European Society Of Parenteral And Enteral Nutrition Research Articles

Editorial introductions.

Editorial introductions.

The relationship between systemic inflammation, body composition and clinical outcomes in patients with operable colorectal cancer at low and medium to high nutritional risk.

Rationale: In accordance with ESPEN (European Society of Parenteral and Enteral Nutrition) guidelines, the combination of malnutrition screening tool (MUST)1, systemic inflammation (mGPS) and body composition (SMI and SMD) were examined in relation to clinical outcomes in patients undergoing surgery for colorectal cancer (CRC).

Editorial introductions

Editorial introductions

Nutrition management of obese critically ill adults: A survey of critical care dietitians in Australia and New Zealand

BackgroundGuideline recommendations for nutrition therapy in critically ill obese adults are inconsistent. This study aimed to describe how dietitians working in an intensive care unit (ICU) in Australia and New Zealand (ANZ) approach managing the nutritional needs of an obese, critically ill adult. MethodsInvitations to participate were via personal email communication. The survey was also disseminated through a research email list and a dietitian-based newsletter. The multiple-choice case-based survey consisted of 12 questions relating to nutrition prescription and were based on international nutrition guideline recommendations including (i) weight used in energy and protein predictive equations; (ii) energy and protein prescription at ICU admission and day 7, (iii) commencement of enteral nutrition, and; (iv) use of supplemental protein. Data are reported as n (%). ResultsSixty-three dietitians participated in the survey. Most commonly, adjusted body weight calculated as ‘weight at BMI 25 kg/m2 + 25% excess weight’ was used in equations to guide energy (44 respondents, 70%) and protein (39 respondents, 62%) prescription. At day 1, energy and protein prescription was most commonly based on the European Society of Parenteral and Enteral Nutrition (ESPEN) guideline recommendation of 20–25 kcal/kg (39 respondents, 62%) and 1.3 g protein/kg adjusted body weight (36 respondents, 57%). Thirteen (21%) respondents had an indirect calorimetry device in their ICU to measure energy expenditure. On day 7, the ESPEN recommendations were again the most common method used for prescribing energy (30 respondents, 48%) and protein (23 respondents. 48%) needs. Thirty-eight dietitians (60%) reported they would use early supplemental protein to meet protein requirements. ConclusionsICU dietitians in ANZ who responded to the survey most commonly report using the ESPEN ICU guideline recommendations (20–25 kcal/kg and 1.3 g protein/kg adjusted body weight) to guide nutrition prescription in an obese critically ill adult. Prospective studies are required to confirm these findings.

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Meeting Minimum ESPEN Energy Recommendations Is Not Enough to Maintain Muscle Mass in Head and Neck Cancer Patients.

The relationship between dietary intake and body composition changes during cancer treatment has not been well characterized. The aim of this study was to compare dietary intake at diagnosis and end of treatment in relation to changes in muscle mass and adiposity in head and neck cancer (HNC) patients. Dietary intakes (three-day food record) and body composition using computed tomography (CT) were assessed at diagnosis (baseline) and after treatment completion (post-treatment). Skeletal muscle (SM) loss was explored as a consequence of energy and protein intake in relation to the minimum and maximum European Society of Parenteral and Enteral Nutrition (ESPEN) guidelines. Higher energy intakes (kcal/kg/day) and increases in energy intake (%) from baseline to post-treatment were correlated with attenuated muscle loss (r = 0.62, p < 0.01; r = 0.47, p = 0.04, respectively). Post-treatment protein intake demonstrated a weak positive correlation (r = 0.44, p = 0.05) with muscle loss, which did not persist when controlling for covariates. Meeting minimum ESPEN energy guidelines (25 kcal/kg/day) did not attenuate SM loss, whereas intakes >30 kcal/kg/day resulted in fewer participants losing muscle. Greater baseline adiposity correlated with greater SM loss (p < 0.001). Energy intakes of 30 kcal/kg/day may be required to protect against SM loss during treatment in HNC patients. The influence of adiposity on SM loss requires further exploration.

Prevalence and predictors of malnutrition in elderly Chinese adults: results from the China Health and Retirement Longitudinal Study.

