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High-Protein Dietary Supplementation and Nutritional Status Improvement

of Malnourished Patients in Hospital Care

Article in The Indonesian Journal of Gastroenterology Hepatology and Digestive Endoscopy · September 2021
DOI: 10.24871/2222021147-153

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 REVIEW ARTICLE

High-Protein Dietary Supplementation

and Nutritional Status Improvement of
Malnourished Patients in Hospital Care
Marcellus Simadibrata*, Fiastuti Witjaksono**, Yohannessa Wulandari**,
Raja Mangatur Haloho*, Rabbinu Rangga Pribadi*, Murdani Abdullah*,
Aditya Rachman*, Anthony Eka Wijaya*,Batara Bisuk*,
Daniel Martin Simadibrata*,***, Rizka Mutiara*, Kaka Renaldi*
*Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Universitas
Indonesia/Dr. Cipto Mangunkusumo National General Hospital, Jakarta
**Department of Nutrition, Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo
General National, Jakarta
***Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo General National, Jakarta

Corresponding author:
Marcellus Simadibrata. Division of Gastroenterology, Department Internal Medicine, Dr. Cipto Mangunkusumo
General National Hospital. Jl. Diponegoro No. 71 Jakarta Indonesia. Phone: +62-21-3153957;
Facsimile: +62-21-3142454. Email: [email protected].

ABSTRACT

Hospital malnutrition is common in Indonesia and other developing countries. In Asia, the prevalence of
hospital malnutrition ranges between 27-39%. The causes of malnutrition in hospital care include insufficient
food intake and increased catabolic processes due to underlying causes such as metabolic disease, infection,
and malignancy. Several studies have demonstrated that malnutrition increases the morbidity and mortality of
hospitalized patients, prolongs hospital stay, and delays recovery. Therefore, healthcare providers must recognize
malnutrition early by conducting nutritional screening and assessment to prevent worsening of malnutrition
and administer the optimal nutritional therapy to patients. Apart from giving a standard diet, high-protein food
supplementation in liquid form remains a suitable alternative for patients, especially since it is easily digestible.
A high protein diet is associated with a better mortality rate, better weight gain, and improved SGA score in
patients.

Keywords: Hospital malnutrition, high-protein dietary supplementation

ABSTRAK

Malnutrisi di rumah sakit adalah masalah yang umum ditemukan di Indonesia dan negara-negara
berkembang lainnya. Di Asia, prevalensi malnutrisi di rumah sakit berkisar antara 27-39%. Malnutrisi di
rumah sakit dapat terjadi akibat asupan nutrisi yang tidak mencukupi dan peningkatan proses katabolik yang
disebabkan oleh beberapa penyebab yang mendasari seperti penyakit metabolik, infeksi, dan keganasan.
Beberapa studi menunjukkan bahwa malnutrisi meningkatkan morbiditas dan mortalitas pada pasien yang
dirawat di rumah sakit, memperpanjang durasi rawat di rumah sakit, dan menunda pemulihan. Oleh karena itu,
tenaga kesehatan harus mengidentifikasi malnutrisi sesegera mungkin dengan melakukan skrining nutrisi dan
penilaian untuk mencegah perburukan malnutrisi dan memberikan terapi nutrisi yang optimal kepada pasien.
Selain memberikan diet standard, suplementasi makanan cair tinggi protein masih termasuk alternatif yang

Volume 22, Number 2, August 2021 147

Marcellus Simadibrata, Fiastuti Witjaksono, Yohannessa Wulandari, Raja Mangatur Haloho, Rabbinu Rangga Pribadi, Murdani Abdullah, Aditya
Rachman, Anthony Eka Wijaya,Batara Bisuk, Daniel Martin Simadibrata, Rizka Mutiara, Kaka Renaldi

tepat bagi pasien, terlebih karena konsistensinya yang cair sehingga mudah ditelan. Diet tinggi protein berkaitan
dengan tingkat mortalitas yang lebih baik, peningkatan berat badan, dan peningkatan skor SGA pada pasien.

