ESPEN diagnostic criteria for malnutrition – A validation study in hospitalized patients

doi:10.1016/j.clnu.2016.08.022

Clinical Nutrition

Volume 36, Issue 5, October 2017, Pages 1326-1332

https://doi.org/10.1016/j.clnu.2016.08.022 Get rights and content

Summary

Background & aims

The European Society for Clinical Nutrition and Metabolism (ESPEN) released a consensus statement for undernutrition diagnosis: ESPEN diagnostic criteria for malnutrition (EDC). The EDC lacks validation and therefore, the present study aims to assess the concurrent and predictive validity of this tool in a cohort of inpatients.

Methods

A prospective observational study took place in a university hospital. Concurrent validity of EDC was evaluated using the Patient Generated Subjective Global Assessment (PG-SGA) nutrition status classification as the reference method. Sensitivity, specificity, positive and negative predictive values were determined. The EDC predictive validity was assessed by its independent association with length of hospital stay (LOS), applying Cox proportional hazards ratio method.

Results

Of the 632 included patients, 455 participants (72%) were nutritionally-at-risk (Nutritional Risk Screening initial screening). For those that had screened positive, 260 (57.1%) and 55 participants (12.1%) were undernourished according to PG-SGA and to EDC, respectively. Compared to PG-SGA, the EDC revealed a sensitivity of 17.1% and a specificity of 98.3%. Positive and negative predictive values were respectively 89.1% and 58.9%. Undernutrition evaluated by EDC was independently associated with lower hazard ratio for being discharged home over time, 0.695 (95% confidence interval: 0.509; 0.950).

Conclusions

The EDC could be used in clinical settings to confirm undernutrition suggested by other methods. The independent association of undernutrition by EDC with LOS shows this method is of clinical relevance.

Introduction

Despite the heterogeneity in the published literature on hospital undernutrition prevalence [1], its frequency is worrying. In developed countries, undernutrition or undernutrition risk is documented to range between circa 10% and 60%. These figures are dependent on disease and patient's characteristics, as well as the method and criteria used for its identification and diagnosis [1], [2], [3], [4], [5], [6], [7]. In fact, although undernutrition assessment of hospitalized patients is recommended by clinical and scientific societies [8], there is no consensus on the most appropriate criteria for undernutrition diagnosis [9].

The European Society for Clinical Nutrition and Metabolism (ESPEN) recently released a consensus statement for undernutrition diagnosis [9]. This consensus was reached by a Delphi-process in an assigned expert group that included e-mail communications, a one-day face-to-face meeting, and ballots as well as an anonymous ballot of ESPEN members. The objective was to select, among a number of nutritional variables, which individual criteria best captures the state of undernutrition: weight loss, reduced body mass index (BMI), reduced fat-free mass index (FFMI), reduced fat mass index, reduced food intake, reduced appetite, a biochemical indicator, or subjective professional evaluation. There was a preference for the use of weight loss, reduced BMI and reduced FFMI. Thus, these three variables were chosen to most accurately reflect undernutrition. According to ESPEN diagnostic criteria for malnutrition (EDC), undernutrition is defined as low BMI or the combined finding of unintentional weight loss and at least one of either reduced BMI or low FFMI [9].

The EDC lacks validation and therefore, the present study aims to assess the concurrent and predictive validity of this tool in a cohort of inpatients.

Section snippets

Study sample and design

A prospective observational study took place in a Portuguese university hospital between July 2011 and December 2014.

Concurrent validity of EDC was evaluated using the Patient Generated Subjective Global Assessment (PG-SGA) [10] nutrition status classification as the reference method. The EDC predictive validity was assessed by its independent association with hospital length of stay (LOS).

Recurring to the daily list of patients admitted to each ward and following a consecutive sampling

Results

According to the NRS-2002 initial screening, 455 inpatients (72%) were nutritionally-at-risk. For those that had screened positive, 260 (57.1%) and 55 participants (12.1%) were undernourished according to PG-SGA and to EDC, respectively.

The baseline characteristics of the participants according to undernutrition status are presented in Table 1. Undernourished patients by PG-SGA were older, presented a decline in functional status and lower mean BMI and FFMI. Moreover, a lower proportion of

Discussion

The present study results showed that EDC is a highly specific method and that undernourished patients evaluated by EDC presented a lower probability of being discharged home from the hospital, after adjusting for co-variables and possible confounders of the association between undernutrition and LOS.

Despite the excellent specificity, EDC sensibility was low and thus a high proportion of undernourished patients according to PG-SGA were classified as not undernourished by EDC. Moreover, the

Statement of authorship

RSG, IF, FP and TFA design the study; RSG and TFA wrote the manuscript; RSG, ASS and AJ collected the data; RSG, ASS, IF, AJ and TFA analysed and interpreted the data; all authors contributed to manuscript preparation, critically revised it and approved the final version of the manuscript.

Conflict of Interest

The authors have no conflicts of interest to declare.

Funding

Rita S. Guerra and Teresa F. Amaral received a grant from ESPEN “Call for validation studies of ESPEN malnutrition criteria”. Rita S. Guerra as a PhD student received a scholarship from Fundação para a Ciência e a Tecnologia, financing program POPH/FSE, under the project SFRH/BD/61656/2009.

Acknowledgements

The authors thank Centro Hospitalar do Porto and to all ward directors for facilitating the data collection.

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¹: Postal address: Serviço de Nefrologia, Centro Hospitalar do Porto/Hospital de Santo António, Largo Prof Abel Salazar, 4099-003 Porto, Portugal.

²: Postal address: Faculdade de Ciências da Nutrição e Alimentação, Universidade do Porto, Rua Dr. Roberto Frias, s/n, 4200-465 Porto, Portugal.

³: Postal address: Unidade de Nutrição, Centro Hospitalar do Porto/Hospital de Santo António, Largo Prof Abel Salazar, 4099-003 Porto, Portugal.

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Original articleESPEN diagnostic criteria for malnutrition – A validation study in hospitalized patients

Summary

Background & aims

Methods

Results

Conclusions

Introduction

Section snippets

Study sample and design

Results

Discussion

Statement of authorship

Conflict of Interest

Funding

Acknowledgements

Clin Nutr

J Acad Nutr Diet

Clin Nutr

Clin Nutr

Clin Nutr

Arch Gerontol Geriatr

J Chronic Dis

Clin Nutr

Clin Nutr

Clin Nutr

Nutrition

Clin Nutr

Clin Nutr

Clin Nutr

J Acad Nutr Diet

Original article
ESPEN diagnostic criteria for malnutrition – A validation study in hospitalized patients