Nutritional Status Changes and Activities of Daily Living after Hip Fracture in Convalescent Rehabilitation Units: A Retrospective Observational Cohort Study from the Japan Rehabilitation Nutrition Database



      Several studies have suggested that malnutrition impedes functional recovery in patients with hip fracture, but there are few reports on improvement in nutritional status and return to activities of daily living (ADL) in these patients.


      This study was conducted to evaluate the relationship between change in nutritional status and recovery of ADL in malnourished patients after hip fracture and to identify predictors of functional recovery among the characteristic features of undernutrition.


      This was a retrospective observational cohort study.


      Data for patients aged ≥65 years with hip fracture and malnutrition (Mini Nutritional Assessment–Short Form [MNA-SF] score ≤7) at the time of admission to convalescent rehabilitation units were obtained from the Japan Rehabilitation Nutrition Database between November 2015 and August 2017.

      Main outcome measures

      The main outcome measures were Functional Independence Measure (FIM) at discharge and the proportion of patients discharged home.

      Statistical analyses performed

      Patients were divided into two groups based on MNA-SF scores at discharge: improvement in nutritional status (>7, IN group) and non-improvement in nutritional status (≤7, NN group). Clinical characteristics and outcomes were compared between the groups. Multivariable regression analysis was performed to adjust for confounders including age, sex, comorbidity, pre-fracture ADL level, and FIM score on admission.


      Of 876 patients, 110 met the eligibility criteria (mean age, 85 years; 78.2% female); 77 of the patients were assigned to the IN group and 33 to the NN group. The patients in the IN group were younger and had higher FIM and MNA-SF scores on admission than those in the NN group. At discharge, the median FIM score was significantly higher in the IN group than in the NN group (110 vs 83, P<0.001). Multivariable analysis revealed a significant association between improvement in nutritional status and higher FIM score at discharge (B=7.377 [B=partial regression coefficient], P=0.036) but no association with discharge to home. Mobility, neuropsychological impairment, and weight loss subscores of MNA-SF were independently associated with discharge FIM score (R2=0.659).


