Diagnostic criteria for malnutrition - An ESPEN Consensus Statement

Perioperative nutrition assessment in musculoskeletal trauma patients: Dietitian evaluation is superior to serum chemistries or modified screening questionnaire for risk stratification

INTRODUCTION

Malnutrition is a potentially modifiable risk factor associated with increased hospital charges, major wound complication, and fracture non-union after orthopaedic surgery. The goal of this study was to examine the relationship between three nutrition screening tools and postoperative complications in patients undergoing acute fracture fixation.

METHODS

Patients aged 18 or older undergoing acute operative fracture fixation at a Level I academic trauma center were screened upon admission using a malnutrition screening questionnaire (MSQ), and classified as low-, moderate- or high risk. Patients at moderate-to-high risk were assessed for clinical malnutrition by dietitian. Serum albumin, transferrin, total lymphocyte count, and 25(OH) Vitamin D were measured preoperatively. Primary outcome measures included twelve-month postoperative surgical and medical complications obtained by retrospective chart review.

RESULTS

Of 373 patients, 17% were moderate-to-high risk of malnutrition by MSQ. Clinical malnutrition was diagnosed by dietitian in 4.3% of patients assessed. Nearly half of all subjects had deficiency in one or more serum biomarkers. Cost of biomarker assays was $624 per patient. Medical or surgical complications occurred in 19% of patients. Dietitian diagnosed malnutrition (clinical malnutrition) was the strongest predictor of complication (OR 3.49, p = 0.017). Hypoalbuminemia was also associated with increased complication risk (OR 1.79, p = 0.045). MSQ score was not correlated with postoperative complication.

CONCLUSIONS

Among the examined malnutrition screening tools, clinical malnutrition had the strongest association with postoperative complication. Hypoalbuminemia was associated with increased odds of complication, however there was a large false positive rate with all tested serum chemistries and high associated hospital charges compared to dietitian assessment. MSQ was a poor predictor of malnutrition and clinical outcome. Dietetic assessment is advised for orthopaedic trauma patients.

Benefits of Oral Nutritional Supplements in Patients with Locally Advanced Nasopharyngeal Cancer during Concurrent Chemoradiotherapy: An Exploratory Prospective Randomized Trial

BACKGROUND

Weight loss during chemoradiotherapy is a major problem in patients with head and neck cancer. The aim of this study was to evaluate the effect of ONS on weight, nutritional status and quality of life (QOL) in patients with loco-regionally advanced nasopharyngeal cancer (NPC) undergoing chemoradiotherapy.

METHODS

Patients with locally advanced NPC treated at a tertiary hospital in China prior to curative chemoradiotherapy were eligible for this exploratory randomized study. Patients were assigned to either the intervention or the control group based on a computer-generated randomization sequence. The intervention group commenced ONS at the start of chemoradiotherapy. Outcomes included body weight, BMI, nutritional status and QOL.

RESULTS

From June 2015 to June 2016, 50 patients with NPC were randomized to intervention and 50 to the control group. Patients in the ONS group had a higher body weight at the end of chemoradiotherapy (59.11 kg vs 58.14 kg, p = 0.036). A higher BMI and prealbumin were observed in the ONS group (p = 0.021 and p = 0.048, respectively). No other differences were found for nutritional status, QOL or clinical outcomes.

CONCLUSION

ONS had beneficial outcomes in terms of reducing weight loss, minimizing BMI decrease and increasing protein intake in loco-regionally advanced NPC patients during chemoradiotherapy.

Impact of interprofessional education for medical and nursing students on the nutritional management of in-patients

Introduction: Despite its frequency, malnutrition is underestimated in its importance for morbidity and mortality. Interprofessional nutrition management can improve patient safety and clinical outcomes. An interprofessional education is considered as the basis for good team cooperation. So far, little data is available on the effects of interprofessional education on measurable outcomes for patients. The objective is to determine to what extent student feedback leads to a change of in-patient nutritional management for a selected internal medical ward. Methodology: In a teaching project based on the method of research oriented learning, medical and nursing students conducted an analysis of the nutritional situation of patients and developed individual treatment plans. The students orally reported their findings to the care teams as well as via a poster presentation to decision-makers of the clinic. A prospective cohort intervention study was conducted to assess the nutritional status of patients before and after student interventions using established screening tools. Differences were tested using t-test and Fisher's exact test. Institutional consequences for nutrition management were recorded descriptively. The teaching unit was evaluated by the students before and after. Results: Malnutrition was found in 59% of patients. Inspired by student feedback, institutional consequences followed: a) routine inpatient screening using Nutritional Risk Screening; and b) the use of pie charts to estimate food intake. Conclusion: The feedback from the results of student interprofessional cooperation led to a sensitization of decision-makers and enabled new measures to improve nutritional management. These can increase patient safety.

May nutritional status worsen during hospital stay? A sub-group analysis from a cross-sectional study

Hospital malnutrition is a detrimental prognostic factor regarding hospital mortality, complications, and length of stay. However, the role of hospitalization itself on nutritional status has not been fully elucidated. We report the results of a secondary analysis from the dataset of a recent cross-sectional study at Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. Data from patients evaluated at admission and discharge were collected and compared. One hundred thirty-nine patients were evaluated. Mean length of stay was 13.6 (± 7.7) days. Patients at risk of malnutrition, according to NRS-2002, were 75 (53.9%), while 63 (45.3%) were malnourished according to ESPEN Criteria. Compared to admission, at discharge, patients reported a significant decrease in Mid-Upper Arm Circumference (MUAC)-from 26.5 cm (± 3.6) to 25.9 cm (± 3.7) (p = 0.016), a reduction in Phase angle (PhA)-from 4.25° (± 1.20) to 4.01° (± 1.15) (p = 0.005), fat-free mass (FFM)-from 47.5 kg (± 9.19) to 44.9 kg (± 9.4) (p = 0.03) and fat-free mass index (FFMI)-from 16.9 kg/m² (± 2.3) to 15.8 kg/m² (± 2.7) (p = 0.04). Laboratory data showed a reduction of albumin-from 29.2 (± 5.7) to 28.0 (± 5.9) (p = 0.01) and Onodera's PNI- from 29.1 (± 5.6) to 27.6 kg (± 5.6) (p = 0.039). At the multivariate linear regression analysis, the variables significantly associated with a worsening of PhA at discharge are the PhA value at admission and the diagnosis of malnutrition according to ESPEN Criteria. Hospitalization leads to significative changes in nutritional status. A clinical concern should be raised about the quality of hospital food and meal times and on the need for a clinical nutritionist on the ward.

Rehabilitation Nutrition for Iatrogenic Sarcopenia and Sarcopenic Dysphagia

Sarcopenia is a very important issue in rehabilitation medicine and nutritional care. The prevalence of sarcopenia in older people is approximately 50% in the rehabilitation setting, and also approximately 15% of inpatients without sarcopenia upon admission developed sarcopenia during hospitalization. There is a concern that secondary sarcopenia may occur iatrogenically during hospitalization. Iatrogenic sarcopenia is defined as sarcopenia caused by the activities of medical staff including doctors, nurses, or other health care professionals in healthcare facilities. Iatrogenic sarcopenia is categorized into activity-related, nutrition-related and disease-related-iatrogenic sarcopenia. Especially in acute phase hospitals, concentrating on the treatment of diseases with less attention to nutrition and activity is more likely to cause iatrogenic sarcopenia. Sarcopenic dysphagia is also an important aspect in rehabilitation medicine and nutritional care. Sarcopenic dysphagia is characterized by swallowing difficulty because of a loss of mass and function in whole-body skeletal and swallowing muscles. Sarcopenic dysphagia can be diagnosed using a 5-step algorithm for the condition. Iatrogenic sarcopenia and sarcopenic dysphagia are affected by nutrition, activity and diseases in a complex manner. Therefore, treatment of iatrogenic sarcopenia and sarcopenic dysphagia requires comprehensive interventions through nutrition management and rehabilitation. Rehabilitation nutrition is effective for preventing and treating iatrogenic sarcopenia and sarcopenic dysphagia. Rehabilitation nutrition can be practiced more effectively and comprehensively by using the rehabilitation nutrition care process, which is a systematic problem-solving method. Further research is required to verify the efficacy of rehabilitation nutrition for preventing or improving iatrogenic sarcopenia and/or sarcopenic dysphagia.

