Food for thought: why does the medical community struggle with research about nutritional therapy in the acute care setting?

Abstract

Although clinical nutrition is a frequently used intervention in inpatient care, high quality trials proving its effectiveness and safety when used in the acutely-ill polymorbid medical inpatient population are largely lacking. From an evolutionary perspective, illness-related low appetite is protective and part of the host response to improve recovery from disease. Large and well performed trials in the intensive care setting have shown deleterious effects of (parenteral) feeding strategies aiming at higher caloric intakes compared to lower intakes, raising the question of whether feeding per se may be simply maladaptive in acute severe illness. Outside critical care, similar large-scale studies are lacking with basic clinical questions regarding the optimal amount/composition of nutrition and best patient selection remaining largely unanswered. Also, the interplay of nutritional interventions and its influence on the microbiome remains largely unclear. Given the magnitude of morbidity caused by malnutrition and the high number of affected patients, it is surprising how little the medical community has invested in better understanding ways to improve this condition. It is now time to perform high-quality trials to better understand how to best deal with this condition in the acute care setting. Such trials will allow change from a one-size-fits-all approach, to more evidence-based, personalized nutritional interventions, ultimately improving patient outcomes. While there is ongoing discussion about definition of malnutrition, we should rather focus on the identification of patients who do or do not benefit from nutritional interventions.

Association of Baseline Inflammation With Effectiveness of Nutritional Support Among Patients With Disease-Related Malnutrition

“…Previous studies have found that inflammation because of acute or chronic disease causes metabolic changes by influencing different pathways. 21,22 Inflammation has effects on appetite and food intake, gastrointestinal functioning of the stomach and gut, and, on a cellular level, on insulin resistance, among others. 23 Among other mechanisms, these effects are mediated by circulating cytokines released as part of the systemic inflammatory response.…”

Bericht über die neue ESPEN-Leitlinie zur Ernährung von polymorbiden, internistischen Patienten

“…Trotz methodischer Herausforderungen aufgrund der heterogenen Patientenpopulation und dem Fehlen von großen Interventionsstudien [24,25], ist es der Arbeitsgruppe gelungen, evidenzbasierte Empfehlungen zur nichtkrankheitsspezifischen Ernährungstherapie bei polymorbiden Patienten zu erarbeiten. Als Resultat sind 22 praktische Empfehlungen und 4 Stellungnahmen entstanden, welche im klinischen Alltag im Umgang mit mangelernährten, hospitalisierten, polymorbiden Patienten genutzt werden können.…”

Was sind Barrieren der Ernährungstherapie bei mangelernährten, hospitalisierten Patienten der Inneren Medizin?

“…Zusammenfassend lässt sich sagen, dass bei internistischen, hospitalisierten Patienten ein hohes Mangelernährungsrisiko besteht und durch eine Ernährungstherapie wahrscheinlich ein Gewinn hinsichtlich niedriger Rehospitalisationsrate und Hospitalisationsdauer sowie vielleicht der Mortalität erreicht werden kann [10]. Die Qualität der heutigen Evidenz ist aber noch zu schwach und es braucht weitere groß angelegte Studien in diesem Bereich [12], dies auch um mögliche Risiken der Ernährung wie das "Refeeding-Syndrom" oder "Overfeeding" auszuschließen [13 -15].…”