Introduction

Disease-related malnutrition, which refers to malnutrition resulting from disease rather than poverty, is a global public health issue. This condition is often associated with substantially increased morbidity, disability, short- and long-term mortality, significantly impaired recovery from illness, and high costs of care.1–3 Most malnutrition in adult hospitalized patients is caused by disease-related malnutrition.4,5 However, prior to the official release of the Global Leadership Initiative on Malnutrition (GLIM) criteria in 2019,6 the terms “nutritional risk (ICD-10: R63.801)” and “malnutrition (ICD-10: E46.x00x003)” were often conflated, and the assessment criteria for both were somewhat confusing.4,7 Nutritional risk refers to the risk that existing or potential nutritional and metabolic factors may cause adverse clinical outcomes such as decreased physiological function, increased complications, and mortality.4,7,8 According to the World Health Organization (https://www.who.int/health-topics/malnutrition#tab=tab_1.Accessed December 14, 2024), malnutrition refers to deficiencies or excesses in nutrient intake, imbalance of essential nutrients, or impaired nutrient utilization. The double burden of malnutrition consists of both undernutrition and overweight and obesity, as well as diet-related noncommunicable diseases. However, in the narrow definition and the GLIM criteria, malnutrition is commonly defined clinically as a state of energy or nutrient deficiency caused by inadequate intake or impaired utilization, with an emphasis on “undernutrition”, which manifests itself in four broad forms: wasting (low weight for height), stunting (low height for age), underweight (low weight for age) and micronutrient deficiencies. Therefore, nutritional risk/malnutrition is referred to as “undernutrition” in this review.

The diagnostic criteria for GLIM follow these three steps5,6 (Table 1): First, nutritional risk screening (use validated screening tools to determine if the patient is at nutritional risk). Second, malnutrition assessment based on existing nutritional risks (This includes phenotypic indicators, including involuntary weight loss, body mass index [BMI], muscle mass loss, and etiologic indicators, including decreased food intake or absorption, inflammation, or disease burden. Those who meet at least one phenotypic indicator and one etiologic indicator can be diagnosed with malnutrition). Third, assess the severity of malnutrition (If the weight loss is >10% within the last 6 months, if the weight loss over 6 months is >20%, or if the BMI is less than 18.5 kg/m2 with generally poor conditions, it is considered severe malnutrition. Moderate malnutrition% = total malnutrition% - severe malnutrition%). According to the GLIM criteria, assessing nutritional risk is the first step in diagnosing malnutrition. Patients who are malnourished inevitably have nutritional risks, but those with nutritional risks are not necessarily malnourished. Unfortunately, despite the known relationship between nutritional risk/malnutrition and poorer outcomes, clinical nutrition has not received sufficient attention worldwide,9–12 and clinical nutriology has seriously lagged behind in terms of advances in clinical medicine. In China, the lack of clarity on the positioning and affiliation of clinical nutrition departments, shortage of clinical nutritionists, and low professional level of dieticians are common phenomena.9 It was not until 2022 that the National Health Commission of China required secondary or higher general and cancer hospitals to establish clinical nutrition departments to standardize and promote the development of clinical nutrition. This situation raises concerns regarding the status of clinical nutrition, especially in low- and middle-income countries (LMICs) or impoverished regions, where it is likely to be even more problematic.13

Table 1 The GLIM Diagnostic Criteria for Malnutrition

In addition to disease-related appetite loss and medication-related side effects, surgery, anesthesia, pain, and psychosocial factors accelerate poor appetite and poor adherence to medical nutrition therapy in perioperative patients.7,14,15 Therefore, perioperative patients face more severe nutritional problems, and perioperative medical quality control and safety management should focus on patients with nutritional risk/malnutrition. However, there is a lack of literature to comprehensively summarize the current epidemiology and development of perioperative nutritional risk/malnutrition. In addition, the current research on perioperative nutrition comes primarily from developed countries or regions, university teaching hospitals, or large tertiary hospitals. Concurrently, perioperative obesity (or overnutrition) has received a great deal of attention in the past few decades. This situation leads to the misconception that perioperative nutritional risk/malnutrition is not common. However, it is more likely that perioperative nutritional risk/malnutrition is overlooked, leading to inadequate diagnosis and a lack of comprehensive medical records.8

This literature review aimed to identify and explore the epidemiology, related adverse outcomes, controversies, and dilemmas of perioperative nutritional risk/malnutrition through studies undertaken over the last 10 years to further the development of perioperative nutritional medicine.