Burden of Premorbid Consumption of Texture Modified Diets in Daily Life on Nutritional Status and Outcomes of Hospitalization

OBJECTIVES

Due to the water-rich cooking process required to soften texture modified diets (TMDs), TMDs may have poorer nutrition. The aim of this study was to investigate the associations between daily premorbid TMD consumption and nutritional status at the time of hospitalization, and its burden on hospitalization outcomes.

DESIGN

Retrospective observational study.

SETTING

An academic hospital.

PARTICIPANTS

The cohort comprised 3,594 older adult patients aged ≥65 years admitted to the hospital.

MEASUREMENTS

Patients were interviewed on admission using a premorbid daily consumption meal form to determine whether the patient ate a TMD. Nutritional status was examined using nutritional screening tools (Mini-Nutritional Assessment Short Form [MNA-SF], Malnutrition Universal Screening Tool [MUST], Geriatric Nutritional Risk Index [GNRI]) and the European Society of Clinical Nutrition and Metabolism (ESPEN)-defined criteria of malnutrition at admission. Length of hospital stay (LOS) and in-hospital mortality were considered outcomes of hospitalization. Multivariate analyses were performed to detect associations between premorbid TMD consumption and nutritional status and outcomes.

RESULTS

The mean age of the subjects was 75.9±7.0 years, including 58% males. Overall, 110 (3.1%) patients consuming a premorbid TMD were identified. They were older (p<0.001), had poor nutritional status (lower MNA-SF score [p<0.001] and GNRI value [p<0.001], higher MUST score [p<0.001], and more prevalent ESPEN-defined malnutrition [61.8% vs. 14.0%, p<0.001] than did patients without a TMD. The mortality rate and LOS of patients with TMD was higher (7.3% vs. 2.9%, p=0.017) and longer (19 days vs. 8 days, p<0.001) than those without TMD. Multivariate analyses showed that TMD consumption was independently associated with poor nutritional status and prolonged LOS after adjusting confounders.

CONCLUSION

Daily consumption of a TMD during the premorbid period affects nutritional status at the time of hospitalization and outcomes. Further studies are necessary to investigate whether nutritional intervention can improve outcomes for people on a TMD.

Malnutrition Screening and Assessment in Hospitalised Older People: a Review

Malnutrition (undernutrition) remains one of the most serious health problems for older people worldwide. Many factors contribute to malnutrition in older people, including: loss of appetite, polypharmacy, dementia, frailty, poor dentition, swallowing difficulties, social isolation, and poverty. Malnutrition is common in the hospital setting, yet often remains undetected by medical staff. The objective of this review is to compare the validity and reliability of Nutritional Screening Tools (NSTs) for older adults in the hospital setting. We also provide an overview of the various nutritional screening and assessment tools used to identify malnutrition in hospitalised older adults. These include: Subjective Global Assessment (SGA), the Mini Nutritional Assessment (MNA), MNA-short form (MNA-SF), Malnutrition Universal Screening Tool (MUST), Simplified Nutritional Appetite Questionnaire (SNAQ), Geriatric Nutrition Risk Index (GNRI) and anthropometric measurements. The prevalence and outcomes of malnutrition in hospitalised older adults are also addressed.

Prevalence and Diagnosis of Sarcopenia in Residential Facilities: A Systematic Review

Assessing sarcopenia, the age-related loss of muscle mass and function, in institutionalized older adults is a challenging task. Data on its prevalence in residential facilities are scant and highly variable. Our objective was to report the prevalence of sarcopenia in older adults living in residential facilities (nursing/long term-care homes and assisted-living facilities) and review the criteria and methodologies used to diagnose sarcopenia in this setting. Bibliographic searches were carried out in 6 electronic databases (Medline via PubMed, Web of Science, Scopus, CINAHL, LILACS, and Cochrane) with the use of the Medical Subject Heading terms "Sarcopenia" and "Residential Facilities." We included studies that evaluated the prevalence of sarcopenia among older adults (aged ≥60 y) living in residential facilities. Forty-four studies were identified, of which 21 studies were included after applying eligibility criteria. The reported prevalence of sarcopenia ranged widely between 17.7% and 73.3% in long term-care homes and between 22% and 87% in assisted-living facilities. Most studies (n = 14) followed the consensus on sarcopenia diagnosis published by the European Working Group on Sarcopenia in Older People. In the other 7 studies, sarcopenia was diagnosed according to muscle mass, which was measured via 5 different techniques, most frequently bioelectrical impedance analysis, establishing cutoff scores for low muscle mass with the use of 5 different indexes, most frequently the skeletal muscle index. There are major differences in study design, methodology, and the approach to sarcopenia diagnosis in this setting, which would, in part, explain the enormous variability in the reported prevalence data. The lack of consensus on the correct diagnostic approach hampers the implementation of appropriate nutritional interventions.

EASL Clinical Practice Guidelines on nutrition in chronic liver disease

A frequent complication in liver cirrhosis is malnutrition, which is associated with the progression of liver failure, and with a higher rate of complications including infections, hepatic encephalopathy and ascites. In recent years, the rising prevalence of obesity has led to an increase in the number of cirrhosis cases related to non-alcoholic steatohepatitis. Malnutrition, obesity and sarcopenic obesity may worsen the prognosis of patients with liver cirrhosis and lower their survival. Nutritional monitoring and intervention is therefore crucial in chronic liver disease. These Clinical Practice Guidelines review the present knowledge in the field of nutrition in chronic liver disease and promote further research on this topic. Screening, assessment and principles of nutritional management are examined, with recommendations provided in specific settings such as hepatic encephalopathy, cirrhotic patients with bone disease, patients undergoing liver surgery or transplantation and critically ill cirrhotic patients.

Sarcopenia as a predictor of poor surgical and oncologic outcomes after abdominal surgery for digestive tract cancer: A prospective cohort study

BACKGROUND & AIMS

Sarcopenia has been widely recognized as an important predictor of poor outcomes in patients with cancer after surgery, but the controversy remains, and its impact on surgical and oncologic outcomes in patients after abdominal surgery for digestive tract cancer is poorly described. The aim of this study was to evaluate the prognostic impact of sarcopenia on surgical and oncologic outcomes in patients after abdominal surgery for digestive tract cancer.

METHODS

Six thousand four hundred and forty-seven consecutive patients who underwent abdominal surgery for digestive tract cancer in our institution were prospectively included. Sarcopenia was defined as skeletal muscle index below the lowest sex-specific quartile using computed tomography scan at L3 before surgery. The surgical and oncologic outcomes were recorded, and univariate and multivariate analyses were performed.

RESULTS

Sarcopenia was present in 1638 of 6447 patients (25.4%) with digestive tract cancer before surgery based on the diagnostic cut-off values (43.13 cm²/m² for men and 37.81 cm²/m² for women). The incidence of postoperative total and pulmonary complications, and 30-day readmission were significantly higher in sarcopenic group than in nonsarcopenic group (37.4% vs 12.9%, P < 0.001; 3.1% vs 2.1%, P = 0.026; 1.1% vs 0.4%, P = 0.003, respectively). The postoperative hospital stay was significantly longer in sarcopenic patients (9.42 ± 3.40 vs 8.51 ± 3.17 days, P < 0.001). There were significantly more patients receiving postoperative chemotherapy or radiotherapy in sarcopenic group than in nonsarcopenic group (73.1% vs 69.2%, P = 0.003; 10.6% vs 8.8%, P = 0.038, respectively), and patients with sarcopenia had significantly more chemotherapy modifications including delay, dose reduction, or termination (48.5% vs 44.2%, P = 0.018). In addition, during the follow-up period, sarcopenic patients had significantly lower rate of overall survival and disease-free survival than nonsarcopenic patients (53.9% vs 69.3%, P = 0.002; 36.8% vs 59.7%, P = 0.000, respectively). In multivariate analysis, sarcopenia was found to be a risk factor for postoperative complications [odds ratio (OR) = 5.418, 95% confidence interval (CI) = 2.986-9.828, P < 0.001], and was an unfavorable prognostic factor for poor overall survival [hazard ratio (HR) = 0.649, 95% CI = 0.426-0.991, P = 0.045] and disease-free survival (HR = 0.514, 95% CI = 0.348-0.757, P = 0.001).

