ESPEN endorsed recommendation
Diagnostic criteria for malnutrition e An ESPEN Consensus Statement
T.Cederholm a ,*,I.Bosaeus b ,R.Barazzoni c ,J.Bauer d ,A.Van Gossum e ,S.Klek f ,
M.Muscaritoli g ,I.Nyulasi h ,J.Ockenga i ,S.M.Schneider j ,M.A.E.de van der Schueren k ,l ,P.Singer m
a
Departments of Geriatric Medicine,Uppsala University Hospital and Public Health and Caring Sciences,Clinical Nutrition and Metabolism,Uppsala University,Uppsala,Sweden b
Clinical Nutrition Unit,Sahlgrenska University Hospital and University of Gothenburg,Gothenburg,Sweden c
Department of Medical,Surgical and Health Sciences,University of Trieste,Trieste,Italy d Department of Geriatric Medicine,Carl von Ossietzky Universit €a t,Oldenburg,Germany e
Department of Gastroenterology,Clinic of Intestinal Diseases and Nutritional Support,Hopital Erasme,Free University of Brussels,Brussels,Belgium f
General and Oncology Surgery Unit,Stanley Dudrick's Memorial Hospital,Skawina,Poland g
Department of Clinical Medicine,Sapienza University of Rome,Rome,Italy h
Department of Nutrition and Dietetics and Department of Medicine,Monash University Central Clinical School,Prahran,Australia i
Department of Gastroenterology,Hepatology,Endocrinology,and Nutrition,Klinikum Bremen Mitte,Bremen,Germany j
Department of Gastroenterology and Clinical Nutrition,University Hospital and University of Nice Sophia-Antipolis,Nice,France k
Department of Nutrition and Dietetics,Internal Medicine,VU University Medical Center,Amsterdam,The Netherlands l
Department of Nutrition,Sports and Health,Faculty of Health and Social Studies,HAN University of Applied Sciences,Nijmegen,The Netherlands m
Department of General Intensive Care,Institute for Nutrition Research,Rabin Medical Center,Sackler School of Medicine,Tel Aviv University,Petah Tikva 49100,Israel
a r t i c l e i n f o
Article history:
Received 27February 2015Accepted 3March 2015Keywords:Malnutrition
Nutritional assessment Body composition De ?nition Consensus Delphi
s u m m a r y
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 modi ?ed 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 identi ?ed 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/m 2)<18.5to de ?ne malnutrition.Option two requires the combined ?nding 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 inde ?nite of time,or >5%over 3months.Reduced BMI is <20or <22kg/m 2in subjects younger and older than 70years,respectively.Low FFMI is <15and <17kg/m 2in females and males,respectively.About 12%of ESPEN members participated in a ballot;>75%agreed;i.e.indicated 7on a 10-graded scale of acceptance,to this de ?nition.
Conclusion:In individuals identi ?ed by screening as at risk of malnutrition,the diagnosis of malnutrition should be based on either a low BMI (<18.5kg/m 2),or on the combined ?nding of weight loss together with either reduced BMI (age-speci ?c)or a low FFMI using sex-speci ?c cut-offs.
?2015Elsevier Ltd and European Society for Clinical Nutrition and Metabolism.All rights reserved.
1.Introduction
Malnutrition due to starvation,disease or ageing can be de ?ned 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
*Corresponding author.Tel.:t46702733192.
E-mail address:tommy.cederholm@pubcare.uu.se (T.
Cederholm).
Contents lists available at ScienceDirect
Clinical Nutrition
journal h omepage:ht tp://w
https://www.doczj.com/doc/a117627659.html,/locate/clnu
https://www.doczj.com/doc/a117627659.html,/10.1016/j.clnu.2015.03.001
0261-5614/?2015Elsevier Ltd and European Society for Clinical Nutrition and Metabolism.All rights reserved.
Clinical Nutrition xxx (2015)1e 6
and impaired clinical outcome from disease”[1].Although this de?nition is well-accepted,the condition lacks clear and generally accepted diagnostic criteria.
During the famine catastrophes in Africa during the1960s,WHO brought attention to the medical aspects of starvation[2].The concepts of kwashiorkor and marasmus were introduced to de?ne a particular protein de?cient condition characterized by hypo-albuminemic peripheral edema and ascites,i.e.kwashiorkor,and a particular energy de?cient state characterized by severe weight loss due to mainly fat store depletion,i.e.marasmus.This classi?-cation 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 de?ciency and loss of protein and energy,the general term of protein-energy malnutrition(PEM) became widely accepted[3].Clinical characteristics used to de?ne PEM have varied over time,but there was never a consensus on diagnostic criteria.Various combinations of clinical,anthropo-metrical,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 dif?culties(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 com-munity settings;Nutritional Risk Screening2002(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 dif?cult to distinguish the effectiveness and ef?cacy 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 [7e9],and the outcomes have re?ected the complexity of the issue and the dif?culties 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 de?nition 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 de?ciencies of macro-and micronutrients and catab-olism 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 de?nitions.
This statement is aimed at helping clinicians to effectively pro-vide therapeutic nutritional interventions,and accordingly,to document clinically relevant malnutrition,and moreover to facili-tate documentation in the Disease Related Group(DRG)and In-ternational Classi?cation 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 scienti?c nutrition?eld 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.
1.1.The consensus group objectives
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 nutri-tional terminology,and to provide a general nutritional disorders concept tree.
2.Methods
2.1.Design of the delphi process and selection of the expert group
ESPEN decided in late2012to launch the initiative.In January 2013representatives of more than40member countries of ESPEN outlined the initiative and acknowledged the process.An interna-tional expert group consisting of experienced clinical scientists was gathered to perform a modi?ed Delphi process.The consensus group participants,i.e.the authors behind this report,were chosen to represent the clinical?elds of medicine,surgery,intensive care, oncology and geriatrics.
It was agreed within the group to base the process on open e-mail communications,face-to-face meetings and on open as well as closed ballots within the group.The intention was to maintain the communication at each step until consensus for each milestone (see below)was reached among all participants before the next step was taken.Furthermore,the group agreed to seek the opinions of the ESPEN members before deciding on the statement.Finally,it was decided to perform validation studies of the?nal statement. This paper reports the process and outcome of the Delphi process, i.e.the consensus based malnutrition diagnostic criteria,while the validation studies are on-going and will be presented separately.
2.2.De?ned milestones of the process
Overall there were?ve major milestones de?ned for the project. These were to
-decide the interrelationship between the screening and the diagnostic process.
-identify the individual criteria that cover the crucial compo-nents of the condition for all patients in all settings.For the sake of feasibility,the goal was to use as few criteria as possible.
-decide on whether and how the individual criteria should be combined to provide an expected high speci?city of the diagnosis.
-come up with clinically relevant cut-off values based on relevant reference populations for the chosen individual criteria.
Finally,an independent milestone was to decide whether the term of undernutrition or malnutrition is to be preferred.
T.Cederholm et al./Clinical Nutrition xxx(2015)1e6 2
3.Results
3.1.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 for nutritional risk by any of the validated screening tools.This consensus group does not recommend any speci?c of the validated tools,as long as the tool is validated for the setting where it is applied.Screening should be sensitive,whereas diagnosis is speci?c.Thus,fewer will be diag-nosed as suffering from malnutrition than the number of subjects that are identi?ed as being at risk.It was acknowledged that measurements that were performed during the screening process could potentially be used also for the diagnostic decision.
“Risk of malnutrition”was suggested to be as a diagnosis with its own ICD Code.The general acceptance of the prevailing malnutrition screening tools relies on the fact that ful?lling the criteria for risk of malnutrition imposes negative clinical outcomes, including death.Therefore it is crucial to commence nutritional therapy as early as possible.Such intervention generates costs. Therefore,the diagnosis of being“at risk of malnutrition”needs to be coded and reimbursed in the ICD and DRG systems.
3.2.Which individual criteria do best capture the state of malnutrition?
Nutritional variables are traditionally categorized as measures of anthropometry,including body composition,biochemical in-dicators and data related to eating capability.The latter include history as well as recording of actual food intake,or information on factors for potential limitations of food intake like anorexia, dysphagia or chewing problems.
A one-day face-to-face meeting was organized to scrutinize these potential diagnostic criteria.Functional measures of strength or power were soon dismissed as part of the diagnosis since they were consensually viewed as not nutrition speci?c enough.Thus, the following variables,or group of variables,were discussed as potential criteria.
3.2.1.Anthropometry
BMI and leg and arm anthropometry,e.g.calf circumference, arm muscle circumference and triceps skinfold,are clinically available objective variables with a fairly wide-spread use.
