NUTRITIONAL SCREENING:
According to the definition of the glossary of terms in clinical malnutrition16, nutritional screening is: "the presumptive identification, in population groups, by means of rapid action tests, of subjects in a situation of malnutrition or who is at risk of altering their nutritional status, in order to act on them early". This is a preventive method, since it detects the risk of suffering from malnutrition. Even if the patients are pre-symptomatic, they may suffer from malnutrition in short period, so acting early and avoiding malnutrition is transcendental. The main objective of nutritional screening is: "to predict the likelihood of an unfavourable prognosis" and "to identify subjects who may benefit from nutritional treatment"17.
More specifically, in cancer patients, the importance of early detection of malnutrition, through appropriate screening implemented and validated in the hospital service, is reflected in facts such as that an early nutritional intervention could restore energy balance and improve the outcome of cachexia18.
Nutritional Risk Screening 2002 (NRS-2002):
Nutritional screening system recommended by ESPEN for inpatients. First, an initial screening is performed, which consists of 4 questions that are answered with yes or no (TABLE 1)19,20,21.
According to the answers:
- If the answer is NO to all 4 questions, the test is repeated at weekly intervals.
- If the answer is YES to any of the questions, the screening in Table 2 is performed: the final screening test is completed, which assesses the nutritional status and severity of the disease (TABLE 2).
In the final screening test, the patient is classified according to nutritional status and severity of the disease, with each score from 0 to 3, absent to severe, respectively. Both columns are then added together and a point is added if the patient is >70 years old. If the total sum is >3 points, there is nutritional risk, so nutritional support is necessary. On the other hand, if it is <3 points, since there is a probability of entering a risk situation throughout the admission, it is recommended to carry out the NRS-2002 weekly to avoid a case of malnutrition in the future.
The NRS-2002 screening test allows normonutrition patients to be discarded more quickly, as no anthropometric measurements are required, which is a great advantage. It is a test with high sensitivity, but low reproducibility13,21.
Although, according to another study, some other test such as PG-SGA seems more appropriate for identifying malnutrition in gynecological cancer patients22, our intention was to develop, validate and implement a screening tool throughout the oncohaematology service in a third level hospital, regardless of the type and location of the tumour.
SAMPLE AND SAMPLING:
The nutritional screening test NRS-2002 and NA was performed on 573 patients, with an inclusion period of one year (June 2017-August 2018), 372 men (64.92%) and 201 women (35.08%), with an average age of 59.46 years, ranging from a minimum of 16 years to a maximum of 93 years, and a median age of 61 years. The oncology and haematology service was chosen for the pioneering implementation of the nutritional screening test and therefore for the study, because patients admitted to these areas are at very high risk of suffering from malnutrition, both on admission and during their stay in hospital. In addition, they are patients with a high time of admission, so it is easier to observe their evolution.
With regard to this study, the NA was performed in all cases, independently of the nutritional screening test, in order to assess its usefulness, as well as its efficiency and effectiveness.
Firstly, the computer support was designed, using a clinical management system for hospital patients, Orion Clinic, specifically through direct access to the Dietetics programme created to carry out the nutritional screening test.
Once the nutritional screening is done, an alert is generated to the nutrition service by means of a list that indicates the test score corresponding to each patient.
NUTRITIONAL SCREENING:
The nutritional screening test is the NRS-2002.
If the final test is positive (>3 points), an alert will be generated to the hospital's nutrition service and the NA will be performed.
Through this assessment, malnutrition is diagnosed and classified according to its degree of severity.
Finally, when malnutrition is diagnosed, the doctor in charge and the nutrition and endocrinology service will be informed so that they can take the necessary measures to prevent or treat HM.
COMPLETE NUTRITIONAL ASSESSMENT:
NA is performed when the nutritional screening test concludes that the patient is at risk of malnutrition or undernutrition. In this study, all patients are tested to ensure that the nutritional screening was performed correctly.
NA consists of anthropometric, biochemical, dietary, and clinical indicators of the patient.
Firstly, the personal data are completed, such as age, sex and the pathology he suffers from. These data are noted in the patient's medical history.
Secondly, the anthropometric assessment is performed, where we ask the usual weight; we weigh and measure the height, the triceps skinfold (TSF) and the mid-arm circumference (MAC); finally, we calculate the weight loss rate (WLR), the BMI and the mid-arm muscle circumference (MAMC).
Unintentional WLR as a form of nutritional depletion is commonly seen in aging, cancer, and many chronic diseases23.
Once all the data are complete, we compare the PT, CB and PMB data in the percentile table and observe in which percentile our patients are and, therefore, the type of malnutrition and protein depletion they suffer. In our study we measured body mass, height, TSF and MAC. With these data we have calculated the BMI and the MAMC with the International Society for the Advancement of Kinanthropometry method (ISAK)24.
The biochemical evaluation is extracted from the daily analyses carried out by the doctor in charge. Urine samples may offer a valid alternative or a complementary addition to serum for nutritional metabolism analyses in large-scale clinical and epidemiological studies25.
In our study we looked at creatinine, lymphocyte and glomerular filtrate data because they are the only nutritionally relevant data that appear in all daily analyses.
With regard to the dietary indicators, first of all, the type of diet is observed and a 24-hour record is made, asking the patient or the accompanying person how much food was ingested at each intake. The dietary indicators give information on both the amount of requirements covered and the composition of the diet. Something to keep in mind, since, for example, a lower intake of protein can be associated with more nausea26, and because although the foods consumed by patients with advanced cancer correspond largely to the typical foods consumed by healthy people27, it is the amounts that will determine to a greater extent the percentage of requirements covered.
The kilocalories and grams of protein of each intake are calculated and added up, calculating the total contribution in the diet. If the patient has any type of supplementation, either oral or by tube, the total intake is noted and calculated. The percentage of covered needs, both in terms of kilocalories and proteins, is then calculated using the following formula: (see Formula 1 in the Supplementary Files)
Finally, the clinical indicators, which are evaluated in a subjective way, either by observation or by asking the patients and, if this is not possible, their companions. In some of them, such as nausea, vomiting, diarrhea or constipation, if they answer yes, the number of times and the duration of these are further deepened; in the case of dysphagia, what texture is compromised.