CONCLUSIONS

Sarcopenia could be used as a strong and independent prognostic factor for poor surgical and oncologic outcomes in patients after abdominal surgery for digestive tract cancer. Identification of preoperative sarcopenia in digestive surgery for cancer and targeted approaches may improve its negative outcomes.

Prevalence of breast cancer-related risk factors in underweight premenopausal women: the Korea National Health and Nutrition Examination Survey IV-VI

PURPOSE

This study aimed to examine the prevalence and trends of breast cancer-related risk factors and characteristics in premenopausal underweight Korean women according to birth year cohort.

METHODS

Socioeconomic and breast cancer-related risk factors were investigated in 13,415 premenopausal women using nationwide cross-sectional surveys performed between 2007 and 2015. Underweight was defined as body mass index < 18.5 kg/m². Multivariable models were created using complex sample procedures.

RESULTS

Underweight women comprised 9.5% of the sample. Compared with those who were obese or of normal weight, underweight women were characterized by younger age, higher rate of metropolitan residence, higher economic status, more education, higher rates of non-manual employment and unmarried status, lower rate of early menarche, higher rates of nulliparity, lower parity, alcohol consumption, and never having breastfed, and lower levels of high physical activity. Multivariable analysis showed that underweight women had a significantly lower rate of early menarche, lower parity, higher nulliparity, older age at first delivery, and lower levels of high physical activity compared to premenopausal women with normal weight. These trends were more apparent among women born in recent years.

CONCLUSIONS

Underweight Korean premenopausal women exhibit distinctive features associated with an increased risk of breast cancer, except for a lower rate of early menarche. These associations were prominent in recent generations. Assessment of the association between underweight and premenopausal breast cancer risk should focus on promoting healthy lifestyles to reduce breast cancer risk.

Characteristics of dietary intake among adult patients in hospitals in a lower middle-income country in Southeast Asia

AIM

Low-dietary intake is a common problem and cause of malnutrition during hospitalisation. This study aims to determine the current dietary intake and food sources of hospitalised adults in Ho Chi Minh City.

METHODS

Participants were adult patients from six general public hospitals in a multi-site survey undertaken in 2016. Dietary intakes for all foods consumed in the previous day were collected via interview using the 24 hours recall method. Nutritional status was assessed using Subjective Global Assessment or BMI.

RESULTS

Data were collected from 887 participants. Most food consumed in hospital was from non-regulated foodservices. Food was self-provided and home-cooked (27.7%), bought from outside the hospital (13.6%), from the hospital canteen (16.8%) or a combination of these (39.4%). Only 1.3% of food was provided by the hospital. Energy intakes were very low with a median of 3550 kJ/day; and only 4.2% of participants met 100% of their energy requirements. Decreased appetite, fullness or restrictions due to medical indications were the most common reasons for low-dietary intake. Malnourished participants were 2.2 times more likely to have low-dietary intake compared to well-nourished participants.

CONCLUSIONS

Non-regulated foodservices in hospital were not able to meet the dietary requirements of patients leading to hospital malnutrition. Standardisation of food from on-site canteens, covering meal costs from universal medical insurance, and developing guides for food provisioning for patients' families are potential solutions to improve patient nutritional status.

Vitamin B12 and folate deficiencies are not associated with nutritional or weight status in older adults

It is not known whether undernutrition causes vitamin B12 and folate deficiencies. The present study aimed to determine whether nutritional status, measured using the Mini Nutritional Assessment (MNA) scale, and body mass index (BMI) are indicators of lower level serum vitamin B12 and folate in older adults. 1007 outpatients aged 65 years or over were included the study. MNA scores >23.5, 17-23.5, <17, were categorized as normal nutritional status, risk of malnutrition, and malnutrition, respectively. Weight status was assessed using BMI and categorized as under or normal weight (<25 kg/m²), overweight (25-30 kg/m²), class I obese (30.0-35 kg/m²), class II obese (35-40 kg/m²), and class III obese (≥40 kg/m²). Vitamin B12 and folate deficiencies were defined as <200 pg/ml and <3 ng/ml, respectively. Among 1007 patients with an average age of 74.3 ± 8.2 years, 6.9% were categorized as having malnutrition and 31.2% were categorized as at risk of malnutrition. While 45.7% of patients were categorized as having vitamin B12 deficiency and 0.9% folate deficiency. There were no differences between patients with malnutrition, at risk of malnutrition, and good nutrition in serum vitamin B12 or folate levels, or the presence of vitamin B12 or folate deficiency after adjustment for age, gender, and education (p > 0.05). The results were the same across BMI classifications (p > 0.05). Vitamin B12 and folate levels are not associated with nutritional or weight status and these should be evaluated independently of BMI and MNA values.

Hand Grip Strength and Its Sociodemographic and Health Correlates among Older Adult Men and Women (50 Years and Older) in Indonesia

Objective

There is lack of knowledge about the patterns and correlates of hand grip strength (HGS) of older adults in Indonesia. This study aims to assess sociodemographic and health determinants of HGS among older adult men and women in Indonesia.

Methods

Participants were 7097 individuals of 50 years and older (mean age 61.2 years, SD=9.4) that participated in the cross-sectional Indonesia Family Life Survey (IFLS-5) in 2014-15. The assessment measures included a questionnaire on sociodemographic characteristics and health variables and anthropometric and HGS measurements. Linear multivariable regression analysis was conducted to estimate the association of social and health variables and HGS.

Results

The mean HGS was 28.2 kgs for men and 17.2 kgs for women. In adjusted linear regression analysis among both men and women, height, being overweight or obese, and having a good self-rated health status were positively associated with HGS, while age, having underweight, low cognitive functioning, and functional disability were negatively associated with HGS. In addition, among men, higher education and medium economic background were positive and having two or more chronic conditions, having severe depressive symptoms, and having moderate sleep impairment were negatively associated with HGS.

Conclusion

The study contributed to a better understanding of patterns and correlates of HGS among older adults in Indonesia. Gender-specific and health related interventions may be needed so as to improve the physical functioning of the growing older populace in Indonesia.

Malnutrition in older adults: screening and determinants

Older adults are at risk of protein-energy malnutrition (PEM). PEM detrimentally impacts on health, cognitive and physical functioning and quality of life. Given these negative health outcomes in the context of an ageing global population, the Healthy Diet for a Healthy Life Joint Programming Initiative Malnutrition in the Elderly (MaNuEL) sought to create a knowledge hub on malnutrition in older adults. This review summarises the findings related to the screening and determinants of malnutrition. Based on a scoring system that incorporated validity, parameters used and practicability, recommendations on setting-specific screening tools for use with older adults were made. These are: DETERMINE your health checklist for the community, Nutritional Form for the Elderly for rehabilitation, Short Nutritional Assessment Questionnaire-Residential Care for residential care and Malnutrition Screening Tool or Mini Nutritional Assessment-Short Form for hospitals. A meta-analysis was conducted on six longitudinal studies from MaNuEL partner countries to identify the determinants of malnutrition. Increasing age, unmarried/separated/divorced status (vs. married but not widowed), difficulties walking 100 m or climbing stairs and hospitalisation in the year prior to baseline or during follow-up predicted malnutrition. The sex-specific predictors of malnutrition were explored within The Irish Longitudinal Study of Ageing dataset. For females, cognitive impairment or receiving social support predicted malnutrition. The predictors for males were falling in the previous 2 years, hospitalisation in the past year and self-reported difficulties in climbing stairs. Incorporation of these findings into public health policy and clinical practice would support the early identification and management of malnutrition.

Effect of Exercise and Nutrition Prehabilitation on Functional Capacity in Esophagogastric Cancer Surgery: A Randomized Clinical Trial

Importance

Preserving functional capacity is a key element in the care continuum for patients with esophagogastric cancer. Prehabilitation, a preoperative conditioning intervention aiming to optimize physical status, has not been tested in upper gastrointestinal surgery to date.

Objective

To investigate whether prehabilitation is effective in improving functional status in patients undergoing esophagogastric cancer resection.

Design, Setting, and Participants

A randomized clinical trial (available-case analysis based on completed assessments) was conducted at McGill University Health Centre (Montreal, Quebec, Canada) comparing prehabilitation with a control group. Intervention consisted of preoperative exercise and nutrition optimization. Participants were adults awaiting elective esophagogastric resection for cancer. The study dates were February 13, 2013, to February 10, 2017.