3.2.2.Body composition
Fat free mass(FFM)and fat mass(FM)can objectively be measured by technical devices like bioelectrical bio-impedance analyses(BIA),dual energy x-ray absorptiometry(DXA), computed tomography(CT),ultrasound or magnetic resonance imaging(MRI).
3.2.3.Weight loss
This re?ects a dynamic process that requires a negative energy balance;i.e.a reduced food intake or increased energy expenditure.
3.2.
4.Anorexia
Loss of appetite is a common complication to disease,medica-tion and ageing.It is one of the most important mechanisms behind weight loss.3.2.5.Reduced food intake
Self-reported or quanti?ed reduction of the food intake is a feature of most of the screening tools.
3.2.6.Biochemical indicators
Markers of visceral protein status,like serum concentrations of albumin have a tradition of being used as markers of nutritional status.In?ammation,due to disease or ageing,is likely the most common cause underlying the development of malnutrition.Thus, in?ammation is an important etiologic factor for malnutrition. 3.2.7.Subjective professional evaluation
After the screening procedure has identi?ed subjects at nutri-tional risk,a subjective evaluation of body composition and phys-ical function performed by experienced health professionals could indicate the diagnosis of malnutrition.
3.3.The result of the criteria ballot in the consensus group
As a result of the consensus group face-to face meeting,a questionnaire was constructed and provided to all group members where they were asked to grade their degree of acceptance from1 to6to include the following variables as one of the diagnostic criteria;i.e.weight loss,reduced BMI,reduced fat free mass index (FFMI),reduced fat mass index(FMI),reduced food intake,reduced appetite,a biochemical marker(visceral proteins or in?ammatory markers),or a subjective evaluation of a professional.The response of the questionnaire was anonymous for all but the facilitator(TC). The scores of1e2,3e4and5e6were denoted against,middle and pro,respectively.Figure1shows the result of the ballot.A fairly clear pattern emerged,as there was a preference in the group for the use of weight loss,reduced BMI and reduced FFMI.
The ensuing e-mail discussion con?rmed that the term weight loss would encompass signi?cant reductions in food intake,appe-tite loss,and for any imbalance between nutrient requirements and intake.Thus,evaluations of food intake and appetite will not add further information beyond weight loss.Nevertheless,data on intake and appetite are important for screening for malnutrition risk.
Next BMI was discussed.Low BMI is commonly accepted in the medical community,and received support from the majority of the consensus group to be one criterion.However,BMI can be misleading as the growing obesity epidemic renders a number of seriously ill and malnourished patients in the normal BMI range although they may have lost a considerable and clinically
relevant
Fig.1.Outcome of the questionnaire on the preference of the individual criteria.Group members were asked to grade from1to6;1?total disagreement and6?total agreement,on the use of each criterion.Scores of1e2was aggregated to being against, scores of5e6as being for(pro)and3e4as in between(middle).
T.Cederholm et al./Clinical Nutrition xxx(2015)1e63
amount of body mass.Due to several question marks on the use of BMI for malnutrition diagnosis some of the consensus group members suggested to omit BMI as a potential criterion.Never-theless in the?nal analysis it was unanimously decided to keep BMI for the?nal selection,due to the fact that BMI has a well-validated outcome predictive value.
For body composition,the pros and cons of fat mass and fat free mass to re?ect nutrition status was discussed.One incentive for ESPEN to launch this malnutrition diagnosis initiative was to test the grounds for promoting body composition measures for diag-nostic https://www.doczj.com/doc/a117627659.html,rmation on relative amounts of fat mass and fat free mass provides far more valuable information than BMI alone,both from functional and metabolic points of view.FFM,i.e. mainly the muscle mass was considered to provide the most rele-vant information.Muscle confers ability to activity,acts as the amino acid pool and is important for energy expenditure and glucose metabolism[14].
According to biochemical indicators,the perception was that visceral proteins like serum albumin concentrations are good in-dicators of disease severity and outcome.In?ammation is today considered the major reason for reduced serum levels of visceral proteins.Thus,visceral proteins should not be used for either screening or diagnosis of malnutrition.The low grade of nutrition speci?city was the major reason for this decision.The question of integrating a biochemical indicator of in?ammatory activity,e.g.C-reactive protein,into the diagnostic format raised another discus-sion.In?ammation has a central etiologic role for catabolism and is an integral feature of cachexia.Thus,in?ammation is rather to be regarded as an etiologic factor than a diagnostic feature of malnutrition.The same reasoning goes for indicators of potential anabolic activity,e.g.insulin-like growth factor-1.
The Consensus group decided that all criteria should be objec-tive as far as possible.Diagnosis by subjective evaluation by an experienced health professional did not meet this criterion.
3.4.Is there an optimal combination of criteria?
Thus,three variables were chosen to most accurately re?ect malnutrition,namely weight loss,reduced BMI and reduced FFMI. The next question was whether and how to combine the variables to best capture the diagnosis.
For this purpose the group performed a second anonymous ballot based on a questionnaire that comprised nine options.For each option,any of the three favored variables was suggested to be mandatory and combined with one or both of the other two vari-ables.Eight out of ten answers were positive for the option where unintentional weight loss should be mandatory,and weight loss should be combined with either reduced BMI or with reduced FFMI. Consensus was reached to suggest both alternatives,i.e.either weight loss and reduced BMI,or weight loss and reduced FFMI, should give the diagnosis of malnutrition.In real clinical life access to body composition measurements is limited,which justi?es keeping both alternatives.
3.5.Which are the clinically relevant cut-off values for the chosen individual criteria?
The next challenge was to?nd valid and clinically relevant cut-off values for weight loss,BMI and FFMI.
3.5.1.Weight loss
Weight loss trajectories differ with clinical condition.Never-theless,involuntary weight loss is a strong predictor of negative outcomes irrespective of magnitude,speed and underlying cause. Naturally,a massive and fast weight loss due to an aggressive cancer disease imposes a higher risk than a smaller and slower weight loss due to ageing.
Thus,consensus was reached to propose two optional cut-offs for unintentional weight loss;i.e.either>5%over the last3 months to cover for acute illnesses,or>10%of habitual weight inde?nite of time to be relevant for chronic conditions.
3.5.2.BMI
WHO advocates BMI<18.5kg/m2as a general cut-off for un-derweight.This cut-off is justi?ed at a public health population level[15],whereas its relevance for clinical and care settings may be questioned.As already mentioned the trend of increasing BMI in all populations world-wide make this acknowledged BMI cut-off value dif?cult to use for the purpose of de?ning malnutrition.Pa-tients struck with highly catabolic diseases may in3e6months lose substantially more than10%of their weight and still have BMI values well above“normal”ranges.Another issue to consider is that epidemiological evidence indicates that older populations display higher optimal BMI intervals(e.g.for survival)than younger people.
Partly due to the strong global acceptance of the WHO cut-off of 18.5kg/m2it was decided unanimously to accept the WHO rec-ommended cut-off of as a criterion that in its own right will be enough to diagnose malnutrition.
With this latter decision it was easy to come to consensus for a complementary suggestion for relevant BMI cut-off values;namely <20kg/m2for subjects<70years of age,and<22kg/m2for subjects 70years and older,remembering the fact that these BMI levels need to be linked to weight loss as de?ned above.The choices of20and 22kg/m2,respectively,were based on consensus in the group. Ethnic and regional variability in BMI may need to be considered.
3.5.3.FFMI
Cut-offs for FFMI need to be linked to the decided cut-offs for BMI on one hand,and to the fact that women have lower FFMI(and higher FMI)than men on the other hand.Based on Swiss reference material[16]it was decided to suggest FFMI<15and<17kg/m2in women and men,respectively.It has to be emphasized that refer-ence values,like for BMI,should be relevant for the speci?c ethnic and cultural context that is at hand.
The result of this process is summarized in the Fact box.
