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Review article: Medical guidelines

Vol. 150 No. 1516 (2020)

Individualised nutritional support in medical inpatients – a practical guideline

  • Annic Baumgartner
  • Nina Kägi-Braun
  • Pascal Tribolet
  • Filomena Gomes
  • Zeno Stanga
  • Philipp Schuetz
Cite this as:
Swiss Med Wkly. 2020;150:w20204


Malnutrition has been defined as a “state resulting from lack of uptake or intake of nutrition, leading to altered body composition and body cell mass, as well as to diminished physical and mental function and impaired clinical outcome from disease.” Particularly for the multimorbid medical inpatient, there are multiple research studies linking malnutrition to adverse clinical outcomes independent of type of acute and chronic illnesses. Importantly, recent trials have shown that malnutrition is indeed a modifiable risk factor with specific individualised nutritional support interventions started at hospital admission having positive effects on the risk of complications, mortality, functional outcomes, rehospitalisation and quality of life. Understanding the optimal use of nutritional support in patients with acute illness is complex – as timing, route of delivery, and the amount and type of nutrients can all affect patient outcome. The aim of this narrative review is to provide a practical guideline for pragmatic and evidence-based assessment and treatment of medical inpatients at nutritional risk. We thereby focus on screening, patient assessment, definition of individual nutritional goals and nutritional support interventions that help patients to reach these goals.


