Diagnostic criteria for malnutrition - An ESPEN Consensus Statement

GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community

RATIONALE

This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings.

METHODS

In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee and a supporting working group with representatives bringing additional global diversity and expertise. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications.

RESULTS

A two-step approach for the malnutrition diagnosis was selected, i.e., first screening to identify "at risk" status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among the GLIM core and supporting working group members. The top five ranked criteria included three phenotypic criteria (non-volitional weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present. Phenotypic metrics for grading severity as Stage 1 (moderate) and Stage 2 (severe) malnutrition are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories.

CONCLUSION

A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure further collaboration and endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The diagnostic construct should be re-considered every 3-5 years.

GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community

BACKGROUND

This initiative aims to build a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings.

METHODS

The Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications.

RESULTS

A 2-step approach for the malnutrition diagnosis was selected, that is, first screening to identify at risk status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among GLIM participants that selected 3 phenotypic criteria (non-volitional weight loss, low body mass index, and reduced muscle mass) and 2 etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least 1 phenotypic criterion and 1 etiologic criterion should be present. Phenotypic metrics for grading severity are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories.

CONCLUSIONS

A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The construct should be re-considered every 3-5 years.

The association between 25(OH)D levels, frailty status and obesity indices in older adults

BACKGROUND

Vitamin D deficiency is common in older adults and has been linked with frailty and obesity, but it remains to be studied whether frail obese older adults are at higher risk of vitamin D deficiency. Therefore, the aim of this study is to explore the association between frailty, obesity indices and serum 25(OH)D concentrations.

METHODS

1447 individuals with 65 years or older, participating in a cross-sectional study (Nutrition UP 65) were included. Frailty, according to Fried et al., body mass index (BMI), waist circumference (WC), body roundness index (BRI) and body shape index (ABSI) were evaluated. A stepwise multinomial logistic regression was carried out to quantify the association between 25(OH)D quartiles and independent variables.

RESULTS

Median 25(OH)D levels were lower in individuals presenting both frailty and obesity (p<0.001). In the multivariate analysis, pre-frailty (OR: 2.65; 95% CI: 1.63-4.33) and frailty (OR: 3.77; 95% CI: 2.08-6.83) were associated with increased odds of lower 25(OH)D serum levels (first quartile). Regarding obesity indices, the highest categories of BMI (OR: 1.74; 95% CI: 1.06-2.86), WC (OR: 3.46; 95% CI: 1.95-6.15), BRI (OR: 4.35; 95% CI: 2.60-7.29) and ABSI (OR: 3.17 95% CI: 1.86-5.38) were directly associated with lower 25(OH)D serum levels (first quartile).

CONCLUSIONS

A positive association between frailty or obesity and lower vitamin D levels was found. Moreover, besides BMI and WC, other indicators of body adiposity, such as BRI and ABSI, were associated with lower 25(OH)D serum concentrations.

Abdominal obesity in normal weight versus overweight and obese hemodialysis patients: Associations with nutrition, inflammation, muscle strength, and quality of life

OBJECTIVE

The biological basis of abdominal obesity leading to more severe outcomes in patients with normal body mass index (BMI) on maintenance hemodialysis (MHD) is unclear. The aim of this study was to compare the properties of abdominal obesity in different BMI categories of patients on MHD.

METHODS

We performed a cross-sectional study of 188 MHD patients (52.7% women; mean age, 69.4 ± 11.5 y) with abdominal obesity in different BMI groups using criteria from the World Health Organization. Appetite and dietary intake, body composition, handgrip strength, malnutrition inflammation score (MIS), inflammatory biomarkers, adipokines, and health-related quality-of-life (QoL) questionnaires were studied.

RESULTS

According to multivariable analyses, abdominally obese patients with normal BMIs consumed less protein per day (P = 0.04); had lower measurements of surrogates of lean (P < 0.001) and fat mass (P < 0.001); and had higher total cholesterol, tumor necrosis factor-α (P < 0.05), and ratios of adiponectin to leptin (P = 0.003) than overweight and obese patients with abdominal obesity. Multivariable analyses showed no differences in handgrip strength among the study groups.The abdominally obese study participants with normal weight had significantly lower scores in role physical (P = 0.003) and pain (P = 0.04) scales after multivariable adjustments.

CONCLUSIONS

Normal-weight MHD patients with abdominal obesity exhibited a more proatherogenic profile in terms of inflammatory markers and adipokine expression, lower body composition reserves, and lower physical ability than patients with abdominal obesity with overweight and obesity. This at least partially explains the abdominal obesity paradox in the MHD population in which worse clinical outcomes are seen in abdominally obese patients with normal BMIs, as opposed to overweight and obese patients who are also abdominally obese.

Nutritional Status During Inpatient Alcohol Detoxification

Aims

As low rates of thiamine are thought to be implicated in alcohol-related cognitive disorders, we wanted to assess patients with alcohol use disorders (AUD) during detoxification for their nutritional status and test if vitamins blood levels were associated with a surrogate of cognitive impairment.

Methods

We performed a retrospective chart review of medical records of 94 consecutive patients hospitalized for alcohol detoxification in a specialized addiction medicine department. Nutritional status was assessed with Body Mass Index (BMI). Vitamins blood levels were available for 80 patients, but thiamine only for 52 patients. The Montreal Cognitive Assessment (MoCA) score was used to screen for cognitive impairment at Day 10 of entry and was available in 59 patients. A binary logistic regression was performed to identify factors associated with MoCA scores below the threshold (26 points).

Results

The mean BMI was 23.28 ± 3.78 kg/m2 and 8.79% of weighted patients qualified for malnutrition. The mean MoCA score was 22.75 ± 4.88 points, and 66% of tested patients were below the threshold of suspected cognitive impairment. No low blood thiamine level was found. In multivariate analysis, BMI, but not vitamins blood rates, was significantly associated with a pathological MoCA screening test.

Conclusion

Clinical examination is more sensitive than biomarkers to determine malnourished AUD patients who are at-risk for cognitive impairment. Malnourished patients with AUD should receive a full neuropsychological testing.

Summary

This retrospective chart review study screened for cognitive disorders during alcohol inpatient detoxification with the MoCA test. Body mass index, but not vitamins blood rates, was associated with a pathological MoCA. Clinical examination is more sensitive than biomarkers to determine malnourished AUD patients who are at-risk for cognitive impairment.

Vitamin D Status Is Associated With Development of Hospital-Acquired Pressure Injuries in Critically Ill Surgical Patients

BACKGROUND

Hospital-acquired pressure injuries (HAPIs) typically develop following critical illness due to immobility and suboptimal perfusion. Vitamin D helps to maintain epithelial cell integrity, particularly at barrier sites such as skin. It is unclear whether vitamin D status is a modifiable risk factor for HAPIs in critically ill patients. Our goal was to investigate the relationship between admission 25-hydroxyvitamin D (25OHD) levels with the development of HAPIs in surgical intensive care unit (ICU) patients.

