Nutrition 124 (2024) 112429

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Nutrition
journal homepage: www.nutritionjrnl.com

Applied nutritional investigation

Should handgrip strength be considered when choosing the

administration mode of oral nutritional supplements in geriatric
patients? A secondary analysis of the MEDPass Trial
Katja Uhlmann M.Sc. a,*, Emilie Reber Ph.D. b, Katja A. Schonenberger Ph.D. b,c, Zeno Stanga b,
Silvia Kurmann M.Sc. a
a
Health Division, Nutrition and Dietetics, Bern University of Applied Sciences, Bern, Switzerland
b
Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
c
Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland

A R T I C L E I N F O A B S T R A C T

Article History: Objective: It is important to individualize nutrition therapy and to identify whether certain patient groups
Received 14 August 2023 benefit from a specific intervention such as oral nutritional supplements (ONS). This study investigated
Received in revised form 9 November 2023 whether patients with weak handgrip strength (HGS) benefit better from ONS administration in the Medica-
Accepted 17 March 2024
tion Pass Nutritional Supplement Program (MEDPass) mode regarding the individual coverage of energy and
protein requirements throughout their hospitalization.
Keywords:
Methods: A secondary analysis of the intention-to-treat data set of the randomized controlled MEDPass trial
Handgrip strength
was conducted. Weak HGS was defined as <27 kg for men and <16 kg for women. Linear mixed-effect mod-
MEDPass
Oral nutritional supplements
els adjusted for the stratification factors energy density of ONS and nutritional risk screening 2002 score
Energy were used to address the aim of the study.
Malnutrition Results: We included 188 participants. Energy and protein coverage did not differ between the patients with
weak or normal HGS depending on ONS administration mode (P = 0.084, P = 0.108). Patients with weak HGS
and MEDPass administration mode tended to have the lowest energy and protein coverage (estimated mean,
77.2%; 95% confidence interval [CI], 69.3% 85% and estimated mean, 95.1%; 95% CI, 85.3% 105%, respec-
tively). Patients with weak HGS and conventional ONS administration had the highest energy and protein
coverage (estimated mean, 90%; 95% CI, 82.8% 97.2% and estimated mean, 110.2%; 95% CI, 101.3% 119%,
respectively).
Conclusion: No clear recommendations regarding the mode of ONS administration depending on HGS can be
made. In clinical practice, appetite and satiety in patients with weak HGS should be monitored, and the ONS
administration mode should be adjusted accordingly.
© 2024 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/)

Introduction Identifying patients at risk for DRM and providing individualized

nutrition therapy is crucial to improving patient outcomes [3 7].
Disease-related malnutrition (DRM) is prevalent in 20% to 60% Oral nutritional supplements (ONS) as a therapy in patients at
of geriatric and medical patients at hospital admission [1 3]. risk for DRM have been shown to improve nutritional status and
patient outcomes such as mortality, hospital length of stay (LOS),
and readmission rate [5,8]. ONS administration in small volumes
The MEDPass Trial was supported by an investigator-initiated study grant from
Abbott Laboratories, Columbus, OH, USA (grant no. ANSW1701). Furthermore, the
(50 120 mL) with medication rounds leads to better compliance
MEDPass Trial was funded by Inselspital University Hospital, Bern, Switzerland, with ONS prescription [9]. This administration mode is called Med-
Bern University of Applied Sciences, Health Department, Bern, Switzerland and the ication Pass Nutritional Supplement Program (MEDPass) [9]. A
Division of Clinical Pharmacy and Epidemiology, University of Basel, CH (third-party recently published randomized controlled trial (RCT) on the MED-
grant no. FO119900). The trial research team had full decision-making authority
Pass versus conventional administration mode of ONS in medical
and responsibility for the investigator-initiated trial and the study course.
*Corresponding author: Tel.: +41 31 848 45 74; Fax: +41 31 848 33 01. and geriatric inpatients found no difference between the adminis-
E-mail address: [email protected] (K. Uhlmann). tration modes regarding coverage of individual energy and protein

https://doi.org/10.1016/j.nut.2024.112429
0899-9007/© 2024 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
2 K. Uhlmann et al. / Nutrition 124 (2024) 112429

