Nutritional Management and Outcomes in Malnourished Medical Inpatients Printed Edition of the Special Issue Published in Journal of Clinical Medicine www.mdpi.com/journal/jcm Zeno Stanga and Philipp Schuetz Edited by Nutritional Management and Outcomes in Malnourished Medical Inpatients Nutritional Management and Outcomes in Malnourished Medical Inpatients Special Issue Editors Zeno Stanga Philipp Schuetz MDPI • Basel • Beijing • Wuhan • Barcelona • Belgrade • Manchester • Tokyo • Cluj • Tianjin Special Issue Editors Zeno Stanga Bern University Hospital Switzerland Philipp Schuetz Aarau and Medical Faculty of the University of Base l Switzerland Editorial Office MDPI St. Alban-Anlage 66 4052 Basel, Switzerland This is a reprint of articles from the Special Issue published online in the open access journal Journal of Clinical Medicine (ISSN 2077-0383) (available at: https://www.mdpi.com/journal/jcm/ special issues/Nutritional Malnourished Medical). For citation purposes, cite each article independently as indicated on the article page online and as indicated below: LastName, A.A.; LastName, B.B.; LastName, C.C. Article Title. Journal Name Year , Article Number , Page Range. ISBN 978-3-03936-491-6 ( H bk) ISBN 978-3-03936-492-3 (PDF) Cover image courtesy of Archive Nutritional Medicine, University Hospital Bern, Switzerland. c © 2020 by the authors. Articles in this book are Open Access and distributed under the Creative Commons Attribution (CC BY) license, which allows users to download, copy and build upon published articles, as long as the author and publisher are properly credited, which ensures maximum dissemination and a wider impact of our publications. The book as a whole is distributed by MDPI under the terms and conditions of the Creative Commons license CC BY-NC-ND. Contents About the Special Issue Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Philipp Schuetz and Zeno Stanga Nutritional Management and Outcomes in Malnourished Medical Inpatients in 2020: The Evidence Is Growing! Reprinted from: J. Clin. Med. 2020 , 9 , 27, doi:10.3390/jcm9010027 . . . . . . . . . . . . . . . . . . 1 Michael Hiesmayr, Silvia Tarantino, Sigrid Moick, Alessandro Laviano, Isabella Sulz, Mohamed Mouhieddine, Christian Schuh, Dorothee Volkert, Judit Simon and Karin Schindler Hospital Malnutrition, a Call for Political Action: A Public Health and NutritionDay Perspective Reprinted from: J. Clin. Med. 2019 , 8 , 2048, doi:10.3390/jcm8122048 . . . . . . . . . . . . . . . . . 5 Lena J. Storck, Reinhard Imoberdorf and Peter E. Ballmer Nutrition in Gastrointestinal Disease: Liver, Pancreatic, and Inflammatory Bowel Disease Reprinted from: J. Clin. Med. 2019 , 8 , 1098, doi:10.3390/jcm8081098 . . . . . . . . . . . . . . . . . 23 Emilie Reber, Kristina Norman, Olga Endrich, Philipp Schuetz, Andreas Frei and Zeno Stanga Economic Challenges in Nutritional Management Reprinted from: J. Clin. Med. 2019 , 8 , 1005, doi:10.3390/jcm8071005 . . . . . . . . . . . . . . . . . 37 Marina V. Viana, Olivier Pantet, Geraldine Bagnoud, Arianne Martinez, Eva Favre, M ́ elanie Charri` ere, Doris Favre, Philippe Eckert and Mette M. Berger Metabolic and Nutritional Characteristics of Long-Stay Critically Ill Patients Reprinted from: J. Clin. Med. 2019 , 8 , 985, doi:10.3390/jcm8070985 . . . . . . . . . . . . . . . . . . 53 Peter J.M. Weijs, Kris M. Mogensen, James D. Rawn and Kenneth B. Christopher Protein Intake, Nutritional Status and Outcomes in ICU Survivors: A Single Center Cohort Study Reprinted from: J. Clin. Med. 2019 , 8 , 43, doi:10.3390/jcm8010043 . . . . . . . . . . . . . . . . . . 71 Paweł Wiech, Dariusz Bazali ́ nski, Izabela Sałaci ́ nska, Monika Binkowska-Bury, Bartosz Korczowski, Artur Mazur, Maria K ́ ozka and Mariusz Dabrowski Decreased Bioelectrical Impedance Phase Angle in Hospitalized Children and Adolescents with Newly Diagnosed Type 1 Diabetes: A Case-Control Study Reprinted from: J. Clin. Med. 2018 , 7 , 516, doi:10.3390/jcm7120516 . . . . . . . . . . . . . . . . . . 81 Emilie Reber, Natalie Friedli, Maria F. Vasiloglou, Philipp Schuetz and Zeno Stanga Management of Refeeding Syndrome in Medical Inpatients Reprinted from: J. Clin. Med. 2019 , 8 , 2202, doi:10.3390/jcm8122202 . . . . . . . . . . . . . . . . . 93 Emilie Reber, Markus Messerli, Zeno Stanga and Stefan M ̈ uhlebach Pharmaceutical Aspects of Artificial Nutrition Reprinted from: J. Clin. Med. 2019 , 8 , 2017, doi:10.3390/jcm8112017 . . . . . . . . . . . . . . . . . 111 Jessica Stirnimann and Guido Stirnimann Nutritional Challenges in Patients with Advanced Liver Cirrhosis Reprinted from: J. Clin. Med. 2019 , 8 , 1926, doi:10.3390/jcm8111926 . . . . . . . . . . . . . . . . . 133 v Emilie Reber, Filomena Gomes, Ilka A. D ̈ ahn, Maria F. Vasiloglou and Zeno Stanga Management of Dehydration in Patients Suffering Swallowing Difficulties Reprinted from: J. Clin. Med. 2019 , 8 , 1923, doi:10.3390/jcm8111923 . . . . . . . . . . . . . . . . . 