3.6.ESPEN membership ballot
For transparency,implementation and awareness purposes the ?nal consensus group suggestion for the malnutrition
diagnostic
T.Cederholm et al./Clinical Nutrition xxx(2015)1e6 4
criteria was presented to the membership of ESPEN to vote for.The ESPEN Newsletter provided the questionnaire by e-mail to all members (~around 3000world-wide).Members were asked to grade their acceptance of the suggestion,as presented in the Fact box,on a scale from 1(very low)to 10(very high).Altogether 344members gave their vote.Figure 2shows the result of the poll;i.e.>75%of the voting members gave a score of 7or more in agreement of the suggestion.A score of 4or less indicating disagreement was given by 10%of the voters.According to the given comments from the members that gave low scores,the absence of functional measures was the major reason for disagreement.3.7.Terminology of malnutrition or undernutrition and the conceptual tree of nutritional disorders
The general perception of the group was that malnutrition and undernutrition is about equally used in the scienti ?c literature and in clinical practice,with a slight preponderance for malnutrition.A potential problem with the term malnutrition is that it literally covers all deviating nutritional states.In the ?rst in-group ballot performed,the group members were asked to anonymously state their preference.The two terms received an equal number of votes,i.e.5vs 6.The pro and con arguments were not strongly in favor of any of the terms and it was decided to leave the question open for the ESPEN member ballot to give a stronger advice.
Thus,in the same ESPEN Newsletter that encouraged ESPEN members to vote for or against the suggested diagnostic criteria (see above),the members were also asked to give their opinion on whether they preferred the term of malnutrition or of undernu-trition.The vote came out as indecisive and split as in the smaller
poll among the consensus group.Malnutrition had a slight pre-ponderance with 53%of the votes as compared to 47%in favor of undernutrition.Due to this uncertain result the consensus group doesn't advocate any speci ?c term,but has chosen to use malnu-trition for this paper.
Finally,a conceptual tree of prevailing nutritional disorders was constructed (Fig.3),acknowledging the complex interactions be-tween the conditions.The structure of Fig.3was discussed as some in the consensus group preferred a less hierarchical arrangement of the conditions.4.Discussion
This ESPEN Consensus Statement provides a novel,compre-hensive,yet simple,format for the diagnosis of malnutrition.The statement acknowledges the well-accepted BMI cut-off of 18.5kg/m 2provided 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 mea-surements.Regarding BMI,there was unanimous consensus that,in the presence of signi ?cant weight loss,BMI levels higher than 18.5kg/m 2may also re ?ect suf ?ciently altered nutritional state to warrant the diagnosis of malnutrition.The proposed cutoff values of 20(<70y)and 22( 70y)kg/m 2was the result from consensus within the group.Validation studies have been launched to possibly con ?rm these indications.
Recent years have seen the development of several malnutrition screening tools,for example NRS-2002,MNA-SF and MUST,which should be used for everybody that comes in contact with health and elderly care.The purpose is to identify the individuals that will need further nutritional assessment and that will need nutritional therapy,in order to prevent the further nutritional deterioration into malnutrition.To be de ?ned as “at risk ”for malnutrition ac-cording to any of the validated screening tools should render its own ICD Code.Many of the validated screening tools in clinical use today also provide grading into manifest malnutrition as well,which is somewhat beyond their primary purpose.Since NRS-2002,MNA-SF and MUST use different criteria and cut-offs,and were designed for different purposes and populations [17],the preva-lence of malnutrition in a speci ?c population will differ with the screening tool used.Moreover,as indicated the appropriate eval-uation of nutritional therapy effects is affected by when the therapy is applied,i.e.in late or early phases of malnutrition,as well as by variations in the diagnostic criteria [18].These examples illustrate how acknowledgment and development of clinical nutrition may suffer from the lack of clear diagnostic criteria for malnutrition.
As indicated the purpose of this initiative was to provide a general diagnosis that is relevant for all subjects in all clinical set-tings.Recent years have seen the advent of improved conceptual-ization and better understanding of different forms of nutritional disorders and malnutrition (Fig.3).Nevertheless,the de ?nition is meant to be valid for all individuals no matter if starvation,acute or chronic disease or ageing is the dominant underlying cause of the state of malnutrition.As with all general diagnoses (compare anemia)they need to be elaborated into sub-diagnoses which indicate their etiologies to facilitate the best treatment.Thus,this ESPEN statement also provides a conceptual tree where pure star-vation,disease-related malnutrition (cachexia)[10,11],and the concepts of sarcopenia [11,12]and frailty [13]are related to,and at least partly over-arched by the general term of malnutrition.
The concepts of cachexia and sarcopenia pinpoint the impor-tance of variations in body composition,i.e.fat and muscle mass,as predictors of clinical outcome.The two-compartment model for body composition,i.e.FMI and FFMI,offers a more
precise
“We want you to indicate on a scale from 1to 10whether you agree strongly ?10,or disagree strongly ?1,with this suggestion ”(see Fact
box).
Fig.3.A conceptual tree of nutritional disorders.
T.Cederholm et al./Clinical Nutrition xxx (2015)1e 65
description of the investigated subject than for example BMI,and is thus providing a clearer justi?cation for clinical decisions.There-fore,it was encouraging to see the strong consensus of the group to advocate the potential requirement of FFMI for the diagnosis of malnutrition.Devices for body composition measurements,e.g. bioelectrical impedance analyzers and DXA machines,are not readily available for daily routine care.Thus it was crucial to not to mandate FFMI for the diagnosis of malnutrition.This Consensus Statement will hopefully drive and promote the need to develop accessible techniques for body composition measurements in all health care settings,i.e.at hospital wards,in primary care,in nursing homes as well as in home elderly care.
Beyond the identi?cation of diagnostic criteria this initiative also aimed to clarify whether the term malnutrition or undernu-trition is to be preferred.As reported above the vote,in the consensus group as well as among the voting ESPEN membership, was more or less split in two halves.For the moment there is a small preponderance for the use of malnutrition in the nutrition com-munity.The uncertain outcome of this issue doesn't justify any strong recommendation.
In conclusion,this ESPEN Consensus Statement has rendered a clear and simple format for the diagnosis of malnutrition.Parallel initiatives are on-going.The strong objective of the current ESPEN statement is to provide malnutrition diagnostic criteria that are independent of etiology,whereas other initiatives state that they aim to provide etiology-driven criteria[8,9].The various global initiatives need to be linked and in the long run it is crucial to reach a global consensus on this important issue.On-going and future validation studies will provide data that may con?rm the feasibility of,or be used to update,the malnutrition criteria of this ESPEN Consensus Statement.
Con?ict of interest
None of the authors display any CoI in the production of this manuscript.Travel expenses for the one-day meeting were reim-bursed by ESPEN.No other grants from any funding agency were offered.
References
[1]Sobotka L,editor.Basics in clinical nutrition.4th ed.Galen;2012.
[2]Jeliffe DB.The assessment of the nutritional status of the community..Geneva:
World Health Organization;1966.Monograph Series No.53.
[3]Waterlow JC,Tomkins AM,Grantham-McGregor SM.Protein energy malnu-
trition.London:Edward Arnold;1992.
[4]Buzby GP,Mullen JL,Matthews DC,Hobbs CL,Rosato EF.Prognostic nutritional
index in gastrointestinal surgery.Am J Surg1980;139:160e7.
[5]Detsky AS,McLaughlin JR,Baker JP,Johnston N,Whittaker S,Mendelson RA,
et al.What is subjective global assessment of nutritional status?JPEN J Parenter Enter Nutr1987;11:8e13.
[6]Kondrup J,Allison SP,Elia M,Vellas B,Plauth https://www.doczj.com/doc/a117627659.html,cational and clinical
practice committee,European society of parenteral and enteral nutrition (ESPEN).ESPEN guidelines for nutrition screening2002.Clin Nutr2003;22: 415e21.
[7]Meijers JM,van Bokhorst-de van der Schueren MA,Schols JM,Soeters PB,
Halfens RJ.De?ning malnutrition:mission or mission impossible?Nutrition 2010;26:432e40.
[8]Jensen GL,Mirtallo J,Compher C,Dhaliwal R,Forbes A,Grijalba RF,et al.In-
ternational consensus guideline committee.Adult starvation and disease-related malnutrition:a proposal for etiology-based diagnosis in the clinical practice setting from the International consensus guideline Committee.Clin Nutr2010;29:151e3.
[9]White JV,Guenter P,Jensen G,Malone A,Scho?eld M.Academy malnutrition
work Group;A.S.P.E.N.Malnutrition task force;A.S.P.E.N.Board of Directors.
Consensus statement:academy of nutrition and dietetics and american soci-ety for parenteral and enteral Nutrition:characteristics recommended for the identi?cation and documentation of adult malnutrition(undernutrition).
J Parenter Enter Nutr2012;36:275e83.
[10]Evans WJ,Morley JE,Argil e s J,Bales C,Baracos V,Guttridge D,et al.Cachexia:
a new de?nition.Clin Nutr2008;27:793e9.
