Rationale: Malnutrition is a common problem in patients with Chronic Obstructive Pulmonary Disease (COPD). Whereas estimation of fat-free muscle mass index (FFMi) with bio-electrical impedance is often used, less is known about muscle thickness measured with ultrasound (US) as a parameter for malnutrition. Moreover, it has been suggested that in this population, loss of muscle mass is characterized by loss of the lower body muscles rather than of the upper body muscles.1 Therefore, we explored the association between FFMi, muscle thickness of the biceps brachii (BB) and the rectus femoris (RF), and malnutrition in patients with COPD. Methods: Patients were assessed at the start of a pulmonary rehabilitation program. Malnutrition was assessed with the Scored Patient-Generated Subjective Global Assessment (PG-SGA). Malnutrition was defined as PG-SGA Stage B or C. FFMi (kg/m²) was estimated with bio-electrical impedance analysis BIA 101® (Akern), using the Rutten equation. Muscle thickness (mm) of the BB and the RF was measured with the handheld BodyMetrix® device (Intelametrix). Univariate and multivariate logistic regression analyses were performed to analyse associations between FFMi and muscle thickness for BB and RF, and malnutrition. Multivariate analysis corrected for sex, age, and GOLD-stage. Odds ratios (OR) and 95% confidence intervals (CI) were presented. A p-level of <0.05 was considered significant. Results: In total, 27 COPD patients (age 64±8.1 years; female 60%, GOLD-stage 3, interquartile range=3-4, BMI 27±6.6 kg/m2) were included in the analyses. In the univariate analysis, FFMi (p=0.014; OR=0.70, 95%CI: -0.12—0.15), RF thickness (p=0.021; OR=0.79, 95%CI: -0.09—0.01), and BB thickness (p=0.006; OR=0.83, 95%CI: -0.06—0.01) were all significantly associated with malnutrition. In the multivariate analysis, FFMi (p=0.031; OR=0.59, 95%CI: -0.18—0.01) and BB thickness (p=0.017; OR=0.73, 95%CI:-0.09—0.01) were significantly associated with malnutrition. None of the co-variables were significantly associated with malnutrition. Conclusion: In this relatively small sample of patients with severe COPD, low FFMi and low BB muscle thickness were both robustly associated with increased odds of being malnourished. BB muscle thickness measured with US may provide added value to the toolbox for nutritional assessment. The results of this exploratory study suggest that upper body muscles may reflect nutritional status more closely than lower body muscles. Reference: 1 Shrikrishna D, Patel M, Tanner RJ, Seymour JM, Connolly BA, Puthucheary ZA, et al. Quadriceps wasting and physical inactivity in patients with COPD. Eur Respir J. 2012;40(5):1115–22.)
Rationale: In this study, we aimed to explore how dietitians’ history-taking questions function during dietary counseling of clients with malnutrition (risk). Fruitful functioning of history-taking questions during the problem identification phase is crucial for dietitians to develop a client-centered dietary treatment plan.Methods: Using discursive psychology, we analyzed the problem identification phase of recorded dietitian-client conversations of 7 dietitians and 17 clients. Discursive psychology is a qualitative, inductive methodology that is used to analyze real-life conversations. Discursive psychology focuses on how descriptions in talk (including wording, intonation, pauses, non-verbal behavior) accomplish actions such as presenting oneself in a particular way.Results: Our analysis shows how, in response to dietitians’ history-taking questions, clients repeatedly demonstrate that they have already made some effort to self-help. Typically, these history-taking questions presume some biopsychosocial factor as the cause of the dietary problems discussed. In response, clients show they already started to eat extra, closely monitored their body weight, and tried to eat despite having no appetite. In addition, clients account for the absence of efforts by claiming various kinds of inability, such as facing difficulties in preparing food for oneself or by questioning whether their underlying medical condition caused the diet-related problem in the first place.Conclusion: This study shows that history-taking questions not only elicit answers with factual information but also evoke clients’ self-presentations. Responses from dietitians show little attention to the relevance of these self-presentations,while clients treat self-help as a normative requirement to demonstrate they have done everything they can before they sought professional help. To optimize the problem identification phase, we suggest that in addition to conversationaltechniques dietitians could increase their attention to clients’ actions performed.
