ESPEN Nutritional Support Recommendations

1 ESPEN Congress Istanbul 2006A Patient's Journey through Complicated PancreatitisESPEN Nutritional Support RecommendationsR. Meyer (Switzerland) ESPEN ESPEN -- Nutritional Support Nutritional Support RecommendationsRecommendations(An Evidence based Approach and the (An Evidence based Approach and the Application in Europe)Application in Europe)RR mymyMeier MDMeier MDAssociate ProfessorAssociate ProfessorUniversity HospitalUniversity HospitalLiestalLiestal, Switzerland, SwitzerlandESPENESPEN--FELANPE Symposium Istanbul 2006 FELANPE Symposium Istanbul 2006 NutritionalNutritionaldeficienciesdefici enciesand and malnutritionmalnutritionarearea a significantsignificantproblemproblemin in clinicalclinicalpracticepracticePrevalen cePrevalenceof of MalnutritionMalnutrition ambulatoryambulatoryoutpatientsoutpatien ts11--15%15% institutionalizedinstitutionalizedpatien tspatients2525--60%60% hospitalizedhospitalizedpatientspatients 3535--65%65%Omran et al, Nutrition 2000 ConsequencesConsequencesof of MalnutritionMalnutritionPoorPoornutritio nalnutritionalstatusstatusreflectsreflec tsthetherate ofrate of inin--hospitalhospitalcomplicationscompl ications lengthlengthof of hospitalhospitalstaystay mortalitymortality costscosts rere--admissionsadmissionsRCT: RCT.

2 Complications andComplications andmortalitymortalityMeta-analysis of 27 RCTs with 1710 patients (complications) and 30 RCTs with 3250 patients (mortality)Neurology, GI disease, liver disease, malignant disease, elderly, abdominal surgery, orthopaedic surgery, critical illness/injury, Hospital ororcommunitycommunityOral supplements Oral supplements orortube tube feedingfeedingComplicationsComplications 28%28%vs. vs. 46%46%1)1)InfectionsInfections24%24%vs. vs. 44%44%2)2)MortalityMortality17 %17 %vs. vs. 24%24%1)1)1)P < ; 2)10 RCTs onlyStratton RJ, Green CJ, Elia M. Disease-related malnutrition. CABI Publishing 2003 CostsCosts1 hospital 1 hospital day day = = 250; 1 250; 1 complicationcomplication= = 8080 NNLOSLOSNNCompCompTotal, Total, Per Per ptpt, , Not atNot at--riskrisk28482848663353354,2984,2981, 5091,509 AtAt--riskrisk13121312994094092,9842,984 2,2752,275 TotalTotal416041607,2837,283 Extra cost Extra cost per per at riskat riskpatient: patient: 766766 Stratton RJ, Green CJ, Elia M.

3 Disease-related malnutrition. CABI Publishing 2003 Important ImplicationImportant ImplicationThe Nutritional statusThe Nutritional statusmust be known inmust be known inall patientsall patientsESPEN Guidelines ESPEN Guidelines forforNutritionNutritionScreening IScreening I All patientsAll patientsshouldshouldbebescreenedscreened ononadmissionadmissionto to hospitalhospital IfIfthethepatient is at patient is at riskrisk, a , a nutritionnutritionplanplanis is workedworkedout out by by thethestaffstaff MonitoringMonitoringand and definingdefiningoutcome has tooutcome has tobebeorganizedorganized CommunicationCommunicationof of resultsresultsof screening, assessment of screening, assessment and and nutritionnutritioncarecareplans plans shouldshouldbebecommunicatedcommunicated to to otherotherhealthcarehealthcareprofession als professionals whenwhenthethepatient is patient is AuditAuditof of Screening 2002, Clin Nutr Education GuidelinesESPEN Guidelines for ESPEN Guidelines for NutritionNutritionScreening IIScreening is not at patient is not at riskrisk, but , but maymayneedneedto to beberere--screenedscreenedat at specifiedspecifiedintervals, intervals, weeklyweeklyduringduringhospital hospital is at patient is at riskriskand a and a nutritionnutritionplan is plan is workedworkedout by out by is at patient is at riskrisk, but , but metabolicmetabolicororfunctionalfunction alproblems problems preventpreventa standard plan a standard plan is doubtdoubtas as whetherwhetherthethepatient is patient is atat--riskriskScreening is a rapid and simple Screening is a rapid and simple processprocessconductedconductedby by admittingadmittingstaffstaffTheTheoutcom eoutcomeof screening must of screening must bebelinkedlinkedto to defineddefinedcoursescoursesof action:of action.

