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Early history of ESPEN

R. CLARK* and E. VINNARS

*Sheffield, UK, +Stockholm, Sweden.

Since the European Society of Parenteral and Enteral Nutrition (ESPEN) is now well established as a major international scientific organisation, it may be of interest to recall how the Society came to be formed and how it evolved during its first few years. A chronological view will be given of the way ESPEN was organised during the early years, followed by a commentary on the development of its many roles.

ESPEN is not the first international society with which European clinical nutrition has been associated. More than 25 years ago the main international forum was the International Union of Nutrition Sciences. At the 1966 ICN Congress in Hamburg a group of clinicians decided to form the International Society of Parenteral Nutrition (ISPN) for discussion of the scientific work arising from the rapid development in Europe of parenteral nutrition in the late 1950s and early 1960s. Initially. ISPN was composed mainly of Europeans but, as interest in parenteral nutrition de- veloped in the USA during the late 1960s the number of American members increased substantially. The ISPN held meetings during the ICN Congresses in Prague in 1969, Mexico City in 1972, Kyoto in 1975 and finally in Rio de Janeiro in 1978.

The foundation of the American Society of Parenteral and Enteral Nutrition (ASPEN) in 1977 changed the international scene. ASPEN quickly es- tablished a much wider appeal for the many American clinical and paraclinical professions associated with the growing clinical interest in nutritional support. thereby providing a national focal point for the asso- ciation and training of medical and non-medical personnel. This meant that support from the USA and Canada for ISPN dropped dramatically and the meeting of ISPN planned for 198 1 in San Diego, with Stanley Dudrick as president and Erik Vinnars as president elect, was no longer viable and had to be cancelled.

A group of Scandinavians. including Oscar Schuberth. Arvid Wretlind and Erik Vinnars from Sweden, and Hans Christian Borresson from Norway attended the second ASPEN meeting in Houston in 1978 and were impressed by its success. It was clear that the aims of ISPN were too narrowly defined and no longer sufficient for the needs of those involved in clinical nutrition in Europe. There was a good case,

therefore, for creating an organisation to provide common ground for European scientists from many disciplines involved in nutritional support. A number of small annual meetings on nutritional support had already been held in Scandinavia which provided a model on which to found a European Society. Shortly after the Swedish group returned from Houston, a British group including Ron Clark, Alan Shenkin. Simon Allison and Harry Lee, visited Stockholm for an informal nutrition meeting and, while travelling together to Linkoping, the British and Swedish groups supported a proposal for a new Society which would have a strong scientific base, differing some- what from the style of ASPEN where, at the time, the educational programme appeared to dominate. It could be said, therefore, that ESPEN started in a Swedish bus! Later that year, in Luxemburg, discus- sions with colleagues from West Germany and the Netherlands, including Professor Ahnefeldt and Rob Wesdorp, were equally enthusiastic. It was there- fore decided to organise an informal international meeting in Stockholm in September 1979 with Oscar Schuberth as President, Erik Vinnars as Organising Secretary and John Wahren as Treasurer. Letters of invitation were sent to as many key individuals as possible in every European country where there was an established interest in parenteral and enteral nutrition.

A group of Europeans from a number of countries met informally at the ASPEN Congress in Boston in 1979 where they discussed the programme for the Stockholm meeting later that year. Two eponymous lectures were established to honour the European contributions to the field by Sir David Cuthbertson and Arvid Wretlind. Four industrial firms based in the United Kingdom gave money for the first Cuthbertson Lecture and one Swedish firm funded the Wretlind lecture. Financial support was obtained from the City

58 EARLY HISTORY OF ESPEN

Council of Stockholm and the Swedish Government. A number of large European industrial organisations also provided money and, importantly, financial guarantees.

