Mette Holst

ESPEN guidelines on definitions and terminology of clinical nutrition

BACKGROUND A lack of agreement on definitions and terminology used for nutrition-related concepts and procedures limits the development of clinical nutrition practice and research. OBJECTIVE This initiative aimed to reach a consensus for terminology for core nutritional concepts and procedures. METHODS The 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. RESULTS Five 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. CONCLUSION An 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.

Measuring nutritional risk in hospitals

About 20%–50% of patients in hospitals are undernourished. The number varies depending on the screening tool amended and clinical setting. A large number of these patients are undernourished when admitted to the hospital, and in most of these patients, undernutrition develops further during hospital stay. The nutrition course of the patient starts by nutritional screening and is linked to the prescription of a nutrition plan and monitoring. The purpose of nutritional screening is to predict the probability of a better or worse outcome due to nutritional factors and whether nutritional treatment is likely to influence this. Most screening tools address four basic questions: recent weight loss, recent food intake, current body mass index, and disease severity. Some screening tools, moreover, include other measurements for predicting the risk of malnutrition. The usefulness of screening methods recommended is based on the aspects of predictive validity, content validity, reliability, and practicability. Various tools are recommended depending on the setting, ie, in the community, in the hospital, and among elderly in institutions. The Nutrition Risk Screening (NRS) 2002 seems to be the best validated screening tool, in terms of predictive validity ie, the clinical outcome improves when patients identified to be at risk are treated. For adult patients in hospital, thus, the NRS 2002 is recommended.

Oral nutritional support of older (65 years+) medical and surgical patients after discharge from hospital: systematic review and meta-analysis of randomized controlled trials

Objective: To estimate the effectiveness of oral nutritional support compared to placebo or usual care in improving clinical outcome in older (65 years+) medical and surgical patients after discharge from hospital. Outcome goals were: re-admissions, survival, nutritional and functional status, quality of life and morbidity. Data sources: Three recent Cochrane reviews and an update of their literature search using MEDLINE, EMBASE, Web of Science. Search terms included randomized controlled trials; humans; age 65+ years; subset: dietary supplements. Review methods: One reviewer assessed trials for inclusion, extracted data and assessed trial quality. Results: Six trials were included (N = 716 randomly assigned participants). All trials used oral nutritional supplements. A positive effect on nutritional intake (energy) and/or nutritional status (weight) (in compliant participants) were observed in all trials. Two pooled analysis was based on a fixed-effects model. No significant effect were found on mortality (four randomized controlled trials with 532 participants, odds ratio 0.80 (95% confidence (CI) interval 0.46 to 1.39)) or re-admissions (four randomized controlled trials with 478 participants, odds ratio 1.07 (95% CI 0.71 to 1.61)). Conclusion: Although the evidence is limited, we suggest that oral nutritional support may be considered for older malnourished medical and surgical patients after discharge from hospital.

Nutritional screening and risk factors in elderly hospitalized patients: association to clinical outcome?

The aim of this study was to test the intervalidity of three different nutrition screening tools towards a broad population of elderly hospitalized patients. The association with risk factors and mortality was investigated. This is a prospective cohort study in three medical, surgical and geriatric settings, in Denmark and Sweden. Patients >65 years were consecutively included. Patients were screened by mini-nutritional assessment (MNA), malnutrition universal screening tool (MUST) and nutritional risk screening (NRS-2002). Anthropometrics, cognitive test (SPMSQ), as well as a questionnaire investigation regarding eating problems and life situation, were performed. Mortality within 12 months was investigated. In total, 233 patients mean (SD) age 81(7.64) years were included. A large variation in prevalence of nutritional risk was determined between the screening tools, MNA was 68% vs. MUST, 47% and NRS 54%, p < 0.0001. An overall agreement of 67% was seen (κ 0.52-0.55). Risk factors were associated with nutritional risk, including depressive mood. Only handgrip strength, fungus in mouth, serum albumin, CRP and cognitive function were associated with mortality. Fungus had the strongest association (OR 3.7; CI 1.19-11.30). The overall mortality rate was 27% during 12 months. However, none of the three screening tools predicted 12-month mortality. The findings show great variation in the prevalence of nutritional risk of under nutrition both between the tools and the settings. The level of agreement between the tools was moderate, and none of the three tools were capable of predicting 12-month mortality. A functional and psychological evaluation including oral health seems recommendable in elderly patients at nutritional risk.