China has the largest population of elderly citizens in the world, with 177 million adults aged 60 years or older. However, no national estimate of malnutrition in elderly Chinese adults exists. We estimated the prevalence and predictors of malnutrition in this population. Data from the second wave of the Chinese Health and Retirement Longitudinal Study (CHARLS) include interview and biomarker data for 6450 subjects aged 60 years or older from 448 different communities in twenty-eight provinces, allowing for nationally representative results. Malnutrition was identified based on the ESPEN (European Society of Parenteral and Enteral Nutrition and Metabolism) criteria. We used multivariable regression to investigate the predictors of malnutrition, including demographic factors, marital status, self-reported health status, self-reported standard of living, health insurance status and education. China. Community-dwelling Chinese adults aged 60 years or older. The prevalence of malnutrition in elderly Chinese adults was 12·6 %. Malnutrition was most common among those who were older (OR=1·09; 95 % CI 1·07, 1·10), male (OR=1·41; 95 % CI 1·10, 1·79), lived in rural areas (v. urban: OR=0·75; 95 % CI 0·57, 1·00) or lacked health insurance (P<0·01). The burden of malnutrition on elderly Chinese adults is significant. Based on current population estimates, up to 20 million are malnourished. Malnutrition is strongly associated with demographic factors, shows a trend to association with health status and is not strongly associated with standard of living or education. A coordinated effort is needed to address malnutrition in this population.

Clinical application of the basic definition of malnutrition proposed by the European Society for Clinical Nutrition and Metabolism (ESPEN): Comparison with classical tools in geriatric care

BackgroundMalnutrition is a prevalent condition related to adverse outcomes in older people. Our aim was to compare the diagnostic capacity of the malnutrition criteria of the European Society of Parenteral and Enteral Nutrition (ESPEN) with other classical diagnostic tools. MethodsCohort study of 102 consecutive in-patients ≥70 years admitted for postacute rehabilitation. Patients were considered malnourished if their Mini-Nutritional Assessment-Short Form (MNA-SF) score was ≤11 and serum albumin <3 mg/dL or MNA-SF ≤ 11, serum albumin <3 mg/dL, and usual clinical signs and symptoms of malnutrition. Sensitivity, specificity, positive and negative predictive values, accuracy likelihood ratios, and kappa values were calculated for both methods: and compared with ESPEN consensus. ResultsOf 102 eligible in-patients, 88 fulfilled inclusion criteria and were identified as “at risk” by MNA-SF. Malnutrition diagnosis was confirmed in 11.6% and 10.5% of the patients using classical methods,whereas 19.3% were malnourished according to the ESPEN criteria. Combined with low albumin levels, the diagnosis showed 57.9% sensitivity, 64.5% specificity, 85.9% negative predictive value,0.63 accuracy (fair validity, low range), and kappa index of 0.163 (poor ESPEN agreement). The combination of MNA-SF, low albumin, and clinical malnutrition showed 52.6% sensitivity, 88.3% specificity, 88.3%negative predictive value, and 0.82 accuracy (fair validity, low range), and kappa index of 0.43 (fair ESPEN agreement). ConclusionsMalnutrition was almost twice as prevalent when diagnosed by the ESPEN consensus, compared to classical assessment methods: Classical methods: showed fair validity and poor agreement with the ESPEN consensus in assessing malnutrition in geriatric postacute care.

Editorial introductions

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Energy and Protein in Critically Ill Patients with AKI: A Prospective, Multicenter Observational Study Using Indirect Calorimetry and Protein Catabolic Rate.

The optimal nutritional support in Acute Kidney Injury (AKI) still remains an open issue. The present study was aimed at evaluating the validity of conventional predictive formulas for the calculation of both energy expenditure and protein needs in critically ill patients with AKI. A prospective, multicenter, observational study was conducted on adult patients hospitalized with AKI in three different intensive care units (ICU). Nutrient needs were estimated by different methods: the Guidelines of the European Society of Parenteral and Enteral Nutrition (ESPEN) for both calories and proteins, the Harris-Benedict equation, the Penn-State and Faisy-Fagon equations for energy. Actual energy and protein needs were repeatedly measured by indirect calorimetry (IC) and protein catabolic rate (PCR) until oral nutrition start, hospital discharge or renal function recovery. Forty-two patients with AKI were enrolled, with 130 IC and 123 PCR measurements obtained over 654 days of artificial nutrition. No predictive formula was precise enough, and Bland-Altman plots wide limits of agreement for all equations highlight the potential to under- or overfeed individual patients. Conventional predictive formulas may frequently lead to incorrect energy and protein need estimation. In critically ill patients with AKI an increased risk for under- or overfeeding is likely when nutrient needs are estimated instead of measured.

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Recommended European Society of Parenteral and Enteral Nutrition protein and energy intakes and weight loss in patients with head and neck cancer.