4 In In thethetwotwolatter cases, latter cases, referralreferralshouldshouldbebemade to an made to an expertexpertfor more for more Screening 2002, Clin Nutr 2003A A completecompletenutritionnutritionassess mentassessmentconsistsconsistsof a of a combinationcombinationof of subjectivesubjectiveand and objectiveobjectiveparametersparametersbu tbutno no singlesingleparameterparameterhas has beenbeenshownshownto to bebeusefulusefulin all in all patientspatients A A nutritionalnutritionalassessmentassessme ntparameterparametershouldshouldbebehigh lyhighlysensitive and sensitive and specificspecific, , unaffectedunaffectedbybyfactorsfactorsun relatedunrelatedto to nutritionnutrition, and , and correlatecorrelatewithwithresponserespon seto to nutritionalnutritionaltherapytherapy Most Most nutritionalnutritionalparametersparamete rslack lack sensitivitysensitivityand and specificityspecificity;;thereforetherefo re, , methodsmethodsof of identifyingidentifyingmalnourishedmalnou rishedpatientspatientsarearenotnotentire lyentirelysatisfactorysatisfactoryAssess mentAssessmentof of thetheNutritionalNutritionalstatusstatus ScreeningScreeningAssessmentAssessmentSc reening is Screening is thetheentryentryto to aastructuredstructuredprocessprocessNutr itionalNutritionalscreeningscreeningIs a tool for rapid and simpleIs a tool for rapid and simpleevaluation of patients at risk ofevaluation of patients at risk ofundernutritionundernutritionNutritiona lNutritionalscreeningscreeningHistoryHis tory:: WeightWeightlosslossoverovertimetime Appetit, Appetit, nauseanausea Food Food intakeintakeFirst First measurementsmeasurements.

5 Body Body weightweight HeightHeightBMIBMIS creeningScreeningtoolstools NutritionalNutritionalRiksRiksIndexIndex 11 SubjectiveSubjectiveglobal assessmentglobal assessment22 MalnutritionMalnutritionUniversal Universal ScreeningScreeningToolTool(MUST)(MUST)33 NutritionalNutritionalRiskRiskScreeningS creening(NRS 2002)(NRS 2002)44 MNA (elderly)MNA (elderly)551 1 VeteransVeteransAffairsAffairs, New , New EnglEnglJ J MedMed199119912 2 DetskyDetskyet al, JPEN, 1984et al, JPEN, 19843 BAPEN3 BAPEN4 4 KondrupKondrupet al, et al, ClinClinNutrNutr200320035 5 VellasVellaset al, Nutrition 1999et al, Nutrition 1999 Recommended by ESPENR ecommended by ESPENN utritionalNutritionalriskriskscreeningsc reeningSubjectiveSubjectiveglobal global assessmentassessment(SGA)(SGA)IIPatientP atient sshistoryhistory((weightweightlossloss, , changechangein in dietarydietaryintakeintake, , gigi--symptomssymptoms,,functionalfuncti onalcapacitycapacity))IIIIP hysicalPhysicalexaminationexamination((m usclesmuscles, , subcutaneoussubcutaneousfatfat, , edemaedema, , ascitesascites))ClinicianClinician ssoveralloveralljudgementjudgement normal normal nutritionalnutritionalstatusstatus mildlymildly significantlysignificantlyDetskyDetskyet al, JPEN, 1984et al, JPEN, 1984malnourishedmalnourished0 (LOW) 0 (LOW) 1 (MEDIUM) 1 (MEDIUM) 2 2 or more or more (HIGH)(HIGH)

