Diagnosis of malnutrition in patients with gastrointestinal diseases: recent observations from a Global Leadership Initiative on Malnutrition perspective.

PURPOSE OF REVIEW: To review recent reports on techniques and tools for screening and diagnosis of malnutrition in gastrointestinal disease, in the light of the newly published definition of malnutrition by the Global Leadership Initiative on Malnutrition (GLIM). RECENT FINDINGS: In 2019, the GLIM concept of malnutrition was published advocating a two-step procedure; first, screening, and second confirmation of the diagnosis that requires a combination of phenotypic and etiologic criteria. Three studies in patients with gastrointestinal disorders so far published utilize the GLIM criteria. Otherwise, traditional tools, as Nutrition Risk Screening-2002, Malnutrition Universal Screening Tool or Subjective Global Assessment are used, and confirm that malnutrition is observed in a substantial number of patients with inflammatory bowel diseases (IBDs), serious liver disorders and various forms of pancreatitis. Common for these disorders is an extensive loss of muscle mass, which is one of the GLIM phenotypic criteria. Such patients often undergo abdominal computed tomography scans that enable psoas muscle mass at L3 or L4 level to be calculated. SUMMARY: The GLIM criteria for the diagnosis of malnutrition are feasible for IBD, liver and pancreas diseases. Pending studies expect to provide data on the clinical relevance to diagnose malnutrition by the GLIM concept.

Clinical nutrition in primary care: ESPEN position paper.

Primary care healthcare professionals (PCHPs) are pivotal in managing chronic diseases and present a unique opportunity for nutrition-related disease prevention. However, the active involvement of PCHPs in nutritional care is limited, influenced by factors like insufficient education, lack of resources, and time constraints. In this position paper The European Society for Clinical Nutrition and Metabolism (ESPEN) promotes the active engagement of PCHPs in nutritional care. We emphasize the importance of early detection of malnutrition by screening and diagnosis, particularly in all individuals presenting with risk factors such as older age, chronic disease, post-acute disease conditions and after hospitalization for any cause. ESPEN proposes a strategic roadmap to empower PCHPs in clinical nutrition, focusing on education, tools, and multidisciplinary collaboration. The aim is to integrate nutrition into medical curricula, provide simple screening tools for primary care, and establish referral pathways to address malnutrition systematically. In conclusion, we urge for collaboration with PCHP organizations to raise awareness, enhance nutrition skills, facilitate dietitian accessibility, establish multidisciplinary teams, and promote referral pathways, thereby addressing the underestimated clinical challenge of malnutrition in primary care.

Guidance for assessment of the inflammation etiologic criterion for the GLIM diagnosis of malnutrition: A modified Delphi approach.

BACKGROUND & AIMS: The Global Leadership Initiative on Malnutrition (GLIM) approach to malnutrition diagnosis is based on assessment of three phenotypic (weight loss, low body mass index, and reduced skeletal muscle mass) and two etiologic (reduced food intake/assimilation and disease burden/inflammation) criteria, with diagnosis confirmed by fulfillment of any combination of at least one phenotypic and at least one etiologic criterion. The original GLIM description provided limited guidance regarding assessment of inflammation and this has been a factor impeding further implementation of the GLIM criteria. We now seek to provide practical guidance for assessment of inflammation in support of the etiologic criterion for inflammation. METHODS: A GLIM-constituted working group with 36 participants developed consensus-based guidance through a modified-Delphi review. A multi-round review and revision process served to develop seven guidance statements. RESULTS: The final round of review was highly favorable with 99 % overall "agree" or "strongly agree" responses. The presence of acute or chronic disease, infection or injury that is usually associated with inflammatory activity may be used to fulfill the GLIM disease burden/inflammation criterion, without the need for laboratory confirmation. However, we recommend that recognition of underlying medical conditions commonly associated with inflammation be supported by C-reactive protein (CRP) measurements when the contribution of inflammatory components is uncertain. Interpretation of CRP requires that consideration be given to the method, reference values, and units (mg/dL or mg/L) for the clinical laboratory that is being used. CONCLUSION: Confirmation of inflammation should be guided by clinical judgement based upon underlying diagnosis or condition, clinical signs, or CRP.