requirements as well as handgrip strength (HGS) [10]. Neverthe- daily energy requirements based on guidelines and dependent on age and BMI
less, to individualize nutrition therapy, it is relevant to identify [5,7]. Daily individual protein requirements were calculated with 1 g/kg body
weight or 0.8 g/kg body weight in case of chronic kidney disease with an estimated
whether certain patient groups benefit better from a specific mode
glomerular filtration rate of <30 mL/min/1.73 m2 without renal replacement ther-
of ONS administration, and subgroup analyses can support these apy [22,23]. Registered dietitians did individual calculations on the requirements
therapeutic decisions [11,12]. of other macronutrients.
HGS may be a suitable parameter to predict the benefit of nutri- ONS intake was reported (accuracy 5 mL) in the electronic health record, and
food service staff reported the amount consumed of each meal component (0, 25,
tion therapy as the correlation between weak HGS and reduced
50, 75, and 100%) on the menu card. Patients were interviewed about snacks and
nutritional and functional status, increased mortality, complication drinks between main meals to assess intake. Energy and protein intake from food
rates, and hospital LOS is well documented [13 19]. Furthermore, was calculated using the LogiMen version 5.4 electronic menu system
it is a simple bedside measurement for muscle strength, which can (Kretschmer-Keller Leonberg, Germany,) which contains data on the energy and
be used in clinical practice easily [19]. Kaegi-Braun, et al. found a protein content of the hospital’s meals and snacks. The nutritional software nut.s
version 1.32.74 (dato Denkwerkzeuge, Vienna, Austria) was used for food and bev-
reduction in 30-d mortality in patients with weak HGS versus in erages not listed in LogiMen. Patients’ energy and protein coverage were calcu-
patients with higher HGS when receiving nutrition therapy [20]. lated based on their mean daily energy and protein intake from ONS and food
Whether patients with weak HGS benefit better from ONS admin- throughout the hospitalization and their energy and protein requirements.
istration in the MEDPass mode is currently unknown, and the sub- Study visits to assess HGS and appetite were conducted at study admission
(day 1) and every 7 d (§2 d) until hospital discharge or up to a maximum of 30 d
ject of this study focuses on individual coverage of energy and after admission [21]. Appetite was assessed with a visual analog scale (VAS; 0 10
protein requirements throughout hospitalization. cm). HGS was measured using a JAMAR Hydraulic Hand Dynamometer (Patterson
Medical, Warrenville, IL, USA) [21]. The measurements were conducted according
Materials and method to the American Society of Hand Therapists guideline [24], with a slight adaption
of the position of the elbow on a stable surface. The patients were seated with the
Design elbow supported on a stable surface (e.g., a table) and bent at 90 degrees. The mea-
surement was conducted with the dominant hand, if possible. Three measure-
This is a quantitative secondary analysis of the open-label MEDPass RCT, ments were conducted per study visit, with a 30s break between measurements.
which was registered on clinicaltrials.gov under NCT03761680. Detailed informa- The highest value was recorded (precision 0.5 kg).
tion on the trial’s methods is described elsewhere [10,21].
Statistical analysis
Population and recruitment
The MEDPass Trial was powered at 80% for the primary outcome of individual
From November 2018 to November 2022, medical and geriatric inpatients at energy coverage. The intention-to-treat data set from the MEDPass trial was used
the Department of General Internal Medicine and the Department of Geriatrics in for this secondary analysis [10]. Patients were included in this secondary analysis
the Tiefenau facility of the Bern University Hospital were checked for eligibility. if they had an HGS measurement on day 1 according to protocol and if total daily
