Good Nutrition Practice | Clinical Nutrition LAM Initiative

Good Nutrition Practice

Practical Steps to Improve the Nutritional Status of Patients

Good nutrition practice is a crucial part of patient management. By following four practical steps, health care professionals can ensure that patients receive the appropriate nutrition at the right time. Nutritional risk screening, assessment, intervention and monitoring assist in the early detection and adequate nutritional management of patients who are suffering from disease-related malnutrition or are at risk of malnutrition.

These practices have been developed by experienced practitioners and clinical experts based on current scientific knowledge. They are intended for daily practice and are quick and easy-to-use.

  1. Nutritional Risk Screening: The First Step in the Fight Against Disease-Related Malnutrition

Accurate screening is the initial step in good nutrition practice. Screening should be performed within 24 hours of admission so that nutrition therapy can be defined and started quickly.

Nutritional risk screening should be done with a recommended screening tool looking at weight relative to height (BMI), weight loss, appetite, and food intake. Nutritional Risk Screening 2002 (NRS 2002) is one of the most widely validated screening tools for the hospital setting, based on 128 studies, and is recommended in the “European Society for Clinical Nutrition and Metabolism (ESPEN) Guidelines for Nutrition Screening 2002.1 NRS 2002 is one of the most validated screening tool for the hospital setting based on 128 studies, with a rapid and simple procedure which can be done non-invasively and routinely by any health care professional in less than five minutes.

Alternately, a Subjective Global Assessment (SGA) can be used to screen patients. SGA is a nutritional non-invasive tool that has been found to be highly predictive of nutrition-associated complications.2 This method considers not only alterations in body composition, but also changes in physiological function.3,4,5 The SGA can also be used for a more in-depth analysis as an assessment tool.

  1. Nutritional Assessment: An In-depth Evaluation of the Causes of Disease-Related Malnutrition

If the initial nutritional risk screening has shown indications for a risk of malnutrition, a more in-depth evaluation follows. A nutritional assessment is crucial to fully understand the patient’s condition. The assessment should analyze the causes of disease-related malnutrition and the risk factors for nutrition and fluid deficiency.

Relevant assessment parameters include disease and treatment-related risk factors such as nausea, dehydration, diarrhea, acute infections; social and psychosocial risk factors such as depression and social isolation; and nutrition-related risk factors such as allergies, anthropometrics conditions and restrictive diets. Biochemical data which are objective and readily available, are also useful means to assess nutritional status.

The assessment should be performed by a nutritional expert (e.g. a dietitian, a clinician knowledgeable in nutrition, a nutrition nurse specialist or by a nutritional support team).

  1. Nutritional Therapy Plan: Improving the Nutritional Status of the Patient

The primary purpose of a nutrition therapy is to stabilize or to increase the weight of the patient and to improve their nutritional status. The aim is to deliver sufficient energy, proteins, micronutrients and fluid to meet the patient’s needs.6 Further objectives of nutritional therapy include the maintenance of immune function and prevention of metabolic complications.7

The development of a nutritional therapy plan by a physician or dietitian should follow these critical steps:

  • Define the nutritional goals for the patient
  • Define the patient’s individual nutritional requirements
  • Define nutritional support and implement nutritional therapy plan
  • Define the route(s) of nutrition
  1. Monitoring Nutrition Therapy: Keeping Patients on Track

Monitoring is an integral part of the nutritional management process which calls for careful documentation and control to estimate the effectiveness of therapy. Each patient’s status should be monitored with defined measurements and observations, such as recording of food and fluid intake, body weight and function and, where appropriate, blood parameters. During the course of the patient’s condition, these monitoring results may lead to adaptations of the nutrition therapy plan. Here, physician, nurses, and dietitians are involved.

Good Nutrition Practice Makes a Difference

Follow these four steps for nutrition management for improved clinical outcomes, such as:7

  • Earlier recognition and intervention in nutritional therapy
  • Fewer complications
  • Fewer infections
  • Improved wound healing
  • Reduced length of stay
  • Quicker mobilization and convalescence
  • Fewer re-hospitalizations
  • Better survival rates
  • Better quality of life
  • Prevention of future costs and health care constraints
  • 1. Kondrup J, Rasmussen HH, Hamberg O et al. Nutritional risk screening (NRS 2002): A new method based on an analysis of controlled clinical trials. Clin Nutr 2003;22(3):321-336.
  • 2. Sheean PM, Peterson SJ, Gurka DP et al. Nutrition assessment: the reproducibility of subjective global assessment in patients requiring mechanical ventilation. Eur J Clin Nutr 2010;64(11):1358-1364.
  • 3. No authors listed. Identifying patients at risk: ADA's definitions for nutrition screening and nutrition assessment. Council on Practice (COP) Quality Management Committee. J Am Diet Assoc 1994;94:838-839.
  • 4. Thomas B, Bishop J (Eds). Manual of Dietetic Practice 4th ed. Oxford: Wiley Blackwell 2007.
  • 5. Barker LA, Gout BS, Crowe TC. Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. Int J Environ Res Public Health 2011;8(2):514-527.
  • 6. National Collaborating Centre for Acute Care (UK). Nutrition Support for Adults Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. NICE Clinical Guidelines, No. 32 London 2006.
  • 7. a. b. Cereda E, Pedrolli C. A.S.P.E.N. recommendations for enteral nutrition: practice is the result of potential benefits, harms, clinical judgment, and ethical issues. JPEN 2010;34(1):103.

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