METHODS

We performed a retrospective cohort study of patients admitted to surgical ICUs at a major teaching hospital in Boston, Massachusetts. To investigate the association of 25OHD levels with subsequent development of HAPIs, we performed logistic regression analyses, controlling for body mass index, Nutrition Risk in the Critically Ill score, ICU length of stay, and cumulative ICU caloric or protein deficit.

RESULTS

A total of 402 patients comprised our analytic cohort. Each unit increment in 25OHD was associated with 11% decreased odds of HAPIs (odds ratio [OR] 0.89; 95% CI 0.840.95). When vitamin D status was dichotomized, patients with 25OHD <20 ng/mL were >2 times as likely to develop HAPIs (OR 2.51; 95% CI 1.065.97) compared with patients with 25OHD >20 ng/mL.

CONCLUSION

In our cohort of critically ill surgical patients, vitamin D status at ICU admission was linked to subsequent development of HAPIs. Randomized, controlled trials are needed to assess whether optimizing 25OHD levels in the ICU can reduce the incidence of HAPIs and improve other clinically relevant outcomes in critically ill patients.

Validity of the new nutrition screening tool Control of Food Intake, Protein, and Anthropometry (CIPA) in non-surgical inpatients

INTRODUCTION

There is no gold-standard method for hospital nutrition screening. The new screening tool termed Control of Food Intake, Protein, and Anthropometry (CIPA) gives positive results when at least one of the following parameters is met: control of food intake for 72 h < 50%, serum albumin < 3 g/dl, body mass index < 18.5 kg/m² or mid-upper arm circumference ≤ 22.5 cm. This method was validated in comparison with Subjective Global Assessment (SGA) in hospitalized patients with non-surgical pathologies.

MATERIAL AND METHODS

A prospective, longitudinal study was performed on 221 consecutively enrolled patients. Prevalence or risk of malnutrition was estimated with CIPA vs. SGA screening at hospital admission and the concordance (k index - K) between the two methods and their sensitivity (S) and specificity (SP) were studied. Mean length of stay (LOS), mortality, and rate of early readmission were analyzed.

RESULTS

The prevalence or risk of malnutrition identified by CIPA and SGA was 35.7% and 23.1%, respectively. K was 0.401 (p < 0.001); S and SP of CIPA vs. SGA were 72.5% and 75.3%, respectively. In contrast to SGA, CIPA-positive patients had an increased mean LOS compared to the negative ones (19.53 vs. 12.63 days, p < 0.001). Both methods detected a major risk of mortality in positive patients, but no difference in early readmission.

CONCLUSIONS

The CIPA and the SGA screening tools detect patients with a higher risk of mortality, but only CIPA identifies patients with an increased mean LOS. CIPA screening proved valid for use in non-surgical inpatients.

Risk, prevalence, and impact of hospital malnutrition in a Tertiary Care Referral University Hospital: a cross-sectional study

Hospital malnutrition is still underestimated among physicians, even in internal medicine settings. This is a cross-sectional study, aiming to estimate the risk, the prevalence and the impact of malnutrition in an Internal Medicine and Gastroenterology Department of a large Italian hospital (Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome). Patients were evaluated within 72 h from admission according to Nutritional Risk Screening-2002 (NRS-2002) and European Society for Clinical Nutrition and Metabolism (ESPEN) Criteria. Anthropometric, laboratory tests and Bioelectrical Impedance Analysis (BIA) derived phase angle were also performed. Length of hospital stay (LOS) and in-hospital mortality were collected. Univariate and multivariate analyses were conducted to correlate nutritional status with LOS and hospital mortality. In 10 months, 300 patients were enrolled: male patients were 172 (57.3%); mean age was 63.7 (± 17.6). At admission, 157 (52.3%) patients were at risk of malnutrition; 116 (38.7%) were malnourished. Malnourished patients had a mean LOS of 11.5 (± 8.0) days, not-malnourished 9.4 (± 6.2) days (p < 0.05). In-hospital mortality did not significantly differ between the two groups. Multivariate analysis shows that both malnutrition (p = 0.04; 95% CI 0.03-3.41) and phase angle (p = 0.004; 95% CI - 1.92 to - 0.37) independently correlate with LOS. In an Internal Medicine and Gastroenterology Department, over half (52.3%) of the patients were found at risk of malnutrition, and over a third (38.7%) were malnourished at hospital admission. Malnutrition and BIA-derived phase angle are independently associated with LOS. ESPEN Criteria and phase angle could be performed at admission to identify patients deserving specific nutritional support.

Nutritional status in patients aged over 65 years and its influence on the quantity and type of complications occurring 3, 6 and 12 months after hospitalisation: a clinical prospective study

BACKGROUND

Malnutrition in hospitalised patients is associated with frequent complications and increased mortality. The present study aimed to determine the prevalence of abnormal nutritional status in patients aged over 65 years with a diagnosis of cardiovascular diseases and also to determine its relationship with the duration of hospitalisation and the incidence of complications over 3, 6 and 12 months of observation. A comparison was also made of diagnostic performance between the various classifications used to diagnose abnormal nutritional status.

METHODS

In total, 76 patients aged over 65 years with cardiovascular conditions were involved in the study. Abnormal nutritional status was identified on the basis of Mini-Nutritional Assessment-Short Form (MNA-SF) test results, laboratory tests and European Society for Clinical Nutrition and Metabolism (ESPEN) nutritional status assessment criteria. During 3, 6 and 12 months of observation, data were collected concerning the number of re-hospitalisations and the presence of complications.

RESULTS

Abnormal nutritional status was reported in 78% of participants. Malnutrition, as diagnosed on the basis of laboratory findings and also on the basis of ESPEN criteria comprising the value of fat free mass index (FFMI), was significantly related to prolonged hospitalisation and an increased complication rate. The results of the MNA-SF test performed at baseline revealed no relationship with the incidence of complications during the first stage of the study.

CONCLUSIONS

Abnormal nutritional status was a common phenomenon in the group of patients under investigation. The set of criteria for assessing the nutritional status that had the highest association with the duration of hospitalisation and the incidence of complications includes laboratory tests and ESPEN criteria comprising the value of FFMI.

Outpatient preoperative oral nutritional support for undernourished surgical patients: A systematic review

AIMS AND OBJECTIVES

To evaluate the effects of preoperative nutritional support using a regular diet for undernourished surgical patients at the outpatient clinic.