Patients >18 y of age with a nutritional risk screening 2002 (NRS 2002) total score energy and protein intake were measured. Patients without ONS prescriptions
of
3 points, an expected minimum hospital LOS of 3 d after NRS according to the were excluded. Weak HGS was defined as <27 kg for men and <16 kg for women
attending medical doctor, and the ability and willingness to provide informed con- [25].
sent were included. Patients who were initially admitted to the critical care unit, To describe the study population, absolute and relative frequencies for the two
<7 d post-surgery, admitted with or scheduled for supplemental/total enteral or groups, weak and normal HGS at day 1, were used for categorical variables, and
parenteral nutrition, or in a terminal condition were excluded. Further exclusion mean and SDs for normally distributed continuous variables. The median and
criteria were dysphagia with the inability to swallow liquids, Mini Mental state interquartile range (IQR) were calculated for continuous variables with abnormal
<16 points, or patients with cystic fibrosis, short bowel syndrome, gastric bypass, distribution [26]. Normal distribution was analyzed visually with histograms. To
acute pancreatitis, acute liver failure, and anorexia nervosa. test for differences in baseline characteristics, the x2 test was used for categorical
variables when assumptions were met (<20% of the absolute frequencies in the
Randomization and intervention contingency table were under 5); otherwise, Fisher’s exact test was used [27]. An
unpaired Student’s t test was used for normally distributed continuous variables,
Patients were randomized according to the stratification factors NRS 2002 total and the Mann Whitney U test was used for abnormally distributed continuous
score and ONS energy density using the Research Electronic Data Capture version variables.
9.1.15 data management program (Vanderbilt University, Nashville, TN, USA). Ran- Energy and protein coverage depending on weak and normal HGS at day 1 was
domization for the NRS 2002 total score was defined as NRS 3, NRS 4, or NRS 5 7 to investigated with linear regression models adjusted for ONS density and NRS 2002
prevent statistical differences regarding the severity of nutritional risk. The NRS total score stratification factors. Furthermore, the estimated means for the sub-
2002 total score includes energy coverage, disease severity, body mass index (BMI), groups were calculated based on these models. To further investigate this poten-
and age as probable confounding factors. Furthermore, the randomization was strat- tial underlying reason for different energy and protein coverages, the course of
ified for the energy density of the prescribed ONS (1.5 or 2 kcal/mL). appetite between weak and normal HGS within the study group and adjusted for
In the MEDPass group, patients received 50 mL of ONS four times daily with ONS density and NRS 2002 was analyzed with a linear mixed model. The signifi-
medication rounds. Medication rounds were timed before breakfast, lunch, dinner, cance level was set at a P < 0.05. For the statistical analysis, the software R version
and about 22:00 h. 1.4.1106 (RStudio, PBC) [28] and the following R-packages were used: ggpubr
ONS administration in the control group was conventional, meaning patients [29], stargazer [30], car [31] emmeans [32], lmerTest [33], and modelbased [34].
received one to four bottles of ONS daily between the main meals or after dinner.
ONS from different manufacturers (Abbott Nutrition, Fresenius Kabi, Nestle
Health Ethical considerations
Science) were prescribed.
The MEDPass study was conducted according to the principles of the World
Outcomes Medical Association [35], ICH-GCP guidelines [36,37], or ISO 14155 norm [38] and
according to the Swiss Federal Act on Research involving Human Beings [39,40].
The patients’ energy and protein requirements were calculated based on The Cantonal Ethics Committee Bern, Switzerland, approved the study protocol.
actual body weight at study admission. Table 1 lists the formulas for calculating

