M.A.E. de van der Schueren

Diagnostic criteria for malnutrition – An ESPEN Consensus Statement

OBJECTIVEnTo 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.nnnMETHODnThe 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.nnnRESULTnFirst, 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.nnnCONCLUSIONnIn 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.

ESPEN guidelines on definitions and terminology of clinical nutrition

BACKGROUNDnA lack of agreement on definitions and terminology used for nutrition-related concepts and procedures limits the development of clinical nutrition practice and research.nnnOBJECTIVEnThis initiative aimed to reach a consensus for terminology for core nutritional concepts and procedures.nnnMETHODSnThe European Society of Clinical Nutrition and Metabolism (ESPEN) appointed a consensus group of clinical scientists to perform a modified Delphi process that encompassed e-mail communication, face-to-face meetings, in-group ballots and an electronic ESPEN membership Delphi round.nnnRESULTSnFive key areas related to clinical nutrition were identified: concepts; procedures; organisation; delivery; and products. One core concept of clinical nutrition is malnutrition/undernutrition, which includes disease-related malnutrition (DRM) with (eq. cachexia) and without inflammation, and malnutrition/undernutrition without disease, e.g. hunger-related malnutrition. Over-nutrition (overweight and obesity) is another core concept. Sarcopenia and frailty were agreed to be separate conditions often associated with malnutrition. Examples of nutritional procedures identified include screening for subjects at nutritional risk followed by a complete nutritional assessment. Hospital and care facility catering are the basic organizational forms for providing nutrition. Oral nutritional supplementation is the preferred way of nutrition therapy but if inadequate then other forms of medical nutrition therapy, i.e. enteral tube feeding and parenteral (intravenous) nutrition, becomes the major way of nutrient delivery.nnnCONCLUSIONnAn agreement of basic nutritional terminology to be used in clinical practice, research, and the ESPEN guideline developments has been established. This terminology consensus may help to support future global consensus efforts and updates of classification systems such as the International Classification of Disease (ICD). The continuous growth of knowledge in all areas addressed in this statement will provide the foundation for future revisions.

The prevalence of malnutrition according to the new ESPEN definition in four diverse populations

BACKGROUND & AIMSnConsensus on the definition of malnutrition has not yet been reached. Recently, The European Society for Clinical Nutrition and Metabolism (ESPEN) proposed a consensus definition of malnutrition. The aim of the present study was to describe the prevalence of malnutrition according to the ESPEN definition in four diverse populations.nnnMETHODSnIn total, 349 acutely ill middle-aged patients, 135 geriatric outpatients, 306 healthy old individuals and 179 healthy young individuals were included in the study. Subjects were screened for risk of malnutrition using the SNAQ. The ESPEN definition of malnutrition, i.e. low BMI (<xa018.5xa0kg/m(2)) or a combination of unintentional weight loss and low FFMI or low BMI was applied to all subjects.nnnRESULTSnScreening identified 0, 0.5, 10 and 30% of the healthy young, the healthy old, the geriatric outpatients and the acutely ill middle-aged patients as being at risk of malnutrition. The prevalence of malnutrition ranged from 0% in the healthy young, 0.5% in healthy old individuals, 6% in the geriatric outpatients to 14% in the acutely ill middle-aged patients. Prevalence of low FFMI was observed in all four populations (14-33%), but concurred less frequently with weight loss (0-13%).nnnCONCLUSIONSnUsing the ESPEN definition, 0%-14% malnutrition was found in the diverse populations. Further work is needed to fully address the validity of a two-step approach, including risk assessment as an initial step in screening and defining malnutrition. Furthermore, assessing the predictive validity of the ESPEN definition is needed.