Materials and Methods Search Strategy and Data Extraction Method

Databases comprising PubMed, Embase, Cochrane Library, Wanfang Academic Journal Full-text Database, China National Knowledge Infrastructure, China Biology Medicine disc, and Chongqing VIP Database were searched for articles published between January 1, 2014 and August 31, 2024 using the following MeSH terms: (“nutritional risk”[Title/Abstract] OR “malnutrition”[Title/Abstract] OR “undernutrition”[Title/Abstract]) AND (“surgery”[Title/Abstract] OR “surgical”[Title/Abstract] OR “operative”[Title/Abstract] OR “operation”[Title/Abstract]). The most relevant original studies, systematic reviews, and high-quality reviews were selected, and the original observational studies were used to explore the epidemiology of nutritional risk and malnutrition. All potentially relevant studies were manually searched based on the references in the identified studies. We excluded protocols, conference proceedings, comments, case reports, editorials, and studies that were not published in full text. Two reviewers performed the screening and data extraction independently. Data were synthesized narratively.

Results Study Selection

The literature search identified 23,408 studies. After removal of duplicates, 12,950 articles were screened at the title and abstract stage for eligibility, with 12,848 not meeting the inclusion criteria and subsequently excluded. Of the 102 articles that proceeded to full-text screening, 16 original observational studies7,8,10,15–27 from seven countries were eligible for this review of nutritional risk, with a sample size of 14,148 adults from the 14 included studies7,8,10,15–25 and 333 children from the two included studies.26,27 For the review of perioperative malnutrition, a total of 25 original observational studies7,8,12,17–19,21,23,26,28–43 from over 75 countries were eligible. The sample size comprised 31,111 adults from 19 included studies7,8,12,17–19,21,23,28–38 and 28,3756 children from the six included studies.26,39–43 The selection process is summarized in a PRISMA flow diagram (Figure 1). The main characteristics of the studies are summarized in Table 2 and Table 3.

Figure 1 PRISMA Flow diagram of search history and study selection. PRISMA, Preferred Reporting Items for Systematic reviews and Meta-Analyses.

Screening Tools and Diagnostic Criteria Screening Tools for Nutritional Risk

The most used screening tool was the Nutrition Risk Screen-2002 (NRS-2002; Supplementary Table 1), which is currently the only nutritional risk screening tool with a strong evidence-based foundation and the goal of improving clinical outcomes.4,5,44 Additionally, attention to perioperative nutritional risk in children remained inadequate compared to that in adults (Table 2). The Screening Tool for Risk on Nutritional Status and Growth (STRONGkids) was used as a nutritional screening tool for children (Table 2).26,27 According to the NRS-2002 and STRONGkids, even patients with overweight or obesity who are about to undergo or have undergone surgery may face nutritional risks.

Table 2 Characteristics of the Included Studies for Nutritional Risk

Other nutritional screening tools for adult perioperative patients included the Mini Nutritional Assessment Short-Form (MNA-SF),8,21 malnutrition universal screening tool,21,24 patient-generated subjective global assessment (PG-SGA)25 and perioperative nutrition screening (PONS)21 (Table 2).

Malnutrition (Undernutrition)

The most used diagnostic criteria were the GLIM criteria for adults, the “Z-score below −2” for weight-for-age, height-for-age, and weight-for-height based on the World Health Organization criteria (https://www.who.int/tools/child-growth-standards. Accessed September 30, 2024) for children (Table 3).

Table 3 Characteristics of the Included Studies for Malnutrition

In addition, albumin (ALB),34 BMI,34 geriatric nutritional risk index,37 MNA-SF,8 PG-SGA,38 prognostic nutritional index (PNI),18 SGA,36 and serum total protein (TP)35 were used to diagnose malnutrition in adult perioperative patients (Table 3).

