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Malnutrition is a condition most commonly arising from the inadequate consumption of nutrients necessary to maintain physiological health and is associated with the development of cardiovascular disease, osteoporosis, and sarcopenia. Malnutrition occurring in the hospital setting is caused by insufficient monitoring, identification, and assessment efforts. Furthermore, the ability of health care workers to identify and recognize malnourished patients is suboptimal. Therefore, interventions focusing on the identification and treatment of malnutrition are valuable, as they reduce the risks and rates of malnutrition within hospitals. Technology may be a particularly useful ally in identifying malnutrition due to scalability, timeliness, and effectiveness. In an effort to explore the issue, this scoping review synthesized the availability of technological tools to detect and identify hospital malnutrition.
Our objective was to conduct a scoping review of the different forms of technology used in addressing malnutrition among adults admitted to hospital to (1) identify the extent of the published literature on this topic, (2) describe key findings, and (3) identify outcomes.
We designed and implemented a search strategy in 3 databases (PubMed, Scopus, and CINAHL). We completed a descriptive numerical summary and analyzed study characteristics. One reviewer independently extracted data from the databases.
We retrieved and reviewed a total of 21 articles. We categorized articles by the computerized tool or app type: malnutrition assessment (n=15), food intake monitoring (n=5), or both (n=1). Within those categories, we subcategorized the different technologies as either hardware (n=4), software (n=13), or both (n=4). An additional subcategory under software was cloud-based apps (n=1). Malnutrition in the acute hospital setting was largely an unrecognized problem, owing to insufficient monitoring, identification, and initial assessments of identifying both patients who are already malnourished and those who are at risk of malnourishment. Studies went on to examine the effectiveness of health care workers (nurses and doctors) with a knowledge base focused on clinical care and their ability to accurately and consistently identify malnourished geriatric patients within that setting.
Most articles reported effectiveness in accurately increasing malnutrition detection and awareness. Computerized tools and apps may also help reduce health care workers’ workload and time spent assessing patients for malnutrition. Hospitals may also benefit from implementing malnutrition technology through observing decreased length of stay, along with decreased foregone costs related to missing malnutrition diagnoses. It is beneficial to study the impact of these technologies to examine possible areas of improvement. A future systematic review would further contribute to the evidence and effectiveness of the use of technologies in assessing and monitoring hospital malnutrition.
An inadequate diet can cause malnutrition, a condition where an individual is not consuming sufficient amounts of nutrients necessary to maintain their current level of physiological health [
Malnutrition increases the risk of developing certain chronic diseases, such as cardiovascular disease, osteoporosis (a debilitating loss of bone density), and sarcopenia (a debilitating loss of muscle tissue, mass, and function) [
Hospital malnutrition has been a historical problem as well as a current troubling issue, with documented prevalence rates as high as 60% in some hospitals [
Addressing, identifying, and monitoring malnutrition properly may improve the outlook for older hospitalized patients. Interventions that focus on identification and treatment of malnutrition have positive influences on decreasing the risks and rates of malnutrition in hospitals [
There are no known scoping reviews, to the best of our knowledge, that have synthesized the availability of technological tools to detect and identify hospital malnutrition. Therefore, we undertook a scoping review of the literature to identify the extent of the published literature on this topic, describe key findings, and identify outcomes.
We followed Arksey and O’Malley’s [
The research questions were as follows: What is the extent of the published literature on using technology to monitor and assess malnutrition within the hospital setting? What is known from the existing literature about the impact and outcomes of implementing technology in such a manner?
We initially developed the complete search in PubMed (
We selected primary articles for inclusion in the scoping review if they discussed applicable technology-based approaches to monitor or assess malnutrition within the hospital or primary care setting. Articles not written in or translated into English were not included.
The definition of “applicable” included systems that were described, designed, or in current use and application at the hospital or primary care setting. We screened articles to determine relevancy of the systems.