Main Outcomes and Measures

The primary outcome was change in functional capacity, measured with absolute change in 6-minute walk distance (6MWD). Preoperative (end of the prehabilitation period) and postoperative (from 4 to 8 weeks after surgery) data were compared between groups.

Results

Sixty-eight patients were randomized, and 51 were included in the primary analysis. The control group were a mean (SD) age, 68.0 (11.6) years and 20 (80%) men. Patients in the prehabilitation group were a mean (SD) age, 67.3 (7.4) years and 18 (69%) men. Compared with the control group, the prehabilitation group had improved functional capacity both before surgery (mean [SD] 6MWD change, 36.9 [51.4] vs -22.8 [52.5] m; P < .001) and after surgery (mean [SD] 6MWD change, 15.4 [65.6] vs -81.8 [87.0] m; P < .001).

Conclusions and Relevance

Prehabilitation improves perioperative functional capacity in esophagogastric surgery. Keeping patients from physical and nutritional status decline could have a significant effect on the cancer care continuum.

Trial Registration

ClinicalTrials.gov Identifier: NCT01666158.

Malnutrition according to ESPEN definition predicts long-term mortality in general older population: Findings from the EPIDOS study-Toulouse cohort

BACKGROUND

The European Society of Clinical Nutrition and Metabolism (ESPEN) has developed a consensus definition of malnutrition. This study aimed to determine the prevalence of malnutrition according to the ESPEN definition in otherwise healthy community-dwelling older women and to explore its value for predicting long-term mortality in this population.

METHODS

This prospective population-based cohort study included 181 women (age ≥75 years) from a subsample of the EPIDémiologie de l'OStéoporose (EPIDOS) study participants from Toulouse. Inclusion criteria were the availability of the data on variables required to apply the ESPEN definition and survival after 7 years of follow-up. Primary outcome was mortality at 12-year follow-up; main covariates were malnutrition assessment according to the ESPEN consensus and its components (unintentional weight loss, BMI, and FFMI). Body composition was assessed by dual-energy X-ray absorptiometry at baseline and at 7-year follow-up. Kaplan-Meier survival curves and adjusted Cox regressions were performed. Analysis was adjusted for age, hypertension, diabetes mellitus, and coronary heart disease as potential confounders.

RESULTS

Complete data were available for 179 of the 181 women in the EPIDOS-Toulouse cohort (83.1 ± 2.2 years) and 13 (7.3%) fulfilled the ESPEN definition for malnutrition at 7-year follow-up. Malnutrition was associated with increased risk of mortality (adjusted HR = 4.4 [95%CI: 1.7-11.3]). Among the ESPEN components, only BMI was associated with increased mortality (adjusted HR=0.6 [95%CI: 0.4-0.9]).

CONCLUSIONS

Although malnutrition prevalence according to the ESPEN definition was relatively low (7.3%) in this sample of otherwise healthy community-dwelling older French women, malnutrition was associated with 4.4-fold higher mortality risk at 12-year follow-up.

Screening for malnutrition in patients admitted to the hospital with a proximal femoral fracture

INTRODUCTION

The prevalence of malnutrition in patients admitted with a proximal femoral fracture is considered high and the negative effects on health are well-studied. The SNAQ and the MNA-SF are two screening tools routinely used during admission of acute medical patients. The aim of this study is to compare the screening capacity of the SNAQ score and the MNA-SF, and to evaluate their predictive values for malnutrition using the ESPEN criteria.

MATERIALS AND METHODS

A single-centre study with data routinely collected prospectively from the original patient records was performed in the Haaglanden Medical Centre Bronovo in the Netherlands. All patients with a proximal femoral fracture consecutively admitted between December 19th 2016 and December 21st 2017 were included. The Intraclass Correlation Coefficient was used to assess the agreement between the malnutrition screening tools and the predictive values were calculated to compare the SNAQ with the MNA-SF using the ESPEN diagnostic criteria as the reference standard.

RESULTS

Data was available from 437 patients. Of all patients admitted with a proximal femoral fracture 16.9% was diagnosed as malnourished by the ESPEN criteria. When screened, 20.1% (SNAQ score) to 47.8% (MNA-SF) of all patients were classified as either at risk for malnutrition or as malnourished. A moderate agreement was found between the MNA-SF and the SNAQ (κ = 0.68). The sensitivity, specificity, PPV and NPV of the SNAQ score were 71.6%, 90.4%, 60% and 94% respectively, compared to 100%, 62.8%, 35.4% and 100% for the MNA-SF.

DISCUSSION

The SNAQ has been proven to be a very specific screening tool and the positive predictive value tends to be higher than that of the MNA-SF. However, 28.4% of all malnourished patients with a proximal femoral fracture had a negative screening test when using the SNAQ score.

CONCLUSIONS

No benefits were observed for the SNAQ over the MNA-SF as a screening tool for malnutrition in admitted patients with a proximal femoral fracture. Missing a significant portion of malnourished patients or those at risk and consequent under treatment of fragile older patients should be avoided. The well-validated MNA-SF seems more preferable as a screening tool for this patient population.

Validated screening tools for the assessment of cachexia, sarcopenia, and malnutrition: a systematic review

Background

There is great overlap between the presentation of cachexia, sarcopenia, and malnutrition. Distinguishing between these conditions would allow for better targeted treatment for patients.

Objectives

The aim was to systematically review validated screening tools for cachexia, sarcopenia, and malnutrition in adults and, if a combined tool is absent, make suggestions for the generation of a novel screening tool.

Design

A systematic search was performed in Ovid Medline, EMBASE, CINAHL, and Web of Science. Two reviewers performed data extraction independently. Each tool was judged for validity against a reference method. Psychometric evaluation was performed as was appraisal of the tools' ability to assess the patient against consensus definitions.

Results

Thirty-eight studies described 22 validated screening tools. The Cachexia score (CASCO) was the only validated screening tool for cachexia and performed well against the consensus definition. Two tools assessed sarcopenia [the Short Portable Sarcopenia Measure (SPSM) and the SARC-F (Strength, Assistance with walking, Rise from a chair, Climb stairs, and Falls)] and scored well against the 1998 Baumgartner definition. The SPSM required large amounts of equipment, and the SARC-F had a low sensitivity. Nineteen tools screened for malnutrition. The 3-Minute Nutrition Score performed best, meeting consensus definition criteria (European Society for Clinical Nutrition and Metabolism) and having a sensitivity and specificity of >80%. No tool contained all of the currently accepted components to screen for all 3 conditions. Only 3 tools were validated against cross-sectional imaging, a clinical tool that is gaining wider interest in body-composition analysis.

Conclusions

No single validated screening tool can be implemented for the simultaneous assessment of cachexia, sarcopenia, and malnutrition. The development of a tool that encompasses consensus definition criteria and directs clinicians toward the underlying diagnosis would be optimal to target treatment and improve outcomes. We propose that tool should incorporate a stepwise assessment of nutritional status, oral intake, disease status, age, muscle mass and function, and metabolic derangement.

Assessing and managing malnutrition in adults in hospital

The term malnutrition refers to both undernutrition and overnutrition. In healthcare, it most often refers to undernutrition, in particular disease-related malnutrition, which can be a result or a cause of an illness. The reasons for malnutrition are multifactorial, and its consequences may include an increased risk of pressure ulcers, reduced mobility and psychological effects such as depression. It is essential that nurses prioritise the nutritional care of all patients and identify those at risk of malnutrition using accurate and reliable nutrition screening tools. If there is a risk of malnutrition, further assessment and nutrition action planning can reduce the risk to the patient and improve their nutritional status. This article discusses the effects of disease-related malnutrition and outlines the role of screening tools and assessment in identifying patients who are malnourished or at risk of becoming malnourished. It also describes the nursing care that should be provided to patients with disease-related malnutrition, and emphasises the importance of using a multidisciplinary team approach involving speech and language therapists, dieticians, occupational therapists and physiotherapists.