Results
Table 1
Calculation of daily energy requirements based on actual BW at study admission
Study population
and depending on age and BMI

Age, y BMI <18.5 kg/m2 BMI
18.5 kg/m2 For the subgroup analysis of HGS at day 1, 188 of 204 partici-
<65 30 kcal/kg BW 27 kcal/kg BW pants were included. Sixteen participants were excluded for the

65 32 kcal/kg BW 30 kcal/kg BW following reasons: no ONS prescription (n = 1 control group), no
BMI, body mass index; BW, body weight energy and protein intake records (n = 1 MEDPass group), and
Adapted from Gomes et al. [5], Volkert et al. [7], Bauer et al. [22], and KDOQI [23]. missing or incorrect HGS measurement at day 1 (n = 7 control
 K. Uhlmann et al. / Nutrition 124 (2024) 112429 3

Table 2 between patients with weak and normal HGS regarding the above-
Baseline characteristics of patients by weak and normal HGS mentioned parameters (P > 0.05). The number of not assessed
HGS meals was higher in patients with weak HGS (n = 33) compared
with patients with normal HGS (n = 10; P < 0.01). Additional data
Parameters Weak (n = 96) Normal (n = 92)
on study procedures are shown in Supplementary Table 1.
Sociodemographic
Women, n (%) 50 (52) 44 (48) Energy and protein coverage
Age, y, mean § SD 84 § 7 80 § 6
Geriatric, n (%) 91 (95) 89 (97)
Anthropometrics mean § SD Table 3 shows the estimated energy and protein coverage
Body weight, kg 65.7 § 15 70.3 § 14.6 means per the linear regression model. Patients with weak HGS
Body mass index, kg/m2 23.8 § 4.5 24.7 § 4.6 and the MEDPass administration mode had the lowest estimated
Requirement, mean § SD
means for energy and protein coverage at 77.2% (95% confidence
Energy requirement, kcal 2012 § 450 2149 § 440
Protein requirement, g 67 § 16 71 § 15 interval [CI], 69.3% 85%) and 95.1% (95% CI, 85.3% 105%), respec-
Nutritional risk, n (%) tively. Patients with weak HGS and conventional ONS administra-
NRS 3 26 (27) 35 (38) tion had the highest energy and protein coverage at 90% (95% CI,
NRS 4 46 (48) 36 (39) 82.8% 97.2%) and 110.2% (95% CI, 101.3% 119%). These differen-
NRS 5-7 24 (25) 21 (23)
Nutritional status subscore 0 6 (6) 6 (7)
ces were not significant for energy coverage (P = 0.084) or protein
Nutritional status subscore 1 40 (42) 50 (54) coverage (P = 0.108).
Nutritional status subscore 2 40 (42) 27 (29)
Nutritional status subscore 3 10 (10) 9 (10) Course of appetite
HGS at day 1, mean § SD
Women, kg 12 § 3 20 § 3
Men, kg 19 § 6 33 § 5 There was no difference in the appetite course in patients with
ONS energy density, n (%) weak and normal HGS regarding the ONS administration mode
1.5 kcal/mL 51 (53) 48 (52) (P = 0.397). Overall, the appetite improved over 2 wk (P = 0.046).
2 kcal/mL 45 (47) 44 (48)
Independent of the ONS administration mode, patients with nor-
Disease category, n (%)
Gastrointestinal diseases 10 (10) 8 (9) mal HGS had a higher appetite than those with weak HGS, but the
Infectious diseases 24 (25) 17 (18) difference was not significant (P = 0.068) (Fig. 1).
Cardiovascular diseases 25 (26) 16 (17)
Neurologic diseases 6 (6) 7 (8)
Discussion
Oncologic diseases 4 (4) 8 (9)
Other diseases 27 (28) 36 (39)
Patients with weak HGS and conventional ONS administration
HGS, handgrip strength; NRS, nutritional risk screening 2002; ONS, oral nutritional
supplementation.
tended to have higher energy and protein coverage than those
with weak HGS and the MEDPass administration mode. However,
there were no significant differences in energy and protein cover-
group and n = 7 MEDPass group). Table 2 presents the baseline age in patients with weak versus normal HGS with MEDPass and
characteristics of patients with weak and normal HGS. conventional ONS administration. Overall, the energy and protein
Patients included were between 67 and 98 y of age. Patients coverage in the main study was high in both ONS administration
with weak HGS were significantly older (84 § 7 y) than patients modes, and an effect of unblinded patients could influence the
with normal HGS (80 § 6 y; P < 0.001). Sex was balanced with 52% energy and protein intake during the study [10].
women in the weak and 48% in the normal HGS groups. Most As a possible reason for the tendency of lower energy and pro-
patients were hospitalized in the geriatric clinic in the weak and tein coverage in patients with weak HGS, the effect on the appetite
normal HGS groups (95% and 97%, respectively). of the MEDPass mode, resulting in a lower intake of energy and
protein at main meals, should be considered. The possible influ-
Study procedures ence of ONS in general and depending on the administration mode
on satiety and appetite has been discussed in previous studies
The mean (SD) duration of ONS prescription for patients with [41 43]. Patients generally classified ONS as a food rather than
weak and normal HGS was 8.9 (4.5) and 8.3 (3.6) d, respectively. medicine, and they felt saturated after ONS intake [42]. Nursing
The median (IQR) ONS intake was 180 mL/d (34 mL/d) in patients staff perceived ONS administrated in the MEDPass mode was con-
with weak HGS and 175 mL/d (30 mL/d) in patients with normal sumed more easily by patients because of the smaller volume and
HGS. Mean (SD) duration of food intake monitoring was 9.4 (4.4) d the patients’ perception that ONS is a medicine [41]. However,
in patients with weak HGS and 8.5 (3.5) d in patients with normal medication rounds usually happen before meals, so patients may
HGS. There was no significant difference in study procedures feel satiated from the ONS and exhibit lower appetite [41].

Table 3
Estimated means and 95% CI for energy and protein coverage (% of individual requirement) as per linear regression model adjusted for ONS energy density and NRS 2002.

HGS

Weak Normal

MEDPass (n = 43) Control (n = 53) MEDPass (n = 49) Control (n = 43)

Coverage, %, mean (95% CI)

Energy 77.2 (69.3 85) 90 (82.8 97.2) 87.3 (79.9 94.8) 82.4 (74.6 90.3)
Protein 95.1 (85.3 105) 110.2 (101.3 119) 105.7 (96.5 115) 99.5 (89.8 109)
HGS, handgrip strength; NRS, nutritional risk screening 2002; ONS, oral nutritional supplementation
4 K. Uhlmann et al. / Nutrition 124 (2024) 112429

Fig. 1. Course of appetite in patients with weak and normal handgrip strength regarding oral nutritional supplement administration mode, adjusted for nutritional risk
screening 2002 and oral nutritional supplement energy density.
HGS, handgrip strength, ONS, oral nutritional supplement.