Guidance for assessment of the inflammation etiologic criterion for the GLIM diagnosis of malnutrition: A modified Delphi approach.

BACKGROUND: The Global Leadership Initiative on Malnutrition (GLIM) approach to malnutrition diagnosis is based on assessment of three phenotypic (weight loss, low body mass index, and reduced skeletal muscle mass) and two etiologic (reduced food intake/assimilation and disease burden/inflammation) criteria, with diagnosis confirmed by fulfillment of any combination of at least one phenotypic and at least one etiologic criterion. The original GLIM description provided limited guidance regarding assessment of inflammation, and this has been a factor impeding further implementation of the GLIM criteria. We now seek to provide practical guidance for assessment of inflammation. METHODS: A GLIM-constituted working group with 36 participants developed consensus-based guidance through a modified Delphi review. A multiround review and revision process served to develop seven guidance statements. RESULTS: The final round of review was highly favorable, with 99% overall "agree" or "strongly agree" responses. The presence of acute or chronic disease, infection, or injury that is usually associated with inflammatory activity may be used to fulfill the GLIM disease burden/inflammation criterion, without the need for laboratory confirmation. However, we recommend that recognition of underlying medical conditions commonly associated with inflammation be supported by C-reactive protein (CRP) measurements when the contribution of inflammatory components is uncertain. Interpretation of CRP requires that consideration be given to the method, reference values, and units (milligrams per deciliter or milligram per liter) for the clinical laboratory that is being used. CONCLUSION: Confirmation of inflammation should be guided by clinical judgment based on underlying diagnosis or condition, clinical signs, or CRP.

Determinants of bioelectrical phase angle in disease.

Phase angle (PhA), a parameter of bioelectrical impedance analysis, is a well-known predictor of morbidity and mortality in various diseases. The causes of decreased PhA are, however, not yet completely understood. We therefore investigated determinants of PhA in 777 hospitalised patients in a retrospective analysis. PhA was assessed by bioelectrical impedance analysis at 50 KHz. Subjective global assessment (SGA) was used to evaluate nutritional status. Age, sex, BMI as well as nutritional status (SGA), benign or malignant disease and C-reactive protein (CRP) were investigated as potential determinants of PhA and standardised PhA (SPhA) = (observed PhA - mean PhA of reference values)/standard deviation of reference values in a general linear model regression analysis. Next to age (estimated effect size, 46·6%; P<0·0001), malnutrition (39·1%; P<0·0001) emerged as a major PhA determinant in our study population. Moreover, sex (6·4%; P<0·0001), CRP (4·4%; P<0·0001) and BMI (3·5%; P < 0·0001) exhibited a significant influence on PhA, whereas malignant disease showed no significant effect in this model. The only significant determinants of SPhA were malnutrition (85·4%; P<0·0001) and inflammation (9·6 %; P<0·0001). In conclusion, next to the established predictors, malnutrition and inflammation have a strong impact on PhA in sick individuals, which partly explains its prognostic power. When investigating the SPhA, only malnutrition and inflammation were found to be significant predictors, as a result of which the SPhA is considered a more suitable indicator of nutritional and health status.

Clinical experiences derived from implementation of an easy to use concept for treatment of wound healing by secondary intention and guidance in selection of appropriate dressings.