Incidence

The incidence of nutritional risk/malnutrition varied across nutritional screening tools, diagnostic criteria for malnutrition, patient characteristics, types of disease and surgery, regions and ethnicities, and healthcare systems.10

Incidence of Preoperative Nutritional Risk (TABLE 2)

The incidence of nutritional risk, using the NRS-2002, was 21.2%7 to 24.1%15 in patients undergoing elective surgery, 53.6%22 in older adults, and 44.3%18 to 70.3%23 in patients with tumors or major elective surgeries. The incidence of nutritional risk in children, according to STRINGOkids, ranged from 50.7%26 to 55.4%.27

Incidence of Preoperative Malnutrition (TABLE 3)

When employing the GLIM criteria, the incidence of malnutrition in surgical patients was 33.3%28 to 77.2%29 in patients with cancer, 18.8%32 to 28.6%30 in patients with cardiovascular disease, 67.1%19 in patients with major hepatobiliary disease, 11.9%17 in patients with gastrointestinal disease, and 19.9%31 in patients undergoing emergency abdominal surgery. The incidence of malnutrition in all pediatric perioperative patients was 19.4%.41 The prevalence of malnutrition was 32.4%43 in children aged 5–18 years with Crohn’s disease who underwent intestinal surgery, 10.8%40 to 20.0%40 in children who underwent cleft lip and palate surgery, 5.8%39 to 15.9%39 in children under 18 years who underwent Fontan surgery, and 60.0%42 to 64.3%42 in children younger than 36 months who underwent surgery for congenital heart defects, using the weight-for-age Z-score, height-for-age Z-score, or weight-for-height Z-score criteria. These data are even more alarming when considering that 50% of patients experience a further significant decrease in body weight during their hospital stay.15

Pathogenesis

Several causes lead to nutritional risk/malnutrition in perioperative patients, including the underlying pathologic processes of disease, inflammation and stress reaction during surgery, and decreased intake due to perioperative fasting and delayed recovery of bowel function.36 The major pathogenic mechanisms are as follows.44,45

Insufficient Intake

Insufficient intake can be due to illness, surgery, pain, fasting, and postoperative nausea and vomiting (PONV).

Increase in Consumption

Inflammatory reactions, oxidative stress, and pain lead to high energy consumption in the body.

Reduction in Bioavailability

Decreased bioavailability of nutrients can be due to diarrhea, PONV, and digestion and absorption disorders.

Metabolic Abnormalities

Metabolic abnormalities are associated with severe diabetes, hyperthyroidism, and liver and kidney failure.

Risk Factors

The identification of perioperative risk factors is essential not only for the prevention and management of nutritional risk/malnutrition but also for improving clinical outcomes in perioperative patients. Perioperative nutritional risk/malnutrition is the result of multiple risk factors and dimensions interacting in the aforementioned pathogenesis. Based on existing research, the major risk factors are as follows (Figure 2):

Figure 2 Perioperative risk factors for nutritional risk/malnutrition. Created in BioRender. He, M. (2025) https://BioRender.com/s25t382..

Abbreviations: ASA, American Society of Anesthesiologists Physical Status Classification.

Advanced and Young Age

Older people have a higher incidence of nutritional risk/malnutrition than adults, owing to their poor baseline conditions, multiple comorbidities, and complex and variable conditions.45 The British Association for Parental and Enteral Nutrition conducted nutritional screening of 31,637 hospitalized patients in the UK from 2007 to 2011 and found that the nutritional risk was associated with advanced age.46

In addition, malnutrition is a highly prevalent condition in hospitalized pediatric patients and has been shown to be associated with increased incidence in pediatric surgery.41 Children aged 1–60 months were vulnerable to malnutrition.26 Among the perioperative children, those aged <5 years had the highest nutritional risk, especially those aged <2 years.40

Sex

Some reports have shown that among perioperative patients, women are more prone to malnutrition than men, especially those aged over 65 years.46,47 However, Thomas et al15 found that the male sex was an independent risk factor for nutritional risk during elective surgery. Other studies have reported no association between sex and nutritional risk/malnutrition.36,48,49 Therefore, sex-related differences in nutritional risk/malnutrition may depend on the study population.

Comorbidities

Patients with chronic wasting diseases or metabolic abnormalities, such as malignancy,38,50 atrophic gastritis,51 chronic renal failure,52,53 cirrhosis,54,55 chronic obstructive pulmonary disease,56 tuberculosis,57 and systemic lupus erythematosus58 have a higher incidence of perioperative nutritional risk/malnutrition.

