Individuelle, evidenzbasierte Ernährung des medizinischen Spitalpatienten: Wo stehen wir heute?

Zusammenfassung

Evidenzbasierte Medizin berücksichtigt die Grundsätze „Beste wissenschaftliche Evidenz“, „Klinische Expertise“ und „Patientenpräferenzen“ und bildet damit die Basis der klinischen Entscheidungsfindung in der modernen Medizin. Ziel ist, die Ernährungsmedizin in gleicher Weise zu praktizieren.

Groß angelegte klinische Studien sind Voraussetzung, um die Ernährungsmedizin wissenschaftlich auf das Niveau der evidenzbasierten Ernährungsmedizin zu heben.

Die Ernährungsmedizinische Forschung steht traditionell vielen Herausforderungen gegenüber. Aufgrund fehlender, hochqualitativer randomisierter Studien war es in der Vergangenheit schwierig, einen hohen Evidenzgrad für Ernährungsmedizinische Fragestellungen zu erlangen und in einigen Bereichen der Ernährungsmedizin ist die Evidenz zur Wirksamkeit von Ernährungsinterventionen noch immer unzureichend.

In den letzten Jahren wurden aber große Fortschritte auf dem Weg zur evidenzbasierten Ernährungsmedizin gemacht. Neue Erkenntnisse aus aktuellen, groß angelegten klinischen Studien und systematischen Analysen haben z. B. die bedeutenden klinischen Verbesserungen, die mit einer zielgerichteten Ernährungstherapie bei mangelernährten hospitalisierten Patienten assoziiert sind, aufgezeigt und damit eine wichtige Lücke im Wissen der Ernährungsmedizin geschlossen.

Abstract

Evidence-based medicine is the art of combining “best external evidence”, “clinical judgement” and “patient values” for an improved daily clinical decision making in modern medicine. The field of medical nutrition should follow these same basic principles. For raising medical nutrition to the level of evidence-based decision making, the availability of high-quality randomized trials and their meta-analyses is crucial. Historically, clinical nutrition research faces different challenges and there was an important lack of strong evidence from large and high-quality trials. While for some questions in medical nutrition there is still insufficient evidence today, in the field of malnutrition important progress has been made over the last years. Particularly, recent trials suggest that individualized nutritional support in malnourished inpatients has strong effects on mortality and other patient-relevant outcomes. These data support an active approach for patient screening, assessment and nutritional treatment when indicated.

Schlüsselwörter

evidenzbasierte Medizin - evidenzbasierte Ernährungsmedizin - Mangelernährung

Keywords

evidence-based medicine - evidence-based medical nutrition - malnutrition

• Literatur

• 1 Kaegi-Braun NBA, Gomes F, Schuetz P. et al. “Evidence-Based Medical Nutrition – a difficult journey, but worth the effort!”. Clinical nutrition; 2020 „in press“
• 2 Sackett DL, Rosenberg WM, Gray JA. et al. Evidence based medicine: what it is and what it isnʼt. BMJ 1996; 312: 71-72
• 3 Masic I, Miokovic M, Muhamedagic B. Evidence based medicine – new approaches and challenges. Acta Inform Med 2008; 16: 219-225
• 4 Crowley J, Ball L, Hiddink GJ. Nutrition in medical education: a systematic review. Lancet Planet Health 2019; 3: e379-e389
• 5 Schuetz P, Haberthür C. «Lass die Nahrung Deine Medizin sein und Medizin Deine Nahrung». Schweizerische Ärztezeitung 2019; 100: 901-902
• 6 Davis CD, Ohlhorst S. The future of nutrition research at the National Institutes of Health. Adv Nutr 2014; 5: 537-540
• 7 Prado CM, Purcell SA, Laviano A. Nutrition interventions to treat low muscle mass in cancer. J Cachexia Sarcopenia Muscle 2020; 11: 366-380
• 8 Casaer MP, Mesotten D, Hermans G. et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011; 365: 506-517
• 9 National Heart Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Rice TW, Wheeler AP, Thompson BT. et al. Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA 2012; 307: 795-803
• 10 Friedli N, Stanga Z, Sobotka L. et al. Revisiting the refeeding syndrome: Results of a systematic review. Nutrition 2017; 35: 151-160
• 11 Schetz M, Casaer MP, Van den Berghe G. Does artificial nutrition improve outcome of critical illness?. Crit Care 2013; 17: 302
• 12 Estruch R, Ros E, Salas-Salvado J. et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013; 368: 1279-1290
• 13 Guasch-Ferre M, Salas-Salvado J, Ros E. et al. The PREDIMED trial, Mediterranean diet and health outcomes: How strong is the evidence?. Nutr Metab Cardiovasc Dis 2017; 27: 624-632
• 14 Merker MGF, Stanga Z, Schuetz P. Evidence-based nutrition for the malnourished, hospitalised patient: one bite at a time. Swiss Medical Weekly 2019; 149: w20112
• 15 Felder S, Lechtenboehmer C, Bally M. et al. Association of nutritional risk and adverse medical outcomes across different medical inpatient populations. Nutrition 2015; 31: 1385-1393
• 16 Imoberdorf R, Meier R, Krebs P. et al. Prevalence of undernutrition on admission to Swiss hospitals. Clin Nutr 2010; 29: 38-41
• 17 Felder S, Braun N, 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: 164-172
• 18 Sir Conrad Sprengell. The aphorisms of Hippocrates, and the sentences of Celsus; with explanations and references to the most considerable Writers in Physick and Philosophy both Ancient and modern. London: R Wilkin and F Bonwick; 1735
• 19 Bally MR, Blaser Yildirim PZ, Bounoure L. et al. Nutritional Support and Outcomes in Malnourished Medical Inpatients: A Systematic Review and Meta-analysis. JAMA Intern Med 2016; 176: 43-53
• 20 Deutz NE, Koletzko B, Pichard C. New legal regulations for clinical trials: an opportunity for the future of Clinical Nutrition research. Clin Nutr 2007; 26: 510-513
• 21 Feinberg J, Nielsen EE, Korang SK. et al. Nutrition support in hospitalised adults at nutritional risk. Cochrane Database Syst Rev 2017 5. CD011598
• 22 Gomes F, Schuetz P, Bounoure L. et al. ESPEN guidelines on nutritional support for polymorbid internal medicine patients. Clin Nutr 2018; 37: 336-353
• 23 Mueller C, Compher C, Ellen DM. American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. clinical guidelines: Nutrition screening, assessment, and intervention in adults. JPEN J Parenter Enteral Nutr 2011; 35: 16-24
• 24 Gomes F, Baumgartner A, Bounoure L. 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: e1915138
• 25 Deutz NE, Matheson EM, Matarese LE. et al. 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
• 26 Schuetz P, Fehr R, Baechli V. et al. Individualised nutritional support in medical inpatients at nutritional risk: a randomised clinical trial. Lancet 2019; 393: 2312-2321
• 27 Kondrup J, Rasmussen HH, Hamberg O. et al. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr 2003; 22: 321-336
• 28 Tignanelli C, Bukowiec JC. Hospital Based Nutrition Support: A Review of the Latest Evidence. J Clin Nutr Diet 2017; 3: 22
• 29 Bounoure L, Gomes F, Stanga Z. et al. Detection and treatment of medical inpatients with or at-risk of malnutrition: Suggested procedures based on validated guidelines. Nutrition 2016; 32: 790-798