  1. 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. doi:.
  2. Schuetz P. “Eat your lunch!” - controversies in the nutrition of the acutely, non-critically ill medical inpatient. Swiss Med Wkly. 2015;145:w14132. doi:.
  3. Schütz P, Bally M, Stanga Z, Keller U. Loss of appetite in acutely ill medical inpatients: physiological response or therapeutic target? Swiss Med Wkly. 2014;144:w13957. doi:.
  4. Sobotka L. Basics in Clinical Nutrition: Nutritional support in different clinical situations. Clin Nutr. 2010;5(3):e153–4. doi:
  5. Cederholm T, Bosaeus I, Barazzoni R, Bauer J, Van Gossum A, Klek S, et al. Diagnostic criteria for malnutrition - An ESPEN Consensus Statement. Clin Nutr. 2015;34(3):335–40. doi:.
  6. Felder S, Braun N, Stanga Z, Kulkarni P, Faessler L, Kutz A, et al. Unraveling the Link between Malnutrition and Adverse Clinical Outcomes: Association of Acute and Chronic Malnutrition Measures with Blood Biomarkers from Different Pathophysiological States. Ann Nutr Metab. 2016;68(3):164–72. doi:.
  7. Deutz NE, Matheson EM, Matarese LE, Luo M, Baggs GE, Nelson JL, et al.; NOURISH Study Group. Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: A randomized clinical trial. Clin Nutr. 2016;35(1):18–26. doi:.
  8. Gomes F, Schuetz P, Bounoure L, Austin P, Ballesteros-Pomar M, Cederholm T, et al. ESPEN guidelines on nutritional support for polymorbid internal medicine patients. Clin Nutr. 2018;37(1):336–53. doi:.
  9. Felder S, Lechtenboehmer C, Bally M, Fehr R, Deiss M, Faessler L, et al. Association of nutritional risk and adverse medical outcomes across different medical inpatient populations. Nutrition. 2015;31(11-12):1385–93. doi:.
  10. Felder S, Lechtenboehmer C, Bally M, Fehr R, Deiss M, Faessler L, et al. Association of nutritional risk and adverse medical outcomes across different medical inpatient populations. Nutrition. 2015;31(11-12):1385–93. doi:.
  11. Gomes F, Schuetz P, Bounoure L, Austin P, Ballesteros-Pomar M, Cederholm T, et al. ESPEN guidelines on nutritional support for polymorbid internal medicine patients. Clin Nutr. 2018;37(1):336–53. doi:.
  12. Reber E, Gomes F, Bally L, Schuetz P, Stanga Z. Nutritional Management of Medical Inpatients. J Clin Med. 2019;8(8):1130. doi:.
  13. Kondrup J, Allison SP, Elia M, Vellas B, Plauth M ; Educational and Clinical Practice Committee, European Society of Parenteral and Enteral Nutrition (ESPEN). ESPEN guidelines for nutrition screening 2002. Clin Nutr. 2003;22(4):415–21. doi:.
  14. Reber E, Gomes F, Vasiloglou MF, Schuetz P, Stanga Z. Nutritional Risk Screening and Assessment. J Clin Med. 2019;8(7):1065. doi:.
  15. Schuetz P, Hausfater P, Amin D, Haubitz S, Fässler L, Grolimund E, et al. Optimizing triage and hospitalization in adult general medical emergency patients: the triage project. BMC Emerg Med. 2013;13(1):12. doi:.
  16. Hersberger L, Bargetzi L, Bargetzi A, Tribolet P, Fehr R, Baechli V, et al. Nutritional risk screening (NRS 2002) is a strong and modifiable predictor risk score for short-term and long-term clinical outcomes: secondary analysis of a prospective randomised trial. Clin Nutr. 2019;S0261-5614(19)33171-1. doi:.
  17. Bounoure L, Gomes F, Stanga Z, Keller U, Meier R, Ballmer P, et al.; Members of the Working Group. Detection and treatment of medical inpatients with or at-risk of malnutrition: Suggested procedures based on validated guidelines. Nutrition. 2016;32(7-8):790–8. doi:.
  18. Branson RD, Johannigman JA. The measurement of energy expenditure. Nutr Clin Pract. 2004;19(6):622–36. doi:.
  19. Boullata J, Williams J, Cottrell F, Hudson L, Compher C. Accurate determination of energy needs in hospitalized patients. J Am Diet Assoc. 2007;107(3):393–401. doi:.
  20. Valentini L, Roth E, Jadrna K, Postrach E, Schulzke JD. The BASA-ROT table: an arithmetic-hypothetical concept for easy BMI-, age-, and sex-adjusted bedside estimation of energy expenditure. Nutrition. 2012;28(7-8):773–8. doi:.
  21. Starke J, Schneider H, Alteheld B, Stehle P, Meier R. Short-term individual nutritional care as part of routine clinical setting improves outcome and quality of life in malnourished medical patients. Clin Nutr. 2011;30(2):194–201. doi:.
  22. McClave SA, DiBaise JK, Mullin GE, Martindale RG. ACG Clinical Guideline: Nutrition Therapy in the Adult Hospitalized Patient. Am J Gastroenterol. 2016;111(3):315–34, quiz 335. doi:.
  23. Cano N, Fiaccadori E, Tesinsky P, Toigo G, Druml W, Kuhlmann M, et al.; DGEM (German Society for Nutritional Medicine); ESPEN (European Society for Parenteral and Enteral Nutrition). ESPEN Guidelines on Enteral Nutrition: Adult renal failure. Clin Nutr. 2006;25(2):295–310. doi:.
  24. Peterson CM, Thomas DM, Blackburn GL, Heymsfield SB. Universal equation for estimating ideal body weight and body weight at any BMI. Am J Clin Nutr. 2016;103(5):1197–203. doi:.
  25. Choban P, Dickerson R, Malone A, Worthington P, Compher C ; American Society for Parenteral and Enteral Nutrition. A.S.P.E.N. Clinical guidelines: nutrition support of hospitalized adult patients with obesity. JPEN J Parenter Enteral Nutr. 2013;37(6):714–44. doi:.. Correction in: JPEN J Parenter Enteral Nutr. 2015;39(6):998. doi:
  26. Kilonzo MM, Vale LD, Cook JA, Milne AC, Stephen AI, Avenell A ; MAVIS Trial Group. A cost-utility analysis of multivitamin and multimineral supplements in men and women aged 65 years and over. Clin Nutr. 2007;26(3):364–70. doi:.
  27. Friedli N, Stanga Z, Culkin A, Crook M, Laviano A, Sobotka L, et al. Management and prevention of refeeding syndrome in medical inpatients: An evidence-based and consensus-supported algorithm. Nutrition. 2018;47:13–20. doi:.
  28. Friedli N, Stanga Z, Sobotka L, Culkin A, Kondrup J, Laviano A, et al. Revisiting the refeeding syndrome: Results of a systematic review. Nutrition. 2017;35:151–60. doi:.