BACKGROUND

Undernutrition (or malnutrition) in surgical patients has severe consequences, that is, more complications, longer hospital stay and decreased quality of life. While systematic reviews show the effects of oral nutritional supplements (ONS), enteral and parenteral nutrition in surgical patients, the effects of normal foods and regular diets remain unclear.

DESIGN

A systematic review.

METHODS

PubMed, CINAHL, Web of Science, PsycINFO, Cochrane Library and EMBASE were searched up to July 24, 2017. Studies on undernourished patients receiving nutritional support using regular or therapeutic diet, performed preoperatively at the outpatient clinic, were considered eligible. Risk of bias was assessed using the Cochrane Risk of Bias tool. Two reviewers independently performed study selection, quality assessment and data extraction.

RESULTS

Six studies with moderate risk of bias were included. Interventions were preoperatively performed in mainly oncological outpatients by dieticians and aimed to reach nutrient requirements. Interventions included consults for counselling and advice, follow-up meetings and encouragements, and ONS. Nutritional status, nutrient intake and quality of life improved in supported patients. Improvements were better in counselled patients compared to patients using supplements. Unsupported patients experienced worse outcomes.

CONCLUSION

Frequent consults with counselling and advice as nutritional support for undernourished patients before surgery result in improvements to nutritional status, intake and quality of life. This statement is supported by weak evidence due to few studies and inadequate methods.

RELEVANCE TO CLINICAL PRACTICE

Nutritional support should be provided to all undernourished surgical patients during preoperative course. Nurses are in key position to provide nutritional support during outpatient preoperative evaluations.

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.

Frailty and nutritional status in older people: the Mini Nutritional Assessment as a screening tool for the identification of frail subjects

INTRODUCTION

Frailty is a condition characterized by reduced resistance to low-level stress events, resulting from the progressive decline of multiple physiological systems observed with aging. Many factors can contribute to the pathogenesis of frailty, and nutritional status appears to play a key role. The objective of the study was to investigate the relationship between nutritional status, evaluated using Mini Nutritional Assessment (MNA), and frailty among older people.

PATIENTS AND METHODS

An observational study was carried out at the University Hospital "Tor Vergata" in Rome among patients aged 65 years or older, with or without hip fracture. The study sample included 62 patients hospitalized for a hip fracture and 50 outpatients without fracture. All subjects underwent blood sampling for laboratory assays and received a multidimensional geriatric evaluation comprising Activity of Daily Living (ADL), Instrumental Activity of Daily Living (IADL), Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS), and MNA. Comorbidity was assessed using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Muscle strength was measured by handgrip dynamometry, and frailty score was calculated using the Survey of Health, Ageing and Retirement in Europe-Frailty Index (SHARE-FI).

RESULTS

Approximately 38% of the study population was frail, with the prevalence of frailty being greater among hospitalized older patients. Among frail subjects, 65% were at risk of malnutrition (RMN) and 10% were malnourished. The prevalence and RMN progressively diminished in the pre-frail group and not frail group. Nutritional status was closely associated with the degree of frailty, and in a logistic regression, MNA was the best variable predicting both pre-frailty and frailty.

DISCUSSION AND CONCLUSION

Malnutrition contributes to the development of frailty. MNA can generate vital information to help identify a substantial part of both frail and pre-frail patients at low cost and care.

Prognostic significance of combined pretreatment lymphocyte counts and body mass index in patients with head and neck cancer treated with radiation therapy

We aimed to investigate the prognostic significance of combined pretreatment lymphocyte counts (LCs) and body mass index (BMI) in patients with head and neck cancer (HNC) treated with radiation therapy (RT). Nine hundred and twelve patients with HNC who were treated with RT were retrospectively reviewed. Survival was analyzed by stratifying the patients according to pretreatment LCs and BMI. Patients with low pretreatment LCs and BMI were characterized by a more advanced T stage, fewer nasopharyngeal subsites, less smoking and drinking, and fewer comorbidities. Patients with low pretreatment LCs and BMI had a significantly poorer overall and distant metastasis-free survival than those with high pretreatment LCs and BMI. No significant differences were observed in terms of local or regional recurrence-free survival. Combined pretreatment LCs and BMI may be more effective at predicting overall and distant metastasis-free survival in patients with HNC treated with RT.

Nutritional status is associated with the degree of cognitive impairment and depressive symptoms in a Greek elderly population

Introduction: Cognitive impairment and malnutrition are two important public health issues in the elderly, which have been associated with their mental health.Aims: This study aims to evaluate the nutritional status of an elderly population in Greece, and its association with the grade of cognitive decline, anthropometric measures and psychological status.Materials and Methods: A total of 2092 elderly men and women were enrolled from seven Greek cities. Mini Nutritional Assessment (MNA), Mini Mental State Examination (MMSE) and Geriatric Depression Scale (GDS) questionnaires were used to assess the impact of nutritional status on cognitive abilities and psychological status of the participants.Results: Of the elderly, 35.0% were at risk of malnutrition and 11.3% were malnourished, while 34.4% of the participants had impaired cognitive function, and 32.3% showed depressive symptoms. Malnutrition was more frequently observed in participants presenting cognitive impairment, and depressive symptoms. In multiple regression analysis, nutritional status was independently associated with cognitive and psychological status.Conclusions: A high prevalence of malnutrition was recorded in this elderly population sample, which was directly associated with cognitive impairment and depression. Diagnostic tools such as MNA, MMSE, and GDS are strongly recommended to be applied as a routine clinical practice in the elderly to timely and effectively address these health problems.

ESPEN guideline on clinical nutrition and hydration in geriatrics

BACKGROUND

Malnutrition and dehydration are widespread in older people, and obesity is an increasing problem. In clinical practice, it is often unclear which strategies are suitable and effective in counteracting these key health threats.

AIM

To provide evidence-based recommendations for clinical nutrition and hydration in older persons in order to prevent and/or treat malnutrition and dehydration. Further, to address whether weight-reducing interventions are appropriate for overweight or obese older persons.

METHODS

This guideline was developed according to the standard operating procedure for ESPEN guidelines and consensus papers. A systematic literature search for systematic reviews and primary studies was performed based on 33 clinical questions in PICO format. Existing evidence was graded according to the SIGN grading system. Recommendations were developed and agreed in a multistage consensus process.

