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.

Regulation of electrolyte and fluid metabolism in multi-stage ultra-marathoners

The purposes of this study were (i) to determine the prevalence of exercise-associated hyponatremia (EAH) in multi-stage ultra-marathoners and (ii) to gain more insight into fluid and electrolyte regulation during a multi-stage race. Body mass, sodium concentration ([Na⁺]), potassium concentration ([K⁺]), creatinine, urea, specific gravity, and osmolality in urine were measured in 25 male ultra-marathoners in the 'Swiss Jura Marathon' 2008 with 11,000 m gain of altitude over 7 stages covering 350 km, before and after each stage. Haemoglobin, haematocrit, creatinine, urea, [Na⁺], [K⁺], and osmolality were measured in plasma before stage 1 and after stages 1, 3, 5, and 7. Two athletes (8%) showed plasma [Na⁺] <135 mmol/l. Body mass, plasma [Na⁺], and plasma [K⁺] remained unchanged (p>0.05). Urine specific gravity (p<0.001) and osmolality in both plasma (p<0.01) and urine (p<0.001) were increased and haematocrit (p<0.0001), haemoglobin (p<0.0001) and plasma albumin were decreased (p<0.001). Plasma volume (p<0.01) and plasma urea (p<0.001) were increased. The K⁺/Na⁺ ratio in urine increased >1.0 after each stage and returned to <1.0 the morning of the next stage (p<0.001). To summarize, more sodium than potassium was excreted during rest. The increased urinary sodium losses during rest are compatible with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) or the cerebral salt-wasting syndrome (CSWS). Further studies are needed to determine the antidiuretic hormone (ADH) and both the atrial natriuretic peptide (ANP) and the brain natriuretic peptide (BNP) during multi-stage races.

Structure-based design, synthesis, and in vitro evaluation of bisubstrate inhibitors for catechol O-methyltransferase (COMT)

The enzyme catechol O-methyltransferase (COMT) catalyzes the Me group transfer from the cofactor S-adenosylmethionine (SAM) to the hydroxy group of catechol substrates. Potential bisubstrate inhibitors of COMT were developed by structure-based design and synthesized. The compounds were tested for in vitro inhibitory activity against COMT obtained from rat liver, and the inhibition kinetics were examined with regard to the binding sites of cofactor and substrate. One of the designed molecules was found to be a bisubstrate inhibitor of COMT with an IC50 = 2 microM. It exhibits competitive kinetics for the SAM and noncompetitive kinetics for the catechol binding site. Useful structure-activity relationships were established which provide important guidelines for the design of future generations of bisubstrate inhibitors of COMT.

Ectopic ossification following total hip arthroplasty: is diffuse idiopathic skeletal hyperostosis a risk factor?

Total hip arthroplasty may be followed by ectopic bone formation. An increased frequency has been suspected in patients with diffuse idiopathic skeletal hyperostosis (DISH). In 204 patients we found that, of the 38 subjects with pre-existing DISH, 29% developed postoperative ossification compared with only 10% in those without DISH (p less than 0.01). DISH is therefore a risk factor for postoperative ectopic bone formation. In a separate study of 1325 patients (not analysed for spinal DISH), we looked for correlations between the severity of postoperative ectopic bone and clinical measurements. Even for the more severe ossification grades (n = 112), only 10% reported serious pain and only 26% had reduced hip flexion (less than 70 degrees). Thus, periprosthetic ectopic bone is not sufficiently important to justify the routine use of preventative drugs such as bisphosphonates in patients with DISH undergoing total hip replacement.