Wasting in Chronic Kidney Disease – a Complex Issue

Chronic kidney disease (CKD) has become a global health burden and is associated with increased morbidity and mortality. In particular, wasting is highly prevalent in later stages of the illness with muscle loss being a common problem. The aetiology and progression of this wasting is complex and multiple states have been identified linked to wasting in CKD. These include: ‘malnutrition’, ‘disease-related malnutrition’, ‘protein-energy wasting’, ‘cachexia’, ‘sarcopenia’, ‘frailty’ and ‘muscle wasting’. The purpose of this paper is to review these terms in the context of CKD. Common features include weight loss, loss of muscle mass and muscle function principally driven by CKD disease specific factors and inflammatory mediators. Disease-related malnutrition would appear to be a more appropriate term for CKD than malnutrition as it take in to consideration disease specific factors such as inflammation for example.  Frailty is commonly associated with age-related decline in physiological function. Development of novel screening tools measuring across multiple domains of nutritional status, muscle and physical function may be useful in CKD. Research into potential treatments are currently underway with focus on multi-modal therapies including nutrition, resistance training and anabolic drugs such as myostatin blockade and selective androgen receptor modulators. A better understanding of different states and terms may help guide assessment and treatment opportunities for patients.

The risk of dysphagia is associated with malnutrition and poor functional outcomes in a large population of outpatient older individuals

Oropharyngeal dysphagia (OD) is a widespread clinical condition among older adults. Although it represents a risk factor for malnutrition, dehydration and aspiration pneumonia, its assessment and contribution to functional decline is often ignored. The aim of the present study was to estimate the prevalence of OD in a large population of non-institutionalized older people and to evaluate its relationship with malnutrition and physical function. 10-item Eating Assessment Tool (EAT-10) and Mini Nutritional Assessment Short Form (MNA-SF) were used to identify the risk of dysphagia and malnutrition. Short Physical Performance Battery (SPPB) and hand-grip strength were used as functional endpoints. The relationship between risk of dysphagia and functional outcomes was tested in a multivariate regression analysis adjusted for age and sex (Model 1) and for other confounders including Mini Mental State Examination (MMSE) and polypharmacy (Model 2). Mean age of 773 subjects (61.3% female) was 81.97 years. The percentage of participants at risk of dysphagia (EAT ≥ 3) was 30.1%, 37.8% of subjects was malnourished (MNA-SF < 8), 46.2% was at risk of malnutrition (MNA-SF:8-11). EAT-10 was significantly and negatively associated to MNA-SF (β = -0.47 ± 0.06, p < 0.0001) and the strength of the relationship was attenuated but still statistically significant in the multivariate model (β = -0.28 ± 0.07, p < 0.0001). A significant and negative relationship was found between EAT-10 and SPPB and hand-grip strength in Model 1 (β = -0.25 ± 0.05, p < 0.0001) and Model 2 (β = -0.07 ± 0.03, p < 0.0001). After categorization of risk of dysphagia in two groups (at risk and not at risk), MNA-SF, SPPB and hand-grip strength were independently associated with higher risk of dysphagia (OR = 0.91, 95%CI = 0.83-0.99, p = 0.03; OR = 0.83, 95%CI = 0.77-0.89, p < 0.0001; OR = 0.96, 95%CI = 0.92-0.99, p = 0.02, respectively). In a large group of outpatient older individuals, we observed a significant negative association between risk of dysphagia and nutritional and physical performance, suggesting that the screening of OD, possibly supported by its assessment, should be implemented in the geriatric setting to potentially prevent the functional decline.

Early Skeletal Muscle Loss in Non-Small Cell Lung Cancer Patients Receiving Chemoradiation and Relationship to Survival

PURPOSE

Sarcopenia is associated with reduced survival in cancer. Currently, data on sarcopenia at presentation and muscle loss throughout treatment are unknown in patients receiving chemoradiation therapy (CRT) for non-small cell lung cancer (NSCLC). This study evaluated skeletal muscle changes in NSCLC patients receiving CRT and relationship with survival.

METHODS

Secondary analysis of 41 patients with NSCLC treated with CRT assessed for skeletal muscle area and muscle density by computed tomography pre-treatment and 3 months post-treatment. Images at week 4 of treatment were available for 32 (78%) patients. Linear mixed models were applied to determine changes in skeletal muscle over time and related to overall survival using Kaplan-Meier plots.

RESULTS

Muscle area and muscle density decreased significantly by week 4 of CRT (- 6.6 cm², 95% CI - 9.7 to - 3.1, p < 0.001; - 1.3 HU, 95% CI - 1.9 to - 0.64, p < 0.001, respectively), with minimal change between week 4 of CRT and 3 months post-CRT follow-up (- 0.2 cm², 95% CI - 3.6-3.1, p = 0.91; - 0.27, 95% CI - 0.91-0.36, p = 0.36, respectively). Sarcopenia was present in 25 (61%) and sarcopenic obesity in 6 (14%) of patients prior to CRT, but not associated with poorer survival. Median survival was shorter in patients with low muscle density prior to treatment although not statistically significant (25 months + 8.3 vs 53 months + 13.0, log-rank p = 0.17).

CONCLUSION

Significant loss of muscle area and muscle density occurs in NSCLC patients early during CRT. A high proportion of patients are sarcopenic prior to CRT; however, this was not significantly associated with poorer survival.

Nutritional management of older hospitalised patients with pressure injuries

This cross-sectional, multicentre study was conducted in hospitals to investigate nutritional interventions conducted in patients aged 70 years or older with (risk of) pressure injuries. A total of 1412 patients from 33 hospitals with 208 wards participated in the study. A standardised questionnaire was used to collect demographic data and data on care dependency, malnutrition risk, risk for/prevalence of pressure injuries, and nutritional interventions. Data analyses were conducted by using descriptive statistics, chi-square tests, or independent t-tests. According to the Braden Scale, 678 (48.0%) of the patients were at risk of developing pressure injuries, and 71 patients (5.0%) had at least one pressure injury (assessed by skin inspection). The most frequently conducted nutritional interventions in patients with pressure injuries were providing support during mealtimes (50.7%), food specifically desired by the patient (40.8%), and conducting a malnutrition screening (39.4%). One quarter of the patients with pressure injuries were referred to a dietitian. The provision of an energy-enriched/protein-enriched diet (18.3%), energy-enriched/protein-enriched snacks (12.7%), or oral nutritional supplements (8.5%) was rare. Nutritional care in older patients with risk of pressure injuries is suboptimal. Health care professionals need to raise awareness regarding the importance of nutrition in the management of patients with pressure injuries.

Non-alcoholic fatty liver disease in underweight patients with inflammatory bowel disease: A case-control study

Non-alcoholic fatty liver disease (NAFLD) was shown to also occur in lean and underweight patients. So far, the prevalence of NAFLD in underweight individuals with and without inflammatory bowel disease (IBD) is insufficiently enlightened. In this cross-sectional age, gender and disease-matched case-control study, underweight patients (BMI<18.5 kg/m2) with inflammatory bowel disease (IBD), who underwent abdominal MRI at 1.5 T/3 T with fat-saturated fast-spin-echo imaging from 10/2005-07/2018 were analysed (control-to-case-ratio 1:1, n = 130). All patients were additionally investigated for duration, history of surgery, medical treatment, laboratory values, liver and spleen diameters. On MRI, liver fat was quantified by two observers based on the relative signal loss on T2-weighted fast spin-echo MR images with fat saturation compared to images without fat saturation. The prevalence of NAFLD/liver steatosis, defined as a measured intrahepatic fat content of at least 5%, was significantly higher in underweight IBD patients than in normal weight patients (87.6% versus 21.5%, p<0.001). Compared to the cases, the liver fat content of the controls was reduced by -0.19 units on average (-19%; 95%Cl: -0.20; -0.14). Similar results were obtained for the subgroup of non-IBD individuals (n = 12; -0.25 units on average (-25%); 95%Cl: -0.35; -0.14). Patients with extremely low body weight (BMI <17.5 kg/m2) showed the highest liver fat content (+0.15 units on average (+15%) compared to underweight patients with a BMI of 17.5-18.5 kg/m2 (p<0.05)). Furthermore, underweight patients showed slightly increased liver enzymes and liver diameters. There were no indications of significant differences in disease duration, type of medications or surgery between cases and controls and also, there were no significant differences between observers or field strengths (p>0.05). The prevalence of liver steatosis was higher among underweight IBD and non-IBD patients compared to normal weight controls. Also, underweight patients showed slightly increased liver enzymes and liver diameters, hinting at initial metabolic disturbances.