      In older patients with hip fracture and malnutrition, improvement in nutritional status was independently associated with improved performance of ADL during inpatient rehabilitation. Weight loss may be an important nutritional indicator for these patients.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the Academy of Nutrition and Dietetics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kanis J.A.
        • Odén A.
        • McCloskey E.V.
        • Johansson H.
        • Wahl D.A.
        • Cooper C.
        • IOF Working Group on Epidemiology and Quality of Life
        A systematic review of hip fracture incidence and probability of fracture worldwide.
        Osteoporos Int. 2012; 23: 2239-2256
        • Haentjens P.
        • Magaziner J.
        • Colón-Emeric C.S.
        • et al.
        Meta-analysis: Excess mortality after hip fracture among older women and men.
        Ann Intern Med. 2010; 152: 380-390
        • Dyer S.M.
        • Crotty M.
        • Fairhall N.
        • et al.
        A critical review of the long-term disability outcomes following hip fracture.
        BMC Geriatr. 2016; 16: 158
        • Tsukutani Y.
        • Hagino H.
        • Ito Y.
        • Nagashima H.
        Epidemiology of fragility fractures in Sakaiminato, Japan: Incidence, secular trends, and prognosis.
        Osteoporos Int. 2015; 26: 2249-2255
      1. Summary of Comprehensive Survey of Living Conditions 2010. Ministry of Health, Labor and Welfare [In Japanese].
        (Accessed September 18, 2017)
        • Goisser S.
        • Schrader E.
        • Singler K.
        • et al.
        Malnutrition according to Mini Nutritional Assessment is associated with severe functional impairment in geriatric patients before and up to 6 months after hip fracture.
        J Am Med Dir Assoc. 2015; 16: 661-667
        • Koren-Hakim T.
        • Weiss A.
        • Hershkovitz A.
        • et al.
        The relationship between nutritional status of hip fracture operated elderly patients and their functioning, comorbidity and outcome.
        Clin Nutr. 2012; 31: 917-921
        • Gumieiro D.N.
        • Rafacho B.P.M.
        • Gonçalves A.F.
        • et al.
        Mini Nutritional Assessment predicts gait status and mortality 6 months after hip fracture.
        Br J Nutr. 2013; 109: 1657-1661
        • Drevet S.
        • Bioteau C.
        • Mazière S.
        • et al.
        Prevalence of protein-energy malnutrition in hospital patients over 75 years of age admitted for hip fracture.
        Orthop Traumatol Surg Res. 2014; 100: 669-674
        • Bruce D.
        • Laurance I.
        • Mcguiness M.
        • Ridley M.
        • Goldswain P.
        Nutritional supplements after hip fracture: Poor compliance limits effectiveness.
        Clin Nutr. 2003; 22: 497-500
        • Myint M.W.W.
        • Wu J.
        • Wong E.
        • et al.
        Clinical benefits of oral nutritional supplementation for elderly hip fracture patients: A single blind randomised controlled trial.
        Age Ageing. 2013; 42: 39-45
        • Tidermark J.
        • Ponzer S.
        • Carlsson P.
        • et al.
        Effects of protein-rich supplementation and nandrolone in lean elderly women with femoral neck fractures.
        Clin Nutr. 2004; 23: 587-596
        • Wyers C.E.
        • Reijven P.L.M.
        • Evers S.M.A.A.
        • et al.
        Cost-effectiveness of nutritional intervention in elderly subjects after hip fracture. A randomized controlled trial.
        Osteoporos Int. 2013; 24: 151-162
        • Avenell A.
        • Smith T.O.
        • Curtain J.P.
        • Mak J.C.
        • Myint P.K.
        Nutritional supplementation for hip fracture aftercare in the older people.
        Cochrane Database Syst Rev. 2016; 11: CD001880
        • Liu M.
        • Yang J.
        • Yu X.
        • et al.
        The role of perioperative oral nutritional supplementation in elderly patients after hip surgery.
        Clin Interv Aging. 2015; 10: 849-858
        • Vellas B.
        • Villars H.
        • Abellan G.
        • et al.
        Overview of the MNA—Its history and challenges.
        J Nutr Health Aging. 2006; 10 (discussion 463-465): 456-463
        • Wang H.P.
        • Liang J.
        • Kuo L.M.
        • Chen C.Y.
        • Shyu Y.I.L.
        Trajectories of nutritional status and cognitive impairment among older Taiwanese with hip fracture.
        J Nutr Health Aging. 2017; 21: 38-45
        • Wakabayashi H.
        • Sakuma K.
        Rehabilitation nutrition for sarcopenia with disability: A combination of both rehabilitation and nutrition care management.
        J Cachexia Sarcopenia Muscle. 2014; 5: 269-277
        • Harris P.A.
        • Taylor R.
        • Thielke R.
        • Payne J.
        • Gonzalez N.
        • Conde J.G.
        Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377-381
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation.
        J Chronic Dis. 1987; 40: 373-383
      2. Standard Tables of Food Composition in Japan—2015, 7th Revised Edition. Ministry of Education, Culture, Sports, Science and Technology.
        (Accessed on February 8, 2018)
        • Tamiya N.
        • Noguchi H.
        • Nishi A.
        • et al.
        Population ageing and wellbeing: Lessons from Japan’s long-term care insurance policy.
        Lancet. 2011; 378: 1183-1192
        • Miyai I.
        • Sonoda S.
        • Nagai S.
        • et al.
        Results of new policies for inpatient rehabilitation coverage in Japan.
