Diagnostic criteria for malnutrition - An ESPEN Consensus Statement

The clinical picture of cachexia: a mosaic of different parameters (experience of 503 patients)

BACKGROUND

Despite our growing knowledge about the pathomechanisms of cancer cachexia, a whole clinical picture of the cachectic patient is still missing. Our objective was to evaluate the clinical characteristics in cancer patients with and without cachexia to get the whole picture of a cachectic patient.

METHODS

Cancer patients of the University Clinic "Klinikum rechts der Isar" with gastrointestinal, gynecological, hematopoietic, lung and some other tumors were offered the possibility to take part in the treatment concept including a nutrition intervention and an individual training program according to their capability. We now report on the first 503 patients at the time of inclusion in the program between March 2011 and October 2015. We described clinical characteristics such as physical activity, quality of life, clinical dates and food intake.

RESULTS

Of 503 patients with cancer, 131 patients (26.0%) were identified as cachectic, 369 (73.4%) as non-cachectic. The change in cachexia were 23% reduced capacity performance (108 Watt for non-cachectic-patients and 83 Watt for cachectic patients) and 12% reduced relative performance (1.53 Watt/kg for non-cachectic and 1.34 Watt/kg for cachectic patients) in ergometry test. 75.6% of non-cachectic and 54.3% of cachectic patients still received curative treatment.

CONCLUSION

Cancer cachectic patients have multiple symptoms such as anemia, impaired kidney function and impaired liver function with elements of mild cholestasis, lower performance and a poorer quality of life in the EORTC questionnaire. Our study reveals biochemical and clinical specific features of cancer cachectic patients.

Discordance between bioelectrical impedance vector analysis and the new ESPEN definition of malnutrition for the diagnosis of hospital malnutrition

BACKGROUND & AIMS

No universally accepted diagnostic criteria for malnutrition are available to date. The aim was to assess the concordance for the diagnosis of hospital malnutrition between the bioelectrical impedance vector analysis (BIVA) and the new definition of malnutrition proposed by the European Society for Clinical Nutrition and Metabolism (ESPEN).

METHODS

A total of 140 adult hospitalized patients were included. The malnutrition risk was assessed by the Nutritional Risk Screening. The ESPEN malnutrition criteria (body mass index (BMI) <18.5 kg/m², weight loss (WL) + low BMI, and WL + low fat free mass index (FFMI) were applied to each patient. The bioelectrical impedance of each patient was measured, and malnutrition was diagnosed using the BIVA method. Diagnostic concordance between the BIVA and the new ESPEN definition was assessed with the Kappa coefficient.

RESULTS

The malnutrition prevalence was higher with the BIVA vs ESPEN definition (22.1% vs 13.6%) in the global population and was similar (12.8% vs 12.1%) in the population at risk of malnutrition. The diagnostic performance of the BIVA was acceptable, with higher sensitivity in patients with fluid overload (FO) and more specificity in euvolemic patients. Diagnostic concordance between the BIVA and the ESPEN definition was poor for the global population (kappa = 0.56) and the population at risk of malnutrition (kappa = 0.67) but was acceptable in patients with FO (kappa = 0.78). However, the discordant BIVA+/ESPEN- patients classified as false positives for BIVA showed clinical and body composition data (low FFMI, low phase angle) consistent with malnutrition.

CONCLUSIONS

According to the clinical and bioelectrical characteristics of the discordant BIVA+/ESPEN- patients, the BIVA could perform better that the new ESPEN definition for the diagnosis of hospital malnutrition, which should be confirmed with other studies.

The efficacy of Protected Mealtimes in hospitalised patients: a stepped wedge cluster randomised controlled trial

BACKGROUND

Protected Mealtimes is an intervention developed to address the problem of malnutrition in hospitalised patients through increasing positive interruptions (such as feeding assistance) whilst minimising unnecessary interruptions (including ward rounds and diagnostic procedures) during mealtimes. This clinical trial aimed to measure the effect of implementing Protected Mealtimes on the energy and protein intake of patients admitted to the subacute setting.

METHODS

A prospective, stepped wedge cluster randomised controlled trial was undertaken across three hospital sites at one health network in Melbourne, Australia. All patients, except those receiving end-of-life care or not receiving oral nutrition, admitted to these wards during the study period participated. The intervention was guided by the British Hospital Caterers Association reference policy on Protected Mealtimes and by principles of implementation science. Primary outcome measures were daily energy and protein intake. The study was powered to determine whether the intervention closed the daily energy deficit between estimated intake and energy requirements measured as 1900 kJ/day in the pilot study for this trial.

RESULTS

There were 149 unique participants, including 38 who crossed over from the control to intervention period as the Protected Mealtimes intervention was implemented. In total, 416 observations of 24-hour food intake were obtained. Energy intake was not significantly different between the intervention ([mean ± SD] 6479 ± 2486 kJ/day) and control (6532 ± 2328 kJ/day) conditions (p = 0.88). Daily protein intake was also not significantly different between the intervention (68.6 ± 26.0 g/day) and control (67.0 ± 25.2 g/day) conditions (p = 0.86). The differences between estimated energy/protein requirements and estimated energy/protein intakes were also limited between groups. The adjusted analysis yielded significant findings for energy deficit: (coefficient [robust 95% CI], p value) of -1405 (-2354 to -457), p = 0.004. Variability in implementation across aspects of Protected Mealtimes policy components was noted.

