Received: 1 December 2020 Revised: 13 January 2021 Accepted: 2 February 2021

DOI: 10.1002/jpen.2085

O R I G I N A L C O M M U N I C AT I O N

Are traditional screening tools adequate for monitoring the

nutrition risk of in-hospital patients? An analysis of the
nutritionDay database

Diana Cardenas MD, PhD1 Charles Bermúdez MD2 Angélica Pérez RD, MSc3
Gustavo Diaz RD, MSc1 Lilia Yadira Cortés RD, PhD4
Claudia Patricia Contreras RD4 Olga Lucía Pinzón-Espitia RD, PhD5
Gabriel Gómez MD6 Maria Cristina González MD, PhD7 Romain Fantin PhD8
José Gutierrez MD9 Isabella Sulz PhD10 Silvia Tarantino MD, PhD11
Michael Hiesmayr MD, PhD10
1
Faculty of Medicine, Research Institute on Nutrition, Genetics and Metabolism, Universidad El Bosque, Bogota, Colombia
2
Surgery Department, Clínica La Colina and Clínica del Country, Bogota, Colombia
3
Nutrition Department, Clínica Coal, Bogota, Colombia
4
Nutrition and Biochemistry Department, Pontificia Universidad Javeriana, Bogota, Colombia
5
Facultad de Medicina, Departamento de Nutrición Humana, Universidad Nacional de Colombia, Hospital Universitario Mayor–Méderi, Universidad del Rosario,
Bogota, Colombia
6
Surgery Department, Clínica del Country, Bogota, Colombia
7
Post-graduate Program in Health and Behavior, Catholic University of Pelotas, Pelotas, Brazil
8
School of Medicine and School of Public Health, Faculty of Medicine, Universidad de Costa Rica, San José, Costa Rica
9
Nutritional Support Unit, Instituto Salvadoreño del Seguro Social, San Salvador, El Salvador
10
Institute for Medical Statistics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University Vienna, Vienna, Austria
11
Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria

Correspondence
Diana Cardenas, MD, PhD, Faculty of Medicine,
Research Institute on Nutrition, Genetics and
Metabolism, Universidad El Bosque, Carrera 7
No. 117 – 15, Bogota, Colombia.
Email: dianacardenasbraz@gmail.com
Funding Information
Funding was received from Abbott Laborato-
ries.
Abstract
Background: Monitoring of adequate food intake is not a priority in hospital patients’
care. The present study aimed to examine selective data from the nutritionDay survey
to determine the impact of food intake during hospitalization on outcomes according
to the nutrition risk status.
Methods: We conducted a descriptive analysis of selected data from 7 consecutive,
annual, and cross-sectional nutritionDay samples from 2009 to 2015. The impact of
food intake on outcomes was assessed by univariate and multivariate Cox models con-
trolling for PANDORA scores.
Results: A total of 7994 adult patients from Colombia, 7243 patients from 9 Latin
American countries, and 155,524 patients worldwid were included. Less than half
of the patients worldwide consumed their entire meal on nutritionDay (41%). The

© 2021 American Society for Parenteral and Enteral Nutrition

JPEN J Parenter Enteral Nutr. 2021;1–10. wileyonlinelibrary.com/journal/jpen 1

2 CARDENAS ET AL

number of reduced eaters is larger in the “no nutrition risk group” than in the “nutrition
risk group” (30% vs 25%). Reduced eating is associated with higher mortality and
delayed discharge in patients, regardless of the nutrition risk status. Patients without
nutrition risk at the screening who ate “nothing, but were allowed to eat” had 6 times
more risk of mortality (hazard ratio, 6.48; 95% CI, 3.5311.87).
Conclusions: This is the first large-scale study evaluating the relationship of food
intake on clinical outcomes showing an increase of in-hospital mortality rates and
a reduction in the probability of being discharged home regardless of the nutrition
risk status. Traditional screening tools may not identify a group of patients who will
become at risk because of reduced intake while in the hospital.