[11]Muscaritoli M,Anker SD,Argil e s J,Aversa Z,Bauer JM,Biolo G,et al.Consensus
de?nition of sarcopenia,cachexia and pre-cachexia:joint document elabo-rated by Special Interest Groups(SIG)“cachexia-anorexia in chronic wasting diseases”and“nutrition in geriatrics.Clin Nutr2010;29:154e9.
[12]Cruz-Jentoft AJ,Baeyens JP,Bauer JM,Boirie Y,Cederholm T,Landi F,et al.
European Working Group on Sarcopenia in older people.Sarcopenia:Euro-pean consensus on de?nition and diagnosis:report of the European Working Group on Sarcopenia in Older People.Age Ageing2010;39:412e23.
[13]Fried LP,Tangen CM,Walston J,Newman AB,Hirsch C,Gottdiener J,et al.
Cardiovascular health study collaborative research group.Frailty in older adults:evidence for a phenotype.J Gerontol A Biol Sci Med Sci2001;56: M146e56.
[14]Biolo G,Cederholm T,Muscaritoli M.Muscle contractile and metabolic
dysfunction is a common feature of sarcopenia of aging and chronic diseases: from sarcopenic obesity to cachexia.Clin Nutr2014;33:737e48.
[15]WHO.Physical status:the use and interpretation of anthropometry.Report of
a WHO expert committee.World Health Organization technical report series
854.1995.
[16]Schutz Y,Kyle UU,Pichard C.Fat-free mass index and fat mass index per-
centiles in Caucasians aged18-98y.Int J Obes Relat Metab Disord2002;26: 953e60.
[17]van Bokhorst-de van der Schueren MA,Guaitoli PR,Jansma EP,de Vet HC.
Nutrition screening tools:does one size?t all?A systematic review of screening tools for the hospital setting.Clin Nutr2014;33:39e58.
[18]Milne AC,Potter J,Vivanti A,Avenell A.Protein and energy supplementation
in elderly people at risk from malnutrition.Cochrane Database Syst Rev 2009;15(2):CD003288.
T.Cederholm et al./Clinical Nutrition xxx(2015)1e6 6
营养评价标准 Company number：【0089WT-8898YT-W8CCB-BUUT-202108】
营养评价（肥胖和营养不良评价）：B M I 一、肥胖评价指标：BMI 中国学龄儿童青少年超重、肥胖筛查BMI分类标准 二、营养不良评价：见表：中国6-19岁男女学龄儿童青少年分年龄BMI筛查消瘦界值范围 学龄儿童青少年营养不良筛查标准范围 本标准给出6～19岁学龄儿童青少年营养不良筛查方法(包括营养不良筛查的界值点范围判断、说明及技术要求)和报告要求。 本标准适用于我国所有地区不同社会经济背景群体（包括各少数民族）的学龄儿童青少年，即小学、中学、大学学生。因各种原因不在学校而年龄在6～19岁范围的儿童少年同样适用。对那些正处于各种急、慢性疾患状态的个体，本标准可成为判断其现时营养状况的参照依据，但在未经诊断排除各种遗传、代谢性疾患情况下，不能简单将其病因归结为“膳食性营养不良”。 1 规范性引用文件
下列文件对于本文件的应用是必不可少的。凡是注日期的引用文件，仅注日期的版本适用于本文件。凡是不注日期的引用文件，其最新版本（包括所有的修改单）适用于本文件。 GB/T 26343-2010 学生健康检查技术规范 2 术语和定义 下列术语和定义适用于本文件。 营养不良：专指因膳食缺乏导致的蛋白质-热量营养不良 protein energy malnutrition, PEM 用以反映儿童膳食营养缺乏的宏量指标，不包括其他特异性维生素、微量元素缺乏性营养不良。 生长迟缓 stunting 主要起因于胎、婴、幼儿阶段的膳食蛋白质-热量摄入不足，导致身高（3岁前身长）低于筛查标准的年龄别身高（stature-for-age）界值范围，属长期性营养不良。 消瘦 wasting 是组成“营养不良”的另一主要成分，属即时性营养不良，起因于现时性的膳食蛋白质-热量摄入不足，导致BMI（Body mass index）低于筛查标准的年龄别BMI界值范围。 身材矮小 short stautue 凡身高低于年龄别身高（stature-for-age）界值范围但高于“生长迟缓”界值范围者，称“身材矮小”。 3 营养不良筛查方法 3.1 分年龄身高筛查生长迟缓界值范围 6～19岁男女学龄儿童青少年分年龄身高筛查生长迟缓界值范围见表，界值点曲线见图。 3.2 分年龄BMI筛查消瘦界值范围 6～19岁男女学龄儿童青少年分年龄BMI筛查消瘦界值范围见表，界值点曲线见图、图。 3.3 营养不良的判断 使用表界值范围进行生长迟缓判断。凡身高小于或等于相应性别、年龄组“生长迟缓”界值点者为生长迟缓。 使用表界值范围进行消瘦判断。凡BMI小于或等于相应性别、年龄组“中重度消瘦”界值点者为中重度消瘦；凡BMI处于相应性别、年龄组“轻度消瘦”界值范围者为轻度消瘦。 3.4 营养不良筛查说明及技术要求
进行性肌营养不良症 百科名片 进行性肌营养不良症 进行性肌营养不良症(英文：progressive muscula dystrophy，PMD)是一种原发横纹肌的遗传性疾病。临床上主要表现为由肢体近端开始的两侧对称性的进行性加重的肌肉无力和萎缩，个别病例尚有心肌受累。有人报道进行性肌营养不良约占神经系统遗传病的29．4％，是神经肌肉疾病中最多见的一种。 概述 进行性肌营养不良症，是一种随着年龄增长，肌肉逐渐萎缩，使行动能力渐渐消失 进行性肌营养不良症 直至完全丧失生活自理能力的疾病。患者最终只能眼睁睁地等待着自己由于心肌衰竭而死亡，国际医学界形象地称之为“渐冰人”。该病症已被International Seven Three Society(国际七三学社)列入十大医学课题进行研究。 进行性肌营养不良症是一组渐进性遗传性骨骼肌变性疾病。主要临床特征为选择性受累的骨髓肌呈渐进性对称性无力和萎缩，最终丧失运动功能。本病为单基因遗传，发病年龄为5～6 岁左右，发生率为出生男婴的13～33/105 。近年研究认为其病变的基本原因在于肌肉细胞膜的异常。
西医定义 进行性肌营养不良症是一组病因不明的，遗传性、进行性肌肉疾病。临床上以进行性加重的肌肉萎缩和无力为其主要特征。 临床表现 假肥大型 (Duchenne型) 由Duchenne (1868年)首先描述，是儿童中最常见的一类肌病。属性连隐性遗传，几乎均影响男孩，占活产男婴的l／3 000～1／4 000(欧美)和l／22 000(日本)。_女性仅为异性染色体携带者，不发病。多于儿童期起病，常以骨盆带肌无力、肌张力低、走路缓慢、易跌为首发症状。病情进展较迅 进行性肌营养不良症 速，可逐渐累及肩胛带、四肢远端肌群及面肌。背部伸肌无力则站立时腰椎过度前凸，臀中肌无力则行走时骨盆向两侧摆动，呈典型的“鸭步”；患儿仰卧位站起时，先翻转为俯卧位，再用双手支持床面及下肢才能缓慢站起称Gowers征；由于肩胛带肌及前锯肌无力，可呈现“游离肩”和“翼状肩胛”，以上为该型的特征性表现。约90％的患儿有肌肉的假性肥大，以腓肠肌最明显，三角肌、股四头肌、臀肌、冈下肌、肱三头肌及舌肌等也可受累。多半患儿还伴有心肌损害，约30％患儿伴有不同程度的智能障碍，病情多呈进行性加重，是进行性肌营养不良症中预后最差的一个类型，多数在15岁左右即不能行走，大部分患者在25～30岁以前因呼吸感染、心力衰竭或慢性消耗而死亡。另外，尚有一种与此型临床表现类似的类型，称为良性假肥大型(Becker型)，由Becker(1957年)首先报道，常在5～25岁期间缓慢起病，病程较长，多在起病后15～20年才不能行走，占出生男孩的3～6／10万，心肌受累少见，智力多正常。 疾病症状 体征:本病根据病患的主要临床特征、起病年龄、肌无力的分布以及病程的长短，大体可以分为以下几型。（一）症状\r\n1．假性肥大型（Duc he nne
