Nutritional support therapy after GLIM criteria may neglect the benefit of reducing infection complications compared with NRS2002: Reanalysis of a cohort study

OBJECTIVES

The aim of this study is to validate the Global Leadership Initiative on Malnutrition (GLIM) criteria and determine the number of Nutritional Risk Screening 2002 (NRS2002)-positive patients who do not meet the GLIM, as well as examine whether these patients would benefit from nutritional support therapy.

METHODS

A reanalysis of a published prospective observational study was performed. The subjects were rediagnosed per the NRS2002 and GLIM criteria. The prevalence of malnutrition was reported, and the difference in rate of infection complications and total complications between the nutritional support therapy and glucose-electrolyte cohorts was calculated.

RESULTS

Among 1831 cases in the original database, 827 cases (45.2%) were NRS2002-positive. A total of 391 cases were identified by the GLIM criteria as malnourished (21.4%) and of these, subjects in the nutritional support therapy cohort had fewer infection complications than those in the glucose-electrolyte cohort (13.0% vs. 23.0%; P = 0.010). The remaining 436 patients were NRS2002 positive but GLIM negative (23.8%). The rate of infection was also significantly lower in the support cohort than in the nonsupport cohort (8.0% vs. 15.7%; P = 0.011). Nutritional support was proven o be a protective factor for infection complications in both GLIM-positive (odds ratio: 0.407; 95% confidence interval, 0.232-0.714; P = 0.002) and NRS2002-positive/GLIM-negative patients [odds ratio: 0.314; 95% confidence interval, 0.161-0.612; P = 0.001).

CONCLUSIONS

The GLIM criteria have been validated, and are useful in identifying malnourished patients who may have fewer infection complications due to nutritional support therapy. However, the criteria neglected half of the patients identified by NRS2002, among whom nutritional support therapy also decreased the rate of infection complications.

Nutrition risk screening in the ICU

PURPOSE OF REVIEW

To review recent studies that may help to identify patients in the ICU who benefit from nutrition support.

RECENT FINDINGS

One recent controlled trial did not show any clinical benefit of nutrition support among a sample of ICU patients who were hitherto believed to benefit from nutrition support. Several recent observational studies suggest benefit of nutrition support among patients who have a high nutric score, in itself derived from an observational study.

SUMMARY

Regrettably, the decision about nutrition support in ICU patients still depends on physiological reasoning: a high degree of inflammation/stress metabolism, which will last for a considerable time, especially among those who are fragile (already malnourished, elderly, those with chronic diseases and/or other comorbidities).

Cerebral Blood Flow Velocity during High Volume Plasmapheresis in Fulminant Hepatic Failure

High volume plasmapheresis has previousy been found to improve neurological statuses in patients with fulminant hepatic failure. We investigated the relationship between the neurological status and cerebral blood flow velocity (Vmean) during high volume plasmapheresis in 18 consecutive patients (ten females and eight males) with fulminant hepatic failure, with a mean age of 43 (range 9 to 57) years. The mean arterial pressure (MAP) and intracranial pressure (ICP) were also recorded. A total of 16% of body weight was exchanged with fresh frozen plasma per day. Thirty-six plasma exchanges were performed with a median of 2 (range 1 to 8) per patient. Eleven of the patients survived (61%), nine after liver transplantation. Following the first high volume plasmapheresis, the coma score improved from 6 (1-8) to 2 (0-8) (p < 0.05), Vmean increased from 40 (14-152) to 62 (16-186) cm S−1 (p < 0.05), and MAP from 72 (35-118) to 94 (47-138) mmHg (p < 0.05). The intracranial pressure (ICP) was monitored and remained unchanged in nine patients whereas the cerebral perfusion pressure (MAP minus ICP) increased in the surviving group from 55 (40-74) to 80 (50-91) mmHg (p = 0.07) in contrast to no changes in the non survival group. In conclusion this study suggests that the neurological status, may improve during high volume plasmapheresis as MAP and Vmean increase the cerebral oxygen delivery.

Management and prevention of refeeding syndrome in medical inpatients: An evidence-based and consensus-supported algorithm

OBJECTIVES

Refeeding syndrome (RFS) can be a life-threatening metabolic condition after nutritional replenishment if not recognized early and treated adequately. There is a lack of evidence-based treatment and monitoring algorithm for daily clinical practice. The aim of the study was to propose an expert consensus guideline for RFS for the medical inpatient (not including anorexic patients) regarding risk factors, diagnostic criteria, and preventive and therapeutic measures based on a previous systematic literature search.

METHODS

Based on a recent qualitative systematic review on the topic, we developed clinically relevant recommendations as well as a treatment and monitoring algorithm for the clinical management of inpatients regarding RFS. With international experts, these recommendations were discussed and agreement with the recommendation was rated.

RESULTS

Upon hospital admission, we recommend the use of specific screening criteria (i.e., low body mass index, large unintentional weight loss, little or no nutritional intake, history of alcohol or drug abuse) for risk assessment regarding the occurrence of RFS. According to the patient's individual risk for RFS, a careful start of nutritional therapy with a stepwise increase in energy and fluids goals and supplementation of electrolyte and vitamins, as well as close clinical monitoring, is recommended. We also propose criteria for the diagnosis of imminent and manifest RFS with practical treatment recommendations with adoption of the nutritional therapy.

CONCLUSION

Based on the available evidence, we developed a practical algorithm for risk assessment, treatment, and monitoring of RFS in medical inpatients. In daily routine clinical care, this may help to optimize and standardize the management of this vulnerable patient population. We encourage future quality studies to further refine these recommendations.