American Society of Anesthesiologist (ASA) Physical Status Classification

The ASA physical status classification is mainly based on the physical condition and perioperative risk, with postoperative complications and mortality increasing with higher ASA grades.59 Patients with higher ASA grades have a higher incidence of nutritional risk/malnutrition17,59 We recommend that the ASA level ≥ 3 be the threshold for this risk factor.59

Major Surgeries (Not Specified [Classified by Doctor])

Patients undergoing gastrointestinal,26,60 malignancy,38,50 heart and great vessels,37,47,61 spine,62 hip,63,64 cranial, bariatric,65,66 and cleft lip and palate surgeries40 are at high nutritional risk and susceptible to malnutrition.

Psychological Disorders and Insufficient Social Support

Psychological disorders caused by illness, surgical trauma, and concomitant treatment during hospitalization, such as anxiety, depression, and cognitive impairment, may increase the nutritional risk.45,49 Patients living in poverty, living alone, and with insufficient social support are at increased nutritional risk.45

Other Factors

Winter,46 smoking,47 taking more than three prescription drugs per day,10 and lower educational levels10 were reported to be associated with increased nutritional risk/malnutrition.

Nutritional Risk/Malnutrition-Related Adverse Perioperative Outcomes

Postoperative complication rates for patients with nutritional and non-nutritional risk undergoing elective surgery were 17% and 7%, respectively.15 The incidence of postoperative adverse events in patients with malnutrition is 2–4 times higher than that in patients without malnutrition.35 Nutrition-related perioperative adverse events included infection, wound healing disorders, reoperation and unplanned readmission, prolonged hospital stay, mortality, perioperative neurocognitive dysfunction (PND), and venous thrombosis (Figure 3).

Figure 3 Nutritional risk/malnutrition-related adverse perioperative outcomes. Created in BioRender. He, M. (2025) https://BioRender.com/s25t382..

Abbreviations: ICU, intensive care unit; PND, perioperative neurocognitive dysfunction.

Infection

Malnutrition contributes to significantly worse postoperative surgical-site infections (SSIs),28,67,68 and preoperative malnutrition occurs in 85% of patients with SSIs.69 Patients with preoperative serum ALB <3.3 g/L have been reported to have a 3-fold increased SSI risk.67 Tan et al21 found that patients with preoperative malnutrition who underwent abdominal surgery for gastrointestinal cancer showed a 2.2-fold increase in postoperative infection-related complications. A high incidence of preoperative malnutrition is associated with pulmonary complications after esophagogastric cancer surgery.29 In addition, nutritional status is significantly correlated with postoperative infections in children, including pneumonia, urinary tract infections, and central venous catheter-associated bloodstream infections, especially those receiving preoperative nutritional support, experiencing developmental delay, or having hypoalbuminemia.41,43

Wound Healing Disorders

It is widely recognized that malnutrition can lead to impaired wound healing.12,25,35,40 In geriatric patients undergoing elective orthopedic surgery, malnutrition increased the risk of wound healing problems approximately six-fold.35

Reoperation and Readmission

The nutritional status of patients significantly correlated with the rate of reoperation.12,43 Meyer et al35 reported that malnutrition increased the risk of reoperation by 1.6 times in older adult patients undergoing elective orthopedic surgery. There is also a significant positive correlation between nutritional risk/malnutrition and patient readmission rates within 30 days of discharge.12,15,21

Prolonged Hospital Stay

Patients with nutritional risk/malnutrition have higher rates of perioperative complications, which undoubtedly result in prolonged hospital stays. The lengths of hospital stay for adult patients undergoing elective surgery with and without nutritional risk were 13 and 7 days, respectively.15 Unosawa et al37 reported that malnutrition is an independent risk factor for patients undergoing elective cardiac surgery who have been hospitalized for more than 1 month, with a risk 3.4 times higher than that for patients with normal nutrition. Ladd et al43 reported that among children with Crohn’s disease who underwent bowel resection, the length of hospital stay was 12 days for severely malnourished children and 6 days for children with normal nutrition.

Mortality

Nutritional risk/malnutrition leads to increased risk of mortality in perioperative patients.12,48,63,70 Abahuje et al36 found that malnutrition on admission was an independent risk factor for perioperative death in 279 patients undergoing emergency surgery at the University of Kigali Teaching Hospital in Rwanda. The mortality rate in patients undergoing emergency surgery with malnutrition was 27.25-times that of patients with normal nutrition.36 According to Feng et al,48 preoperative malnutrition can lead to a 2.5-fold increase in long-term postoperative mortality.