MSIS标准 肌肉与骨骼感染协会(Muscularskeletal Infection Society,MSIS)召集一组专家深入分析了现有证据，并在此基础上对假体周围关节感染作出新的定义。 符合以下标准，假体周围关节感染明确存在。①存在与假体相通的窦道；或②受累人工关节的2处假体周围组织或关节液标本中分离出同一病原体；或③满足以下6条中4条：?红细胞沉降率(ESR)或C反应蛋白(CRP)水平升高，?滑膜白细胞计数升高，?滑膜中性粒细胞(PMN)百分比升高，?受累关节出现化脓表现，?假体周围组织或关节液标本中1次培养分离出微生物，?400倍放大率下，假体周围组织的病理学分析在5个高倍镜视野下发现>5个中心粒细胞。若满足标准③中少于4条，假体周围关节感染可能存在。 AAOS标准共识 假体周围感染 2010年6月18日 1．在没有可靠证据来将髋膝关节置换术后假体周围感染的可能性进行分层的情况下，建议将患者分为假体周围感染高度可能性和低度可能性两组，以便进一步进行不同的检查而明确诊断。推荐强度：专家共识 假体周围感染高度可能性定义：有至少1项假体周围感染的临床表现（疼痛和/或僵硬），并同时具备以下至少1项者：（1）具有假体周围感染的危险因素；（2）有假体周围感染的体征（关节红肿皮温高或窦道形成）；（3）X线可见早期（置换术后5年以内）假体松动或骨溶解。 假体周围感染低度可能性定义：只有1项假体周围感染的临床表现（疼痛或僵硬），同时不具备以下任何1项者：（1）具有假体周围感染的危险因素；（2）有假体周围感染的体征（关节红肿皮温高或窦道形成）；（3）X线可见早期（置换术后5年以内）假体松动或骨溶解。（假体周围感染的危险因素。） 具有循证证据的危险因素如下：被置换关节之前有过感染史（膝）；手术时皮肤切口处有浅表感染（髋和膝）；肥胖（髋）；手术时间超过2.5小时（髋和膝）；免疫抑制状态（膝）（具体指：HIV感染、糖尿病、肝炎、接受化疗或应用免疫抑制药物、自身免疫疾病、炎症性关节炎、慢性肾功能不全、肝衰竭、营养不良、镰状细胞病、血友病以及实体器官移植的患者）。 专家共识的危险因素如下：最近1年内有过细菌或真菌感染；该关节在关节置换后以往已发生过感染；皮肤病（银屑病、慢性蜂窝织炎、淋巴水肿、慢性静脉瘀滞、皮肤溃疡）；使用静脉注射的药物；最近3年内有过耐甲氧西林金黄色葡萄球菌（MRSA）感染或定植；其它部位的活动性感染。 2．将红细胞沉降率（ESR）和C反应蛋白（CRP）作为诊断髋膝关节置换术后假体周围感染主要评估指标。推荐强度：强
中医治愈奇病 进行性肌营养不良症(痿症) [病案]黄某,男,40岁。1975年3月10日初诊。患者于1974 年6月底患泄泻,治愈后一周发现右手拧不动自来水龙头,左 手亦觉无力,难以蹲下,以后手足无力日益明显,症状逐渐加重,以致体重减轻消瘦,肌肉萎软,上肢不能上举,穿衣脱衣亦需他 人帮助,平卧时抬头困难,下肢不能自行蹲下站起,大便时要扶 着凳子,不能上下公共汽车,手脚及小腿显得肥大,穿鞋由39 码改为41码,全身有僵硬感,上述症状与睡眠休息却无关系。患者皮肤干燥搔痒,口不干饮食减少,既不能饱食,不耐饥饿, 毛发腋毛易于脱落,面色黯滞多黑斑,舌质两边及口唇均有大 片青紫色瘀斑,两少腹亦有大片棕色斑块,脉缓软。检查:肌肉 消瘦萎软,右手肘后部及右眼眶上部各有一慢性溃疡面,不化脓,但亦久久不能愈合,其他无异常。曾去多方求治,均诊断为“进行性肌营养不良症”(假性肥大型),治疗数月无效。 [治则]益气活血化瘀。 [方药]黄芪30～120克,川芎6克,当归尾9克,桃仁9克,赤芍9克,地龙9克,川牛膝9克。每剂3次服,服药30余剂,自觉肢 体较前有力,活动亦有进步,毛发脱落得到控制,但皮肤搔痒加剧,故方中加桂枝6克,炙甘草12克。再服50多剂,患者上肢 抬举较高,能半蹲拾东西,两处慢性溃疡亦渐好转,毛发始长新。
以后改用健脾升气活血化瘀,用黄芪30克,党参15克,升麻6克,柴胡6克,陈皮3克,当归9克,白术9克,桂枝6克,赤芍9克,炙甘草9克。再服30多剂,患者手能上举,能自己穿衣服,能蹲下,两溃疡区基本愈合,唇舌、少腹瘀斑消退,病情好转。以后用补中益气汤合桂枝甘草汤加赤芍、丹参。前后服药近半年,四肢力量恢复正常,形体肥满,不仅生活能自理,能上下 公共汽车,步行10余公里亦不觉累,诸症均恢复正常,手可提20公斤重东西。随访一年正常。(见《新中医》1977年第4期) [评析]进行性肌营养不良症多认为是一种遗传性疾病。本患者尚未发现有关线索,该病属于中医痿证范畴,患者唇舌有瘀斑,少腹有斑块,面色黯滞,瘀血症状突出,毛发脱落亦为瘀,故《医林改错》云：“不知皮里肉外血瘀,阻塞血路,新血不能养发,故发脱落。”又因脾主肌肉,主四肢、四肢不用,肌肉萎软脾虚之故,所以开始以补阳还五汤加味主治。以后病情有所进步,改用健脾升气佐活血化瘀之品,使脾健,饮食精微得以上升,又因祛瘀使脉络通,使饮食精微得以运行输布,使肌肉得到充分营养,故而治愈。(李祥云)
小儿营养不良的治疗原则和临床评价 小儿营养不良一般是指蛋白质 - 能量营养不良（protein –energy malnutrition, PEM），是由于缺乏能量和/或蛋白质等常量营养素而致的慢性营养缺乏症，主要见于婴幼儿期。临床表现为进行性消瘦、体重减轻或水肿，严重者常有脏器功能紊乱，死亡率较高，是发展中国家儿童死亡的主要原因之一。 营养不良的非医学原因是贫穷、食物短缺；家长缺乏营养知识，忽视科学喂养方法，也是导致患儿食物短缺的非医学原因。但患儿的发病原因大多不是单纯的食物短缺。在营养不良、社会习惯、环境和急、慢性疾病之间存在着复杂的交互影响，并不是单单提供适当的食物即可解决的问题。因此，儿科临床医生有必要加强对小儿营养不良的认识，全面认识其复杂的发病原因和临床情况，对患儿进行正确细心的临床评价，掌握治疗原则和方法，以改善患儿的营养及健康状况，提高救治成功率。 1临床诊断和评价 1.1诊断线索根据患儿体重不增或减轻、皮下脂肪减少及全身各系统功能障碍的表现，及其它营养素缺乏的症状和体征，重度病例诊断不难，轻度者可被忽视。定期对体重、身长、皮下脂肪、上臂围等生长发育指标进行监测，有利于轻度或早期营养不良患儿的诊断。确诊后还需详细询问病史和进一步检查，以做出病因诊断。
1.2 诊断依据小儿营养不良的诊断，依据的是患儿的病史、临床表现、体格测量和辅助检查，临床医生需综合分析这些临床资料，才能做出正确、全面的诊断。 1.2.1病史应掌握小儿的膳食摄入情况、饮食习惯，进行膳食调查以评价蛋白质和热能的摄入情况，有无影响消化和吸收的慢性消耗性疾病的存在，并了解家庭的一般状况，家属的生长模式、家长的身高、体重和对孩子的关心程度。 1.2.2临床表现①消瘦型：以总热量缺乏为主，兼有蛋白质缺乏，又称为能量营养不良，患儿最早出现的症状是体重不增，继之体重减轻，消瘦、皮下脂肪减少，皮下脂肪消减先自腹部开始，以后依次为躯干、四肢、臀部，最后为面部，腹部皮下脂肪层是判断营养不良程度的重要指标之一。病久者皮肤干燥、苍白，烦燥不安，肌肉松驰，身高也低于正常。病情进一步加剧时体重明显减轻，皮下脂肪大量消耗，各种临床症状也逐步加重，肌肉萎缩，肌张力低下，精神萎靡、反应差，体温偏低，心音低钝、脉细无力，食欲低下，常腹泻、便秘交替。尿浓缩功能障碍，出现多尿和尿比重低。②水肿型：以蛋白质严重缺乏为主，而总热量接近需要量，又称蛋白质营养不良，多发生于单纯谷粉喂养的小儿，轻者仅下肢水肿，重者外生殖器、上肢、腹部及颜面部等均有凹陷性水肿，也可见胸水、腹水，常有食欲减退、精神不振、肝脏肿大。③混合型：临床表现介于两者之间。