Early goal-directed nutrition versus standard of care in adult intensive care patients: the single-centre, randomised, outcome assessor-blinded EAT-ICU trial

PURPOSE

We assessed the effects of early goal-directed nutrition (EGDN) vs. standard nutritional care in adult intensive care unit (ICU) patients.

METHODS

We randomised acutely admitted, mechanically ventilated ICU patients expected to stay longer than 3 days in the ICU. In the EGDN group we estimated nutritional requirements by indirect calorimetry and 24-h urinary urea aiming at covering 100% of requirements from the first full trial day using enteral and parenteral nutrition. In the standard of care group we aimed at providing 25 kcal/kg/day by enteral nutrition. If this was not met by day 7, patients were supplemented with parenteral nutrition. The primary outcome was physical component summary (PCS) score of SF-36 at 6 months. We performed multiple imputation for data of the non-responders.

RESULTS

We randomised 203 patients and included 199 in the intention-to-treat analyses; baseline variables were reasonably balanced between the two groups. The EGDN group had less negative energy (p < 0.001) and protein (p < 0.001) balances in the ICU as compared to the standard of care group. The PCS score at 6 months did not differ between the two groups (mean difference 0.0, 95% CI -5.9 to 5.8, p = 0.99); neither did mortality, rates of organ failures, serious adverse reactions or infections in the ICU, length of ICU or hospital stay, or days alive without life support at 90 days.

CONCLUSIONS

EGDN did not appear to affect physical quality of life at 6 months or other important outcomes as compared to standard nutrition care in acutely admitted, mechanically ventilated, adult ICU patients. Clinicaltrials.gov identifier no. NCT01372176.

Assessment of adult malnutrition and prognosis with bioelectrical impedance analysis: phase angle and impedance ratio

PURPOSE OF REVIEW

Malnutrition affects prognosis in many groups of patients. Although screening tools are available to identify adults at risk for poor nutritional status, a need exists to improve the assessment of malnutrition by identifying the loss of functional tissues that can lead to frailty, compromised physical function, and increased risk of morbidity and mortality, particularly among hospitalized and ill patients and older adults. Bioimpedance analysis (BIA) offers a practical approach to identify malnutrition and prognosis by assessing whole-body cell membrane quality and depicting fluid distribution for an individual.

RECENT FINDINGS

Two novel applications of BIA afford opportunities to safely, rapidly, and noninvasively assess nutritional status and prognosis. One method utilizes single-frequency phase-sensitive measurements to determine phase angle, evaluate nutritional status, and relate it to prognosis, mortality, and functional outcomes. Another approach uses the ratio of multifrequency impedance values to indicate altered fluid distribution and predict prognosis.

SUMMARY

Use of basic BIA measurements, independent of use of regression prediction models and assumptions of constant chemical composition of the fat-free body, enables new options for practical assessment and clinical evaluation of impaired nutritional status and prognosis among hospitalized patients and elders that potentially can contribute to improved patient care and clinical outcomes. However, these novel applications have some technical and physiological limitations that should be considered.

Nutrition support in hospitalised adults at nutritional risk

BACKGROUND

The prevalence of disease-related malnutrition in Western European hospitals is estimated to be about 30%. There is no consensus whether poor nutritional status causes poorer clinical outcome or if it is merely associated with it. The intention with all forms of nutrition support is to increase uptake of essential nutrients and improve clinical outcome. Previous reviews have shown conflicting results with regard to the effects of nutrition support.

OBJECTIVES

To assess the benefits and harms of nutrition support versus no intervention, treatment as usual, or placebo in hospitalised adults at nutritional risk.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid SP), Embase (Ovid SP), LILACS (BIREME), and Science Citation Index Expanded (Web of Science). We also searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp); ClinicalTrials.gov; Turning Research Into Practice (TRIP); Google Scholar; and BIOSIS, as well as relevant bibliographies of review articles and personal files. All searches are current to February 2016.

SELECTION CRITERIA

We include randomised clinical trials, irrespective of publication type, publication date, and language, comparing nutrition support versus control in hospitalised adults at nutritional risk. We exclude trials assessing non-standard nutrition support.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane and the Cochrane Hepato-Biliary Group. We used trial domains to assess the risks of systematic error (bias). We conducted Trial Sequential Analyses to control for the risks of random errors. We considered a P value of 0.025 or less as statistically significant. We used GRADE methodology. Our primary outcomes were all-cause mortality, serious adverse events, and health-related quality of life.