Although the 1979 Stockholm meeting, which was formally opened by the King of Sweden, will always be regarded as the first ESPEN Congress, the Society was not formally established until one year later. The Stockholm meeting, lasting 3 days, with one for education, attracted 700 participants from all over Europe and was judged a success in scientific and financial terms. At an informal General Assembly it was agreed to set up the European Society of Parental and Enteral Nutrition devoted to the study of meta- bolic problems associated with acute disease and their nutritional implication and management. The multidisciplinary nature of the subject was empha- sised and would be reflected in its membership. It was also proposed that there should be an official publication or journal of the Society and Clinical Nutrition was accordingly established under its first Editor-in-Chief, Ron Clark. The location for the next meeting was provided by Ivan Johnstone at Newcastle in the United Kingdom, giving the organising commit- tee less than a year to prepare it. Doubt was expressed at the Stockholm meeting whether there was sufficient need for yearly meetings but the majority view was inclined to follow the ASPEN example with an annual congress, while agreeing to review the decision regu- larly. A group of three, Erik Vinnars. Ron Clark and Ad Grunert, was commissioned to write a constitu- tion for the Society to be presented to the Newcastle meeting, which with Ivan Johnston as President and Peter Wright as Secretary, attracted 800 participants. The meeting comprised, as in Stockholm, a 1 day educational session with 2 days for the scientific meeting. At its General Assembly, the inception of the Society was formally acknowledged and the con- stitution agreed. The Officers of the Society were to be the President who would hold office for one year, with Secretary, Treasurer and two Auditors who would hold office for 4 years forming an Executive Com- mittee responsible for the management of the Society. In addition, a Council was established comprising one key member from each participating country who would hold office for 3 years and to whom the Exe- cutive Committee would be responsible. The Council would nominate the members of the executive who would then be approved by the General Assembly.

As the need to establish a European Society had received strong support from West Germany, and in particular from Professor Ahnefield. it was agreed that the third meeting of the Society would be held in Ulm. Unfortunately it proved impossible to hold the

3rd Congress in Western Germany the following year and the Society was faced with the problem 01 finding an alternative venue. At a late point in the meeting Rob Wesdorp. having discussed it with his colleagues at the meeting and by phone with his Dean, Dr Greep at Maastricht, volunteered to host the meeting. an offer gratefully received by the Society. It was becoming clear at this early stage in ESPEN’s development that Congress venues needed to be planned well ahead of time. Gunther Kleinberger offered to organise the 4th Congress in Vienna.

In the months leading up to the Maastricht meeting an ESPEN delegation went to the next meeting of ASPEN at New Orleans in 1981 to establish a formal working relationship with ASPEN. One of the points of discussion raised by ESPEN was the possibility of a joint publication between the two Societies. This proved impracticable which gave added impetus to a group (Ron Clark, Robert Wesdorp and Ad Grunert) set up at the Newcastle Congress to negotiate the establishment of an ESPEN journal.

At the 3rd Congress in Maastricht (President Rob Wesdorp and Secretary Peter Soeters) there were 1300 participants and a wide range of original contri- butions, symposia and workshops. There was a large industrial exhibition indicating the strong interest which the Society had stimulated outside the scien- tific world and emphasising the interdependence of clinical and industrial groups in the development of nutritional support. The interests and responsibilities of the Society were increasing as it continued to grow and a Scientific Committee was therefore established to assist in planning the scientific direction of the meetings, with an Educational Committee to advise on and organise the educational elements of the Society, and with an Industrial Committee to develop links between industry and the Society.

The 4th Congress in Vienna was well organised, matching the magnificence of the Hofburg Palace and attracting a record attendance of 1800 parti- cipants. As organising secretary, Gunther Kleinberger achieved a personal success and established a record in publishing the Proceedings of the Congress in less than 6 months. Although rapidly achieving maturity as a Society, ESPEN was still experiencing growing pains, particularly in the manner in which it was organised. The need for a firm policy to maintain continuity and high standards for abstract selection and organisation of symposia and workshops be- came clear. The Scientific Committee therefore laid down guidelines for the assessment of abstracts and appointed panels of reviewers. It had become evi- dent also that the President, in office for only 1 year and burdened with the heavy responsibility of

CLINIC‘AL. YLITRITlOh 5Y

on partnership, which provided the working format on which the organisation of future congresses was based.

