Ingvar Bosaeus

Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by Special Interest Groups (SIG) "cachexia-anorexia in chronic wasting diseases" and "nutrition in geriatrics"

Chronic diseases as well as aging are frequently associated with deterioration of nutritional status, loss muscle mass and function (i.e. sarcopenia), impaired quality of life and increased risk for morbidity and mortality. Although simple and effective tools for the accurate screening, diagnosis and treatment of malnutrition have been developed during the recent years, its prevalence still remains disappointingly high and its impact on morbidity, mortality and quality of life clinically significant. Based on these premises, the Special Interest Group (SIG) on cachexia-anorexia in chronic wasting diseases was created within ESPEN with the aim of developing and spreading the knowledge on the basic and clinical aspects of cachexia and anorexia as well as of increasing the awareness of cachexia among health professionals and care givers. The definition, the assessment and the staging of cachexia, were identified as a priority by the SIG. This consensus paper reports the definition of cachexia, pre-cachexia and sarcopenia as well as the criteria for the differentiation between cachexia and other conditions associated with sarcopenia, which have been developed in cooperation with the ESPEN SIG on nutrition in geriatrics.

Body fluid volume determination via body composition spectroscopy in health and disease

The assessment of extra-, intracellular and total body water (ECW, ICW, TBW) is important in many clinical situations. Bioimpedance spectroscopy (BIS) has advantages over dilution methods in terms of usability and reproducibility, but a careful analysis reveals systematic deviations in extremes of body composition and morbid states. Recent publications stress the need to set up and validate BIS equations in a wide variety of healthy subjects and patients with fluid imbalance. This paper presents two new equations for determination of ECW and ICW (referred to as body composition spectroscopy, BCS) based on Hanai mixture theory but corrected for body mass index (BMI). The equations were set up by means of cross validation using data of 152 subjects (120 healthy subjects, 32 dialysis patients) from three different centers. Validation was performed against bromide/deuterium dilution (NaBr, D2O) for ECW/TBW and total body potassium (TBK) for ICW. Agreement between BCS and the references (all subjects) was -0.4 +/- 1.4 L (mean +/- SD) for ECW, 0.2 +/- 2.0 L for ICW and -0.2 +/- 2.3 L for TBW. The ECW agreement between three independent reference methods (NaBr versus D2O-TBK) was -0.1 +/- 1.8 L for 74 subjects from two centers. Comparing the new BCS equations with the standard Hanai approach revealed an improvement in SEE for ICW and TBW by 0.6 L (24%) for all subjects, and by 1.2 L (48%) for 24 subjects with extreme BMIs (<20 and >30). BCS may be an appropriate method for body fluid volume determination over a wide range of body compositions in different states of health and disease.

Diagnostic criteria for malnutrition – An ESPEN Consensus Statement

OBJECTIVE To provide a consensus-based minimum set of criteria for the diagnosis of malnutrition to be applied independent of clinical setting and aetiology, and to unify international terminology. METHOD The European Society of Clinical Nutrition and Metabolism (ESPEN) appointed a group of clinical scientists to perform a modified Delphi process, encompassing e-mail communications, face-to-face meetings, in group questionnaires and ballots, as well as a ballot for the ESPEN membership. RESULT First, ESPEN recommends that subjects at risk of malnutrition are identified by validated screening tools, and should be assessed and treated accordingly. Risk of malnutrition should have its own ICD Code. Second, a unanimous consensus was reached to advocate two options for the diagnosis of malnutrition. Option one requires body mass index (BMI, kg/m(2)) <18.5 to define malnutrition. Option two requires the combined finding of unintentional weight loss (mandatory) and at least one of either reduced BMI or a low fat free mass index (FFMI). Weight loss could be either >10% of habitual weight indefinite of time, or >5% over 3 months. Reduced BMI is <20 or <22 kg/m(2) in subjects younger and older than 70 years, respectively. Low FFMI is <15 and <17 kg/m(2) in females and males, respectively. About 12% of ESPEN members participated in a ballot; >75% agreed; i.e. indicated ≥7 on a 10-graded scale of acceptance, to this definition. CONCLUSION In individuals identified by screening as at risk of malnutrition, the diagnosis of malnutrition should be based on either a low BMI (<18.5 kg/m(2)), or on the combined finding of weight loss together with either reduced BMI (age-specific) or a low FFMI using sex-specific cut-offs.

