Ask the Expert: everything you need to know about personalized nutrition for inpatients

An evidence-based approach

• Malnutrition is a prevalent issue amongst patients under medical supervision, particularly in older patients with multiple morbidities. A lack of available data to support the best approach to nutrition for inpatients has meant innovation or medical R&D staff have been unable to implement any significant, beneficial changes to medical nutrition. This article, however, discusses the latest research and findings in order to provide suggestions for an evidence-based approach to personalized nutrition in hospital settings.
  
• In our latest ask-the-expert interview, we spoke to Professor Philipp Schütz, who has been involved in some of the recent studies, about how physicians, R&D professionals, researchers and hospital staff can use personalized nutrition to improve clinical outcomes in patients.
  
• This research is key in benefiting the wider medical community. For example, it can help aid and inform projects such as the EAN, dsm-firmenich and other partners’ recently formed malnutrition working group, which has the aim of minimalizing malnutrition in older people in care settings.

Personalized nutrition: one bite at a time

Within medical nutrition, the concept of evidence-based, individualized nutritional support, or personalized nutrition, is a relatively unexplored subject. However, recent studies have demonstrated that a personalized approach to medical nutrition has great potential to improve clinical outcomes in patients.

A reduced appetite is a common reaction to acute disease. Fasting stimulates autophagy (intracellular recycling of defective structures), allowing the body to clean out damaged organelles and promoting the regeneration of new, healthy ones, which can help the body overcome certain diseases.

However, with the increase of non-communicable diseases (NCDs) - often chronic illnesses - this mechanism isn’t always effective. In many cases, reduced appetite is not helpful to the body and leads to malnourishment, which instead, worsens health outcomes.¹ In theory, individualized nutrition plans can help bridge nutritional gaps to prevent the patient becoming malnourished.

In recent years, some small-scale studies have suggested that individualized nutritional support can have positive effects on clinical outcomes in medical patients. However, meta-analyses of these studies have recognized that a lack of significant results in proving the effectiveness of a personalized approach is likely due to methodological issues and low statistical power, rather than the effectiveness of the approach itself.²

To accurately test if a personalized approach to medical nutrition is beneficial, and how, large-scale studies exploring the effect of personalized nutritional plans for hospitalized patients have been carried out in recent months. For example, the NOURISH (Nutrition effect On Unplanned Readmissions and Survival in Hospitalized patients) trial has recently tested the effect of a protein-based nutritional supplement, vs a placebo, on clinical outcomes in older malnourished patients. The results suggest the supplement contributed to improved outcomes, such as a reduction in 90-day mortality, although the primary composite endpoint including hospital readmission or death was not significantly improved by the nutritional intervention.

Another significant study, with a notably large sample size, further highlighting the potential of personalized nutrition for hospitalized patients is the EFFORT (The Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial) study. This trial found that personalized nutritional plans for inpatients at nutritional risk significantly improved clinical outcomes, including lower risk for complications and reduced mortality.³ You can read more about this study and its findings here to learn more about Personalized Nutrition.

Ask-the-expert interview with Professor Schütz

To further understand the potential impact of these studies, we spoke to medical nutrition expert Professor Schütz from the University Department of Internal Medicine, Kantonsspital Aarau and Medical Faculty of the University of Basel, Switzerland. He was the principal investigator of the EFFORT study and here, he shares his thoughts on furthering the research and implementing findings to benefit patients.

Q: Why are the recent trials for evidence-based nutrition, such as EFFORT, so important for inpatients?

A: Although malnutrition is a highly prevalent condition in the inpatient setting, particularly in older patients with multiple morbidities, the medical community has struggled to find efficient, evidence-based approaches for its prevention and treatment. The importance of proving effectiveness cannot be understated. As compliance is frequently an issue due to reduced appetite and the limited appeal of medical nutrition approaches (such as oral supplements or even enteral and parenteral nutrition), the benefits need to be proven to encourage usage.