Evaluating the concurrent validity of body mass index (BMI) in the identification of malnutrition in older hospital inpatients

BACKGROUND

Nutrition screening and assessment tools often include body mass index (BMI) as a component in identifying malnutrition risk. However, rising obesity levels will impact on the relevancy and applicability of BMI cut-off points which may require re-evaluation. This study aimed to explore the relationship between commonly applied BMI cut-offs and diagnosed malnutrition.

METHODS

Data (age, gender, BMI and Subjective Global Assessment (SGA) ratings) were analysed for 1152 inpatients aged ≥65 years across annual malnutrition audits (2011-2015). The receiver operation characteristic (ROC) curve analysed the optimal BMI cut-off for malnutrition and concurrent validity of commonly applied BMI cut-offs in nutritional screening and assessment tools.

RESULTS

Malnutrition prevalence was 36.0% (n = 372) using SGA criteria (not malnourished, moderate or severe malnutrition). Median age was 78.7 (IQR 72-85) years, median BMI 25.4 (IQR 21.8-29.7) kg/m²; 52.1% male and 51.2% overweight/obese. ROC analysis identified an optimal BMI cut-off of <26 kg/m², 80.8% sensitivity and 61.5% specificity (AUC 0.802, 95% CI 0.773, 0.830; p < 0.0001). Commonly applied BMI cut-offs (between 18.5 and 23 kg/m²) failed to meet the alpha-priori requirement of 80% sensitivity and 60% specificity. However, BMI <23 kg/m² had the highest agreement (κ = 0.458) with malnutrition diagnosed using the SGA.

CONCLUSIONS

Both malnutrition and overweight/obesity are common in older inpatients. Continuing increases in the prevalence of overweight and obesity will impact on the sensitivity of BMI as a screening component for malnutrition risk. The current study suggests tools developed over a decade ago may need to be revisited in future.

Prevalence of malnutrition using harmonized definitions in older adults from different settings - A MaNuEL study

BACKGROUND & AIMS

Malnutrition is widespread among older people and related to poor outcome. Reported prevalences vary widely, also because of different diagnostic criteria used. This study aimed to describe prevalences in several populations of older persons in different settings using harmonized definitions.

METHODS

Available studies within the Joint Programming Initiative (JPI) Knowledge Hub 'Malnutrition in the Elderly' (MaNuEL) were used to calculate and compare prevalences of malnutrition indicators: low BMI (<20 kg/m²; age-specific BMI <20 if age 65-<70 and <22 kg/m² if age ≥70 years), previous weight loss (WL), moderate and severe decrease in food intake, and combined BMI <20 kg/m² and/or WL in participants aged ≥65 years.

RESULTS

Fifteen samples with in total 5956 participants (59.3% women) were included: 7 consisting of community-dwelling persons, 2 studies in geriatric day hospitals, 3 studies in hospitalized patients and 3 in nursing homes. Mean age of participants ranged between 67 and 87 years. Up to 4.2% of community-dwelling persons had a BMI <20 kg/m², 1.6 and 9% of geriatric day hospital patients, 4.5-9.4% of hospital patients and 3.8-18.2% of nursing home residents. Using age-specific cut-offs doubled these prevalences. WL was reported in 2.3-10.5% of community-dwelling persons, 6% and 12.6% of geriatric day hospital patients, 5-14% of hospitalized patients and 4.5-7.7% of nursing home residents. Severe decrease in food intake was recorded in up to 9.6% of community-dwelling persons, 1.5% and 12% of geriatric day hospital patients, 3.4-34.2% of hospitalized patients and 1.5-8.2% of nursing home residents. The criteria age-specific BMI and WL showed opposing prevalences across all settings. Compared to women, low BMI and moderate decrease in food intake showed low prevalences in men but similar prevalences were observed for weight loss and severe decrease in food intake. In half of the study samples, participants in a younger age group had a higher prevalence of WL compared to those of an older age group. Prevalence of BMI <20 kg/m² and WL at the same time did not exceed 2.6% in all samples. The highest prevalences were observed based on combined definitions when only one of the three criteria had to be present.

CONCLUSIONS

Prevalences for different criteria vary between and within the settings which might be explained by varying functional status. The criteria used strongly affect prevalence and it may be preferable to look at each criterion separately as each may indicate a nutritional problem.

Nutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS)

BACKGROUND

The optimal nutritional therapy in the field of pancreatic surgery is still debated.

METHODS

An international panel of recognized pancreatic surgeons and pancreatologists decided that the topic of nutritional support was of importance in pancreatic surgery. Thus, they reviewed the best contemporary literature and worked to develop a position paper to provide evidence supporting the integration of appropriate nutritional support into the overall management of patients undergoing pancreatic resection. Strength of recommendation and quality of evidence were based on the approach of the grading of recommendations assessment, development and evaluation Working Group.

RESULTS

The measurement of nutritional status should be part of routine preoperative assessment because malnutrition is a recognized risk factor for surgery-related complications. In addition to patient's weight loss and body mass index, measurement of sarcopenia and sarcopenic obesity should be considered in the preoperative evaluation because they are strong predictors of poor short-term and long-term outcomes. The available data do not show any definitive nutritional advantages for one specific type of gastrointestinal reconstruction technique after pancreatoduodenectomy over the others. Postoperative early resumption of oral intake is safe and should be encouraged within enhanced recovery protocols, but in the case of severe postoperative complications or poor tolerance of oral food after the operation, supplementary artificial nutrition should be started at once. At present, there is not enough evidence to show the benefit of avoiding oral intake in clinically stable patients who are complicated by a clinically irrelevant postoperative pancreatic fistula (a so-called biochemical leak), while special caution should be given to feeding patients with clinically relevant postoperative pancreatic fistula orally. When an artificial nutritional support is needed, enteral nutrition is preferred whenever possible over parenteral nutrition. After the operation, regardless of the type of pancreatic resection or technique of reconstruction, patients should be monitored carefully to assess for the presence of endocrine and exocrine pancreatic insufficiency. Although fecal elastase-1 is the most readily available clinical test for detection of pancreatic exocrine insufficiency, its sensitivity and specificity are low. Pancreatic enzyme replacement therapy should be initiated routinely after pancreatoduodenectomy and in patients with locally advanced disease and continued for at least 6 months after surgery, because untreated pancreatic exocrine insufficiency may result in severe nutritional derangement.

CONCLUSION

The importance of this position paper is the consensus reached on the topic. Concentrating on nutritional support and therapy is of utmost value in pancreatic surgery for both short- and long-term outcomes.

Longitudinal Body Composition Changes and the Importance of Fat-Free Mass Index in Locally Advanced Nasopharyngeal Carcinoma Patients Undergoing Concurrent Chemoradiotherapy

Aim: This was a prospective investigation of longitudinal body composition changes in patients with nasopharyngeal carcinoma undergoing concurrent chemoradiotherapy (CCRT) and a comparison of the Patient-Generated Subjective Global Assessment (PG-SGA) and the ESPEN (European Society for Clinical Nutrition and Metabolism) diagnostic criteria (EDC) as evaluation methods. Methods: All patients received standard CCRT according to 2 centers’ current practices. Body composition parameters were determined by bioelectrical impedance analysis and obtained weekly from baseline until the end of treatment. The nutritional status of all patients was evaluated by the PG-SGA and EDC. Results: Forty-eight patients were eligible for analysis. Most body composition parameters, including body cell mass, fat mass, fat-free mass, and skeletal mass, as well as body weight, body mass index, and PG-SGA score, significantly decreased during CCRT (P = .00). The PG-SGA was shown to have better sensitivity than the EDC; however, the 2 different evaluation methods were found to have a perfect concordance at Week 4 and Week 6 (κ = 0.91 and 0.96, P = .00 and .00, respectively). Pearson correlation analyses showed that fat-free mass index and body weight were positively correlated with global quality of life score (r = 0.81, P = .00; r = 0.78, P = .00, respectively). Conclusions: This study has shown that body composition parameters, especially fat-free mass index, are valuable for diagnosing malnutrition in patients with nasopharyngeal carcinoma receiving CCRT. We recommend that these bioelectrical impedance analysis techniques should be increasingly implemented in nutritional assessments.