KEYWORDS
food intake, longitudinal study, malnutrition mortality, nutrition risk, nutrition screening

CLINICAL RELEVANCY STATEMENT
Monitoring adequate food intake is not a priority in clinical routine,
despite many guidelines suggesting food intake documentation. The
study found that less than half of patients worldwide consumed their
entire meal on nutritionDay, and reduced food intake during hospital-
ization is strongly associated with poor patient outcomes, regardless
of their nutrition risk status. Thus, screening for nutrition risk using
the Malnutrition Screening Tool may not identify a group of patients at
risk because of reduced intake during the hospital stay. The traditional
monitoring of nutrition risk by screening tool applications regularly
during the hospital stay should include stricter intake monitoring.
INTRODUCTION
Inadequate feeding and malnutrition are important health issues that
burden public health, economic, and social development in low- and
high-income countries.1 Insufficient nutrition intake in hospitals has
been a matter of concern in recent decades. In Europe, the Resolution
on Food and Nutritional Care in Hospitals addressed this problem
and was approved by the Council of Europe in 2003.2 In the US, the
malnutrition dialogue proceedings conducted by Avalere Health with
multiple US stakeholders advocate for effective nutrition, including
optimal food intake.3 In Latin America, this problem was addressed by
the International Declaration on the Right to Nutritional Care and the
Fight Against Malnutrition, signed in May 2019.4 This global concern
was motivated by evidence of the impact of patients’ insufficient
nutrient intake on the prevalence and degree of malnutrition and
outcomes. It has been shown that this is linked to an increase in the
rate of infections, a higher percentage of cardiac complications, and
frequency of readmissions, besides inducing poor wound healing and,
thus, a prolonged hospital stay. Moreover, suboptimal food intake has
been associated with an increased risk of dying in hospital.5 -9
Screening for nutrition risk has been acknowledged as a key step
in the nutrition care process to promote adequate food intake and
timely nutrition therapy.10,11 In the hospital, food intake history
is an element of the most widely used nutrition screening tools
(eg, the Nutritional Risk Score 2002 [NRS 2002], the Malnutrition
Screening Tool [MST], and the Malnutrition Universal Screening Tool
[MUST]).12–14 Moreover, reduced food intake has been incorporated
in the GLIM (Global Leadership Initiative on Malnutrition) etiologic cri-
teria for malnutrition diagnosis.15 The relationship of timely nutrition
screening and nutrition intervention has improved clinical outcomes
and economic burden.8 Thus, identifying insufficient nutrition intake
during hospitalization is a crucial aspect of the nutrition care process.
In response to the international call to improve nutrition care
launched by the Council of Europe Resolution, the European Society
for Clinical Nutrition and Metabolism (ESPEN) worked hand in hand
with the Medical University of Vienna to develop the nutritionDay
survey. nutritionDay is a 1-day survey with a 1-month follow-up
cross-sectional study that aims to evaluate hospitalized patients’ food
intake as well as nutrition care processes and nutrition care-related
structures. NutritionDay is a recognized and valued tool able to
provide valid nutrition-related information in a timely manner.16
The survey allows a snapshot of the unit’s nutrition care processes,
including the food intake at 1 meal, as an indicator of total food intake.
In past years, published data using the nutritionDay results have
contributed to a better understanding of the impact of suboptimal
food intake and the subsequent outcomes.17–21 Therefore, analysis of
data on food intake during nutritionDay in Colombia, Latin America,
and worldwide between 2009 and 2015 allowed us to evaluate the
impact of inadequate food intake on mortality at 30 days and on the
probability of being discharged home for in-hospital adult Colombian
patients according to their nutrition risk status. The aim of the study is
to examine selective data from the nutritionDay survey to determine
the impact of food intake during hospitalization on outcomes according
to the nutrition risk status.
JOURNAL OF PARENTERAL AND ENTERAL NUTRITION
METHODS
The nutritionDay survey
Since 2006, the nutritionDay survey, an international 1-day survey
with a 1-month follow-up cross-sectional study, has aimed to improve
knowledge and awareness on malnutrition in hospitals. As part of a
comprehensive project to improve health outcomes, the Colombian
Clinical Nutrition Association (ACNC) has been coordinating partici-
pation in nutritionDay nationally since 2010, after the participation of
1 single hospital in the country for the first time in 2009. Over 6 con-
secutive years, from 2010 to 2015, the ACNC launched a national call
to action, promoting country hospitals’ participation in nutritionDay,
still guaranteeing the anonymity of the participants’ units. The national
coordinators of the included Latin American countries have registered
all the units on the nutritionDay database (www.nutritionday.org).
All participating hospitals were trained each year on all procedures
related to this project. After data were collected manually on sheets of
paper, each hospital mailed them in by post. All data were collected in
1 place at the ACNC office and verified for accuracy by the coordinator
to ensure the quality and completeness of the information. Finally,
the data were entered into the nutritionDay database by the same
person. After analysis of the data by the nutritionDay office, the ACNC
prepared a report and communicated the national results to each
institution.
The individuals included in the study were all hospitalized adult
patients who gave their informed consent for participation according
to each country’s regulations. Patients hospitalized in intensive care
units, patients under 18 years old, and women who were pregnant or
had recently given birth were excluded.
Data collection
For this study, we used the Colombian, Latin American, and worldwide
data from 2009 to 2015. Data after 2015 were not included because
the questionnaire was modified after that.22 The data were collected
using 4 official nutritionDay questionnaires processed by voluntary
healthcare professionals and students. The first questionnaire included
information about the nutrition team and the hospital structure, and
it was completed by the nutritionDay hospital coordinator. The second
questionnaire included information about the patient, such as age,