Kata kunci : Malnutrisi di rumah sakit, suplementasi makanan tinggi protein

INTRODUCTION as a condition caused by insufficient nutritional intake

that causes changes in body composition (decreased
Malnutrition is defined as a condition that results
fat-free mass (FFM) and, more specifically, decreased
from a deficiency, excess, or imbalance of energy,
cell mass) and body function.10 Malnourished patients
protein, and other nutrients. Generally, malnutrition
in the hospital are often closely related to disease-
can be classified as undernutrition or overnutrition,
related malnutrition, where malnutrition occurs due
commonly known as obesity. 1 The diagnosis of
to an underlying disease process found in patients or
malnutrition is made through comprehensive history
occurs during extended hospital stays. Malnutrition is
taking regarding nutritional intake, anthropometric
not regularly diagnosed in hospitals; approximately
measurements, and nutrition-related laboratory
one-third of patients without malnutrition become
examinations.
malnourished during hospitalization.11 The cause
Malnutrition is a common problem in hospitalized
for this hospital malnutrition is decreased food
patients. It is often found in developing countries
intake caused by decreased appetite, uncomfortable
around the world. The numbers of hospital malnutrition
gastrointestinal symptoms, decreased ability to
vary between 15-70%.2,3 A study in Canada reported
masticate and swallow, or even the nil per os (NPO) to
the prevalence of malnutrition to be 45%.2 In Europe,
the underlying diseases experienced by the patients.11
the prevalence of hospital malnutrition was 20-30%,
profoundly found in the elderly and patients with
Malnutrition in Hospital Care
malignancy.4,5 Meanwhile, in Asia, the prevalence
of malnutrition in the hospital was 27-39%.6 These The prevalence of malnutrition in hospitals ranges
discrepancies in the prevalence of malnutrition between 20-50% depending on the population and
between regions are primarily driven by the differences diagnostic criteria.12 According to the 2013 Indonesian
in the study population and the screening method used Basic Health Research report, the prevalence of the
for detecting malnutrition. adult population experiencing nutritional deficiencies
Hospital malnutrition can occur due to insufficient was 8.7%. In Jakarta, a study reported that 20-60% of
nutritional intake, impaired absorption, loss of nutrition patients suffered from malnutrition, 69% experienced a
due to underlying diseases, or increased metabolic decrease in nutritional status during their hospital stay.13
requirements during a disease.3 Several studies have
highlighted that malnutrition in the hospital increases Classification and Diagnosis of Malnutrition
morbidity and mortality, prolongs hospital stay, and
Currently, there are several types of malnutrition
delays recovery.2,7,8 This would subsequently increase
classifications. One of the most frequently used
the cost of care in hospitals.9 Thus, nutritional support
classifications for malnutrition in adults is based on the
is needed to lower morbidity and mortality, increase
body mass index (BMI) recommended by the World
treatment efficacy, shorten the length of hospital
Health Organization (WHO) in 2004, which divides
stay, and improve the quality of life. This nutritional
patients into mild, moderate, and severe malnutrition
status improvement can be achieved by giving food
(Table 1).14
supplementation. Currently, various liquid food
Aside from the WHO's BMI criteria, malnutrition
supplementation formulas are made both commercially
in adults can be confirmed by various methods, such
and in the hospital. Since liquid helps food be swallowed
as the ESPEN 2015 recommendations, the American
more easily, liquified foods have become suitable
Society for Parenteral and Enteral Nutrition (ASPEN)
alternative forms of nutrition used in hospitals.
recommendations, which primarily utilize clinical
Table 1. Adult malnutrition classification according to the WHO14
MALNUTRITION
Body mass index (kg/m2) Classification
17.00–18.49 Mild malnutrition
The European Society for Clinical Nutrition and 16.00–16.99 Moderate malnutrition
Metabolism (ESPEN) consensus defined malnutrition < 16.00 Severe malnutrition