Perioperative Neurocognitive Dysfunction

Nutrition is involved in neurodegeneration, and malnutrition is associated with an increased risk of neurodegenerative diseases, especially in women, older individuals, and patients with hypertension.71 Patients with good nutritional status have better postoperative cognitive function.64 Preoperative nutritional risk/malnutrition are independent risk factors for PND.72–74 It has been reported that patients with nutritional risk undergoing coronary artery bypass grafting have a 1.56 to 6.32-fold increased risk of postoperative delirium.72,73 In addition, preoperative enteral-enriched nutrition improves postoperative cognitive impairment in rats.75 Therefore, some researchers have suggested that nutritional interventions should be implemented in patients with nutritional risk/malnutrition to reduce the risk of PND.64

Venous Thrombosis

Evidence shows that nutritional risk/malnutrition is a high-risk factor for venous thrombosis, especially in patients with tumors76,77 or fractures78 or those undergoing major surgery.79,80 Lijfering et al81 considered that nutritional interventions may reduce the risk of venous thrombosis but also noted that this is difficult to confirm through prospective clinical trials due to limitations in clinical ethics, follow-up, and survivor bias. The ability of nutritional interventions to prevent cerebral microvascular thrombosis82 and deep venous thrombosis83 has been demonstrated in rat models.

Other Adverse Outcomes

Nutritional risk/malnutrition increases the risk of unplanned reintubation,12 unplanned intensive care unit admission,35 failure to wean off a ventilator within 48 hours,12 non-home discharge,12 perioperative blood transfusion,12,17,26 postoperative fistula formation,24,40 and postoperative long-term bedridden state,37 resulting in decreased short- and long-term quality of life after surgery.84

Discussion Low Rates of Perioperative Nutrition Screening and Medical Nutrition Therapy

Although perioperative nutritional risk/malnutrition-related adverse effects have been widely recognized and reported, the importance of nutrition management in clinical medicine is not well understood by clinical medical teams, and perioperative nutrition screening and medical nutrition therapy rates remain low.1,15 In some regions of Western Europe and the United States, only 20% to 38% of perioperative patients undergo nutritional risk screening during the perioperative period.47 In 2016, a survey questionnaire from 325 trauma and orthopedic departments in Germany showed that only 56% of perioperative patients underwent nutritional assessment.11 Another survey of gastrointestinal surgeons in Europe showed that nutritional risk screening was common prior to surgery (62% in Italy to 96% in Poland) but less frequently performed postoperatively (19% in Poland to 54% in Germany), using varied screening methods.85 A study from three Belgian hospitals found that none of the patients undergoing elective major surgery received preoperative dietary advice, nutritional counseling, or nutrient supplementation.10 Malnutrition in older adults is overlooked and underdiagnosed in the United States, affecting up to 60% of hospitalized patients aged 65 years and older, with less than 5% documented in medical records.8

Numerous Nutritional Screening Tools and Malnutrition Diagnosis Criteria: No Consensus on the Optimal Assessment Method

Although the GLIM proposed a consensus-based framework to standardize the diagnosis of malnutrition worldwide, it has not been widely disseminated and effectively applied.21,33,85 The evidence obtained using the GLIM criteria is still insufficient based on the guidelines outlined by Keller et al,86 and other tools for nutrition assessment are still being developed and used.36,87 The confusion between nutritional risk and malnutrition is common in clinical practice.10

Various Nutritional Risk Screening Tools and Diagnostic Criteria for Malnutrition

Wide variation exists in approaches to screen malnutrition risk or identify malnutrition in surgical patients, using a range of tools and nutrition markers.88 European countries recommend the NRS-2002 as the preferred tool for nutritional risk assessment of hospitalized patients.89–91 The PONS is recommended by the American Society for Enhanced Recovery for perioperative nutritional screening.92 According to a survey questionnaire from Germany,11 the most commonly used nutritional risk screening tool is BMI (74%), followed by the MNA (30%), laboratory indicators (ALB and TP, 29%), and NRS-2002 (19%).

