What are the recommendations of the European Society for Clinical Nutrition and Metabolism (ESPEN) Guidelines for Nutrition Screening 2002 for identifying and managing malnutrition in patients?

ESPEN Guidelines for Nutrition Screening 2002: Recommendations for Identifying and Managing Malnutrition

The ESPEN Guidelines for Nutrition Screening 2002 recommend that all patients should be screened on admission to hospital or other institutions using validated tools such as NRS-2002 or MNA (for elderly), with screening outcomes linked to defined courses of action including nutritional care plans. 1

Key Components of Nutritional Screening

Purpose and Importance

• Approximately 30% of hospitalized patients are undernourished, with many developing further undernutrition during their stay 1
• Nutritional screening aims to predict the probability of better or worse outcomes due to nutritional factors and determine whether nutritional treatment would be beneficial 1
• Screening results must lead to appropriate interventions to improve outcomes including:
  • Improved mental and physical function
  • Reduced complications
  • Accelerated recovery
  • Reduced resource consumption (e.g., shorter hospital stays) 1

Recommended Screening Tools

1. Nutritional Risk Screening 2002 (NRS-2002)

   • Recommended for hospitalized patients 1, 2
   • Two-step screening process:
     • Initial screening: BMI <20.5, weight loss within 3 months, reduced food intake in the last week, severe illness
     • Final screening: Detailed assessment of nutritional status impairment (0-3) and disease severity (0-3)
   • Age adjustment: Add 1 point if ≥70 years
   • Score ≥3 indicates nutritional risk requiring intervention 1
   • Strong predictive value for prolonged hospitalization and postoperative complications 2, 3

2. Mini Nutritional Assessment (MNA)

   • Specifically validated for geriatric populations 1, 2
   • Incorporates important geriatric syndromes like immobility and neuropsychological problems 2
   • MNA-Short Form can be completed quickly and effectively predicts poor appetite and weight loss 2

3. Malnutrition Universal Screening Tool (MUST)

   • High specificity among screening tools 2
   • Recommended for community settings 2
   • Shows better correlation with ESPEN diagnostic criteria for malnutrition compared to NRS-2002 4

Comprehensive Nutrition Care Process

1. Screening Process

• All patients should be screened on admission to hospital or other institutions 1
• Screening should be conducted by admitting staff or community healthcare teams 1
• Screening outcomes must lead to one of four defined actions:
  • Patient not at risk: Re-screen at specified intervals (e.g., weekly)
  • Patient at risk: Staff develops nutrition plan
  • Patient at risk with metabolic/functional problems: Refer to expert
  • Uncertainty about risk status: Refer to expert 1

2. Nutritional Assessment

• For patients identified as at-risk, a detailed examination should be conducted by an expert clinician, dietitian, or nutrition nurse 1
• Assessment includes:
  • Full history and physical examination
  • Evaluation of functional consequences of undernutrition (muscle weakness, fatigue, depression)
  • Review of medications and eating patterns
  • Gastrointestinal assessment (dentition, swallowing, bowel function)
  • Laboratory tests as appropriate 1

3. Monitoring and Outcome Evaluation

• Regular monitoring of intervention effectiveness through:
  • Dietary intake recording
  • Body weight measurements
  • Functional assessments
  • Detection of possible side effects 1
• Weekly rescreening for hospitalized patients 2

4. Communication

• Nutritional data and care plans must be communicated when patients are transferred between care settings 1
• This ensures continuity of nutritional care across healthcare environments 1

5. Audit

• Systematic documentation enables audit of outcomes to inform future policy decisions 1

Special Considerations for Different Settings

Hospital Setting

• Disease factors assume greater importance alongside nutritional variables 1
• NRS-2002 is particularly effective in this setting, with good predictive value for clinical outcomes 3
• Patients with score ≥3 on NRS-2002 show higher probability of infection and 2.7 times higher risk of death 3

Elderly Patients

• MNA or MNA-SF is preferred due to high sensitivity for detecting malnutrition risk in this population 2
• For patients >65 years, MNA-SF has very high sensitivity (94.4%) but lower specificity (39.0%) 5

Community Setting

• MUST is recommended for community settings with high specificity 2
• Focus primarily on nutritional variables rather than disease factors 1

Implementation Pitfalls to Avoid

• Relying solely on BMI without considering body composition 2
• Overestimating the importance of serum albumin, which reflects inflammation more than nutritional status 2
• Failing to consider functional and psychological factors in geriatric patients 2
• Incorrectly calculating screening scores 2
• Not acting on high-risk scores with appropriate interventions 2
• Lack of communication when transferring patients between care settings 1

By implementing these ESPEN guidelines for nutritional screening, healthcare organizations can systematically identify patients at nutritional risk and provide appropriate interventions to improve clinical outcomes and reduce healthcare costs 6.