Abstract
Background
Malnutrition is a critical issue among older inpatients, yet limited large-scale research related to this issue has been conducted in China. This study aimed to examine the nutritional status and support of older inpatients in China, assess the associations between disease categories and malnutrition on admission, and explore effective nutritional intervention.
Methods
A total of 24,139 older participants from the China Nutrition Fundamental Data 2020 Project were included. Malnutrition was measured by the Global Leadership Initiative on Malnutrition criteria. Adjusted odds ratios (aORs) were calculated using logistic analysis.
Results
The overall frequency of malnutrition on admission was 18.9%. Participants with infections were more likely to have malnutrition (aOR = 1.929, 95% CI 1.486–2.504). Risks that were also noted for malnutrition included neoplasms (aOR = 1.822, 95% CI 1.697–1.957), hemic and lymphatic diseases (aOR = 1.671, 95% CI 1.361–2.051), nervous system diseases (aOR = 1.222, 95% CI 1.126–1.326), respiratory diseases (aOR = 1.613, 95% CI 1.490–1.746), and digestive system diseases (aOR = 1.462, 95% CI 1.357–1.577). Further, 32.26% inpatients with malnutrition during hospitalization didn’t receive nutritional support. Oral nutrition supplements, enteral tube feeding, and parenteral nutrition were associated with stable or improved nutritional status.
Conclusions
Older inpatients were at a high risk for malnutrition but did not receive adequate nutritional intervention. More resources and attention need to be devoted to the nutritional status of older inpatients and targeted nutritional support.
Keywords: Global Leadership Initiative on Malnutrition, Malnutrition, Nutritional support, Older, Inpatient
1. Introduction
Malnutrition, encompassing both undernutrition and overnutrition [1], remains a considerable problem in older people [2] but is easily neglected. Associated with hospital length of stay (LOS) [3,4], poor rehabilitation outcome [5], readmission [6], and mortality [7], the huge burden of malnutrition among older inpatients requires great public health concerns. Considering that China has already had 280.04 million people aged 60 years and above which accounts for 19.8% of the total population in 2022, the threat of malnutrition is likely to be exacerbated. Therefore, assessing nutritional status at the national level and exploring individualized nutritional support deserves the attention of China and other governments.
In 2017, the National Nutrition Plan (2017–2030) was released in China to enhance nutritional awareness and strengthen nutrition intervention [8]. The plan calls for comprehensive nutritional screening, evaluation, diagnosis, and treatment of inpatients. Adverse health outcomes are always common and complex [9] among older inpatients with malnutrition, underscoring the need for appropriate support. Although studies have been conducted on malnutrition in older people with specific diseases [10], from specific regions [11], or in particular age groups [12], comprehensive national nutritional status among older inpatients in China has not been reported yet.
Moreover, there were no harmonized diagnostic criteria for the tools that could be applicable to assess malnutrition [13] before the issue of the Global Leadership Initiative on Malnutrition (GLIM) [14]. GLIM criteria have been validated in older Chinese inpatients [15] and other countries, regions and populations and are globally recognized for its accuracy [[16], [17], [18]]. The guidelines recommended that nutritional support should be provided to malnourished inpatients during hospitalization due to its apparent beneficial effect [19]. However, to the best of our knowledge, there is no study showing nutritional status on a national level and examining the association between nutritional support and nutritional status in Chinese patients by considering this new consensus.
Therefore, this study aims to investigate the nutritional status of inpatients aged 60 years and above and explore the association between nutritional support and changes in nutritional status, based on multicentered the China Nutrition Fundamental Data 2020 (CNFD 2020) Project.
2. Materials and methods
2.1. Study design and participants
The CNFD 2020 Project is administered by the National Institute of Hospital Administration (NHC) and conducted from August 2020 to August 2021. First, a total of 30 provinces (autonomous regions and municipalities) in mainland China were included (one autonomous region withdrew from the project because of the lack of dieticians). Second, 2–25 secondary or tertiary hospitals in each province (autonomous regions and municipalities) were selected. Third, the target of 200 cases per hospital was achieved through continuous convenient sampling. More than 50 thousand participants were selected as a representative sample of Chinese inpatients. Individual demographic, nutritional status, and related information were collected. This study focused on adult participants aged 60 years and above, and participants were excluded if the data missed among the key variables such as nutritional support or disease category and burden of disease, and information on nutritional status. Finally, 24,139 participants were included in the analysis.