The main objective of this case-cohort-type observational study conducted at different Surgical Departments of the Charité-Universitätsmedizin in Berlin was to evaluate the sequential use concept first described by Systagenix Wound Management in 2007. Fifty-two patients with different wound healing by secondary intention were treated for 7 weeks at the Charité-Universitätsmedizin in Berlin. A multidisciplinary team worked together to reach consensus in wound assessment; in classification of infection status according to the criteria described by European Wound Management Association (EWMA); in treatment protocol and on dressings to be used to 'cover' wounds. Before dressing application, all wounds were cleaned from debris. Following the sequential use concept, wounds classified as stages 2 and 3 were dressed with SILVERCEL(®) and TIELLE(®) or TIELLE PLUS(®) to 'clean' the wounds. After 2-3 weeks, treatment was changed to PROMOGRAN PRISMA(®) and TIELLE(®) to 'close and cover' wounds, thus providing optimal wound healing. Wounds classified as non infected were dressed with PROMOGRAN PRISMA(®) and TIELLE(®) during the complete treatment period. Patients were asked to evaluate the treatment using a simplified questionnaire developed at the Charité-Universitätsmedizin in Berlin. Wounds comprised 37 surgical procedures, 8 chronic mixed ulcer, 4 pressure sores, 1 diabetic foot ulcer, 1 venous leg ulcer, and 1 mixed arterial/venous ulcer. At baseline, 12 wounds were classified as stage 3, 38 wounds as stage 2 and 2 wounds as stage 1. After 7 weeks of treatment, all patients showed a positive clinical response to the sequential use treatment. Results of wound size showed a high significant progression of wound healing expressed with a profound reduction of wound area (P in all measurements <0·001, chi-square test) and improved granulation. This study summarises the clinical experiences derived from the evaluation of the sequential use concept in the daily clinical practice of wound treatment. On the basis of the wound healing results, patients' evaluation of treatment and the clinicians' and staff experiences, this concept was implemented at different Surgical Departments of the Charité-Universitätsmedizin in Berlin.

Malnutrition in Older Adults-Recent Advances and Remaining Challenges.

Malnutrition in older adults has been recognised as a challenging health concern associated with not only increased mortality and morbidity, but also with physical decline, which has wide ranging acute implications for activities of daily living and quality of life in general. Malnutrition is common and may also contribute to the development of the geriatric syndromes in older adults. Malnutrition in the old is reflected by either involuntary weight loss or low body mass index, but hidden deficiencies such as micronutrient deficiencies are more difficult to assess and therefore frequently overlooked in the community-dwelling old. In developed countries, the most cited cause of malnutrition is disease, as both acute and chronic disorders have the potential to result in or aggravate malnutrition. Therefore, as higher age is one risk factor for developing disease, older adults have the highest risk of being at nutritional risk or becoming malnourished. However, the aetiology of malnutrition is complex and multifactorial, and the development of malnutrition in the old is most likely also facilitated by ageing processes. This comprehensive narrative review summarizes current evidence on the prevalence and determinants of malnutrition in old adults spanning from age-related changes to disease-associated risk factors, and outlines remaining challenges in the understanding, identification as well as treatment of malnutrition, which in some cases may include targeted supplementation of macro- and/or micronutrients, when diet alone is not sufficient to meet age-specific requirements.

Nutritional status as marker for disease activity and severity predicting mortality in patients with systemic sclerosis.

OBJECTIVE: To assess and analyse nutritional status in patients with systemic sclerosis (SSc) and identify possible associations with clinical symptoms and its prognostic value. METHODS: Body mass index (BMI) and parameters of bioelectrical impedance analysis (BIA) were assessed in 124 patients with SSc and 295 healthy donors and matched for sex, age and BMI for comparisons. In patients with SSc, BMI and BIA values were compared with clinical symptoms in a cross-sectional study. In a prospective open analysis, survival and changes in the nutritional status and energy uptake induced by nutritional treatment were evaluated. RESULTS: Patients with SSc had reduced phase angle (PhA) values, body cell mass (BCM), percentages of cells, increased extracellular mass (ECM) and ECM/BCM values compared with healthy donors. Malnutrition was best reflected by the PhA values. Of the patients with SSc, 69 (55.7%) had malnutrition that was associated with severe disease and activity. As assessed by multivariate analysis, low predicted forced vital capacity and high N-terminal(NT)-proBNP values discriminated best between good and bad nutritional status. Among different clinical parameters, low PhA values were the best predictors for SSc-related mortality. BMI values were not related to disease symptoms or mortality. Fifty per cent of patients with SSc had a lower energy uptake related to their energy requirement, 19.8% related to their basal metabolism. Nutritional treatment improved the patients' nutritional status. CONCLUSIONS: In patients with SSc, malnutrition is common and not identified by BMI. BIA parameters reflect disease severity and provide best predictors for patient survival. Therefore, an assessment of nutritional status should be performed in patients with SSc.

