What is Clinical Nutrition?
Properly Managing a Patient’s Energy Balance
Food and proper nutrition intake are fundamental to good health and resistance to disease. In the hospital setting, clinical nutrition refers to the management of a patient’s energy balance, ensuring they receive sufficient quantities of fluids and nutrients such as proteins, lipids, glucose, vitamins, and minerals.
In the majority of hospital patients, high quality hospital food sufficiently meets the dietary needs. However, more than 50 percent of patients in the hospital do not eat their entire meal.1 This type of insufficient dietary intake can lead to further deterioration of the nutritional status. For example, in the case of patients with stroke or other neurological conditions, who may have swallowing difficulties or problems with self-feeding, nutritional requirements cannot be met with regular hospital diet. For patients unable or unwilling to eat, clinical nutrition support involving oral nutritional supplements (ONS), enteral tube feeding and/or parenteral nutrition becomes indispensable.2
Fighting Disease-Related Malnutrition
Disease-related malnutrition impacts patients of all ages and is not restricted to one health care setting.3 Disease-related malnutrition and the risk of malnutrition are common in many hospital wards, including geriatrics, oncology, surgery, internal medicine, and gastroenterology.4
To counteract disease-related malnutrition and its deleterious consequences, such as poor wound healing, infections, complications, and multi-organ failure, timely identification of impaired nutritional status and rapid initiation of effective clinical nutrition treatment are crucial for patients in nutritional risk groups.3
The steps in good nutritional care include:
- Screening of patient nutritional condition
- Thorough assessment of patient needs and requirements
- Development of nutritional strategy
- Proper calculation of energy and nutrient requirements
- Decision on the route of administration
- Tight monitoring of the nutritional therapy
- Adaptation to new clinical condition: calories, type of nutrition, route of administration
What Are the Major Types of Clinical Nutrition Support?
When addressing disease-related malnutrition, the choice of clinical nutrition support depends on the patient’s clinical state. Enteral nutrition (EN), parenteral nutrition (PN), or a combination of both may be indicated according to the outcome of a formal nutrition assessment. A range of strategies may be used to manage disease-related malnutrition.
To read more about the different types of clinical nutrition support, please click here.
The Benefits of Clinical Nutrition
Clinical trials have shown that adequate clinical nutrition improves patient outcomes by:
- Improving wound healing8
- Reducing incidence of complications8,9,10,11
- Lowering rate of infections6,8,10,11
- Shortening duration of mechanical ventilation6,12
- Reducing length of hospital stay9,13
- Increasing mobilization, and convalescence8
- Increasing survival8,9,12,14,15
- Improving quality of life16
As an example, when patients received supplemental PN to fill the nutrition gap left by EN feeding, they developed 11 percent fewer hospital-acquired infections than patients solely on EN.6
The effect of perioperative total PN in surgical patients showed to depend especially on the patient’s constitution. Whereas patients categorized as either borderline or mildly malnourished had no demonstrable benefit from total PN, severely malnourished patients experienced fewer noninfectious complications, and no concomitant increase in infectious complications.17
Clinical Nutrition Can Help to Reduce Health Care Costs
By improving patient health, clinical nutrition reduces the burden on health care resources, delivering economic benefits coming from shorter hospital stays, fewer readmissions, and lowered cost of care.
BAPEN undertook a cost analysis of the use of ONS in hospitals in the UK. Data was extracted from randomized controlled trials (RCTs) of ONS versus standard care. The pooled results from the analysis indicated a mean net cost saving from the use of ONS of USD 1,283* (£849) per patient, based on bed-day costs or USD 450* (£298) per patient if calculated using complication rates.2,6,18
Another multicenter, randomized, controlled trial revealed that when EN and supplemental PN were contraindicated and perioperative total PN was administered, costs can be reduced by USD 13,959 for every complication avoided.19
Early Intervention Is Key to Better Outcomes
Early PN in critically ill patients may significantly and meaningfully reduce the total costs of care. Clinical nutrition introduced at the earliest stages of disease-related malnutrition plays a key role in better patient outcomes and improved quality of care.20
Clinical Nutrition Addresses Growing Problem in Latin America
Disease-related malnutrition is a serious problem all over the world, in both developed and developing nations.
In hospitalized patients, throughout different patient groups and across varied settings, the estimated prevalence of disease-related malnutrition ranges from 30 percent in Europe,21 36 percent in China,22 40 percent in the U.S.23 up to 50 percent in Latin America.24
The use of clinical nutrition is a vital opportunity to improve care and outcomes for patients.
