Barriers to nutritional intake in patients with acute hip fracture: time to treat malnutrition as a disease and food as a medicine?

Abstract

Inadequate energy and protein intake leads to malnutrition; a clinical disease not without consequence post acute hip fracture. Data detailing malnutrition prevalence, incidence, and intake adequacy varies widely in this patient population. The limited success of reported interventional strategies may result from poorly defined diagnostic criteria, failure to address root causes of inadequate intake, or errors associated with selection bias. This pragmatic study used a sequential, explanatory mixed methods design to identify malnutrition aetiology, prevalence, incidence, intake adequacy, and barriers to intake in a representative sample of 44 acute hip fracture patients (73% female; mean age, 81.7 ± 10.8 years). On admission, malnutrition prevalence was 52.2%. Energy and protein requirements were only met twice in 58 weighed 24 h food records. Mean daily patient energy intake was 2957 kJ (50.9 ± 36.1 kJ·kg(-1)) and mean protein intake was 22.8 g (0.6 ± 0.46 g·kg(-1)). This contributed to a further in-patient malnutrition incidence of 11%. Barriers to intake included patient perceptions that malnutrition and (or) inadequate intake were not a problem, as well as patient and clinician perceptions that treatment for malnutrition was not a priority. Malnutrition needs to be treated as a disease not without consequence, and food should be considered as a medicine after acute hip fracture.

Need for the Integrated Nutrition Pathway for Acute Care (INPAC): gaps in current nutrition care in five Canadian hospitals

“…Many barriers to food intake were identified by staff in all sites, which corroborate findings from other research [19,23]. The Nutrition Care in Canadian Hospitals (NCCH) study identified numerous barriers in the areas of illness (poor appetite, nausea, pain), eating difficulties (difficulty opening packages, inability to reach meal trays) and organizational barriers (not receiving help to eat, missing meals due to tests) [19].…”

“…Research has also shown that many patients experience barriers to food intake, such as interrupted meals, or inability to open packages, leading to deterioration of their nutritional status while in hospital [19][20][21]. Unidentified malnutrition on admission and iatrogenic or worsening of malnutrition increases length of stay and also affects patients after discharge, including an increased likelihood of readmission [3,11,19,22,23].…”

Protein and Older Persons

“…34,35 Malnutrition in general, and especially protein deficiency, has to be regarded as a predisposing factor for osteoporosis and sarcopenia, which are both key factors in the causes of fall-related fractures. Although protein deficiency is present in many patients with hip fracture at hospital admission, it may deteriorate further as a consequence of insufficient protein intake during the hospital stay.…”

Additive effects of nutritional supplementation, together with isphosphonates, on bone mineral density after hip fracture: a 12-month randomized controlled study

“…Inadequate intake of protein and total calories, leading to malnutrition, is common among hip fracture patients 1,2. After a hip fracture, a catabolic state develops, characterized by increased loss of bone mineral density (BMD) during the first year 3–5.…”