CONCLUSIONS

The findings of this trial mirror the findings of other observational studies of Protected Mealtimes implementation where nutritional intakes were observed. Very few positive improvements to nutritional intake have been identified as a result of Protected Mealtimes implementation. Instead of this intervention, approaches with a greater level of evidence for improving nutritional outcomes, such as mealtime assistance, other food-based approaches and the use of oral nutrition support products to supplement oral diet, should be considered in the quest to reduce hospital malnutrition.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12614001316695 ; registered 16th December 2014.

Validity of bioelectrical impedance analysis in estimation of fat-free mass in colorectal cancer patients

BACKGROUND & AIMS

Bioelectrical impedance analysis (BIA) is an accessible and cheap method to measure fat-free mass (FFM). However, BIA estimates are subject to uncertainty in patient populations with altered body composition and hydration. The aim of the current study was to validate a whole-body and a segmental BIA device against dual-energy X-ray absorptiometry (DXA) in colorectal cancer (CRC) patients, and to investigate the ability of different empiric equations for BIA to predict DXA FFM (FFM_DXA).

METHODS

Forty-three non-metastatic CRC patients (aged 50-80 years) were enrolled in this study. Whole-body and segmental BIA FFM estimates (FFM_{whole-bodyBIA}, FFM_segmentalBIA) were calculated using 14 empiric equations, including the equations from the manufacturers, before comparison to FFM_DXA estimates.

RESULTS

Strong linear relationships were observed between FFM_BIA and FFM_DXA estimates for all equations (R² = 0.94-0.98 for both devices). However, there were large discrepancies in FFM estimates depending on the equations used with mean differences in the ranges -6.5-6.8 kg and -11.0-3.4 kg for whole-body and segmental BIA, respectively. For whole-body BIA, 77% of BIA derived FFM estimates were significantly different from FFM_DXA, whereas for segmental BIA, 85% were significantly different. For whole-body BIA, the Schols* equation gave the highest agreement with FFM_DXA with mean difference ±SD of -0.16 ± 1.94 kg (p = 0.582). The manufacturer's equation gave a small overestimation of FFM with 1.46 ± 2.16 kg (p < 0.001) with a tendency towards proportional bias (r = 0.28, p = 0.066). For segmental BIA, the Heitmann* equation gave the highest agreement with FFM_DXA (0.17 ± 1.83 kg (p = 0.546)). Using the manufacturer's equation, no difference in FFM estimates was observed (-0.34 ± 2.06 kg (p = 0.292)), however, a clear proportional bias was detected (r = 0.69, p < 0.001). Both devices demonstrated acceptable ability to detect low FFM compared to DXA using the optimal equation.

CONCLUSION

In a population of non-metastatic CRC patients, mostly consisting of Caucasian adults and with a wide range of body composition measures, both the whole-body BIA and segmental BIA device provide FFM estimates that are comparable to FFM_DXA on a group level when the appropriate equations are applied. At the individual level (i.e. in clinical practice) BIA may be a valuable tool to identify patients with low FFM as part of a malnutrition diagnosis.

Revisiting nutritional support for allogeneic hematologic stem cell transplantation-a systematic review

In 2009, the American Society of Parenteral and Enteral Nutrition and its European counterpart (Euopean Society for Parenteral and Enteral Nutrition) published guidelines regarding nutritional support of patients with hematologic stem cell transplantation. Our aim was to do an up-to-date literature review regarding benefit of nutritional interventions and treatment recommendations. We searched MEDLINE, EMBASE and Cochrane Library for interventional and observational clinical studies. We extracted data based on a predefined case report form and assessed bias. Out of 459 potential abstracts, 13 studies of mostly moderate quality with a total of 18 167 patients were included. Two very large trials reported negative associations of malnutrition and survival, transplant-related mortality and relapse risk. Some trials found enteral nutrition (EN) to be as effective as parenteral nutrition (PN) with lower complication rates. In addition, EN was associated with better survival, less acute GvHD and faster neutrophil recovery. A neutropenic diet was not superior regarding overall survival, but in contrast resulted in higher infection risk. Current moderate quality studies show negative associations of malnutrition and clinical outcomes, with EN being superior to PN. There was no benefit of neutropenic diets. Large, randomized controlled studies are needed to better understand optimal nutritional support in this patient population.

Age-dependent risk factors for malnutrition in traumatology and orthopedic patients

OBJECTIVE

The aim of this study was to investigate the prevalence of risk of malnutrition (RoM) in an orthopedic and traumatology patient cohort with a broad range of ages. In addition to the classical indicators for risk assessment (low body mass index, weight loss, and comorbidity), this study aimed to analyze the effects of lifestyle factors (eating pattern, smoking, physical activity) on RoM.

METHODS

The prospective cohort study included 1053 patients in a level 1 trauma center in Germany. RoM was assessed by Nutritional Risk Screening (NRS) 2002 and for the elderly additionally by Mini Nutritional Assessment (MNA). Age-dependent risk factors identified in univariate statistical analysis were used for multivariate logistic regression models.