6 ROUTINE CLINICAL CAREROUTINE CLINICAL CAREOBSERVE OBSERVE TREAT TREAT Acute disease effectAcute disease effectAddAddaascorescoreof 2of 2if thereif therehashasbeen orbeen orisislikely tolikely tobe nobe noorornutritional intake fornutritional intake for> 5 > 5 daysdaysHospitalHospital--refer to dietitian orrefer to dietitian orimplement local policiesimplement local food first followed byGenerally food first followed byfood fortification and food fortification and supplementssupplementsCare HomesCare Homes(as(asfor hospitalfor hospital))CommunityCommunity(as(asfor hospitalfor hospital))Malnutrition Universal Screening ToolMalnutrition Universal Screening Tool(MUST)(MUST)for adultsfor adultsBMI (kg/m2)BMI (kg/m2)0 : > : > : = : = : 2 : << lossWeight lossin 3in 3--66monthsmonths0 : 0 : <<5 %5 %11: = 5: = 5--10 %10 %22::>>10 %10 %HospitalHospital--document dietary anddocument dietary andfluid intake forfluid intake for33daysdaysCare HomesCare Homes(as(asfor hospitalfor hospital))CommunityCommunity--Repeat screeningRepeat screening,, <1<1mo tomo to>6>6momo((withwithdietary advice if necessarydietary advice if necessary))Repeat screeningRepeat screeningHospitalHospital--every weekevery weekCare HomesCare Homes--every monthevery monthCommunityCommunity--every year forevery year forspecial groupsspecial groups, , >75 y>75 yOVERALL RISK OF UNDERNUTRITIONOVERALL RISK OF UNDERNUTRITIONN utritionalNutritionalRiskRiskScreeningSc reening(NRS 2002) (NRS 2002)

7 128 128 randomizedrandomizedtrialstrials ClassifyingClassifyingthethepatientspati entswithwithrespectrespectto to nutritionalnutritionalstatusstatusand and severityseverityof of diseasedisease DeterminingDeterminingwhetherwhetherthet heeffecteffectof of nutritionalnutritionalinterventioninterv entionon on clinicalclinicaloutcomeoutcomewas positive was positive ororabsentabsentIsIsbasedbasedon an on an analysisanalysisof of controlledcontrolledclinicalclinicaltria lstrials PatientsPatientsat at nutritionalnutritionalriskrisk(N = 75 (N = 75 trialstrials)) 43 43 trialstrialsshowedshoweda positive a positive effecteffectononclinicalclinicaloutcomeo utcome PatientsPatientsnotnotat at nutritionalnutritionalriskrisk(N = 53 (N = 53 trialstrials)) 14 14 trialstrialsshowedshoweda positive a positive effecteffectononclinicalclinicaloutcomeo utcome(p = )(p = ) LikelihoodLikelihoodratio (ratio (truetruepositive / positive / falsefalsepositive)positive) all (CI: (CI: ) ) TPN (71 TPN (71 trialstrials) (CI: ) (CI: ) ) oral/enteral (56 oral/enteral (56 trialstrials) ( ) ( ) )Kondrup et al, Clin Nutr, 2003 ResultsResults::NutritionalNutritionalRi skRiskScreeningScreening(NRS(NRS--2002)2 002)Initial Initial screeningscreening IsIsBMI < BMI < YesYesNoNo Has Has thethepatientpatientlost lost weightweightwithinwithinthethelast 3 last 3 monthsmonths?

