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.

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.

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.

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.

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.

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.

Bioelectrical phase angle and impedance vector analysis--clinical relevance and applicability of impedance parameters.

BACKGROUND & AIMS: The use of phase angle (PhA) and raw parameters of bioelectrical impedance analysis (BIA) has gained attention as alternative to conventional error-prone calculation of body composition in disease. This review investigates the clinical relevance and applicability of PhA and Bioelectrical Impedance Vector Analysis (BIVA) which uses the plot of resistance and reactance normalized per height. METHODS: A comprehensive literature search was conducted using Medline identifying studies relevant to this review until March 2011. We included studies on the use of PhA or BIVA derived from tetrapolar BIA in out- and in-patient settings or institutionalized elderly. RESULTS: Numerous studies have proven the prognostic impact of PhA regarding mortality or postoperative complications in different clinical settings. BIVA has been shown to provide information about hydration and body cell mass and therefore allows assessment of patients in whom calculation of body composition fails due to altered hydration. Reference values exist for PhA and BIVA facilitating interpretation of data. CONCLUSION: PhA, a superior prognostic marker, should be considered as a screening tool for the identification of risk patients with impaired nutritional and functional status, BIVA is recommended for further nutritional assessment and monitoring, in particular when calculation of body composition is not feasible.

Effect of sexual dimorphism on muscle strength in cachexia.

BACKGROUND: Reduced muscle strength is a cardinal feature in cachexia. We investigated whether weight loss is associated differently with muscle strength in men and women in a large cohort of hospitalized patients. METHODS: One thousand five hundred hospitalized patients (whereof 718 men, mean age 57.6 ± 16.0 years, mean body mass index (BMI) 24.6 ± 4.8 kg/m²) were included in the study. Non-edematous involuntary weight loss was determined with Subjective Global Assessment; isometric maximal muscle strength was evaluated by hand grip strength. Mid-upper arm circumference and triceps skinfold were used to calculate arm muscle area. Interrelationship between sex and weight loss was evaluated by regression analysis performed with the general linear model (GLM) allowing adjustment for continuous and categorical variables and corrected for age, arm muscle area (AMA), BMI, and diagnosis category (benign/malignant disease) as potentially confounding covariates. RESULTS: Both men and women exhibited a significant stepwise decrease of hand grip strength with increasing weight loss. Age, sex, moderate and severe weight loss, BMI, and AMA were significant predictors of hand grip strength. The GLM moreover revealed a significant sex × weight loss effect, since grip strength was similarly decreased in moderate weight loss in men and women when compared to control patients without weight loss (8.5% in men and 10.5% in women, not significant (n.s.)), but the further reduction of grip strength in severe weight loss was significantly different between men and women (10.6% vs. 4.1%, P = 0.033). CONCLUSIONS: Our findings indicate sex-specific differences in muscle strength response to weight loss.

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.

Hand grip strength: outcome predictor and marker of nutritional status.

BACKGROUND & AIMS: Among all muscle function tests, measurement of hand grip strength has gained attention as a simple, non-invasive marker of muscle strength of upper extremities, well suitable for clinical use. This review outlines the prognostic relevance of grip strength in various clinical and epidemiologic settings and investigates its suitability as marker of nutritional status in cross-sectional as well as intervention studies. METHODS: Studies investigating grip strength as prognostic marker or nutritional parameter in cross-sectional or intervention studies were summarized. RESULTS AND CONCLUSIONS: Numerous clinical and epidemiological studies have shown the predictive potential of hand grip strength regarding short and long-term mortality and morbidity. In patients, impaired grip strength is an indicator of increased postoperative complications, increased length of hospitalization, higher rehospitalisation rate and decreased physical status. In elderly in particular, loss of grip strength implies loss of independence. Epidemiological studies have moreover demonstrated that low grip strength in healthy adults predicts increased risk of functional limitations and disability in higher age as well as all-cause mortality. As muscle function reacts early to nutritional deprivation, hand grip strength has also become a popular marker of nutritional status and is increasingly being employed as outcome variable in nutritional intervention studies.

Cutoff percentiles of bioelectrical phase angle predict functionality, quality of life, and mortality in patients with cancer.

BACKGROUND: The bioelectrical phase angle has shown predictive potential in various diseases, but general cutoffs are lacking in the clinical setting. OBJECTIVES: This study evaluated the prognostic value of the fifth percentile of sex-, age-, and body mass index-stratified phase angle reference values in patients with cancer with respect to nutritional and functional status, quality of life, and 6-mo mortality. In a second step, we also studied the effect of the standardized phase angle (with a z score to determine individual deviations from the population average) on these variables. DESIGN: A total of 399 patients with cancer were studied. Phase angle was obtained with bioelectrical impedance analysis; muscle function was assessed by handgrip strength and peak expiratory flow. Quality of life was determined by the European Organization for Research and Treatment of Cancer questionnaire. Nutritional status was assessed by using Subjective Global Assessment. Survival of patients was documented after 6 mo. RESULTS: Patients with a phase angle of less than the fifth reference percentile had significantly lower nutritional and functional status, impaired quality of life (P lt 0.0001), and increased mortality (P lt 0.001). The standardized phase angle emerged as a significant predictor for malnutrition and impaired functional status in generalized linear model regression analyses. It was also a stronger indicator of 6-mo survival than were malnutrition and disease severity in the Cox regression model (P lt 0.0001) and according to the receiver operating characteristic curve. CONCLUSIONS: The standardized phase angle is an independent predictor for impaired nutritional and functional status and survival. The fifth phase angle reference percentile is a simple and prognostically relevant cutoff for detection of patients with cancer at risk for these factors.

Differences of energy expenditure and physical activity patterns in subjects with various degrees of obesity.

BACKGROUND & AIMS: An imbalance of energy intake and energy expenditure leads to obesity. However, little detailed information of energy expenditure and physical activity patterns in obese subjects is available. Therefore, we assessed total energy expenditure (TEE) with its components resting energy expenditure (REE) and activity thermogenesis (AT) and the patterns of physical activity in non-obese and in subjects with different degrees of obesity. METHODS: TEE and activity pattern were assessed with the SenseWear™ armband in 78 subjects (46 ± 12 years; 28 with normal weight/overweight, 13 each with obesity I° and II°, and 24 with obesity III°). In addition, REE was measured by indirect calorimetry and AT was calculated. RESULTS: Although TEE (and REE) increased with increasing weight category from 2567 (1437) kcal/d in non-obese subjects to 3033 (1931) kcal/d in subjects with obesity III° (p=0.016, p<0.001, respectively) body weight adjusted TEE decreased from 33.1 to 22.1 kcal/kg/d (p<0.001). This was mainly due to decreased body weight adjusted AT (11.3-5.8 kcal/kg/d, p<0.001). AT consisted almost completely of non-exercise AT. In particular, for obese subjects exercise-related AT was negligible. CONCLUSIONS: Higher degrees of obesity are associated with decreased body weight adjusted AT. These differences have to be considered for therapeutic strategies.