RESULTS

We provide eighty-two evidence-based recommendations for nutritional care in older persons, covering four main topics: Basic questions and general principles, recommendations for older persons with malnutrition or at risk of malnutrition, recommendations for older patients with specific diseases, and recommendations to prevent, identify and treat dehydration. Overall, we recommend that all older persons shall routinely be screened for malnutrition in order to identify an existing risk early. Oral nutrition can be supported by nursing interventions, education, nutritional counseling, food modification and oral nutritional supplements. Enteral nutrition should be initiated if oral, and parenteral if enteral nutrition is insufficient or impossible and the general prognosis is altogether favorable. Dietary restrictions should generally be avoided, and weight-reducing diets shall only be considered in obese older persons with weight-related health problems and combined with physical exercise. All older persons should be considered to be at risk of low-intake dehydration and encouraged to consume adequate amounts of drinks. Generally, interventions shall be individualized, comprehensive and part of a multimodal and multidisciplinary team approach.

CONCLUSION

A range of effective interventions is available to support adequate nutrition and hydration in older persons in order to maintain or improve nutritional status and improve clinical course and quality of life. These interventions should be implemented in clinical practice and routinely used.

Validity of four nutritional screening tools against subjective global assessment for inpatient adults in a low-middle income country in Asia

BACKGROUND/OBJECTIVES

Hospital malnutrition is a common problem worldwide. This study aims to assess the validity of widely used nutritional screening tools for hospitalized adults in acute care settings in Ho Chi Minh City, Vietnam.

SUBJECTS/METHODS

Participants in this study were 693 adult patients from six general public hospitals, in a multi-center survey undertaken in April and May, 2016. The criterion validity of the Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), Nutrition Risk Screening (NRS-2002) and Mini Nutrition Assessment-Short Form (MNA-SF), modified MST (MST combined with low BMI), and BMI as independent tools were assessed using Subjective Global Assessment (SGA) or low BMI (<18.5 kg/m²) as the reference method. Area under curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using the ROC curve method to determine the validity of screening tools.

RESULTS

NRS-2002, modified MST (MST + low BMI), MUST, and BMI at 21 kg/m² showed moderate/fair validity compared to the reference method (SGA or BMI). MST alone and MNA-SF showed poor validity due to low sensitivity (41.8 and 35.0% for MST and MNA-SF, respectively).

CONCLUSIONS

Based on specificity and sensitivity, the first choice for the most appropriate screening tool for use in Vietnam is the NRS-2002, following by the MST + BMI, MUST, and BMI alone at the cut-off value of 21 kg/m². Further investigation on the feasibility and acceptability are required to determine the most appropriate screening tools for use within the Vietnamese context.

Optimizing Nutrition for the Surgical Patient: An Evidenced Based Update to Dispel Five Common Myths in Surgical Nutrition Care

Traditional practices in the delivery of nutrition to the surgical patient include reliance on nonspecific laboratory markers to define malnutrition, prolonged periods of nil per os, early and liberal initiation of parenteral nutrition, withholding enteral feedings based on gastric residual volume measurements, and pursuing feeding tube access for most patients unable to take oral nutrition. However, recent studies call into question all of these practices. This review aims to provide evidenced-based support to abandon these myths regarding nutrition delivery and offer practical up-to-date advice for best practices in patient care.

Cancer cachexia: Diagnosis, assessment, and treatment

Cancer cachexia is a multi-factorial syndrome, which negatively affects quality of life, responsiveness to chemotherapy, and survival in advanced cancer patients. Our understanding of cachexia has grown greatly in recent years and the roles of many tumor-derived and host-derived compounds have been elucidated as mediators of cancer cachexia. However, cancer cachexia remains an unmet medical need and attempts towards a standard treatment guideline have been unsuccessful. This review covers the diagnosis, assessment, and treatment of cancer cachexia; the elements impeding the formulation of a standard management guideline; and future directions of research for the improvement and standardization of current treatment procedures.

Diagnosing clinical malnutrition: Perspectives from the past and implications for the future

This review, intended for both researchers and clinicians, provides a history of the definition of clinical malnutrition. Despite global efforts, we remain without one clear, objective, internationally accepted definition; clarity in this regard will ultimately improve our evaluation and monitoring of nutritional status to achieve optimal patient outcomes. In this review we explore the development of the term malnutrition and its diagnosis and application in the setting of acute and chronic disease. We begin in the second century A.D. with the work of the Greek physician Galen who is credited as the first to apply the term marasmus to characterize three categories of malnutrition, which are surprisingly similar to components of current international definitions. We then highlight significant developments over the next 2000 years culminating in our current application of the clinical diagnosis of malnutrition. A perspective on historical practices may inform current efforts toward a global definition and diagnosis of malnutrition.

Current Evidence about Nutrition Support in Cardiac Surgery Patients-What Do We Know?

Nutrition support is increasingly recognized as a clinically relevant aspect of the intensive care treatment of cardiac surgery patients. However, evidence from adequate large-scale studies evaluating its clinical significance for patients&rsquo; mid- to long-term outcome remains sparse. Considering nutrition support as a key component in the perioperative treatment of these critically ill patients led us to review and discuss our understanding of the metabolic response to the inflammatory burst induced by cardiac surgery. In addition, we discuss how to identify patients who may benefit from nutrition therapy, when to start nutritional interventions, present evidence about the use of enteral and parenteral nutrition and the potential role of pharmaconutrition in cardiac surgery patients. Although the clinical setting of cardiac surgery provides advantages due to its scheduled insult and predictable inflammatory response, researchers and clinicians face lack of evidence and several limitations in the clinical routine, which are critically considered and discussed in this paper.

Is being malnourished according to the ESPEN definition for malnutrition associated with clinically relevant outcome measures in geriatric outpatients?

Background and aim

A body of evidence is supporting the association between (the risk of) malnutrition in relation to physical performance, muscle strength, risk for depression and cognitive status in geriatric outpatients. Associations between being malnourished according to the newly proposed ESPEN definition for malnutrition and clinically relevant outcome measures of the aforementioned variables have not been confirmed yet. Therefore, the aim of this study was to examine the association between being malnourished according to the ESPEN definition and clinically relevant outcome measures in geriatric outpatients.

Methods

Associations between malnutrition and handgrip strength (HGS, kg), short physical performance battery (SPPB-score, points), timed up and go test (TUG, seconds), and hospital anxiety and depression scale (HADS depression score, points), were analysed using linear regression. History of falls (falls, yes/no) and a low score on the Mini Mental-State Examination (MMSE-score ≤ 24 points) were analysed using logistic regression. All analyses were adjusted for age and gender.

Results

A total of 185 geriatric outpatients (60% women) were included. The mean age was 82 (± 7.3) years. Being malnourished (8.2%) according to the ESPEN definition was significantly associated with a lower HGS (− 3.38 kg, p = 0.031), lower SPPB score (− 1.8 point, p = 0.025), higher TUG time (1.35 times higher time, p = 0.020) and higher HADS depression score (2.03 times higher score, p = 0.007). Being malnourished tended towards an association with falls (OR 3.84, p = 0.087). No significant association was found with low MMSE score (OR 2.61, p = 0.110).