RESULTS

The prevalence of patients at RoM (NRS ≥3) was 22%. In the three age categories (<50 y, 50-69 y, and ≥70 y), loss of appetite, weight loss, number of comorbidities, drugs and gastrointestinal symptoms significantly increased RoM in univariate statistical analysis. In patients ages ≥70 y, several disease- and lifestyle-related factors (not living at home, less frequent consumption of vegetables and whole meal bread, low physical activity, and smoking) were associated with RoM. Multivariate logistic regression model for the total study population identified weight loss (odds ratio [OR], 6.09; 95% confidence interval [CI], 4.14-8.83), loss of appetite (OR, 3.81; 95% CI, 2.52-5.78), age-specific low BMI (OR, 1.87; 95% CI, 1.18-2.97), number of drugs taken (OR, 1.19; 95% CI, 1.12-1.26), age (OR, 1.03; 95% CI, 1.02-1.04), and days per week with vegetable consumption (OR, 0.938; 95% CI, 0.89-0.99) as risk factors.

CONCLUSION

Malnutrition in trauma and orthopedic patients is not only a problem related to age. Lifestyle-related factors also contribute significantly to malnutrition in geriatric patients.

Inadequacy of Body Weight-Based Recommendations for Individual Protein Intake-Lessons from Body Composition Analysis

Current body weight-based protein recommendations are ignoring the large variability in body composition, particularly lean mass (LM), which drives protein requirements. We explored and highlighted the inter-individual variability of weight versus body composition-adjusted protein intakes by secondary analysis in three cohorts of (1) 574 healthy adults (mean ± SD age: 41.4 ± 15.2 years); (2) 403 cirrhotic patients (age: 44.7 ± 12.3 years) and (3) 547 patients with lung cancer (age: 61.3 ± 8.2 years). LM was assessed using different devices (magnetic resonance imaging, dual-energy X-ray absorptiometry, computer tomography, total body potassium and bioelectrical impedance), body weight-based protein intake, its ratio (per kg LM) and mean protein requirement were calculated. Variability in protein intake in all cohorts ranged from 0.83 to 1.77 g protein per kg LM per day using (theoretical protein intake of 60 g protein per day). Calculated mean protein requirement was 1.63 g protein per kg LM per day; consequently, 95.3% of healthy subjects, 100% of cirrhotic and 97.4% of cancer patients would present with a low protein intake per kg LM. Weight-adjusted recommendations are inadequate to address the LM specific differences in protein needs of healthy subjects or clinical populations. Absolute protein intake seems to be more relevant compared to the relative proportion of protein, which in turn changes with different energy needs.

Thickness of the adductor pollicis muscle in nutritional assessment of surgical patients

Objective

To evaluate the correlation between thickness of the muscle adductor pollicis and anthropometric measurements, body mass index and Subjective Global Assessment in the nutritional assessment of surgical patients.

Methods

The study population comprised patients admitted to the general and reconstructive surgery unit of a university hospital in the city of Vitória (ES), Brazil. The inclusion criteria were patients evaluated in the first 48 hours of admission, aged ≥20 years, hemodynamically stable, with no edema or ascites. Data analysis was performed using the software Statistical Package for Social Science 21.0, significance level of 5%.

Results

The sample consisted of 150 patients that were candidates to surgery, mean age of 42.7±12.0 years. The most common reasons for hospitalization were surgical procedures, gastrintestinal diseases and neoplasm. Significant association was observed between thickness of adductor pollicis muscle and Subjective Global Assessment (p=0.021) and body mass index (p=0.008) for nutritional risk. Significant correlation was found between thickness of adductor pollicis muscle and arm muscle circumference, corrected arm muscle area, calf circumference and body mass index. There were no significant correlations between thickness of adductor pollicis muscle and triceps skinfold and age.

Conclusion

The use of thickness of adductor pollicis muscle proved to be an efficient method to detect malnutrition in surgical patients and it should be added to the screening process of hospitalized patients, since it is easy to perform, inexpensive and noninvasive.

A gradient-boosted model analysis of the impact of body mass index on the short-term outcomes of critically ill medical patients

Objective

To evaluate the impact of body mass index on the short-term prognosis of non-surgical critically ill patients while controlling for performance status and comorbidities.

Methods

We performed a retrospective analysis on a two-year single-center database including 1943 patients. We evaluated the impact of body mass index on hospital mortality using a gradient-boosted model that also included comorbidities and was assessed by Charlson’s comorbidity index, performance status and illness severity, which was measured by the SAPS3 score. The SAPS3 score was adjusted to avoid including the same variable twice in the model. We also assessed the impact of body mass index on the length of stay in the hospital after intensive care unit admission using multiple linear regressions.

Results

A low value (< 20kg/m²) was associated with a sharp increase in hospital mortality. Mortality tended to subsequently decrease as body mass index increased, but the impact of a high body mass index in defining mortality was low. Mortality increased as the burden of comorbidities increased and as the performance status decreased. Body mass index interacted with the impact of SAPS3 on patient outcome, but there was no significant interaction between body mass index, performance status and comorbidities. There was no apparent association between body mass index and the length of stay at the hospital after intensive care unit admission.

