

Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: Results from the Nutrition Care Day Survey 2010

Background & aims The Australasian Nutrition Care Day Survey (ANCDS) ascertained if malnutrition and poor food intake are independent risk factors for health-related outcomes in Australian and New Zealand hospital patients. Methods Phase 1 recorded nutritional status (Subjective Global Assessment) and 24-h food intake (0, 25, 50, 75, 100% intake). Outcomes data (Phase 2) were collected 90-days post-Phase 1 and included length of hospital stay (LOS), readmissions and in-hospital mortality. Results Of 3122 participants (47% females, 65 ± 18 years) from 56 hospitals, 32% were malnourished and 23% consumed ≤ 25% of the offered food. Malnourished patients had greater median LOS (15 days vs. 10 days, p < 0.0001) and readmissions rates (36% vs. 30%, p = 0.001). Median LOS for patients consuming ≤ 25% of the food was higher than those consuming ≤ 50% (13 vs. 11 days, p < 0.0001). The odds of 90-day in-hospital mortality were twice greater for malnourished patients (CI: 1.09–3.34, p = 0.023) and those consuming ≤ 25% of the offered food (CI: 1.13–3.51, p = 0.017), respectively. Conclusion The ANCDS establishes that malnutrition and poor food intake are independently associated with in-hospital mortality in the Australian and New Zealand acute care setting.

Do the skeletons in the hospital closet still exist? What do they eat?

One aim of the Australasian Nutrition Care Day Survey (ANCDS) was to explore dietary intake and nutritional status of acute care hospital patients. Dietitians from 56 hospitals in Australia and New Zealand completed a 24-hour nutritional status and dietary intake audit of 3000 adult patients. Participants were evaluated for nutritional risk using the Malnutrition Screening Tool (MST). Those ‘at risk’ underwent nutritional assessment using Subjective Global Assessment (SGA). Dietitians observed participants’ dietary intake at each main meal and recorded mid-meal intake via participant interviews. Intakes were recorded as 0%, 25%, 50%, 75%, or 100% of that offered for each meal during the 24-hour audit. Preliminary results for 1550 participants (males = 853; females = 697), age = 64 ± 17 years and BMI = 27 ± 7 kg/m2. Fifty-five percent (n = 853) of the participants had BMI > 25 kg/m2. The MST identified 41% (n = 636) ‘at risk’ for malnutrition. Of those ‘at risk’, 70% were assessed as malnourished resulting in an overall malnutrition prevalence of 30% (25% moderately malnourished, 5% severely malnourished). One-quarter of malnourished participants (n = 118) were on standard hospital diets without additional nutritional support. Fifty percent of malnourished patients (n = 235) and 40% of all patients (n = 620) had an overall 24-hour food consumption of ≤50% during the 24-hour audit. The ANCDS found that skeletons in the hospital closet continue to exist and that acute care patients continue to have suboptimal dietary intake. The ANCDS provides valuable insight into gaps in existing nutrition care practices.

The impact of malnutrition and decreased food intake on length of stay, readmission, and mortality in acute care patients

Rationale: The Australasian Nutrition Care Day Survey (ANCDS) evaluated if malnutrition and decreased food intake are independent risk factors for negative outcomes in hospitalised patients. Methods: A multicentre (56 hospitals) cross-sectional survey was conducted in two phases. Phase 1 evaluated nutritional status (defined by Subjective Global Assessment) and 24-hour food intake recorded as 0, 25, 50, 75, and 100% intake. Phase 2 data, which included length of stay (LOS), readmissions and mortality, were collected 90 days post-Phase 1. Logistic regression was used to control for confounders: age, gender, disease type and severity (using Patient Clinical Complexity Level scores). Results: Of 3122 participants (53% males, mean age: 65±18 years) 32% were malnourished and 23% consumed�25% of the offered food. Median LOS for malnourished (MN) patients was higher than well-nourished (WN) patients (15 vs. 10 days, p<0.0001). Median LOS for patients consuming �25% of the food was higher than those consuming �50% (13 vs. 11 days, p<0.0001). MN patients had higher readmission rates (36% vs. 30%, p = 0.001). The odds ratios of 90-day in-hospital mortality were 1.8 times greater for MN patients (CI: 1.03 3.22, p = 0.04) and 2.7 times greater for those consuming �25% of the offered food (CI: 1.54 4.68, p = 0.001). Conclusion: The ANCDS demonstrates that malnutrition and/or decreased food intake are associated with longer LOS and readmissions. The survey also establishes that malnutrition and decreased food intake are independent risk factors for in-hospital mortality in acute care patients; and highlights the need for appropriate nutritional screening and support during hospitalisation. Disclosure of Interest: None Declared.