MAIN RESULTS

We included 244 randomised clinical trials with 28,619 participants that met our inclusion criteria. We considered all trials to be at high risk of bias. Two trials accounted for one-third of all included participants. The included participants were heterogenous with regard to disease (20 different medical specialties). The experimental interventions were parenteral nutrition (86 trials); enteral nutrition (tube-feeding) (80 trials); oral nutrition support (55 trials); mixed experimental intervention (12 trials); general nutrition support (9 trials); and fortified food (2 trials). The control interventions were treatment as usual (122 trials); no intervention (107 trials); and placebo (15 trials). In 204/244 trials, the intervention lasted three days or more.We found no evidence of a difference between nutrition support and control for short-term mortality (end of intervention). The absolute risk was 8.3% across the control groups compared with 7.8% (7.1% to 8.5%) in the intervention groups, based on the risk ratio (RR) of 0.94 (95% confidence interval (CI) 0.86 to 1.03, P = 0.16, 21,758 participants, 114 trials, low quality of evidence). We found no evidence of a difference between nutrition support and control for long-term mortality (maximum follow-up). The absolute risk was 13.2% in the control group compared with 12.2% (11.6% to 13%) following nutritional interventions based on a RR of 0.93 (95% CI 0.88 to 0.99, P = 0.03, 23,170 participants, 127 trials, low quality of evidence). Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.We found no evidence of a difference between nutrition support and control for short-term serious adverse events. The absolute risk was 9.9% in the control groups versus 9.2% (8.5% to 10%), with nutrition based on the RR of 0.93 (95% CI 0.86 to 1.01, P = 0.07, 22,087 participants, 123 trials, low quality of evidence). At long-term follow-up, the reduction in the risk of serious adverse events was 1.5%, from 15.2% in control groups to 13.8% (12.9% to 14.7%) following nutritional support (RR 0.91, 95% CI 0.85 to 0.97, P = 0.004, 23,413 participants, 137 trials, low quality of evidence). However, the Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.Trial Sequential Analysis of enteral nutrition alone showed that enteral nutrition might reduce serious adverse events at maximum follow-up in people with different diseases. We could find no beneficial effect of oral nutrition support or parenteral nutrition support on all-cause mortality and serious adverse events in any subgroup.Only 16 trials assessed health-related quality of life. We performed a meta-analysis of two trials reporting EuroQoL utility score at long-term follow-up and found very low quality of evidence for effects of nutritional support on quality of life (mean difference (MD) -0.01, 95% CI -0.03 to 0.01; 3961 participants, two trials). Trial Sequential Analyses showed that we did not have enough information to confirm or reject clinically relevant intervention effects on quality of life.Nutrition support may increase weight at short-term follow-up (MD 1.32 kg, 95% CI 0.65 to 2.00, 5445 participants, 68 trials, very low quality of evidence).

AUTHORS' CONCLUSIONS

There is low-quality evidence for the effects of nutrition support on mortality and serious adverse events. Based on the results of our review, it does not appear to lead to a risk ratio reduction of approximately 10% or more in either all-cause mortality or serious adverse events at short-term and long-term follow-up.There is very low-quality evidence for an increase in weight with nutrition support at the end of treatment in hospitalised adults determined to be at nutritional risk. The effects of nutrition support on all remaining outcomes are unclear.Despite the clinically heterogenous population and the high risk of bias of all included trials, our analyses showed limited signs of statistical heterogeneity. Further trials may be warranted, assessing enteral nutrition (tube-feeding) for different patient groups. Future trials ought to be conducted with low risks of systematic errors and low risks of random errors, and they also ought to assess health-related quality of life.

Early goal-directed nutrition in ICU patients (EAT-ICU): protocol for a randomised trial

INTRODUCTION

Extensive weight loss has been docu-mented in intensive care unit (ICU) survivors, primarily as the result of muscle loss, leading to impaired physical function and reduced quality of life. The aim of the EAT-ICU trial is to test the effect of early goal-directed protein-energy nutrition based on measured requirements on short-term clinical outcomes and long-term physical quality of life in ICU patients.

METHODS

The EAT-ICU trial is a single-centre, randomised, parallel-group trial with concealed allocation and blinded outcome assessment. A total of 200 consecutive, acutely admitted, mechanically ventilated intensive care patients will be randomised 1:1 to early goal-directed nutrition versus standard of care to show a potential 15% relative risk reduction in the primary outcome measure (physical function) at six months (two-sided significance level α = 0.05; power β = 80%). Secondary outcomes include energy- and protein balances, metabolic control, new organ failure, use of life support, nosocomial infections, ICU- and hospital length of stay, mortality and cost analyses.

CONCLUSION

The optimal nutrition strategy for ICU patients remains unsettled. The EAT-ICU trial will provide important data on the effects of early goal-directed protein-energy nutrition based on measured requirements in these patients.

FUNDING

The EAT-ICU trial is funded by Copenhagen University Hospital, Rigshospitalet and Fresenius Kabi A/S and supported by The European Society for Clinical Nutrition and Metabolism (ESPEN).

TRIAL REGISTRATION

Clinicaltrials.gov identifier no. NCT01372176.

Nutritional-risk scoring systems in the intensive care unit

PURPOSE OF REVIEW

There is a need to develop a screening tool to assist clinical staff in deciding whether or not a patient in the ICU should be given nutrition support. The purpose of this review is to analyze the recent randomized trials in this context.

RECENT FINDINGS

Five trials describe the effect of early supplemental parenteral nutrition. Four of these trials suggested a positive effect on clinical outcome. The results, including lengths of stay in the ICU (range on average: 3-17 days) and lengths of mechanical ventilation (range on average: 2-11 days), are discussed within the nutritional and metabolic framework of patients in intensive care. The limitations of existing screening tools, Nutritional Risk Screening 2002 (NRS 2002) and Nutrition risk in the critically ill (NUTRIC score) are described, and it also appears that the APACHE II score is not useful for predicting a possible benefit of nutrition support.

SUMMARY

As a tentative conclusion, it is recommended to provide adequate nutrition support to severely ill patients who are likely to stay in the ICU with mechanical ventilation for a week or more.

Health effects of protein intake in healthy adults: a systematic literature review