Nutrition in chronic pancreatitis

The pancreas is a major player in nutrient digestion. In chronic pancreatitis both exocrine and endocrine insufficiency may develop leading to malnutrition over time. Maldigestion is often a late complication of chronic pancreatic and depends on the severity of the underlying disease. The severity of malnutrition is correlated with two major factors: (1) malabsorption and depletion of nutrients (e.g., alcoholism and pain) causes impaired nutritional status; and (2) increased metabolic activity due to the severity of the disease. Nutritional deficiencies negatively affect outcome if they are not treated. Nutritional assessment and the clinical severity of the disease are important for planning any nutritional intervention. Good nutritional practice includes screening to identify patients at risk, followed by a thoroughly nutritional assessment and nutrition plan for risk patients. Treatment should be multidisciplinary and the mainstay of treatment is abstinence from alcohol, pain treatment, dietary modifications and pancreatic enzyme supplementation. To achieve energy-end protein requirements, oral supplementation might be beneficial. Enteral nutrition may be used when patients do not have sufficient calorie intake as in pylero-duodenal-stenosis, inflammation or prior to surgery and can be necessary if weight loss continues. Parenteral nutrition is very seldom used in patients with chronic pancreatitis and should only be used in case of GI-tract obstruction or as a supplement to enteral nutrition.

Management of acute intestinal failure: A position paper from the European Society for Clinical Nutrition and Metabolism (ESPEN) Special Interest Group

Intestinal failure (IF) is the consequence of a reduction of gut function below the minimum necessary for the absorption of nutrients from the gastrointestinal tract. Types I and II comprise acute intestinal failure (AIF). Although its prevalence is relatively low, type II AIF is serious and requires specialist multidisciplinary care, often for prolonged periods before its resolution. The key aspects are: sepsis control, fluid and electrolyte resuscitation, optimization of nutritional status, wound care, appropriate surgery and active rehabilitation. The ESPEN Acute Intestinal Failure Special Interest Group (AIF SIG) has devised this position paper to provide a state-of-the-art overview of the management of type II AIF and to point out areas for future research.

Individualised dietary counselling for nutritionally at-risk older patients following discharge from acute hospital to home: a systematic review and meta-analysis.

BACKGROUND Many older patients are undernourished after hospitalisation. Undernutrition impacts negatively on physical function and the ability of older patients to perform activities of daily living at home after discharge from acute hospital. The present study aimed to evaluate the evidence for an effect of individualised dietary counselling following discharge from acute hospital to home on physical function, and, second, on readmissions, mortality, nutritional status, nutritional intake and quality of life (QoL), in nutritionally at-risk older patients. METHODS A systematic review of randomised controlled trials was conducted. The overall quality of the evidence was assessed according to Grading of Recommendations Assessment, Development and Evaluation system (GRADE) criteria. RESULTS Four randomised controlled trials (n = 729) were included. Overall, the evidence was of moderate quality. Dietitians provided counselling in all studies. Meta-analyses showed a significant increase in energy intake [mean difference (MD) = 1.10 MJ day(-1), 95% confidence interval (CI) = 0.66-1.54, P < 0.001], protein intake (MD = 10.13 g day(-1), 95% CI = 5.14-15.13, P < 0.001) and body weight (BW) (MD = 1.01 kg, 95% CI = 0.08-1.95, P = 0.03). Meta-analyses revealed no significant effect on physical function assessed using hand grip strength, and similarly on mortality. Narrative summation of effects on physical function using other instruments revealed inconsistent effects. Meta-analyses were not conducted on QoL and readmissions as a result of a lack of data. CONCLUSIONS Individualised dietary counselling by dietitians following discharge from acute hospital to home improved BW, as well as energy and protein intake, in older nutritionally at-risk patients, although without clearly improving physical function. The effect of this strategy on physical function and other relevant clinical outcomes warrants further investigation.

