Importance of clinical nutrition in gastrointestinal diseases

Nutritional treatment (clinical nutrition) is a medical procedure involving the assessment of the patient’s nutritional status and needs, and administration of an adequate supply of energy, protein, electrolytes, vitamins, trace elements, and water by enteral, parenteral, or oral feeding, while monitoring the clinical status. It is an integral part of the treatment process. Indications for nutritional treatment are current malnutrition or expected inability to incorporate a full oral diet for more than 7 days.¹

The incidence of malnutrition is high in patients with advanced gastrointestinal diseases. Malnutrition increases the risk of complications and worsens prognosis, while proper nutrition mitigates these risks.^2,3 Disease‑related malnutrition is exacerbated in hospitalized individuals and has a significant negative impact on patient outcomes, hospitalization time, and treatment costs. Unfortunately, nutritional status is often not assessed in outpatients, and the inclusion of nutritional treatment in comprehensive gastroenterology treatment is rare.

Aim of the guideline

The aim of the guideline was to improve the modern diagnosis of malnutrition and to facilitate the implementation and management of clinical nutrition in patients with gastrointestinal diseases in Poland, in accordance with the current state of knowledge. The recommendations of the Agency for Health Technology Assessment and Tariff System (AOTMiT) on the principles of the guideline construction were considered in its development. AOTMiT is a Polish consultative and advisory entity with legal personality, supervised by the Polish Minister of Health, whose role is to assist the Minister of Health in the decision‑making process with regard to the financing of medicines and other technologies in the health care system. Health technology assessment is used in a way that is reproducible, transparent, within a specified methodological standard, and evidence‑based.

Health issues covered in the guideline

The following issues are discussed in this guideline: 1) diagnosis of malnutrition; 2) gastrointestinal tract access for enteral nutrition; 3) vascular access for parenteral nutrition; 4) clinical nutrition in inflammatory bowel diseases (IBDs); 5) clinical nutrition in acute pancreatitis (AP); 6) clinical nutrition in chronic pancreatitis (CP); 7) clinical nutrition in liver disease; 8) clinical nutrition in a geriatric patient.

Target patient populations

The recommendations relate to the management of adult patients with gastrointestinal diseases requiring nutritional assessment, diagnosis of malnutrition, and / or the use of clinical nutrition.

Recommendations

Our recommendations, with the quality of the evidence and strength of the recommendations, are listed below. The phrase We recommend indicates a statement regarding which the authors have reached consensus on the benefits the patient would derive from the treatment, and this statement should be followed wherever possible. The phrase We suggest means that the patient may benefit from the treatment, and this recommendation should be considered in therapeutic decision‑making. The phrase We do not recommend indicates a statement regarding which the authors have reached full agreement on the increased risk or a lack of additional benefit for the patient.

Interpretation of the guideline

Each therapeutic recommendation is accompanied by 3 pieces of information (Tables 1 and 2): 1) quality of the evidence, classified as high, moderate, low, or very low; 2) strength of the recommendation, classified as strong or weak; and 3) degree of expert consensus (voting score presented on the Likert scale of 1–6, with 1 indicating total rejection of the recommendation, and 6 indicating total support).

Diagnosis of malnutrition and indications for clinical nutrition

Absolute and relative contraindications to clinical nutrition

Contraindications to enteral feeding comprise^3,17,18:

1. Gastrointestinal failure (significant mechanical or functional gastrointestinal transit disorders, high‑output intestinal fistula with a short segment of intestine below the fistula or no access to this segment, significant malabsorption); in such cases, the implementation of parenteral nutrition should be considered;

2. Inability to access the gastrointestinal tract (anatomical abnormalities after surgery, significant contraindications to percutaneous enteral access, other generalized lesions in the peritoneal cavity, eg, portal hypertension); in such cases, the implementation of parenteral nutrition should be considered;

3. Poor prognosis of a patient ineligible for nutritional treatment (agony, advanced terminal condition);

4. Lack of consent from the patient.

Contraindications to parenteral nutrition comprise^19,20:

1. Hemodynamic instability;

2. Failure of vital organs;

3. Severe metabolic disorders (except for hypertriglyceridemia [serum triglyceride level >9.065 mmol/l]; in this case, it is not necessary to stop parenteral nutrition completely but infusion of fat emulsions needs to be stopped);