height, weight, medical condition, comorbidities, and type of nutrition
intake. The third questionnaire, which was to be completed by the
patients themselves, comprised questions about food intake during the
survey day, including how much they had eaten of the meal: “all,” “half,”
“a quarter,” “nothing, but allowed,” or “nothing, not allowed.” Reduced
eaters are defined as those patients eating “a quarter,” “nothing, but
allowed,” and “nothing, not allowed.” Hospital outcomes were collected
30 days after the initial collection day using the fourth questionnaire.
The options of the outcome were as follows: patients could still be in
the hospital, could have been transferred to another hospital, could
have been transferred to long-term care, could have been in rehabilita-
3
tion, could have been discharged home, could have died in the hospital,
or other. The number of missing entries was also reported. The detailed
information about the questionnaires has been previously published.6
The nutrition risk is not directly recorded in nutritionDay. However,
the database contains the corresponding questions, allowing an
estimation of the MST score:14 “Have you lost weight unintentionally
within the last 3 months?” And, “If yes, by how many pounds/kilograms
did your weight decrease?” Patients were also asked to give their rea-
son for eating less, with options including “loss of appetite,” “problems
with swallowing/chewing,” “nausea,” and “other.” Exact points were
calculated and divided into categories MST 0–1 point and MST ≥ 2
points. The number of missing entries was also reported.
Statistics and analysis
Descriptive statistics are presented with median and interquartile
range (IQR), mean and standard deviation, or proportions. Statistical
analysis was done using R 3.5.1 (July 2018).
Colombian and Latin American data from 2009 to 2015 were
used to examine food intake and nutrition risk during nutritionDay.
To assess the association between food intake, discharge home, and
in-hospital mortality, a multivariate survival analysis by the Fine-Gray
model was used with Colombian data from 2010–2015. Data from
2009 were excluded because only a single hospital participated. Only
patients with reported outcomes of in-hospital mortality, discharge
home, length of stay (LOS) after nutritionDay, and previous LOS
could be used. For age adjustment, another 17 patients with missing
values had to be excluded. Overall, 6529 patients were included in the
analysis (Figure 1). Clinical units were considered as repeated factors
to account for patients’ clustering, and LOS before nutritionDay
was added to adjust for cross-sectional bias.23 Severity adjustment
was done with variables from the Patient- And Nutrition-Derived
Outcome Risk Assessment (PANDORA) score.24 PANDORA is a simple
scoring system useful in predicting 30-day in-hospital mortality of
general inpatients based on easily available demographic, disease, and
nutrition-related patient data. It was developed for use in risk strati-
fication. As the amount of meal eaten is in PANDORA, the score itself
could not be used in our analysis. Thus, relevant variables were added
to the model if applicable (variables of age, body mass index [BMI], can-
cer diagnostic, and ability to walk). For BMI, a “missing” category was
added because about 50% of values were missing. Additionally, fluid
status could not be used because it was only reported in <300 patients
(<4%). The unit specialty was only used for surgical/nonsurgical and
was not more detailed, as other specialties were underrepresented.
Ethical approval
The nutritionDay project was approved by the Ethical Committee of
the Medical University, Vienna (EK407/2005), and is amended annu-
ally. This trial was registered at clinicaltrials.gov as NCT02820246. In
Colombia, the project has also been approved annually by the Ethical
4 CARDENAS ET AL
F I G U R E 1 Flowchart describing participants in nutritionDay from 2009 to 2015 in worldwide, Latin American, and Colombian units. *Latin
America does not include Columbia. MST, Malnutrition Screening Tool
Committee of the Universidad El Bosque since 2010 (UEB 5022018)
and by hospitals when required.
RESULTS
Demographics
Colombia participated in nutritionDay over 7 years (2009–2015),
having a total of 7994 patients from 248 units. Latin America partic-
ipated with a total of 7243 patients from 337 units from Argentina,
Brazil, Chile, the Dominican Republic, Mexico, Panama, Paraguay, El
Salvador, and Uruguay. The worldwide data include 155,524 patients
from 8336 units. Figure 1 shows the flowchart describing nutritionDay
participants from 2009 to 2015 worldwide, in Latin American and
Colombian units.
The Colombian patients had a median age of 62 years (IQR, 46–75),
and 52% were male, with a mean BMI of 24.7 ± 5.3 kg/m2 . Colombian
patients’ characteristics as compared with those of Latin American and
worldwide patients from 2009 to 2015 are described in Table 1.
Nutrition intake on nutritionDay
The proportion of patients that ate “all” their hospital meal during
the nutritionDay was 45% in Colombia, 41% worldwide, and 40% in
Latin America. Twelve percent of Colombian patients reported eating
“nothing” despite being “allowed” to, and 9% reported eating “nothing”
because they were “not allowed,” for example, before an elective
surgery. Table 2 shows the reported food intake on nutritionDay in
Colombia, Latin America, and worldwide from 2009 to 2015.
Association between food intake on nutritionDay and
outcomes
For the 2006–2015 cohort, overall mortality was 3.7%, with large
variations between countries or regions. Table 3 displays the adjusted
hazard ratios (HRs) on meal intake for 6529 patients either dying in the
hospital or being discharged home. After adjustment for LOS before
nutritionDay and relevant PANDORA score variables (age, BMI, cancer
diagnosis, ability to walk), the Fine-Gray model showed that patients
who did not eat “all” the meal served on nutritionDay are at increased
risk of in-hospital death in the 30 days following nutritionDay. If the
amount of the meal eaten is “half,” the HR is 2.25 (95% CI, 1.48–3.41;
P < .001). If “a quarter,” the HR is 3.51 (95% CI, 2.34–5.28; P < .001). If
“nothing, not allowed,” the HR is 3.70 (95% CI, 2.32–5.89; P < .001). If
the patient ate “nothing, allowed,” the mortality HR rose to 5.66 (95%
CI, 3.89–8.23; P < .001).
After adjustment for LOS before nutritionDay and for the relevant
PANDORA score variables (age, BMI, cancer diagnosis, free mobility),
the Fine-Gray model showed that patients who ate “a quarter” of the
JOURNAL OF PARENTERAL AND ENTERAL NUTRITION 5