疾病名：进行性肌营养不良症 英文名：progressive myodystrophy 缩写： 别名：progressive muscular dystrophy；进行性肌萎缩；进行性肌营养不良ICD号：G71.0 分类：神经内科 概述：进行性肌营养不良症(progressive myodystrophy)是一组由遗传因素所致的原发性骨骼肌疾病，其临床主要表现为缓慢进行的肌肉萎缩、肌无力及不同程度的运动障碍。本病可由多种遗传方式引起，其临床表现各具有不同的特点，因而形成许多类型。本节仅就其中较主要的类型进行概要介绍。 流行病学：多发生于儿童和青少年。Duxhenne型(Duchenne muscular dystrophy，DMD)是肌营养不良中发病率最高的一型，其发病率为30/10万。Becker型(Beker muscular dystrophy，BMD)发病率为3/10万。远端型、眼肌型及眼咽型等均较少见。 病因：本病的发病机制研究已为世人所瞩目。数十年来，相继提出的有血管性、神经性、肌纤维再生错乱和细胞膜缺陷等学说，但大量的研究证据表明细胞膜缺陷在本病发生有重要地位。三分之一新生男婴患儿是由于基因突变所引起。 随着分子生物学研究的深入开展，本病的病因和发病机制有了进一步阐明。已明确本病是一类单基因遗传病，遗传方式多样，不少致病基因已得到定位和克隆，部分基因产物已得到阐明，有的致病基因尚不明。相关基因位点突变可引起其表达产物肌膜结构蛋白的缺陷和异常而致病。 对其不同类型、不同亚型的分子机制也有了新的认识。其中以Duchenne 型和Becker型肌营养不良(DMD，BMD)的研究最为深入。DMD为X连锁隐C D D C D D C D D C D D
临床营养评价 临床医生在对病人进行营养治疗前必需对病人的营养现状作出正确判断，以便合理地进行临床营养治疗。目前使用较普遍的临床营养评价方法有两种：一种是以测定身体组成为主（body compsition assessment BCA ）的临床营养评价方法；另一种则是主观的全面评价方法（subjective global assessment SGA ）。前者需要测定病人的身高、体重、三头肌皮褶厚度、血浆蛋白、氮平衡等客观资料；后者则主要依靠详尽的病史和体格检查等资料。 （一）BCA 临床营养评价方法 1977年Blackburn 所研究的BCA 营养评价方法在临床得到使用，此后随着医学科学的发展，更多的新技术被用到身体组成的测定中，使BCA 法得到不断完善，如用稳定同位素测定身体中的各种元素，用中子活化分析法测定病人的身体组成等等。但上述新技术往往需要昂贵的设备，不适合临床医生对病人作简易快速的营养评价，本文作重介绍的BCA 营养评价方法主要包括人体测量及生化检验等方面的资料，临床医生需对这些资料进行综合分析才能对病人的营养状态作出正确判断。 1．人体测量 人体测量是简便易行的营养评价方法，内容包括身高、体重、皮褶厚度、上臂围、上臂肌围等，上述指标的意义及测定方法在本章第二节的居民营养状况评价中已有详细阐述，临床要注意的是：急性、饥饿性或消耗性疾病或创伤，体重下降达原来体重的30%时，是一个致死的界限，临床工作者不一定能注意到这一点；而当慢性体重丧失时，病人可耐受大于30%的体重丧失。 临床称量病人体重后可通过计算三个参数来评定营养状况：①理想体重百分率（%），表示病人实际体重偏离总体标准的程度；②通常体重百分率（％），表示平常体重的改变；③近期体重改变率（％），表示短期内体重损失的程度。计算公式和评价标准如下（表1及表2）： 100*%患者平时体重 患者现体重 患者平时体重）体重变化（-= 实际体重 理想体重百分率（%）= ?100 理想体重 实际体重 通常体重百分率（％）= ?100 通常体重 通常体重-实测体重 近期体重改变率（％）= ?100 通常体重 表1 依据体重对营养状态进行评定 正常 轻度营养不良 中度营养不良 重度营养不良 理想体重百分率（%） >90 80~90 60~80 <60 通常体重百分率（％） >95 85~95 75~85 <75 表2 近期体重改变率对体重损失的评定（仅供参考） 时间 显著体重损失 严重体重损失 1周 1~2% >2%
营养评价标准BMI 一.肥胖评价指标：BMI 中国学龄儿童青少年超重.肥胖筛查BMI分类标准年龄岁男超重 Kg/m2 男肥胖 Kg/m2 女超重 Kg/m2 女肥胖 Kg/m2718.120.318.119.9919.622.520.022.11121.024.721.924.5 1322.626.423.026.31523.527.423.727.41724.028.024.028.0 2. 营养不良评价：见表：中国6-19岁男女学龄儿童青少年分年龄BMI筛查消瘦界值范围学龄儿童青少年营养不良筛查标准范围本标准给出6～19岁学龄儿童青少年营养不良筛查方法(包括营养不良筛查的界值点范围判断.说明及技术要求)和报告要求。 本标准适用于我国所有地区不同社会经济背景群体（包括各少数民族）的学龄儿童青少年，即小学.中学.大学学生。因各种原因不在学校而年龄在6～19岁范围的儿童少年同样适用。对那些正处于各种急.慢性疾患状态的个体，本标准可成为判断其现时营养状况的参照依据，但在未经诊断排除各种遗传.代谢性疾患情况下，不能简单将其病因归结为“膳食性营养不良”。 1 规范性引用文件下列文件对于本文件的应用是必不可少的。凡是注日期的引用文件，仅注日期的版本适用于本文件。凡是不注日期的引用文件，其最新版本（包括所有的修改单）适用
于本文件。G B/T26343-xx 学生健康检查技术规范2 术语和定义下列术语和定义适用于本文件。 营养不良：专指因膳食缺乏导致的蛋白质-热量营养不良protein energy malnutrition, PEM 用以反映儿童膳食营养缺乏的宏量指标，不包括其他特异性维生素.微量元素缺乏性营养不良。 生长迟缓 stunting 主要起因于胎.婴.幼儿阶段的膳食蛋白 质-热量摄入不足，导致身高（3岁前身长）低于筛查标准的年龄别身高（stature-for-age）界值范围，属长期性营养不良。 消瘦 wasting 是组成“营养不良”的另一主要成分，属即时性营养不良，起因于现时性的膳食蛋白质-热量摄入不足，导致BMI（Body mass index）低于筛查标准的年龄别BMI界值范围。 身材矮小 short stautue 凡身高低于年龄别身高（stature-for-age）界值范围但高于“生长迟缓”界值范围者，称“身材矮小”。 3 营养不良筛查方法 3.1 分年龄身高筛查生长迟缓界值范围6～19岁男女学龄儿 童青少年分年龄身高筛查生长迟缓界值范围见表A.1，界值点曲线见图A.1。 3.2 分年龄BMI筛查消瘦界值范围6～19岁男女学龄儿童青 少年分年龄BMI筛查消瘦界值范围见表B.1，界值点曲线见图B.1.图B.2。
蛋白质营养不良的分类和判断？ 答：蛋白质营养不良的分类： 1）水肿型营养不良；以蛋白质缺乏为主。 2）消瘦型营养不良；以能量不足为主。 3）混合型营养不良即蛋白质和能量均有不太程度的缺乏。 蛋白质营养不良的判断可以通过主要体征来判断： 1）水肿型营养不良：主要表现为水肿、腹泻、常伴发感染、头发稀少易脱落、表情淡漠或情绪不好。 2）消瘦型营养不良：主要表现皮下脂肪和骨骼肌显著消耗和内在器官萎缩。四肢犹如“皮包骨” 3）混合型营养不良主要体征：生长停滞，体重下降，易遭受感染，也可发生低血压，低体温和心跳过速等症状。 2、什么标准人？标准人的概念和计算方法。 答：以体重60kg成年男子从事轻体力劳动者为标准人，由于调查对象年龄、性别和劳动强度有很大的差别，所以无法用营养素的平均摄入量进行互相间的比较，一般将各个人群都折合成标准人进行比较。以其能量供给量10.03MJ(2400kcal)作为1，其他各类人员按其能量推荐量与10.03MJ之比得出各类人的折合系数。然后将一个群体各类人的折合系数乘以其人日数之和被其总人日数除即得出该人群折合标准的系数（混合系数）。 3、分别写出三种有氧运动方式和无氧运动方式。 答：有氧运动：步行、骑车、游泳 （健美操，慢跑等） 无氧运动：举重、跳跃、快跑 （力量训练，器械训练等） 4、鱼贝类肉中甲基汞来源毒性特点及中毒表现？ 答：来源：含汞的废水排入江河湖海后，其中所含的金属汞或无机汞可以在水体（尤其是底层污泥）中某些微生物的作用下转变为毒性更大的有机汞，并可由于食物链的生物富集作用而在鱼体内达到很高的含量。毒性特点：汞是强蓄积性毒物，在人体内可长期存在。中毒表现：主要表现是神经系统损害的症状。如运动失调、语言障碍、视野缩小、听力障碍、感觉障碍及精神症状等，严重者可致瘫痪、肢体变形、吞咽困难甚至死亡。甲基汞还有致畸作用和胚胎毒性
原文链接：https://www.doczj.com/doc/a117627659.html,/341jyyblz/2015/1228/317627.html 进行性肌营养不良症有哪些类型 进行性肌营养不良症是一组遗传性骨骼肌变性疾病，病理上以骨骼肌纤维变性、坏死为主要特点，临床上以缓慢进行性发展的肌肉萎缩、肌无力为主要表现，部分类型还可累及心脏、骨骼系统。传统上分为假肥大型肌营养不良、面肩肱型肌营养不良、肢带型肌营养不良、Emery-Dreifuss肌营养不良、眼咽型肌营养不良、眼型肌营养不良、远端型肌营养不良和先天性肌营养不良。按照遗传方式可分为性连锁隐性遗传型、常染色体显性遗传和常染色体隐性遗传型。 进行性肌营养不良症有哪些类型 进行性肌营养不良症是一组遗传性疾病，多数有家族史，散发病例可为基因突变。在肌细胞膜外基质、跨膜区、细胞膜内面以及细胞核膜上有许多蛋白，基因变异可导致编码蛋白的缺陷，导致肌营养不良。由于不同的蛋白在肌细胞结构中所起的作用不完全相同，导致不同类型的肌营养不良。 不同类型的进行性肌营养不良有着不同的症状表现。专家指出假肥大型的进行性肌营养不良，主要就是患者儿出生后走路的时间较晚，7岁以后的症状会一年比一年的重，14岁以前患者就会丧失行走的能力。一般贝克型的肌营养不良是比杜兴型的少，多在5岁后会出现肌肉力弱，患者的病情进展是比较缓慢的，患者在成年后可有不同程度的运动的困难。 另外一种进行性肌营养不良为强直性的肌营养不良，主要表现就是患者的面肌、咀嚼肌以及锁乳突肌、肩带肌和四肢肌肉会变的萎缩。表现就是患者用力或是握拳后，再松开就很困难，一般在天气寒冷的情况下就可以加重本病。 最后还有一种进行性肌营养不良就是面肩肱型的肌营养不良，主要就是患者的面部表情肌、肩部肌肉以及上臂的肱二、三头肌的萎缩很无力，这个时候患者可出现双眼的闭合无力，吹哨以及鼓腮、双肩的上抬很困难。所以及时治疗是很关键的，避免错过治疗的最好时期。
