M.A.E. van Bokhorst-de van der Schueren

Diagnosis and treatment of (disease-related) in-hospital malnutrition: The performance of medical and nursing staff

BACKGROUND & AIMS Malnutrition continues to be an important problem in health care which is still under recognized and underrated in developed countries. This study aims to describe current practice in diagnosing and treating malnutrition by medical doctors, medical students and nurses prior, during and after hospitalisation. METHODS Prospective analysis of current practice in assessing nutritional status and prescribing treatment by medical and nursing staff in a cohort of hospitalised patients from the general medical wards of the VU University Medical Center, Amsterdam. Comparison of objective identification of malnutrition by an independent observer with subjective identification by the medical and nursing staff. Quantification of diagnosing, treating and communicating malnutrition before, during and following hospital stay by medical doctors, medical students and nurses by evaluating the written information in medical and nursing charts, and referral and discharge letters. RESULTS Three hundred and ninety-five women and men, aged 19-96 years, were included from June to September 2005. The prevalence of malnutrition was 31.9%. Nutritional information was not mentioned in written referrals. Medical doctors performed nutritional assessment in 15.3%, medical students in 52.8%, and nurses in 29.9% of their patients. Medical doctors were the most capable of differentiating between malnourished and well-nourished patients as a basis for undertaking nutritional assessment, although this was still inadequate. Little nutritional intervention was applied during hospital stay. Information on nutritional status was lacking in most discharge letters. Nutritional follow-up was appointed in 1.2%. CONCLUSIONS Nutritional assessment and intervention were not sufficiently applied by any professional at any stage of the pre-, actual and post-hospitalisation period.

Differences in immune status between well-nourished andmalnourished head and neck cancer patients

Malnutrition is reported to occur in approximately 30% of head and neck cancer patients. Also, impaired immunocompetence is described as a common phenomenon in this patient group. The purpose of this study was to assess the possible relationship between malnutrition and some prognostically important immune parameters in head and neck cancer patients. Thirty-two malnourished (recent weight loss >/= 10%) and 34 well-nourished patients undergoing curative treatment for advanced head and neck cancer were studied prospectively, and six parameters of their immune status (leucocytes, lymphocytes, lymphocyte phenotyping, monocytes, HLA-DR expression on monocytes and serum interleukin-10) were determined on the day of panendoscopy. Reference values for monocytes, HLA-DR expression and interleukin-10 were obtained from 43 healthy controls. Although the number of monocytes was elevated in both patient groups, the HLA-DR expression on these monocytes was significantly lower in the malnourished than in the well-nourished and control groups. Tumor stage, tumor localization, recurrence after initial radiotherapy, age and gender were not correlated to HLA-DR expression. No relationships emerged between nutritional status and lymphocyte subsets. Malnourished head and neck cancer patients show a significantly lower HLA-DR expression on monocytes than well-nourished ones and healthy controls. According to the literature this would imply an increased risk for postoperative complications. Indeed, postoperative complications occur more frequently in malnourished than in well-nourished patients.

Screening malnutrition in hospital outpatients. Can the SNAQ malnutrition screening tool also be applied to this population

BACKGROUND & AIMS It is known from earlier studies that only 15% of the malnourished hospital outpatient population is recognized and receives nutritional treatment. To increase this number, a quick and easy malnutrition screening tool would be helpful. Because such a tool is lacking, we developed one by using the SNAQ (Short Nutritional Assessment Questionnaire) as a basis. The aim of this study was to develop a quick and easy malnutrition screening tool and to measure its diagnostic accuracy in malnourished hospital outpatients. METHODS First, an optimal set of questions was selected for the preoperative outpatient population. Secondly, the diagnostic accuracy for the preoperative outpatients was determined (979 patients) and finally, the diagnostic accuracy for general hospital outpatients was established (705 patients). RESULTS The three original SNAQ questions proved to be the best set of questions for the outpatient population as well. In the preoperative and general outpatient population the diagnostic accuracy resulted respectively in a sensitivity of 53% and 67%, a specificity of 97% and 98%, a positive predictive value of 69% and 72% and a negative predictive value of 94% and 97%. CONCLUSIONS With an acceptable diagnostic accuracy it may be concluded that the original SNAQ malnutrition screening tool is valid for the hospital outpatient population.

