Nutrition Support Therapy

 

Am Fam Physician. 2021 Dec ;104(6):580-588.

Author disclosure: No relevant financial affiliations.

Nutrition support therapy is the delivery of formulated enteral or parenteral nutrients to restore nutritional status. Family physicians can provide nutrition support therapy to patients at risk of malnutrition when it would improve quality of life. The evidence for when to use nutrition support therapy is inconsistent and based mostly on low-quality studies. Family physicians should work with registered dietitian nutritionists to complete a comprehensive nutritional assessment for patients with acute or chronic conditions that put them at risk of malnutrition. When nutrition support therapy is required, enteral nutrition is preferred for a patient with a functioning gastrointestinal tract, even in patients who are critically ill. Parenteral nutrition has an increased risk of complications and should be administered only when enteral nutrition is contraindicated. Family physicians can use the Mifflin-St Jeor equation to calculate the resting metabolic rate, and they should consult with a registered dietitian nutritionist to determine total energy needs and select a nutritional formula. Patients receiving nutrition support therapy should be monitored for complications, including refeeding syndrome. Nutrition support therapy does not improve quality of life in patients with dementia. Clinicians should engage in shared decision-making with patients and caregivers about nutrition support in palliative and end-of-life care.

Nutrition support therapy is the delivery of formulated enteral or parenteral nutrients to maintain or restore nutritional status. Enteral nutrition (EN) support is the provision of nutrition using an enteral device inserted into the gastrointestinal (GI) tract. Parenteral nutrition (PN) support is the provision of nutrition intravenously. The evidence for when to use nutrition support therapy is inconsistent and based mostly on low-quality studies. Family physicians can provide nutrition support therapy to patients at risk of malnutrition when it would improve quality of life. This article focuses on caring for adults who need nutrition support therapy, which generally occurs in the hospital setting.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Physicians should work with a registered dietitian nutritionist who uses the Nutrition Care Process framework to assess the need for nutrition support therapy in patients at risk of malnutrition.6

C

Guidelines recommended using a standard process for assessing nutritional risk.

Consider initiating EN feedings within 24 hours of gastrointestinal surgery.13

B

A systematic review of low-quality studies showed a decreased length of hospital stay, but no effect on other outcomes.

In nonsevere acute pancreatitis, initiate early oral feeding. If nutrition support therapy is needed, use EN over total PN.14,15

A

A systematic review showed no harms of early feeding and a reduced length of stay; a systematic review showed that in patients needing nutrition support, EN significantly decreased morbidity and mortality compared with total PN.

Use EN over PN in patients with a functioning gastrointestinal tract.12

B

A systematic review of low-quality studies showed that EN may have fewer serious adverse events than PN.

In critically ill patients who need nutrition support therapy, use EN instead of PN or a combination of the two.4,1719

A

A large randomized controlled trial and a systematic review of low-quality studies comparing EN and PN in critically ill patients showed no difference in 90-day mortality. However, using EN may result in fewer respiratory infections and shorter hospital stays, and it is more cost-effective.

Consider using high-carbohydrate, high-protein, low-fat EN in patients with burns on more than 10% of their total body surface area.25

B

A systematic review of low-quality studies showed that using a high-carbohydrate, high-protein, low-fat EN formula may result in a lower incidence of pneumonia compared with use of a low-carbohydrate, high-protein, high-fat diet.

In patients with dementia, avoid tube feeding.32

C

A nonsystematic review found no evidence that tube feeding improved outcomes.


EN = enteral nutrition; PN = parenteral nutrition.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Physicians should work with a registered dietitian nutritionist who uses the Nutrition Care Process framework to assess the need for nutrition support therapy in patients at risk of malnutrition.6

C

Guidelines recommended using a standard process for assessing nutritional risk.

Consider initiating EN feedings within

The Authors

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MARY N. R. LESSER, PhD, RD, is a continuing lecturer at the University of California, Berkeley, and a pediatric registered dietitian and researcher at the Children's Hospital Oakland (Calif.) Research Institute and UCSF Benioff Children's Hospital, Oakland....

LENARD I. LESSER, MD, MSHS, is the medical director of population health and family physician at One Medical, San Francisco, Calif., and an assistant volunteer clinical instructor in the Department of Family and Community Medicine at the University of California, San Francisco.

Address correspondence to Lenard I. Lesser, MD, MSHS, One Medical, 1 Embarcadero Center, Ste. 1900, San Francisco, CA 94111 (email: llesser@onemedical.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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