espen congress the hague 2017 · a.2. inadequate nutritional intake is common, and patient factors...

ESPEN Congress The Hague 2017Upcoming ESPEN Guidelines

Polymorbid internal medicine inpatients guidelines

F. Gomes (CH)

ESPEN guidelines on nutritional support for

polymorbid internal medicine patients

Filomena Gomes, RD PhD

(on behalf of the Working Group)

Filomena Gomes & Philipp

Schuetz (CH) - coordinators

Lisa Bounoure (CH)

Peter Austin (UK)

María Ballesteros-Pomar (ES)

Tommy Cederholm (SE)

Jane Fletcher (UK)

Alessandro Laviano (IT)

Kristina Norman (DE)

Kalliopi-Anna Poulia (EL)

Paula Ravasco (PT)

Stephane M. Schneider (FR)

Zeno Stanga (CH)

C. Elizabeth Weekes (UK)

Stephan C. Bischoff (DE)

Working group

2

3

Shareholder No relevant conflicts of interest to declare

Grant / Research Support No relevant conflicts of interest to declare

Consultant No relevant conflicts of interest to declare

Employee No relevant conflicts of interest to declare

Paid Instructor No relevant conflicts of interest to declare

Speaker bureau No relevant conflicts of interest to declare

Other No relevant conflicts of interest to declare

Introduction

Polymorbidity (AKA multimorbidity):

• co-occurrence of at least two chronic health conditions in the same person (Lefèvre, 2014; WHO, 2008, Marengoni, 2011)

• > 70% of the hospitalized adult population, associated with higher mortality and healthcare burden (Steiner, 2014)

• prevalence increases with age, but > 50% people affected with this problem are < 65 years (Barnett, 2011)

• clinical guidelines mainly created for single diseases pt with multiple conditions?

4

Guidelines for

polymorbid

patients!

6

MethodsPragmatic definition of polymorbidity (individual vs. study

population):

• at least 2 co-occurring chronic diseases present in at least 50% of

the study population

• a Charlson comorbidity index or mean number of diseases or

drugs (medications) > 1.5

• In case of uncertainties, study authors were contacted if not

reached, consensus decision within the WG

Example of an included study (Norman, 2011) - mean number of chronic

diseases/patient and drugs/patient in each group was:

IG - 5 chronic illness/patient and 5 drugs/pt

CG - 4.6 chronic illness/patient and 3.9 drugs/pt 7

Inclusion/exclusion criteriaCriteria Inclusion Exclusion

Pa

tie

nts

ch

ara

cte

risti

cs

Human adults aged ≥ 18 years Non human, < 18 years, pregnant women

Patients hospitalized in acute care wards

Pt in critical/intensive care units, surgical patients

Pt living in long-term care facilities; outpatients

Pt receiving end of life care

- Polymorbid inpatients population as defined by:

a) at least 2 co-occurring chronic diseases present in at least

50% of the study population

b) mean number of diseases or drugs/medication or

Charlson comorbidity index > 1.5

If in doubt, authors contacted; if no reply, WG consensus

decision about inclusion/exclusion

Healthy population

Less than 50% of the study population has 2 co-

occurring diseases

Outcomes

Nutritional outcomes (e.g. weight, energy and protein intake)

Clinical outcomes (e.g. mortality, infections)

Patient-centred outcomes (e.g. quality of life)

Healthcare resources

Language

and yearEnglish; no restriction on publication year

8

Methodology (SOP for ESPEN guidelines):

• initial meeting (Jan 2016) to define clinical questions (PICO), inclusion/exclusion crietria, search terms

• systematic literature search (1 single author) in secondary sources & primary sources (Medline, Embase and the Cochrane Library), until April 2016

• literature selection quality assessment assignment of level of evidence for included papers draft of recommendation grade of recommendation

• online voting (Feb 2017) final consensus conference (Apr 2017)

9

10

Clinical

questions

E + P

requirements

Monitoring

Indication

Micronutrient

requirements

Route of

feeding

Timing

Procedure of

intervention

Disease-

specific

nutrients

11

TimingUse of

specific

nutrients

Polymorbid

medical

inpatient

population?