The purpose of this systematic review is to assess the evidence behind the dietary requirement of protein and to assess the health effects of varying protein intake in healthy adults. The literature search covered the years 2000-2011. Prospective cohort, case-control, and intervention studies were included. Out of a total of 5,718 abstracts, 412 full papers were identified as potentially relevant, and after careful scrutiny, 64 papers were quality graded as A (highest), B, or C. The grade of evidence was classified as convincing, probable, suggestive or inconclusive. The evidence is assessed as: probable for an estimated average requirement of 0.66 g good-quality protein/kg body weight (BW)/day based on nitrogen balance studies, suggestive for a relationship between increased all-cause mortality risk and long-term low-carbohydrate-high-protein (LCHP) diets; but inconclusive for a relationship between all-cause mortality risk and protein intake per se; suggestive for an inverse relationship between cardiovascular mortality and vegetable protein intake; inconclusive for relationships between cancer mortality and cancer diseases, respectively, and protein intake; inconclusive for a relationship between cardiovascular diseases and total protein intake; suggestive for an inverse relationship between blood pressure (BP) and vegetable protein; probable to convincing for an inverse relationship between soya protein intake and LDL cholesterol; inconclusive for a relationship between protein intake and bone health, energy intake, BW control, body composition, renal function, and risk of kidney stones, respectively; suggestive for a relationship between increased risk of type 2 diabetes (T2D) and long-term LCHP-high-fat diets; inconclusive for impact of physical training on protein requirement; and suggestive for effect of physical training on whole-body protein retention. In conclusion, the evidence is assessed as probable regarding the estimated requirement based on nitrogen balance studies, and suggestive to inconclusive for protein intake and mortality and morbidity. Vegetable protein intake was associated with decreased risk in many studies. Potentially adverse effects of a protein intake exceeding 20-23 E% remain to be investigated.

Impact of preoperative nutritional support on clinical outcome in abdominal surgical patients at nutritional risk

OBJECTIVE

This multicenter, prospective cohort study evaluated the effect of preoperative nutritional support in abdominal surgical patients at nutritional risk as defined by the Nutritional Risk Screening Tool 2002 (NRS-2002).

METHODS

A consecutive series of patients admitted for selective abdominal surgery in the Peking Union Medical College Hospital and the Beijing University Third Hospital in Beijing, China were recruited from March 2007 to July 2008. Data were collected on the nutritional risk screening (NRS-2002), the application of perioperative nutritional support, surgery, complications, and length of stay. A minimum of 7 d of parenteral nutrition or enteral nutrition before surgery was considered adequate preoperative nutritional support.

RESULTS

In total 1085 patients were recruited, and 512 of them were at nutritional risk. Of the 120 patients with an NRS score at least 5, the complication rate was significantly lower in the preoperative nutrition group compared with the control group (25.6% versus 50.6%, P = 0.008). The postoperative hospital stay was significantly shorter in the preoperative nutrition group than in the control group (13.7 ± 7.9 versus 17.9 ± 11.3 d, P = 0.018). Of the 392 patients with an NRS score from 3 to 4, the complication rate and the postoperative hospital stay were similar between patients with and those without preoperative nutritional support (P = 1.0 and 0.770, respectively).

CONCLUSION

This finding suggests that preoperative nutritional support is beneficial to patients with an NRS score at least 5 by lowering the complication rate.

Food for patients at nutritional risk: a model of food sensory quality to promote intake

BACKGROUND & AIMS

The aim was to investigate food sensory quality as experienced and perceived by patients at nutritional risk within the context of establishing a framework to develop foods to develop foods to promote intake.

METHODS

Patients at nutritional risk (NRS-2002; food intake ≤ 75% of requirements) were observed at meals in hospital (food choice, hunger/fullness/appetite scores). This was followed by a semi-structured interview based on the observations and focusing on food sensory perception and eating ability as related to food quality. Two weeks post-discharge, a 3-day food record was taken and interviews were repeated by phone. Interviews were transcribed, coded, and analysed thematically.

RESULTS

Patients (N = 22) from departments of gastrointestinal surgery, oncology, infectious medicine, cardiology, and hepatology were interviewed at meals (N = 65) in hospital (82%) and post-discharge (18%). Food sensory perception and eating ability dictated specific food sensory needs (i.e., appearance, aroma, taste, texture, temperature, and variety defining food sensory quality to promote intake) within the context of motivation to eat including: pleasure, comfort, and survival. Patients exhibited large inter- and intra-individual variability in their food sensory needs.

CONCLUSIONS

The study generated a model for optimising food sensory quality and developing user-driven, innovative foods to promote intake in patients at nutritional risk.

Provision of protein and energy in relation to measured requirements in intensive care patients

BACKGROUND & AIMS

Adequacy of nutritional support in intensive care patients is still a matter of investigation. This study aimed to relate mortality to provision, measured requirements and balances for energy and protein in ICU patients.

DESIGN

Prospective observational cohort study of 113 ICU patients in a tertiary referral hospital.

RESULTS

Death occurred earlier in the tertile of patients with the lowest provision of protein and amino acids. The results were confirmed in Cox regression analyses which showed a significantly decreased hazard ratio of death with increased protein provision, also when adjusted for baseline prognostic variables (APACHE II, SOFA scores and age). Provision of energy, measured resting energy expenditure or energy and nitrogen balance was not related to mortality. The possible cause-effect relationship is discussed after a more detailed analysis of the initial part of the admission.

CONCLUSION

In these severely ill ICU patients, a higher provision of protein and amino acids was associated with a lower mortality. This was not the case for provision of energy or measured resting energy expenditure or energy or nitrogen balances. The hypothesis that higher provision of protein improves outcome should be tested in a randomised trial.

How nutritional risk is assessed and managed in European hospitals: a survey of 21,007 patients findings from the 2007-2008 cross-sectional nutritionDay survey

BACKGROUND & AIMS

Recognition and treatment of undernutrition in hospitalized patients are not often a priority in clinical practice.

OBJECTIVES

We investigated how the nutritional risk of patients is determined and whether such assessment influences daily nutritional care across Europe and in Israeli hospitals.

METHODS

1217 units from 325 hospitals in 25 countries with 21,007 patients participated in a longitudinal survey "nutritionDay" 2007/2008 undertaken in Europe and Israel. Screening practice, the type of tools used and whether energy requirements and intake are assessed and monitored were surveyed using standardized questionnaires.