第三次实验内容 进行性肌营养不良症（DMD）基因检测 一、实验目的： 掌握进行性肌营养不良症基因检测的一种简便方法。 二、实验原理： PCR技术具有特异性强、灵敏度高、操作简便、省时，对待检原始材料质量要求低等特点，而多重PCR（multiplex PCR）则是用几对引物在同一个PCR反应体系中进行扩增。这样可以同时扩增出几个不同专一靶区域的片段。 进行性肌营养不良症(Duchenne muscular dystrophy，DMD)是一组原发于肌肉组织的遗传病，特点是进行性加重的肌肉萎缩和无力，本病呈X连锁隐性遗传，一般男性儿童发病。临床表现腿的假性肥大，血清酶学明显升高。 DMD基因定位于Xq21.2-21.3之间，全长2.4kb左右，有79个外显子组成，编码1个3685个氨基酸、分子量为427 kD的蛋白质一抗肌营养不良蛋白(dystrophin)，这种蛋白具有稳定细胞膜和细胞内钙调节的功能。 抗肌营养不良蛋白的编码基因有多种突变形式，60％是外显子缺失突变，5％是重复突变，另35％可能是很小的DNA片段缺失或点突变。通常选择DMD基因中9个缺失热点的外显子扩增，可检出缺失突变中的90%。 本实验设计为扩增DMD基因中4个外显子（8,19,45,48），其中外显子45 和48在中国患者中的检出率分别为26%和48%。 三、实验准备： 实验材料：正常对照和DMD患者外周血DNA样本。 实验器材： 实验试剂： 四、实验步骤： 1、正常对照外周血DNA样本、DMD患者外周血DNA样本分别进行PCR扩增（第二次课上已经做好）。 2、琼脂糖凝胶电泳。 ①配制2%的琼脂糖凝胶 ②取PCR扩增样品10μl加入3μl的6×载样缓冲液，混匀后，加入样品孔内。 ④ 140V，电泳2小时左右。 ⑤卸胶，紫外仪上观察电泳条带，判断扩增产物的有无及片段大小。 五、实验结果： 正常对照样本有4条带，从负极往正极分别为外显子45、48、19和8。 DMD患者缺失不同的外显子。 六、注意事项： 1、引物设计时长度 15～30个碱基为宜，G+C含量一般为40%～60%。 2、退火温度决定PCR反应的特异性，退火温度高PCR反应的特异性好；温度低，有时会 有非特异性条带。 3、Mg2+浓度对扩增产物的特异性及产量有显著影响，Mg2+浓度低，扩增产物的特异性 好，但有时产量低；Mg2+浓度高，扩增产物的特异性差，有非特异性条带。
第一部分医院感染基本知识 1、什么是医院感染？ 医院感染是指住院病人在医院内（入院48小时后）获得的感染，包括在住院期间发生的感染和在医院内获得出院后发生的感染。医院工作人员在医院内获得的感染也属院内感染。 2、根据引起医院感染病原体来源的不同，医院感染分哪两类？ （1）外源性感染：又称交叉感染。 （2）内源性感染：又称自身感染。 3、医院感染的危险因素有哪些？ 新诊疗技术的开展、各种侵袭性操作、住院时间长、长期应用广谱抗生素、慢性基础疾病如肿瘤、糖尿病等。 4、医院感染的易感人群有哪些？ （1）机体免疫机能严重受损者。 （2）婴幼儿及老年人。 （3）接受放化疗和免疫抑制剂治疗者。 （4）长期使用广谱抗菌药物者。 （5）接受各种侵袭性操作的患者。 （6）住院时间长者。 （7）手术时间长者。 （8）营养不良者。 5、哪些情况属于医院感染？ （1）无明确潜伏期的感染，规定入院48小时后发生的感染为医
院感染；有明确潜伏期的感染，自入院时起超过平均潜伏期后发生的感染为医院感染。 （2）本次感染直接与上次住院有关。 （3）在原有感染基础上出现其它部位新的感染（除外脓毒血症迁徙灶），或在原感染已知病原体基础上又分离出新的病原体（排除污染和原来的混合感染）的感染。 （4）新生儿在分娩过程中和产后获得的感染。 （5）由于诊疗措施激活的潜在性感染，如疱疹病毒、结核杆菌等的感染。 （6）医务人员在医院工作期间获得的感染。 6、哪些情况不属于医院感染？ （1）皮肤黏膜开放性伤口只有细菌定植而无炎症表现。 （2）由于创伤或非生物性因子刺激而产生的炎症表现。 （3）新生儿经胎盘获得（出生后48小时内发病）的感染，如单纯疱疹、弓形体病、水痘等。 （4）患者原有的慢性感染在医院内急性发作。 7、呼吸机相关性肺炎应如何诊断？ （1）病人施行人工机械通气（MIV）治疗后可解除MIV48小时内发生的肺部感染，患者出现粘痰，肺部啰音，并伴发热，或白细胞总数和（或）嗜酸性粒细胞比例增高，或X线显示肺部有炎性浸润性病变。 （2）病人有原有的肺部感染基础上施行MIV治疗48小时以上，
进行性肌肉营养不良 杜兴氏肌肉营养不良症 遗传性的肌肉萎缩病可分为 进行性的营养不良症，临床特征为进行性加重的肌肉萎缩和无力，这属遗传性疾病，是基因缺肌所引起，无有效的治疗措施，防治方法主要是做好遗传咨询，产前检查，携带者家谱分析和检查，是预防本病在下一代发生的重要措施。 杜兴氏肌肉营养不良症（Duchenne Muscular Dystrophy ，DMD ），乃遗传性肌肉萎缩病。它的基因（Dystrophin gene ）存在于X 性染色体中（Xp21 ），因此它是透过性连锁式隐性遗传型态传播的。男性只有一个x性染色体，因此病患者大多为男性；若女性的一对x性染色体中其一个携有异变的Dystrophin 基因，她便成为一个DMD 的携带者，她的儿子有二分一的机会成为病患者，她的女儿则有二分一机会成为DMD 基因携带者。 Dystrophin 基因乃现时所知人类基因中体积较大的一种，它的制成品Dystroph in ，与其他相关的蛋白质，是稳定肌肉细胞膜的一个重要部份。它最重要的功能是维持肌肉细胞的稳定性，使它在肌肉收缩的过程中，不会受到破坏，杜兴氏病患者因肌肉中缺少了Dystrophin ，令到肌肉自出生后，便不断受到破坏和萎缩。Dystrop hin 基因亦会受到另一种较轻微的突变所影响，导致病情较轻的碧加氏肌肉营养不良症（Becker's Muscular Dystrophy ，BMD ）。 进行性肌营养不良的六种检查办法 来源：时间：2010-5-5 10:37:56 进行性肌营养不良（假肥大型）是一种由位于X染色体上隐性致病基因控制的一种遗传病,特点为骨骼肌进行性萎缩，肌力逐渐减退，最后完全丧失运动能力。主要发生于男孩；女性则为遗传基因携带者，有明显的家族发病史。 （一）血清酶测定： 1、血清肌酸磷酸激酶（CPK）：CPK增高是诊断本病重要而敏感的指标，可在出生后或出现临床症状之前已有增高，当病程迁延时活力逐渐下降。亦可用于检查基因携带者，阳性率为60-80%。 血清中肌酸磷酸激酶CPK含量增高，在活动性肌病中，尤其是假肥大型肌营养不良病人中，可显著升高达1000至数千单位。 2、血清肌红蛋白（MB）：在本病早期及基因携带者中也多显著增高。 3、血清丙酮酸酶（PK）：也很敏感， 20岁以下正常男女血清PK值为119.00，20岁以上男性为84.30，女性为77.50，以上三项血清酶中CRK，PK的阳性率
【疾病名】进行性肌营养不良症 【英文名】progressive myodystrophy 【缩写】 【别名】progressive muscular dystrophy；进行性肌萎缩；进行性肌营养不良 【ICD号】G71.0 【概述】 进行性肌营养不良症(progressive myodystrophy)是一组由遗传因素所致的原发性骨骼肌疾病，其临床主要表现为缓慢进行的肌肉萎缩、肌无力及不同程度的运动障碍。本病可由多种遗传方式引起，其临床表现各具有不同的特点，因而形成许多类型。本节仅就其中较主要的类型进行概要介绍。 【流行病学】 多发生于儿童和青少年。Duxhenne型(Duchenne muscular dystrophy，DMD)是肌营养不良中发病率最高的一型，其发病率为30/10万。Becker型(Beker muscular dystrophy，BMD)发病率为3/10万。远端型、眼肌型及眼咽型等均较少见。 【病因】 本病的发病机制研究已为世人所瞩目。数十年来，相继提出的有血管性、神经性、肌纤维再生错乱和细胞膜缺陷等学说，但大量的研究证据表明细胞膜缺陷在本病发生有重要地位。三分之一新生男婴患儿是由于基因突变所引起。 随着分子生物学研究的深入开展，本病的病因和发病机制有了进一步阐明。已明确本病是一类单基因遗传病，遗传方式多样，不少致病基因已得到定位和克隆，部分基因产物已得到阐明，有的致病基因尚不明。相关基因位点突变可引起其表达产物肌膜结构蛋白的缺陷和异常而致病。 对其不同类型、不同亚型的分子机制也有了新的认识。其中以Duchenne型和Becker型肌营养不良(DMD，BMD)的研究最为深入。DMD为X连锁隐性遗传病，致病基因已定位于X染色体短臂2区1带2～3亚带(Xp21．2～21．3)，其基因的cDNA已经被克隆，全长为14kb，有60～65个外显子，基因表达产物为抗肌萎缩蛋白(dystrophin，Dys)。当基因出现大片段缺失、重复或其他形式变异如点突变时，导致Dys缺如或结构功能异常是DMD致病的根本原因。BMD基