A simple remote nutritional screening tool and practical guidance for nutritional care in primary practice during the COVID-19 pandemic.

Challenging periods like the COVID-19 pandemic require fast and efficient adaptations of the healthcare system. It is vital that every patient has access to nutritional care as a part of primary healthcare services, even if social distancing measures are adopted. Therefore, we propose a simple remote nutritional screening tool and practical guidance for nutritional care in primary practice, and their implementation into telemedicine processes and digital platforms suitable for healthcare providers. The acronym for the tool is R-MAPP, as for Remote - Malnutrition APP, while the tool will be available also as an app. This protocol consists of two simple validated clinical tools for identifying nutritional risk and loss of muscle mass and function -Malnutrition Universal Screening Tool ('MUST') and SARC-F (5-item questionnaire: Strength, Assistance with walking, Rise from a chair, Climb stairs and Falls) - and additional practical guidance on nutritional interventions for family physicians.

ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection.

The COVID-19 pandemics is posing unprecedented challenges and threats to patients and healthcare systems worldwide. Acute respiratory complications that require intensive care unit (ICU) management are a major cause of morbidity and mortality in COVID-19 patients. Patients with worst outcomes and higher mortality are reported to include immunocompromised subjects, namely older adults and polymorbid individuals and malnourished people in general. ICU stay, polymorbidity and older age are all commonly associated with high risk for malnutrition, representing per se a relevant risk factor for higher morbidity and mortality in chronic and acute disease. Also importantly, prolonged ICU stays are reported to be required for COVID-19 patients stabilization, and longer ICU stay may per se directly worsen or cause malnutrition, with severe loss of skeletal muscle mass and function which may lead to disability, poor quality of life and additional morbidity. Prevention, diagnosis and treatment of malnutrition should therefore be routinely included in the management of COVID-19 patients. In the current document, the European Society for Clinical Nutrition and Metabolism (ESPEN) aims at providing concise guidance for nutritional management of COVID-19 patients by proposing 10 practical recommendations. The practical guidance is focused to those in the ICU setting or in the presence of older age and polymorbidity, which are independently associated with malnutrition and its negative impact on patient survival.

Global Leadership Initiative on Malnutrition (GLIM): Guidance on Validation of the Operational Criteria for the Diagnosis of Protein-Energy Malnutrition in Adults.

BACKGROUND: The Global Leadership Initiative on Malnutrition (GLIM) created a consensus-based framework consisting of phenotypic and etiologic criteria to record the occurrence of malnutrition in adults. This is a minimum set of practicable indicators for use in characterizing a patient/client as malnourished, considering the global variations in screening and nutrition assessment, and to be used across different healthcare settings. As with other consensus-based frameworks for diagnosing disease states, these operational criteria require validation and reliability testing, as they are currently based solely on expert opinion. METHODS: Several forms of validation and reliability are reviewed in the context of GLIM, providing guidance on how to conduct retrospective and prospective studies for criterion and construct validity. RESULTS: There are some aspects of GLIM that require refinement; research using large databases can be employed to reach this goal. Machine learning is also introduced as a potential method to support identification of the best cut points and combinations of indicators for use with the different forms of malnutrition, which the GLIM criteria were created to denote. It is noted as well that validation and reliability testing need to occur in a variety of sectors and populations and with diverse persons using GLIM criteria. CONCLUSION: The guidance presented supports the conduct and publication of quality validation and reliability studies for GLIM.

Hepatic 11beta-HSD1 mRNA expression in fatty liver and nonalcoholic steatohepatitis.