Inulin and oligofructose do not influence the absorption of cholesterol, or the excretion of cholesterol, Ca, Mg, Zn, Fe, or bile acids but increases energy excretion in ileostomy subjects

OBJECTIVE: To investigate the effects of inulin and oligofructose on cholesterol absorption and excretion of cholesterol, bile acids, energy, nitrogen and minerals in man.DESIGN: Double-blind cross-over study.SETTING: Metabolic kitchen with policlinic visits, Sahlgrenska Hospital, Göteborg, SwedenSUBJECTS: Patients with conventional ileostomy because of ulcerative colitis.INTERVENTIONS: 17 g of inulin, 17 g of oligofructose and 7 g of sucrose were added to a controlled diet during three experimental periods of three days each. Ileostomy effluents were collected and analysed. Differences between experimental and control diet were investigated with the Wilcoxon’s sign and values test.RESULTS: Inulin and oligofructose were recovered in the ileostomy effluent to 88% (95% CI, 76–100%) and 89% (64–114%) respectively. Dry solid excretion increased by 14.4 g (11.3–17.5) on inulin, and by 14.7 g (13.0–16.4 g) on oligofructose and energy excretion increased 245 kJ (190–307 kJ) on inulin and 230 kJ (217–315 kJ) on oligofructose compared to control diet (P<0.05). Cholesterol absorption, excretion of cholesterol, bile acids, nitrogen, fat, calcium, magnesium, zinc and iron were not affected by inulin and oligofructose.CONCLUSIONS: Inulin and oligofructose are not digested in the small intestine. They do not affect mineral excretion and hence hardly mineral absorption. They do not increase fat or nitrogen excretion from the small intestine. Any physiological effect of inulin and oligofructose is probably mediated through other mechanisms than altered excretion from the small intestine.SPONSORSHIPS: This work was supported by grants from Swedish Council for Agriculture and Forestry, from Gothenburg Medical Society and from ORAFTI Ltd Belgium.

Increased body fat mass and decreased extracellular fluid volume in adults with growth hormone deficiency

OBJECTIVE Growth hormone deficiency in adults with hypopituitarism has previously received little attention. Recent data, however, suggest that GH deflciency might be essential for the long‐term prognosis of these patients. Earlier studies have documented that GH regulates body composition; in this, body composition in adult patients with hypopituitarism including GH deficiency was studied. DESIGN A follow‐up study of patients with hypopituitarism on routine replacement therapy with l‐thyroxine, cortisone acetate and sex steroids.

Dietary intake and resting energy expenditure in relation to weight loss in unselected cancer patients

Weight loss and anorexia are frequent findings in advanced cancer. The progressive wasting could be attributed to changes in dietary intake and/or energy expenditure mediated by metabolic alterations. In this study, we analyzed dietary intake in generalized malignant disease of solid tumor type in relation to resting energy expenditure (REE) and reported weight loss. In a group of 297 unselected cancer patients from a university hospital outpatient clinic, dietary intake of energy and macronutrients from a 4‐day food record, REE by indirect calorimetry, height, weight and weight loss were recorded. Protein intake was validated against 24 hr urine nitrogen in a subgroup (n = 53), and no indication of systematic misreporting was found. Mean daily dietary intake was below maintenance requirements, 26 ± 10 kcal/kg. Weight loss of more than 10% was present in 43% of patients and elevated REE (>110% of predicted) in 48%. Dietary intake did not differ between normo‐ and hypermetabolic patients, nor was tumour type or gender related to energy and protein intake. Weight loss could not be accounted for by diminished dietary intake since energy intake in absolute amounts was not different and intake per kilogram body weight was higher in weight‐losing patients compared to weight‐stable patients. Dietary macronutrient composition did not differ from the general population. Dietary intake of energy and protein was decreased, but dietary macronutrient composition did not appear to be changed. Weight loss and hypermetabolism were frequent and not compensated for by an increase in spontaneous food intake. Our results indicate that an expected up‐regulation of dietary intake in response to elevated energy expenditure is frequently lost in cancer patients. This may be the explanation behind cancer cachexia rather than a primary decrease in appetite.

Palliative nutritional intervention in addition to cyclooxygenase and erythropoietin treatment for patients with malignant disease: Effects on survival, metabolism, and function

The role of nutrition in the palliative treatment of patients with malignancy‐related cachexia is unclear. The goal of the current study was to determine whether specialized, nutrition‐focused patient care could improve integrated whole‐body metabolism and functional outcome in unselected weight‐losing patients with malignant disease who were receiving systemic antiinflammatory (cyclooxygenase [COX]‐inhibitory) treatment along with erythropoietin (EPO) support.