RESULTS

Fifty-two percent (range 21-73%) of the units in the different regions reported a screening routine which was most often performed with locally developed methods and less often with national tools, the Nutrition Risk Screening-2002, or the Malnutrition Universal Screening Tool. Twenty-seven percent of the patients were subjectively classified as being "at nutritional risk", with substantial differences existing between regions. Independent factors influencing the classification of nutritional risk included age, BMI <18.5 kg/m(2), unintentional weight loss, reduced food intake in the previous week and on nutritionDay (for all parameters, p < 0.0001). The energy goal was defined as >=1500 kcal in 76% of the patients, but 43% of patients did not reach this goal.

CONCLUSIONS

The process of nutrition risk assessment varied between units and countries. Additionally, energy goals were frequently not met. More effort is needed to implement current guidelines within daily clinical practice.

Effect of a high protein meat diet on muscle and cognitive functions: a randomised controlled dietary intervention trial in healthy men

BACKGROUND

Recommendations to use other criteria than N-balance for defining protein requirements have been proposed. However, little evidence to support other measures such as physiological functions is available.

OBJECTIVE

To investigate the effects of a usual (UP) versus a high protein (HP) diet on muscle function, cognitive function, quality of life and biochemical regulators of protein metabolism.

DESIGN

A randomised intervention study was conducted with 23 healthy males (aged 19-31 yrs). All subjects consumed a Usual Protein (UP) diet (1.5 g protein/kg BW) for a 1-wk run-in period before the intervention period where they were assigned to either a UP or a High Protein (HP) diet (3.0 g protein/kg BW) for 3-wks with controlled intake of food and beverages. Blood and urine samples were taken along with measurements of physiological functions at baseline and at the end of the intervention period.

RESULTS

The HP group improved their reaction time significantly compared with the UP group. Branched chain amino acids and phenylalanine in plasma were significantly increased following the HP diet, which may explain the improved reaction time.

CONCLUSION

Healthy young males fed a HP diet improved reaction time. No adverse effects of the HP diet were observed. This trial was registered at www.clinicaltrials.gov as NCT00621231.

Measuring nutritional risk in hospitals

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

Validation of reaction time as a measure of cognitive function and quality of life in healthy subjects and patients

OBJECTIVE

Malnutrition is a common problem in hospitalized patients and is related to decreased cognitive function and impaired quality of life (QoL). We investigated the validity of reaction time as a simple bedside tool for measuring cognitive function in healthy subjects and patients, and additionally the relationships with QoL and malnutrition in patients.

METHODS

Healthy subjects (N = 130) were assessed for simple and complex reaction time and cognitive function (Addenbrooke cognitive examination, ACE). Patients (N = 70) were assessed for simple and complex reaction time, cognitive function (ACE), and QoL (short-form health survey) (N = 40).

RESULTS

Reaction time was related to cognitive function in both healthy subjects and patients. Reaction time was inversely related to the physical component summary of QoL in patients (r = -0.42, P < 0.001). Five of eight QoL scales and the mental component summary of QoL were significantly lower in malnourished patients. Reaction time and ACE were impaired in patients compared to healthy subjects, but not further impaired in malnourished patients.

CONCLUSION

Simple reaction time test is related to cognitive function in healthy subjects and patients and to QoL in patients. Complex reaction time test is related to more components of cognitive function. Thus, simple and complex reaction time tests could serve as bedside measurements reflecting, respectively, QoL or cognitive function.

Adult starvation and disease-related malnutrition: a proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committee

BACKGROUND & AIMS

Multiple definitions for malnutrition syndromes are found in the literature resulting in confusion. Recent evidence suggests that varying degrees of acute or chronic inflammation are key contributing factors in the pathophysiology of malnutrition that is associated with disease or injury.

METHODS

An International Guideline Committee was constituted to develop a consensus approach to defining malnutrition syndromes for adults in the clinical setting. Consensus was achieved through a series of meetings held at the A.S.P.E.N. and ESPEN Congresses.

RESULTS

It was agreed that an etiology-based approach that incorporates a current understanding of inflammatory response would be most appropriate. The Committee proposes the following nomenclature for nutrition diagnosis in adults in the clinical practice setting. "Starvation-related malnutrition", when there is chronic starvation without inflammation, "chronic disease-related malnutrition", when inflammation is chronic and of mild to moderate degree, and "acute disease or injury-related malnutrition", when inflammation is acute and of severe degree.

CONCLUSIONS

This commentary is intended to present a simple etiology-based construct for the diagnosis of adult malnutrition in the clinical setting. Development of associated laboratory, functional, food intake, and body weight criteria and their application to routine clinical practice will require validation.

The beta-adrenergic antagonist propranolol partly abolishes thermogenic response to bioactive food ingredients

A combination of tyrosine, capsaicin, catechins, and caffeine has been shown to possess a thermogenic effect in humans. The present objective was to investigate whether the thermogenic response to the bioactive combination (BC) could be diminished or abolished by propranolol. Twenty-two men (age, 29.0 +/- 7.1 years; body mass index, 26.0 +/- 3.6 kg/m(2); mean +/- SD) participated in a 4-way, randomized, double-blind, placebo-controlled crossover study. The effect of the following was tested: (1) placebo, (2) BC, (3) BC + 5 mg propranolol, and (4) BC + 10 mg propranolol. Resting metabolic rate, respiratory quotient, and the thermogenic response were measured for 5 hours postintake. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate, and appetite ratings were assessed every half hour. The BC increased resting metabolic rate by 5% (73 [36; 110] kJ/5 h, mean [95% confidence interval], P < .0001) compared with placebo. Both propranolol doses blunted the thermogenic response by 50% compared with placebo (P < .01). The BC increased SBP by 3% (4 +/- 1 mm Hg, P = .003) compared with placebo. The effect of BC on SBP was reduced by 25% by propranolol (P = .07). The BC (with or without propranolol) increased DBP by 6% (4 +/- 1 mm Hg, P </= .0002). Propranolol decreased heart rate by 5% (3 +/- 1 beats per minute, P < .0001) compared with placebo and BC. No effects were observed on appetite ratings. In conclusion, the study confirms the thermogenic properties of BC. The 50% reduction of the thermogenic response by propranolol indicates that beta-adrenergic pathways are partly responsible for the thermogenic response.