TA B L E 1 Relevant demographic data of Colombian hospitalized patients on nutritionDay 2009–2015 compared with Latin American and
worldwide hospital patients

Variable Colombia, n = 7994 Latin America, n = 7243 P-value Worldwide, n = 155,524 P-value
Age, years 62 (46–75) 58 (42–70) <.001 a
66 (52–78) <.001a
Sex, female 3839 (48%) 3291 (45%) .008b 76,849 (49%) .001b
Weight (kg) 64.9 ± 14.3 67 ± 16.8 <.001c 70.8 ± 19.1 <.001c
Height (m) 162.3 ± 9.7 163.5 ± 11 <.001 c
165.7 ± 11.5 <.001c
BMI 24.7 ± 5.3 25 ± 5.5 .005c 25.6 ± 6.1 <.001c
Any ICU stay before nutritionDay 1222 (15%) 847 (12%) <.001 b
16,817 (11%) <.001b

Note: Data are shown as median (interquartile range), n (%), or mean ± standard deviation.
Abbreviations: BMI, body mass index; ICU, intensive care unit.
a
Wilcox rank test.
χ test.
b 2
c
t-test.

TA B L E 2 Food intake on nutritionDay in Colombia, Latin America, and worldwide 2009–2015

Amount of meal eaten Colombia Latin America P-value Worldwide P-value

All 3400 (43%) 2635 (36%) <.001a 57,724 (37%) <.001a
Half 1664 (21%) 1711 (24%) 40,313 (26%)
Quarter 889 (11%) 1174 (16%) 20,555 (13%)
Nothing, allowed 885 (11%) 471 (7%) 9151 (6%)
Nothing, not allowed 652 (8%) 528 (7%) 11,857 (8%)
Missing 504 (6%) 724 (10%) 15,924 (10%)
a
P-value from χ2 test.

meal or less had a lower probability of being discharged. If the amount
of the meal eaten is “half,” the HR is 1.00 (95% CI, 0.95–1.06; P = .946);
if “a quarter,” the HR is 0.85 (95% CI, 0.78–0.94; P = .001); if “nothing,
allowed,” the HR is 0.77 (95% CI, 0.68–0.86; P < .001); and if “nothing,
not allowed,” the HR is 0.82 (95% CI, 0.74–0.91; P < .001).
Food intake, nutrition risk, and outcomes
Thirty-eight percent of the sample had an MST score of ≥2. The
number of reduced eaters (quarter; nothing, allowed; nothing, not
allowed) is larger in the MST 0–1 group (n = 2078, 30%) than in the

TA B L E 3 Estimated HRs for dying in the hospital or being discharged home according to the amount of meal eaten on nutritionDay based on
multiple Fine-Gray modela (Colombian patients N = 6529)

