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  • ESPEN Congress Lisbon 2015

    ESPEN diagnostic criteria for malnutritionT. Cederholm (SE)

    ESPEN GUIDELINES

  • DiagnosticCriteriaforMalnutrition AnESPENConsensusStatement

    TheDiagnosisofmalnutritionmissionormissionimposible?

  • Objectives

    Definediagnosticcriteriaformalnutrition Thescienceandpracticeofclinicalnutritionsuffersfromthelackofacleardefinition

    UpdateofICD10

    WorkingGroup:TommyCederholm,IngvarBosaeus,PierreSinger,RoccoBarazzoni,JuergenBauer,AndreVanGossum,MariandevanderSchueren,MaurizioMuscaritoli,IbolyaNyulasi,JohannOchenga,StanislawKlek,StephaneSchneider

  • ESPENBluebookdefinitionofundernutrition

    BasicsinClinicalNutrition,4thEdition2011,p.21

  • Rationale

    Toachievediagnosticcriteriaforthegeneralstateofmalnutritionthatisindependentfrometiologyandclinicalsetting.

    Tounifythelanguage Tofindadiagnosisthatenablescomparisonsbetweencountries,clinicalsettingsetc.

    Thesecriteriadonotreplaceetiologybasedconceptsordefinitions

  • Poll 304ESPENvotesTerminology

    53%malnutrition47% undernutrition

  • Thenutritioncareprocess

    Screening/riskevaluation Assessment Treatment Monitoring

  • Thenutritioncareprocess

    Screening/riskevaluation Assessment

    diagnosis Treatment Monitoring

    Acleardiagnosticprocedurehasbeenmissing

  • Conclusion:Thisstudyshowsthatthereisnofullagreementamongexpertsontheelementsdefiningmalnutrition.Theresultsofthisstudymayfuelthediscussion withinthenutritionalsocieties,whichwillmostideallyleadtoaninternationalconsensusonadefinitionandoperationalismofmalnutrition.

  • ESPENapproachforinternationalconsensus

    A modifiedDelphiprocess: ProjectintroducedESPENWintermeeting(Jan13) ConstitutionoftheConsensusGroup(Feb13) Email,facetofacemeeting(spring/summer13) Questionnaires/ballots/Delphipolls(fall13/winter14) ConsensusstatementFeb2014 GeneralESPENPollspring2014 ClinicalNutritionpublicationspring2015 Validationstudies....

  • Diagnosticcriteriaformalnutrition

    Step2.Diagnosis BMI10% (indefinitetime)/>5% last3mocombinedwitheither BMI

  • Rationale

    Weightloss givesthedynamicdimensionandcovers Anorexia,teethproblems,dysphagia Insufficientfoodintake

    BMI and/orFFM givesstructuralmeasures Functionalandbiochemicalindicatorsaretoounspecific(consensusafterextensivediscussions)

    ESPENMembersPollMay2014

  • ESPENPoll 304votes

    Criteria

    26%

    ~70%8/10agreement

    1=stronglydisagree,...,10=stronglyagree

    1

    5

    8

    10

  • Validationstudies249acutelyill(5818y) 30%wereatriskformalnutrition(SNAQ)14%malnourishedaccordingtoEDC 135outpatientgeriatricsubjects(817y)10%wereatrisk6% malnourishedaccordingtoEDC Healthyold(n=306,743y)andhealthyyoung(n=179,233y);0.5and0%wereatriskand0.5and0%weremalnourishedaccordingtoEDCRojeretal,ClinNutr2015

    335generalhospitalpatients15/19/35%weremalnourishedorcachecticaccordingtoEDC/EvansorFearon.3monthsand1yearmortalitywaswellpredictedonlybyEDCRondeletal.ESPENPoster2015

    632hospitalizedpatientsNRS2002:72%atrisk,48%malnorishedEDC:12%malnourished.RelatedtoLOSAmaraletal.ESPENPoster2104

  • ASPEN/ANDconsensusstatement

    WhiteetalJPEN2012;36:27583

    Etiologybaseddefinition

    Diagnosisofmalnutritionindependentofetiologyandclinicalsetting/ESPEN

    HowtoalignwithourAmericancolleaguesandfriends?

  • ASPEN/ANDconsensusstatement

    WhiteetalJPEN2012;36:27583

    Because nosingleparameterisdefinitiveforadultmalnutrition,theidentificationof2ormoreofthefollowing6characteristicsisrecommendedfordiagnosis:InsufficientenergyintakeWeightlossLossofmusclemassLossofsubcutaneous fatLocalizedorgeneralizedfluidaccumulationthatmaysometimesmaskweightlossDiminishedfunctionalstatusasmeasuredbyhandgripstrength

  • Ongoingissuestodiscuss etiology Nutritiondisordersandnutritionrelatedconditions

    Malnutrition;syn:Undernutrition Diseaserelatedmalnutrition(DRM)

    Cachexia(=inflammatoryinducedDRM) AcutediseaseorInjuryrelatedmalnutrition Chronicdiseaserelatedmalnutrition Cancercachexia

    NoncachecticDRM(=DRMwithoutinflammation)

    Starvation fooddeprivation Sarcopenia Frailty

  • Comingsteps

    Validationstudies... TerminologyGuidelines AlignwithASPEN/AND Reviseifnecessary

    Thestorycontinues...Thanks

  • ASPEN/ANDconsensusstatement

    Maloneetal.NutrClinPract2013

    Notfeasibleinclinicalpractice