The 6th Congress in Milan, under the Presidency of Federico Bozzetti, was a return to the larger size of meeting and was scientifically successful. A new scheme of registration fee was introduced to reduce the cost of future congresses for students and young researchers. The increasing educational role as an important aspect of ESPEN function was identified by the establishment of the first postgraduate course which was run in Brussels by the Education Com- mittee. At this Congress also. the organisation of the Society passed into new hands with the election ot Yvon Carpentier and Peter Soeters to the respective posts of Honorary Secretary and Treasurer. They succeeded Erik Vinnars and John Wahren, who had taken ESPEN through a number of crises in its for- mative years and established the foundation from which ESPEN was to develop into an important inter- national society. rapidly gaining the respect of the main national and international bodies involved in clinical nutrition.

The 7th Congress was held in Munich with Gunther Dietze as President. There were many highlights of this Congress but perhaps the most memorable was of the late Sir David Cuthbertson conducting the orchestra at the first performance of the ESPEN song. in typical Bavarian style, during the main social event at the Hothrauhaus. Attempts continued at Munich to control the costs of the congress and to provide the younger participants with subsidisation of their regis- tration fees and the award of Travel Fellowships, to ensure their continuing participation in large numbers. Because the organisation of ESPEN had by this time become almost routine, steps were taken to widen the participation of the membership in running the affairs of the Society. The Scientific and Educational committees were enlarged to enable them to respond to their increasingly important role. ESPEN members were aware of the benefits to host countries which their meetings could bring, but it was clear that some countries were in no position to host :I congress

for some time. To facilitate the spread ot’ knowledge.

therefore, and provide scientific interchange. smaller additional meetings were planned for Budapest in 1987 and Tel Aviv in 1988 as the first step to provid- ing postgraduate or advanced training in nutritional support.

Since Munich. annual Congresses have continued to prosper, with meetings in Paris under President Claude Ricour in 1986 and in Barcelona in 1987 with Antonio Sitges-Serra as President. In I988 the first Eastern European meeting was held in Leipzig under

Table 1 ESPEN Officers

Etecutive Chairman

Honoral-y Secretary

Honorary Treasurer

Chair Scientific Commitce

R Clark G Dietze P Soeters E Vinnars Y Carpentier A Sitges-Serra P Schauder J Wahren P Soeters A Shenkin L Cynober S Eriksson C Matuchansky M Rennie

1982-1986 lY8f%lYYO IY90-1994 1979-1984 1984-1988 1988-1992 1992-1996 1974-1984 1984-19Xx 1988-1991 1997-1996

organising the next Congress. was prevented from also providing continuous leadership of the ESPEN executive committee. It was decided therefore to create a new post of Chairman of the Executive Com- mittee who would have responsibility for the affairs of ESPEN during a 4 year term of office. This pro- vided a successful solution and enabled the President to concentrate solely on the Congress.

The 5th Congress was held in Brussels under the Presidency of Yvon Carpentier. There had been a feeling that ESPEN was growing too big too quickly and an attempt was made to control the size of the Congress to about 700 participants by reducing the number of papers, symposia and workshops in order to ensure that scientific quality was maintained, while at the same time reducing the cost of the Congress and its registration fees, which were starting to escalate. However, attendance was almost twice that antici- pated and it had to be accepted that the size of most future ESPEN Congresses would be in the region of IS00 and, on occasion. even greater. There was also a view that the name of the Society was not especially appropriate, designating technique rather than topic, and it was thought ‘Clinical Nutrition’, the name of the journal. would be more appropriate for inclusion in the title. This was not generally acceptable to the membership, perhaps because the familiar acronym ESPEN had now become generally accepted as the term associated with the Society. As with all previous meetings. the Brussels Congress was a financial success, enabling ESPEN to develop its role further by offering Travel Fellowships to one or two young researchers from each country who submitted abstracts of quality, and to organise the funding of research in the form of ESPEN Research Fellowships. It was also at the Brussels Congress that the Officers of ESPEN and the Congress Organising Committee finally evolved a sound integrated relationship. based

