Decreased food intake is a risk factor for mortality in hospitalised patients: The NutritionDay survey 2006

doi:10.1016/j.clnu.2009.05.013

Clinical Nutrition

Volume 28, Issue 5, October 2009, Pages 484-491

https://doi.org/10.1016/j.clnu.2009.05.013 Get rights and content

Summary

Background & aims

Malnutrition is a known risk factor for the development of complications in hospitalised patients. We determined whether eating only fractions of the meals served is an independent risk factor for mortality.

Methods

The NutritionDay is a multinational one-day cross-sectional survey of nutritional factors and food intake in 16,290 adult hospitalised patients on January 19th 2006. The effect of food intake and nutritional factors on death in hospital within 30 days was assessed in a competing risk analysis.

Results

More than half of the patients did not eat their full meal provided by the hospital. Decreased food intake on NutritionDay or during the previous week was associated with an increased risk of dying, even after adjustment for various patient and disease related factors. Adjusted hazard ratio for dying when eating about a quarter of the meal on NutritionDay was 2.10 (1.53–2.89); when eating nothing 3.02 (2.11–4.32). More than half of the patients who ate less than a quarter of their meal did not receive artificial nutrition support. Only 25% patients eating nothing at lunch receive artificial nutrition support.

Conclusion

Many hospitalised patients in European hospitals eat less food than provided as regular meal. This decreased food intake represents an independent risk factor for hospital mortality.

Introduction

Already in 1977 Hill et al. showed that many surgical patients¹ have signs of malnutrition. Poor nutritional status has been identified as an indicator for an increased likelihood of complications.2, 3, 4, 5 Inadequate food intake has been shown to increase mortality in a small group of selected patients,⁵ but food intake was not stratified and neither nutritional status nor recent changes in nutrition behaviour were considered. A poor nutrient intake was associated with a higher rate of infections, poor wound healing, more frequent cardiac complications and hence prolonged hospital stay.2, 6, 7, 8, 9, 10, 11, 12, 13 The proportion of hospitalised patients with an altered nutritional status based on criteria such as body mass index (BMI), recent weight loss or a history of undernutrition was between 7 and 50%⁴ and largest in South America.12, 13 Simple interventions to increase food intake such as protected meal times, more menu choices, additional snacks, motivation of patients or sip feedings have been proposed to prevent or reverse a further loss in body weight.14, 15 However, the effect of the fraction of the meal eaten on mortality has not been determined on a large scale.

Insufficient nutritional intake in hospital was addressed in 2003 by a resolution from the European Council¹⁶; and in 2006 by guidelines by UK's National Institute for Health and Clinical Excellence (NICE)¹⁷: however, it is unknown whether these initiatives have had any impact on nutrition care in European hospitals.

We designed the NutritionDay Study 2006 to determine the effect of food intake on all cause 30-day mortality in a large number of hospitalised patients in addition to nutritional and clinical risk factors.

Section snippets

Study design, questionnaires and recruitment

The NutritionDay Study consisted of a one-day cross-sectional audit of patient food intake followed by an outcome evaluation 30 days later. The audit was done using three questionnaires (Supplementary material eFig. 1, eFig. 2, eFig. 3a and 3b: the actual 2009 version of the NutritionDay questionnaires), available in 27 languages (free download from www.nutritionday.org). The first questionnaire addressed the structure of the ward in which the patient resided to be completed with the help of

Demographics

A total of 16,455 patients treated in 748 wards from 256 hospitals in 25 countries participated. Wards from 16 different specialties participated. Ward size ranged from 18 to 31 beds. Median patient recruitment within each ward was 93% (IQR 75–100%) of occupied beds. From the 16,455 participating patients, 16,290 (99%) were aged 18 or older and these individuals (Table 1) are included in all analyses. The patients' characteristics are described in Table 2. Nutrition history was obtained from

Discussion

The NutritionDay Study 2006 was designed to determine the effect of decreased food intake and other common nutritional risk factors on the outcomes of hospitalised patients. We found that 60% of the patients present on NutritionDay in the participating hospitals did not eat their full regular meal. We found that, in this single-day audit of food intake, even when taking into account other variables, a progressive increase of 30-day mortality was associated with decreased food intake.

Clearly,

Conclusions

The NutritionDay Study 2006 clearly shows that decreased food intake and altered nutritional status are still a major problem within European hospitals, and that little is being done about it. Patients who do not finish their meals should be considered to be at an increased risk of acquiring a significant protein-energy deficit within few days, and that they should immediately be considered for nutritional care. We believe that fractions of the meal eaten, at least for one meal, should be

Conflict of interest

All authors have clearly declared no conflict of interest for this project.

Acknowledgments

The NutritionDay Study 2006 was funded by an international project submission grant of the Medical University Vienna (55%), an unrestricted educational grant of the Austrian Association for Clinical Nutrition (AKE) 15% and the European Society for Clinical Nutrition and Metabolism (ESPEN) 30%.

The project outline and idea for the NutritionDay Study was from MH. The project was designed by MH, KS, PB, PH and coordinated by KS. The pilot project was conducted by ASH. MH, CP, PS were responsible

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As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.
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View all citing articles on Scopus

^☆: Conference presentation: Preliminary descriptive data have been presented at the ESPEN Congress 2008 in Florence.

^o: See www.nutritionday.org.

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Decreased food intake is a risk factor for mortality in hospitalised patients: The NutritionDay survey 2006☆

Summary

Background & aims

Methods

Results

Conclusion

Introduction

Section snippets

Study design, questionnaires and recruitment

Demographics

Discussion

Conclusions

Conflict of interest

Acknowledgments

Lancet

Nutrition

Clin Nutr

Eur J Intern Med

Eur J Intern Med

Clin Nutr

Nutrition

Nutrition

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