Outcome Level of meal eaten HR (95% CI) P-value

b
Dying in the hospital All Reference
Half 2.25 (1.48–3.41) <.001
Quarter 3.51 (2.34–5.28) <.001
Nothing, allowed 5.66 (3.89–8.23) <.001
Nothing, not allowed 3.70 (2.32–5.89) <.001
c
Being discharged home All Reference
Half 1.00 (0.95–1.06) .946
Quarter 0.85 (0.78–0.94) <.001
Nothing, allowed 0.77 (0.68–0.86) <.001
Nothing, not allowed 0.82 (0.74–0.91) <.001

Abbreviation: HR, hazard ratio.

a
Adjusted for length of stay before nutritionDay and relevant PANDORA (Patient- And Nutrition-Derived Outcome Risk Assessment) score variables.
b
HR > 1 indicates higher mortality risk..
c
HR < 1 indicates delayed discharge.
6 CARDENAS ET AL

FIGURE 2 Malnutrition Screening Tool (MST) score per amount eaten

TA B L E 4 Multiple Fine-Gray model for dying in the hospital according to MST score (Colombian patients n = 6478)

MST 0–1 MST ≥ 2

Variable Level a
HR (95% CI) P-value HRa (95% CI) P-value
Meal eaten All Reference Reference
Half 0.90 (0.4–2.04) .795 2.81 (1.58–4.98) <.001
Quarter 2.80 (1.34–5.87) .006 3.30 (1.87–5.85) <.001
Nothing, allowed 6.48 (3.53–11.87) <.001 4.26 (2.46–7.37) <.001
Nothing, not allowed 3.06 (1.35–6.96) .008 3.61 (1.87–6.98) <.001
LOS before nutritionDay Per day 1.01 (1.00–1.02) .051 1.01 (1.00–1.01) .251
Age group, years <40 0.45 (0.16–1.28) .135 0.47 (0.23–0.93) .032
40–49 0.80 (0.29–2.22) .668 0.57 (0.28–1.18) .129
50–59 2.03 (1.06–3.88) .034 1.15 (0.67–1.95) .614
60–69 Reference Reference
70–79 0.98 (0.51–1.90) .954 1.57 (1.00–2.48) .052
80–89 1.42 (0.68–2.95) .349 1.44 (0.86–2.42) .165
≥90 1.70 (0.54–5.30) .364 2.07 (0.94–4.57) .072
BMI group <18.5 1.01 (0.37–2.76) .982 0.96 (0.52–1.78) .900
18.5–24.9 Reference Reference
25.0–29.9 0.61 (0.29–1.29) .196 0.67 (0.36–1.26) .216
≥30.0 0.40 (0.12–1.41) .154 0.57 (0.24–1.37) .208
Missing 0.77 (0.48–1.23) .268 0.88 (0.60–1.29) .520
Cancer Yes 3.90 (2.19–6.93) <.001 2.34 (1.52–3.61) <.001
Able to walk alone Yes Reference Reference
With assistance 2.48 (1.47–4.19) <.001 1.58 (1.05–2.39) .030
No 5.62 (3.33–9.48) <.001 1.97 (1.26–3.07) .003
Specialty Surgery 0.45 (0.27–0.74) .002 0.69 (0.48–0.99) .043

Abbreviations: BMI, body mass index; HR, hazard ratio; LOS, length of stay; MST, Malnutrition Screening Tool.
a
HR > 1 indicates higher mortality risk.

MST ≥ 2 group (n = 1737, 25%) (P < .001). Figure 2 shows the MST
score per amount eaten for all patients.
Tables 4 and 5 display the HR on meal intake for 6478 patients either
dying in the hospital or being discharged home, analyzing the two MST
score groups individually. After adjustment for LOS before nutrition-
Day and relevant PANDORA score variables (age, BMI, cancer diag-
nosis, ability to walk), the Fine-Gray model showed that patients with
reduced intake on nutritionDay are at an increased risk of in-hospital
death in the 30 days following nutritionDay and a longer stay in the hos-
pital despite the MST score group. In the Fine-Gray model on dying and
being discharged home, cancer diagnosis and reduced mobility are also
risk factors independent of the MST score.
JOURNAL OF PARENTERAL AND ENTERAL NUTRITION 7

TA B L E 5 Multiple Fine-Gray model for being discharged home according to MST score (Colombian patients n = 6478)