Body mass index, weight change and mortality in the elderly. A 15 y longitudinal population study of 70 y olds

Objective: To examine the relationship between body mass index (BMI) at age 70, weight change between age 70 and 75, and 15 y mortality.Design: Cohort study of 70-y-olds.Setting: Geriatric Medicine Department, Göteborg University, Sweden.Subjects: A total of 2628 (1225 males and 1403 females) 70-y-olds examined in 1971–1981 in Gothenburg, Sweden.Results: The relative risks (RRs) for 15 y mortality were highest in the lowest BMI quintiles of males 1.20 (95% CI 0.96–1.51) and females 1.49 (95% CI 1.14–1.96). In non-smoking males, no significant differences were observed across the quintiles for 5, 10 and 15 y mortality. In non-smoking females, the highest RR (1.58, 95% CI 1.15–2.16) for 15 y mortality was in the lowest quintile. After exclusion of first 5 y death, no excess risks were found in males for following 5 and 10 y mortality across the quintiles. In females, a U-shaped relation was observed after such exclusions. BMI ranges with lowest 15 y mortality were 27–29 and 25–27 kg/m2 in non-smoking males and females, respectively. A weight loss of≥10% between age 70 and 75 meant a significantly higher risk for subsequent 5 and 10 y mortality in both sexes relative to individuals with ‘stable’ weights.Conclusion: Low BMI and weight loss are risk factors for mortality in the elderly and smoking habits did not significantly modify that relationship. The BMI ranges with lowest risks for 15 y mortality are relatively higher in elderly. Exclusion of early deaths from the analysis modified the weight–mortality relationship in elderly males but not in females.Sponsorship: See Acknowledgements.European Journal of Clinical Nutrition (2001) 55, 482–492

Height and body weight in the elderly. I. A 25-year longitudinal study of a population aged 70 to 95 years.

Objective: To describe longitudinal changes in height and body weight between the ages of 70 and 95 y.Design: Longitudinal cohort study with representative sample of 70-y-olds.Setting: Department of Geriatric Medicine, Göteborg University, Sweden.Subjects: 449 males and 524 females, aged 70 y, living in Göteborg were examined in 1971–72 and this study population participated on 11 occasions during a 25-year follow-up.Results: Mean height decreased 4 and 4.9 cm in males and females respectively and the trend was significant between the ages of 70 and 95 y in both sexes. Between 70 and 75 y of age, a significant difference was found between quintiles of body height where in the highest quintile height was lowered by 0.4 and 0.3 cm/y, in males and females respectively, and in the lowest quintile by 0.1 cm/y in both sexes. Mean body weight decreased 3.2 and 5.1 kg in males and females respectively, from age 70 to 95 y. The trend was significant over 22 and 20 y for males and females, respectively. Between the ages of 70 and 80 y, individuals in highest quintile of body weight decreased at a rate of 0.8 and 0.6 kg/y, three times higher than those in lowest quintile. Due to the decrease in both height and weight over time, body mass index (BMI) was less affected.Conclusion: Height, body weight and BMI decreased significantly in both sexes after age 70 y, and there was a gender difference in the trend. The results can be used as reference data for Swedish elderly and might be of importance to the understanding of anthropometry with the ageing process.Sponsorship: See acknowledgements.

Diagnostic Criteria for the Classification of Cancer-Associated Weight Loss

PURPOSE Existing definitions of clinically important weight loss (WL) in patients with cancer are unclear and heterogeneous and do not consider current trends toward obesity. METHODS Canadian and European patients with cancer (n = 8,160) formed a population-based data set. Body mass index (BMI) and percent WL (%WL) were recorded, and patients were observed prospectively until death. Data were entered into a multivariable analysis controlling for age, sex, cancer site, stage, and performance status. Relationships for BMI and %WL to overall survival were examined to develop a grading system. RESULTS Mean overall %WL was -9.7% ± 8.4% and BMI was 24.4 ± 5.1 kg/m(2), and both %WL and BMI independently predicted survival (P < .01). Differences in survival were observed across five categories of BMI (< 20.0, 20.0 to 21.9, 22.0 to 24.9, 25.0 to 27.9, and ≥ 28.0 kg/m(2); P < .001) and five categories of %WL (-2.5% to -5.9%, -6.0% to -10.9%, -11.0% to -14.9%, ≥ -15.0%, and weight stable (± 2.4%); P < .001). A 5 × 5 matrix representing the five %WL categories within each of the five BMI categories was graded based on median survival and prognostic significance. Weight-stable patients with BMI ≥ 25.0 kg/m(2) (grade 0) had the longest survival (20.9 months; 95% CI, 17.9 to 23.9 months), and %WL values associated with lowered categories of BMI were related to shorter survival (P < .001), as follows: grade 1, 14.6 months (95% CI, 12.9 to 16.2 months); grade 2, 10.8 months (95% CI, 9.7 to 11.9 months); grade 3, 7.6 months (95% CI, 7.0 to 8.2 months); and grade 4, 4.3 months (95% CI, 4.1 to 4.6 months). Survival discrimination by grade was observed within specific cancers, stages, ages, and performance status and in an independent validation sample (n = 2,963). CONCLUSION A robust grading system incorporating the independent prognostic significance of both BMI and %WL was developed.