Anthropometry Has Not Been Widely Used in Clinical Practice

Except for the widespread use of BMI, other anthropometric measures such as abdominal circumference, arm circumference, and triceps skinfold thickness are rarely used in clinical practice. However, severe protein-calorie malnutrition requires evidence of changes in body composition and cannot be extrapolated solely from anthropomorphic measures.41

Laboratory Indicators for Nutritional Assessment are Controversial

Due to the simplicity and ease of obtaining laboratory indicators for perioperative patients, ALB,93 TP,35 prealbumin,93 hemoglobin,94,95 and PNI,96,97 have been used clinically to aid in the assessment of patient nutritional status. Historically, malnutrition has been identified in perioperative patients using laboratory values such as ALB.34,93 In emergency general surgery, the most commonly used primary or secondary marker of nutritional status to define malnutrition was BMI, followed by ALB level.88 Most of these studies defined malnutrition as ALB <3.5 g/dL34,35 and focused on the impact of hypoproteinemia on perioperative prognosis,67 such as increased incidence of SSIs, pneumonia, urinary tract infections, and sepsis. However, the assessment of nutritional status using laboratory indicators is limited and controversial because of factors such as stress response, inflammation, infusion, and acute and chronic blood loss during the perioperative period.

Lack of Full Consideration of Perioperative Nutrition Risk/Malnutrition Symptoms

Symptoms such as nausea, taste changes, fatigue, pain, and decreased activity are not fully considered in perioperative nutritional risk screening.

An ideal method should accurately assess the nutritional status of the body and predict nutrition-related complications. High sensitivity, good specificity, and simplicity are the main requirements for the development of nutritional assessment methods for clinical practice. Multiple nutritional screening or assessment methods may be used simultaneously for the comprehensive assessment of nutritional risk/malnutrition.

Low Evidence-Based Clinical Nutrition Research and Lack of in-Depth Mechanistic Studies

Due to clinical ethical issues, multiple clinical confounders, follow-up limitations, and survivor bias, current research in clinical nutrition is mainly focused on observational studies (many of them retrospective) and surveys, making it difficult to verify the impact of nutritional interventions on patient outcomes through randomized controlled trials.81,98 Considering the basic condition of the patient, the severity of the disease, the comprehensive medical level, and the important role of surgery and anesthesia, it is difficult to explain the role of nutritional intervention in the overall prognosis of the disease. A recent landmark trial99 used perioperative amino acids infusion to reduce the occurrence of acute kidney injury in cardiac surgery. Explaining the mechanisms by which amino acids influence renal function will provide a deeper understanding of the physiological basis for nutritional interventions.

However, the lagging development of clinical nutrition and the shortage of clinical nutritionists have limited the development of basic clinical nutrition research and in-depth mechanism exploration, making it difficult to elucidate the relationship between nutritional risk/malnutrition and adverse outcomes at the pathophysiological, genetic, or molecular levels.

Inconsistent Timing of Nutritional Assessment

The preoperative period may represent an attractive window for nutritional assessment and the initiation of therapy to optimize the patient’s nutritional status and physical function prior to surgery. Numerous studies have shown that preoperative nutritional status is most strongly associated with perioperative adverse outcomes.100 The first outpatient visit before surgery15 is the ideal time point for preoperative nutritional screening because it can better predict perioperative risks while avoiding additional medical interventions and the impact of disease progression on nutritional assessment. In this setting, an additional preoperative hospital stay for nutritional support could be ruled out, whereas the positive effects on the postoperative course could be achieved.15 In addition, the first day after admission,18,19 as recommended by the ESPEN and Chinese Society for Parenteral and Enteral Nutrition guidelines, is also an ideal time to perform preoperative nutritional screening.

Multidisciplinary Collaboration is Required for Perioperative Nutrition Management

Since clinical nutritionists are not directly involved in the process of diagnosing and treating disease, there is currently a disconnect between the aim of nutritionists and the needs of hospitalized patients. Nutritionists cannot obtain the patient’s nutritional diagnosis and treatment needs in a timely manner, and the patients lack subjective initiative in clinical nutrition treatment. Furthermore, surgeons, anesthesiologists, and nurses play a crucial role in diagnosing and managing conditions in the perioperative period. Regrettably, the intricacies of malnutrition’s evaluation and management are not widely comprehended by these professionals.101 In addition, pain, PONV, and fasting are important causes of increased nutritional risk and poor adherence to nutritional interventions in perioperative patients. Therefore, perioperative nutrition therapy requires a multidisciplinary team,8 including anesthesia, nursing, nutrition, and surgeons. Considering the impact of nutrition on the long-term prognosis of patients,39 long-term nutritional follow-up and the involvement of rehabilitation therapists are also required after discharge. More importantly, given the prevalence of perioperative nutritional risk/malnutrition worldwide, a foundation in understanding nutritional issues is essential for anesthesiologists, surgeons, and nurses. This is a topic that is typically bypassed in medical education programs.