EFFORT sheds new light on the benefits of evidence-based nutrition, showing that individualized nutritional support reduces severe complications and improves mortality in medical inpatients, with positive effects on functional outcomes and quality of life. This is a big step in the acceptance of personalized nutrition in the medical field, as it allows medical professionals to develop an evidence-based approach to supporting patients.

Q: How will the results of EFFORT impact current approaches for patient care?

A: These results should prompt us to improve our management of malnutrition in hospital settings, moving the nutritional status of patients up in the list of medical priorities, for example, this new approach should start with a systematic screening for risk of malnutrition in admitted patients, effective assessment of nutritional status in multidisciplinary teams, including dieticians, nurses and physicians, and early start of individualized adequate nutritional support of at-risk patients to reach nutritional goals.

Q: What has the trial revealed about the cost related benefits of evidence-based nutritional interventions?

A: As we are some of the first scientists to test the medical benefits of personalized nutrition for medical patients on a large scale, we’ve not evaluated costs benefits in detail just yet. However, studies have shown significant clinical benefits from a rather small intervention, suggesting cost-related benefits are attainable.

Q: What needs to be done to raise awareness of these benefits?

A: It is essential to raise awareness of the risks of malnutrition in inpatients. Not only to the medical community, but also the patients and their relatives. Physicians and hospital CEOs are highly influential when it comes to the implementation of such nutritional approaches. For personalized nutrition to fulfil its potential in medical applications, we need to educate these key stakeholders with the latest scientifically backed data.

Q: How can the negative effects of nutritional over-treatment in some studies be explained, and what can be done to overcome them?

A: Further evidence is the solution to overcome any ambiguity around nutritional effectiveness. Currently, there is a lack of large-scale trials that have used rigorous methodology with high protocol adherence. For example, the NOURISH study measured the use of a high-protein pill vs a low protein placebo, which makes it unclear whether the effects were due to the specific formula used or the difference in proteins. While the EFFORT study helps fill this knowledge gap, more research carried out with similar methodology and standards will help us to explore this further.

We can also consider that the term “personalized medicine” relates to the observation that not all patients show the same response to medical therapies. For example, while some patients may show a marked benefit from nutritional therapy, other patients may have limited or even no benefit from that intervention. Whether or not a patient benefits from nutritional therapy may relate to illness-specific factors (e.g., comorbidities, acute vs. chronic course) or patient-specific factors (e.g., age, gender, genetic elements). Additionally, specific signatures may exist which will help in identifying patients who may or may not benefit from nutritional therapy. Understanding such factors will be of great importance in the future to use nutritional interventions more specifically and efficiently.

Q: What areas do future clinical trials need to address for there to be greater evidence on the positive role nutrition can play in improving outcomes for medical patients?

A: Understanding the optimal use of nutritional support in patients with acute illness is complex because timing, route of delivery, and the amount and type of nutrients may all affect patient outcomes. Further research and clinical trials are required to better understand, step by step, how we can use clinical nutrition best to maximize recovery of our patient. Future research should consider elements such as timing, dose and feasibility of nutritional treatment. It’s important that any new study is well-conducted using an adequate sample size, to ensure accurate conclusions are drawn from the results.

Q: What can be done to encourage the continuation of nutritional support once a patient has left hospital care?

A: It is important to continue monitoring the nutritional status of patients after discharge, because there is a significant risk of deterioration of nutritional status once they leave the hospital. The positive effects of any nutritional support are likely to be more pronounced if continued, so considering guidelines and support here for patients and their relatives or caregivers is also a key factor to achieving the best outcomes.

A: This research is key in furthering the potential of personalized nutrition for the medical field. The practical implementation of such plans is of great importance to dsm-firmenich. For example, a recently-formed malnutrition working group, ran by the European Aging Network EAN with input from dsm-firmenich, has the aim of creating guidelines about nutrition care in social services facilities for elderly. This is alongside providing a practical toolkit for the management of elderly care organizations.

Research has the potential to help both shape and validate any recommendations to improve the nutritional status and associated health benefits, such as clinical outcomes.