2.2. Malnutrition diagnosis
GLIM defined malnutrition based on three phenotypic criteria and two etiologic criteria [14]. In GLIM criteria, NRS-2002 screening [20] is first required. The severity of disease, impaired nutritional status, and age are overall included to obtain a total score ranging from 0 to 7 [21]. A score over 3 points indicates the patient is at nutritional risk and nutritional support is needed [21]. At least one phenotype (non-volitional weight loss, low body mass index, and reduced muscle mass) and one etiologic criterion (reduced food intake or assimilation and disease burden/inflammation) are then required to diagnose malnutrition at least. Whether the patient was diagnosed with malnutrition was assessed at the moments of admission and during hospitalization. Changes in nutritional status were measured by the change between the nutritional diagnosis on admission and the GLIM criteria during hospitalization, which includes three categories (deteriorated, stable, and improved).
2.3. Nutritional support
Patients received individualized nutritional support according to dieticians’ advice following international guidelines [22]. Nutritional support contains the following five ways: (1) hospital feeding (meals are provided by the hospital kitchen), (2) oral nutrition supplements, (3) enteral tube feeding, (4) parenteral nutrition, and (5) no nutritional support.
2.4. Sociodemographic and clinical characteristics
Socio-demographic variables (gender, age, nationality, and education) were selected for adjustment in the study. Gender was categorized into two groups (male and female). Age was divided into four categories (60–64, 65–80, and ≥81). Nationality included five categories (Han, Hui, Mongolian, Manchu, and else). Education level was categorized as uneducated, primary or middle school, high school, and undergraduate and above. Besides, disease categories were diagnosed at the time of patient admission.
2.5. Statistical analysis
Categorical variables were presented as frequencies and percentages. The disparity in nutritional status across different groups was examined by chi-square. The factors associated with nutritional status were further assessed using binary logistic regression, with p < 0.05 as the level of statistical significance. Multivariate logistic regression models were then used to test potential association between nutritional support and change in nutritional status. Measures of effect were analyzed as adjusted odd ratios (ORs) and their 95% confidence intervals (95% CIs). Data were analyzed in SPSS (version 26.0, IBM Corp).
3. Results
3.1. Sample characteristics
A total of 24,139 older inpatients were enrolled in the study (Table 1), of which a greater proportion were male (58.97%), in the age group of 65–80 years (60.46%), Han nationality (96.98%), with a primary school or middle school of education (55.18%). Malnutrition on admission occurred more frequently in patients aged over 80 years than 65–80 years and 60–64 years. Among the 15 disease categories, circulatory system diseases (34.77%) were the most common, followed by endocrine, nutritional and metabolic diseases (25.30%), neoplasms (22.68%), and respiratory diseases (20.61%). Approximately 18.9% of older inpatients were diagnosed with malnutrition at the time of admission. The prevalence of most disease categories (e.g., infections, neoplasms, and hemic and lymphatic diseases) significantly differed between malnourished and well-nourished inpatients on admission.
Table 1.
Baseline characteristics of the study participants.