Results

Number of abstracts retrieved in

Included

studiesMedline EmbaseCochrane

LibraryTotal

Question 1 369 737 381 1401 2

Question 2 188 267 183 404 11

Question 3 318 532 327 859 1

Question 4 114 156 26 189 1

Question 5 162 220 82 395 2

Question 6 3 8 2 13 0

Question 7 116 174 102 223 2

Question 8 349 462 282 598 2

Question 9 6 4 10 19 10

Question 10 61 95 141 260 2

Question 11 18 23 7 25 2

Question 12 89 93 28 146 3

12 clinical questions

4532 retrieved

abstracts

38 included studies

22 recommendations

4 statements

12

Online voting and levels of agreement

• strong consensus (agreement of >90%) in 68% of recommendations

and 75% of statements

• consensus (agreement of >75-90%) in 32% of recommendations and

25% of statements

• no recommendations or statements reached an agreement < 75%

feedback from online voting used to modify and improve

recommendations in order to reach a higher degree of acceptance at

the final consensus meeting recommendations and statements with

< 90% agreement were discussed second voting: consensus >

89% was reached for all of the recommendations. 13

Summary of clinical questions and recommendations

Topic Clinical question and recommendation(s)/ statement(s)

Ind

ica

tio

n 1. Nutritional support based on screening and/or assessment vs. no screening and/or assessment

1.1. A quick and simple nutritional screening method using different validated tools should be applied to identify

malnutrition risk. In patients at risk, a more detailed assessment should be performed and a treatment plan should be

developed (….)

(Grade of recommendation (GR) B - strong consensus)

Ro

ute

of

fee

din

g

2. In malnourished polymorbid inpatients or those at high risk of malnutrition whose nutritional requirements

can be met orally: oral nutritional supplements (ONS), +/- nutritional counseling, vs. no ONS?

2.1. ONS high in energy and protein shall be considered to improve their nutritional status and quality of life.

(GR A - strong consensus)

2.2. Nutrient-specific ONS should be administered, when they may maintain muscle mass, reduce mortality or improve

quality of life

(GR B - consensus)

2.3. ONS should be considered as a cost-effective way of intervention towards improved outcomes

(GR B - strong consensus)

3. In pt where nutritional requirements cannot be met orally: enteral nutrition (EN) vs. parenteral nutrition (PN)

(total or supplemental)?

3.1. EN can be administered and may be superior to PN because of a lower risk of infectious and non-infectious

complications.

(GR 0 - strong consensus) 14

En

erg

y r

eq

uir

em

en

ts

4. Estimation of energy requirements with a prediction equation vs. a weight-based formula in pt

requiring nutritional support

4.1. Energy requirements can be estimated using indirect calorimetry (IC), a published prediction equation or a

weight-based formula.

(GR 0 - strong consensus)

4.2 In the absence of IC, total energy expenditure (TEE) for polymorbid older patients (aged > 65 years) can be

estimated using the formula 27 kcal/kg actual body weight (BW). Resting energy expenditure (REE) can be

estimated using the formula 18 - 20 kcal/kg BW with the addition of activity or stress factors to estimate TEE.


4.3.a In the absence of IC, REE for severely underweight patients can be estimated using the formula 30 kcal/kg

BW.

(GR 0 - consensus)

4.3.b. This target of 30 kcal/kg BW in severely underweight patients should be cautiously and slowly achieved, as

this is a population at high risk of refeeding syndrome.

(GR GPP - strong consensus)

Pro

tein

req

uir

em

en

ts

5. Protein targets higher than 1.0g/kg BW/day vs. a lower target in patients requiring nutritional support

5.1. Pt shall receive a minimum of 1.0 g of protein/kg BW/day in order to prevent body weight loss, reduce the risk

of complications and hospital readmission and improve functional outcome.


15

Mic

ron

utr

ien

ts

req

uir

em

en

ts

6. In pt exclusively fed orally: supplementation of micronutrients (vitamins and trace

elements) vs. no supplementation

6.1. Adequate intake of micronutrients (vitamins and trace elements) to meet daily estimated

requirements should be ensured.


6.2. Pt with documented or suspected micronutrient deficiencies should be repleted.


Dis

ea

se-s

pecif

ic n

utr

ien

ts

7. Disease-specific nutritional supplementation (e.g. fibre, omega 3 fatty acids, BCAA,

glutamine, etc.) vs. standard formulations

7.1. In pt with pressure ulcers, specific amino-acids (arginine and glutamine) and β-hydroxy β-

methylbutyrate (ßHMB) can be added to oral/enteral feeds to accelerate the healing of pressure

ulcers.