The impact of using a malnutrition screening tool in a hospital setting: a mixed methods study

BACKGROUND/OBJECTIVES

Malnutrition risk screening represents a crucial starting point for the successful management of malnourished patients. This study was conducted to (1) examine the effect of the use of a malnutrition screening tool on process indicators of nutritional care and (2) explore healthcare professionals' perceptions and opinions regarding this tool.

METHODS

A mixed methods design was used. A controlled pretest-posttest study was conducted to carry out quantitative analyses, and semi-structured, qualitative interviews were held. Quantitative data were analysed with descriptive statistics, Chi-squared tests, Student's t-tests and Kruskal-Wallis H tests, using SPSS 23. Qualitative data were analysed by performing a qualitative content analysis using MAXQDA 12. Two comparable hospitals participated in the study, representing one intervention group (IG) and one control group (CG). The Graz Malnutrition Screening Tool (GMS) was implemented and used in the IG for at least 1 month, while the CG received no intervention.

RESULTS

The use of the screening tool positively correlated with significant improvements in the process indicators of nutritional care after 1 month, in terms of the number of nutritional interventions and the frequency of documentation of the diagnosis and the patient's weight and height. The content of the interviews revealed that nearly all professionals involved perceived the overall screening process positively. Few barriers were identified.

CONCLUSIONS

The results of this study show that the use of a screening tool has a positive, short-term impact on the hospital's process quality of nutritional care. Ongoing efforts are required to sustainably maintain these positive changes. During this process, positive attitudes, nomination of motivated 'opinion-leaders' and concerted management support are helpful facilitators.

Adequacy of nutrition and body weight in patients with early stage dementia: The cognition and aging study

BACKGROUND & AIMS

Recent evidence highlights the effects of obesity, diabetes and hypertension in the development of Alzheimer's disease. Involuntary body weight changes in patients with different stages of dementia can be related to clinical factors of the patient per se or support from their caregivers. Understanding the interactions among factors is important to establish a monitoring paradigm to guide treatment strategies.

METHODS

A total of 345 patients with very mild (n = 224) and mild stage (n = 121) dementia were enrolled from a multi-disciplinary dementia clinic. Clinical data (comorbidities, Mini-Mental State Examination [MMSE] scores, neuropsychiatric inventory [NPI] scores, eating behavior questionnaire), nutritional state (Mini-Nutritional Assessment [MNA] or MNA short form [MNA-SF]) and body mass index (BMI) were recorded. Nutritional state and BMI served as the two major outcome measures, and factors for analysis included diagnosis, dementia severity and clinical data.

RESULTS

There was a significant correlation between MNA-SF and MNA (r = .898, p < 0.01), but a 24% mismatch in case dislocation was found using the at-risk or malnutrition criteria. Factors related to obesity included male sex, higher MNA-SF and MNA scores, diabetes mellitus and hypertension, while acceptable discrimination for obesity (BMI≧23 kg/m²) was obtained with a MNA-SF score of 12/13 or MNA score of 21/22. NPI was the only independent factor related to both MNA-SF (β = -.06, P < 0.001) and MNA (β = -.1, P < 0.001). A BMI of 22-23 kg/m² was adequate in this group of patients with early stage dementia from nutritional and comorbidity perspectives. After controlling for BMI, the patients with advanced dementia had higher swallowing problem and appetite change scores.

CONCLUSIONS

In these patients with early stage dementia, a higher BMI indicated adequate nutritional status and higher MMSE, but also higher rates of comorbidities, diabetes mellitus and hypertension.

Applications of the new ESPEN definition of malnutrition and SARC-F in Chinese nursing home residents

We aimed to compare the predictive capacity of malnutrition, sarcopenia, and malnutrition combined with sarcopenia for mortality in nursing home residents. We conducted a prospective study in four nursing homes in China. Nutrition status and sarcopenia were measured according to the new European Society of Clinical Nutrition and Metabolism (ESPEN) definition and SARC-F, respectively. The study population was divided into four groups: malnutrition with sarcopenia (MN+/SA+), malnutrition without sarcopenia (MN+/SA−), sarcopenia without malnutrition (MN−/SA+), and normal nutrition without sarcopenia (MN−/SA−). The participants were followed up for 12 months. We included 329 participants. Thirty-eight participants (11.6%) had MN+/SA+, 38 participants (11.6%) had MN+/SA−, and 93 participants (28.3%) had MN−/SA+. The 1-year mortality was 18.3%, 21.5%, 18.4%, and 47.4% in the MN−/SA−, MN−/SA+, MN+/SA−, and MN+/SA+ groups, respectively. Compared to participants with MN−/SA−, participants with MN+/SA+ were at a significantly higher risk of mortality (adjusted hazard ratio [HR]: 3.19, 95% confidence interval [CI] 1.71–5.95); however, MN−/SA+ (adjusted HR: 1.24, 95% CI 0.69–2.22) and MN+/SA− (adjusted HR: 0.95, 95% CI 0.41–2.19) were not predictors of mortality. In conclusion, the coexistence of malnutrition and sarcopenia is a significant predictor of mortality in a study population of Chinese nursing home residents.

Hypoalbuminemia: Pathogenesis and Clinical Significance

Hypoalbuminemia is associated with inflammation. Despite being addressed repeatedly in the literature, there is still confusion regarding its pathogenesis and clinical significance. Inflammation increases capillary permeability and escape of serum albumin, leading to expansion of interstitial space and increasing the distribution volume of albumin. The half‐life of albumin has been shown to shorten, decreasing total albumin mass. These 2 factors lead to hypoalbuminemia despite increased fractional synthesis rates in plasma. Hypoalbuminemia, therefore, results from and reflects the inflammatory state, which interferes with adequate responses to events like surgery or chemotherapy, and is associated with poor quality of life and reduced longevity. Increasing or decreasing serum albumin levels are adequate indicators, respectively, of improvement or deterioration of the clinical state. In the interstitium, albumin acts as the main extracellular scavenger, antioxidative agent, and as supplier of amino acids for cell and matrix synthesis. Albumin infusion has not been shown to diminish fluid requirements, infection rates, and mortality in the intensive care unit, which may imply that there is no body deficit or that the quality of albumin “from the shelf” is unsuitable to play scavenging and antioxidative roles. Management of hypoalbuminaemia should be based on correcting the causes of ongoing inflammation rather than infusion of albumin. After the age of 30 years, muscle mass and function slowly decrease, but this loss is accelerated by comorbidity and associated with decreasing serum albumin levels. Nutrition support cannot fully prevent, but slows down, this chain of events, especially when combined with physical exercise.

Handgrip Strength, but Not 5-Meter Walk, Adds Value to a Clinical Nutrition Assessment

BACKGROUND

Decreased physical functioning is associated with malnutrition and common in acute care patients; determining loss of function is often considered part of a comprehensive nutrition assessment. Handgrip strength (HGS) and 5-meter timed walk (5m) are functional measures used in a variety of settings. This analysis sought to determine which functional measure could be added to a hospital nutrition assessment, based on its feasibility and capacity to discriminate patient subgroups.

METHODS

Eligible medical patients (no delirium/dementia, admitted from community; n = 1250), recruited from 5 hospitals that participated in a previous multisite action research study, provided data on demographics, HGS, 5m, nutrition status, perceived disability, and other characteristics.

RESULTS

Significantly more patients (z = 17.39, P < .00001) were able to complete HGS than 5m (92% versus 43%, respectively). Median HGS was 28.0 kg for men and 14.7 kg for women. Of patients who completed the 5m, mean completion time was 8.98 seconds (median, 6.79 seconds, SD = 6.59). 5m and HGS scores were significantly worse with patient-perceived disability (z = -9.56, t = 10.69, respectively; P < .0001; 95% confidence interval [CI], [7.33, 10.63]; [1.76, 3.18]). HGS was associated with nutrition status (t = 4.13, P < .001; 95% CI [2.02, 5.67]), although it showed poor validity as a single nutrition indicator.

CONCLUSIONS

These data indicate that HGS is a more useful functional measure than 5m when added to a hospital nutrition assessment. Determination of HGS cutpoints to identify low strength in acute care patients will promote its use.

Prevalence and predictors of malnutrition in elderly Chinese adults: results from the China Health and Retirement Longitudinal Study

Objective

China has the largest population of elderly citizens in the world, with 177 million adults aged 60 years or older. However, no national estimate of malnutrition in elderly Chinese adults exists. We estimated the prevalence and predictors of malnutrition in this population.