ESPEN endorsed recommendation Diagnostic criteria for malnutrition e An ESPEN Consensus Statement T.Cederholm a ,*,I.Bosaeus b ,R.Barazzoni c ,J.Bauer d ,A.Van Gossum e ,S.Klek f , M.Muscaritoli g ,I.Nyulasi h ,J.Ockenga i ,S.M.Schneider j ,M.A.E.de van der Schueren k ,l ,P.Singer m a Departments of Geriatric Medicine,Uppsala University Hospital and Public Health and Caring Sciences,Clinical Nutrition and Metabolism,Uppsala University,Uppsala,Sweden b Clinical Nutrition Unit,Sahlgrenska University Hospital and University of Gothenburg,Gothenburg,Sweden c Department of Medical,Surgical and Health Sciences,University of Trieste,Trieste,Italy d Department of Geriatric Medicine,Carl von Ossietzky Universit €a t,Oldenburg,Germany e Department of Gastroenterology,Clinic of Intestinal Diseases and Nutritional Support,Hopital Erasme,Free University of Brussels,Brussels,Belgium f General and Oncology Surgery Unit,Stanley Dudrick's Memorial Hospital,Skawina,Poland g Department of Clinical Medicine,Sapienza University of Rome,Rome,Italy h Department of Nutrition and Dietetics and Department of Medicine,Monash University Central Clinical School,Prahran,Australia i Department of Gastroenterology,Hepatology,Endocrinology,and Nutrition,Klinikum Bremen Mitte,Bremen,Germany j Department of Gastroenterology and Clinical Nutrition,University Hospital and University of Nice Sophia-Antipolis,Nice,France k Department of Nutrition and Dietetics,Internal Medicine,VU University Medical Center,Amsterdam,The Netherlands l Department of Nutrition,Sports and Health,Faculty of Health and Social Studies,HAN University of Applied Sciences,Nijmegen,The Netherlands m Department of General Intensive Care,Institute for Nutrition Research,Rabin Medical Center,Sackler School of Medicine,Tel Aviv University,Petah Tikva 49100,Israel a r t i c l e i n f o Article history: Received 27February 2015Accepted 3March 2015Keywords:Malnutrition Nutritional assessment Body composition De ?nition Consensus Delphi s u m m a r y 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 modi ?ed 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 identi ?ed 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/m 2)<18.5to de ?ne malnutrition.Option two requires the combined ?nding 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 inde ?nite of time,or >5%over 3months.Reduced BMI is <20or <22kg/m 2in subjects younger and older than 70years,respectively.Low FFMI is <15and <17kg/m 2in females and males,respectively.About 12%of ESPEN members participated in a ballot;>75%agreed;i.e.indicated 7on a 10-graded scale of acceptance,to this de ?nition. Conclusion:In individuals identi ?ed by screening as at risk of malnutrition,the diagnosis of malnutrition should be based on either a low BMI (<18.5kg/m 2),or on the combined ?nding of weight loss together with either reduced BMI (age-speci ?c)or a low FFMI using sex-speci ?c cut-offs. ?2015Elsevier Ltd and European Society for Clinical Nutrition and Metabolism.All rights reserved. 1.Introduction Malnutrition due to starvation,disease or ageing can be de ?ned 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 *Corresponding author.Tel.:t46702733192. E-mail address:tommy.cederholm@pubcare.uu.se (T. Cederholm). Contents lists available at ScienceDirect Clinical Nutrition journal h omepage:ht tp://w https://www.doczj.com/doc/a117627659.html,/locate/clnu https://www.doczj.com/doc/a117627659.html,/10.1016/j.clnu.2015.03.001 0261-5614/?2015Elsevier Ltd and European Society for Clinical Nutrition and Metabolism.All rights reserved. Clinical Nutrition xxx (2015)1e 6