Multi-modal intervention improved oral intake in hospitalized patients. A one year follow-up study

BACKGROUND Good nutritional practice (GNP) includes screening, nutrition plan and monitoring, and is mandatory for targeted treatment of malnourished patients in hospital. AIMS To optimize energy- and protein-intake in patients at nutritional risk and to improve GNP in a hospital setting. METHODS A 12-months observational multi-modal intervention study was done, using the top-down and bottom-up principle. All hospitalized patients (>3 days) were included. SETTING A university hospital with 758 beds and all specialities. MEASUREMENTS Record audit of GNP, energy- and protein-intake by 24-h recall, patient interviews and staff questionnaire before and after the intervention. INTERVENTIONS Based on pre-measurements, nutrition support teams in each department made targeted action plans, supervised by an expert team. Education, diagnose-specific nutrition plans, improved menus and eating environment, and awareness were initiated. STATISTICS Mann-Whitney and Kruskal-Wallis test was used for ordinal data, and Pearson Chi square test for nominative data. RESULTS Overall 545 patients participated (287 before/258 after) from 26/22 departments. There were no significant differences regarding sex, age, BMI or previous weight loss before and after the intervention. Result-indicators: Energy intake improved from 52% to 68% (p < 0.007), and protein intake from 33% to 52% (p < 0.001) (>75% of requirements). Intake of less than 50% of requirements decreased with 50%. Process-indicators: Screening improved from 56% to 77% (p < 0.001), nutrition plans from 21% to 56% (p < 0.0001), and monitoring food intake from 29% to 58% (p < 0.0001). CONCLUSIONS Intake of energy and protein as well as GNP improved using a multi-modal top-down and bottom-up approach.

Nutrition Therapy in the Transition between Hospital and Home: An Investigation of Barriers

Aims and Objectives. This study aimed to investigate barriers for nutrition therapy in the transition between hospital and home and hereby to identify areas for potential improvements. Background. Though the focus on nutritional risk is improving in hospital, there seems to be less effort to maintain or even improve nutritional status after discharge and during the rehabilitation period. Design. Qualitative focus group interviews. Methods. Semistructured focus group interviews with experienced multiprofessional staff from hospital, home care, nursing homes, and general practise. The study was done in the county of Aalborg with about 280.000 inhabitants regarding homecare and general practise as well as Aalborg University Hospital, Denmark. Results. Interviews were generated with 41 professionals from hospital, general practise, and home care. Barriers identified between settings included the following aspects: economic, organisation, and education. The impression of professionals was that few patients are discharged with nutrition therapy, compared to who could benefit from nutrition therapy after discharge. Most often, reasons were a short in-hospital stay and lack of knowledge and interest. Moreover, lack of clinical guidelines throughout all settings, time consumption, lack of transparency regarding economy and workflows, and lack of assistance from experts regarding complicated nutritional problems were identified. Conclusions. Many barriers were found in hospital as well as in the community and general practise. These were most often practical as well as organizational. Improvements of clinical guidelines and instructions and improvement of knowledge and communication at all levels are needed. Relevance to Clinical Practise. This study emphasizes that responsibility needs to be taken for patients whom are still at nutritional risk at discharge, and even before hospitalization. Nurses and doctors in and outside hospital are in need of improved knowledge, standard care plans, and instructions.

Effect of meal portion size choice on plate waste generation among patients with different nutritional status. An investigation using Dietary Intake Monitoring System (DIMS).

BACKGROUND The trolley meal system allows hospital patients to select food items and portion sizes directly from the food trolley. The nutritional status of the patient may be compromised if portions selected do not meet recommended intakes for energy, protein and micronutrients. The aim of this study was to investigate: (1) the portion size served, consumed and plate waste generated, (2) the extent to which the size of meal portions served contributes to daily recommended intakes for energy and protein, (3) the predictive effect of the served portion sizes on plate waste in patients screened for nutritional risk by NRS-2002, and (4) to establish the applicability of the dietary intake monitoring system (DIMS) as a technique to monitor plate waste. METHODS A prospective observational cohort study was conducted in two hospital wards over five weekdays. The DIMS was used to collect paired before- and after-meal consumption photos and measure the weight of plate content. RESULTS The proportion of energy and protein consumed by both groups at each meal session could contribute up to 15% of the total daily recommended intake. Linear mixed model identified a positive relationship between meal portion size and plate waste (P = 0.002) and increased food waste in patients at nutritional risk during supper (P = 0.001). CONCLUSION Meal portion size was associated with the level of plate waste produced. Being at nutritional risk further increased the extent of waste, regardless of the portion size served at supper. The use of DIMS as an innovative technique might be a promising way to monitor plate waste for optimizing meal portion size servings and minimizing food waste.