Design

Data from the second wave of the Chinese Health and Retirement Longitudinal Study (CHARLS) include interview and biomarker data for 6450 subjects aged 60 years or older from 448 different communities in twenty-eight provinces, allowing for nationally representative results. Malnutrition was identified based on the ESPEN (European Society of Parenteral and Enteral Nutrition and Metabolism) criteria. We used multivariable regression to investigate the predictors of malnutrition, including demographic factors, marital status, self-reported health status, self-reported standard of living, health insurance status and education.

Setting

China.

Subjects

Community-dwelling Chinese adults aged 60 years or older.

Results

The prevalence of malnutrition in elderly Chinese adults was 12·6 %. Malnutrition was most common among those who were older (OR=1·09; 95 % CI 1·07, 1·10), male (OR=1·41; 95 % CI 1·10, 1·79), lived in rural areas (v. urban: OR=0·75; 95 % CI 0·57, 1·00) or lacked health insurance (P<0·01).

Conclusions

The burden of malnutrition on elderly Chinese adults is significant. Based on current population estimates, up to 20 million are malnourished. Malnutrition is strongly associated with demographic factors, shows a trend to association with health status and is not strongly associated with standard of living or education. A coordinated effort is needed to address malnutrition in this population.

The role of nutrition in ageing: A narrative review from the perspective of the European joint action on frailty - ADVANTAGE JA

BACKGROUND AND PURPOSE

There is sufficient evidence that nutrition and frailty status are related. In order to deliver quality management of frail and pre-frail patients, clinicians and dieticians should understand the role of nutrition in the concept of frailty. This study examines the role of nutrition in ageing in general, malnutrition and the risk of frailty, individual nutritional factors as the risk factors of frailty and lastly nutritional interventions that have a significant role in frailty.

METHODS

A literature search was conducted in the following databases: PubMed, Cochrane, Embase, Cinahl and UpToDate. The criterion in selecting the literature was that articles were published between 2002 and 2017. From 39,885 initial hits, 28 publications were selected.

RESULTS

Malnutrition or being at risk of malnutrition increases the risk of frailty and its consequences. With regard to the importance of recognizing malnutrition and the risk of malnutrition, the Mini Nutritional Assessment is a validated tool with acceptable sensitivity/specificity to be used for screening and assessment. Frail patients who are at an elevated risk of falls and fractures need Vitamin D supplementation. The promotion of a Mediterranean diet and a protein intake of at least 1-1.2 g per kilogram of body weight per day is beneficial.

CONCLUSIONS

One of the main variable risk factors for the development of frailty can be unsuitable nourishment and there is evidence that nutrition and frailty status are related. Successful comprehensive management of frailty requires a balanced healthy nutrition at all ages, preferably in combination with physical activity.

Comparison of Three Nutritional Screening Tools to Predict Malnutrition Risk and Detect Distinctions Between Tools in Cancer Patients Receiving Radiochemotherapy

The aim of this study was to compare three screening tools for malnutrition in patients with head and neck cancers or central nervous system tumors (CNS) who are undergoing radiochemotherapy. The study evaluated 124 adult cancer patients. The Subjective Global Assessment (SGA), Mini-Nutritional Assessment (MNA), and Nutritional Risk Screening 2002 (NRS-2002) were chosen to assess the risk of malnutrition. The prevalence of patients at nutritional risk was 31% with SGA, 31% with MNA and 23% with NRS-2002 in all patients. The agreement between SGA and MNA was substantial (κ = 0.886, P < 0.001); the agreement between SGA and NRS-2002 was moderate (κ = 0.713, P < 0.001); and the agreement between MNA and NRS-2002 was also moderate (κ = 0.795, P < 0.001). In subgroup analysis, SGA and MNA substantially (κ = 0.973, P < 0.001), SGA and NRS-2002 moderately (κ = 0.722, P < 0.001), and MNA and NRS-2002 moderately (κ = 0.747, P < 0.001) agreed in head and neck cancer patients. In CNS tumor patients, SGA and MNA slightly (κ = 0.390, P = 0.005), SGA and NRS-2002 fairly (κ = 0.457, P =0.001), and MNA and NRS-2002 substantially (κ = 0.878, P < 0.001) agreed. The best agreement in tools was observed between SGA with MNA in all patients. Further studies in different tumor groups will enhance our understanding of current tools for malnutrition detection of radiotherapy patient.

ESPEN guideline on clinical nutrition in the intensive care unit

Following the new ESPEN Standard Operating Procedures, the previous guidelines to provide best medical nutritional therapy to critically ill patients have been updated. These guidelines define who are the patients at risk, how to assess nutritional status of an ICU patient, how to define the amount of energy to provide, the route to choose and how to adapt according to various clinical conditions. When to start and how to progress in the administration of adequate provision of nutrients is also described. The best determination of amount and nature of carbohydrates, fat and protein are suggested. Special attention is given to glutamine and omega-3 fatty acids. Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy. Monitoring of this nutritional therapy is discussed in a separate document.

Malnutrition according to ESPEN consensus predicts hospitalizations and long-term mortality in rehabilitation patients with stable chronic obstructive pulmonary disease

BACKGROUND

Nutritional disorders are frequent in patients with chronic pulmonary obstructive disease (COPD) and have negative health impacts. This study aimed to explore the value of the European Society of Clinical Nutrition and Metabolism (ESPEN) definition of malnutrition (and/or its individual components) to predict hospitalizations and mortality at 2 years, and to determine the prevalence of malnutrition in COPD patients referred to pulmonary rehabilitation.

METHODS

The study was a prospective analysis of 118 patients with COPD free of exacerbations and/or hospital admissions in the previous two months. Main outcome variables were mortality, hospital admissions, and length of stay at 2-year follow-up; main covariates were malnutrition assessment according to the ESPEN definition and its components: unintentional weight loss, body mass index, and fat-free mass index (FFMI). Body composition was assessed by bioimpedance analysis. Kaplan-Meier survival curves and linear regression analyses were performed, adjusting for age and airflow obstruction as potential confounders.

RESULTS

The observed prevalence of malnutrition was 24.6%. Malnutrition was associated with increased mortality risk (HR = 3.9 [95% CI: 1.4-10.62]). FFMI was independently associated with increased mortality (HR = 17.0 [95% CI: 2.24-129.8]), which persisted after adjustment for age and lung function (adjusted HR = 13.0 [95% CI: 1.67-101.7]). Low age-related body mass index was associated with increased risk of hospital admissions.

CONCLUSIONS

Malnutrition according to ESPEN criteria, highly prevalent in patients with stable COPD referred to pulmonary rehabilitation, was associated with 4 times greater mortality risk after 2 years. Low FFMI was associated with a 17-fold increase in mortality risk, suggesting independent predictive value.

Transthyretin for the routine assessment of malnutrition: A clinical dilemma highlighted by an international survey of experts in the field

The value of transthyretin (TTR) measurement for assessing malnutrition is under debate due to its sensitivity to inflammation and frequent confusion over its meaning (i.e. as a marker of diagnosis, prognosis, or efficacy of refeeding). Moreover, there is still no ESPEN/ASPEN guideline on its use and cut-off values. Here the aim was to evaluate the overall perception of the value of this parameter and its utilization worldwide. A panel of international experts in the field were surveyed on the use of TTR in clinical practice in their country, on the guidelines issued by their national health authorities, and on the cut-off values used to diagnose malnutrition. A total of 31 experts (nutrition [n = 9], surgery [n = 8], critical care [n = 4], geriatrics [n = 4], biology [n = 3], pediatrics [n = 1], internal medicine [n = 1] and gastroenterology [n = 1]) from 16 countries participated. TTR only appears in Italian, Polish, British and French national guidelines giving cut-off values for mild/moderate/severe malnutrition. TTR is frequently used in research yet rarely if ever in clinical practice in most countries, the reasons cited being lack of evidence for its usefulness, lack of specificity, or its high cost/effectiveness ratio. Given the difficulty of finding a consensus tool for the diagnosis of malnutrition, there is every reason to consider such a simple and inexpensive marker as TTR. However, further studies are needed to define and unify international guidelines on the use of TTR in terms of inflammation level and the associated cut-off values.