Conclusion

This study is the first to confirm the association between being malnourished, defined by the ESPEN definition and clinically relevant outcome measures in geriatric outpatients.

Prevalence of malnutrition and impact on clinical outcomes in cancer services: A comparison of two time points

BACKGROUND

The prevention and management of malnutrition is increasingly recognised as a significant element of cancer care. By identifying and comparing cancer malnutrition in two large cross-sectional cancer populations, this study aims to provide a greater understanding of clinical characteristics and trajectories relating to cancer malnutrition.

METHODS

A multi-centre point prevalence study was conducted in Victoria, Australia at two time points (March 2012, May 2014). Adults with cancer receiving ambulatory chemotherapy, radiotherapy and multi-day inpatients were included. The presence of malnutrition was determined using Patient Generated-Subjective Global Assessment (PG-SGA). Demographic, clinical information and 30-day outcomes were collected.

RESULTS

The study included 1677 patients in 2012 (17 sites) and 1913 patients in 2014 (27 sites). Older age, ≥5% weight loss, hospital admission and metastatic disease were factors significantly associated with malnutrition. Patients with upper gastrointestinal, head and neck and lung cancers were more likely to be malnourished. Malnutrition was associated with infection and poor outcomes at 30-days. Malnutrition prevalence reduced from 31% in 2012 to 26% in 2014 (p = 0.002). This reflects a reduction in patients with malnutrition receiving ambulatory chemotherapy, those with upper gastrointestinal or colorectal cancers and those residing in regional areas.

CONCLUSION

The study has provided a comprehensive description of cancer malnutrition prevalence representative of all treatment settings, tumour types and stages of disease. This provides valuable insight into cancer malnutrition enabling oncology services to identify opportunities to embed identification and prevention strategies into models of care, resulting in improved patient outcomes and reduced health care costs.

Optimization of nutrition during allogeneic hematologic stem cell transplantation

PURPOSE OF REVIEW

Malnutrition before and during hematopoietic stem cell transplantation (HSCT) is an independent risk factor for mortality in patients undergoing hematopoietic stem cell transplantation. Yet, optimal use of nutritional support to improve outcomes remains controversial. Our aim was to do an up-to-date literature review regarding nutritional therapy in allogeneic HSCT, the neutropenic diet and the use of immunonutrients.

RECENT FINDINGS

Several observational studies find malnutrition to be associated with poor outcome, increased complications and lower overall survival. There are, however, few interventional trials proving the benefits of nutritional therapy in this population compared with no nutritional treatment. Regarding routes of treatment, studies suggested that parenteral nutrition is associated with higher risk for complications compared with enteral nutrition. Whether the use of specific formulas, such as immunonutrition, has a beneficial effect on clinical outcome is not established yet. Strict use of neutropenic diets did not show a reduction in infection risk and clinical outcome, and can no longer be recommended.

SUMMARY

Our updated search confirms that malnutrition is a strong negative predictor for outcome, yet optimal use of nutritional interventions to prevent or treat malnutrition remains ill-defined. There is need for larger randomized trials to better address these issues in the future.

Comparison of three common nutritional screening tools with the new European Society for Clinical Nutrition and Metabolism (ESPEN) criteria for malnutrition among patients with geriatric gastrointestinal cancer: a prospective study in China

OBJECTIVE

The aim of this study was to evaluate and compare three common nutritional screening tools with the new European Society for Clinical Nutrition and Metabolism (ESPEN) diagnostic criteria for malnutrition among elderly patients with gastrointestinal cancer.

RESEARCH METHODSANDPROCEDURES

Nutritional screening tools, including the Nutritional Risk Screening 2002 (NRS 2002), the Malnutrition Universal Screening Tool (MUST) and the Short Form of Mini Nutritional Assessment (MNA-SF), were applied to 255 patients with gastrointestinal cancer. We compared the diagnostic values of these tools for malnutrition, using the new ESPEN diagnostic criteria for malnutrition as the 'gold standards'.

RESULTS

According to the new ESPEN diagnostic criteria for malnutrition, 20% of the patients were diagnosed as malnourished. With the use of NRS 2002, 52.2% of the patients were found to be at high risk of malnutrition; with the use of MUST, 37.6% of the patients were found to be at moderate/high risk of malnutrition; and according to MNA-SF, 47.8% of the patients were found to be at nutritional risk. MUST was best correlated with the ESPEN diagnostic criteria (К=0.530, p<0.001) compared with NRS 2002 (К=0.312, p<0.001) and MNA-SF (К=0.380, p<0.001). The receiver operating characteristic curve of MUST had the highest area under the curve (AUC) compared with NRS 2002 and MNA-SF.

CONCLUSIONS

Among the tools, MUST was found to perform the best in identifyingmalnourished elderly patients with gastrointestinal cancer distinguished by the new ESPEN diagnostic criteria for malnutrition. Nevertheless, further studies are needed to verify our findings.

TRIAL REGISTRATION NUMBER

ChiCTR-RRC-16009831; Pre-results.

Large regional disparities in prevalence, management and reimbursement of hospital undernutrition

BACKGROUND/OBJECTIVES

Undernutrition is a frequent condition among hospitalized patients, with a significant impact on patient's outcome and hospital costs. Whether undernutrition is reported similarly at the national level has seldom been assessed. We aimed to (1) assess regional differences within Switzerland regarding undernutrition prevalence, management, and cost reimbursement and (2) identify the factors associated with reporting of undernutrition status and its management.

SUBJECTS/METHODS

Observational cross-sectional study including routine statistics from the Swiss hospital discharge databases for years 2013 and 2014 (seven administrative regions). All adults aged ≥20 with length of hospital stay of at least 1 day was included. Reported undernutrition was defined based on the International Classification of Diseases (ICD)-10 codes. Nutritional management and "reimbursable" undernutrition codes were also assessed.

RESULTS

Of the initial 1,784,855 hospitalizations, 3.6% had reported undernutrition, the prevalence ranging between 1.8% (Ticino) and 4.6% (Mittelland). Use of different undernutrition-related ICD-10 codes also varied considerably across regions. Multivariable analysis showed a twofold variation in reported undernutrition: multivariable-adjusted odds ratio and 95% confidence interval relative to Eastern Switzerland: 2.31 (2.23, 2.38) for Mittelland and 0.74 (0.70, 0.79) for Ticino. Over half (59.6%) of hospitalizations with reported undernutrition also included information on undernutrition management, ranging between 28.6% (Ticino) and 67.2% (Zürich). Only one third (36.8%) of undernutrition-related codes were reimbursable, ranging between 8.3% (Ticino) and 50.7% (Zürich).