60 EARLY HISTORY OF ESPEN

Table 2 ESPEN Presidents

1979 Oscar Schuber 1986 Claude Ricour 1980 Ivan Johnston I987 Antonio Sitges-Serra 1981 Robert Wesdorp 1988 Wolfgang Hartig 1982 Erwin Deutch 19x9 Jukka Takala 1983 Yvon Carpentier 1990 George Androulahis 1983 Federico Bozzetti 1991 Ivo de Leeuw 19x5 Gunther Dietre 1992 Herbert Lochs

the Presidency of Wolfgang Hartig. In 1989 the Congress took place in Helsinki with Jukka Takala as President, 1990 in Athens (George Androulakis, President), 1991 in Antwerp (Ivo de Leeuw, President) and 1992 in Vienna (Herbert Lochs, President).

The style of each ESPEN Congress will always differ to emphasise the character of the host country and reflect its particular nutritional interest. At the same time, however, the scientific content and the format of the meeting retains a pattern in accord with the views of the Executive of ESPEN and its Scien- tific and Educational Committees. Inevitably strains develop in the relationship between, on the one hand, the local organising committee who want to produce a distinctive meeting of high scientific quality which responds to local needs and pressures, and, on the other, the requirement to develop ESPEN within a framework of continuity and confirmity which the ESPEN committees see as their role. The tensions which these differing responsibilities created. far from being destructive, have in fact invigorated the Society. The working relationships which have evolved from this have contributed greatly to the secure future which the Society has ahead of it. A striking feature of every ESPEN occasion, noticeable particularly to those attending for the first time, has been the general atmosphere of informality and friendliness. This is reflected in the popularity of the social events which bring all participants together and achieve a blend of members and guests from all disciplines. The inter- disciplinary nature of ESPEN is an important and vital ingredient which contributes to the high scientific quality of each Congress; the membership reflects a balance between the clinical and basic science interests, vital to the development of the subject. It was recog- nised from the beginning that the encouragement and development of young scientists in the field of clinical nutrition was important both for the future of the topic and the Society. and a programme of support was created for those aged below 35 years by providing increasing numbers of research fellowships and travel awards.

ESPEN’s educational role has lagged behind its scientific effort, but is now being strengthened. At

first. the educational sessions were directed at the nationals of the host country during the Congress. However, they proved just as popular with large numbers from all disciplines from elsewhere in Europe. The programme has evolved therefore to cater for specialist groups, i.e. dietitians, nurses. phar- macists and physicians and it is intended to continue this development by extending the programme. in parallel with the scientific programme, beyond the single day format of the past. Postgraduate training is becoming an increasingly important issue in the general context of continuing education, accreditation and specialist qualification. The first formally organ- ised postgraduate venture was a course organised in Brussels in 1984 but this was not deemed a success and the format was discontinued. In 1985 a successful workshop on amino acid metabolism was organised in conjunction with Ajinomoto in Hamburg and this was followed by the larger postgraduate meetings arranged around symposia and scientific sessions on specific topics in Budapest 1987 and Israel 1988. Workshops on specific topics have also been held in Maastricht in 1990 and in Dundee. followed by residential courses in Maastricht and Leuwen.

Maintenance of a high quality scientific content at each ESPEN Congress was recognised as essential to the continuing development of the Society. This responsibility was vested in the Scientific Committee whose primary role is to evaluate the abstracts sub- mitted for each Congress, of which there may be between 400 and 500, and to select from these 70-100 oral presentations and 100-150 posters. The Scientific Committee also appoints a panel of reviewers for each topic, representing local expertise from the host country, ESPEN members, and independent scien- tists, not necessarily associated with ESPEN. Adjudi- cation by each reviewer is based on a standard format to ensure standardisation, and successful abstracts are allocated as either oral or poster sessions accord- ing to their suitability for each format. It has been a policy of the Society that oral and poster presenta- tions should have equal prominence, and the award of prizes for the best poster and oral presentations indi- cates the Society’s continuing commitment to both forms of presentation. The Scientific Committee also adjudicates the awards of Travel Fellowships on the basis of the quality of abstracts submitted by those aged under 3.5 years of age and now awards Research Fellowships and Project Grants from ESPEN resources and from research grants donated by Ajinomoto, Abbott Laboratories. Kabi-Pharmacia and Clintec.