Nutritional risk, malnutrition (undernutrition), overweight, obesity and nutrition support among hospitalized patients in Beijing teaching hospitals

The purpose of this study was to test the suitability of Nutritional Risk Screening 2002 (NRS 2002) among hospitalized patients and to determine the prevalence of nutritional risk, undernutrition, overweight, obesity, nutritional support and the changes of nutritional risk from admission to discharge or over a two-week period. A prospective descriptive design was used to describe patients' data collected at three Beijing teaching hospitals. A total number of 1500 consecutive patients, who met the inclusion criteria on admission and provided informed consent, were enrolled. The NRS 2002 was completed by 97.7% of all patients in this study. The overall prevalence of nutritional risk was 27.3%, the prevalence of undernutrition, overweight and obesity was 9.2%, 34.8%, and 10.2%, respectively at admission. Only 24.9% of patients who were at nutritional risk received nutritional support while 6% of non-risk patients received nutritional support. The overall prevalence of nutritional risk changed from 27.3% to 31.9% (p < 0.05), and the prevalence of undernutrition, overweight and obesity changed from 9.2% to 11.7% (p < 0.05), from 34.8% to 31.8% (p > 0.05) and from 10.2% to 8.6% (p > 0.05), respectively during hospitalization. Nutritional Risk Screening 2002 was a feasible nutritional risk screening tool in selected Beijing teaching hospitals. The prevalence of nutritional risk observed was nearly 30%. Inappropriate use of nutritional support was observed in hospitalized patients. The prevalence of nutritional risk increased in surgical patients during hospitalization.

Comparative survey on nutritional risk and nutritional support between Beijing and Baltimore teaching hospitals

OBJECTIVE

We tested the feasibility of using the Nutritional Risk Screening 2002 tool among hospitalized medical patients in Beijing and Baltimore and determined the prevalence of nutritional risk, nutritional support, and nutritional risk changes from admission to discharge or over a 2-wk period.

METHODS

A comparative design was used to compare data collected at Beijing and Baltimore teaching hospitals from April 2006 to April 2007. A total of 500 consecutive medical patients, 300 from Beijing and 200 from Baltimore, who met the inclusion criteria on admission and provided informed consent were enrolled.

RESULTS

Among the hospitalized patients, 94.0% in Beijing and 99.5% in Baltimore were able to complete the Nutritional Risk Screening 2002. Prevalences of nutritional risk were 39.0% and 51.0%, respectively (P < 0.05). For the patients at nutritional risk, only 17.9% in Beijing and 14.7% in Baltimore used parenteral nutrition or enteral nutrition (P = 0.518). For non-risk patients, 3.3% in Beijing used nutritional support, whereas no patient in Baltimore used this support (P = 0.095). Prevalences of nutritional risk changed from 39.0% to 38.5% (P = 0.892) during hospitalization in Beijing and from 51.0% to 41.4% in Baltimore (P = 0.055).

CONCLUSION

The Nutritional Risk Screening 2002 was feasible in the Beijing and Baltimore teaching hospitals. The prevalence of nutritional risk observed in Baltimore was higher than that in Beijing. No difference was observed in the application rate of nutritional support and changes in nutritional risk during hospitalization between these two hospitals.

EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome

BACKGROUND & AIMS

The aim of the study was to implement nutritional risk screening (NRS-2002) and to assess the association between nutritional risk and clinical outcome.

METHODS

NRS-2002 was implemented in 26 hospital departments (surgery, internal medicine, oncology, intensive care, gastroenterology and geriatrics) in Austria, the Czech Republic, Egypt, Germany, Hungary, Lebanon, Libya, Poland, Romania, Slovakia, Spain and Switzerland. Being a prospective cohort study, randomly selected adult patients were included at admission and followed during their hospitalisation. Data were collected on the nutritional risk screening, complications, mortality, length of stay and discharge. The correlation between risk status and clinical outcome was assessed and adjusted for confounders (age, speciality, diagnoses, comorbidity, surgery, cancer and region) by multivariate regression analysis.

RESULTS

Of the 5051 study patients, 32.6% were defined as 'at-risk' by NRS-2002. 'At-risk' patients had more complications, higher mortality and longer lengths of stay than 'not at-risk' patients and these variables were significantly related to components of NRS-2002, also when adjusted for confounders.

CONCLUSIONS

Components of NRS-2002 are independent predictors of poor clinical outcome.

Insufficient nutritional knowledge among health care workers?

BACKGROUND & AIMS

Though a great interest and willingness to nutrition therapy, there is an insufficient practice compared to the proposed ESPEN guidelines for nutrition therapy. The aim of this questionnaire was to study doctors and nurses' self-reported knowledge in nutritional practice, with focus on ESPEN's guidelines in nutritional screening, assessment and treatment.

METHODS

A questionnaire about different aspects of nutritional practice was answered by 4512 doctors and nurses in Denmark, Sweden and Norway.

RESULTS

The most common cause for insufficient nutritional practice was lack of nutritional knowledge. Twenty-five percent found it difficult to identify patient in need of nutritional therapy, 39% lacked techniques for identifying malnourished patients, and 53% found it difficult to calculate the patients' energy requirement and 66% lacked national guidelines for clinical nutrition. Twenty-eight percent answered that insufficient nutrition practice could lead to complications and prolonged hospital stay. Those that answered that their nutritional knowledge was good had also a better nutritional practice.