This study evaluates the concurrent validity of five malnutrition screening tools to identify older hospitalized patients against the Global Leadership Initiative on Malnutrition (GLIM) diagnostic criteria as limited evidence is available. The screening tools Short Nutritional Assessment Questionnaire (SNAQ), Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST), Mini Nutritional Assessment—Short Form (MNA-SF), and the Patient-Generated Subjective Global Assessment—Short Form (PG-SGA-SF) with cut-offs for both malnutrition (conservative) and moderate malnutrition or risk of malnutrition (liberal) were used. The concurrent validity was determined by the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the level of agreement by Cohen’s kappa. In total, 356 patients were included in the analyses (median age 70 y (IQR 63–77); 54% male). The prevalence of malnutrition according to the GLIM criteria without prior screening was 42%. The conservative cut-offs showed a low-to-moderate sensitivity (32–68%) and moderate-to-high specificity (61–98%). The PPV and NPV ranged from 59 to 94% and 67–86%, respectively. The Cohen’s kappa showed poor agreement (k = 0.21–0.59). The liberal cut-offs displayed a moderate-to-high sensitivity (66–89%) and a low-to-high specificity (46–95%). The agreement was fair to good (k = 0.33–0.75). The currently used screening tools vary in their capacity to identify hospitalized older patients with malnutrition. The screening process in the GLIM framework requires further consideration.
Aanleiding Ondervoeding komt nog veel voor in Nederland, vooral bij zieken en ouderen. Dieetbehandeling bij ondervoeding bestaat uit eiwit- en energierijke voeding. Omdat de meeste verrijkte producten op dierlijke basis zijn, zijn verrijkte producten op plantaardige basis zeer beperkt. Hierdoor wordt de kans op effectieve dieetbehandeling van ondervoeding bij mensen die een plantaardige (plantbased) voeding willen gebruiken beperkt. Doel PROVE beoogt het plantbased assortiment eiwit- en energieverrijkte voeding te innoveren, vanuit samenwerking tussen leveranciers van plantaardige grondstoffen (Avebe), producenten van medische voeding (Nutricia), producenten/distributeurs van maaltijden (Van Smaak), zorginstellingen (Zorggroep Groningen, Martini ziekenhuis) en een hogeschool (Hanzehogeschool Groningen). Binnen PROVE wordt een pakket van wensen samengesteld rondom o.a. sensorische eigenschappen, productsamenstelling, houdbaarheid, milieugerelateerde eigenschappen en kosten door patiënten en diëtisten, voor een productconcept geschikt voor patiënten met (risico op) ondervoeding die plantbased willen eten. Hiermee willen we bijdragen aan de noodzakelijke verschuiving naar een meer plantbased en minder dierlijk voedingspatroon (eiwittransitie). Praktijkopbrengst Op basis van het pakket van eisen kan een plantbased productconcept worden ontwikkeld, dat bijdraagt aan een volwaardig voedingspatroon dat voorziet in de verhoogde voedingsbehoefte bij ondervoeding. Met de ruimere keuze in verrijkte producten kunnen patiënten die een plantbased voeding gebruiken hun voedingsinname en voedingstoestand beter behouden danwel verbeteren. Diëtisten zullen door een ruimere keuze aan verrijkte plantbased producten minder handelingsverlegen zijn in de dieetbehandeling van ondervoeding bij deze doelgroep. Innovatie Binnen PROVE brengen we alle schakels in de keten bijeen, van grondstof tot patiënt, waarmee we krachten bundelen en slagingskansen optimaliseren om als eerste consortium het plantbased assortiment voor patiënten met ondervoeding(srisico) uit te breiden. Vervolgonderzoek In vervolgonderzoek wordt op basis van het pakket van eisen dat voortvloeit uit het voorgestelde KIEM project een prototype van het productconcept ontworpen, waarna deze wordt geëvalueerd bij patiënten.