Validity of nutritional screening with MUST and SNAQ in hospital outpatients

Background/Objectives:The majority of hospital outpatients with undernutrition is unrecognized, and therefore untreated. There is a need for an easy and valid screening tool to detect undernutrition in this setting. The aim of this study was to determine the diagnostic accuracy of the MUST (Malnutrition Universal Screening Tool) and SNAQ (Short Nutritional Assessment Questionnaire) tools for undernutrition screening in hospital outpatients.Methods:In a large multicenter-hospital-outpatient population, patients were classified as: severely undernourished (body mass index (BMI) <18.5 (<65 years) or <20 (⩾65 years) and/or unintentional weight loss >5% in the last month or >10% in the last 6 months), moderately undernourished (BMI 18.5–20 (<65 years) or 20–22 (⩾65 years) and/or 5–10% unintentional weight loss in the last 6 months) or not undernourished. Diagnostic accuracy of the screening tools versus the reference method was expressed as sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV).Results:Out of the 2236 outpatients, 6% were severely and 7% were moderately undernourished according to the reference method. MUST and SNAQ identified 9% and 3% as severely undernourished, respectively. MUST had a low PPV (Se=75, Sp=95, PPV=43, NPV=98), whereas SNAQ had a low Se (Se=43, Sp=99, PPV=78, NPV=96).Conclusions:The validity of MUST and SNAQ is insufficient for hospital outpatients. While SNAQ identifies too few patients as undernourished, MUST identifies too many patients as undernourished. We advise to measure body weight, height and weight loss, in order to define undernutrition in hospital outpatients.

Effects of the daily consumption of protein enriched bread and protein enriched drinking yoghurt on the total protein intake in older adults in a rehabilitation centre: a single blind randomised controlled trial.

ObjectivesTo investigate the effects of protein enriched bread and drinking yoghurt, substituting regular products, on the total protein intake and the distribution of protein intake over the day in older adults.DesignA single blind randomised controlled trial.SettingRehabilitation centre.ParticipantsOlder adults (≥ 55 years) admitted to a rehabilitation centre after hospital discharge (n=34).InterventionParticipants received a high protein diet (protein enriched bread and protein enriched drinking yoghurt; n=17) or a regular diet (regular bread and regular drinking yoghurt; n=17) for three consecutive weeks.MeasurementsTotal protein intake and protein intake per meal, measured twice weekly over a three weeks period (six measurements per participant).ResultsCompared with controls, patients who received the protein enriched products had a significantly higher protein intake (115.3 g/d vs 72.5 g/d, P<0.001; 1.6 g/kg/d vs 1.1 g/kg/d, P<0.001). The intervention group consumed quantities over the recommended level (25–30 g/meal) during each of the three meals (32.5 g, 30.0 g, 34.8 g/meal), where the control group consumed quantities below the recommended level during breakfast (17.7 g) and lunch (18.4 g).ConclusionsThe use of protein enriched products, replacing regular products, results in a significant increased daily protein intake in older adults. In addition, the daily consumption of protein enriched products improves protein distribution over the day.

