Nutritional support involves the use of specially formulated nutritional formulas to restore adequate energy intake. Family physicians can work closely with registered dietitian nutritionists in conducting a comprehensive nutritional assessment and selecting an effective therapeutic approach.
When diet or oral supplementation cannot fulfill nutritional needs, artificial nutrition support through tube feeding into the stomach or vein may be recommended. Recent advances in nutrient formulation, equipment and gastrointestinal and venous access devices have enabled such therapy to deliver significant clinical benefits in older patients.
Defining the Indications for Nutrition Support
No matter their age, gender, ethnicity or background, every patient needs nutrition. When illness or injury limit their ability to consume food directly, nutritional support therapy becomes necessary in order to receive essential vitamins and minerals via another route; this process is known as nutritional supplement therapy.
Specialized nutritional supports include enteral and parenteral (PN) feedings. Both may be administered using a feeding tube placed directly into either the stomach or small intestine and their use depends on each individual patient’s clinical situation and medical requirements.
Family physicians must recognize that malnutrition negatively impacts quality of life and increases morbidity and mortality rates for their patients, so they should collaborate with dietitian nutritionists in conducting nutritional assessments in those at risk due to chronic or acute illness that put them at an increased risk for malnutrition. Enteral nutrition is preferable when maintaining an efficient gastrointestinal tract can be maintained; otherwise PN may be necessary. PN may be reserved for individuals who cannot consume oral food due to intolerability issues.
Indications for Enteral and Parenteral Nutrition
Nutritional support provides essential calories, nutrients, electrolytes and minerals for patients unable to meet their daily nutritional requirements through oral consumption alone. Nutritional supplementation allows them to remain as independent as possible while increasing quality of life. There are two primary methods for providing such support – enteral (EN) or parenteral (PN).
EN feeds, administered through a feeding tube in the gastrointestinal tract, provide vital nutrition and meet caloric requirements. They may serve as either the sole or complementary means to oral consumption for those unable to eat due to illness, injury or trauma.
PN delivers vital nutrients and energy via an intravenous catheter in either your central or peripheral vein. Until recently, indications for PN were limited to patients unable to tolerate EN feedings due to malabsorption issues or severe GI losses – however with new formulations becoming available it has become safer and more effective for some.
Costs of Nutrition Support
One study demonstrated that patients managed by a multidisciplinary nutrition support team experienced significantly shorter hospital stays compared to control groups due to decreased readmission rates and lower hospital-acquired infections, as well as less mortality risk from nutritional care.
However, total care costs were slightly higher for patients receiving nutritional support because they remained hospitalized longer due to higher risks for malnutrition that necessitated additional attention and care.
A multidisciplinary nutrition support team is an integral component of quality patient care, ensuring high patient outcomes at an acceptable cost. Composition may differ, though dietitians and physicians typically make up this team. They can help decrease inappropriate PN usage to increase hospital revenue; however, overall cost savings would likely be smaller without access to non-ONS feeding options as often.
Clinical Trials of Nutrition Support
Although logically it would seem that providing routine specialized nutritional support would improve malnutrition and thus outcomes among polymorbid medical inpatients, clinical trial evidence of this is limited; indeed, several trials indicate such interventions may even be harmful.
To address this problem, we conducted a systematic search for randomized clinical trials (RCTs) that randomly assigned noncritically ill hospitalized patients to either nutritional support intervention vs standard hospital food and then compared outcomes between both groups. Studies were included if they provided protocol-guided caloric and protein support and standard hospital food as control groups to measure its effect on mortality, infection rates, nonelective readmission rates, functional outcome assessment results, length of hospital stay lengthenings as well as energy intake and weight changes between groups.
Results of an updated systematic review and meta-analysis involving 27 RCTs with 6803 patients showed that nutritional support is associated with lower mortality and nonlective readmission rates as well as greater energy intake and weight increase, with stronger associations found among newer trials than older ones, possibly reflecting improved study design or higher quality nutrition interventions.