Conclusion

Body mass index does appear to influence the shortterm outcomes of critically ill medical patients, who are generally underweight. This association was independent of comorbidities and performance status.

Is it safe to perform rectal anastomosis in gynaecological debulking surgery without a diverting stoma?

AIM

Colorectal resection is frequently performed during cytoreductive surgery for gynaecological malignancy. The aim of this study was to assess the safety of colorectal anastomosis, and especially low rectal anastomosis, in the absence of a protective stoma in patients with gynaecological cancer and peritoneal metastasis.

METHOD

Patient data were retrospectively collected from a database for gynaecological cancer procedures carried out between January 2013 and July 2015. All patients who underwent a colorectal resection during cytoreduction were included in the study. The primary outcome was anastomotic leakage in the presence or absence of a diverting stoma. Secondary outcome parameters were complications and reoperations.

RESULTS

In the period of study, 43 major colorectal procedures were performed on 37 women. The most common colorectal procedure was low rectal resection (n = 22; 59%) followed by anterior rectal resection (n = 7; 19%) and sigmoid resection (n = 4; 11%). Five (14%) patients underwent Hartmann's procedure. In three (8%) patients, a diverting loop ileostomy was created.

CONCLUSION

Low rectal resection during debulking procedures for gynaecological cancers with peritoneal carcinomatosis can safely be performed by an experienced surgeon without a diverting stoma.

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

BACKGROUND

In 2015 the European Society for Clinical Nutrition and Metabolism (ESPEN) presented new consensus criteria for the diagnosis of malnutrition. Whereas most previous definitions were based on involuntary weight loss and/or a low BMI, the ESPEN definition added Fat Free Mass Index (FFMI) to the set of criteria.

AIM

To study the predictive value of the new ESPEN diagnostic criteria for malnutrition on survival, with specific focus on the additional value of FFMI.

METHODS

Included were 335 hospitalized adult patients of the VU University Medical Center Amsterdam (60% female, age 58 ± 18 y). Three sets of criteria for malnutrition were used to study the predictive value for survival: Dutch definition for malnutrition, ESPEN diagnostic criteria for malnutrition and ESPEN diagnostic criteria for malnutrition without FFMI criterion. The association between malnutrition and three-months and one-year overall survival was analyzed by log rank tests and Cox regression. In multivariate analyses, adjustments were made for gender, age, care complexity and length of stay.

RESULTS

Ninety patients (27%) were classified as malnourished by any of the sets of criteria; malnourished patients had significant lower survival rates than non-malnourished patients at three months (84% vs 94%; p = 0.01) and one year (76% vs 87%; p = 0.02). After adjustments, malnutrition remained significantly associated with three-months survival for the Dutch definition for malnutrition (HR:2.25, p = 0.04) and the ESPEN diagnostic criteria for malnutrition (HR:2.76, p = 0.02). Malnutrition remained significantly associated with one-year survival for the ESPEN diagnostic criteria for malnutrition (HR:2.17, p < 0.02) and the ESPEN diagnostic criteria for malnutrition without FFMI (HR:2.66, p < 0.01).

CONCLUSION

The new ESPEN definition for malnutrition is predictive for both three-months and one-year survival in a general hospital population, whereas definitions without FFMI are predictive for either three-months or one year survival.

Association of nutritional status-related indices and chemotherapy-induced adverse events in gastric cancer patients

Background

Malnutrition in gastrectomized patients receiving chemotherapy is associated with the susceptibility to chemotherapy-related adverse events. This study evaluated pre-operative nutritional status-related indices associated with adverse events in post-operation gastric cancer patients receiving chemotherapy.

Methods

Medical records of 234 gastrectomized patients under adjuvant tegafur/gimeracil/oteracil chemotherapy with extended lymph node dissection were analyzed. Nutritional status assessment included Patient-Generated Subjective Global Assessment (PG-SGA), body weight, body mass index, serum albumin concentration, and Nutrition Risk Index (NRI). Chemotherapy-originated adverse events were determined using Common Terminology Criteria for Adverse Events.

Results

PG-SGA indicated 59% of the patients were malnourished, and 27.8% of the patients revealed serious malnutrition with PG-SGA score of ≥9. Fifteen % of patients lost ≥10% of the initial body weight, 14.5% of the patients had hypoalbuminemia (<3.5 g/dL), and 66.2% had NRI score less than 97.5 indicating moderate to severe malnutrition. Hematological adverse events were present in 94% (≥grade 1) and 16.2% (≥grade 3). Non-hematological adverse events occurred in 95.7% (≥grade1) and 16.7% (≥grade 3) of the patients. PG-SGA and NRI score was not associated with treatment-induced adverse events. Multivariate analyses indicated that female, low body mass index, and hypoalbuminemia were independent risk factors for grade 3/4 hematological adverse events. Age was an independent risk factor for grade 3/4 non-hematological adverse events. Neutropenia was the most frequently occurring adverse event, and associated risk factors were female, total gastrectomy, and hypoalbuminemia.

Conclusions

Hypoalbuminemia, not PG-SGA or NRI may predict chemotherapy-induced adverse events in gastrectomized cancer patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2934-5) contains supplementary material, which is available to authorized users.