Lack of Reports for Community Hospitals, Small Hospitals, LMICs, or Poor Regions

Current research on perioperative nutrition mostly comes from developed countries or regions, university teaching hospitals, or large tertiary hospitals. However, perioperative nutritional risk/malnutrition may be more severe in community hospitals, small hospitals, LMICs, or poor regions, leading to alarming perioperative adverse outcomes. An international multicenter study from the GlobalSurg Collaborative and NIHR Global Health Unit on Global Surgery showed that the burden of severe malnutrition following elective surgery for colorectal or gastric cancer is disproportionately high in LMICs (62.5%) and upper-middle-income countries (44.4%).28 It is essential to reduce knowledge gaps regarding malnutrition and perioperative mortality in high-income countries and LMICs.13

Under-Recognition of Micronutrient Malnutrition

Current studies have focused primarily on the impact of protein-energy malnutrition on adverse perioperative patient outcomes. However, little is known about the impact of micronutrient malnutrition, such as vitamins and minerals.35 Epidemiological studies have shown that the incidences of vitamin D, vitamin B12, and folate deficiencies are high, especially in the older adult population. Recent studies have shown that bariatric surgery leads to micronutrient deficiencies.102 Patients undergoing elective orthopedic surgery with severe vitamin D deficiency (<12 ng/mL) exhibit a higher rate of postoperative falls.35 Therefore, it is necessary to pay attention to perioperative micronutrient malnutrition.35

Conclusion

According to the National Surgical Quality Improvement Program of the American Association of Surgeons, malnutrition is one of the few modifiable preoperative risk factors associated with poor perioperative outcomes. Given the prevalence and underestimation of preoperative nutritional risk/malnutrition and its associated adverse outcomes, perioperative patients should undergo nutritional screening at the first outpatient visit before surgery and/or on admission. Early, timely, and comprehensive nutritional intervention during the perioperative period is expected to improve medical quality and safety, enhanced recovery after surgery, and clinical patient outcomes. Most importantly, a multidisciplinary team is needed to collaborate in the implementation of perioperative nutrition management. Given that the prevention and treatment of patients with malnutrition risk or malnutrition usually require a period much longer than the anticipated length of stay, research on the relationship between perioperative nutrition and disease prognosis and its potential mechanisms, targeted prevention, and the development of nutritional supplements may be new directions for study in this field in the future.

Abbreviations

ALB, Albumin; ASA, American Society of Anesthesiologist; BMI, Body mass index; GLIM, Global Leadership Initiative on Malnutrition; LMICs, Low- and middle-income countries; MNA-SF, MiniNutritional Assessment Short-Form; NRS-2002, Nutrition Risk Screen-2002; PG-SGA, Patient-generated subjective global assessment; PND, Perioperative neurocognitive dysfunction; PNI, Prognostic nutritional index; PONS, Perioperative nutrition screening; SGA, Subjective global assessment; SSIs, Surgical-site infections; STRINGOkids, Screening Tool for Risk on Nutritional Status and Growth; TP, Total protein.

Data Sharing Statement

Data sharing does not apply to this article.

Author Contributions

All authors made a significant contribution to the work reported, either in the conception, study design, execution, acquisition of data, and analysis and interpretation, or in all these areas; took part in drafting, revising, or critically reviewing the article; approved the final version of the manuscript to be published; agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding

This study was supported by grants from the Provincial Project of Sichuan Medical and Health Care Promotion Institute (no. KY2022SJ0044), the Science and Technology Project of Guizhou Provincial Health Commission (no. gzwkj2021-178), the Sichuan Science and Technology Program (no. 2023JDRC0095), the Major Project of Jinniu District Medical Association (no. JNKY2021-02), and from the Talent Training Quality and Teaching Reform Project of Chengdu University (no. cdjgb2022252). The sponsors had no involvement in any stage of the study.

Disclosure

The authors declare they have no competing interests in this work.

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