Information regarding attenuation of weight loss in patients with head and neck cancer consuming energy and protein intakes at levels recommended by the European Society of Parenteral and Enteral Nutrition (ESPEN) is limited. Newly diagnosed patients with head and neck cancer (n = 38) consuming food orally had weight and 3-day diet records prospectively collected at baseline, the end of treatment, and at the 2.5-month follow-up. Weight loss of patients consuming the ESPEN recommendations of ≥30 kcal/kg/d energy and 1.2 g/kg/d protein versus those consuming less were compared. Weight loss of oral nutrition supplement consumers versus oral nutrition supplement nonconsumers was also compared. Despite ≥30 kcal/kg/d intakes at posttreatment and follow-up, mean weight loss was 10.3% from baseline to posttreatment, and 4.0% from posttreatment to follow-up. At posttreatment, oral nutrition supplement consumers with intakes ≥30 kcal/kg/d lost twice as much weight as nonconsumers with intakes of ≥30 kcal/kg/d (p = .001). Current ESPEN recommendations may not attenuate weight loss in patients with head and neck cancer, especially those consuming oral nutrition supplements. © 2016 Wiley Periodicals, Inc. Head Neck 38:1248-1257, 2016.

Malnutrition in Long-term Hospitalized Patients

Anahtar kelimeler: malnutrisyon; beslenme; hemsirelik bakimi The European Society of Parenteral and Enteral Nutrition (ESPEN) makes important distinctions in the definition of malnutrition, to differentiate the terms “cachexia”,“sarcopenia” and “malnutrition”. Cachexia which is a multi-factor syndrome chacracterized by severe loss of body weight, fat and muscle is mostly displayed as increased protein catabolism. The malnutrition is in hospitalized patients may be accompanied by cachexia (illness-associated) but also be unaccompanied3.

The Current Role of Parenteral Nutrition in the Hospitalized Patient

The role of early versus late initiation of total parenteral nutrition in critically ill patients is a topic of debate among nutrition experts. The European Society of Parenteral and Enteral Nutrition (ESPEN) recommends that all patients who are not expected to be on normal nutrition within 3 days of ICU admission should receive parenteral nutrition (PN) within 24–48 h if enteral nutrition (EN) is contraindicated or if they cannot tolerate EN. The American Society of Parenteral and Enteral Nutrition (ASPEN) guidelines recommend that if early EN is not feasible or available the first 7 days following admission to the ICU, no supplemental PN support therapy should be provided. Since the release of these guidelines, several large multi-center trials have been published that may alter the previously published recommendations. With the anticipated release of the new ASPEN guidelines, a number of recent studies will not be evaluated since the cut-off for the inclusion of new studies was December 31, 2013. The current article reviews both the ESPEN and ASPEN guidelines for the recommendation of PN support in critically ill adult patients and reviews large multi-center studies that were performed since these guidelines were published.

PTH-194 Palliative home parenteral nutrition (HPN) – tertiary gi oncology centre audit of practice

<h3>Introduction</h3> The European Society of Parenteral and Enteral Nutrition (ESPEN) guidelines state that “in intestinal failure (IF), long term PN should be offered if enteral nutrition is insufficient, expected survival due to tumour progression is longer than 2–3 months, it is expected that HPN can stabilise or improve performance status and quality of life and the patient desires this mode of nutrition support”. This study aims to review current practice in the prescribing patterns of palliative HPN, following publication of the guidelines. <h3>Method</h3> Retrospective casenote review of patients with cancer set up on HPN, between May 2011 and February 2015. GSTT is a tertiary GI oncology and regional IF centre. <h3>Results</h3> There were 12 patients (10 male, 2 female) set up on HPN, and one on Home IV fluids, within the 45 months period. One patient died awaiting HPN but had received PN at his local hospital prior to transfer. The majority of patients had primary GI cancer (12/13). The median age was 51 years (range 26–70 years). The total length of HPN was 1323 days, with a catheter related blood stream infection rate of 0.8/1000 catheter days. The median length on HPN was 86 days (range 1–310 days). Mortality is 62%, with a median of 37 days HPN (range 0–111 days). Chemotherapy was administered concurrently with HPN in 62%. There has been an increase in patient numbers, with 4 started in the first 3 years, and a further 9 patients set up over the last 9 months. This indicates a growing awareness and utilisation of palliative TPN. <h3>Conclusion</h3> The overall median length of HPN was 86 days, in keeping with the ESPEN guidelines of expected survival of longer than 60 days. We appear to be using HPN appropriately and are improving patient selection. There is anticipated increasing demand for HPN in the palliative setting, necessitating appropriate resource allocation regionally. <h3>Disclosure of interest</h3> None Declared. <h3>Reference</h3> Bozetti F, Arends J, Micklewright A, <i>et al</i>. ESPEN guidelines on parenteral nutrition: non-surgical oncology. Clin Nutr. 2009;28:445–454

Assessment of nutritional status in the healthcare setting in Spain.