4. Inability to establish a safe vascular access;

5. A functional gastrointestinal tract allowing for another method of feeding;

6. Poor prognosis of a patient ineligible for nutritional therapy (agony, advanced terminal condition);

7. Lack of consent from the patient.

Endoscopic access for enteral nutrition

Patients who cannot be fed effectively via the oral route require enteral nutritional treatment. In the case of an unobstructed, properly functioning gastrointestinal tract, enteral nutrition is preferred. Enteral feeding tubes can be inserted through natural orifices (nostrils, mouth) or percutaneously. Nasogastric (NGT) and nasojejunal (NJT) tubes are flexible probes inserted into the stomach or intestine, respectively, through the nose. Percutaneous gastrostomy provides nutritional access to the stomach through abdominal integuments that can be created surgically (percutaneous surgical gastrostomy), endoscopically (percutaneous endoscopic gastrostomy [PEG]), or under radiological control (ultrasound or fluoroscopy: radiologically inserted gastrostomy). Percutaneous jejunostomy consists in providing access to the small intestine; the access can be created surgically (percutaneous surgical jejunostomy) or endoscopically (direct percutaneous endoscopic jejunostomy [D‑PEJ]). PEG with extended access to the small intestine (percutaneous endoscopic gastrojejunostomy [PEG‑J]) involves insertion of a percutaneous gastrostomy tube through which an additional, smaller‑diameter tube is inserted into the small intestine.²¹

Indications for endoscopic access for enteral nutrition

Contraindications to endoscopic access for enteral nutrition

Choice of endoscopic access for enteral nutrition and perioperative management

Prevention and management of perioperative adverse events

Postoperative management of endoscopic feeding access

Dislocation, replacement, and removal of feeding access

Vascular access for parenteral nutrition

Statement 27

Patients with IBDs are at a high risk of developing malnutrition, and we recommend performing a nutritional assessment in every inpatient and in a selected group of outpatients (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 0%; 5 – Acceptance, 6%; 6 – Total support, 94%.

Comments are provided in Supplementary material. See appropriate references.^73,74,76

Statement 28

In patients with IBDs, we recommend a diet rich in n‑3 fatty acids and poor in n‑6 fatty acids (quality of evidence: low; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 10%; 5 – Acceptance, 40%; 6 – Total support, 50%.

Comments are provided in Supplementary material. See appropriate references.⁷⁷

Statement 29

We do not recommend a diet rich in highly processed foods and food additives, including emulsifiers (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 0%; 5 – Acceptance, 25%; 6 – Total support, 75%.

Comments are provided in Supplementary material. See appropriate references.^73,75,78

Statement 30

At the current stage of knowledge, no recommendation can be made regarding dietary fiber intake for patients with IBDs (quality of evidence: low; strength of recommendation: weak).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 6%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 13%; 5 – Acceptance, 44%; 6 – Total support, 37%.

Comments are provided in Supplementary material. See appropriate references.^73,79,80

Statement 31

A nonprotein energy supply of 20–25 kcal/kg body weight (BW)/day is recommended in patients with IBDs (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 6%; 5 – Acceptance, 37%; 6 – Total support, 56%.

Comments are provided in Supplementary material. See appropriate references.⁷³

Statement 32

We recommend a protein supply of approximately 1 g/kg BW/day in patients with IBDs. During the period of disease exacerbation, we recommend increasing the protein supply to 1.2–1.5 g/kg BW/day (quality of evidence: low; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 0%; 5 – Acceptance, 31%; 6 – Total support, 69%.

Comments are provided in Supplementary material. See appropriate references.^73,75

Statement 33

At the current stage of knowledge, it is not possible to make a recommendation on the specific oral diet that should be followed by patients with IBDs in the exacerbation phase of the disease to help achieve remission (quality of evidence: low; strength of recommendation: weak).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 6%; 4 – Partial acceptance, 25%; 5 – Acceptance, 38%; 6 – Total support, 31%.

Comments are provided in Supplementary material. See appropriate references.^73-76,81

Statement 34

We recommend oral nutritional supplements (ONSs) as an adjunctive therapy to the standard diet as the first stage of nutritional intervention in patients with a negative protein–calorie balance (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 6%; 5 – Acceptance, 25%; 6 – Total support, 69%.

Comments are provided in Supplementary material.

Statement 35

If oral nutrition becomes insufficient, we recommend enteral nutrition as the next step in patients with a functional gastrointestinal tract (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 13%; 5 – Acceptance, 12%; 6 – Total support, 75%.