CONTEXT: Nonalcoholic fatty liver disease represents the hepatic manifestation of the metabolic syndrome. Nonalcoholic steatohepatitis (NASH) is the progressive form of liver injury. The pathophysiology that leads to NASH is not well understood. OBJECTIVE: We hypothesize that an altered cortisol metabolism in the liver may be a pathogenetic factor. DESIGN AND PATIENTS: 75 patients (28 men, 47 women) underwent liver biopsy for elevation in liver enzymes. Histological diagnosis identified normal liver in eight, fatty liver in 20, NASH grade 1 in 22, grade 2 in nine, grade 3 in three patients, and other forms of hepatitis or cirrhosis in 13 patients. We quantified hepatic 11beta-hydroxysteroid dehydrogenase type1 (11beta-HSD1) and hexose-6-phosphate-dehydrogenase (H6PDH) mRNA expression by real-time PCR. In addition, analysis of 24 h urinary excretion of cortisol metabolites using GCMS was performed and compared with healthy controls. RESULTS: 11beta-HSD1 mRNA expression correlated significantly (R2= 0.809; P < 0.001) with H6PDH mRNA expression, negatively with waist-to-hip ratio in women (R2= 0.394; P= 0.005), but not with urinary (THF + 5alpha-THF)/THE ratio, total cortisol metabolite excretion, age, BMI, degree of fatty liver or NASH stages. Total cortisol metabolite excretion was increased in patients with fatty liver or NASH compared with healthy controls. CONCLUSIONS: Our data suggest that expression of hepatic 11beta-HSD1 and H6PDH are closely interlinked. 11beta-HSD1 gene expression does not seem to be involved in the pathogenesis of fatty liver or NASH. However, those patients showed an increased 5alpha- and 5beta-reduction of cortisol leading to an increased cortisol turnover rate and an activation of the HPA axis.

Malnutrition and depression in the institutionalised elderly.

Malnutrition and depression are highly prevalent in the institutionalised elderly and can lead to unfavourable outcomes. The aim of the present study was to assess associations between nutritional status and depressive symptoms and to explore their impact on self-caring capacity and quality of life (QoL) in elderly nursing-home residents (NHR). We conducted a cross-sectional study with 114 NHR (eighty-six female) with a mean age of 84.6 (sd 9.1) years. Nutritional status was assessed with the Mini Nutritional Assessment (MNA). Depressive symptoms were rated with the Geriatric Depression Scale (GDS). Self-caring capacity was measured with the Barthel index (BI) and QoL was assessed with the short-form thirty-six-item (SF-36) questionnaire. Of the NHR, twenty-six (22.8 %) were malnourished according to the MNA and sixty-six (57.9 %) were at nutritional risk. Of the residents, seventy-five could be assessed with the GDS, whereof sixteen (21.3 %) had major and twenty-six (34.7 %) had minor depressive symptoms. GDS scores tended to be higher in patients with impaired nutritional status (5.4 (sd 3.6) in well-nourished subjects and 6.9 (sd 3.2) in residents with malnutrition or at risk of malnutrition). The MNA correlated significantly with the GDS (r - 0.313; P = 0.006) and the GDS emerged as the only independent risk factor for malnutrition in a multiple regression analysis, whereas age, sex, care level, number of prescriptions and self-caring capacity had no influence. The BI was not reduced in patients with a high GDS. QoL was affected in malnourished residents as well as in study participants with depressive symptoms. The results of the present study point towards an association between malnutrition and depressive symptoms. However, the relationship is complex and it remains unclear whether depression in NHR is the cause or consequence of impaired nutritional status. Further studies are needed to identify the direction of this relationship and to assess the effect of depression treatment on nutritional and functional status as well as on QoL.

Nutrition education in medical schools (NEMS). An ESPEN position paper.