| Item | Total (%) | Malnutrition on admission (%) | Well-nourished on admission (%) | p |
|---|---|---|---|---|
| Total | 24,139 (100) | 4559 (18.90) | 19,580 (80.10) | |
| Gender | ||||
| Male | 14,234 (58.97) | 2727 (19.16) | 11,507 (80.84) | 0.196 |
| Female | 9905 (41.03) | 1832 (18.50) | 8073 (81.50) | |
| Age (years) | ||||
| 60–64 | 5178 (26.76) | 945 (18.25) | 4233 (81.75) | 0.045 |
| 65–80 | 15,876 (60.46) | 2984 (18.80) | 12,892 (81.20) | |
| ≥81 | 3085 (12.78) | 630 (20.42) | 2455 (79.18) | |
| Nationality | ||||
| Han | 23,410 (96.68) | 4414 (18.86) | 18,996 (81.14) | 0.482 |
| Hui | 146 (0.60) | 29 (19.86) | 117 (80.14) | |
| Mongolian | 69 (0.29) | 13 (18.74) | 56 (81.26) | |
| Manchu | 91 (0.38) | 13 (14.29) | 78 (85.71) | |
| Else | 423 (1.75) | 90 (21.28) | 333 (78.72) | |
| Education | ||||
| Uneducated | 4036 (16.72) | 775 (19.20) | 3261 (80.80) | 0.574 |
| Primary school or middle school | 13,319 (55.18) | 2525 (18.96) | 10,794 (81.04) | |
| High school | 5157 (21.36) | 955 (18.52) | 4202 (81.48) | |
| Undergraduate and above | 1627 (6.74) | 304 (18.68) | 1323 (81.32) | |
| Disease | ||||
| Infections | 269 (1.11) | 83 (30.86) | 186 (69.14) | <0.001 |
| Neoplasms | 5475 (22.68) | 1459 (26.65) | 4016 (73.35) | <0.001 |
| Hemic and lymphatic diseases | 468 (1.94) | 130 (27.78) | 338 (82.22) | <0.001 |
| Endocrine, nutritional and metabolic diseases | 6106 (25.30) | 888 (14.54) | 5218 (85.46) | <0.001 |
| Nervous system diseases | 4197 (17.39) | 903 (21.52) | 3294 (78.48) | <0.001 |
| Otorhinolaryngologic diseases | 282 (1.17) | 52 (18.44) | 230 (81.56) | 0.847 |
| Circulatory system diseases | 8392 (34.77) | 1431 (17.05) | 6961 (82.95) | <0.001 |
| Respiratory diseases | 4101 (20.61) | 1047 (25.53) | 3054 (74.47) | <0.001 |
| Digestive system diseases | 4976 (16.99) | 1185 (23.81) | 3791 (76.19) | <0.001 |
| Skin and connective tissue diseases | 109 (0.45) | 21 (19.27) | 88 (81.73) | 0.919 |
| Musculoskeletal diseases | 442 (1.83) | 97 (21.95) | 345 (78.05) | 0.097 |
| Immune system diseases | 207 (0.86) | 46 (22.22) | 161 (77.78) | 0.218 |
| Urogenital diseases | 3560 (14.75) | 497 (13.96) | 3063 (86.04) | <0.001 |
| Birth injuries and pregnancy complications | 62 (0.26) | 10 (16.13) | 52 (83.87) | 0.579 |
3.2. Factors associated with nutritional status on admission
Older inpatients with infections had the highest relative risk of malnutrition on admission, with an adjusted odds ratio of 1.929 (95% CI 1.486–2.504). Increased risks were also noted for malnutrition on admission in neoplasms (aOR = 1.822, 95% CI 1.697–1.957), hemic and lymphatic diseases (aOR = 1.671, 95% CI 1.361–2.051), nervous system diseases (aOR = 1.222, 95% CI 1.126–1.326), respiratory diseases (aOR = 1.613, 95% CI 1.490–1.746), and digestive system diseases (aOR = 1.462, 95% CI 1.357–1.577). The study also identified that patients with endocrine, nutritional and metabolic diseases (aOR = 0.666, 95% CI 0.615–0.722), circulatory system diseases (aOR = 0.830, 95% CI 0.774–0.889), and urogenital diseases (aOR = 0.659, 95% CI 0.596–0.729) were negatively associated with malnutrition on admission. While statistically significant relationship of otorhinolaryngologic diseases (aOR = 0.970, 95% CI 0.717–1.314), skin and connective tissue diseases (aOR = 1.022, 95% CI 0.634–1.657), musculoskeletal diseases (aOR = 1.211, 95% CI 0.965–1.521), immune system diseases (aOR = 1.232, 95% CI 0.886–1.712) and birth injuries and pregnancy complications (aOR = 0.828, 95% CI 0.421–1.631) with malnutrition on admission were not found. The details are shown in Fig. 1.
Fig. 1.
Associations of disease categories with malnutrition on admission.