The Use of Technology for Estimating Body CompositionStrengths and Weaknesses of Common Modalities in a Clinical Setting [Formula: see text]

Assessment of body composition, both at single time points and longitudinally, is particularly important in clinical nutrition practice. It provides a means for the clinician to characterize nutrition status at a single time point, aiding in the identification and diagnosis of malnutrition, and to monitor changes over time by providing real-time information on the adequacy of nutrition interventions. Objective body composition measurement tools are available clinically but are often underused in nutrition care, particularly in the United States. This is, in part, due to a number of factors concerning their use in a clinical context: cost and accessibility of equipment, as well as interpretability of the results. This article focuses on the factors influencing interpretation of results in a clinical setting. Body composition assessment, regardless of the method, is inherently limited by its indirect nature. Therefore, an understanding of the strengths and limitations of any method is essential for meaningful interpretation of its results. This review provides an overview of body composition technologies available clinically (computed tomography, dual-energy x-ray absorptiometry, bioimpedance, ultrasound) and discusses the strengths and limitations of each device.

A high visceral adipose tissue-to-skeletal muscle ratio as a determinant of major complications after pancreatoduodenectomy for cancer

OBJECTIVE

Complication rates after pancreatic resections remain high despite improvement in perioperative management. The effects of body composition and the relationship among different body compartments on surgical morbidity are not comprehensively investigated. The aim of this study was to assess whether the evaluation of different body compartments and their relationship was associated with the development of major postoperative complications after pancreatoduodenectomy (PD) for cancer.

METHODS

We retrospectively analyzed 124 patients who underwent PD and had a staging computed tomography (CT) scan at our center. CT scan was used to measure abdominal skeletal muscle area and volume, as well as visceral fat area (VFA) and volume. The total abdominal muscle area (TAMA) was then normalized for height. The severity of complications was assessed. Univariate and multivariate analyses were performed to investigate correlations between the above variables and postoperative complications. The receiver operating characteristic curve methodology was used to investigate the predictive ability of each parameter.

RESULTS

Major complications occurred in 42 patients (33.9%). The prevalence of sarcopenia was 24.2%. Regression analyses revealed no correlation between abdominal muscular and adipose tissue areas. Univariate analysis showed that the depletion of muscle area normalized for height was not per se predictive of complications (P = 0.318). Multivariate logistic regression showed that the VFA/TAMA was the only determinant of major complications (odds ratio, 3.20; 95% confidence interval, 1.35-7.60; P = 0.008). The model predictive performance was 0.735 (area under the curve) with a sensitivity of 64.3% and a specificity of 74.4%.

CONCLUSION

Sarcopenic obesity is a strong predictor of major complications after PD for cancer.

Bioelectrical impedance phase angle as a prognostic indicator of survival in head-and-neck cancer

BACKGROUND

Phase angle could be an alternative to subjective global assessment for the assessment of nutrition status in patients with head-and-neck cancer.

METHODS

We prospectively evaluated a cohort of 75 stage iiib and iv head-and-neck patients treated at the Otolaryngology Department, Head and Neck Surgery, Medical University of Lublin, Poland. Bioelectrical impedance analysis was performed in all patients using an analyzer that operated at 50 kHz. The phase angle was calculated as reactance divided by resistance (Xc/R) and expressed in degrees. The Kaplan-Meier method was used to calculate survival.

RESULTS

Median overall survival in the cohort was 32.0 months. At the time of analysis, 47 deaths had been recorded in the cohort (62.7%). The risk of shortened overall survival was significantly higher in patients whose phase angle was less than 4.733 degrees than in the remaining patients (19.6 months vs. 45 months, p = 0.0489; chi-square: 3.88; hazard ratio: 1.8856; 95% confidence interval: 1.0031 to 3.5446).

CONCLUSIONS

Phase angle might be prognostic of survival in patients with advanced head-and-neck cancer. Further investigation in a larger population is required to confirm our results.

Muscle wasting in heart failure : The role of nutrition

Muscle wasting and malnutrition are common complications in patients with advanced heart failure (HF); however, both remain underdiagnosed and undertreated although they both play relevant roles in the progression of HF. The risk of muscle wasting in patients with HF increases in those patients with malnutrition or at risk of malnutrition. Muscle wasting and malnutrition are thought to be positively influenced by adequate therapeutic interventions such as physical activity and nutritional support. Consequently, early detection of malnutrition in patients with HF is recommended. This review discusses muscle wasting and nutritional status, describing the effects of malnutrition on muscle wasting in patients with HF. We review specific issues related to muscle wasting and nutritional status in patients with HF; however, no established strategies currently exist to focus on patients suffering from muscle wasting with malnutrition.