ESPEN expert group recommendations for action against cancer-related malnutrition

Patients with cancer are at particularly high risk for malnutrition because both the disease and its treatments threaten their nutritional status. Yet cancer-related nutritional risk is sometimes overlooked or under-treated by clinicians, patients, and their families. The European Society for Clinical Nutrition and Metabolism (ESPEN) recently published evidence-based guidelines for nutritional care in patients with cancer. In further support of these guidelines, an ESPEN oncology expert group met for a Cancer and Nutrition Workshop in Berlin on October 24 and 25, 2016. The group examined the causes and consequences of cancer-related malnutrition, reviewed treatment approaches currently available, and built the rationale and impetus for clinicians involved with care of patients with cancer to take actions that facilitate nutrition support in practice. The content of this position paper is based on presentations and discussions at the Berlin meeting. The expert group emphasized 3 key steps to update nutritional care for people with cancer: (1) screen all patients with cancer for nutritional risk early in the course of their care, regardless of body mass index and weight history; (2) expand nutrition-related assessment practices to include measures of anorexia, body composition, inflammatory biomarkers, resting energy expenditure, and physical function; (3) use multimodal nutritional interventions with individualized plans, including care focused on increasing nutritional intake, lessening inflammation and hypermetabolic stress, and increasing physical activity.

Protein-enriched ‘regular products’ and their effect on protein intake in acute hospitalized older adults; a randomized controlled trial

BACKGROUND & AIMSnEspecially in older adults, maintaining muscle mass is essential to perform activities of daily living. This requires a sufficient protein intake. However, protein intake in hospitalized older adults is often insufficient. Thus far different nutrition intervention strategies have failed to show success in reaching sufficient protein intake in hospitalized older adults. The effect of recently developed protein-enriched bread and drinking yoghurt on protein intake is still unknown. Therefore, the objective of this study was to examine the effect of protein-enriched bread and drinking yoghurt on the protein intake of acute hospitalized older adults (≥55 years).nnnMETHODSnThis study was performed as a single blind randomized controlled trial in 47 hospitalized elderly acutely admitted to a university hospital. During three consecutive days participants received either ad libitum protein-enriched bread and drinking yoghurt or normal, non-enriched products as part of their daily meals. The protein-enriched bread contained 6.9 g of protein per serving and the normal bread 3.8 g of protein. For drinking yoghurt this was 20.0 g and 7.5 g of protein per serving respectively. The products were almost isocaloric. Food intake of participants was measured and nutritional values were calculated according to the Dutch Food Composition Table. An independent sample t-test was used to compare protein intake between the intervention and control group.nnnRESULTSnAnalyses illustrate a protein intake in the intervention group of 75.0 ± 33.2 g per day versus 58.4 ± 14.5 g in the control group (p = 0.039). Intervention patients had a mean protein intake of 1.1 g/kg/day, with 36% of the patients reaching the minimum requirement of 1.2 g/kg/day; in control patients this was 0.9 g/kg/day (p = 0.041) and 8% (p = 0.030). Bread and drinking yoghurt contributed almost equally to the increased intake of protein in the intervention group.nnnCONCLUSIONSnThe use of protein-enriched bread and drinking yoghurt, consumed as part of regular meals, is a promising and feasible solution to increase the protein intake of acutely ill patients. It needs to be confirmed whether the use of these products will also result in a better clinical outcome. ClinicalTrials.gov ID number: NCT01907152.

The assessment of anorexia in patients with cancer: cut-off values for the FAACT-A/CS and the VAS for appetite

PurposeAnorexia is a frequently observed symptom in patients with cancer and is associated with limited food intake and decreased quality of life. Diagnostic instruments such as the Anorexia/Cachexia Subscale (A/CS) of the Functional Assessment of Anorexia/Cachexia Therapy (FAACT) questionnaire and the visual analog scale (VAS) for appetite have been recommended in the assessment of anorexia, but validated cut-off values are lacking. This study aimed to obtain cut-off values of these instruments for the assessment of anorexia in patients with cancer.MethodsThe FAACT–A/CS and the VAS for appetite were administered to patients with cancer before start of chemotherapy. As reference standard for anorexia, two external criteria were used: (1) a cut-off value of ≥2 on the anorexia symptom scale of the EORTC QLQ C-30 and (2) the question “Do you experience a decreased appetite?” (yes/no). ROC curves were used to examine the optimal cut-off values for the FAACT–A/CS and VAS.ResultsA total of 273 patients (58xa0% male; 64.0xa0±xa010.6xa0years) were included. The median score on the FAACT–A/CS was 38 (IQR 32–42) points and 77 (IQR 47–93) points on the VAS. Considering both external criteria, the optimal cut-off value for the FAACT–A/CS was ≤37 (sensitivity (se) 80xa0%, specificity (sp) 81xa0%, positive predictive value (PV+) 79xa0%, negative predictive value (PV−) 82xa0%) and for the VAS was ≤70 (se 76xa0%, sp 83xa0%, PV+ 80xa0%, PV− 79xa0%).ConclusionsFor the assessment of anorexia in patients with cancer, our study suggests cut-off values of ≤37 for the FAACT–A/CS and ≤70 for the VAS. Future studies should confirm our findings in other patient samples.