CONCLUSIONS

In Switzerland, there is considerable regional variation regarding reporting of undernutrition prevalence, management, and cost reimbursement. Undernutrition appears to be insufficiently managed and valued.

Diagnostic accuracy of undernutrition codes in hospital administrative discharge database: improvements needed

OBJECTIVES

Hospital administrative databases are widely used for disease monitoring. Undernutrition is highly prevalent among hospitalized patients but the diagnostic accuracy of undernutrition coding in administrative data is poorly known. This study examined the diagnostic accuracy of undernutrition coding in administrative hospital discharge databases.

METHODS

A retrospective cross-sectional study was conducted using 2013 and 2014 administrative data of the Internal Medicine Unit of the Lausanne University Hospital (n = 2509). Two reference diagnoses were defined: Confirmed undernutrition (2002 nutrition risk screening [NRS-2002] score ≥3 plus body mass index [BMI] < 18.5 kg/m²) and probable undernutrition (NRS-2002 ≥ 3 plus any prescribed nutritional management plus BMI ≥18.5 and <20 kg/m² if age <70 y [ < 22 kg/m² if age ≥70 y]). Missing BMI values were imputed.

RESULTS

Of the 2509 eligible patients, 262 (10.4%) were classified as confirmed and 631 (25.2%) as probable undernutrition. The sensitivity, specificity, and negative and positive predictive values (and corresponding 95% confidence intervals) for undernutrition codes using confirmed undernutrition were 43.0 (37.0-49.3), 87.2 (85.8-88.6), 92.9 (91.7-94.0), and 28.2 (23.8-32.8), respectively. The corresponding values using both confirmed and probable undernutrition were 30.0 (27.2-32.9), 93.4 (92.0-94.6), 66.7 (64.7-68.7), and 75.1 (70.6-79.3), respectively. Similar findings were obtained after stratifying for sex or age groups or restricting the analysis to patients with non-missing BMI data.

CONCLUSIONS

The undernutrition codes in hospital discharge data have good specificity but the sensitivity and positive predictive values are low.

Pharyngeal fistulas after total laryngectomy with and without tracheostoma plasty according to Herrmann

PURPOSE

Pharyngeal fistula (PF) is one of the most common complications after total laryngectomy (TL). The tracheostoma plasty technique according to Herrmann (TPH) represents an alternative surgical technique to shape the tracheostoma. The aim of this study was to determine whether the performance of a TPH affects the incidence of PF after TL. A secondary aim was to identify potential risk factors for the development of PF with regard to TPH.

METHODS

Retrospective evaluation of records of 151 consecutive patients at two tertiary care centers with regard to the occurrence and risk factors of PF after TL with and without TPH.

RESULTS

60 patients with TPH and 91 patients without TPH contributed to the results. The overall incidence of PF was 21.2% (32 out of 151). 23.3% (14 out of 60) of patients with TPH and 19.8% (18 of 91) of patients without TPH developed a PF (p = 0.91). Binary logistic regression analysis revealed significant influence of salvage surgery on the risk to develop PF (odds ratio = 2.9; 95% CI 1.16-7.23; p = 0.026). The occurrence of PF was not significantly influenced by any other investigated factors including performance of TPH.

CONCLUSIONS

Performance of TPH after TL does not increase the incidence of PF. Thus, TPH can be considered as a safe alternative surgical technique for the shaping of the tracheostoma following TL.

Disease Specific Aspects of Malnutrition in Neurogeriatric Patients

Malnutrition in elderly patients is a common condition. Nevertheless, there is evidence on specific risk factors and problems of malnutrition in geriatric patients with neurological diseases. In this review, we summarize recent knowledge on malnutrition in different neurological diseases with a focus on elderly patients. This overview also provides strategies for a more specific and profound assessment of neurogeriatric patients to improve identification and treatment of malnutrition. Early and consequent treatment of malnutrition can lead to a decreased progression of the neurological disease and to a better quality of life in geriatric patients.

A comprehensive nutritional survey of hospitalized patients: Results from nutritionDay 2016 in China

AIMS

Prevalence of malnutrition is a common and serious issue responsible for the morbidity and mortality rate among hospitalized patients. We aimed to provide an actual and comprehensive situation of the nutritional characteristics, nutritional support and the risk factors for malnutrition among hospitalized patients in China.

METHODS

We analyzed the data from nutritionDay audit 2016 in China. The international daylong cross-sectional survey was performed on November 10th, 2016 via filling out several questionnaires regarding information on patients' illness, food intake history, weight change and nutritional care. Re-assessment of patients' outcome questionnaire was performed 30 days later.

RESULTS

Total of 781 patients from 9 hospitals and 8 kinds of departments were enrolled in this report. Of these, malnutrition rate was 29.6%. Parenteral nutrition (251/344, 73.0%) was the primary nutrition support form in Chinese hospitals. However, 41.8% (136/325) of patients at nutritional risk or already diagnosed with malnutrition did not received any form of nutritional support, whereas 34.0% (155/456) well-nourished patients did. Patients with malnutrition had extended length of hospital stay and poor 30-day outcomes compared to well-nourished patients. Nutritional support could benefit nutritional risk or malnutrition patients, rather than well-nourished patients. Moreover, major lesion types, self-related health, food intake last week were independent risk factors of malnutrition (all p<0.05).

CONCLUSIONS

Chinese hospital staff is generally lack of knowledge and awareness of malnutrition. Self-related health, major lesion types and food intake are associated with malnutrition.

Interview based malnutrition assessment can predict adverse events within 6 months after primary and revision arthroplasty - a prospective observational study of 351 patients

Background

Being at risk for malnutrition can be observed among hospitalized patients of all medical specialties. There are only few studies in arthroplasty dealing with defining and assessing malnutrition as such a potentially risk. This study aims to identify the risk for malnutrition following primary (pAP) and revision arthroplasty (rAP) (1) using non-invasive interview based assessment tools and to analyze effects on clinical outcome (2) and quality of life (3).

Methods

A consecutive series of hospitalized patients of a Department of Arthroplasty at a Level 1 Trauma Center in Western Europe was observed between June 2014 and June 2016. Patients were monitored for being at risk for malnutrition at hospital admission (T1) and 6 months post surgery (T2) by non-invasive interview based assessment tools (NRS 2002, SF-MNA, MNA). Adverse events, length of hospital stay and quality of life (HRQL, SF-36) were monitored.