Comments are provided in Supplementary material. See appropriate references.^73,75,82,83

Statement 36

In adult patients in the active phase of CD (mild and moderate forms), we recommend considering the introduction of a specialized CD exclusion diet, alone or in combination with enteral nutrition (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 13%; 5 – Acceptance, 31%; 6 – Total support, 56%.

Comments are provided in Supplementary material. See appropriate references.^73,75,83,84

Statement 37

We do not recommend enteral nutrition in adult patients with UC who are effectively fed via the oral route, nor parenteral nutrition in patients with a functioning gastrointestinal tract (quality of evidence: low; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 6%; 5 – Acceptance, 25%; 6 – Total support, 69%.

Statement 38

In severe exacerbation of UC, we suggest enteral nutrition as the first‑line management in patients with a functional gastrointestinal tract. We recommend parenteral nutrition in this patient group when the patient cannot be effectively fed via the gastrointestinal route (quality of evidence: low; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 6%; 5 – Acceptance, 25%; 6 – Total support, 69%.

Comments are provided in Supplementary material. See appropriate references.^85-87

Statement 39

In malnourished patients with indications for surgery, if possible, we recommend delaying surgery for 7 to 14 days or longer, until the nutritional status improves. The optimal timing of surgery should be based on the benefit of continued metabolic preparation and the urgency of surgery due to increasing or regressing clinical symptoms (quality of evidence: low; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 6%; 5 – Acceptance, 19%; 6 – Total support, 75%.

Comments are provided in Supplementary material. See appropriate references.^73,82,87-90

Statement 40

We recommend that patients with AP be considered at a moderate‑to‑high nutritional risk due to the catabolic nature of the disease and the impact of nutritional status on the disease course (quality of evidence: moderate; strength of recommendation: weak).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 13%; 5 – Acceptance, 31%; 6 – Total support, 56%.

Comments are provided in Supplementary material. See appropriate references.^91,92,95,96

Statement 41

We recommend early initiation of oral nutrition in patients with predicted mild AP after resolution of complaints, regardless of lipase activity (quality of evidence: moderate, strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 0%; 5 – Acceptance, 6%; 6 – Total support, 94%.

Comments are provided in Supplementary material. See appropriate references.^97-99

Statement 42

We recommend the implementation of enteral nutrition from the start of hospitalization in all malnourished patients and individuals with predictive factors for severe AP, and within 72 hours of admission to a hospital in all patients in whom oral nutrition does not cover 60% of the protein–calorie requirements (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 13%; 5 – Acceptance, 12%; 6 – Total support, 75%.

Comments are provided in Supplementary material. See appropriate references.^100-105

Statement 43

When nutrient requirements cannot be met via the gastrointestinal route (contraindications, intolerance, lack of access), we recommend supplementary or total parenteral nutrition not exceeding metabolic limits (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 7%; 5 – Acceptance, 6%; 6 – Total support, 87%.

Comments are provided in Supplementary material. See appropriate references.^91,106-109

Statement 44

In patients with severe AP and concomitant obesity, we suggest supplying an isocaloric high‑protein diet (>1.3 g/kg adjusted BW/day) in the acute phase of the disease (quality of evidence: low; strength of recommendation: weak).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 25%; 5 – Acceptance, 19%; 6 – Total support, 56%.

See appropriate references.^{20,91,110,111}

Statement 45

We recommend assessing the nutritional status of patients with CP at each follow‑up outpatient visit, at least every 12 months, based on clinical scales, symptoms, anthropometric assessment, and available biochemical and imaging data (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 6%; 5 – Acceptance, 25%; 6 – Total support, 69%.

Comments are provided in Supplementary material. See appropriate references.^91,112-118

Statement 46

Restrictive diets are not recommended for patients with CP (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 0%; 5 – Acceptance, 13%; 6 – Total support, 87%.

Comments are provided in Supplementary material. See appropriate references.^117,119-125

Statement 47

We recommend the implementation of ONS in patients with CP in the following clinical situations: 1) in malnourished patients, when oral nutrition is insufficient to meet the protein and caloric requirements; 2) in individuals with persistent symptoms of malabsorption despite adequate enzyme supplementation and exclusion of small intestinal bacterial overgrowth (SIBO) (quality of evidence: low; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 0%; 5 – Acceptance, 31%; 6 – Total support, 69%.