Nutritional evaluation in cirrhosis: Emphasis on the phase angle

Protein-calorie malnutrition (PCM) is a common condition in cirrhotic patients, leading to a worse prognosis, complications, poor quality of life and lower survival rates. Among ways of assessing nutritional status, there are anthropometric methods such as the evaluation of the triceps skinfold, the arm circumference, the arm muscle circumference and the body mass index, and non-anthropometric methods such as the subjective global assessment, the handgrip strength of non-dominant hand, and the bioelectrical impedance analysis (BIA). PCM is frequently under-diagnosed in clinical settings in patients with cirrhosis due to the limitations of nutritional evaluation methods in this population. BIA is a useful method, but cannot be indicated in patients with abnormal body composition. In these situations, the phase angle (PA) has been used, and can become an important tool in assessing nutritional status in any situation. The PA is superior to anthropometric methods and might be considered as a nutritional indicator in cirrhosis. The early characterization of the nutritional status in patients with cirrhosis means an early nutritional intervention, with a positive impact on patients' overall prognosis. Among the usually accepted methods for nutritional diagnosis, the PA provides information in a quick and objective manner.

Defining malnutrition: A plea to rethink

In a recent consensus report in Clinical Nutrition the undernourished category of malnutrition was proposed to be defined and diagnosed on the basis of a low BMI or unintentional weight loss combined with low BMI or FFMI with certain cut off points. The definition was endorsed by ESPEN despite recent endorsement of a very different definition. The approach aims to assess whether nutritional intake is sufficient but is imprecise because a low BMI does not always indicate malnutrition and individuals with increasing BMI's may have decreasing FFM's. The pathophysiology of individuals, considered to be malnourished in rich countries and in areas with endemic malnutrition, results predominantly from deficient nutrition combined with infection/inflammation. Both elements jointly determine body composition and function and consequently outcome of disease, trauma or treatment. When following the consensus statement only an imprecise estimate is acquired of nutritional intake without knowing the impact of inflammation. Most importantly, functional abilities are not assessed. Consequently it will remain uncertain how well the individual can overcome stressful events, what the causes are of dysfunction, how to set priorities for treatment and how to predict the effect of nutritional support. We therefore advise to consider the pathophysiology of malnourished individuals leading to inclusion of the following elements in the definition of malnutrition: a disordered nutritional state resulting from a combination of inflammation and a negative nutrient balance, leading to changes in body composition, function and outcome. A precise diagnosis of malnutrition should be based on assessment of these elements.

Who receives oral nutritional supplements in nursing homes? Results from the nutritionDay project

BACKGROUND & AIMS

Oral nutritional supplements (ONS) can be helpful for nursing home (NH) residents to prevent or treat malnutrition. Presently little is known about the use of ONS in NHs and the factors associated with its use. Thus, the aim of this analysis was to describe the use of ONS in NHs participating in the nutritionDay project and to determine characteristics of NH residents receiving ONS.

METHODS

Data from nutritionDay (nD), a cross-sectional multicenter study with standardized questionnaires on resident and NH level were analyzed. NH residents participating between 2007 and 2014 aged 65 years or older were included. Unit characteristics (2 variables), general residents' characteristics (18), residents' nutritional status (3) and residents' nutrition (4) were of interest as potential predictors of the use of ONS (no vs yes). Univariate binary logistic regression (LR) analyses were performed for all variables, and significant predictors (p < 0.05) subsequently included in a multivariate analysis (backwards LR).

RESULTS

13.9% of 23,689 NH residents received ONS. Univariate analysis identified all variables as predictors. After multivariate analysis 19 variables remained in the model (Nagelkerke's R² = 0.319). Odds ratios (OR [95% Confidence Interval]) of receiving ONS were highest in residents receiving supplementary parenteral nutrition (29.05 [14.85-56.81]; however only 1.1% of all participants) and fortified diet (11.91 [8.52-16.64]; 5.7%). The odds ratio of receiving ONS was 3.26 ([2.86-3.71]; 18.3%) for residents being classified as at risk of malnutrition and 4.56 ([3.86-5.40]; 10.0%) for malnourished residents according to NH staff. Low BMI and weight loss in the last year increased the odds of receiving ONS by 2.34 ([1.93-2.84]; 16.0%) and 1.38 ([1.23-1.54]; 32.8%), respectively. Furthermore, increasing age, cognitive and functional impairment, low food intake on nD, neurological disease and cancer were associated with an increased likelihood of the use of ONS. In NH units with a nutritional expert (67.1%) and units performing a nutritional assessment at least once a month (71.6%), the odds of receiving ONS were also significantly increased (1.89 [1.71-2.10] and 1.17 [1.06-1.29]).

CONCLUSION

In NHs who participated in the nutritionDay, ONS are used for residents with poor nutritional and functional status and often in combination with other nutritional interventions. Future studies need to clarify the role of NH staff in the prescription and distribution of ONS and focus on the reasons for and adequacy of the use of ONS in NHs.

Short-term effects of a computer-based nutritional nursing training program for inpatient hospital care

RATIONALE

This study aimed to explore whether a computer-based training in eating and nutrition for hospital nursing staff can influence the precision in nutritional treatment and care.

