Elsevier

Clinical Nutrition

Volume 34, Issue 3, June 2015, Pages 335-340
Clinical Nutrition

ESPEN endorsed recommendation
Diagnostic criteria for malnutrition – An ESPEN Consensus Statement

https://doi.org/10.1016/j.clnu.2015.03.001Get rights and content

Summary

Objective

To provide a consensus-based minimum set of criteria for the diagnosis of malnutrition to be applied independent of clinical setting and aetiology, and to unify international terminology.

Method

The European Society of Clinical Nutrition and Metabolism (ESPEN) appointed a group of clinical scientists to perform a modified Delphi process, encompassing e-mail communications, face-to-face meetings, in group questionnaires and ballots, as well as a ballot for the ESPEN membership.

Result

First, ESPEN recommends that subjects at risk of malnutrition are identified by validated screening tools, and should be assessed and treated accordingly. Risk of malnutrition should have its own ICD Code. Second, a unanimous consensus was reached to advocate two options for the diagnosis of malnutrition. Option one requires body mass index (BMI, kg/m2) <18.5 to define malnutrition. Option two requires the combined finding of unintentional weight loss (mandatory) and at least one of either reduced BMI or a low fat free mass index (FFMI). Weight loss could be either >10% of habitual weight indefinite of time, or >5% over 3 months. Reduced BMI is <20 or <22 kg/m2 in subjects younger and older than 70 years, respectively. Low FFMI is <15 and <17 kg/m2 in females and males, respectively. About 12% of ESPEN members participated in a ballot; >75% agreed; i.e. indicated ≥7 on a 10-graded scale of acceptance, to this definition.

Conclusion

In individuals identified by screening as at risk of malnutrition, the diagnosis of malnutrition should be based on either a low BMI (<18.5 kg/m2), or on the combined finding of weight loss together with either reduced BMI (age-specific) or a low FFMI using sex-specific cut-offs.

Introduction

Malnutrition due to starvation, disease or ageing can be defined as “a state resulting from lack of uptake or intake of nutrition leading to altered body composition (decreased fat free mass) and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease” [1]. Although this definition is well-accepted, the condition lacks clear and generally accepted diagnostic criteria.

During the famine catastrophes in Africa during the 1960s, WHO brought attention to the medical aspects of starvation [2]. The concepts of kwashiorkor and marasmus were introduced to define a particular protein deficient condition characterized by hypo-albuminemic peripheral edema and ascites, i.e. kwashiorkor, and a particular energy deficient state characterized by severe weight loss due to mainly fat store depletion, i.e. marasmus. This classification did not turn out as relevant for the recognition and diagnosis of malnutrition that was increasingly observed in hospitals in the Western countries during the later decades of the last century. Since depletion is usually a combined deficiency and loss of protein and energy, the general term of protein-energy malnutrition (PEM) became widely accepted [3]. Clinical characteristics used to define PEM have varied over time, but there was never a consensus on diagnostic criteria. Various combinations of clinical, anthropometrical, biochemical and immunological measures were used (e.g. Refs. [4], [5]).

The last decades have seen the advent of several malnutrition screening tools that have reached increased acceptance due to their clinical feasibility. These screening tools combine about the same variables, i.e. weight loss, body mass index (BMI), signs of eating difficulties (e.g. appetite loss or reduced food intake) and a grading of on-going disease severity. ESPEN recognizes the following risk screening tools to be used in the hospital, elderly care and community settings; Nutritional Risk Screening 2002 (NRS-2002), Mini Nutritional Assessment-Short Form (MNA-SF) and Malnutrition Universal Screening Tool (MUST) [6]. The major use of these tools is to screen for malnutrition risk. The subsequent clinical actions should be assessment of underlying mechanisms and type of nutritional problems, in order to design personalized nutritional therapies. The diagnostic procedure usually ends there. The reasons for this are many-fold. One may be the imperative to focus on the implementation of the malnutrition risk screening procedures over the past years. Another apparent reason is the lack of consensus over diagnostic criteria. In the absence of such criteria, it is difficult to distinguish the effectiveness and efficacy of nutritional therapies when applied in different phases of the patients decline into malnutrition. The effects of nutritional therapy given at an early stage, before body protein and energy stores have been depleted, might differ as compared to when given at a late stage with overt depletion.