145 Maria F. Vasiloglou, Jane Fletcher and Kalliopi-Anna Poulia Challenges and Perspectives in Nutritional Counselling and Nursing: A Narrative Review Reprinted from: J. Clin. Med. 2019 , 8 , 1489, doi:10.3390/jcm8091489 . . . . . . . . . . . . . . . . . 165 Andrea Kopp Lugli, Aude de Watteville, Alexa Hollinger, Nicole Goetz and Claudia Heidegger Medical Nutrition Therapy in Critically Ill Patients Treated on Intensive and Intermediate Care Units: A Literature Review Reprinted from: J. Clin. Med. 2019 , 8 , 1395, doi:10.3390/jcm8091395 . . . . . . . . . . . . . . . . . 175 Marta Delsoglio, Najate Achamrah, Mette M. Berger and Claude Pichard Indirect Calorimetry in Clinical Practice Reprinted from: J. Clin. Med. 2019 , 8 , 1387, doi:10.3390/jcm8091387 . . . . . . . . . . . . . . . . . 193 Irene Hoyas and Miguel Leon-Sanz Nutritional Challenges in Metabolic Syndrome Reprinted from: J. Clin. Med. 2019 , 8 , 1301, doi:10.3390/jcm8091301 . . . . . . . . . . . . . . . . . 213 Emilie Reber, Rachel Strahm, Lia Bally, Philipp Schuetz and Zeno Stanga Efficacy and Efficiency of Nutritional Support Teams Reprinted from: J. Clin. Med. 2019 , 8 , 1281, doi:10.3390/jcm8091281 . . . . . . . . . . . . . . . . . 225 Paula Ravasco Nutrition in Cancer Patients Reprinted from: J. Clin. Med. 2019 , 8 , 1211, doi:10.3390/jcm8081211 . . . . . . . . . . . . . . . . . 243 Emilie Reber, Filomena Gomes, Lia Bally, Philipp Schuetz and Zeno Stanga Nutritional Management of Medical Inpatients Reprinted from: J. Clin. Med. 2019 , 8 , 1130, doi:10.3390/jcm8081130 . . . . . . . . . . . . . . . . . 257 Stephan R. Vavricka and Thomas Greuter Gastroparesis and Dumping Syndrome: Current Concepts and Management Reprinted from: J. Clin. Med. 2019 , 8 , 1127, doi:10.3390/jcm8081127 . . . . . . . . . . . . . . . . . 269 Emilie Reber, Filomena Gomes, Maria F. Vasiloglou, Philipp Schuetz and Zeno Stanga Nutritional Risk Screening and Assessment Reprinted from: J. Clin. Med. 2019 , 8 , 1065, doi:10.3390/jcm8071065 . . . . . . . . . . . . . . . . . 283 Cristina Cuerda, Maria F. Vasiloglou and Loredana Arhip Nutritional Management and Outcomes in Malnourished Medical Inpatients: Anorexia Nervosa Reprinted from: J. Clin. Med. 2019 , 8 , 1042, doi:10.3390/jcm8071042 . . . . . . . . . . . . . . . . . 303 Julie Mareschal, Najate Achamrah, Kristina Norman and Laurence Genton Clinical Value of Muscle Mass Assessment in Clinical Conditions Associated with Malnutrition Reprinted from: J. Clin. Med. 2019 , 8 , 1040, doi:10.3390/jcm8071040 . . . . . . . . . . . . . . . . . 321 vi Dorothee Volkert, Anne Marie Beck, Tommy Cederholm, Emanuele Cereda, Alfonso Cruz-Jentoft, Sabine Goisser, Lisette de Groot, Franz Großhauser, Eva Kiesswetter, Kristina Norman, et al. Management of Malnutrition in Older Patients—Current Approaches, Evidence and Open Questions Reprinted from: J. Clin. Med. 2019 , 8 , 974, doi:10.3390/jcm8070974 . . . . . . . . . . . . . . . . . . 341 C ́ eline Isabelle Laesser, Paul Cumming, Emilie Reber, Zeno Stanga, Taulant Muka and Lia Bally Management of Glucose Control in Noncritically Ill, Hospitalized Patients Receiving Parenteral and/or Enteral Nutrition: A Systematic Review Reprinted from: J. Clin. Med. 2019 , 8 , 935, doi:10.3390/jcm8070935 . . . . . . . . . . . . . . . . . . 357 Mette M Berger, Olivier Pantet, Antoine Schneider and Nawfel Ben-Hamouda .Micronutrient Deficiencies in Medical and Surgical Inpatients Reprinted from: J. Clin. Med. 2019 , 8 , 931, doi:10.3390/jcm8070931 . . . . . . . . . . . . . . . . . . 375 An Jacobs, Ines Verlinden, Ilse Vanhorebeek and Greet Van den Berghe Early Supplemental Parenteral Nutrition in Critically Ill Children: An Update Reprinted from: J. Clin. Med. 2019 , 8 , 830, doi:10.3390/jcm8060830 . . . . . . . . . . . . . . . . . . 393 Ulrich Keller Nutritional Laboratory Markers in Malnutrition Reprinted from: J. Clin. Med. 2019 , 8 , 775, doi:10.3390/jcm8060775 . . . . . . . . . . . . . . . . . . 405 vii About the Special Issue Editors Zeno Stanga studied medicine at the University of Bern and obtained board certification in internal and general medicine in 1995. He trained in general internal medicine, nutritional medicine and metabolism in several hospitals in Switzerland. After research fellowships in Nottingham (U.K.) and Charleston (USA), he founded a nutritional support team in 2001 and leads the nutritional medicine unit at the University Hospital of Bern. He is currently associate professor for internal and nutritional medicine at the Medical Faculty of the University of Bern. He is a member of the appointment commission and active in several working groups of the medical faculty. Professor Stanga was responsible for the Swiss