(Nutrition [tw] OR Malnutrition [tw] OR Nutritional [tw] OR Hospital malnutrition [tw] OR Dietary assessment [tw] OR Food habits [tw] OR Eating [tw] OR Diet records [tw] OR Nutritional assessment [tw] OR nutrition support [tw] OR food habits [MeSH] OR eating [MeSH] OR diet records [MeSH] OR nutritional assessment [MeSH])
AND
(Monitoring [tw] OR Screening [tw] OR Technology-based dietary assessment [tw] OR Food record [tw] OR Recording [tw] OR Assessment [tw])
AND
(Device [tw] OR informatics [tw] OR technology [tw] OR computer [tw] OR Web based [tw] OR image based [tw] OR image retrieval [tw] OR picture [tw] OR digital photography [tw] OR mobile device [tw] OR mobile technology [tw] OR smartphone [tw] OR technology assist [tw] OR multimedia tool [tw] OR electronic [tw] OR wearable [tw] OR signal processing, Computer-Assisted/instrumentation* [MeSH] OR software [MeSH] OR wireless technology/instrumentation* [MeSH])
AND
(hospital [tw] OR primary care [tw] OR care [tw])
Technology-based approaches referred to any tool or system that was technology driven or computer based, and that comprised a hardware component or a software component (including Web- and cloud-based apps). Essentially, technology-based approaches excluded any conventional nutrition support tools that only included paper-based methods traditionally used for nutrition assessment.
We excluded studies that primarily considered nontechnologically driven or noncomputer-based solutions to address hospital malnutrition. We also excluded technologically driven or computer-based solutions based in hospitals, such as hospital accounting systems or inventory systems, that had no relevance to nutrition. For the purposes of our review, we excluded studies that primarily dealt with nutrition management systems focusing on prenatal and neonatal patients. The primary aim of this scoping review was to identify technologically relevant systems for use in hospitals for adults.
We selected articles in the following 2 phases: (1) title, abstract, and keyword review phase, and (2) full-text review phase.
Phase 1 review considered all search results. We developed a relevance form adapted from the template used by Griebel et al [
We organized the articles according to what the tool or app measured: malnutrition assessment, food intake monitoring, or both. Within these 3 categories, we subcategorized the articles by the type of technology used: software (including cloud-based apps), hardware based (including portable devices), or both.
The goal of this scoping review was to analyze eligible articles to obtain an overview of the scientific literature on technological and computer-based approaches to nutrition monitoring and assessment in hospitals. With this goal in mind, we summarized and present the collection of key messages and concepts from eligible publications. We developed a data synthesis and characterization form to include the following study characteristics: authors; year of publication; country of origin; publication type; aims and purpose; description of the patients or participants; description of the article; type of technology used (hardware, software, or both); availability of the tool or app (theoretic, prototypic, in use, or validated); outcomes of the intervention; and cost implications (if available).
The search returned 5444 articles. We deemed a total of 21 of those articles to be relevant after phase 1 and 2 reviews. Malnutrition assessment was the most frequent aim (n=15, 71%), followed by nutrition intake monitoring (n=5, 24%), followed by an app that measured both components (n=1, 5%) (
Most of the malnutrition assessment articles discussed technology based on software created and incorporated within the hospital’s own computer system (n=12, 80%). Subcategorized within the software category was an article that proposed a cloud-based system for malnutrition assessment (n=1, 7%). Some studies directly used a hardware component (portable device) that assessed malnutrition (n=2, 13%).
Among the food intake monitoring articles, 2 (40%) studies contained a hardware component and 3 (60%) used technology that contained both a hardware and a software component.
One article mentioned an inclusive nutrition system that contained technology for both malnutrition assessment and food intake monitoring.
The largest share of publications on the topic originated from the United States (n=7, 33%), followed by the United Kingdom (n=4, 19%), Spain (n=2, 10%), Taiwan, Philippines, the Netherlands, France, China, Australia, Argentina, and Israel, each with 1 article (n=1, 4.8%).