148 The Indonesian Journal of Gastroenterology, Hepatology and Digestive Endoscopy

 High-Protein Dietary Supplementation and Nutritional Status Improvement of Malnourished Patients in Hospital Care

features, or according to objective laboratory values. refeeding syndrome. This syndrome can present as
The ESPEN recommendation (2015) diagnosed and a potentially fatal electrolyte shift when insulin is
classified malnutrition in two different ways (Table 2). released in response to nutritional intake (especially
carbohydrates). Although the evidence suggests
Table 2. Malnutrition diagnosis criteria according to the ESPEN
consensus (2015)14 that refeeding syndrome risk is highest in severely
Alternative 1 Alternative 2 malnourished patients, the low-calorie diet is still
BMI< 18.5 kg/m2 Unintentional weight loss of more than 10% widely and safely adopted.15 However, this approach
within an unspecified time frame or;
Unintentional weight loss of more than 5% may be too conservative for maximizing nutritional
within 3 months, accompanied by at least: (1)
BMI < 20 kg/m2 for aged < 70 years or BMI <22 recovery in most hospitalized patients. In the United
kg/m2 for aged ≥70 years, or; (2) Fat free mass States, administering a high-calorie diet to moderately
index (FFMI) <15 kg/m2 for females or FFMI < 17
kg/m2 for male malnourished adolescents (those with a BMI of about
Note: Before using the ESPEN 2015 criteria for diagnosing malnutrition,
patients must have fulfilled the malnutrition risk criteria according to a
75-85% than required) caused by anorexia nervosa
validated screening tool showed better weight gain than a low-calorie diet.15
A meta-analysis and systematic review are done by
Furthermore, the ASPEN recommendations Gomes F et al to study the association between nutritional
can clinically determine malnutrition if two of the support and clinical outcomes in inpatients who are
following six criteria are present: (1) Inadequate intake. malnourished or at nutritional risk.16 The study collected
Malnutrition can be a result of inadequate intake or 27 clinical trials with a total of 6803 patients included in
assimilation of food and nutrients. The main criterion the study. The patients who are included are all medical
for diagnosing malnutrition requires an analysis of inpatients who are not critically ill with malnutrition or
dietary intake at the onset of illness and comparing at risk of malnutrition and are assigned to nutritional
it with the estimated daily needs. Clinicians need to intervention and control groups with various clinical
gather information about the dietary intake, estimate the conditions. The primary outcome was the mortality and
optimal energy requirements, and compare them with secondary outcome, including non-elective hospital
the estimated consumed energy. Inadequate intake is readmission, length of stay, infection rate, functional
assessed as a percentage of the estimated energy needed outcome, daily caloric, protein intake, and weight change.
over a certain period; (2) Weight loss. Clinicians need Mortality rate in with nutritional intervention group
to evaluate any weight loss, including the presence or and control group was 8.3% (230 of 2,758) and 11.0%
absence of low or high body fluids. Assessment of body (307/2787) respectively and show significant reduction
weight changes over a certain period is necessary, and of mortality rate in intervention group (OR = 0.73;
the percentage of weight loss compared to the initial 95% CI: 0.56-0.97; p = 0.03). Non elective hospital
weight must be calculated; (3) Decreased muscle admission rate also show significant difference between
mass. Loss of muscle mass can be seen in the muscles intervention group 14.7% (280/1903) and control
located in the temporal region, clavicle (pectoral and group 18% (339/1880) with intervention group have
deltoid muscle), interosseous scapula, latissimus dorsi, fewer non elective admissions (RR = 0.76; 95% CI:
trapezius, thigh, and calf muscles; (4) Decreased 0.60-0.96; p = 0.02). The intervention group also is
subcutaneous fat mass. Subcutaneous fat loss can be associated with higher energy intake (1618 kcal in the
seen in the orbital area, triceps, and fat between the intervention group vs. 1331 kcal in the control group;
ribs; (5) Any local or generalized fluid accumulation. mean difference, 365 kcal; 95% CI: 272-458 kcal) and
Clinicians need to evaluate the presence of generalized protein intake (59 g in the intervention group vs. 48
or localized (specifically to the extremities, vulvar/ g in the control group; mean difference, 17.7g; 95%
scrotal edema, and ascites) fluid build-up. Weight loss CI: 12.1-23.3 g). Consequently, there is a significant
often goes undetected due to fluid retention (edema) increase in body weight associated with better muscle
and is often observed as weight gain; (6) Decrease in mass (0.63 kg in the intervention group vs -0.19 kg in
functional status as measured by grip strength. the control group; mean difference, 0.73 kg; 95% CI:
0.32-1.13 kg).However there is no significant difference
HIGH-PROTEIN DIET between control and intervention group in a infection
rate (4.8%[88 of 1817] vs. 5.6%[102 of 1825]; OR =
Current recommendations for malnourished
0.86; 95% CI: 0.64-1.16, functional outcome at follow
patients with refeeding syndrome are conservative.
up 17.3 vs. 16.9 points; mean difference in Barthel index
The recommended diet of 1200 kcal/day with daily
score, 0.32 points; 95% CI: -0.51 to 1.15), and length of
increments of about 200 kcal/day is intended to avoid