BACKGROUND & AIMS: Nutrition education is necessary in the training of healthcare professionals, including medical students. However, recent surveys showed that there is a high variability within Medical Schools in different countries. The aim of this ESPEN position paper is to identify a minimum curriculum knowledge in nutrition that serves to improve the training of the future doctors and how to solve the main barriers of its implementation in university centres. METHODS: In 2017, the ESPEN Executive Committee launched the Nutrition Education in Medical Schools (NEMS) Project and formed a core working group including members of the ESPEN Nutrition Education Study Group (NESG) and representatives of several European Medical Schools. This group met in Brussels, on 19th July 2018 and decided to prepare a position paper on this topic. RESULTS: Five main learning objectives and twenty-one topics on human nutrition, within its three domains (basic, applied and clinical nutrition) were identified to be fulfilled at the end of training in all Medical Schools. The experts showed the following key factors for its implementation: establish a nutrition curriculum committee, use different models of integration of the contents in the curriculum (vertical and horizontal), have a multidisciplinary and experienced faculty, incorporate a variety of teaching models, and evaluate the programme periodically. CONCLUSIONS: Nutrition Education is necessary and should be mandatory in all Medical Schools. This position paper aims at improving this gap knowledge and gives some clues for a successful implementation of the changes in the medical curriculum at university centres.

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

BACKGROUND: This initiative aims to build a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings. METHODS: The Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications. RESULTS: A 2-step approach for the malnutrition diagnosis was selected, that is, first screening to identify at risk status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among GLIM participants that selected 3 phenotypic criteria (non-volitional weight loss, low body mass index, and reduced muscle mass) and 2 etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least 1 phenotypic criterion and 1 etiologic criterion should be present. Phenotypic metrics for grading severity are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories. CONCLUSIONS: A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The construct should be re-considered every 3-5 years.

Disease-related malnutrition but not underweight by BMI is reflected by disturbed electric tissue properties in the bioelectrical impedance vector analysis.

The calculation of body composition using bioelectrical impedance analysis in sick and hospitalized patients is hampered due to altered hydration state. We wanted to investigate how disease-related malnutrition assessed by the Subjective Global Assessment (SGA) is reflected in the bioelectrical impedance vector analysis. Patients with benign gastrointestinal disease (n 242) were entered in the study. Nutritional status was assessed by SGA. Arm muscle and fat area were estimated by anthropometry, muscle function was determined by hand grip strength. Whole body impedance measurements were made at 50 kHz. Ninety-eight patients were considered well nourished (SGA A), ninety-four were classified moderately malnourished (SGA B) and fifty patients were classified severely malnourished (SGA C) according to the SGA. The mean vector was significantly displaced between SGA C and SGA A and B, showing comparable resistance with a significantly reduced reactance, indicating comparable hydration but loss of dielectrical mass of soft tissues. This distinctive vector migration was not seen when studying the patients grouped according to BMI. In conclusion, disease-related malnutrition as assessed by the SGA is associated with a distinctive bioelectrical vector migration, implying that abnormal tissue structure and not reduced body mass only occurs in disease-related malnutrition. These disturbances are not seen in underweight according to BMI. Bioelectrical impedance vector analysis appears to be an attractive tool to identify disease-related malnutrition and to monitor nutritional intervention.

Effects of food fortification on nutritional and functional status in frail elderly nursing home residents at risk of malnutrition.

OBJECTIVE: Malnutrition is a frequent problem in the elderly and is associated with an impaired functional status and higher morbidity and mortality. In this study we evaluated the effect of a 12-wk nutritional intervention with fortified food on nutritional and functional status in nursing home residents at risk of malnutrition. METHODS: Nutritional status was assessed with the Mini Nutritional Assessment. Body composition was measured with bioelectrical impedance analysis. Functional status was assessed with handgrip strength, peak flow, the Barthel Index, and the Physical Functioning component of the Short Form 36 questionnaire. The residents were assigned to a group receiving the standard food of the nursing home or a group with a protein- and energy-enriched diet and snacks. RESULTS: Sixty-five nursing home residents were included; 62 were at nutritional risk and 3 were severely malnourished according to the Mini Nutritional Assessment. Protein intake was significantly higher in the group on the enriched diet, whereas energy intake did not differ from the group on the standard diet. Both groups significantly improved most nutritional and body composition parameters during the intervention period. We did not observe convincing improvements in muscle function. Furthermore, the Barthel Index and the Physical Functioning component of the Short Form 36 questionnaire declined in all participants. CONCLUSION: Standard food in this nursing home provided sufficient energy and macronutrients. Provision of snacks was not effective in increasing energy intake. Although nutritional status improved, functional status did not increase as a consequence. Functional frailty in this study population seems to be influenced more by age-related morbidity and immobilization than by nutritional intake.