  29. Wong A, Chew A, Wang CM, Ong L, Zhang SH, Young S. The use of a specialised amino acid mixture for pressure ulcers: a placebo-controlled trial. J Wound Care. 2014;23(5):259–60, 262–4, 266–9. doi:.
  30. Vandewoude MFJ, Paridaens KMJ, Suy RAL, Boone MAA, Strobbe H. Fibre-supplemented tube feeding in the hospitalised elderly. Age Ageing. 2005;34(2):120–4. doi:.
  31. Elia M, Engfer MB, Green CJ, Silk DB. Systematic review and meta-analysis: the clinical and physiological effects of fibre-containing enteral formulae. Aliment Pharmacol Ther. 2008;27(2):120–45. doi:.
  32. Whelan K, Schneider SM. Mechanisms, prevention, and management of diarrhea in enteral nutrition. Curr Opin Gastroenterol. 2011;27(2):152–9. doi:.
  33. National Institute for Health and Clinical Excellence. Guidance. Intravenous Fluid Therapy: Intravenous Fluid Therapy in Adults in Hospital. London: Royal College of Physicians (UK) National Clinical Guideline Centre; 2013.
  34. Volkert D, Beck AM, Cederholm T, Cruz-Jentoft A, Goisser S, Hooper L, et al. ESPEN guideline on clinical nutrition and hydration in geriatrics. Clin Nutr. 2019;38(1):10–47. doi:.
  35. Hegerová P, Dědková Z, Sobotka L. Early nutritional support and physiotherapy improved long-term self-sufficiency in acutely ill older patients. Nutrition. 2015;31(1):166–70. doi:.
  36. Gariballa S, Forster S, Walters S, Powers H. A randomized, double-blind, placebo-controlled trial of nutritional supplementation during acute illness. Am J Med. 2006;119(8):693–9. doi:.
  37. Mendenhall CL, Moritz TE, Roselle GA, Morgan TR, Nemchausky BA, Tamburro CH, et al. Protein energy malnutrition in severe alcoholic hepatitis: diagnosis and response to treatment. The VA Cooperative Study Group #275. JPEN J Parenter Enteral Nutr. 1995;19(4):258–65. doi:.
  38. Stratton R. The impact of nutritional support on appetite and food intake. Clin Nutr. 2001;20:147–52. doi:.
  39. Fuhrman MP. The albumin-nutrition connection: separating myth from fact. Nutrition. 2002;18(2):199–200. doi:.
  40. Eckart A, Struja T, Kutz A, Baumgartner A, Baumgartner T, Zurfluh S, et al. Relationship of nutritional status, inflammation, and serum albumin levels during acute illness: A prospective study. Am J Med. 2019;S0002-9343(19)30975-1. [Epub ahead of print.] doi:.
  41. Hernández-Aranda JC, Gallo-Chico B, Luna-Cruz ML, Rayón-González MI, Flores-Ramírez LA, Ramos Muñoz R, et al. Desnutrición y nutrición parenteral total: estudio de una cohorte para determinar la incidencia del síndrome de realimentación [Malnutrition and total parenteral nutrition: a cohort study to determine the incidence of refeeding syndrome]. Rev Gastroenterol Mex. 1997;62(4):260–5. Spanish.
  42. González Avila G, Fajardo Rodríguez A, González Figueroa E. [The incidence of the refeeding syndrome in cancer patients who receive artificial nutritional treatment]. Nutr Hosp. 1996;11(2):98–101. Spanish.
  43. Preiser JC, van Zanten AR, Berger MM, Biolo G, Casaer MP, Doig GS, et al. Metabolic and nutritional support of critically ill patients: consensus and controversies. Crit Care. 2015;19(1):35. doi:.
  44. Rüfenacht U, Rühlin M, Wegmann M, Imoberdorf R, Ballmer PE. Nutritional counseling improves quality of life and nutrient intake in hospitalized undernourished patients. Nutrition. 2010;26(1):53–60. doi:.
  45. 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. doi:.
  46. Schuetz P, Fehr R, Baechli V, Geiser M, Deiss M, Gomes F, et al. Individualised nutritional support in medical inpatients at nutritional risk: a randomised clinical trial. Lancet. 2019;393(10188):2312–21. doi:.
  47. Loman BR, Luo M, Baggs GE, Mitchell DC, Nelson JL, Ziegler TR, et al.; NOURISH Study Group. Specialized High-Protein Oral Nutrition Supplement Improves Home Nutrient Intake of Malnourished Older Adults Without Decreasing Usual Food Intake. JPEN J Parenter Enteral Nutr. 2019;43(6):794–802. doi:.
  48. Gomes F, Baumgartner A, Bounoure L, Bally M, Deutz NE, Greenwald JL, et al. Association of Nutritional Support With Clinical Outcomes Among Medical Inpatients Who Are Malnourished or at Nutritional Risk: An Updated Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(11):e1915138. doi:.
  49. Liu CJ, Latham NK. Progressive resistance strength training for improving physical function in older adults. Cochrane Database Syst Rev. 2009;(3):CD002759. doi:.
  50. Yang Y, Breen L, Burd NA, Hector AJ, Churchward-Venne TA, Josse AR, et al. Resistance exercise enhances myofibrillar protein synthesis with graded intakes of whey protein in older men. Br J Nutr. 2012;108(10):1780–8. doi:.
  51. Artaza-Artabe I, Sáez-López P, Sánchez-Hernández N, Fernández-Gutierrez N, Malafarina V. The relationship between nutrition and frailty: Effects of protein intake, nutritional supplementation, vitamin D and exercise on muscle metabolism in the elderly. A systematic review. Maturitas. 2016;93:89–99. doi:.
  52. Balagopal P, Schimke JC, Ades P, Adey D, Nair KS. Age effect on transcript levels and synthesis rate of muscle MHC and response to resistance exercise. Am J Physiol Endocrinol Metab. 2001;280(2):E203–8. doi:.
  53. Burd NA, West DW, Moore DR, Atherton PJ, Staples AW, Prior T, et al. Enhanced amino acid sensitivity of myofibrillar protein synthesis persists for up to 24 h after resistance exercise in young men. J Nutr. 2011;141(4):568–73. doi:.
  54. Holeček M. Beta-hydroxy-beta-methylbutyrate supplementation and skeletal muscle in healthy and muscle-wasting conditions. J Cachexia Sarcopenia Muscle. 2017;8(4):529–41. doi:.
  55. Cramer JT, Cruz-Jentoft AJ, Landi F, Hickson M, Zamboni M, Pereira SL, et al. Impacts of High-Protein Oral Nutritional Supplements Among Malnourished Men and Women with Sarcopenia: A Multicenter, Randomized, Double-Blinded, Controlled Trial. J Am Med Dir Assoc. 2016;17(11):1044–55. doi:.

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