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Marcellus Simadibrata, Fiastuti Witjaksono, Yohannessa Wulandari, Raja Mangatur Haloho, Rabbinu Rangga Pribadi, Murdani Abdullah, Aditya
Rachman, Anthony Eka Wijaya,Batara Bisuk, Daniel Martin Simadibrata, Rizka Mutiara, Kaka Renaldi

stay 11.5 days vs 12.0 days; mean difference, -0.24 days; in the geriatrics population with comorbidities. Exclusion
95% CI: -0.58 to 0.09). Funnel plots test were done and criteria including patients with diabetes mellitus (type
showed no evidence of any publication bias. 1 or 2) due to product composition not intended for
This study suggests an association between patients with diabetes, current active cancer or under
increased protein intake and energy intake in the treatment, impairment of renal and liver function as these
intervention group; consequently, there is an increased patients might have impairment in protein metabolism.
weight which is beneficial for undernutrition patients. Selected patients were randomly allocated to consume
There is also added benefit of reduced mortality and two servings of HP-HMB or placebo for 90 days post-
hospital readmission in the intervention group. discharge for the hospital.
A placebo-controlled double-blinded randomized Both groups are similar in baseline demographic
controlled trial done by Deutz NE et al study and clinical characteristics. Both groups have similar
malnourished geriatric patients with various clinical treatment adherence. Primary endpoint show significant
conditions (congestive heart failure, acute myocardial difference in 90 days mortality with 4.8% and 9.7%
infarction, or chronic obstructive pulmonary disease).17 (p = 0.018) relative risk 0.49 (95% CI: 0.27-0.90) in
The intervention group was given HP-HMB (high intervention group and control group respectively.
protein enriched with β-hydroxy-β-methyl butyrate) However, both rates of the first readmission and/or death
with standard care (n = 328). The Control group was and readmission in these groups did not differ statistically.
given a placebo with standard care (n = 324). The Secondary endpoints show a significant difference in 30
primary end point was 90-day post-discharge incidence and 60 day mortality rate (2.9% vs. 6.2%; p = 0.049)
of death or non-elective readmission. Secondary and (4.2% vs.8.7%; p = 0.020) respectively. On day 90
endpoints included 30- and 60-day post-discharge intervention group had a higher proportion of patients
incidence of death or readmission, length of stay, SGA with SGA-A (well-nourished) in comparison to the
class, body weight, and activities of daily living score. control group and this resulted in significantly higher odds
Patient selection criteria were aged ≥ 65 years old (OR ¼ 2.04; 95% CI: 1.28 - 3.25; p = 0.009) (Figure 1).
with recent hospital admission with a primary diagnosis In addition, there is also a significant weight gain in
of CHF, AMI, or COPD with SGA class of B. These the intervention group compared to the control group on
patients were screened due to higher risk of malnutrition day 30. No significant effects were seen in the length of