Certificate of Advanced Studies in Clinical Nutrition and acted on the board of directors of the Swiss Society of Clinical Nutrition for 20 years. He has published over 150 scientific papers and is associate editor of the ESPEN Blue Book. Philipp Schuetz was born in Switzerland and studied Medicine at the University of Basel, Switzerland, and the University Kremlin Bicetre in Paris, France. He is a board-certified internist and endocrinologist with special interest in clinical nutrition. He is the head of internal medicine and emergency medicine Kantonsspital Aarau and part of the faculty of medicine at the university in Basel, Switzerland. He has published more than 300 studies and research articles in high-impact journals including Lancet, JAMA, Annals of Internal Medicine , and many others. Prof. Schuetz obtained a research professorship from the Swiss National Science Foundation (SNF) and was principal investigator of the EFFORT trial, the largest-yet randomized controlled trial examining the clinical effects of clinical nutrition in medical ward patients. ix Journal of Clinical Medicine Editorial Nutritional Management and Outcomes in Malnourished Medical Inpatients in 2020: The Evidence Is Growing! Philipp Schuetz 1,2, * and Zeno Stanga 3 1 Department of Endocrinology, Diabetes and Clinical Nutrition, University Department of Internal Medicine, Kantonsspital, CH-5001 Aarau, Switzerland 2 Medical Faculty of the University of Basel, CH-4056 Basel, Switzerland 3 Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, and University of Bern, CH-3008 Bern, Switzerland; Zeno.Stanga@insel.ch * Correspondence: Philipp.Schuetz@unibas.ch Received: 16 December 2019; Accepted: 18 December 2019; Published: 20 December 2019 Access to adequate food is a fundamental human right. There is no doubt that nutrition is essential in maintaining health and preventing or treating disease. Particularly when patients are a ff ected by disease-related malnutrition, their risk of adverse clinical outcomes increases significantly and optimizing nutritional support becomes mandatory [1,2]. There is ongoing debate about what constitutes an optimal nutritional care process in terms of screening, assessment, and use of nutritional support in di ff erent patient populations. Issues include dose and quality of proteins and total energy, route of delivery, and whether or how nutritional support needs to be adjusted for specific medical and metabolic conditions. As we move toward personalized medicine, which is based on patients’ individual needs, an understanding of these di ff erent factors is important. Well-planned clinical studies of high methodological quality are needed to develop the best approach to providing individualized nutritional support [3]. Historically, much of the evidence regarding e ff ects of nutritional support has come from small interventional trials and observational studies with cross-sectional or cohort-study designs, whereas there was an important lack of large-scale randomized interventional research, which is needed to establish causal e ff ects rather than just statistical associations [ 4 , 5 ]. As a consequence, the medical community has struggled to design e ffi cient, evidence-based approaches for the prevention and treatment of malnutrition [4]. Recently, however, the results of several high-quality trials have provided important new insights that advance nutritional science significantly and translate nutrition research into practice [ 6 ]. Regarding prevention of cardiovascular disease through nutrition, the PREDIMED (Prevenci ó n con Dieta Mediterr á nea) trial provided strong evidence that a Mediterranean diet supplemented with extra-virgin olive oil or with mixed nuts reduces the risk of cardiovascular and metabolic disease by about 30% over five years [ 7 ]. Regarding the use of clinical nutrition in patients at nutritional risk or with established malnutrition, two trials found nutritional support to be highly e ff ective. First, the multicenter, randomized, placebo-controlled NOURISH trial (Nutrition e ff ect On Unplanned ReadmIssions and Survival in Hospitalized patients) including 652 older adults a ff ected by malnutrition found that a high-protein oral nutritional supplement containing beta-hydroxy-beta-methylbutyrate was associated with a significant reduction in 90 day mortality, with a number needed to treat (NNT) of 20 [ 8 ]. Second, the EFFORT (E ff ect of early nutritional support on Frailty, Functional Outcomes and Recovery of malnourished medical inpatients Trial) including 2028 medical inpatients at nutritional risk in eight Swiss hospitals showed that protocol-guided individualized nutritional support designed to achieve protein and energy targets results in significantly lower rates of severe complications (NNT = 25) and mortality (NNT = 37) compared to regular hospital food [ 9 , 10 ]. Moreover, functional J. Clin. Med. 2020 , 9 , 27; doi:10.3390 / jcm9010027 www.mdpi.com / journal / jcm J. Clin. Med. 2020 , 9 , 27 decline was significantly lower, and quality of life as well as activities of daily living significantly improved. A recent meta-analysis including these two trials and several other trials also came to the conclusion that nutritional support in the malnourished medical inpatient population reduces the risk for both, mortality and hospital readmission by about 25% [6]. Evidence-based medicine is an approach used to optimize decision-making by emphasizing evidence from properly designed and well-conducted research, typically randomized trials and meta-analyses from such trials. With the growing number of high-quality trials such as the ones mentioned above, we are increasingly able to practice “evidence-based clinical nutrition” and to adapt nutrition to the individual patient’s needs. This Special Issue of the Journal of Clinical Medicine (JCM) focuses on a topic that is critical for hospitals today: “Nutritional Management and Outcomes in Malnourished Medical Inpatients”. This special edition presents a number of reviews and original research articles in the field of nutritional management and clinical outcomes in malnourished medical inpatients. Twenty-six important articles illustrate the di ff erent facets of this complex and timely topic. The articles included cover the process of nutritional care, including screening tools to identify nutritional risk (Nutritional risk screening and assessment [ 11 ]), patient muscle mass assessment including bioimpedance analysis (Clinical value of muscle mass assessment in clinical conditions associated with malnutrition [ 12 ]; Decreased bioelectrical impedance phase angle in hospitalized children and adolescents with newly diagnosed type 1 diabetes: a case-control study [ 13 ]), nutritional biomarkers (Nutritional laboratory markers in malnutrition [ 14 ]), nutritional therapy planning (Indirect calorimetry in clinical practice [ 15 ]; Micronutrient deficiencies in medical and surgical inpatients [ 16 ]), use of nutritional support overall (E ffi cacy and e ffi ciency of nutritional support teams [ 17 ]; Challenges and perspectives in nutritional counselling and nursing: a narrative review [ 18 ]) and in specific patient populations (e.g., medical patients, critical care patients, geriatric patients, oncologic patients, patients after allogenic stem cell transplantation, patients with dysphagia or eating disorders, as well as the nutritional challenges associated with metabolic disorders) (Nutritional management of medical inpatients [ 19 ]; Medical nutrition therapy in critically ill patients treated on intensive and intermediate care units: a literature review [ 20 ]; Metabolic and nutritional characteristics of long-stay critically ill patients [ 21 ]; Protein intake, nutritional status, and outcomes in intensive care unit survivors: a single-center cohort study [ 22 ]; Early supplemental parenteral nutrition in critically ill children: an update [ 23 ]; Management of malnutrition in older patients—current approaches, evidence, and open questions [ 24 ]; Nutrition in cancer patients [ 25 ]; Management of dehydration in patients su ff ering swallowing di ffi culties [ 26 ]; Nutrition in gastrointestinal diseases: liver, pancreatic, and inflammatory bowel diseases [ 27 ]; Nutritional management and outcomes in malnourished medical inpatients: anorexia nervosa [ 28 ]; Nutritional challenges in metabolic syndrome [ 29 ]; Nutritional challenges in patients with advanced liver cirrhosis [ 30 ]). Potential complications of nutritional interventions, such as refeeding syndrome (Management of refeeding syndrome in medical inpatients [ 31 ]), and treatment challenges posed by gastric motility disorders are discussed (Gastroparesis and dumping syndrome: current concepts and management [ 32 ]). Economic aspects of nutritional management (Economic challenges in nutritional management [ 33 ]) and specific considerations such as pharmaceutical / therapeutic aspects of artificial nutrition are additionally reviewed (Management of glucose control in non-critically ill, hospitalized patients receiving parenteral and / or enteral nutrition: a systematic review [ 34 ]; Pharmaceutical aspects of artificial nutrition [35]). Last but not least, the call for political commitment in the treatment of malnutrition is of key importance. Health care institutions and associations must be mobilized to take action against malnutrition by expanding information and public-awareness-raising campaigns, adopting supportive policies, as well as allocating resources (Hospital malnutrition, a call for political action: a public health and nutritionDay perspective [ 36 ]). Stakeholders including political organizations, nutritional social networks, and researchers will be valuable promoters of this important political priority in the future. J. Clin. Med. 2020 , 9 , 27 Understanding the optimal use of nutritional therapy is highly complex. Timing, route of delivery, and the amount and type of nutrients all play important roles and potentially a ff ect patient outcomes. Recent trials provide important information to strengthen the evidence regarding the use of nutritional therapy in specific patient populations, but there are still important questions to be addressed by robust clinical trials in the future. It is now important to incorporate these recent findings into clinical practice in order to ensure that our patients receive high-quality, safe, and optimal care. Author Contributions: P.S. and Z.S. wrote this article and take full responsibility for its content. All authors have read and agreed to the published version of the manuscript. Funding: The article processing charge was funded by the Research Fund of the Department of Diabetes, Endocrinology, Nutritional Medicine, and Metabolism and in part by Nestl é Health Science. Conflicts of Interest: The authors declare no conflict of interest. References 1. Felder, S.; Lechtenboehmer, C.; Bally, M.; Fehr, R.; Deiss, M.; Faessler, L.; Kutz, A.; Steiner, D.; Rast, A.C.; Laukemann, S.; et al. Association of nutritional risk and adverse medical outcomes across di ff erent medical inpatient populations. Nutrition 2015 , 31 , 1385–1393. [CrossRef] [PubMed] 2. Felder, S.; Braun, N.; Stanga, Z.; Kulkarni, P.; Faessler, L.; Kutz, A.; Steiner, D.; Laukemann, S.; Haubitz, S.; Huber, A.; et al. Unraveling the Link between Malnutrition and Adverse Clinical Outcomes: Association of Acute and Chronic Malnutrition Measures with Blood Biomarkers from Di ff erent Pathophysiological States. Ann. Nutr. Metab. 2016 , 68 , 164–172. [CrossRef] [PubMed] 3. Merker, M.; Gomes, F.; Stanga, Z.; Schuetz, P. Evidence-based nutrition for the malnourished, hospitalised patient: One bite at a time. Swiss Med. Wkly. 2019 , 149 , w20112. [CrossRef] [PubMed] 4. Schuetz, P. Food for thought: Why does the medical community struggle with research about nutritional therapy in the acute care setting? BMC Med. 2017 , 15 , 38. [CrossRef] 5. Ioannidis, J.P.A. The Challenge of Reforming Nutritional Epidemiologic Research. JAMA 2018 , 320 , 969–970. [CrossRef] 6. Gomes, F.; Baumgartner, A.; Bounoure, L.; Bally, M.; Deutz, N.E.; Greenwald, J.L.; Stanga, Z.; Mueller, B.; Schuetz, P. Association of nutritional support with clinical outcomes among hospitalized medical patients: an updated systematic review and meta-analysis. JAMA Netw. Open 2019 , 2 , e1915138. [CrossRef] 7. Estruch, R.; Ros, E.; Salas-Salvado, J.; Covas, M.I.; Corella, D.; Aros, F.; Gomez-Gracia, E.; Ruiz-Gutierrez, V.; Fiol, M.; Lapetra, J.; et al. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet Supplemented with Extra-Virgin Olive Oil or Nuts. N. Engl. J. Med. 2018 , 378 , e34. [CrossRef] 8. Deutz, N.E.; Matheson, E.M.; Matarese, L.E.; Luo, M.; Baggs, G.E.; Nelson, J.L.; Hegazi, R.A.; Tappenden, K.A.; Ziegler, T.R. Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: A randomized clinical trial. Clin. Nutr. 2016 , 35 , 18–26. [CrossRef] 9. Schuetz, P.; Fehr, R.; Baechli, V.; Geiser, M.; Gomes, F.; Kutz, A.; Tribolet, P.; Bregenzer, T.; Hoess, C.; Pavlicek, V.; et al. Individualized nutritional support in medical inpatients at nutritional risk: A randomized clinical trial. Lancet 2019 , 393 , 2312–2321. [CrossRef] 10. Schuetz, P.; Fehr, R.; Baechli, V.; Geiser, M.; Gomes, F.; Kutz, A.; Tribolet, P.; Bregenzer, T.; Hoess, C.; Pavlicek, V.; et al. Design and rationale of the e ff ect of early nutritional therapy on frailty, functional outcomes and recovery of malnourished medical inpatients (EFFORT): A pragmatic, multicenter, randomized-controlled trial. Int. J. Clin. Trials 2018 , 5 , 142–150. [CrossRef] 11. Reber, E.; Gomes, F.; Vasiloglou, M.F.; Schuetz, P.; Stanga, Z. Nutritional Risk Screening and Assessment. J. Clin. Med. 2019 , 8 , 1065. [CrossRef] [PubMed] 12. Mareschal, J.; Achamrah, N.; Norman, K.; Genton, L. Clinical Value of Muscle Mass Assessment in Clinical Conditions Associated with Malnutrition. J. Clin. Med. 2019 , 8 , 1040. [CrossRef] [PubMed] 13. Wiech, P.; Bazalinski, D.; Salacinska, I.; Binkowska-Bury, M.; Korczowski, B.; Mazur, A.; Kozka, M.; Dabrowski, M. Decreased Bioelectrical Impedance Phase Angle in Hospitalized Children and Adolescents with Newly Diagnosed Type 1 Diabetes: A Case-Control Study. J. Clin. Med. 2018 , 7 , 516. [CrossRef] [PubMed] 14. Keller, U. Nutritional Laboratory Markers in Malnutrition. J. Clin. Med. 2019 , 8 , 775. [CrossRef] J. Clin. Med. 2020 , 9 , 27 15. Delsoglio, M.; Achamrah, N.; Berger, M.M.; Pichard, C. Indirect