Conventional ONS administration allows for an individualized investigating the ability of HGS to identify patients who will bene-
administration of ONS in terms of time and volume. fit better from nutrition therapy or a specific ONS administration
To our knowledge, the effect of ONS administration in MEDPass mode. Based on the results of this subgroup analysis, no clear rec-
mode on appetite is scarcely investigated. The course of appetite ommendations on ONS administration mode can be made for
was assessed in the MEDPass trial, and no difference between patients concerning their HGS. However, a possible negative effect
patients in the MEDPass and control group was observed [10]. Fur- on the appetite of ONS administration in the MEDPass mode in
thermore, the course of appetite did not differ between the sub- patients with weak HGS should be evaluated in individualized
groups in our analysis; only patients with normal HGS showed a nutrition therapy, and the ONS administration mode should be
tendency to have a higher appetite than patients with weak HGS chosen accordingly.
independent of ONS administration mode. No significant difference
in energy intake from food between the MEDPass group and the Strengths and limitations
control group was found in two studies [44,45]. A before after
study reported a significantly higher percentage of intake at main The MEDPass trial demonstrates good quality in study design
meals (mean +7.3%; SD 13.4%) after introducing the MEDPass and data collection and adequate power. Patients’ energy and pro-
mode [46]. A second before after study reported higher energy tein intake were assessed daily, and hospital food was prepared
and protein intake (19%) from food after 4 wk of ONS administra- according to recipes, which were also used to calculate energy and
tion in the MEDPass mode but lower total energy intake protein intake from hospital food [21].
(food + ONS) of 17% and no change in total protein intake com- Energy and protein requirements were calculated using prag-
pared with before [47]. These studies, as well as our analysis, sug- matic formulae according to international guidelines. These formu-
gest that appetite is not negatively affected by ONS administration lae do not foresee calculations according to adjusted body weight
in the MEDPass mode. However, the before after studies have a in overweight or obese patients or adjustments for mobility. Fur-
risk of bias, and our analysis was not sufficiently powered for our thermore, adjustments were not made in patients with edema.
outcomes. Therefore, it remains unclear if ONS administration in Therefore, requirements may have been over- or underestimated
the MEDPass mode has a negative effect on appetite in patients in part of the trial population. The definition of the weak and nor-
with weak HGS. mal HGS cutoffs was based on the current literature. For the defini-
To include HGS in nutrition assessment and follow-up, the sug- tion of the HGS cutoff values according to Dodds et al., ethnicity
gested time between the measurements is
1 wk [48]. HGS is a and age distribution of the MEDPass data set were considered, and
valuable assessment tool for geriatric inpatients as LOS is often lon- a study with a large sample was chosen [25]. However, the ade-
ger in geriatric patients than in the general population. In Switzer- quacy and, therefore, the influence of these cutoffs on the results
land, 11% of mainly geriatric patients made up for half of remain unknown. Furthermore, medications were not recorded in
hospitalization days from 2017 to 2019 [49]. In our trial, the mean the MEDPass trial and could potentially influence appetite or gas-
(SD) duration of food intake monitoring was 9.4 (4.4) d in patients trointestinal function. The statistical analysis was adjusted for the
with weak HGS and 8.5 (3.5) d in those with normal HGS. However, stratification factors used in randomization. However, even if strat-
according to the Organization for Economic Cooperation and ification for NRS 2002 total score minimizes bias, the statistical
Development, the mean hospital LOS in Switzerland was 6.8 d in model did not consider specific differences in sociodemographic
2021, rendering the usefulness of a second HGS measurement dur- and anthropometric data. They might have had some influence on
ing hospitalization questionable [50]. the results.
To our knowledge, few studies have been conducted on the
ability of HGS to identify patients who would benefit better from Conclusion
nutrition therapy or a specific ONS administration mode. Kaegi-
Braun et al., found a reduction in 30-d mortality in patients with This study found a tendency for lower energy and protein cov-
weak HGS when receiving nutrition therapy compared with those erage in patients with weak HGS in patients receiving ONS in the
with normal HGS [20]. To make therapeutic decisions based on MEDPass mode compared with patients with weak HGS who
HGS measurements in nutrition therapy, more research is needed received it conventionally.
 K. Uhlmann et al. / Nutrition 124 (2024) 112429 5

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