* Calculated based on an exchange rate of 1.5111 (Source: Bloomberg 01/09/15)
- 1. Hiesmayr M, Schindler K, Pernicka E et al. Decreased food intake is a risk factor for mortality in hospitalized patients: The Nutrition Day survey 2006. Clin Nutr 2009;28(5):484-491.
- 2. a. b. 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.
- 3. a. b. MNI: Medical Nutritional International Industry. Oral Nutritional Supplements to tackle malnutrition. A summary of the evidence base. Third version 2012.
- 4. Pirlich M, Schutz T, Kemps M et al. Prevalence of malnutrition in hospitalized medical patients: Impact of underlying disease. Dig Dis 2003;21(3):245-251.
- 5. Kreymann KG, Berger MM, Deutz NE et al. ESPEN Guidelines on Enteral Nutrition: Intensive care. Clinical Nutrition 2006;25(2):210–223.
- 6. a. b. c. d. e. Heidegger CP, Berger MM, Graf S et al. Optimization of energy provision with supplemental parenteral nutrition in critically ill patients: A randomized controlled clinical trial. Lancet 2013;381(9864):385-93.
- 7. Sobotka L, Wanten G, Camilo ME. Metabolic complications of parenteral nutrition. In: Sobotka L, editor. Basics in Clinical Nutrition. Prague: Galen 2011:411-417.
- 8. a. b. c. d. e. Waitzberg DL. Efficacy of nutritional support: Evidence-based nutrition and cost-effectiveness. Nestle Nutr Workshop Ser Clin Perform Programme 2002;7:257-271.
- 9. a. b. c. Correia ML, Waitzberg DL. The Impact of Malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr 2003;22(3):235-239.
- 10. a. b. Jie B, Jiang ZM, Nolan MT et al. Impact of nutritional support on clinical outcome in patients at nutritional risk: A multicenter, prospective cohort study in Baltimore and Beijing teaching hospitals. Nutrition 2010;26:1088-1093.
- 11. a. b. Kennedy JF, Nightingdale JM. Cost savings of an adult hospital nutrition support team. Nutrition 2005;21:1127-1133.
- 12. a. b. Alberda C, Gramlich L, Jones N et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: Results of an international multicenter observational study. Int Care Med 2009;35:1728-1737.
- 13. Martin CM, Doig GS, Heyland DK et al. Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT). CMAJ 2004;170:197-204.
- 14. Weijs PJ, Stapel SN, de Groot SD et al. Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill patients: A prospective observational cohort study. JPEN 2012;36:60-68.
- 15. Strack van Schijndel RJ, Weijs PJ, Koopmans RH et al. Optimal nutrition during the period of mechanical ventilation decreases mortality in critically ill, long-term acute female patients: A prospective, observational cohort study. Crit Care 2009;13:R132.
- 16. Ha L, Hauge T, Spenning AB et al. Individual, nutritional support prevents undernutrition, increases muscle strength and improves QoL among elderly at nutritional risk hospitalized for acute stroke: A randomized, controlled trial. Clin Nutr 2010;29:567-573.
- 17. The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. Perioperative total parenteral nutrition in surgical patients. N Engl J Med 1991;325(8):525-532.
- 18. Elia M, Stratton RJ, Russell C et al. The cost of disease-related malnutrition in the UK and economic considerations for the use of oral nutritional supplements (ONS) in adults. Redditch, BAPEN 2005.
- 19. Eisenberg JM, Glick HA, Buzby GP, et al. Does perioperative total parenteral nutrition reduce medical care costs? JPEN 1993;17(3):201-209.
- 20. Doig GS, Simpson F. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a full economic analysis of a multicenter randomized controlled trial based on US costs. Clinicoecon Outcomes Res 2013;5:369-79.
- 21. Beck AM, Balknäs UN, Fürst P et al. Food and nutritional care in hospitals: how to prevent undernutrition – Report and guidelines from the Council of Europe. Clin Nutr 2001;20(5):455-60.
- 22. Liang X, Jiang ZM, Nolan MT et al. Comparative survey on nutritional risk and nutritional support between Beijing and Baltimore teaching hospitals. Nutrition. 2008;24(10):969-76.
- 23. Bruun LI, Bosaeus I, Bergstad I et al. Prevalence of malnutrition in surgical patients: Evaluation of nutritional support and documentation. Clin Nutr 1999;18:141-147.
- 24. Correia MI, Campos AC. Prevalence of hospital malnutrition in Latin America: The multicenter ELAN study. Nutrition 2003;19:823-825.