MST 0–1 MST ≥ 2

Variable Level HRa (95% CI) P-value HRa (95% CI) P-value
Meal eaten All Reference Reference
Half 1.06 (0.98–1.14) .126 0.94 (0.84–1.06) .315
Quarter 1.03 (0.91–1.16) .636 0.74 (0.64–0.85) <.001
Nothing, allowed 0.81 (0.69–0.94) .007 0.74 (0.63–0.86) <.001
Nothing, not allowed 0.85 (0.75–0.96) .008 0.78 (0.66–0.93) .006
LOS before nutritionDay Per day 0.99 (0.98–0.99) <.001 0.99 (0.99–0.99) <.001
Age group, years <40 1.12 (0.99–1.26) .069 1.17 (1.01–1.35) .032
40–49 1.11 (0.98–1.26) .092 1.09 (0.94–1.26) .277
50–59 0.94 (0.84–1.05) .300 1.01 (0.86–1.18) .932
60–69 Reference Reference
70–79 1.05 (0.94–1.18) .385 1.04 (0.91–1.2) .545
80–89 1.04 (0.91–1.19) .573 1.16 (0.97–1.39) .110
≥90 1.15 (0.86–1.54) .353 1.01 (0.69–1.49) .948
BMI group <18.5 0.90 (0.74–1.11) .333 1.00 (0.82–1.23) .989
18.5–24.9 Reference Reference
25.0–29.9 1.03 (0.90–1.18) .681 1.06 (0.91–1.25) .436
≥30.0 1.21 (1.06–1.37) .003 1.16 (0.93–1.44) .191
Missing 1.28 (1.09–1.50) .003 1.18 (1.00–1.39) .046
Cancer Yes 0.94 (0.78–1.13) .490 0.9 (0.72–1.13) .385
Able to walk alone Yes Reference Reference
With assistance 0.83 (0.77–0.91) <.001 0.78 (0.70–0.87) <.001
No 0.57 (0.5–0.66) <.001 0.70 (0.61–0.80) <.001
Specialty Surgery 1.10 (0.92–1.32) .290 1.02 (0.87–1.19) .850

Abbreviations: BMI, body mass index; HR, hazard ratio; LOS, length of stay; MST, Malnutrition Screening Tool.
a
HR < 1 indicates delayed discharge.

