Cost-effectiveness of treating malnutrition

The cost-effectiveness of identifying and treating malnutrition in hospitals: a systematic review

Mitchell and Porter, JHND Early View


Disease-related malnutrition is known to have significant clinical and economic consequences. This systematic review of recent evidence aimed to establish the cost-effectiveness of identifying and treating malnutrition in the hospital setting.


A search of four electronic databases and the Internet was conducted for relevant publications from 2003 to 2013. The search strategy considered both nutritional care and healthcare costs. Hospitalised adults with, or at risk of malnutrition, were the focus of the review. Eligibility criteria included publications of original research to identify or treat malnutrition through usual care. Studies with a focus on enteral and parenteral nutrition interventions were beyond the scope of the review. Methodological quality was assessed using the Consensus on Health Economic Criteria checklist.


Of the 1174 records identified through database searching, 19 full-text articles were assessed for eligibility. Three studies were included in the final review, highlighting the absence of recent high quality cost-effectiveness studies in this field. One economic modelling study and two prospective clinical trials were included of moderate to high methodological quality.


Definite conclusions could not be drawn regarding the cost-effectiveness of individual interventions because of the heterogeneity of treatments, controls and populations. The present review highlights an evidence gap in the care of malnourished hospitalised adults, limiting the ability of clinicians and healthcare managers to make informed, cost-effective treatment decisions. Further economic evaluations are needed and should be considered as a routine component of future research.

Oral nutrition supplements and growth in children

Longitudinal growth and health outcomes in nutritionally at-risk children who received long-term nutritional intervention

Huyhn et al JHND Early View.


The benefits of short-term oral nutritional supplementation (ONS) in undernourished children are well-established. The benefits of long-term ONS in promoting longitudinal growth and health in children who are at risk of undernutrition have not been reported previously.


In this 48-week prospective, single-arm, multicentre trial, 200 Filipino children aged 3–4 years with weight-for-height percentiles from 5th to 25th (WHO Child Growth Standards) were enrolled. Parents received dietary counselling at baseline, and at weeks 4 and 8. Two servings of ONS (450 mL) were consumed daily, providing 450 kcal, 13.5 g protein and micronutrients. Weight, height, dietary intake using 24-h dietary recalls, and physical activity and appetite using the visual analogue scales were assessed at baseline and weeks 4, 8, 16, 24, 32, 40 and 48. The number of sick days for acute illnesses was collected over the study period.


At baseline, mean age was 41.2 months with 50% being male. Weight-for-height percentiles showed the greatest increase in the first 4 weeks (12.1 and 12.8 percentiles, respectively, P < 0.0001) and remained significantly higher than baseline (P < 0.0001) but were relatively stable from week 4 onwards. Height-for-age percentiles increased steadily over time and became significantly higher than baseline from week 24 onwards (P < 0.0001). Appetite and physical activity scores at all post-baseline visits improved from baseline (P < 0.0001), and a reduction in the number of sick days from week 16 onwards was also observed (P < 0.0001). Higher parental education level, being male and higher baseline weight-for-height percentiles were significantly associated with higher ponderal and linear growth over time in repeated measures analysis of covariance.


Intervention consisting of initial dietary counselling and continued ONS helped sustain normal growth after a catch-up growth in nutritionally at-risk children.

Dietary counselling improves outcomes for at-risk elderly following hospital discharge

Individualised dietary counselling for nutritionally at-risk older patients following discharge from acute hospital to home: a systematic review and meta-analysis

Munk et al., JHND Early View


Many older patients are undernourished after hospitalisation. Undernutrition impacts negatively on physical function and the ability of older patients to perform activities of daily living at home after discharge from acute hospital. The present study aimed to evaluate the evidence for an effect of individualised dietary counselling following discharge from acute hospital to home on physical function, and, second, on readmissions, mortality, nutritional status, nutritional intake and quality of life (QoL), in nutritionally at-risk older patients.


A systematic review of randomised controlled trials was conducted. The overall quality of the evidence was assessed according to Grading of Recommendations Assessment, Development and Evaluation system (GRADE) criteria.


Four randomised controlled trials (n = 729) were included. Overall, the evidence was of moderate quality. Dietitians provided counselling in all studies. Meta-analyses showed a significant increase in energy intake [mean difference (MD) = 1.10 MJ day−1, 95% confidence interval (CI) = 0.66–1.54, < 0.001], protein intake (MD = 10.13 g day−1, 95% CI = 5.14–15.13, < 0.001) and body weight (BW) (MD = 1.01 kg, 95% CI = 0.08–1.95, = 0.03). Meta-analyses revealed no significant effect on physical function assessed using hand grip strength, and similarly on mortality. Narrative summation of effects on physical function using other instruments revealed inconsistent effects. Meta-analyses were not conducted on QoL and readmissions as a result of a lack of data.


