Malnutrition, under-nutrition and/or obesity, may develop due to disease but may also cause disease. The prevalence of under-nutrition among hospitalized patients is high: 40-60% are either already under-nourished on admittance or at-risk of becoming malnourished. As in the general population, the prevalence of overweight and obesity in hospitalized patients is high: 25-60% have a BMI above 25 kg/m2. Though obese these patients may also be undernourished in the sense of lack of protein or micronutrients. Malnourished patients have prolonged stays at hospital, an increased rate of infection and use of prescription medication, and take longer to recover.
Acknowledging the adverse effects of malnutrition on health, since 2006 it has been mandatory to screen all patients for nutritional risk within 24 hours of admittance at all hospitals in the Capital Region, Denmark. The compliance to and the validity of the nutritional risk screening procedure warrants documentation. The recommended procedure is currently (December 2012) to treat for under-nutrition if evaluation suggests that the patient will benefit from nutritional support. In overweight patients and those suffering from the co-morbidities of overweight the guidelines stipulate initiation of lifestyle changes post discharge.
The overall aim of the studies presented in this thesis is to investigate whether it is possible to optimize patient nutrition, and how best to do this. Investigations were performed to:
• Discover the proportion of hospitalized patients receiving nutritional risk screening within the stipulated time limit.
• Evaluate the validity of the screening by comparison with information in medical records.
• Evaluate the feasibility and cost of having phlebotomists register weight, height, alcohol consumption, smoking habits and primary nutritional risk screening on their rounds, and register the data in the laboratory report.
• Investigate the effect of weight loss induced by low energy diet on physical status in obese moderate-to-severe heart failure patients, and to assess the effect on cardiovascular risk factors.
To meet these objectives three studies were performed.
In the first study a thorough audit of all patients hospitalized at Copenhagen University Hospital Gentofte, Denmark during September 2008 was conducted in order to assess the proportion of patients being screened for nutritional risk and the validity of the screening (Paper I). The present study is, to my knowledge, the only study investigating the validity of performed nutritional risk screenings by comparing them with medical records.
Eight per cent of patients were correctly screened for nutritional risk. A total of 24% of 2393 patients were nutritionally screened during admittance, of which 65% were screened within the stipulated time limit. The validity of the performed nutritional risk screenings was assessed by correlating with medical records during the same admittance. Of the conducted nutritional risk screenings 48% were inadequate, or registered weight, height, recent weight loss and/or recent loss of energy intake, or registration of disease severity, disagreed with data registered in other places in the medical record. The most common fault was
vi
a too low total score in the nutritional risk screening, which a failure to supply nutritional support to patients who would have benefited from treatment.
The second study was a pilot study at three departments at Copenhagen University Hospital Gentofte, Denmark designed to investigate the possibility of outsourcing registration of lifestyle factors and nutritional risk screening (Paper II). Of 822 patients, 33% were referred to nutritional screening and lifestyle factor registration, and 24% had their data registered. The referred patients for whom no nutritional screening was performed had either been transferred to another department or discharged. It took on average 12 (5-30) minutes to collect the data and entering data took 9 (3-35) minutes, giving a total of 24 (8-55) minutes per patient. This would cost approximately 10€ per patient. The results of this trial, with its low referral rate, suggest that the method would only identify a small proportion of the patients at-risk of malnutrition if implemented throughout Copenhagen University Hospital Gentofte. Moreover, price per patient is relatively high.
The third study was a randomized controlled intervention trial investigating the effect of weight loss in 33 obese moderate-to-severe heart failure patients (Paper III). Low energy diet (800 kcal per day in four weeks followed by four weeks of 1200 kcal daily) resulted in approximately 12 kg median weight loss, which primarily consisted of fat mass (≈66%). There was a significant difference between groups in regards to changes in weight, hip and waist circumference. The intervention group showed 11% improvements in a six-minute walk test, and 16% improvements in maximum oxygen uptake. The intervention group also displayed a slight but significant reduction in plasma lipids and glucose. Some patients also showed improvement in their diabetes and could reduce their medication. We observed no adverse effects of the intervention. These results suggest that supplemental weight loss as treatments in obese heart failure patients seems applicable in a clinical setting. More research is necessary before implementation as a routine treatment.