CONCLUSION

The self-reported nutritional knowledge was inadequate among Scandinavian doctors and nurses. Increased nutritional knowledge seems to improve the nutritional practice. A combination of an integrated nutrition curriculum during the education, together with post-graduated education for both physicians and nurses should be established.

Management and perception of hospital undernutrition—A positive change among Danish doctors and nurses

BACKGROUND

Undernutrition in hospitals is a common problem associated with increased morbidity and mortality, prolonged convalescence and duration of hospital stay and increased health care costs. During recent years several initiatives have brought hospital undernutrition into focus and guidelines and standards have been published. In 1997, a questionnaire-based survey among Danish hospital doctors and nurses in selected departments concluded that clinical nutrition did not fulfil accepted standards.

AIMS

We wished to determine if improvements had occurred in the intervening period.

METHOD

Thus, in 2004 a similar questionnaire was sent to 4000 randomly selected Danish hospital doctors and nurses and responses were compared to those from 1997. The questionnaire dealt with attitudes and practice in the areas of nutritional screening, treatment plan, monitoring as well as with knowledge, education, tools and guidelines, organisation and possible barriers to implementation of nutritional screening and therapy.

RESULTS

The overall response rate was 38%. We observed a marked improvement especially in screening procedures, calculation of energy intake in at-risk patients and local availability of guidelines. Many departments had appointed staff members with special interest and knowledge in clinical nutrition.

CONCLUSION

Although significant positive changes had thus occurred, the main barriers against implementation of good nutrition care continued to be lack of knowledge, interest and responsibility, in combination with difficulties in making a nutrition plan. This will be the focus of future activities.

[The malnutritioned patient]

The prevalence of disease-related malnutrition is high among surgical patients, and the condition tends to worsen during hospital stay due to an inadequate dietary intake. The etiology is mechanical obstruction in many cases but also the endocrine condition of stress-metabolism plays a significant role. Several randomized studies and metaanalyses have indicated that clinical outcome improves with adequate nutrition support. Despite this evidence, recent studies indicate that little is done in daily clinical practice. A combined effort from hospital managers, doctors, nurses and clinical dieticians is required to improve this care gap.

A method for implementation of nutritional therapy in hospitals

BACKGROUND AND AIMS

Many barriers make implementation of nutritional therapy difficult in hospitals. In this study we investigated whether, a targeted plan made by the staff in different departments could improve nutritional treatment within selected quality goals based on the ESPEN screening guidelines.

METHODS

The project was carried out as a continuous quality improvement project. Four different specialities participated in the study with a nutrition team of both doctors, nurses, and a dietician, and included the following methods: (1) Pre-measurement: assessment of quality goals prior to study including the use of screening of nutritional risk (NRS-2002), whether a nutrition plan was made, and monitoring was documented in the records. (2) INTERVENTION: multidisciplinary meeting for the ward staff using a PC-based meeting system for detecting barriers in the department concerning nutrition, elaboration of an action plan and implementation of the plan. (3) Re-measurement: as in (1) based on information from records and patient interviews, and an evaluation based on focus group interview with the staff. Patients who gave informed consent to participate in the study (>14 years) were included consecutively. Mann-Whitney and Kruskal-Wallis test was used for ordinal data, and Pearson chi(2) test for nominative data. P values <0.05 were considered significant. The study was performed in accordance with the Research Ethics Committee.

RESULTS

In this study 141/122 patients were included before/after the implementation period with a mean weight loss within the last 3 months of 6.2 and 5.2 kg, respectively. Before the study we found that BMI was not measured. More than half of the patients had a weight loss within the last 3 months, and 40% had a weight loss during hospitalization, and this was not documented in the records. About 75% had a food intake less than normal within the last week, and nearly one-third were at a severe nutritional risk, and only 33% of these had a nutrition plan, and 18% a plan for monitoring. Barriers concerning nutrition included low priority, no focus, no routine or established procedures, and insufficient knowledge, lack of quality and choice of menus, and lack of support from general manager of the hospital. The staff introduced individually targeted procedures including assigning of responsibility, a nutrition record, electronic calculator of energy intake, upgrading of the dieticians and special diets, communication, and educational programs. A great consistency existed between barriers for targeted nutrition effort and ideas for improvement of the quality goals between the different departments. Quality assessment after study showed an overall significant improvement of the selected quality goals.

CONCLUSION

The introduction of a new method for implementation of nutritional therapy according to ESPEN screening guidelines seems to improve nutritional therapy in hospitals. The method included assessment of quality goals, identification of barriers and individual targeted plans for each department followed by an evaluation process. The model has to be refined further with relevant clinical endpoints.

Nutritional routines and attitudes among doctors and nurses in Scandinavia: A questionnaire based survey

BACKGROUND AND AIMS

Hospital malnutrition is prevalent, but nutritional practice in hospitals has a low priority. To improve the quality in nutritional routine, ESPEN has developed standards to improve the inadequate and insufficient nutritional treatments seen today. However, there is a discrepancy between the standards and clinical practice. This study was conducted to investigate nutritional practice in different hospital settings in relation to these standards (e.g.: screening of all patients, assessment of at-risk patients) among Scandinavian doctors and nurses.

METHODS

A questionnaire about nutritional attitudes and routine was mailed to doctors and nurses in Denmark, Sweden and Norway.