Most of the articles reported semiexperimental studies (n=16), followed by descriptive studies (n=3), a randomized controlled trial (RCT; n=1), and a retrospective study (n=1). Semiexperimental studies may dominate the field because they all introduced a novel malnutrition assessment or nutrition intake monitoring tool, which was primarily being tested for accuracy and effectiveness (on patients, participants, or extracted data) against universally accepted and standardized malnutrition assessment tools (eg, Mini Nutritional Assessment-Short Form [MNA-SF], Subjective Global Assessment [SGA], or Full Nutrition Assessment [FNA]) or expert opinions.
Most of the studies tested their tools and apps on patients or participants (n=14). Additionally, most of the studies reported that their tool or app was able to increase malnutrition detection or awareness (n=14). The same articles reported a degree of accuracy respective to their tool or app as determined by using validated tools (eg, MNA-SF, SGA, or FNA) or clinical nutrition expert and dietician consultations or testing (n=15).
Flowchart summarizing the results.
Number of articles by year of publication.
A key concept mentioned in some of the articles that included a software component is automated data collection. For example, some software systems included features that allowed other departments within the hospital, such as the biochemical laboratory, to update a patient’s blood test results automatically [
Another feature of software apps was the ability to display a nutrition diagnosis (eg, undernourished, malnourished, low protein energy metabolism), an automated warning, or an alert once relevant data parameters were assessed. Some apps provided automated alerts that informed health care workers when a patient was assessed as being at risk for malnutrition [
Only 1 study had cloud-based technological components. It allowed health care workers to create an account, log in, and begin manually entering patient data, such as biochemical markers [
For the hardware component, portable devices were used to assess malnutrition risk. Largely based in the 1980s, these portable devices were pocket computers, where physical, anthropometric, and laboratory results could be manually entered to produce a malnutrition assessment [
Most of the interventions had successful outcomes (n=16, 76%) [
In addition to saving time and improving detection rates, 4 articles discussed the economic benefits and potential costs saved from incorporating the mentioned technology into practice [
Of the tools and apps reviewed, less than half (n=9) were available for further clinical testing and implementation within other hospital systems [
The 2 research questions formulated at the beginning of this scoping review were as follows: What is the extensiveness of the existing literature? What are the key impacts and outcomes? We discuss the outcomes in terms of effectiveness and accuracy of tools and apps; financial implications; efficiency and educational implications; and future and ethical implications.
A total of 15 of the 21 tools and apps examined in this scoping review were effective in accurately increasing malnutrition detection and awareness using either malnutrition assessment apps or nutrition intake monitoring tools [
Effectiveness was tested in a variety of ways, including evaluation studies, an RCT, and prototype testing conducted on a sample of patients or participants. The malnutrition assessment apps’ effectiveness and accuracy were tested against common practice-validated nutrition screening tools used globally by hospitals, such as the MNA-SF, SGA, and FNA tools; or they were directly assessed based on expert opinions of clinical dieticians and clinical nutrition experts. The nutrition intake monitoring tools’ accuracy and effectiveness were tested by comparing results from the estimated amount of food consumed with the actual amount of food consumed [
The results show that malnutrition assessment tools and apps were the dominant forms of technology used to measure malnutrition outcomes, while nutrition intake monitoring tools were used to a lesser extent. Malnutrition assessment tools and apps may dominate the literature because they may offer greater incentives and benefits than nutrition intake monitoring tools, which by their nature may require additional hospital expenditures on infrastructure (such as recording hardware or cameras). One possible incentive for using malnutrition assessment tools and apps may be their relative ease of implementation compared with nutrition intake monitoring tools. This may be due to the fact that most malnutrition assessment apps incorporated software programs, which may easily be adapted into a hospital’s existing electronic infrastructure [
Some of the most simplified apps used Excel files that were tied into an algorithm developed by the authors [
From an economic perspective, malnutrition is associated with increased LOS and readmission rates within hospitals [
A total of 3 of the reviewed articles mentioned economic incentives associated with implementing technology-based approaches for malnutrition assessment [