DISCUSSION
Our study aimed to evaluate the relationship between inadequate
food intake and mortality and the risk of being discharged home of
in-hospital adult patients according to their nutrition risk status. The
nutritionDay database analysis for the period of 2009–2015 showed
that more than half of hospitalized patients did not eat “all” of the
meal on nutritionDay and that reduced food intake is strongly asso-
ciated with poor patient outcome, independent of the nutrition risk
status. As emerged in a recent nutritionDay published analysis, daily
monitoring of patients’ nutrition intake as part of the routine nutri-
tion care process is applied in <50% of patients regardless of whether
they have eaten “all” or “nothing” on nutritionDay.25 Thus, it appears
evident that the promotion of hospital food intake monitoring should
figure among the priorities within the unit’s routine nutrition care
process.
It has been shown that hospital food intake varied substantially
across the world.8 Our results are consistent with the previously
reported prevalence of between 50% and 60% reduced meal intake.8
We found that in Colombia, Latin America, and worldwide, less than
half of the patients consume their full meal (45%, 40%, and 41%,
respectively). These results are similar to the 46% reported in an
analysis of European hospital nutritionDay data6 and higher than the
37% found in the US population.18
In this study, we did not explore the reasons for reduced meal
intake. However, the main factors associated with reduced meal intake
in hospitalized patients and the differences between geographical
regions were analyzed in 2 previous studies using worldwide data
from nutritionDay.6,26 It was found that modifiable and nonmodifiable
reasons can explain reduced meal intake in hospitalized patients, and
they are associated with patients’ condition (clinical, physical) and
factors related to the quality of hospital food.
We analyzed the association between food intake and outcomes
(mortality and discharge home) after adjustment for length bias
and relevant PANDORA score variables. We found that Colombian
patients who ate “nothing, but allowed to eat” had a 23% lower
probability of being discharged home and a risk of mortality that
was almost 6 times higher than that of patients who had eaten their
entire meal. The Colombian results are similar to those observed in
the US population, where patients who did not eat their full meal
8 CARDENAS ET AL
on nutritionDay, despite having permission to do so, had a mortality
rate that was 6 times higher.18 However, there is a lower association
with in-hospital mortality in the European population, where the
corresponding HR for mortality is almost 3 times higher. The patients
who ate “a quarter” of their meal on nutritionDay showed a mortality
risk 3.5 times higher, similar to the US population and higher than the
corresponding mortality risk in the European population.6
Traditionally, screening tools are applied at admission and repeat-
edly during hospitalization to identify patients at risk and, therefore,
those who can benefit from nutrition therapy. Importantly, these tools
do not include current food intake, and although weight loss is often
a criterion, it is difficult to assess in hospitalized patients with fluid
shift.12,13 For example, the NRS 2002 includes the criterion “reduced
dietary intake in the last week”; the MST asks, “Have you been eating
poorly because of a decreased appetite?”; and the MUST includes
that “there is likely to be no nutrition intake for >5 days.” None of the
currently used screening tools include criteria for current food intake.
Thus, in a multivariate analysis, we aimed to explore whether the
impact of reduced food intake on outcomes was different according
to the nutrition risk status. We showed that reduced eaters, indepen-
dently from their nutrition risk status, had a higher risk of dying in the
hospital and had a lower probability of being discharged home. Thus,
it is possible that screening for nutrition risk using the MST does not
identify a group of patients at risk owing to reduced intake while in
the hospital. The traditional monitoring of nutrition risk by applying
screening tools weekly during hospital stays should contain stricter
monitoring for current food intake.
Our study shows that reduced mobility and cancer diagnosis are
also risk factors for poor outcomes, regardless of the MST score.
Contrary to actual food intake, cancer diagnosis and mobility are
more frequently considered among the nutrition screening tools’
criteria. Indeed, a cancer diagnosis is considered in the “disease”
criteria, and mobility is considered in some screening tools, such as
the Mini-Nutritional Assessment (MNA) and NRS 2002, but not in the
MST. Thus, the MST may also miss a group of patients at risk owing to
reduced mobility.
The major strength of the present study is the large number of
patients included. Moreover, the voluntary participation of Colombian
multidisciplinary professionals in nutritionDay has a huge impact on
the awareness and promotion of hospital nutrition care. However,
the study has limitations. First, participating units could not be rep-
resentative of Colombian hospitals. The ACNC promotes recruitment
voluntarily and through dietitians and clinical nutrition specialists. This
recruitment could result in the participation of units with a particular
interest in nutrition care. Second, nutritionDay measures the quantity
of only 1 meal consumed, which may not represent all daily intake. It
is necessary to specify that it has been previously validated as a good
indicator for total food intake, and it has been shown that the effect
on outcome was similar for all 3 meals.8 Determining total food intake
is a matter for specialized dietetic personnel and will not be possible
during nutritionDay.15
Third, selection bias is a frequent limitation in cross-sectional
studies. The adjustment for length bias in cross-sectional studies is
thus necessary to get appropriate estimates and to avoid overrepre-