Figure 2. Nutritional status and weight change17

150 The Indonesian Journal of Gastroenterology, Hepatology and Digestive Endoscopy

 High-Protein Dietary Supplementation and Nutritional Status Improvement of Malnourished Patients in Hospital Care

stay and average daily living score. Post hoc analysis on The Rationale for Giving High-protein Liquid Food
COPD subgroups shows an improvement of handgrip Supplementation
strength in intervention groups compared to the control
Malnutrition is positively associated with poor
group. (1.56 ± 0.67 vs. 0.34 ± 0.63, p = 0.0413)
patient outcomes. However, this condition remains
Similar to the previous meta-analysis, this study has
treatable, mainly when there is adequate nutritional
shown a significant reduction of the mortality rate in the
management. Identifying patients with malnutrition or at
group with high protein intake compared to the control
risk of malnutrition is the first step in the multidiscipline
group. An increased nutritional status, as shown by
treatment process. It is crucial to identify such patients
SGA score, is an improvement. Followed by increase
as early as possible so that nutrition therapy can be
weight which is shown to improved malnutrition
started in a timely and effective manner. A quick and
status in geriatric patients. Increase handgrip strength
accurate assessment method is helpful, especially in an
is also an indicator of nutrition status and is strongly
interdisciplinary approach (Figure 1).
associated with favourable clinical outcomes. Overall
Therefore, screening for the risk of malnutrition
this study also supports giving a high protein diet to
with a rapid and straightforward tool should be carried
improve the patient's condition.
out systematically in hospitalized patients. A detailed
High-protein Liquid Supplementations currently
and comprehensive malnutrition assessment should
available on the market include commercial and hospital
be performed in all patients with malnutrition or at
liquid foods. Examples of commercial high-protein liquid
risk of developing the condition. Trained workers
food include Peptisol (Kalbe Farma), which contains 14 g
should perform this screening using subjective and
of protein/200 mL. New Ensure Enlive (Abbott) contains
objective parameters such as clinical history, physical
20 g of protein and 350 kcal per bottle. Protein (Otsuka),
examination, BMI measurement, assessing the body's
which contains 10 g of protein and 212 kcal per 200 ml
function, and laboratory values. This systematic and
of serving).18,19,20 Liquid food formula produced in Cipto
standardized screening will ultimately reduce treatment
Mangunkusumo Hospital includes the CLLM milk with
costs.15,22,23,24
60 g of protein per 1000 kcal (Table 3).21
Nutrition is an effective treatment option to prevent
Table 3. Composition of liquid food formula CLLM (Cipto and/or treat malnutrition, thus reducing morbidity and
Mangunkusumo Hospital, Jakarta)21
mortality. The results of a study in Asia suggested
CLLM 60-gram Formula Content Per 1000 kcal
Carbohydrate 126 grams that providing nutritional support to patients at risk of
Protein 60.3 grams malnutrition and patients who are already experiencing
Total Fat 32.7 grams
Cholesterol 330 milligrams malnutrition can reduce morbidity and mortality,
Vitamin improve quality of life and/or function; and reduce
Vitamin A 2209 RE
Vitamin E 5.89 grams the length of stay in the hospital, use of resources,
Vitamin B1 (Thiamine) 680 milligrams
Vitamin B2 (Riboflavin) 847 milligrams
and cost of care.23 Oral nutritional therapy was also
Vitamin B3 (Niacin) 4.27 milligrams reported to increase the body weight and BMI of
Vitamin B5 (Pantothenic acid) 2.66 milligrams
Vitamin B6 (Pyridoxine) 508 milligrams postoperative gastrointestinal cancer patients despite
Vitamin B9 (Folic acid) 47.5 micrograms no significant improvement in the patient's quality of
Vitamin B12 (Cobalamin) 1.22 micrograms
Vitamin C 57.5 milligrams life. Several preliminary studies in Indonesia showed

Figure 1. Nutrition care algorithm10

Volume 22, Number 2, August 2021 151

Marcellus Simadibrata, Fiastuti Witjaksono, Yohannessa Wulandari, Raja Mangatur Haloho, Rabbinu Rangga Pribadi, Murdani Abdullah, Aditya
Rachman, Anthony Eka Wijaya,Batara Bisuk, Daniel Martin Simadibrata, Rizka Mutiara, Kaka Renaldi