Early identification of undernourished patients in the healthcare setting, and their nutritional treatment, are essential if the harmful effects of poor nourishment are to be avoided and care costs kept down. The aim of assessing nutritional status is to determine the general health of a patient from a nutritional viewpoint. All hospitalised patients should undergo nutritional screening within 24-48 h of admission, as should any patient who shows signs of being malnourished when visiting any healthcare centre. The infrastructure and resources available, the possibilities of automisation, and the healthcare setting in which such assessment must be performed, etc., determine which method can be used. The European Society of Parenteral and Enteral Nutrition (ESPEN) recommends the use of the Nutritional Risk Screening-2002 (NRS-2002) method for hospitalised patients, the Malnutrition Universal Screening Tool (MUST) in the community healthcare setting, and the first part of the Mini-Nutritional Assessment (MNA) for elderly patients. In centres where screening can be computerised, the CONUT® or INFORNUT® methods can be used. A nutritional diagnosis is arrived at using the patient's medical history, a physical examination (including anthropometric assessment), biochemical analysis, and functional tests. No single variable allows a diagnosis to be made. The Subjective Global Assessment (SGA) and MNA tests are useful in nutritional assessment, but they are not universally regarded as the gold standard. At our hospital, and at many other centres in the Spanish health system, the Nutritional Status Assessment (NSA) method (in Spanish Valoración del Estado Nutricional) is used, which involves the SGA method, the taking of anthropometric measurements, and biochemical analysis. After making a nutritional diagnosis, which should be included in the patient's medical history adhering to International Classification of Diseases code 9 (ICD- 9), and prescribing a nutritional treatment, the patient should be followed up. No single marker can be used to monitor progress; interpretations will once again require examination of the patient's medical history, the taking of anthropometric measurements and laboratory tests. Depending on whether a patient is ambulatory or hospitalised, the follow-up assessment times and variables measured will differ.

Editorial introductions

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Timing of the initiation of parenteral nutrition in critically ill adults

BackgroundCritical illness in hospitalized patients induces anorexia: aninability to eat suitably, predisposing to nutritional deficit,weakness, infections, increased duration of mechanicalventilation, delayed recovery and death [1]. To date,whether artificial nutritional support improves outcomesfor critically ill patients is unclear. Enteral nutrition isassociated with fewer complications than parenteral nutri-tion, and is less expensive [2], but enteral nutrition alonedoes not often achieve caloric targets. Combining paren-teral and enteral nutrition could prevent nutritional deficit.However, this strategy may carry the risk of overfeeding,which has been associated with complications such as liverdysfunction [3]. Current clinical practice guidelines fornutritional support in critically ill patients are largely basedon expert opinion, and differ substantially across conti-nents, in particular about the timing to start parenteralnutrition. The European Society of Parenteral and EnteralNutrition (ESPEN) recommends the commencement ofparenteral nutrition within 2 days after admission to theintensive care unit (ICU) for patients who cannot be ade-quately fed enterally [4], while the American and Canadianguidelines recommend early initiation of enteral nutrition,but suggest starting parenteral nutrition after a week inpatients who are not malnourished at baseline [5].SummaryCasaer and coworkers [6] in a randomized, multicenter trial,comparedanearlytoalateinitiationofparenteralnutritioninadults admitted to the ICU who were not malnourished atbaseline [body-mass index (BMI) of C17] in order to sup-plement insufficient enteral nutrition. The primary endpoints were the number of days spent in ICU (for survivorsand non-survivors), and the time to discharge from the ICU.In 2,312 patients, parenteral nutrition was initiated within48 h after ICU admission, whereas in 2,328 patients, it wasnot initiated before the eighth day from admission. ThemedianstayintheICUwas1 dayshorterinthelate-initiationgroup than in the early-initiation group (3 vs. 4 days,respectively, P = 0.02), which was reflected in a relativeincrease of 6.3% of the likelihood of earlier discharge alivefrom the ICU [hazard ratio 1.06, 95% confidence interval(CI), 1.00–1.13, P = 0.04]. Considering the secondary out-comes, patients in the late-initiation group had fewer healthassistance related infections (22.8 vs. 26.2%, P = 0.008), alowerincidenceofcholestasis(32.6vs.38.4%,P\0.001),areduction in the proportion of patients requiring more than2 days of mechanical ventilation (36.3 vs. 40.2%,P = 0.006), a median reduction of 3 days in the duration ofrenal replacement therapy (7 vs. 10 days, P = 0.008) and areduction in mean health care costs of €1,110 as comparedwith the early-initiation group (€16863 vs. €17973,P = 0.04). The safety outcomes (in-hospital mortality rates,survival at 90 days, rates of nutrition-related complications)weresimilarinthetwogroups,buthypoglycaemiawasmorecommon in the late-initiation group patients (3.5 vs. 1.9%,P = 0.001). Although enteral nutrition was initiated if pos-sible in the majority of patients, the post hoc subgroupanalyses including patients for whom early enteral nutritionwas contraindicated showed the same results.

Evidence based practice guidelines for the nutritional management of malnutrition in adult patients across the continuum of care

Evidence based practice guidelines for the nutritional management of malnutrition in adult patients across the continuum of care