The constitution of ESPEN has always contained a clause entitling the Society to publish its own journal over which it could hold editorial but not financial

CLINICAL NLTKITION hl

remain independent of direct or indirect commercial influences, while at the same time maintaining close co-operating with industry. Attempts to formalise this relationship, with the creation of an Industrial Liaison Committee, was unsuccessful because the in- terests of industry were never seen as separate from the aims of the Society and a distinctive role could never be defined. This has been recognised by the inclusion of industrial members within the committee structure. The Scientific and Executive Committees have also been expanded to include all disciplines.

The constitution provided for the election by the General Assembly of the Society of not more than 6 people to Honorary Membership in recognition of their contribution to the field of clinical nutrition. Three were elected at the Maastricht Congress. Oscar Schuber and Arvid Wretlind were recognised for their long-standing contribution to the development of parenteral nutrition. and Sir David Cuthbertson for his lifetime study of the metabolic responses to injury and sepsis, which are fundamental to the under- standing of the nutritional care of the critically ill. One year later Dr Conrad Lang was elected to Honorary Membership for the contribution which his elemental work made to the study of nutrition. At the Paris meeting Erik Vinnars was elected for his scientific contribution to the nutritional impact of critical ill- ness. especially in amino acid metabolism. in con- junction with his important role in the establishment of ESPEN. and Ron Clark was similarly recognised at the Barcelona meeting I year later. A vacancy in the list of Honorary Membership was created follow- ing the death of Dr Lang, and Dr John Kinney of Columbia University was elected at the Helsmki meeting for his outstanding scientific contribution to the field in a wide range of metabolic phenomena associated with critical illness and his long association with ESPEN.

It is to be hoped that the Society will continue to evolve and develop, promoting basic science, good clinical practice and continuing education. Above all. it must continue to attract young workers in the field and retain their interest in running the Society in the future.

control. Initially, it was difficult to foresee what support such a journal would have in Europe but. following an unsuccessful attempt to establish a joint journal with ASPEN, Churchill Livingstone was selected from a number of European publishers and the first volume of the journal named Clinical Nutri- tiorl was published in 1982-83 under the editorship of Ron Clark. Each volume consisted initially of 4 issues of 100 pages in camera-ready style, which meant that every issue was set up in the editor’s office before presentation to the publishers. This style of publication was not wholly acceptable and, once the initial viability of the journal had been established, the format was changed to the traditional form of typesetting. The editorship then passed to Frank Woods, who quickly established Clinical Nutrition in the list of international journals on nutrition, attracting papers from a wide range of countries and the most respected laboratories. Simon Allison succeeded him in 1987 and expanded the journal further to 6 issues per year, each containing 64 pages. The circulation has now reached 1100 and the journal is cited in most leading indices, including Current Contents, Life Sciences.

The Executive Committee has remained the central organising body of ESPEN. Its principle role is to maintain an effective administrative structure in place between Annual Congresses and to ensure that there is adequate control of the finances of the Society. Efforts have been made to maintain continuity of style and content between the Congresses and to ensure high scientific standards. The Executive has also established links with major clinical nutrition societies in Europe and elsewhere, especially with ASPEN with whom good relationships have been established on the basis of mutual respect.

The interdependence of the pharmaceutical industry and research in clinical nutrition, both basic and applied, has been evident throughout ESPEN’s exist- ence. Much of the Society’s development has benefited from the patient and understanding support by indus- try through its contribution to the finances of the Society, its support of the industrial exhibition, and its sponsorship of meetings and research funds. It was recognised by everyone that the Society should

.Su/wn~ vsim dote: Z June 1993: Acceptance date: 28 September 1993