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Meta-Analysis
. 2019 Nov 1;2(11):e1915138.
doi: 10.1001/jamanetworkopen.2019.15138.

Association of Nutritional Support With Clinical Outcomes Among Medical Inpatients Who Are Malnourished or at Nutritional Risk: An Updated Systematic Review and Meta-analysis

Filomena Gomes  1   2 , Annic Baumgartner  1 , Lisa Bounoure  1 , Martina Bally  1 , Nicolaas E Deutz  3 , Jeffrey L Greenwald  4 , Zeno Stanga  5 , Beat Mueller  1 , Philipp Schuetz  1
Affiliations
Meta-Analysis

Association of Nutritional Support With Clinical Outcomes Among Medical Inpatients Who Are Malnourished or at Nutritional Risk: An Updated Systematic Review and Meta-analysis

Filomena Gomes et al. JAMA Netw Open. .

Abstract

Importance: Malnutrition affects a considerable proportion of the medical inpatient population. There is uncertainty regarding whether use of nutritional support during hospitalization in these patients positively alters their clinical outcomes.

Objective: To assess the association of nutritional support with clinical outcomes in medical inpatients who are malnourished or at nutritional risk.

Data sources: For this updated systematic review and meta-analysis, a search of the Cochrane Library, MEDLINE, and Embase was conducted from January 1, 2015, to April 30, 2019; the included studies were published between 1982 and 2019.

Study selection: A prespecified Cochrane protocol was followed to identify trials comparing oral and enteral nutritional support interventions with usual care and the association of these treatments with clinical outcomes in non-critically ill medical inpatients who were malnourished.

Data extraction and synthesis: Two reviewers independently extracted data and assessed risk of bias; data were pooled using a random-effects model.

Main outcomes and measures: The primary outcome was mortality. The secondary outcomes included nonelective hospital readmissions, length of hospital stay, infections, functional outcome, daily caloric and protein intake, and weight change.

Results: A total of 27 trials (n = 6803 patients) were included, of which 5 (n = 3067 patients) were published between 2015 and 2019. Patients receiving nutritional support compared with patients in the control group had significantly lower rates of mortality (230 of 2758 [8.3%] vs 307 of 2787 [11.0%]; odds ratio [OR], 0.73; 95% CI, 0.56-0.97). A sensitivity analysis suggested a more pronounced reduction in the risk of mortality in recent trials (2015 or later) (OR, 0.47; 95% CI, 0.28-0.79) compared with that in older studies (OR, 0.94; 95% CI, 0.72-1.22), in patients with established malnutrition (OR, 0.52; 95% CI, 0.34-0.80) compared with that in patients at nutritional risk (OR, 0.85; 95% CI, 0.62-1.18), and in trials with high protocol adherence (OR, 0.67; 95% CI, 0.54-0.84) compared with that in trials with low protocol adherence (OR, 0.88; 95% CI, 0.44-1.76). Nutritional support was also associated with a reduction in nonelective hospital readmissions (14.7% vs 18.0%; risk ratio, 0.76; 95% CI, 0.60-0.96), higher energy intake (mean difference, 365 kcal; 95% CI, 272-458 kcal) and protein intake (mean difference, 17.7 g; 95% CI, 12.1-23.3 g), and weight increase (0.73 kg; 95% CI, 0.32-1.13 kg). No significant differences were observed in rates of infections (OR, 0.86; 95% CI, 0.64-1.16), functional outcome (mean difference, 0.32; 95% CI, -0.51 to 1.15), and length of hospital stay (mean difference, -0.24; 95% CI, -0.58 to 0.09).

Conclusions and relevance: This study's findings suggest that despite heterogeneity and varying methodological quality among trials, nutritional support was associated with improved survival and nonelective hospital readmission rates among medical inpatients who were malnourished and should therefore be considered when treating this population.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Bounoure reported receiving grants from the Swiss National Science Foundation (SNSF) and from Forschungsrat of the Kantonsspital Aarau during the conduct of the study and grants from Neste Health Science and from Abbott Nutrition outside the submitted work. Dr Deutz reported receiving grants, institutional support, and personal fees from Abbott Nutrition outside the submitted work. Dr Stanga reported receiving grants and institutional support from Nestle Health Science, Fresenius Kabi, and Abbott Nutrition outside the submitted work. Dr Schuetz reported receiving grants and institutional support from Nestle and grants from Abbott outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Forest Plot Comparing Nutritional Intervention vs Control for Mortality, Stratified by Publication Year
A Mantel-Haenszel random-effects model was used. Squares indicate mean values, with the size of squares reflecting the weight and the lines indicating 95% CIs. Diamonds indicate pooled estimates, with horizontal points of the diamonds indicating 95% CIs. OR indicates odds ratio.
Figure 2.
Figure 2.. Forest Plot Comparing Nutritional Intervention vs Control for Nonelective Hospital Readmissions, Stratified by Publication Year
A Mantel-Haenszel random-effects model was used. Squares indicate mean values, with the size of squares reflecting the weight and the lines indicating 95% CIs. Diamonds indicate pooled estimates, with horizontal points of the diamonds indicating 95% CIs. RR indicates risk ratio. aCalculated and approximated from readmission frequency. bCalculated and approximated from readmission rate.
See this image and copyright information in PMC

Comment in

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