Comments in Supplementary material. See appropriate references.^125,126

Statement 48

We recommend supplementation of fat‑soluble vitamins (A, D, E, and K), magnesium, and iron in patients with CP and symptoms of malabsorption syndrome. In patients with CP without malabsorption syndrome, we do not recommend supplementation of all fat‑soluble vitamins (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 7%; 5 – Acceptance, 12%; 6 – Total support, 81%.

Comments are provided in Supplementary material. See appropriate references.^{90,113,116-118,127-131}

Statement 49

We recommend the implementation of enteral feeding in patients with CP who cannot tolerate an oral diet, and who experience persistent nausea and vomiting, abdominal pain, delayed gastric emptying, or progressive weight loss refractory to oral therapy (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 13%; 5 – Acceptance, 12%; 6 – Total support, 75%.

Comments are provided in Supplementary material. See appropriate references.^132-137

Statement 50

We recommend the implementation of parenteral nutrition in patients with gastrointestinal failure, intolerance of enteral nutrition, or progressive weight loss refractory to enteral nutrition (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 0%; 5 – Acceptance, 13%; 6 – Total support, 87%.

Comments are provided in Supplementary material. See appropriate references.^123,133,138

Statement 51

For the calculation of the basal energy and protein requirements of patients with cirrhosis without ascites, we recommend taking the actual BW, whereas for patients with cirrhosis and ascites, we suggest using one of the following methods to estimate metabolically active BW (excluding peritoneal fluid weight): 1) ideal BW calculated based on height (height [cm] – 100); 2) BW measured just after peritoneal fluid discharge; 3) difference between actual BW and fluid weight representing 5% of current weight for mild ascites, 10% for moderate ascites, and 15% for advanced ascites, depending on the severity of the ascites, with an additional subtraction of 5% of BW for bilateral peripheral edema of the lower extremities (quality of evidence: low; strength of recommendation: weak).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 12%; 5 – Acceptance, 44%; 6 – Total support, 44%.

Comments are provided in Supplementary material. See appropriate references.^142-144

Statement 52

In patients with nonalcoholic steatohepatitis (metabolic dysfunction–associated steatohepatitis), we recommend a Mediterranean diet and weight reduction, as they are associated with reduced insulin resistance and hepatic steatosis as well as a lower risk of ischemic heart disease and diabetes (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 25%; 5 – Acceptance, 31%; 6 – Total support, 44%.

Comments are provided in Supplementary material. See appropriate references.^{141,143,145,146}

Statement 53

In patients with cirrhosis, we recommend a daily total energy intake of 30–35 kcal/kg/day and a protein supply of 1.5 g/kg/day for malnourished patients and 1.2 g/kg/day for other patients, taking metabolic limits into account (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 0%; 5 – Acceptance, 19%; 6 – Total support, 81%.

Comments are provided in Supplementary material. See appropriate references.^{111,139,140,142,147-152}

Statement 54

We recommend withholding enteral feeding for 48–72 hours after an episode of esophageal / gastric variceal bleeding (until bleeding is controlled), as enteral feeding makes endoscopic intervention more difficult, increases visceral flow, and may exacerbate variceal bleeding (quality of evidence: low; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 7%; 5 – Acceptance, 37%; 6 – Total support, 56%.

Comments are provided in Supplementary material. See appropriate references.^153-155

Statement 55

In patients with advanced alcoholic liver disease, we recommend a daily total energy intake of 30–35 kcal/kg/day and a protein supply of 1.2–1.5 g/kg/day, taking metabolic limits into account (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 6%; 5 – Acceptance, 25%; 6 – Total support, 69%.

Comments are provided in Supplementary material. See appropriate references.^141,156-158

Statement 56

We recommend monitoring blood ammonia levels and strict glycemic control during feeding in patients with acute liver failure (quality of evidence: low; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 7%; 5 – Acceptance, 31%; 6 – Total support, 62%.

Comments are provided in Supplementary material. See appropriate references.^{20,141,142,158,159}

Statement 57

To reduce frailty syndrome in patients being prepared for liver transplantation, we recommend a daily total energy intake of 30–35 kcal/kg/day and a protein supply of 1.2–1.5 g/kg/day, taking metabolic limits into account (quality of evidence: low; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 0%; 5 – Acceptance, 44%; 6 – Total support, 56%.

Comments are provided in Supplementary material. See appropriate references.^{141,142,144,160,161}

Statement 58

To prevent liver damage associated with parenteral nutrition, we recommend not exceeding metabolic limits and avoiding excessive macronutrient energy supply (overfeeding) (quality of evidence: low; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 0%; 5 – Acceptance, 25%; 6 – Total support, 75%.