METHOD

A pre-intervention and post-intervention study was conducted with a cross-sectional design at each time point. The settings were one intervention (IH) and two control hospitals (CH1 and CH2). Hospital inpatients >18 years old at baseline (2012; n = 409) and follow-up (2014; n = 456) were included. The computer-based training was implemented during a period of 3 months in the IH with 297 (84%) participating registered nurses and nurse assistants. Nutritional risk was screened for using the Minimal Eating Observation and Nutrition Form. Nutritional treatment and care was recorded using a standardized protocol

RESULTS

In the IH, there was an increase in the share of patients at UN risk that received energy-dense food (+16.7%) and dietician consultations (+17.3%) between baseline and follow-up, while fewer received feeding assistance (-16.2%). There was an increase in the share of patients at UN risk that received energy-dense food (+19.5%), a decrease in oral nutritional supplements (-30.5%) and food-registrations (-30.6%) in CH1, whereas there were no changes in CH2. 'Overtreatment' (providing nutritional treatment to those not at UN risk) was significantly higher in CH2 (52.7%) than in CH1 (14.3%) and in the IH (25.2%) at follow-up.

CONCLUSION

The computer-based training seemed to increase the probability for patients at UN risk in the IH to receive nutritional treatment without increasing overtreatment.

Phase Angle and Impedance Ratio: Reference Cut-Points From the United States National Health and Nutrition Examination Survey 1999-2004 From Bioimpedance Spectroscopy Data

BACKGROUND

Raw bioimpedance parameters (eg, 50-kHz phase angle [PA] and 200-kHz/5-kHz impedance ratio [IR]) have been investigated as predictors of nutrition status and/or clinical outcomes. However, their validity as prognostic measures depends on the availability of appropriate reference data. Using a large and ethnically diverse data set, we aimed to determine if ethnicity influences these measures and provide expanded bioimpedance reference data for the U.S.

POPULATION

METHODS

The National Health and Nutrition Examination Survey (NHANES) is an ongoing compilation of studies conducted by the U.S. Centers for Disease Control and Prevention designed to monitor nutrition status of the U.S.

POPULATION

The NHANES data sets analyzed were from the years 1999-2000, 2001-2002, and 2003-2004.

RESULTS

Multivariate analysis showed that PA and IR differed by body mass index (BMI), age, sex, and ethnicity (n = 6237; R² = 41.2%, P < .0001). Suggested reference cut-points for PA stratified by age decade, ethnicity, and sex are provided.

CONCLUSION

Ethnicity is an important variable that should be accounted for when determining population reference values for PA and IR. We have provided sex-, ethnicity-, and age decade-specific reference values from PA for use by future studies in U.S.

POPULATIONS

Interdevice differences are likely to be important contributors to variability across published population-specific reference data and, where possible, should be evaluated in future research. Ultimately, further validation with physiologically relevant reference measures (eg, dual-energy x-ray absorptiometry) is necessary to determine if PA/IR are appropriate bedside tools for the assessment of nutrition status in a clinical population.

Rapunzel syndrome: a rare cause of hypoproteinaemia and review of literature

Rapunzel syndrome is an extremely rare condition associated with trichophagia (hair eating disorder) secondary to a psychiatric illness called trichotillomania (hair-pulling behaviour). It is most commonly seen in children and adolescents. Untreated cases can lead to a number of complications. We present a case of a middle-aged woman with sudden intractable vomiting and constipation associated with bilateral pedal oedema and significant weight loss. Laboratory investigations revealed low serum protein levels. Laparotomy was performed, and a hairball was removed from her stomach and ileum. The patient was managed with the help of a psychiatrist and was given nutritional support. We performed a comprehensive search and summarised data for a total of 88 cases. No time or language limit was placed. The purpose of this discussion is to highlight the clinical spectrum of Rapunzel syndrome and also to report its rare association with hypoproteinaemia.

Sarcopenia in overweight and obese patients is a predictive factor for postoperative complication in gastric cancer: A prospective study

BACKGROUND

Sarcopenia is a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength. This study aims to explore the prevalence of sarcopenia in overweight and obese gastric cancer (GC) patients and figured out the impacts of sarcopenia on the postoperative complication of overweight and obese GC patients.

METHODS

According to the recommended body-mass index (BMI) for Asian populations by WHO, we conducted a prospective study of overweight and obese gastric cancer patients (BMI ≥ 23 kg/m²) under curative gastrectomy from August 2014 to December 2015. Including lumbar skeletal muscle index, handgrip strength and gait speed as the sarcopenic components were measured before surgery. Patients were followed up after gastrectomy to gain the actual clinical outcomes. Factors contributing to postoperative complications were analyzed by univariate and multivariate analysis.

RESULTS

Total of 206 overweight or obese patients were enrolled in this study, 14 patients were diagnosed sarcopenia and were demonstrated having significantly association with higher risk of postoperative complications, higher hospital costs, and higher rate of 30-days readmission compared with the non-sarcopenic ones. On the basis of univariate and multivariate analysis, sarcopenia was an independent risk factor for postoperative complication of overweight and obese patients with gastric cancer (P = 0.002).

CONCLUSION

Sarcopenia is an independent predictor of postoperative complications in overweight or obese patients with gastric cancer after radical gastrectomy.

ESPEN guidelines on definitions and terminology of clinical nutrition

BACKGROUND

A lack of agreement on definitions and terminology used for nutrition-related concepts and procedures limits the development of clinical nutrition practice and research.

OBJECTIVE

This initiative aimed to reach a consensus for terminology for core nutritional concepts and procedures.

METHODS

The European Society of Clinical Nutrition and Metabolism (ESPEN) appointed a consensus group of clinical scientists to perform a modified Delphi process that encompassed e-mail communication, face-to-face meetings, in-group ballots and an electronic ESPEN membership Delphi round.