A critical appraisal of nutritional intervention studies in malnourished, community dwelling older persons

BACKGROUND & AIMSnWith the rapidly increasing number of malnourished older persons in the community, this review aims to summarize the effects of nutritional intervention studies for this target group.nnnMETHODSnBased on 2 previous reviews (2009, 2011) an update of the literature was performed. Selected were higher quality studies which included malnourished community dwelling older adults who received dietetic counselling and/or oral nutritional supplements.nnnRESULTSnTen studies were included. Six studies showed (trends towards) weight gain. Meta-analysis showed a modest effect of the intervention on weight gain, standardized mean difference 0.210xa0kg (95% CI 0.03-0.40). Effects on other relevant functional and clinical outcomes were inconsistent. Studies were hampered by low sample sizes, low adherence to the interventions, and participants not meeting nutritional requirements.nnnCONCLUSIONnCurrently, nutritional intervention studies for malnourished community dwelling older adults show limited effects, which may be caused by methodological shortcomings and participants not meeting treatment goals. High quality studies are eagerly awaited to be able to identify (sub)groups of older persons who are most likely to benefit from nutritional support.

The new ESPEN diagnostic criteria for malnutrition predict overall survival in hospitalised patients

BACKGROUNDnIn 2015 the European Society for Clinical Nutrition and Metabolism (ESPEN) presented new consensus criteria for the diagnosis of malnutrition. Whereas most previous definitions were based on involuntary weight loss and/or a low BMI, the ESPEN definition added Fat Free Mass Index (FFMI) to the set of criteria.nnnAIMnTo study the predictive value of the new ESPEN diagnostic criteria for malnutrition on survival, with specific focus on the additional value of FFMI.nnnMETHODSnIncluded were 335 hospitalized adult patients of the VU University Medical Center Amsterdam (60% female, age 58xa0±xa018xa0y). Three sets of criteria for malnutrition were used to study the predictive value for survival: Dutch definition for malnutrition, ESPEN diagnostic criteria for malnutrition and ESPEN diagnostic criteria for malnutrition without FFMI criterion. The association between malnutrition and three-months and one-year overall survival was analyzed by log rank tests and Cox regression. In multivariate analyses, adjustments were made for gender, age, care complexity and length of stay.nnnRESULTSnNinety patients (27%) were classified as malnourished by any of the sets of criteria; malnourished patients had significant lower survival rates than non-malnourished patients at three months (84% vs 94%; pxa0=xa00.01) and one year (76% vs 87%; pxa0=xa00.02). After adjustments, malnutrition remained significantly associated with three-months survival for the Dutch definition for malnutrition (HR:2.25, pxa0=xa00.04) and the ESPEN diagnostic criteria for malnutrition (HR:2.76, pxa0=xa00.02). Malnutrition remained significantly associated with one-year survival for the ESPEN diagnostic criteria for malnutrition (HR:2.17, pxa0<xa00.02) and the ESPEN diagnostic criteria for malnutrition without FFMI (HR:2.66, pxa0<xa00.01).nnnCONCLUSIONnThe new ESPEN definition for malnutrition is predictive for both three-months and one-year survival in a general hospital population, whereas definitions without FFMI are predictive for either three-months or one year survival.