Adjusted ORs (95% CI) were performed by logistic analysis using backward elimination method (likelihood ratio), adjusted for covariates (gender, age, nationality, education). Adjusted OR, adjusted odds ratio; CI, confidence interval.
3.3. Nutritional support and nutritional status
Nutritional support was given during hospitalization. As shown in Table 2, 50.21% inpatients with malnutrition on admission did not receive nutritional support. Approximately 32.26% inpatients with malnutrition did not receive nutritional support during hospitalization. While within the others 40.09% inpatient with malnutrition received hospital feeding, 24.58% oral nutrition supplements, 9.22% enteral tube nutrition, and 10.10% parenteral nutrition. During patients’ hospitalization, 4.4% of inpatients’ nutritional status deteriorated, 77.98% stable and 17.62% improved.
Table 2.
Nutritional support distribution of older inpatients in different nutritional status N (%).
| No nutrition support | Hospital feeding | Oral nutrition supplements | Enteral tube feeding | Parenteral nutrition | Total | |
|---|---|---|---|---|---|---|
| Malnutrition on admission | 2289 (50.21) | 1790 (39.0) | 361 (7.92) | 159 (3.49) | 192 (4.21) | 4559 (18.89) |
| Malnutrition during hospitalization | 441 (32.26) | 548 (40.09) | 336 (24.58) | 123 (9.22) | 138 (10.10) | 1367 (5.66) |
| Change in nutritional status | ||||||
| Deteriorated | 239 (2.88) | 428 (4.40) | 243 (14.30) | 91 (11.52) | 105 (10.99) | 1061 (4.40) |
| Stable | 9585 (79.08) | 7526 (78.20) | 1188 (69.92) | 575 (72.78) | 691 (72.36) | 18,825 (77.98) |
| Improved | 2187 (18.04) | 1670 (17.35) | 268 (15.77) | 124 (15.70) | 159 (16.65) | 4253 (17.62) |
| Total | 12,121 (50.21) | 9624 (39.87) | 1677 (7.04) | 790 (3.27) | 955 (3.96) | 24,139 |
3.4. Factors associated with change in nutritional status
The associations between different methods of nutritional support and change in nutritional status in the whole sample population were shown in Fig. 2. No nutritional support was associated with stable nutritional status (aOR = 0.681, 95% CI 0.520–0.891). Oral nutrition supplements, enteral tube feeding, and parenteral nutrition were associated with change in nutritional status in all groups. The strength of the association between oral nutrition supplements and change in nutritional status was more pronounced among those with improved nutrition (aOR = 3.929, 95% CI 3.045–5.074). No significant association was observed between hospital feeding and any change in nutritional status.
Fig. 2.
Associations of nutritional support with change in nutritional status.
Adjusted ORs (95% CI) were performed by logistic analysis using backward elimination method (likelihood ratio), adjusted for covariates (gender, age, nationality, education). Adjusted OR, adjusted odds ratio; CI, confidence interval.
4. Discussion
In this large, multi-center study of older inpatients, the overview of nutritional status and associated risk factors of older inpatients in China were expanded. Additionally, our study identified the associations of nutritional support with changes in nutritional status of the older population during hospitalization.
The results of this investigation indicated that 18.90% of participants were malnourished on admission. Our findings of malnutrition on admission are similar to the previous study conducted on a small scale [4], providing empirical support for the positive effects of the Chinese National Nutrition Plan in consideration of the disparity compared with the proportion of 24.58% in the 2013–2015 study [23]. Nevertheless, the proportion is still higher than 12.6% on the basis of the overall older adults living in the community [24] and some developed countries [25], which reminds more older people living at dangerous nutritional status at the time of admission. Moreover, what worth our attention is that the comparisons should be treated carefully due to the application of various nutritional assessment instruments [26] and differences in geography and participants. In any case, the importance of nutritional status should be emphasized as we found high malnutrition rates in older inpatients.