RESULTS

Altogether, 4512 (1753 doctors, 2759 nurses) answered the questionnaire. Both screening and assessment of at-risk patients differ between the countries. Nutritional screening was more common in Denmark (40%), compared to Sweden (21%) and Norway (16%). Measuring dietary intake in nutritional at-risk patients was more common in Denmark (46%), compared to Sweden (37%) and Norway (22%). However, all countries agreed that nutritional screening (92%, 88%, 88%) and measuring dietary intake (97%, 95%, 97%) were important, Denmark, Sweden and Norway, respectively.

CONCLUSION

There is a large discrepancy between nutritional attitudes and practice. The standards suggested from the ESPEN are not fulfilled.

ESPEN Guidelines on Enteral Nutrition: Liver disease

Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in patients with liver disease (LD). It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. EN by means of ONS is recommended for patients with chronic LD in whom undernutrition is very common. ONS improve nutritional status and survival in severely malnourished patients with alcoholic hepatitis. In patients with cirrhosis, TF improves nutritional status and liver function, reduces the rate of complications and prolongs survival. TF commenced early after liver transplantation can reduce complication rate and cost and is preferable to parenteral nutrition. In acute liver failure TF is feasible and used in the majority of patients.

Introductory to the ESPEN Guidelines on Enteral Nutrition: Terminology, definitions and general topics

The ESPEN guidelines on enteral nutrition are the first evidence-based European recommendations for enteral nutrition. They were established by European experts for a variety of disease groups. During guideline development it became evident that terms and definitions in clinical nutrition have been used inconsistently depending on medical disciplines as well as regional and personal preferences. Therefore, to increase explanatory accuracy it was necessary to unify them. In this chapter terms and definitions used throughout all guidelines are explained. Additionally answers to more general questions, which might be important in most indications are dealt with, i.e. use of fibre containing and diabetes formulae.

Body fat loss achieved by stimulation of thermogenesis by a combination of bioactive food ingredients: a placebo-controlled, double-blind 8-week intervention in obese subjects

BACKGROUND

A combination of tyrosine, capsaicin, catechines and caffeine may stimulate the sympathetic nervous system and promote satiety, lipolysis and thermogenesis. In addition, dietary calcium may increase fecal fat excretion.

OBJECTIVE

To investigate the acute and subchronic effect of a supplement containing the above mentioned agents or placebo taken t.i.d on thermogenesis, body fat loss and fecal fat excretion.

DESIGN

In total, 80 overweight-obese subjects ((body mass index) 31.2+/-2.5 kg/m(2), mean+/-s.d.) underwent an initial 4-week hypocaloric diet (3.4 MJ/day). Those who lost>4% body weight were instructed to consume a hypocaloric diet (-1.3 MJ/day) and were randomized to receive either placebo (n=23) or bioactive supplement (n=57) in a double-blind, 8-week intervention. The thermogenic effect of the compound was tested at the first and last day of intervention, and blood pressure, heart rate, body weight and composition were assessed.

RESULTS

Weight loss during the induction phase was 6.8+/-1.9 kg. At the first exposure the thermogenic effect of the bioactive supplement exceeded that of placebo by 87.3 kJ/4 h (95%CI: 50.9;123.7, P=0.005) and after 8 weeks this effect was sustained (85.5 kJ/4 h (47.6;123.4), P=0.03). Body fat mass decreased more in the supplement group by 0.9 kg (0.5; 1.3) compared with placebo (P<0.05). The bioactive supplement had no effect on fecal fat excretion, blood pressure or heart rate.

CONCLUSION

The bioactive supplement increased 4-h thermogenesis by 90 kJ more than placebo, and the effect was maintained after 8 weeks and accompanied by a slight reduction in fat mass. These bioactive components may support weight maintenance after a hypocaloric diet.

Nutrition in end stage liver disease

This chapter will focus on studies within the last 5 years of nutrition in end stage liver disease, but earlier studies illustrating the present state of affairs will also be mentioned. The first part will focus on descriptive epidemiological studies that help to set the scene for the intervention studies, which will be described in the second part. Each part will discuss liver cirrhosis, acute liver failure and liver transplantation separately. The aim is to provide the reader with sufficient background for the decision in clinical practice about when to see nutrition support as an important part of treatment of the patient.

Diagnostik der Mangelernährung des älteren Menschen

The concept of malnutrition in the geriatric population describes a deficient state of energy and nutrient intake with harmful clinical consequences. Despite of having a significant effect on morbidity and mortality, there are no generally accepted criteria for diagnosing malnutrition in the elderly. With increasing age the general recognition of the nutritional status becomes more important for the diagnosis of malnutrition than isolated parameters. Recording a patient"s history must include any weight loss and changes in appetite. Reasons for a diminished nutritional intake must be explored systematically as well. As part of physical examination one has to pay attention to clinical signs of malnutrition (general muscular atrophy, loss of subcutaneous fat) and to signs of micronutrient deficiencies. The documentation of oral intake can supply important evidence for deficient intake of energy and nutrients. Of special relevance among anthropometric values are a BMI of less than 20 kg/m and calf circumference of less than 31 cm. Individual follow-up data are superior to isolated measurements Laboratory diagnostic tests (for example albumin) are of minor importance for the diagnosis of malnutrition because of their low specificity. As a consequence of unsolved methodical problems, bioelectrical impedance analysis can currently be recommended only to those who are experienced with this method and its limitations. Screening and assessment tools like Mini Nutritional Assessment (MNA) and Nutritional Risk Screening(NRS) are helpful for a quick and simple identification of malnourished patients and those who are at risk. The MNA is especially applicable for people who live independently and for cooperative residents of nursing homes. The NRS is a valuable alternative for hospital patients and those unable to cooperate. Screening for malnutrition should be routine practice in the elderly population, especially for those at high risk for it like in hospitals and in nursing homes.