Percentiles for skeletal muscle index, area and radiation attenuation based on computed tomography imaging in a healthy Caucasian population

Background/objectivesMuscle mass is a key determinant of nutritional status and associated with outcomes in several patient groups. Computed tomography (CT) analysis is increasingly used to assess skeletal muscle area (SMA), skeletal muscle index (SMI) and muscle radiation attenuation (MRA). However, interpretation of these muscle parameters is difficult since values in a healthy population are lacking. The aim of this study was to provide sex specific percentiles for SMA, SMA and MRA in a healthy Caucasian population and to examine the association with age and BMI in order to define age- and BMI specific percentiles.Subjects/methodsIn this retrospective cross-sectional study CT scans of potential kidney donors were used to assess SMA, SMI and MRA at the level of the third lumbar vertebra. Sex specific distributions were described and, based on the association between age/BMI and muscle parameters, age, and BMI specific predicted percentiles were computed. The 5th percentile was considered as cut-off.ResultsCT scans of 420 Individuals were included (age range 20–82 years and BMI range 17.5–40.7u2009kg/m2). Sex specific cut-offs of SMA, SMI and MRA were 134.0u2009cm2, 41.6u2009cm2/m2 and 29.3 HU in men and 89.2u2009cm2, 32.0u2009cm2/m2 and 22.0 HU in women, respectively. Correlations were negative between age and all three muscle parameters, positive between BMI and SMA/SMI and negative between BMI and MRA, resulting in age- and BMI specific percentiles.ConclusionsThis study provides sex specific percentiles for SMA, SMI, and MRA. In addition, age- and BMI specific percentiles have been established.

Systematic review and meta-analysis of the evidence for oral nutritional intervention on nutritional and clinical outcomes during chemo(radio)therapy: current evidence and guidance for design of future trials

Abstract Background Driven by reduced nutritional intakes and metabolic alterations, malnutrition in cancer patients adversely affects quality of life, treatment tolerance and survival. We examined evidence for oral nutritional interventions during chemo(radio)therapy. Design We carried out a systematic review of randomized controlled trials (RCT) with either dietary counseling (DC), high-energy oral nutritional supplements (ONS) aiming at improving intakes or ONS enriched with protein and n-3 polyunsaturated fatty acids (PUFA) additionally aiming for modulation of cancer-related metabolic alterations. Meta-analyses were carried out on body weight (BW) response to nutritional interventions, with subgroup analyses for DC and/or high-energy ONS or high-protein n-3 PUFA-enriched ONS. Results Eleven studies were identified. Meta-analysis showed overall benefit of interventions on BW during chemo(radio)therapy (+1.31u2009kg, 95% CI 0.24–2.38, Pu2009=u20090.02, heterogeneity Qu2009=u200921.1, Pu2009=u20090.007). Subgroup analysis showed no effect of DC and/or high-energy ONS (+0.80u2009kg, 95% CI −1.14 to 2.74, Pu2009=u20090.32; Qu2009=u200910.5, Pu2009=u20090.03), possibly due to limited compliance and intakes falling short of intake goals. A significant effect was observed for high-protein n-3 PUFA-enriched intervention compared with isocaloric controls (+1.89u2009kg, 95% CI 0.51–3.27, Pu2009=u20090.02; Qu2009=u20093.1u2009Pu2009=u20090.37). High-protein, n-3 PUFA-enriched ONS studies showed attenuation of lean body mass loss (Nu2009=u20092 studies) and improvement of some quality of life domains (Nu2009=u20093 studies). Overall, studies were limited in number, heterogeneous, and inadequately powered to show effects on treatment toxicity or survival. Conclusion This systematic review suggests an overall positive effect of nutritional interventions during chemo(radio)therapy on BW. Subgroup analyses showed effects were driven by high-protein n-3 PUFA-enriched ONS, suggesting the benefit of targeting metabolic alterations. DC and/or high-energy ONS were less effective, likely due to cumulative caloric deficits despite interventions. We highlight the need and provide recommendations for well-designed RCT to determine the effect of nutritional interventions on clinical outcomes, with specific focus on reaching nutritional goals and providing the right nutrients, as part of an integral supportive care approach.