Estimation of dietary calcium intake

Dear Editor,With great pleasure we read the article by Macdonaldet al., describing the validation of a 23-item question-naire for estimating dietary calcium intake, the CaQ [1].We encourage this initiative as we are in search of aneasy, accurate, and feasible way to estimate the calciumintake of our patients as well.Recently, there has been a lot of attention for thepossible elevated cardiovascular risks of surplus calciumsupplementation on the one hand and calcium deficien-cy on the other hand in patients with osteoporosis. Tobe able to prescribe the adequate amount of calciumsupplementation, a practical tool to validly estimate thedietary intake of calcium is not available to clinicians.Most dietary assessment methods are too time-consuming for clinical practice. The gold standard ofassessing dietary calcium intake is a 7-day food diarywith weighed portion sizes, which is laborious for cli-nicians as well as for patients, and therefore not feasiblein clinical practice. Food frequency questionnaires(FFQ) are far more practical; however, they still consistof many questions and thus are not feasible in clinicalpractice either.Macdonald et al. validated their 23-item CaQ againsttwo “gold standards”: a 7-day food diary (n=33), whichis close to a real gold standard, although portion sizeswere estimated rather than weighed, and a FFQ (n=72),which is similar to the CaQ except for being moreelaborate. The authors conclude that their CaQ is anadequate tool to assess daily calcium intake when scor-ing between 700 and 1,200 mg.Although we were excited to see the work ofMacdonald et al., we missed a detailed report on thenumber of patients that has an estimated calcium intakeoutside a predefined clinically relevant area. Forexample, if an intake of 1,000 mg would be considerednormal, a difference of 250 mg between the goldstandard and the questionnaire would be clinicallyrelevant, as patients below 750 mg would benefit fromsupplementation. From a clinician’s perspective, it isimportant to know how many patients fall within theclinically relevant area, in order to judge the applicabilityof the CaQ for prescription of calcium supplements topatients.We recently validated a calcium intake list with only threeitems, which underestimated calcium intake compared toa dietary history with a clinically relevant difference ofmore than 250 mg in 56 % of patients [2]. Using ourlist to prescribe calcium supplements would mean thattoo many patients would be given too much calcium,possibly resulting in elevated cardiovascular risks.Currently, we are in the process of refining the list inorder to improve sensitivity and specificity for use inclinical practice.We look forward to validation studies of calciumintake lists in other cohorts of osteoporosis patients tosee if these lists are valid across cultures and diets andto decide on clinically relevant cutoff points for theprescription of calcium medication.

P321: Survival of malnourished elderly patients receiving post-adischarge nutritional support; a randomized controlled study

SURVIVAL OF MALNOURISHED ELDERLY PATIENTS RECEIVING POST-DISCHARGE NUTRITIONAL SUPPORT; A RANDOMIZED CONTROLLED STUDY Floor Neelemaat* 1, Suzanne van Keeken2, Jacqueline Langius1, Marian de van der Schueren1, Abel Thijs3, Judith Bosmans4 1Nutrition and Dietetics / Internal Medicine, VU University Medical Center, 2Nutrition and Health, VU University, 3Internal Medicine, VU University Medical Center, 4Health Sciences, VU University, Amsterdam, Netherlands Rationale: In malnourished elderly patients, a post-discharge individualized nutritional intervention has shown to have positive effects on body weight, lean body mass, fall incidents and functional limitations1,2. However, the impact on survival is still unclear. Therefore, the aim of this randomized controlled study was to examine the effect of this nutritional intervention on survival in malnourished elderly patients. Methods: 210 malnourished elderly patients, aged ≥60 years, were randomized during hospitalization to a 3months post-discharge nutritional intervention group (protein and energy enriched diet, oral nutritional supplements, vitamin D3/calcium supplement and dietetic telephone counseling) or to a control group (usual care regimen). Survival data was evaluated 1 year and 4 years post-discharge. Survival analyses were performed using intention-to-treat analysis by Cox regression. Results: The study population consisted of 94 men (45%) and 116 women with a mean age of 74.5 (SD 9.5) years. Baseline characteristics were not different between groups. There were no statistically significant differences in survival between groups (Table 1). Table 1: Survival rates at 1 and 4 years following 3-months post-discharge nutritional intervention in malnourished elderly patients

SAT0359 Rheumatologists underestimate daily calcium intake in patients with osteoporosis