As health care costs in North America are on the rise and since the costs relating to malnutrition account for some of that expenditure, the results suggest that implementing such technology in the hospital setting could save costs [
Because older patients experience increased rates of deconditioning within the hospital, hospitals may find it beneficial to undertake efforts that identify malnutrition faster than conventional methods. Giovannelli et al [
The economic incentive is also extended to patients. They benefit not only physiologically from earlier malnutrition detection but also financially through decreased spending related to deconditioning outside of the hospital for homecare or nursing care [
In hospitals and other medical settings where there is a “pay-for-performance” infrastructure, the detection of malnutrition may result in
The results suggest that technological nutrition support tools and apps may help reduce health care workers’ workload and time spent assessing patients for malnutrition [
The results also showed that certain tools and apps can collect relevant data either automatically or by being entered manually into the system. In our review, more articles discussed tools or apps that were able to automatically collect data. Some of the studies described their nutrition support technologies as being able to monitor, assess, and identify hospital malnutrition cases relatively independently or with minimal input from health care workers [
Technology that has the ability to run independently or with minimal input may be beneficial in hospital areas where noise pollution is abundant, or in areas where there is relatively little time for health care workers to manually collect and analyze malnutrition information (eg, in the intensive or critical care unit). Additionally, some hospitals choose to lay off health care workers, which increases the workload and patient to nurse ratio, adding further strain on malnutrition monitoring and assessment efforts [
Furthermore, nutrition support tools and apps may have educational implications for health care workers, including nurses and doctors. Dieticians and clinical nutrition experts have more years of formal schooling and experience relating to malnutrition assessment and identification than do nurses and doctors [
However, none of the articles discussed the ease of use from the user’s perspective. The importance of establishing a usability rating may help determine the tool’s or app’s
It is common practice that scoping reviews do not address issues of quality appraisal relating to the sources of literature used. In this scoping review, we tried to use and capture peer-based research articles that directly tested their tool or app on a cohort of patients or participants. A few articles in this scoping review contained technology in the
Additionally, each of the reviewed research articles included different and unique types of software and hardware technologies respective to their study. Future research should seek to test the efficacy of one type of computer tool or app across different hospitals in the form of RCTs in order to contribute to a higher level of evidence for the field. It would also be interesting for future efforts to compare and test the outcomes of using malnutrition assessment tools and apps versus nutrition intake monitoring tools.
It is likely that we excluded some relevant research articles from this review, as we screened only English-language publications. Some studies (n=8) did not pass phase 2 relevance screening because of the language restriction. These studies might have added further applications and outcomes in this scoping review. Perhaps future efforts to translate these publications will add value and knowledge to the field. Lastly, because this was a review study, we based our analysis solely on the information found in each included article, which was up-to-date only at the time of publication.
The use of technologies for monitoring food intake and assessing malnutrition are beginning to be considered for future hospital processes that aim to identify, diagnose, and assess hospital malnutrition. Many computerized tools and apps are being developed worldwide to address the problem of hospital malnutrition. It is beneficial to study the impact of these technologies to examine their applicability and possible areas of improvement.
Search terms by database.
Adapted data characterization form.
Full Nutrition Assessment
length of stay
Mini Nutritional Assessment-Short Form
Rambam Automated Nutrition Computerized Screening
randomized controlled trial
Subjective Global Assessment
This work was supported by a Discovery Grant (RGPIN-2014- 04743) from the Natural Sciences and Engineering Research Council of Canada (NSERC).
DT and JL designed the research; DT conducted the research; JL provided essential materials; DT analyzed the data; DT and JL wrote the paper; and DT and JL had primary responsibility for the final content. All authors read and approved the final manuscript.
None declared.