sentation of patients who are more severely ill, older, or malnourished;
have more comorbidities, necessitating more complex, repeated
interventions; or have interventions that limit mobility and autonomy,
such as surgical interventions.23
PRACTICAL IMPLICATIONS
Colombia promoted and signed the International Declaration on the
Right to Nutritional Care and the Fight Against Malnutrition, which
recognizes nutrition care as a human right,4 on May 3, 2019. The
Cartagena Declaration implies, for the signatory parties, an important
moral commitment to ensure that all patients benefit from the nutri-
tion care process. Like any other human right, indicators are essential
in implementing standards and commitments to support policy formu-
lation and impact assessment and transparency.27 The proportion of
patients with optimal food intake in hospitals and the proportion of
patients with suboptimal feeding or at nutrition risk or receiving nutri-
tion therapy have been proposed as outcome indicators for this human
right.28 Thus, the present study’s results on food intake in hospitals
will help define the indicators of the implementation of the human
right to nutrition care. Moreover, this human right could effectively be
monitored through the assessment of food intake adequacy. Usually,
food intake monitoring is a task for the bedside nurse, who, within in
the framework of an interdisciplinary approach, should be encouraged
to systematically monitor food intake on a meal-by-meal basis.
Efforts must focus on implementing public policy and effective
legislation and programs addressing optimal nutrition care and
disease-related malnutrition. Improving knowledge of the impact of
food intake on outcomes could support these efforts. In the future,
using these indicators as goals and benchmarks will help in the
design, implementation, monitoring, and evaluation of public health
interventions in clinical nutrition.
CONCLUSIONS
Inadequate food intake is frequent in hospitalized patients, and
patients not having eaten a full meal in the hospital have higher 30-day
mortality rates and are less likely to be discharged home, regardless
of their nutrition risk status. Monitoring food intake as part of optimal
nutrition care must be promoted. The participation of Colombia
and other Latin American countries in the nutritionDay survey is an
opportunity to increase knowledge and awareness of this issue and
identify national variations in patients’ food intake.
ACKNOWLEDGMENTS
The authors acknowledge A. Correa RD, C. P. Figueroa RD, C. Posada
RD, Y. Cuellar RD, Y. Rodriguez RD, M. C. Gomez RD, S. Zuluaga RD, D.
Garcia RD, N. Rivera RD, N. Martinez RD, N. Quevedo RD, A. Navas MD,
L. Osorio RD, A. Meneses RD, R. L. Diaz RD, R. Sarmiento RD, L. Torres
RD, K. Espinosa RD, I. Trejus RD, E. L. Horta RD, M. Acevedo RD, M.
JOURNAL OF PARENTERAL AND ENTERAL NUTRITION
Reyes RD, E. Y. Porras RD, K. G. Sarmiento RD, P. Villareal RD, J. Martin
RD, R. C. Santos RD, E. Moncada RD, M. Muñoz RD, R. Puerto RD, A. L.
Ripol RD, C. Preciado RD, J. Barbosa RD, M. R. Alba RD, L. Rodriguez
RD, E. Ossa RD, N. Perez RD, E. Gomez RD, I. Poveda RD, G. Gonzalez
RD, K. Tovar RS, M. T. Viloria RD, D. Pareja RD, S. Gamboa RD, S. Corre-
dor RD, C. Vacca RD, L. Montoya RD, L. M. Velez RD, E. Cabarcas RD, A.
Contreras RD, A. Coral RD, B. Beltran RD, Y. Correa RD, H. del Rio RD,
C. E. Espinosa RD, G. Lopez RD, M. Torrente RD, S. Jaimes RD, E. Castillo
RD, C. Medina RD, A. Veloza RD, G. Chavez RD, P. Valencia RD, N. Perez
RD, K. Ariza RD, K. Sarmiento RD, D. Prieto RD, A. Rivera RD, D. Trejus
RD, D. Gonzalez RD, M. E. Varela RD, S. Alfaro RD, M. Jimenez RD, A.
Luna RD, D. Flautero RD, P. Savino RD, A. Amaya RD, and C. Carvajal RD.
The authors would like to give the aforementioned special recognition
for their dedicated efforts and commitment to nutritionDay world-
wide. The nutritionDay study in Colombia has received support from
Abbott.
CONFLICT OF INTERESTS
Charles Bermúdez speaker for Abbott, Baxter, B. Braun, Takeda,
Amarey, and Fresenius. Pérez is speaker for Abbott, Baxter, B. Braun,
and Amarey. Diana Cardenas has been a speaker for Baxter, Fresenius,
and Abbott. Claudia Patricia Contreras is a speaker for Abbott Colom-
bia, and Gabriel Gómez is the Regional Medical Director for Abbott
Nutrition. Michael Hiesmayr. is member of advisory boards for Nestle
and a speaker at congresses for Abbott, Nestle, Fresenius, and Baxter.
Gustavo Diaz, Lilia Yadira Cortés, Olga Lucía Pinzón-Espitia, Maria
Cristina González, Romain Fantin, José Gutierrez, Isabella Sulz, and
Silvia Tarantino do not have any conflicts of interest.
AUTHOR CONTRIBUTIONS
Diana Cardenas, Gustavo Diaz, Isabella Sulz, Silvia Tarantino, and
Michael Hiesmayr equally contributed to the conception and design of
the research; Angélica Pérez, Maria Cristina González, Gustavo Diaz,
Lilia Yadira Cortés, Claudia Patricia Contreras, Gabriel Gómez, José
Gutierrez, and Olga Lucía Pinzón-Espitia contributed to the acqui-
sition and analysis of the data; Michael Hiesmayr, Diana Cardenas,
Romain Fantin, Charles Bermúdez, and Isabella Sulz contributed to the
interpretation of the data; Diana Cardenas drafted the manuscript. All
authors critically revised the manuscript, agree to be fully account-
able for ensuring the integrity and accuracy of the work, and read and
approved the final manuscript.
ORCID
Diana Cardenas MD, PhD https://orcid.org/0000-0002-0709-0307
Charles Bermúdez MD https://orcid.org/0000-0001-5401-019X
Gustavo Diaz RD, MSc https://orcid.org/0000-0002-9216-7873
Olga Lucía Pinzón-Espitia RD, PhD https://orcid.org/0000-0002-
9827-2244
Maria Cristina González MD, PhD https://orcid.org/0000-0002-
3901-8182
Michael Hiesmayr MD, PhD https://orcid.org/0000-0003-4091-
4424
9
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How to cite this article: Cardenas D., Bermúdez, C., Pérez, A.
et al. Are traditional screening tools adequate for monitoring
the nutrition risk of in-hospital patients? An analysis of the
nutritionDay database. Journal of Parenteral and Enteral
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