Calorimetry in Clinical Practice. J. Clin. Med. 2019 , 8 , 1387. [CrossRef] 16. Berger, M.M.; Pantet, O.; Schneider, A.; Ben-Hamouda, N. Micronutrient Deficiencies in Medical and Surgical Inpatients. J. Clin. Med. 2019 , 8 , 931. [CrossRef] 17. Reber, E.; Strahm, R.; Bally, L.; Schuetz, P.; Stanga, Z. E ffi cacy and E ffi ciency of Nutritional Support Teams. J. Clin. Med. 2019 , 8 , 1281. [CrossRef] 18. Vasiloglou, M.F.; Fletcher, J.; Poulia, K.A. Challenges and Perspectives in Nutritional Counselling and Nursing: A Narrative Review. J. Clin. Med. 2019 , 8 , 1489. [CrossRef] 19. Reber, E.; Gomes, F.; Bally, L.; Schuetz, P.; Stanga, Z. Nutritional Management of Medical Inpatients. J. Clin. Med. 2019 , 8 , 1130. [CrossRef] 20. Kopp Lugli, A.; de Watteville, A.; Hollinger, A.; Goetz, N.; Heidegger, C. Medical Nutrition Therapy in Critically Ill Patients Treated on Intensive and Intermediate Care Units: A Literature Review. J. Clin. Med. 2019 , 8 , 1395. [CrossRef] 21. Viana, M.V.; Pantet, O.; Bagnoud, G.; Martinez, A.; Favre, E.; Charriere, M.; Favre, D.; Eckert, P.; Berger, M.M. Metabolic and Nutritional Characteristics of Long-Stay Critically Ill Patients. J. Clin. Med. 2019 , 8 , 985. [CrossRef] [PubMed] 22. Weijs, P.J.M.; Mogensen, K.M.; Rawn, J.D.; Christopher, K.B. Protein Intake, Nutritional Status and Outcomes in ICU Survivors: A Single Center Cohort Study. J. Clin. Med. 2019 , 8 , 43. [CrossRef] [PubMed] 23. Jacobs, A.; Verlinden, I.; Vanhorebeek, I.; Van den Berghe, G. Early Supplemental Parenteral Nutrition in Critically Ill Children: An Update. J. Clin. Med. 2019 , 8 , 830. [CrossRef] [PubMed] 24. Volkert, D.; Beck, A.M.; Cederholm, T.; Cereda, E.; Cruz-Jentoft, A.; Goisser, S.; de Groot, L.; Grosshauser, F.; Kiesswetter, E.; Norman, K.; et al. Management of Malnutrition in Older Patients-Current Approaches, Evidence and Open Questions. J. Clin. Med. 2019 , 8 , 974. [CrossRef] 25. Ravasco, P. Nutrition in Cancer Patients. J. Clin. Med. 2019 , 8 , 1211. [CrossRef] 26. Reber, E.; Gomes, F.; Daehn, I.; Vasiloglou, M.F.; Stanga, Z. Management of Dehydration in Patients Su ff ering Swallowing Di ffi culties. J. Clin. Med. 2019 , 8 , 1923. [CrossRef] 27. Storck, L.J.; Imoberdorf, R.; Ballmer, P.E. Nutrition in Gastrointestinal Disease: Liver, Pancreatic, and Inflammatory Bowel Disease. J. Clin. Med. 2019 , 8 , 1098. [CrossRef] 28. 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Laesser, C.I.; Cumming, P.; Reber, E.; Stanga, Z.; Muka, T.; Bally, L. Management of Glucose Control in Noncritically Ill, Hospitalized Patients Receiving Parenteral and / or Enteral Nutrition: A Systematic Review. J. Clin. Med. 2019 , 8 , 935. [CrossRef] 35. Reber, E.; Messerli, M.; Stanga, Z.; Muehlebach, S. Pharmaceutical Aspects of Artificial Nutrition. J. Clin. Med. 2019 , 8 , 2017. [CrossRef] 36. Hiesmayr, M.; Tarantino, S.; Moick, S.; Laviano, A.; Sulz, I.; Mouhieddine, M.; Schuh, C.; Volkert, D.; Simon, J.; Schindler, K. Hospital malnutrition, a call for political action: A public health and nutritionDay perspective. J. Clin. Med. 2019 , 8 , 2048. [CrossRef] © 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http: // creativecommons.org / licenses / by / 4.0 / ). Journal of Clinical Medicine Article Hospital Malnutrition, a Call for Political Action: A Public Health and NutritionDay Perspective Michael Hiesmayr 1, *, Silvia Tarantino 1 , Sigrid Moick 1 , Alessandro Laviano 5 , Isabella Sulz 2 , Mohamed Mouhieddine 1 , Christian Schuh 2 , Dorothee Volkert 6 , Judit Simon 3 and Karin Schindler 4 1 Division Cardio-thoracic and Vascular Anesthesia and Intensive Care, Medical University Vienna, 1090 Vienna, Austria; silvia.tarantino@meduniwien.ac.at (S.T.); sigrid.moick@gmail.com (S.M.); mohamed.mouhieddine@meduniwien.ac.at (M.M.) 2 Center for Medical Statistics, Informatics and Intelligent Systems, Medical University Vienna, 1090 Vienna, Austria; isabella.sulz@meduniwien.ac.at (I.S.); christian.schuh@meduniwien.ac.at (C.S.) 3 Department of Health Economics, Center for Public Health, Medical University Vienna, 1090 Vienna, Austria; judit.simon@meduniwien.ac.at 4 Department of Internal Medicine III, Medical University Vienna, 1090 Vienna, Austria; karin.schindler@meduniwien.ac.at 5 Department of Translational and Precision Medicine, Universit à degli Studi di Roma “La Sapienza”, 00185 Roma, Italy; alessandro.laviano@uniroma1.it 6 Institute for Biomedicine of Ageing, Friedrich-Alexander Universität Erlangen-Nürnberg, 90408 Nürnberg, Germany; dorothee.volkert@fau.de * Correspondence: michael.hiesmayr@meduniwien.ac.at; Tel.: + 43-(0)1-40400-41080 Received: 29 September 2019; Accepted: 14 November 2019; Published: 22 November 2019 Abstract: Disease-related malnutrition (DRM) is prevalent in hospitals and is associated with increased care needs, prolonged