Markers of disease severity are associated with malnutrition in Parkinson's disease

Objective In Parkinson's disease (PD), commonly reported risk factors for malnutrition in other populations commonly occur. Few studies have explored which of these factors are of particular importance in malnutrition in PD. The aim was to identify the determinants of nutritional status in people with Parkinson's disease (PWP). Methods Community-dwelling PWP (>18 years) were recruited (n = 125; 73M/52F; Mdn 70 years). Self-report assessments included Beck's Depression Inventory (BDI), Spielberger Trait Anxiety Inventory (STAI), Scales for Outcomes in Parkinson's disease – Autonomic (SCOPA-AUT), Modified Constipation Assessment Scale (MCAS) and Freezing of Gait Questionnaire (FOG-Q). Information about age, PD duration, medications, co-morbid conditions and living situation was obtained. Addenbrooke's Cognitive Examination (ACE-R), Unified Parkinson's Disease Rating Scale (UPDRS) II and UPDRS III were performed. Nutritional status was assessed using the Subjective Global Assessment (SGA) as part of the scored Patient-Generated Subjective Global Assessment (PG-SGA). Results Nineteen (15%) were malnourished (SGA-B). Median PG-SGA score was 3. More of the malnourished were elderly (84% vs. 71%) and had more severe disease (H&Y: 21% vs. 5%). UPDRS II and UPDRS III scores and levodopa equivalent daily dose (LEDD)/body weight(mg/kg) were significantly higher in the malnourished (Mdn 18 vs. 15; 20 vs. 15; 10.1 vs. 7.6 respectively). Regression analyses revealed older age at diagnosis, higher LEDD/body weight (mg/kg), greater UPDRS III score, lower STAI score and higher BDI score as significant predictors of malnutrition (SGA-B). Living alone and higher BDI and UPDRS III scores were significant predictors of a higher log-adjusted PG-SGA score. Conclusions In this sample of PWP, the rate of malnutrition was higher than that previously reported in the general community. Nutrition screening should occur regularly in those with more severe disease and depression. Community support should be provided to PWP living alone. Dopaminergic medication should be reviewed with body weight changes.

Reply - Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality

Dear Editor We thank Dr Klek for his interest in our article and giving us the opportunity to clarify our study and share our thoughts. Our study looks at the prevalence of malnutrition in an acute tertiary hospital and tracked the outcomes prospectively.1 There are a number of reasons why we chose Subjective Global Assessment (SGA) to determine the nutritional status of patients. Firstly, we took the view that nutrition assessment tools should be used to determine nutrition status and diagnose presence and severity of malnutrition; whereas the purpose of nutrition screening tools are to identify individuals who are at risk of malnutrition. Nutritional assessment rather than screening should be used as the basis for planning and evaluating nutrition interventions for those diagnosed with malnutrition. Secondly, Subjective Global Assessment (SGA) has been well accepted and validated as an assessment tool to diagnose the presence and severity of malnutrition in clinical practice.2, 3 It has been used in many studies as a valid prognostic indicator of a range of nutritional and clinical outcomes.4, 5, 6 On the other hand, Malnutrition Universal Screening Tool (MUST)7 and Nutrition Risk Screening 2002 (NRS 2002)8 have been established as screening rather than assessment tools.

Current practice in nutrition assessment for the management of Parkinson’s disease in Australia and Canada

AIM: To document and compare current practice in nutrition assessment of Parkinson’s disease by dietitians in Australia and Canada in order to identify priority areas for review and development of practice guidelines and direct future research. METHODS: An online survey was distributed to DAA members and PEN subscribers through their email newsletters. The survey captured current practice in the phases of the Nutrition Care Plan. The results of the assessment phase are presented here. RESULTS: Eighty-four dietitians responded. Differences in practice existed in the choice of nutrition screening and assessment tools, including appropriate BMI ranges. Nutrition impact symptoms were commonly assessed, but information about Parkinson’s disease medication interactions were not consistently assessed. CONCLUSIONS: he variation in practice related to the use of screening and assessment methods may result in the identification of different goals for subsequent interventions. Even more practice variation was evident for those items more specific to Parkinson’s disease and may be due to the lack of evidence to guide practice. Further research is required to support decisions for nutrition assessment of Parkinson’s disease.