Results

351 (283 pAP/ 68 rAP) patients were included. At T1, 13.4% (47) / 23.9% (84) / 27.4% (96) and at T2 7.3% (18) / 17.1% (42) / 16.0% (39) of all patients were at risk for malnutrition regarding NRS/SF-MNA/MNA. Prevalence of malnutrition risk was higher in rAP (22.1–29.4%) compared to pAP (11.3–26.9%). Patients being at risk for malnutrition showed prolonged hospitalization (NRS 14.5 to 12.5, SF-MNA 13.7 to 12.4, MNA 13.9 to 12.3 days, p < 0.05), delayed mobilization (NRS 2.1 to 1.7, SF-MNA 1.8 to 1.7, MNA 1.9 to 1.7 days), lower values in HRQL and more adverse events.

Conclusions

There is a moderate to high prevalence of risk for malnutrition in arthroplasty that can easily be assessed through interview based screening tools. Being at risk for malnutrition can reduce the clinical outcome following pAP and rAP. Patients with an impaired nutritional status show reduced values in physical and mental aspects of HRQL. Non-invasive interview-based nutritional assessment can predict adverse events in primary and revision total arthroplasty and can therefore help identifying patients at risk before surgery.

Trial registration

The study protocol was approved by the local ethics committee (193/2014BO2) and registered at the German Clinical Trials Register according to WHO standard (DKRS00006192).

Malnutrition, poor food intake, and adverse healthcare outcomes in non-critically ill obese acute care hospital patients

BACKGROUND & AIMS

Obesity, defined as a BMI ≥ 30 kg/m², has demonstrated protective associations with mortality in some diseases. However, recent evidence demonstrates that poor nutritional status in critically ill obese patients confounds this relationship. The purpose of this paper is to evaluate if poor nutritional status, poor food intake and adverse health-related outcomes have a demonstrated association in non-critically ill obese acute care hospital patients.

METHODS

This is a secondary analysis of the Australasian Nutrition Care Day Survey dataset (N = 3122), a prospective cohort study conducted in hospitals from Australia and New Zealand in 2010. At baseline, hospital dietitians recorded participants' BMI, evaluated nutritional status using Subjective Global Assessment (SGA), and recorded 24-h food intake (as 0%, 25%, 50%, 75%, and 100% of the offered food). Post-three months, participants' length of stay (LOS), readmissions, and in-hospital mortality data were collected. Bivariate and regression analyses were conducted to investigate if there were an association between BMI, nutritional status, poor food intake, and health-related outcomes.

RESULTS

Of the 3122 participants, 2889 (93%) had eligible data. Obesity was prevalent in 26% of the cohort (n = 750; 75% females; 61 ± 15 years; 37 ± 7 kg/m²). Fourteen percent (n = 105) of the obese patients were malnourished. Over a quarter of the malnourished obese patients (N = 30/105, 28%) consumed ≤25% of the offered meals. Most malnourished obese patients (74/105, 70%) received standard diets without additional nutritional support. After controlling for confounders (age, disease type and severity), malnutrition and intake ≤25% of the offered meals independently trebled the odds of in-hospital mortality within 90 days of hospital admission in obese patients.

CONCLUSION

Although malnourished obese experienced significantly adverse health-related outcomes they were least likely to receive additional nutritional support. This study demonstrates that BMI alone cannot be used as a surrogate measure for nutritional status and warrants routine nutritional screening for all hospital patients, and subsequent nutritional assessment and support for malnourished patients.

Nutritional status and gait speed in a nationwide population-based sample of older adults

The association between nutritional status and gait speed remains unclear. This study described gait speed in older adults and quantified the association between overweight, obesity, undernutrition risk and gait speed. Gait speed as potential indicator of nutritional outcomes was also explored. A cross-sectional analysis was conducted in a population-based sample of 1,500 older adults ≥65 years old. Compared to “normal body mass index” women, odds ratio for a slow gait speed was approximately 2-fold higher in“overweight”, 4-fold higher in “obese” and 6-fold higher in women at “undernutrition risk”. “Undernutrition risk” category resulted from joining “undernutrition risk/undernutrition”. For men, these associations were in the same direction, but the odds ratio estimates halved. In women, identified gait speed cut-offs were 0.87 m/s for “obesity” and 0.79 m/s for “undernutrition risk”. In men, 0.94 m/s is the cut-off in which most older adults were correctly classified relative to “undernutrition risk”. About half of Portuguese older adults presented a gait speed ≤0.8 m/s. Overweight, obesity and undernutrition risk were directly and increasingly associated with slow gait speed, but approximately twice as high in women compared to men. Gait speed revealed potential utility in marking nutritional problems, but further investigation is recommended.

Association Between Malnutrition and Depression Among Community-Dwelling Older Chinese Adults

Malnutrition and depression are of important concern among older adults. We investigated the association between malnutrition and depression among community-dwelling older Chinese adults and how both affect health care costs. Data from 4916 older adults (age ≥60 years) collected as part of 2013-Wave II China Health and Retirement Longitudinal Study (CHARLS) survey were analyzed. Measures of body mass index and weight loss were used as indicators of malnutrition. Malnourished subjects were 31% more likely to be depressed than their non-malnourished counterparts (odds ratio = 1.311, P < .1). Health care–related cost was ¥591.8 higher for malnourished older adult per year compared to a non-malnourished counterpart ( P < .1), thus confirming that incidence of depression coupled with malnutrition significantly increases health care–related costs. These results highlight the importance of malnutrition and depression screening and treatment for older Chinese community-dwelling adults, and the importance of community-based nutrition-specific programs that could address the needs of the affected populations.

Variability of nutritional practices in peritransplant period after allogeneic hematopoietic stem cell transplantation: a survey by the Complications and Quality of Life Working Party of the EBMT

Recommendations on screening and nutritional support for patients undergoing hematopoietic stem cell transplantation (HSCT) have been presented by international nutritional societies, but nutritional practices remain poorly standardized. Following the general policy of the European Society for Blood and Marrow Transplantation (EBMT) to standardize transplantation procedures, the Complications and Quality of Life Working Party and Nursing Research Group carried out a survey among all EBMT centers about their current nutritional practices. The aim of this study was to better understand current practices, differences from available guidelines, and possible barriers for recommended nutritional therapy. Responses from 90 centers (19%) from 23 countries were received. We observed a marked variability in nutritional care between EBMT centers and a substantial lack of standardized operating procedures in screening patients for malnutrition and management of gastrointestinal GVHD. Furthermore, our study confirmed neutropenic diet as standard of care in most centers as well a preference for parenteral nutritional support over enteral. On the basis of these findings, future EBMT efforts will focus on better implementation of international nutritional guidelines into clinical practice.