hospital stay, delayed rehabilitation and death. Nutrition care process related activities such as screening, assessment and treatment has been advocated by scientific societies and patient organizations but implementation is variable. We analysed the cross-sectional nutritionDay database for prevalence of nutrition risk factors, care processes and outcome for medical, surgical, long-term care and other patients ( n = 153,470). In 59,126 medical patients included between 2006 and 2015 the prevalence of recent weight loss (45%), history of decreased eating (48%) and low actual eating (53%) was more prevalent than low BMI (8%). Each of these risk factors was associated with a large increase in 30 days hospital mortality. A similar pattern is found in all four patient groups. Nutrition care processes increase slightly with the presence of risk factors but are never done in more than 50% of the patients. Only a third of patients not eating in hospital receive oral nutritional supplements or artificial nutrition. We suggest that political action should be taken to raise awareness and formal education on all aspects related to DRM for all stakeholders, to create and support responsibilities within hospitals, and to create adequate reimbursement schemes. Collection of routine and benchmarking data is crucial to tackle DRM. Keywords: malnutrition; hospital; nutrition care; continuity of care; mortality; process indicators; benchmarking; disease related malnutrition. 1. Introduction Disease-related malnutrition (DRM) is highly prevalent in hospitalized patients and associated with complications and poor outcome [ 1 – 3 ]. Malnutrition in hospitals originates from imbalances, either deficiencies or excesses, in nutrients intake compared with body needs. Nutritional status and needs may be modified acutely or chronically by the disease process itself. Further deterioration may occur due to hospitalization, thus making the population of hospitalized patients very di ff erent from J. Clin. Med. 2019 , 8 , 2048; doi:10.3390 / jcm8122048 www.mdpi.com / journal / jcm J. Clin. Med. 2019 , 8 , 2048 the general population. Prolonged nutrients imbalance is associated with change in body mass index (BMI). Association between body mass index (BMI) and mortality is U-shaped in the general population and J-shaped in patients, especially with chronic diseases, meaning that mortality is higher if BMI is low and lower in patients with increased lean body mass and even obesity [ 4 , 5 ]. This observation called “obesity paradox” underscores the importance of a “good” nutrition status for patients with illnesses for short and long-term outcomes. Malnutrition in hospitalized patients often addresses an evident poor nutritional status (low BMI and low muscle mass) whereas being at risk of malnutrition is derived from a set of risk factors typically associated with a loss in lean body mass persisting over a certain period of time [ 6 ]. Nutrition care in hospitals is a treatment for patients with malnutrition and a preventive intervention for patients at risk of malnutrition. Nevertheless, nutrition care is still an underrated field when compared to medical diagnostics procedures, or pharmacological and technological interventions in hospitals. There are several reasons why nutrition care has received so little attention in acute care hospitals. There is a common knowledge deficit reflected in a lack of proper education in university curricula for healthcare professionals (doctors, nurses, care assistants) combined with patients and relatives giving low value to nutrition as part of a successful therapy of the primary disease. Since no immediate e ff ects of nutrition can be expected during a short hospital length of stay, the attention for nutrition related issues is often low. Standard nutrition care processes such as screening, assessment, planning and monitoring together with documentation and continuity of care are not regular parts of care on all hospital wards [ 7 ]. Moreover, food provision and related tasks are not considered part of healthcare responsibilities. Food provision is not part of the medical budget but usually of the administrative budget of a hospital where cost reduction is not considered to influence directly patient care. Inadequate management of food provision might a ff ect food quality, presentation [ 8 ] and composition and, subsequently, patient care. Food costs are to be added to the overall malnutrition related costs. Patients with malnutrition usually stay longer in hospitals, are more often re-hospitalized or transferred to long-term care [ 9 – 12 ]. Each of these, together with the reimbursement schemes, do create additional costs for the healthcare system. Insights on improved hospital nutrition care processes and reduced healthcare costs come from the