        Neurorehabil Neural Repair. 2011; 25: 540-547
        • Kaiser M.
        • Bauer J.
        • Ramsch C.
        • et al.
        Validation of the Mini Nutritional Assessment Short-Form (MNA-SF): A practical tool for identification of nutritional status.
        J Nutr Health Aging. 2009; 13: 782-788
        • Koren-Hakim T.
        • Weiss A.
        • Hershkovitz A.
        • et al.
        Comparing the adequacy of the MNA-SF, NRS-2002 and MUST nutritional tools in assessing malnutrition in hip fracture operated elderly patients.
        Clin Nutr. 2016; 35: 1053-1058
        • Chumney D.
        • Nollinger K.
        • Shesko K.
        • Skop K.
        • Spencer M.
        • Newton R.A.
        Ability of Functional Independence Measure to accurately predict functional outcome of stroke-specific population: Systematic review.
        J Rehabil Res Dev. 2010; 47: 17-29
      3. Power and Sample Size Calculation [computer program]. Version 3.0. Dupont WD, Plummer WD. Department of Biostatistics, Vanderbilt School of Medicine, Nashville, TN2009
        • Inoue T.
        • Misu S.
        • Tanaka T.
        • et al.
        Pre-fracture nutritional status is predictive of functional status at discharge during the acute phase with hip fracture patients: A multicenter prospective cohort study.
        Clin Nutr. 2017; 36: 1320-1325
      4. SPSS Statistics [computer program]. Version 21. IBM Corporation, Armonk, NY2012
        • Nishioka S.
        • Okamoto T.
        • Takayama M.
        • et al.
        Malnutrition risk predicts recovery of full oral intake among older adult stroke patients undergoing enteral nutrition: Secondary analysis of a multicentre survey (the APPLE study).
        Clin Nutr. 2017; 36: 1089-1096
        • Kalm L.M.
        • Semba R.D.
        They starved so that others be better fed: Remembering Ancel Keys and the Minnesota experiment.
        J Nutr. 2005; 135: 1347-1352
        • Bell J.J.
        • Bauer J.D.
        • Capra S.
        • Pulle R.C.
        Concurrent and predictive evaluation of malnutrition diagnostic measures in hip fracture inpatients: A diagnostic accuracy study.
        Eur J Clin Nutr. 2014; 68: 358-362
        • Marshall S.
        • Young A.
        • Bauer J.
        • Isenring E.
        Nutrition screening in geriatric rehabilitation: Criterion (concurrent and predictive) validity of the Malnutrition Screening Tool (MST) and the Mini Nutritional Assessment-Short Form (MNA-SF).
        J Acad Nutr Diet. 2016; 116: 795-801
        • Marshall S.
        Protein-energy malnutrition in the rehabilitation setting: Evidence to improve identification.
        Maturitas. 2016; 86: 77-85
        • Campillo B.
        • Paillaud E.
        • Bories P.N.
        • Noel M.
        • Porquet D.
        • Leparc J.C.
        Serum levels of insulin-like growth factor-1 in the three months following surgery for a hip fracture in elderly: Relationship with nutritional status and inflammatory reaction.
        Clin Nutr. 2000; 19: 349-354
        • Paillaud E.
        • Bories P.N.
        • Le Parco J.C.
        • Campillo B.
        Nutritional status and energy expenditure in elderly patients with recent hip fracture during a 2-month follow-up.
        Br J Nutr. 2000; 83: 97-103
        • Bell J.
        • Bauer J.
        • Capra S.
        • Pulle C.R.
        Barriers to nutritional intake in patients with acute hip fracture: Time to treat malnutrition as a disease and food as a medicine?.
        Can J Physiol Pharmacol. 2013; 91: 489-495
        • Hagobian T.A.
        • Braun B.
        Physical activity and hormonal regulation of appetite: Sex differences and weight control.
        Exerc Sport Sci Rev. 2010; 38: 25-30
        • Tsutsumimoto K.
        • Doi T.
        • Makizako H.
        • et al.
        The association between anorexia of aging and physical frailty: Results from the National Center for Geriatrics and Gerontology’s study of geriatric syndromes.
        Maturitas. 2017; 97: 32-37
        • Reider L.
        • Hawkes W.
        • Hebel J.R.
        • et al.
        The association between body mass index, weight loss and physical function in the year following a hip fracture.
        J Nutr Health Aging. 2013; 17: 91-95
        • Di Monaco M.
        • Vallero F.
        • Di Monaco R.
        • Tappero R.
        • Cavanna A.
        Skeletal muscle mass, fat mass, and hip bone mineral density in elderly women with hip fracture.
        J Bone Miner Metab. 2007; 25: 237-242
        • Nishioka S.
        • Wakabayashi H.
        • Nishioka E.
        • Yoshida T.
        • Mori N.
        • Watanabe R.
        Nutritional improvement correlates with recovery of activities of daily living among malnourished elderly stroke patients in the convalescent stage: A cross-sectional study.
        J Acad Nutr Diet. 2016; 116: 837-843
        • Kawasaki Y.
        • Sakai M.
        • Nishimura K.
        • et al.
        Criterion validity of the visual estimation method for determining patients' meal intake in a community hospital.
        Clin Nutr. 2016; 35: 1543-1549


      S. Nishioka is chief, Department of Clinical Nutrition and Food Service, Nagasaki Rehabilitation Hospital, Nagasaki, Japan.


      H. Wakabayashi is a lecturer, Department of Rehabilitation Medicine, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan.


      R. Momosaki is an associate professor, Department of Rehabilitation Medicine, Teikyo University School of Medicine University Hospital, Mizonokuchi, Kawasaki-city, Kanagawa, Japan.