Renata Valaitis

Malnutrition or frailty? Overlap and evidence gaps in the diagnosis and treatment of frailty and malnutrition1

There is increasing awareness of the detrimental health impact of frailty on older adults and of the high prevalence of malnutrition in this segment of the population. Experts in these 2 arenas need to be cognizant of the overlap in constructs, diagnosis, and treatment of frailty and malnutrition. There is a lack of consensus regarding the definition of malnutrition and how it should be assessed. While there is consensus on the definition of frailty, there is no agreement on how it should be measured. Separate assessment tools exist for both malnutrition and frailty; however, there is intersection between concepts and measures. This narrative review highlights some of the intersections within these screening/assessment tools, including weight loss/decreased body mass, functional capacity, and weakness (handgrip strength). The potential for identification of a minimal set of objective measures to identify, or at least consider risk for both conditions, is proposed. Frailty and malnutrition have also been shown to result in similar negative health outcomes and consequently common treatment strategies have been studied, including oral nutritional supplements. While many of the outcomes of treatment relate to both concepts of frailty and malnutrition, research questions are typically focused on the frailty concept, leading to possible gaps or missed opportunities in understanding the effect of complementary interventions on malnutrition. A better understanding of how these conditions overlap may improve treatment strategies for frail, malnourished, older adults.

More-2-Eat: evaluation protocol of a multi-site implementation of the Integrated Nutrition Pathway for Acute Care

BackgroundNutrition care in hospitals is often haphazard, and malnourished patients are not always readily identified and do not receive the care they require. The Integrated Nutrition Pathway for Acute Care (INPAC) is an algorithm designed to improve the prevention, detection and treatment of malnutrition in medical and surgical patients. More-2-Eat is an evaluation of the implementation of INPAC care activities (e.g. screening) in five diverse medical units from different hospitals in Canada. The primary purpose is to understand how tailored implementation affects INPAC uptake and factors that impact this implementation. The principal outcome is a toolkit that can provide guidance to others.MethodsThis participatory action research uses a before-after time series design to address several research questions focused on implementation and uptake of INPAC (e.g., Does the implementation of INPAC improve the detection of malnutrition? Do nutrition care related knowledge, attitudes and practices scores of unit staff change with the implementation of INPAC?). A six-month developmental phase where baseline data were collected is followed by a twelve-month implementation phase and a three-month sustainability phase. Qualitative and quantitative data are collected concurrently, and to address key research questions, these data are merged. Quantitative data are collected on-site by trained local dietitians and include chart audits of nutrition care practices and a more detailed assessment of recruited patients on quality of life, disability, frailty, food intake and barriers to food intake. Thirty-day post discharge follow up for these patients occurs by researchers via a telephone interview at three time points within baseline and implementation phases, to ascertain the same and other outcomes (e.g. readmission to hospital). Qualitative data include focus groups and key informant interviews completed by researchers, monthly teleconferences among the sites and site-completed forms that track implementation activities. Resource utilization of dietitian time for various care activities (e.g. assessment) and staff time to assist patients at mealtimes is also collected.DiscussionMore-2-Eat provides an example of how implementation can be tailored when a care algorithm is embedded into routine practice. The project also highlights important learning points with respect to data collection and techniques to support implementation.Trial registrationRetrospectively registered ClinTrials.gov Identifier: NCT02800304 June 7, 2016.

Need for the Integrated Nutrition Pathway for Acute Care (INPAC): gaps in current nutrition care in five Canadian hospitals