Comments are provided in Supplementary material. See appropriate references.^162-165

Statement 59

We suggest that in older patients with diagnosed malnutrition or at a high nutritional risk who reside in 24‑hour and inpatient health care units ONSs should be administered in the traditional manner or at the time of solid medication administration, that is, in accordance with the Medication Pass Nutritional Supplement Program system (quality of evidence: moderate; strength of recommendation: weak).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 19%; 5 – Acceptance, 37%; 6 – Total support, 44%.

Comments are provided in Supplementary material. See appropriate references.¹⁶⁷

Statement 60

In older patients with oropharyngeal dysphagia, we recommend a clinical assessment of swallowing function by a speech therapist or phoniatrist. In older patients diagnosed with malnutrition, those at a high nutritional risk, and those with oropharyngeal dysphagia, we recommend modifying the consistency of the meals consumed and fortifying the diet as the first step. We recommend enteral nutrition in patients in whom adequate energy and protein requirements cannot be met via the oral route despite attempts to use compensatory techniques to improve swallowing (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 7%; 5 – Acceptance, 31%; 6 – Total support, 62%.

Comments are provided in Supplementary material. See appropriate references.^168,169

Statement 61

We recommend that a multidisciplinary nutrition support team, coordinated by physicians, nurses, dieticians, and pharmacists, be established in each 24‑hour and inpatient health care unit, and that a standard operating procedure for nutritional care is in place (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 7%; 4 – Partial acceptance, 6%; 5 – Acceptance, 12%; 6 – Total support, 75%.

Comments are provided in Supplementary material. See appropriate references.¹⁷⁰

Statement 62

We recommend routine assessment for malnutrition and high nutritional risk using validated clinical questionnaires in all hospitalized older patients, including those with excess body weight. In the case of a positive screening assessment for malnutrition, we recommend assessing the degree of malnutrition and then implementing an appropriate nutritional intervention (quality of evidence: high; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 7%; 5 – Acceptance, 12%; 6 – Total support, 81%.

Comments are provided in Supplementary material. See appropriate references.^171,172

Statement 63

In older patients, we recommend a daily energy intake of 30 kcal/kg BW/day, which should be individually adjusted according to the nutritional status, physical activity level, and coexisting chronic diseases (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 0%; 5 – Acceptance, 25%; 6 – Total support, 75%.

Comments are provided in Supplementary material. See appropriate references.^3,173,174

Statement 64

In older patients, we recommend a daily protein supply of at least 1 g/kg BW/day. If required, the dose may be higher, with individual adjustment for nutritional status, physical activity level, and chronic comorbidities (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 0%; 5 – Acceptance, 38%; 6 – Total support, 62%.

Comments in Supplementary material. See appropriate references.^175,176

Statement 65

We suggest the use of leucine‑enriched formulations with vitamin D₃ supplementation in nutritional interventions with special‑purpose medical foods due to the efficacy of these ingredients in sarcopenia in older patients (quality of evidence: moderate; strength of recommendation: weak).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 25%; 5 – Acceptance, 44%; 6 – Total support, 31%.

Comments are provided in Supplementary material. See appropriate references.^177,178

Statement 66

For enteral feeding in older patients, we suggest fiber‑containing nutrient mixtures (quality of evidence: low; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 6%; 5 – Acceptance, 50%; 6 – Total support, 44%.

Comments are provided in Supplementary material.

Statement 67

In older patients diagnosed with malnutrition or at a high risk of malnutrition requiring enteral or parenteral nutrition, we recommend starting it immediately, and that the caloric content of the formulas be gradually increased over the first 3 days to establish a metabolic limit and minimize the risk of refeeding syndrome.

We also recommend monitoring potassium, magnesium, and phosphorus levels during the first 3 days of nutritional treatment; all these minerals should be supplemented even in mild deficiencies. We recommend performing biochemical tests on subsequent days depending on the metabolic stability of the hospitalized patient, but at least once a week (quality of evidence: moderate; strength of recommendation: strong).

Scale of endorsement: 1 – Total rejection, 0%; 2 – No acceptance, 0%; 3 – Partial rejection, 0%; 4 – Partial acceptance, 0%; 5 – Acceptance, 25%; 6 – Total support, 75%.

Comments are provided in Supplementary material. See appropriate references.^179-182