Malnutrition and impaired muscle strength in patients with Crohn's disease and ulcerative colitis in remission.

OBJECTIVE: This prospective, controlled, and multicentric study evaluated nutritional status, body composition, muscle strength, and quality of life in patients with inflammatory bowel disease in clinical remission. In addition, possible effects of gender, malnutrition, inflammation, and previous prednisolone therapy were investigated. METHODS: Nutritional status (subjective global assessment [SGA], body mass index, albumin, trace elements), body composition (bioelectrical impedance analysis, anthropometry), handgrip strength, and quality of life were assessed in 94 patients with Crohn's disease (CD; 61 female and 33 male, Crohn's Disease Activity Index 71 +/- 47), 50 patients with ulcerative colitis (UC; 33 female and 17 male, Ulcerative Colitis Activity Index 3.1 +/- 1.5), and 61 healthy control subjects (41 female and 20 male) from centers in Berlin, Vienna, and Bari. For further analysis of body composition, 47 well-nourished patients with inflammatory bowel disease were pair-matched by body mass index, sex, and age to healthy controls. Data are presented as median (25th-75th percentile). RESULTS: Most patients with inflammatory bowel disease (74%) were well nourished according to the SGA, body mass index, and serum albumin. However, body composition analysis demonstrated a decrease in body cell mass (BCM) in patients with CD (23.1 kg, 20.8-28.7, P = 0.021) and UC (22.6 kg, 21.0-28.0, P = 0.041) compared with controls (25.0 kg, 22.0-32.5). Handgrip strength correlated with BCM (r = 0.703, P = 0.001) and was decreased in patients with CD (32.8 kg, 26.0-41.1, P = 0.005) and UC (31.0 kg, 27.3-37.8, P = 0.001) compared with controls (36.0 kg, 31.0-52.0). The alterations were seen even in patients classified as well nourished. BCM was lower in patients with moderately increased serum C-reactive protein levels compared with patients with normal levels. CONCLUSION: In CD and UC, selected micronutrient deficits and loss of BCM and muscle strength are frequent in remission and cannot be detected by standard malnutrition screening.

Is bioelectrical impedance vector analysis of value in the elderly with malnutrition and impaired functionality?

OBJECTIVE: The calculation of body composition using bioelectrical impedance analysis is difficult in the elderly because most equations have been found to be inadequate, especially in the malnourished elderly. We therefore evaluated the use of bioelectrical impedance vector analysis in elderly nursing home residents. METHODS: One hundred twelve nursing home residents were included in the study (34 men, 78 women, age 85.1 y, age range 79.1-91.4 y). Nutritional status was determined by the Mini Nutritional Assessment (MNA), functional status was assessed by handgrip strength, knee extension strength, and Barthel's index, and bioelectrical impedance analysis was performed using Nutriguard M (Data Input, Darmstadt, Germany). RESULTS: Twenty-two nursing home residents were classified as well nourished (MNA I), 80 were considered to be at nutritional risk (MNA II), and 10 were classified as malnourished (MNA III). Handgrip strength, knee extension strength, and Barthel's index were lower in MNA II and MNA III than in MNA I. Phase angle also decreased significantly with the MNA (4.0, 3.8-4.7 degrees; 3.7, 3.3-4.3 degrees; and 2.9, 2.6-3.5 degrees). There was a significant displacement of the mean vector in MNA II and MNA III compared with MNA I. CONCLUSION: The bioelectrical impedance vector analysis resistance/reactance graph could represent a valuable tool to assess changes in body cell mass and hydration status in elderly nursing home residents.