8 ? Has Has thethepatientpatienthadhada a reducedreduceddietarydietaryintakeintake in in thethelast last weekweek?? IsIsthethepatientpatientseverelyseverely illill? (? ( ICU). ICU) IfIf NoNo to all to all questionsquestions, , rere--screenedscreenedat at IfIf YesYes to to anyanyquestionquestion, , thethefinal final al, et al, ClinClinNutrNutr20032003 AnswerAnswerYesYesNoNoYesYesNoNoYesYesNo NoNutritionalNutritionalRiskRiskScreenin gScreening(NRS(NRS--2002)2002)Final Final ScreeningScreeningIIAbsentAbsentScore 0 Score 0= Normal = Normal nutritionalnutritionalstatusstatusMildMi ldScore 1 Score 1 WtWtlossloss>5% in 3 >5% in 3 monthsmonthsororFood Food intakeintakebelowbelow5050--75% normal 75% normal requirementrequirementininpreceedingprec eedingweekweekModerateModerateScore 2 Score 2 WtWtlossloss>5% in 2 >5% in 2 monthsmonthsororBMI BMI + + impairedimpairedgeneralgeneralconditionc onditionororFood Food intakeintake2525--50% normal 50% normal requirementrequirementin in preceedingpreceedingweekweekSevereSevere Score 3 Score 3 WtWtlossloss>5% in 1 >5% in 1 momo(>15% in 3 (>15% in 3 momo))

9 OrorBMI < + BMI < + impairedimpairedgeneralgeneralconditionconditionororFood Food intakeintake00--25% normal 25% normal requirementrequirementin in preceedingpreceedingweekweek((ImpairedImpairednutritionalnutritionalstatusstatus))Kondrup et al, Clin Nutr 2003 NutritionalNutritionalRiskRiskScreeningScreening(NRS(NRS--2002)2002)Final Final screeningscreeningIIII((SeveritySeverityof of diseasedisease))AbsentAbsentScore 0 Score 0 Normal Normal nutritionalnutritionalrequirementsrequirementsMildMildScore 1 Score 1 Hip Hip fracturefracture, , chronicchronicpatientspatients, in , in particularparticularwithwithacuteacutecomplicationscomplications: : cirrhosiscirrhosis, COPD, , COPD, chronicchronichemodialysishemodialysis, , diabetesdiabetes, , oncologyoncologyModerateModerateScore 2 Score 2 Major Major abdominalabdominalsurgerysurgery, , , , hematologichematologicmalignancymalignancySevereSevereScore 3 Score 3 HeadHeadinjuryinjury, , bonebonemarrowmarrowtransplantationtransplantation, , Intensive Intensive carecarepatientspatients(APACHE>10).

10 (APACHE>10).Kondrup et al, Clin Nutr 2003 NutritionalNutritionalriskriskscreenings creeningESPEN ESPEN NRS 2002 NRS 2002 ImpairedImpairednutritonalnutritonalstat usstatusweightweightlossloss% % overovertime, time, foodfoodintakeintake, , BMI (Score 0 BMI (Score 0--3)3) SeveritySeverityof of diseasediseasemild to mild to severesevere(Score 0(Score 0--3)3) Age Age overover70 70 yearsyearsad 1 pointad 1 pointKondrupKondrup, , ClinClinNutrNutr, 2003, 2003 IfIfthethetotal total scorescoreisis3 3 oreoremoremorenutritionalnutritionalsupp ortsupportisisindicatedindicatedNutritio nalNutritionalriskriskscreeningscreening //assessmentassessmentMini Mini NutritionalNutritionalassessmentassessme nt(MNA)(MNA)I. I. ScreeningScreening(14 (14 pointspoints))((foodfoodintakeintake, , weightweightlossloss, BMI, , BMI, mobilitymobility))>12 >12 notnotat at riskrisk<11 <11 possiblepossiblemalnutritionmalnutrition II. II. AssessmentAssessment(16 (16 pointspoints))(life style, (life style, numbernumberof of mealsmeals, mode of , mode of feedingfeeding, MAC, MACectect.))