Swiss EFFORT study. In patients with risk of malnutrition, nutrition intake was improved with enriched meals or oral nutritional supplements, food intake was monitored and was associated with better outcomes and reduced healthcare costs [11]. These multiple barriers and the lack of proper attention to DRM and nutrition care in hospitals has been formally addressed at a political level by a resolution of the European Council in 2003 but was not followed by national regulatory actions [ 3 ].This lack of action led to several independent initiatives. The European Society for Clinical Nutrition and Metabolism (ESPEN) (www.espen.org) together with the Medical University of Vienna developed a tailored action to tackle malnutrition in hospitals and healthcare institutions [ 4 ]. The resulting project “nutritionDay” aimed to generate more awareness on DRM with a yearly one-day data collection on patient’s malnutrition risk factors, outcomes and quality indicators of nutrition care (www.nutritionday.org). In the nutritionDay analysis, several nutrition related risk factors, such as low BMI, recent weight loss and reduced food intake (in the week before nutritionDay or on nutritionDay itself), were found to be independently associated with death within 30 days in hospital [ 4 ]. In an another analysis that led to the development of the PANDORA score for prediction of death in hospital within 30 days after nutritionDay, decreased food intake was identified among the seven most important risk factors as it contributed 3–12 points out of a maximum of 75 points to the final score [ 5 ]. nutritionDay rapidly became a worldwide benchmarking tool for monitoring and improving nutrition care in hospital wards [ 13 – 15 ]. Patient related risk factors for decreased eating have a similar pattern in all world regions [ 16 ] and nutrition care processes implementation appears highly variable [7]. A multi-stakeholder initiative to promote screening for risk of disease-related malnutrition / undernutrition and implement nutritional care across Europe “Optimal Nutritional Care J. Clin. Med. 2019 , 8 , 2048 for All” has started an annual meeting with national nutrition societies and political representatives in 2008 [ 17 ]. The last meeting in Sintra, Portugal in 2018 involved representatives from 18 countries that had already joined the initiative and had the motto: “Optimal Nutrition Care across Europe: Fair Access and Shared Decision Making”. The decision was taken together with the European Patient Forum [ 18 ] to translate relevant guidelines into a lay version to increase the possibility for patients to take informed responsibility [19]. The human right for proper nutrition care was acknowledged in the Cartagena declaration [ 20 ] and signed on 3rd May 2019 by all presidents of the Latin American Federation of Nutritional Therapy, Clinical Nutrition (FELANPE). The declaration includes 13 principles, such as patient empowerment, dignity, ethical principles, justice and equity and urges the United Nations and the Human Rights Council to recognize the Right to Nutrition Care as a human right in line with the “Sustainable Development Goals” [21]. The worldwide Global Leadership Initiative on Malnutrition (GLIM) composed by the major nutrition societies aims at defining universally accepted criteria for DRM [ 22 ]. This process is still ongoing with planned steps of validation and regular updating. Current recommendations from scientific societies emphasize that it is mandatory to identify the malnourished as well as those at risk early during hospitalization to trigger proper treatment or a set of preventive measures [ 19 ]. The recommended three step process consists of screening, assessing and developing a nutrition care plan. A further important and less appreciated step is that nutrition care needs to be monitored and adapted to the patient’s changing condition. Finally, proper documentation and communication of a comprehensive care plan to the next sector, “extramural health care”, and the patients themselves are essential to ensure continuity of care. To be e ffi cient, responsibilities need to be cleared delineated and all relevant stakeholder (Table 1) involved. Table 1. List and role of important stakeholders. 1. Within the hospital a. Patients and their relatives b. Care persons i. Nurses Screening, diet ordering, documentation ii. Physicians Assessment, ordering, documentation, information iii. Dieticians Assessment, documentation iv. Physiotherapists E ff ect monitoring v. Speech Therapists Swallowing disorders vi. Pharmacists Clinical nutrition supply and counselling c. Kitchen / Catering services i. Administrators Budget ii. Chefs Standards, variety, quality control iii. Kitchen aids Presentation iv. Delivering sta ff Monitoring d. Hospital administration Budget, plannin