BackgroundMalnutrition is common in hospitalized patients and is associated with increased mortality, length of stay, and risk of re-admission. The consensus based Integrated Nutrition Pathway for Acute Care (INPAC) was developed and validated to enhance patients’ nutrition care and improve clinical outcomes. As part of the More-2-Eat project (M2E), five hospitals implemented INPAC activities (e.g. screening) in a single medical unit. The purpose of this paper is to demonstrate the care gaps with respect to INPAC activities on these five units prior to implementation. Results were used as part of a needs assessment on each unit, demonstrating where nutrition care could be improved and tailoring of implementation was required.MethodsCross-sectional data was collected by site research associates (RAs) using a standardized audit form once per week for 4 weeks. The audit contents were based on the INPAC algorithm. All medical charts of patients on the study unit on the day of the audit were reviewed to track routine nutrition care activities (e.g. screening). Data was descriptively displayed with REDCap™ and analyzed using R Studio software.ResultsLess than half of patients (249/700, 36%) were screened for malnutrition at admission. Of those screened, 36% (89/246) were at risk for malnutrition yet 36% (32/89) of these patients did not receive a dietitian assessment. Also, 21% (33/157) of patients who were not screened at risk were assessed. At least one barrier to food intake was noted in 85% of patient medical charts, with pain, constipation, nausea or vomiting being the most common. Many of these barriers were addressed through INPAC standard nutrition care strategies that removed the barrier (e.g. 41% were provided medication for nausea). Advanced nutrition care strategies to improve intake were less frequently recorded (39% of patients).ConclusionThese results highlight the current state of nutrition care and areas for improvement regarding INPAC activities, including nutrition screening, assessment, and standard and advanced nutrition care strategies to promote food intake. The results also provided baseline data to support buy-in for INPAC implementation in each M2E study unit.Trial registrationRetrospectively registered ClinTrials.gov Identifier: NCT02800304, June 7, 2016.

A Qualitative Evaluation of the eaTracker® Mobile App

Background: eaTracker® is Dietitians of Canada’s online nutrition/activity self-monitoring tool accessible via website and mobile app. The purpose of this research was to evaluate the eaTracker® mobile app based on user perspectives. Methods: One-on-one semi-structured interviews were conducted with adult eaTracker® mobile app users who had used the app for ≥ 1 week within the past 90 days. Participants (n = 26; 89% female, 73% 18–50 years) were recruited via email. Interview transcripts were coded using first level coding and pattern coding, where first level codes were grouped according to common themes. Results: Participants mentioned several positive aspects of the mobile app which included: (a) Dashboard displays; (b) backed by dietitians; (c) convenience and ease of use; (d) portion size entry; (e) inclusion of food and physical activity recording; and (f) ability to access more comprehensive information via the eaTracker® website. Challenges with the mobile app included: (a) Search feature; (b) limited food database; (c) differences in mobile app versus website; and (d) inability to customize dashboard displayed information. Suggestions were provided to enhance the app. Conclusion: This evaluation provides useful information to improve the eaTracker® mobile app and also for those looking to develop apps to facilitate positive nutrition/physical activity behavior change.

Nutrition Care after Discharge from Hospital: An Exploratory Analysis from the More-2-Eat Study

Many patients leave hospital in poor nutritional states, yet little is known about the post-discharge nutrition care in which patients are engaged. This study describes the nutrition-care activities 30-days post-discharge reported by patients and what covariates are associated with these activities. Quasi-randomly selected patients recruited from 5 medical units across Canada (n = 513) consented to 30-days post-discharge data collection with 48.5% (n = 249) completing the telephone interview. Use of nutrition care post-discharge was reported and bivariate analysis completed with relevant covariates for the two most frequently reported activities, following recommendations post-discharge or use of oral nutritional supplements (ONS). A total of 42% (n = 110) received nutrition recommendations at hospital discharge, with 65% (n = 71/110) of these participants following those recommendations; 26.5% (n = 66) were taking ONS after hospitalization. Participants who followed recommendations were more likely to report following a special diet (p = 0.002), different from before their hospitalization (p = 0.008), compared to those who received recommendations, but reported not following them. Patients taking ONS were more likely to be at nutrition risk (p < 0.0001), malnourished (p = 0.0006), taking ONS in hospital (p = 0.01), had a lower HGS (p = 0.0013; males only), and less likely to believe they were eating enough to meet their body’s needs (p = 0.005). This analysis provides new insights on nutrition-care post-discharge.