Individualised dietary counselling by dietitians following discharge from acute hospital to home improved BW, as well as energy and protein intake, in older nutritionally at-risk patients, although without clearly improving physical function. The effect of this strategy on physical function and other relevant clinical outcomes warrants further investigation.

DASH score and risk of coronary stenosis

Relationship between Dietary Approaches to Stop Hypertension score and Alternative Healthy Eating Index score with plasma asymmetrical dimethylarginine levels in patients referring for coronary angiography

Mokhtari et al. JHND Early View


Asymmetrical dimethyl arginine (ADMA) is a competitive inhibitor in the production of nitric oxide (NO) from arginine and NO plays an important role in the preservation of vascular dilation. Elevated ADMA is a strong predictive factor for coronary artery disease (CAD). Dietary Approaches to Stop Hypertension (DASH) and Alternative Healthy Eating Index (AHEI) patterns contain factors that may influence plasma ADMA levels. The present study examined the association between the DASH score and AHEI score with plasma ADMA concentration in people with suspected heart disease selected for coronary angiography.


This cross-sectional study was conducted in 148 people aged 40–80 years who were referred for coronary angiography. The DASH diet score and AHEI score were calculated for each individual based on food groups. Plasma ADMA levels were measured by high-performance liquid chromatography.


ADMA concentrations were higher in the CAD group compared to the non-CAD group [0.98 (0.37) μmol L−1 compared to 0.84 (0.42) μmol L−1= 0.02]. There was a significant negative association between the quartile DASH score and ADMA concentration (standardised β = −0.172, P = 0.038). The ADMA concentration was lower in patients who were at the highest quartile of DASH score compared to patients with the lowest quintile score. The ADMA concentration and quartiles of AHEI score were not significantly associated.


Higher scores of the DASH diet are associated with lower plasma ADMA levels and with reduced coronary artery stenosis.

Common author errors


As Editor I often receive emails from prospective authors who wish to know whether their manuscript falls within the scope of the Journal of Human Nutrition and Dietetics. Nine times out of ten my answer is ‘Yes’, but I am happy to give that pre-submission advice. Unfortunately, although scope of the journal is often checked, authors submitting papers make a number of basic mistakes which delay the submission process and ultimately a decision on whether to publish their paper. Not doing these things first time round means that you will end up with a longer list of annoying revisions. All of these errors can be avoided by careful reference to our Guidelines for Authors. The frequency of errors seems to suggest that most people don’t bother to check our requirements.

Here are the most common problems:

Abstract not structured

JHND abstracts are expected to be structured with sub-headings for Background, Methods, Results, Conclusions. Abstracts should be no more than 250 words.

Requirements for reporting of human studies and reviews

The journal has made a commitment to comply with international guidelines on the reporting of intervention trials, the conduct of observational studies, and systematic review methodologies. This is a means of increasing the quality of the work which we publish. Since January 1st 2015 we have had a requirement for papers to show that they comply with CONSORT, STROBE or PRISMA guidance, as appropriate. This is an absolute requirement and if authors cannot demonstrate compliance we will reject their manuscript. Generally there will be an opportunity to demonstrate compliance after initial review should a resubmission be invited, but it would save time to include it with the initial submission.

Referencing Style

In September 2014 JHND made a change to the referencing style used in our publications. This is still catching a lot of people out and making for time-consuming revisions. Our style is now the Vancouver style and you can see how it works here. Personally I find adding references to be a total pain in the derriere as I am not a user of Endnote or similar tools. To have to do it twice would cause me severe angst.

Exceeding the word limit

Although the journal is published only online, we have a page budget that is rather constraining. We receive many more papers than we could possibly publish and as a result our acceptance rate is currently only 15%. Due to these constraints we have a word limit for manuscripts which is now tightly enforced. Manuscripts should be no longer than 4000 words, and even shorter if there are large numbers of tables and figures to be published. Papers that are over the word-limit run the risk of encountering the ultimate horror of the editor saying ‘Make it shorter’ and the referees saying ‘You need to add this…’.


Missing out all of those little extras

As scientists we just want to communicate our work as clearly and as quickly as possible. It is easy to focus on writing the normal elements of the manuscript, adding in the tables and graphs, doing the pesky reference list and then just submitting it. What we often forget are all the various statements that are now mandatory for almost all journals:

  • Conflict of interest statement
  • Acknowledgment of funding source
  • Statement of ethical approval
  • Statement of author contributions

None of these take much time to do (but they do count within your word limit!), but are an absolute requirement for publication.