that providing adequate high-protein nutrition could malnutrition. Furthermore, nutritional therapy with
improve nutritional status and immunity, thereby high-protein liquid food supplementation can be an
accelerating the healing process and shortening the effective alternative therapy for malnourished patients
length of stay.25 in the hospital. However, it must be highlighted that
To date, not much is known regarding the cost- not all patients benefited from a high protein diet;
effectiveness of administering nutritional therapy to for example, in patients with chronic kidney disease
such patients. Thus, this warrants further research in with end-stage renal disease, protein intake must be
the area before clinical implementation. Additionally, restricted because it can damage the kidney further.
it may also be essential to study the metabolic system
and the gut microbiome diversity in patients given
REFERENCES
nutritional therapy.26
1. Meijers JMM, van Bokhorst-de van der Schueren MAE, Schols
JMGA, Soeters PB, Halfens RJG. Defining malnutrition:
Contraindication of High Protein Diet in Mission or mission impossible? Nutrition 2010;26:432–40.
Malnourished Patients 2. Allard JP, Keller H, Jeejeebhoy KN, Laporte M, Duerksen
DR, Gramlich L, et al. Malnutrition at hospital admission
One study by Hanna RM et al highlights a high - contributors and effect on length of stay: a prospective
protein diet contraindication in malnourished patients.27 cohort study from the Canadian malnutrition task force. JPEN
The study explores patients with chronic kidney 2014;40:487–97.
3. Correia MITD, Perman MI, Waitzberg DL. Hospital
disease or end-stage renal disease with protein-energy
malnutrition in Latin America: a systematic review. Clin Nutr
wasting. Protein-energy wasting (PEW) is a state of 2017;36:958–67.
nutritional and metabolic derangements in patients with 4. Schindler K, Pernicka E, Laviano A, Howard P, Schütz T,
chronic kidney disease and end-stage renal disease Bauer P, et al. How nutritional risk is assessed and managed
characterized by simultaneous loss of systemic body in European hospitals: a survey of 21,007 patients findings
from the 2007-2008 cross-sectional nutritionDay survey. Clin
protein and energy stores. A Hypercatabolic state Nutr 2010;29:552–9.
induced by uremia, anorexia due to poor appetite, 5. Álvarez-Hernández J, Planas Vila M, León-Sanz M, García de
and inflammation from systemic condition or dialysis Lorenzo A, Celaya-Pérez S, García-Lorda P, et al. Prevalencia
process might explain the negative balance of protein y costes de la malnutrición en pacientes hospitalizados; estudio
PREDyCES®. Nutr Hosp 2012;27:1049–59.
and energy stores from the body. The processes above
6. Lim SL, Ong KCB, Chan YH, Loke WC, Ferguson M, Daniels
will lead to cachexia, fat loss, and lean muscle mass L. Malnutrition and its impact on cost of hospitalization,
loss; therefore, nutritional therapy is required for length of stay, readmission and 3-year mortality. Clin Nutr
patients with protein-energy wasting. 2012;31:345–50.
7. Ray S, Laur C, Golubic R. Malnutrition in healthcare
Dietary intervention in these patients is required to
institutions: A review of the prevalence of under-nutrition in
preserve lean muscle mass and provide adequate energy hospitals and care homes since 1994 in England. Clin Nutr
supply, which is vital to the health of dialysis patients. 2013;33:829–35.
Recommended protein intake for these patients is 0.6- 8. Rahman A, Wu T, Bricknell R, Muqtadir Z, Armstrong D.
0.8 g/kg/day and dietary calorie intake of 30-35 kcal/ Malnutrition Matters in Canadian Hospitalized Patients:
Malnutrition Risk in Hospitalized Patients in a Tertiary Care
kg/day for patient stage IIIB-V CKD. However, the risk Center Using the Malnutrition Universal Screening Tool. Nutr
of negative protein balance low protein diet (LPD) is Clin Pract 2015;30:709–13.
recommended due to the higher risk of CKD progression 9. Khalatbari-Soltani S, Marques-Vidal P. The economic cost of
with a higher protein diet. However, kidney disease hospital malnutrition in Europe; a narrative review. Clin Nutr
ESPEN 2015;10:e89–94.
progression through LPD is more beneficial in younger 10. Soeters PB, Reijven PLM, van Bokhorst-de van der Schueren
patients. As such, protein restriction in older populations MAE, Schols JMGA, Halfens RJG, Meijers JMM, et al.
should be balanced against PEW, which would result in A rational approach to nutritional assessment. Clin Nutr
worse renal and mortality outcomes. 2008;27:706–16.
11. Guenter P, Jensen G, Patel V, Miller S, Mogensen KM,
Malone A, et al. Addressing disease-related malnutrition in
CONCLUSION hospitalized patients: A call for a national goal. Jt Comm J
Qual Patient Saf 2015;41:469–73.
Rapid and accurate assessment methods will be 12. Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact
of disease-related malnutrition. Clin Nutr 2008;27:5–15.
beneficial for detecting malnutrition, especially when
13. FW LI, Sukmaniah S, Octovia. Buku Ajar Diagnosis dan
using an interdisciplinary approach. Furthermore, Terapi Medik Penyakit Gizi Utama. In Jakarta: Penerbit
treatment costs can be reduced through systematic Universitas Indonesia 2018.
and standardized screening of patients at risk of