(GR 0 - consensus)

7.2. In older pt requiring enteral nutrition, formulas enriched in a mixture of soluble and insoluble

fibers can be used to improve bowel function.


16

Tim

ing

8. Early nutritional support (i.e. provided less than 48h post hospital admission) vs. later nutritional support

8.1. Early nutritional support should be performed, as sarcopenia could be decreased and self-sufficiency could be

improved


9. Continued use of nutritional support after discharge vs. during inpatient stay alone

9.1. In malnourished pt/at risk of malnutrition, nutritional support shall be continued after hospital discharge in order

to maintain or improve body weight and nutritional status.


9.2. In malnourished pt/at risk of malnutrition, nutritional support should be continued post hospital discharge to

maintain or improve functional status and quality of life.


9.3. In malnourished pt/at risk of malnutrition aged 65 and older, continued nutritional support post hospital discharge

with either ONS or individualized nutritional intervention shall be considered to lower mortality.


17

Mo

nit

ori

ng

10. Monitoring of physical functions, when possible, vs. monitoring of nutritional parameters (e.g. body

weight, energy and protein intakes)

10.1. Nutritional parameters should be monitored to assess responses to nutritional support, while functional indices

should be used to asses other clinical outcomes (i.e., survival, quality of life)


11. Meeting >75% of energy and/or protein requirements (as an indicator of compliance) vs. lower %

11.1. In pt with reduced food intake and hampered nutritional status, at least 75% of calculated energy and protein

requirements should be achieved in order to reduce the risk of adverse outcomes.


11.2. Energy and protein fortified foods can be used in order to reach those relevant energy and protein targets in

polymorbid medical inpatients.


Pro

ce

du

re o

f

inte

rve

nti

on

12. Organizational changes in nutritional support (e.g. intervention of a steering committee, implementation

of protected mealtimes, different budget allocation) vs. no changes

12.1. Organizational changes in nutritional support provision should be implemented for pt malnourished/at risk of

malnutrition. In particular, interventions that ensure the provision of fortified menus, establishing a nutrition support

team and the use of multi-disciplinary nutrition protocols should be implemented.

(GR B - strong consensus )

18

No

n-P

ICO

qu

es

tio

ns

a) Does underlying disease have an impact on expected outcome from nutritional support?

a.1. The severity of acute-phase response may be used by clinicians as part of the criteria for selecting patients for

nutritional screening, follow-up, and intervention.

(Level of Evidence (LE) 1+; strong consensus)

a.2. Inadequate nutritional intake is common, and patient factors contributing to poor intake should be considered

in designing nutritional interventions. (…) Poor intake is associated with several common patient/environmental

characteristics, e.g. disease severity, anorexia, bedridden, hospital routines, therapeutic diets, etc.

(LE 4 - strong consensus)

b) How long should nutritional support be given in order to have an impact on the clinical course?

b. Although there is evidence to recommend the continued nutritional support post-hospital discharge on

malnourished pt/at risk of malnutrition, the ideal duration of the intervention has not yet been determined.

(LE4; strong consensus)

c) Are there risks of polypharmacy and drug-nutrient interaction (in polymorbid pt)?

c. There is an important possibility of drug-drug or drug-nutrient interactions that needs to be taken into account,

by establishing a pharmacist-assisted management plan for any interactions.

(LE3; consensus)19

Statements

Discussion

• Major challenge: is the study population polymorbid?

- Cannot use search terms for polymorbidity large number of abstracts

- Need to obtain and read full paper (+ contact author)

• Future: encourage authors of future trials to report data on multiple comorbidities + use it as key words

• Other challenges: unavoidable overlap

with other disease-specific guidelines20

• Despite the methodological difficulties, we reviewed the

evidence behind several important aspects of nutritional

support for polymorbid medical inpatients, from

screening until post-discharge, including drug-nutrient

interactions

• Complex needs of this population access to dietetic

expertise to assess, manage and monitor nutritional status

and nutritional intervention

• Community-based approaches (at nutritional risk

population) prevention and early intervention21

• Evidence is still limited in several areas need of larger,

well conducted RCTs in this population, e.g. EFFORT trial

22

Bounoure & Gomes et al, Nutrition 32 (2016) 790–798

References• Lefèvre T, d’Ivernois JF, De Andrade V, Crozet C, Lombrail P, Gagnayre R. What do we mean by multimorbidity? An

analysis of the literature on multimorbidity measures, associated factors, and impact on health services organization.