Association of energy and protein intakes with length of stay, readmission and mortality in hospitalised patients with chronic obstructive pulmonary disease

Low energy and protein intakes have been associated with an increased risk of malnutrition in outpatients with chronic obstructive pulmonary disease (COPD). We aimed to assess the energy and protein intakes of hospitalised COPD patients according to nutritional risk status and requirements, and the relative contribution from meals, snacks, drinks and oral nutritional supplements (ONS), and to examine whether either energy or protein intake predicts outcomes. Subjects were COPD patients (n 99) admitted to Landspitali University Hospital in 1 year (March 2015–March 2016). Patients were screened for nutritional risk using a validated screening tool, and energy and protein intake for 3 d, 1–5 d after admission to the hospital, was estimated using a validated plate diagram sheet. The percentage of patients reaching energy and protein intake ≥75 % of requirements was on average 59 and 37 %, respectively. Malnourished patients consumed less at mealtimes and more from ONS than lower-risk patients, resulting in no difference in total energy and protein intakes between groups. No clear associations between energy or protein intake and outcomes were found, although the association between energy intake, as percentage of requirement, and mortality at 12 months of follow-up was of borderline significance (OR 0·12; 95 % CI 0·01, 1·15; P=0·066). Energy and protein intakes during hospitalisation in the study population failed to meet requirements. Further studies are needed on how to increase energy and protein intakes during hospitalisation and after discharge and to assess whether higher intake in relation to requirement of hospitalised COPD patients results in better outcomes.

Different risk scores consider different types of risks: the deficiencies of the 2015 ESPEN consensus on diagnostic criteria for malnutrition

In 2015, an European Society for the Parenteral and Enteral Nutrition malnutrition diagnosis consensus was published to unify the definition and simplify the diagnostic procedure of malnutrition, in which 'nutritional risk', 'malnutrition risk' and 'at risk of malnutrition' were referred to several times, and 'at risk of malnutrition' was encouraged to be coded and reimbursed in the International Classification of Diseases and diagnosis-related group system systems. However, there may be some mistakes when using the concepts of different 'risk' mentioned above. In this study, we aimed to explain different 'risks' using the original concept by different screening tools to clarify the definition and provide a recommendation for nutritional screening.

Trajectories of functional decline in older adults with neuropsychiatric and cardiovascular multimorbidity: A Swedish cohort study

BACKGROUND

Functional decline is a strong health determinant in older adults, and chronic diseases play a major role in this age-related phenomenon. In this study, we explored possible clinical pathways underlying functional heterogeneity in older adults by quantifying the impact of cardiovascular (CV) and neuropsychiatric (NP) chronic diseases and their co-occurrence on trajectories of functional decline.

METHODS AND FINDINGS

We studied 2,385 people ≥60 years (range 60-101 years) participating in the Swedish National study of Aging and Care in Kungsholmen (SNAC-K). Participants underwent clinical examination at baseline (2001-2004) and every 3 or 6 years for up to 9 years. We grouped participants on the basis of 7 mutually exclusive clinical patterns of 0, 1, or more CV and NP diseases and their co-occurrence, from a group without any CV and NP disease to a group characterised by the presence of CV or NP multimorbidity, accompanied by at least 1 other CV or NP disorder. The group with no CV and/or NP diseases served as the reference group. Functional decline was estimated over 9 years of follow-up by measuring mobility (walking speed, m/s) and independence (ability to carry out six activities of daily living [ADL]). Mixed-effect linear regression models were used (1) to explore the individual-level prognostic predictivity of the different CV and NP clinical patterns at baseline and (2) to quantify the association between the clinical patterns and functional decline at the group level by entering the clinical patterns as time-varying measures. During the 9-year follow-up, participants with multiple CV and NP diseases had the steepest decline in walking speed (up to 0.7 m/s; p < 0.001) and ADL independence (up to three impairments in ADL, p < 0.001) (reference group: participants without any CV and NP disease). When the clinical patterns were analyzed as time varying, isolated CV multimorbidity impacted only walking speed (β -0.1; p < 0.001). Conversely, all the clinical patterns that included at least 1 NP disease were significantly associated with decline in both walking speed (β -0.21--0.08; p < 0.001) and ADL independence (β -0.27--0.06; p < 0.05). Groups with the most complex clinical patterns had 5%-20% lower functioning at follow-up than the reference group. Key limitations of the study include that we did not take into account the specific weight of single diseases and their severity and that the exclusion of participants with less than 2 assessments may have led to an underestimation of the tested associations.

CONCLUSIONS

In older adults, different patterns of CV and NP morbidity lead to different trajectories of functional decline over time, a finding that explains part of the heterogeneity observed in older adults' functionality. NP diseases, alone or in association, are prevalent and major determinants of functional decline, whereas isolated CV multimorbidity is associated only with declines in mobility.

Comparing Western and Eastern criteria for sarcopenia and their association with survival in patients with pancreatic cancer

BACKGROUND & AIMS

Sarcopenia and cachexia are associated with pancreatic cancer and serve as important adverse prognostic factors. Body composition can be analyzed by routine computed tomography (CT) for cancer staging and has been used to study many types of cancer. The CT measurements are robust, but the diagnostic criteria for sarcopenia vary among different studies. Age, sex and race are important factors that affect muscle and fat masses. This study aimed to analyze the effect of different sarcopenia diagnostic criteria on the prognosis of patients with pancreatic cancer.

METHODS

Patients with newly diagnosed pancreatic cancer at National Taiwan University Hospital between October 2013 and October 2016 were retrospectively reviewed in this study. Body composition was assessed using cross-sectional CT images to calculate the total skeletal muscle (TSM) index. The concordance and interobserver variability of the TSM measurements were evaluated using both the Western criteria and the Eastern criteria. Kaplan-Meier analyses and the Cox proportional hazard ratio with two different diagnostic criteria for sarcopenia were used to compare the effect on overall survival (OS).

RESULTS

A total of 146 patients with pancreatic cancer were enrolled. The TSM index measured by the Western institute was highly correlated with that measured by the Eastern institute (r = 0.953, p < 0.001). The prevalence of sarcopenia in the patient group at baseline was 66.4% (97/146) by the Western criteria and 11.0% (16/146) by the Eastern criteria, and only low agreement was found between the Western and Eastern criteria (Kappa value = 0.028, p = 0.149). Patients who were sarcopenic by the Western criteria showed no significant difference in OS versus those who were not sarcopenic (p = 0.807). However, patients who were sarcopenic by the Eastern criteria showed a significant difference in OS versus those who were not sarcopenic in a univariate analysis (p = 0.008) and multivariate analysis after adjustment for AJCC stage (p = 0.014).

CONCLUSIONS

Our study demonstrates that different diagnostic criteria may result in different diagnoses and that sarcopenia is an important poor prognostic factor for pancreatic cancer when appropriate diagnostic criteria are selected.