Our study identified risk profiles associated with malnutrition. Among disease categories, infections were associated with the highest adjusted odds ratio for malnutrition. In addition, neoplasms, hemic and lymphatic diseases, nervous system diseases, respiratory diseases, and digestive system diseases also had a strong association with malnourished status. Previous studies have reported that diseases are always accompanied by insufficient activity capacity [22], inflammation [27], anorexia [28], psychological problems [29], and intake of medication [30], leading to malnutrition. In clinical practice, disease diagnosis and treatment need to be accompanied by nutrition screening, assessment, and appropriate intervention [31].
However, a significant inverse association was also found in endocrine, nutritional and metabolic diseases, circulatory system diseases, and urogenital diseases. This is likely to be attributed to prevention and intervention of malnutrition before admission. Nutritional changes and symptoms in patients with these diseases are more likely to be of concern [32]. Moderate studies have shown associations between lifestyle factors and malnutrition, including low physical function, low appetite, and eating dependency [33]. The access to nutritional knowledge and care for older people and their families, including online courses [34], nutritional telemedicine [35], and the involvement of family physicians [36], makes it possible for older people to receive appropriate nutritional support. Lifestyle or preventive intervention had been taken prior to hospital admission.
We found that a large proportion of malnourished older inpatients still did not receive any nutritional support, which is concordant with previous studies [37]. Furthermore, our study proved that no nutritional support was negatively associated with stable nutritional status, and there was no significant association between no nutritional support and improved nutrition status. Nutritional support is worth consideration as it can counteract some of the adverse outcomes of malnutrition and improve clinical outcomes [38], such as shortening the average LOS [39], and improving quality of life [40]. Hospital feeding was predominant among patients receiving nutritional support, with fewer patients receiving other nutritional support. Whereas hospital feeding was found to be not well accepted in previous study [41], it might be due to patients’ loss of appetite [41] and food factors [42,43], which makes supplementing protein [44] or other needed ingredients by the application of other nutritional support essential.
The role of nutritional support in nutrition improvement work for inpatients was supported by the positive association of oral nutrition supplements, enteral tube feeding, and parenteral nutrition with improved nutritional status. As the first choice for general older inpatients with malnutrition, the benefits of enteral nutrition, including oral nutrition supplements and enteral tube feeding [45], have been identified [46,47]. Parenteral nutrition is given when the provision of enteral nutrition fails to achieve the target feeding amount of 60% [48]. It is important to note that the nutritional needs of each older patient vary depending on their nutritional status, disease conditions, and medication use [49], and individualized and comprehensive nutritional support programs are required in clinical practice [19], taking into account potential risks [50,51].
Although the large nationally representative sample of older inpatients was firstly used in our study, which accurately estimated the prevalence of inpatients malnutrition in China. Our study also has limitations from a critical perspective. Firstly, although this was a highly nationally representative survey, it mainly involved patients from tertiary hospitals, and it is uncertain whether the conclusions can be adequately applied to the older patients from primary care institutions. Secondly, the length of treatment with nutritional support was not considered due to a lack of data availability. Thirdly, the factors influencing malnutrition are complex. Longitudinal studies are needed to further investigate the effect of socioeconomic status, dietary, length of stay, and healthcare system factors on nutritional status of older inpatients.
5. Conclusions
The results of this study threw light on the serious malnutrition challenges for older hospitalized patients, strengthened the evidence on the relationship between diseases and malnutrition, and revealed effective ways to improve nutritional status. More research is needed to identify how to prevent malnutrition and appropriate treatment for the various settings.
Funding and conflict to interest statements
This study is supported by grants from National Key Research and Development Program (SQ2023YFC3600014), National Nature Science Foundation of China (72004073, 72374079), CIFST— Abbott Foundation of Food Nutrition and Safety (2022-M01), Research Project of Humanities and Social Sciences of the Ministry of Education (20YJC630134). None of the authors declared a conflict of interest.
Ethics
Oral informed consent was obtained from all enrolled participants. The experiments comply with the current laws of the China. This project (No: ZS-2614) was approved by the central ethics committee at the Peking Union Medical College Hospital. The study was registered at https://www.chictr.org.cn/historyversionpub.aspx (No: NCT05694104).
Contributor Information
Shu-Yan Guo, Email: guoshuyan@niha.org.cn.
Shang-Feng Tang, Email: sftang2018@hust.edu.cn.
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