Revue d'Épidémiologie et de Santé Publique. 2014;62(5):305-14.

• World Health Organization. The World Health Report 2008: primary health care (now more than ever). World Health

Organization 2008.

• Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, et al. Aging with multimorbidity: A systematic

review of the literature. Ageing Research Reviews. 2011;10(4):430-9

• Steiner CA, Friedman B. Hospital utilization, costs, and mortality for adults with multiple chronic conditions, Nationwide

Inpatient Sample, 2009. Preventing chronic disease. 2013;10.

• Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for

health care, research, and medical education: a cross-sectional study. The Lancet. 2012;380(9836):37-43.

• Bischoff SC, Singer P, Koller M, Barazzoni R, Cederholm T, van Gossum A. Standard operating procedures for ESPEN

guidelines and consensus papers. Clin Nutr 2015;34:1043e51.

• Norman K, Pirlich M, Smoliner C, Kilbert A, Schulzke JD, Ockenga J, et al. Cost effectiveness

of a 3-month intervention with oral nutritional supplements in disease-related malnutrition: a randomised controlled pilot

study. Eur J Clin Nutr 2011;65:735e42.

• Bounoure L, Gomes F, Stanga Z, Keller U, Meier R, Ballmer P, et al. Detection and treatment of medical inpatients with

or at-risk of malnutrition: suggested procedures based on validated guidelines. Nutrition 2016;32:790e8.

23

Question Title of the included study Author, Publication year Evidence of polymorbidityLevel of

evidence

1Cost-effectiveness of an interdisciplinary intervention in geriatric

inpatients to prevent malnutritionRypkema, 2013

Agreeement within working group, following attempt to contact author

2+

1Impact of nutritional support on clinical outcome in patients at

nutritional risk: A multicenter, prospective cohort study in Baltimore and Beijing teaching hospitals

Jie, 2010Agreeement within working group, following attempt to contact author

2+

2Early nutritional support and physiotherapy improved long-term

self-sufficiency in acutely ill older patientsHegerová, 2015 Confirmed by author 1++

2Dietary supplementation and quality of life of older patients: a

randomized, double-blind, placebo-controlled trialGariballa, 2007

Mean number of chronic diseases and drugs: 1.7 and 3.5 in the control group,

respectively; 1.9 and 3.5 in the intervention group, respectively

1++

2Effects of dietary supplements on depressive symptoms in older

patients: a randomised double-blind placebo-controlled trialGariballa, 2007 b)


respectively; 1.9 and 3.5 in the intervention group, respectively

1++

2A randomized, double-blind, placebo-controlled trial of

nutritional supplementation during acute illnessGariballa, 2006


respectively; 1.9 and 3.5 the intervention group, respectively

1++

2Protein energy malnutrition in severe alcoholic hepatitis:

diagnosis and response to treatmentMendenhall, 1995

> 2 co-occurring chronic diseases in > 50% of the study population

1-

2Short-term individual nutritional care as part of routine clinical setting improves outcome and quality of life in malnourished

medical patientsStarke, 2011

Mean number of drugs: 7 in the control group, 6 the intervention group

1++

2Nutritional support and functional status in undernourished

geriatric patients during hospitalization and 6-month follow-up.Volkert, 1996

Reported in the paper: "All patients suffered from multiple diseases (...). The mean number of prescribed drugs was

2.4".

2+

2Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: A

randomized clinical trial Deutz, 2016

Mean Charlson comorbidity index: 2.05 in the control group, 2.12 in the

intervention group. 1++

2Impact of Oral Nutritional Supplementation on Hospital

OutcomesPhilipson, 2003 Mean Charlson comorbidity index: 3.5 2++

2Protein Energy Supplements in Unwell Elderly Patients - A

Randomized Controlled TrialPotter, 2001


2++

2Routine oral nutritional supplementation for stroke patients in

hospital (FOOD): a multicentre randomised controlled trial.Dennis, 2005


1++

3Impact of nutritional support on clinical outcome in patients at

nutritional risk: A multicenter, prospective cohort study in Baltimore and Beijing teaching hospitals