Previous important consensus initiatives have been attempted [7], [8], [9], and the outcomes have reflected the complexity of the issue and the difficulties to reaching consensus. It was considered that these results “… may fuel the discussion within the nutritional societies, which will most ideally lead to an international consensus on a definition and operationalism of malnutrition” [7].

There is moreover a confusion of terminology. Malnutrition, protein-energy malnutrition, undernutrition, depletion, wasting, cachexia are some of the terms used to denominate the condition that ensues deficiencies of macro- and micronutrients and catabolism of protein and energy stores due to disease and ageing. The malnutrition-related concepts cachexia [10], [11], sarcopenia [11], [12] and frailty [13] are today well-established. The current initiative doesn't challenge their definitions.

This statement is aimed at helping clinicians to effectively provide therapeutic nutritional interventions, and accordingly, to document clinically relevant malnutrition, and moreover to facilitate documentation in the Disease Related Group (DRG) and International Classification of Diseases (ICD) systems.

Malnutrition should be recognized as a serious clinical risk factor. In real clinical settings this is not the case, partly due to the lack of simple and unequivocal diagnostic criteria. It is crucial to reach consensus on diagnostic criteria for malnutrition in order to unify the terminology (e.g. for ICD-10), to enhance the legitimacy of nutritional practices, to improve clinical care and to move the clinical and scientific nutrition field forward. For this purpose the European Society of Clinical Nutrition and Metabolism (ESPEN) appointed a consensus group with a clear mission to provide criteria for the diagnosis of malnutrition.

The primary objective was to reach consensus for simple, clear and generally applicable diagnostic criteria of malnutrition in the sense of energy and protein store depletion. The intention was to provide criteria that are independent from etiologic mechanisms, and that can be used for all patients and in all clinical settings.

Secondary objectives were to try to bring clarity to the nutritional terminology, and to provide a general nutritional disorders concept tree.

Section snippets

Design of the delphi process and selection of the expert group

ESPEN decided in late 2012 to launch the initiative. In January 2013 representatives of more than 40 member countries of ESPEN outlined the initiative and acknowledged the process. An international expert group consisting of experienced clinical scientists was gathered to perform a modified Delphi process. The consensus group participants, i.e. the authors behind this report, were chosen to represent the clinical fields of medicine, surgery, intensive care, oncology and geriatrics.

It was agreed

How are screening and the diagnostic procedures interrelated?

There was a strong consensus from e-mail communications, a one-day face-to-face meeting, and an anonymous group ballot that the diagnostic procedure has to be based on the outcome of a screening evaluation. Nutritional screening is always mandatory in all clinical and care settings, since it is unanimously recognized that patients affected by acute and chronic diseases are at high risk of developing nutritional impairment. Diagnostic measures are only needed for those cases that score positive

Discussion

This ESPEN Consensus Statement provides a novel, comprehensive, yet simple, format for the diagnosis of malnutrition. The statement acknowledges the well-accepted BMI cut-off of 18.5 kg/m2 provided by WHO. In addition, it introduces an alternative and partly new format based on the combination of unintentional weight loss, and low BMI or low FFMI, where the latter drives the necessity to use modern techniques for body composition measurements. Regarding BMI, there was unanimous consensus that,

Conflict of interest

None of the authors display any CoI in the production of this manuscript. Travel expenses for the one-day meeting were reimbursed by ESPEN. No other grants from any funding agency were offered.

Fact box: Two alternative ways to diagnose malnutrition. Before diagnosis of malnutrition is considered it is mandatory to fulfil criteria for being “at risk” of malnutrition by any validated risk screening tool.

Alternative 1:

  • BMI <18.5 kg/m2

Alternative 2:

  • Weight loss (unintentional) > 10% indefinite of

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