RESULTS

Five key areas related to clinical nutrition were identified: concepts; procedures; organisation; delivery; and products. One core concept of clinical nutrition is malnutrition/undernutrition, which includes disease-related malnutrition (DRM) with (eq. cachexia) and without inflammation, and malnutrition/undernutrition without disease, e.g. hunger-related malnutrition. Over-nutrition (overweight and obesity) is another core concept. Sarcopenia and frailty were agreed to be separate conditions often associated with malnutrition. Examples of nutritional procedures identified include screening for subjects at nutritional risk followed by a complete nutritional assessment. Hospital and care facility catering are the basic organizational forms for providing nutrition. Oral nutritional supplementation is the preferred way of nutrition therapy but if inadequate then other forms of medical nutrition therapy, i.e. enteral tube feeding and parenteral (intravenous) nutrition, becomes the major way of nutrient delivery.

CONCLUSION

An agreement of basic nutritional terminology to be used in clinical practice, research, and the ESPEN guideline developments has been established. This terminology consensus may help to support future global consensus efforts and updates of classification systems such as the International Classification of Disease (ICD). The continuous growth of knowledge in all areas addressed in this statement will provide the foundation for future revisions.

Underweight Is an Independent Risk Factor for Renal Function Deterioration in Patients with IgA Nephropathy

Studies on the relationship between body mass index (BMI) and renal progression in IgA Nephropathy (IgAN) were limited, especially for underweight patients with IgAN. To elucidate the clinical features and effect of underweight on renal function deterioration in this disease, we recruited IgAN patients with diagnostic age ≥18 years old and a baseline estimated glomerular filtration rate (eGFR) ≥15 ml/min/1.73m² from our center between 1985 and 2014. Patients secondary to systemic diseases or follow-up less than 6 months were excluded. All patients’ clinical data at renal biopsy and during follow-up were recorded. Renal outcome was defined as end-stage kidney disease (ESRD). Baseline body mass index (BMI) was calculated by weight (kg) over squared height (m²). According to WHO Asian guideline, BMI was categorized as follows: <18.5kg/m² (underweight), 18.5–22.99kg/m² (normal weight), 23–27.49kg/m² (overweight) and obese (≥27.5 kg/m²). Of 930 primary IgAN patients enrolled in this study, mean age at renal biopsy was 37.6 years and 49.2% were men. Totally, 114 (12.3%) ESRD occurred after a mean follow-up of 47.1 months. More ESRD happened in underweight patients (17.3%) compared to patients with normal weight (13.2%), overweight (11.0%) or obesity (9.5%). By multivariate Cox regression analysis, underweight was independently associated with a higher risk of ESRD after adjustment for demographic characteristics and clinical variables (HR: 3.5, 95% CI: 1.3–9.5, P = 0.01) comparing to normal weight. Underweight patients had lower hemoglobin, serum uric acid, triglycerides, cholesterol and lymphocyte counts than patients with normal weight. Furthermore, BMI was positively correlated with serum C3 (r = 0.25, p <0.001). Our research finds that underweight is an independent risk factor for kidney disease progression in IgAN, which might be associated with malnutrition status and decreased C3 levels.

Prevalence of malnutrition and sarcopenia in a post-acute care geriatric unit: Applying the new ESPEN definition and EWGSOP criteria

BACKGROUNDS & AIMS

The European Society of Clinical Nutrition and Metabolism (ESPEN) consensus definition of malnutrition has been applied in hospitalized older diabetics and middle-aged patients, geriatric outpatients, and healthy elderly and young individuals. In a post-acute care setting, our aim was to assess malnutrition (ESPEN definition) and determine its relationship with sarcopenia in older in-patients deconditioned due to an acute process.

METHODS

Eighty-eight in-patients aged ≥70 years with body mass index (BMI) <30 kg/m² were included (84.1 years old; 62% women) and screened for malnutrition risk using biochemical markers and Mini-Nutritional Assessment-Short Form (MNA-SF). The ESPEN definition was applied: 1) BMI <18.5 kg/m² or 2) unintentional weight loss plus a) low BMI or b) low fat-free mass index (FFMI). European Working Group on Sarcopenia in Older People (EWGSOP) criteria were also applied.

RESULTS

Unintentional weight loss occurred in 27 (30.7%) of 88 in-patients considered "at risk" by MNA-SF. Malnutrition prevalence was 4.5%, 7.9%, and 17% using ESPEN definitions 1, 2a, and 2b, respectively; 19.3% were malnourished. Prevalence of sarcopenia was 37.5%, of which 90.9% fulfilled ESPEN malnutrition criteria, a significant association (p = 0.02). No differences in biochemical markers were observed between patients with or without malnutrition or sarcopenia.

CONCLUSIONS

ESPEN criteria constitute an appropriate tool to establish a malnutrition diagnosis in post-acute care. Sarcopenia, as defined by EWGSOP, was present in 37.5% of patients, of which 90.9% fulfilled ESPEN criteria; therefore, malnutrition was significantly related to sarcopenia. Additional work is needed to determine further implications of the ESPEN consensus definition.