Background Calcium supplements are widely used for the prevention and treatment of osteoporosis. However, in recent literature there is a controversy whether or not excessive calcium supplementation may be associated with increased risk of cardiovascular events (1-2). In daily practice, rheumatologists at the VUmc use a short calcium list to estimate the dietary intake of calcium, which is the basis for the prescribed amount of calcium supplementation. An accurate estimation is important to be able to prescribe the adequate amount of calcium supplementation to reach the recommended levels of 1000-1200 mg of calcium per day, without a possible increase of the risk of cardiovascular events. Objectives Validation of a short calcium intake list used by rheumatologists with a detailed dietary history (DH), assessed by a dietician, as the reference method. Methods This cross-sectional study included patients attending the outpatient department of rheumatology at the VUmc for the treatment of primary or secondary osteoporosis. For participating in this study, subjects had to be diagnosed with and treated for osteoporosis, based on a low T-score in hip and/or lumbar spine, with or without a vertebral fracture. In addition, subjects in the group of secondary osteoporosis had to be diagnosed with a rheumatic disorder. The short calcium list calculated calcium intake by asking for the amount of portions of milk, yoghurt (multiplied by 180 mg of calcium per portion), and cheese (multiplied by 155 mg of calcium per portion). In addition, 250 mg of calcium from other products was added. This short list was compared with a DH with specific focus on calcium products and extra attention for portion sizes of dairy products and cheese. On forehand, a difference of at least 250 mg of calcium between both methods was formulated as clinically relevant. Results Sixty-six subjects (31 with primary osteoporosis and 35 with secondary osteoporosis) were included. The mean nutritional calcium intake measured via the short calcium list (825±259 mg) was lower than via the DH (1113±424 mg) (p<0.001). Furthermore, the mean difference between both methods was 289±346 mg of calcium: in 37 of the 66 patients (56.1%) the short calcium list scored more than 250 mg lower than the DH, and in only 4 of the 66 patients (6.1%) the short calcium list scored more than 250 mg higher than the DH. In total, 55 patients (83.3%) reached an overall intake higher than the upper limit of the recommendation of 1200 mg of calcium per day. Conclusions The short calcium list gives a substantial and clinically relevant underestimation of dietary calcium intake in more than 55% of the patients. Therefore, the short calcium list is not a valid method to measure calcium intake of patients with osteoporosis. This is a clinically relevant finding because of the rumour around an increased risk of cardiovascular events associated with a too high overall calcium intake. References Bolland MJ, et al. BMJ 2008 Feb 2;336(7638):262-6. Lewis JR, et al. J Bone Miner Res 2011 Jan;26(1):35-41. Disclosure of Interest None Declared

PP024-SUN FALL INCIDENTS DECREASE AFTER SHORT-TERM ORAL NUTRITIONAL INTERVENTION IN MALNOURISHED ELDERLY PATIENTS: A RANDOMIZED CONTROLLED TRIAL

little information is available about nutritional status and outcome of NH residents suffering from one or both of these problems. Methods: Data about Dy (yes vs no), CI (no/moderate vs severe), malnutrition (BMI 5 kg [WL]) were collected in yearly intervals from 2007 until 2010 by local nursing staff of voluntarily participating institutions using standardized questionnaires. Analysis was restricted to units with complete information and residents aged 65 y (7585 residents from 9 European countries). The prevalence of malnutrition and poor outcome in residents without Dy and CI (Dy CI ), with either Dy (Dy+ CI ) or CI (Dy CI+) and those with both problems (Dy+ CI+) was compared. Results: Mean age of the residents was 87±8 y, 82% were female. 15.6% suffered from Dy, 32.6% from CI. 62.0% were free of and 10.1% had both problems. The prevalence of malnutrition according to BMI and staff classification was lowest in Dy CI and highest in Dy+ CI+ (table). Mortality (23.5% vs. 12.2%) was significantly higher and WL> 5 kg after 6 months (19.4% vs. 9.4%) more prevalent in those with Dy compared to those without Dy independent of CI.

P152 THE SNAQRC, AN EASY TRAFFIC LIGHT SYSTEM AS A FIRST STEP IN THE RECOGNITION OF UNDERNUTRITION IN RESIDENTIAL CARE

Objective Development and validation of a quick and easy screening tool for the early detection of undernourished residents in nursing homes and residential homes.