152 The Indonesian Journal of Gastroenterology, Hepatology and Digestive Endoscopy

 High-Protein Dietary Supplementation and Nutritional Status Improvement of Malnourished Patients in Hospital Care

14. Consultation W expert. Appropriate body-mass index for Asian

population and its implications for policy and intervention
strategies. Int J Electron 2004;363:157–63.
15. Garber AK, Mauldin K, Michihata N, Buckelew SM, Shafer M,
Moscicki A, et al. Higher calorie diets increase rate of weight
gain and shorten hospital stay in hospitalized adolescents with
anorexia Nervosa. J Adolesc Health 2015;53:579–84.
16. Gomes F, Baumgartner A, Bounoure L, Bally M, Deutz
NE, Greenwald JL, 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.
17. Deutz NE, Matheson EM, Matarese LE, Luo M, Baggs GE,
Nelson JL, et al. readmission and mortality in malnourished,
older, hospitalized adults treated with a specialized oral
nutritional supplement: A randomized clinical trial. Clin nutr
(Edinburgh, Lothian) 2016;35:18–26.
18. Wuryanti S, Sayogo S, Ahmad SA. The effect of high protein
enteral nutrition on protein status in acute stroke patients. Med
J Indones 2005;14:37–43.
19. Shake AN. Ensure ® Enlive ® Advanced Nutrition Shake
Product Information: Ensure ® Enlive ® Advanced Nutrition
Shake Ensure ® Enlive ® Advanced Nutrition Shake. In
2019.p.1–4.
20. Masood DrA. Quick Review of Clinical Nutrition. In Pakistan;
2019.
21. Mangunkusumo RDrC. Instalasi gizi dan produksi makanan
RSCM. Jakarta; 2020.
22. Tappenden KA, Quatrara B, Parkhurst ML, Malone AM,
Fanjiang G, Ziegler TR. Critical role of nutrition in improving
quality of care: an interdisciplinary call to action to address
adult hospital malnutrition. J Acad Nutr Diet 2013;113:1219–
37.
23. Avelino-Silva TJ, Jaluul O. Malnutrition in Hospitalized older
patients: management strategies to improve patient care and
clinical outcomes IJGE 2017;11:56–61.
24. Lovesley D, Parasuraman R, Ramamurthy A. Combating
hospital malnutrition: dietitian-led quality improvement
initiative. Clin Nutr ESPEN 2019;30:19–25.
25. Rahardja FM. Nutrition in Pulmonary Tuberculosis and
Malnutrition. DJM 2015;14:80–8.
26. Reber E, Gomes F, Vasiloglou MF, Schuetz P, Stanga Z.
Nutritional Risk Screening and Assessment. J Clin Med
2019;8:1065.
27. Hanna RM, Ghobry L, Wassef O, Rhee CM, Kalantar-Zadeh
K. A Practical Approach to Nutrition, Protein-Energy Wasting,
Sarcopenia, and Cachexia in Patients with Chronic Kidney
Disease. BPU 2020;49:202–11.

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