Jie, 2010Agreeement within working group, following attempt to contact author

2+

4Energy requirements in frail elderly people: A review of the

literatureGaillard 2007

Some included studies described patients as polymorbid

2++

5Short-term individual nutritional care as part of routine clinical setting improves outcome and quality of life in malnourished

medical patientsStarke, 2011

Mean number of drugs: 7 in the control group, 6 in the intervention group

1++

5Protein is an important component of nutritional support

predicting complications in malnourished hospitalised patients details of our previous randomised controlled trial (RCT)

Drommer, 2015Mean number of drugs: 7 in the control

group, 6 in the intervention group1++

7The use of a specialised amino acid mixture for pressure ulcers: a

placebo-controlled trial. Wong, 2014 Confirmed by author 1+

7 Fibre-supplemented tube feeding in the hospitalised elderly Vandewoude, 2005 Confirmed by author 1++

8Early nutritional support and physiotherapy improved long-term

self-sufficiency in acutely ill older patientsHegerová, 2015 Confirmed by author 1+

8Impact of early enteral nutrition on short term prognosis after

acute strokeZheng, 2015

> 2 co-occurring chronic diseases in > 50% of the study population

1-

24

9Prevention of malnutrition in older people during

and after hospitalisation: results from a randomised controlled clinical trial

Gazzotti, 2003Mean number of drugs: 5.8 in the control group, 5.5 in the

intervention group1++

9

Three month intervention with protein and energy rich supplements improve muscle function and

quality of life in malnourished patients with non-neoplastic gastrointestinal disease--a randomized

controlled trial

Norman, 2008 Mean number of drugs: 6 in the

control group, 4 in the intervention group

1+

9Cost-effectiveness of a 3-month intervention with

oral nutritional supplements in disease-related malnutrition: a randomised controlled pilot study.

Norman, 2011

Mean number of chronic diseases and drugs: 4.6 and 3.9

in the control group, respectively; 5 and 5 in the

intervention group, respectively

1+

9Individualized nutritional intervention during and

after hospitalization: the nutrition intervention study clinical trial

Feldblum, 2011

Mean Charlson comorbidity index: 2.5 in the control group,

2.2 in the intervention group, 2.4 in the "in-hospital" treatment

group

1-

9Randomized clinical trial of nutritional counseling

for malnourished hospital patientsCasals, 2015

Agreeement within working group, following attempt to

contact author1-

9Nutritional supplementation and dietary advice in

geriatric patients at risk of malnutrition.Persson, 2007 Confirmed by author 1+

9Post-discharge nutritional support in malnourished elderly individuals improves functional limitations

Neelemaat 2011 Confirmed by author 1++

9Oral nutritional support in malnourished elderly

decreases functional limitations with no extra costsNeelemaat 2012 a) Confirmed by author 1++

9Short-term oral nutritional intervention with protein and vitamin D decreases falls in malnourished older

adultsNeelemaat 2012 b) Confirmed by author 1++

9Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: A randomized clinical trial

Deutz, 2016Mean Charlson comorbidity

index: 2.05 in the control group, 2.12 in the intervention group

1++

10Protein energy malnutrition in severe alcoholic hepatitis: diagnosis and response to treatment

Mendenhall, 1995> 2 co-occurring chronic diseases in > 50% of the study population

1-

10

Three month intervention with protein and energy rich supplements improve muscle function and

quality of life in malnourished patients with non-neoplastic gastrointestinal disease-A randomized

controlled trial.

Norman, 2008 Mean number of drugs: 6 in the

control group, 4 in the intervention group

1-

11Protein-Energy Undernutrition Among Elderly

Hospitalized PatientsSullivan, 1999 Confirmed by author 2++

11Positive effect of protein-supplemented hospital

food on protein intake in patients at nutritional risk: a randomised controlled trial

Munk, 2014Agreeement within working group, following attempt to

contact author1+

12Cost savings of an adult hospital nutrition support

teamKennedy, 2005 Confirmed by author 2+

12Positive effect of protein-supplemented hospital

food on protein intake in patients at nutritional risk: a randomised controlled trial

Munk, 2014Agreeement within working group, following attempt to

contact author1+

12Cost-effectiveness of an interdisciplinary

intervention in geriatric inpatients to prevent malnutrition

Rypkema, 2013Agreeement within working group, following attempt to

contact author2+

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