Showing papers on "Clinical nutrition published in 2018"

Why nutrition education is inadequate in the medical curriculum : a qualitative study of students' perspectives on barriers and strategies

Abstract: The provision of nutrition care by doctors is important in promoting healthy dietary habits, and such interventions can lead to reductions in disease morbidity, mortality, and medical costs. However, medical students and doctors report inadequate nutrition education and preparedness during their training at school. Previous studies investigating the inadequacy of nutrition education have not sufficiently evaluated the perspectives of students. In this study, students’ perspectives on doctors’ role in nutrition care, perceived barriers, and strategies to improve nutrition educational experiences are explored. A total of 23 undergraduate clinical level medical students at the 5th to final year in the School of Medicine and Health Sciences of the University for Development Studies in Ghana were purposefully selected to participate in semi-structured individual interviews. Students expressed their opinions and experiences regarding the inadequacy of nutrition education in the curriculum. Each interview was audio-recorded and later transcribed verbatim. Using the constant comparison method, key themes were identified from the data and analysis was done simultaneously with data collection. Students opined that doctors have an important role to play in providing nutrition care to their patients. However, they felt their nutrition education was inadequate due to lack of priority for nutrition education, lack of faculty to provide nutrition education, poor application of nutrition science to clinical practice and poor collaboration with nutrition professionals. Students opined that their nutrition educational experiences will be improved if the following strategies were implemented: adoption of innovative teaching and learning strategies, early and comprehensive incorporation of nutrition as a theme throughout the curriculum, increasing awareness on the importance of nutrition education, reviewing and revision of the curriculum to incorporate nutrition, and involving nutrition/dietician specialists in medical education. Though students considered nutrition care as an important role for doctors they felt incapacitated by non-prioritisation of nutrition education, lack of faculty for teaching of nutrition education, poor application of nutrition science and poor collaboration with nutrition professionals. Incorporation of nutrition as a theme in medical education, improving collaboration, advocacy and creating enabling environments for nutrition education could address some of the barriers to nutrition education.

Comparison of three common nutritional screening tools with the new European Society for Clinical Nutrition and Metabolism (ESPEN) criteria for malnutrition among patients with geriatric gastrointestinal cancer: a prospective study in China.

Abstract: Objective The aim of this study was to evaluate and compare three common nutritional screening tools with the new European Society for Clinical Nutrition and Metabolism (ESPEN) diagnostic criteria for malnutrition among elderly patients with gastrointestinal cancer. Research methodsandprocedures Nutritional screening tools, including the Nutritional Risk Screening 2002 (NRS 2002), the Malnutrition Universal Screening Tool (MUST) and the Short Form of Mini Nutritional Assessment (MNA-SF), were applied to 255 patients with gastrointestinal cancer. We compared the diagnostic values of these tools for malnutrition, using the new ESPEN diagnostic criteria for malnutrition as the ‘gold standards’. Results According to the new ESPEN diagnostic criteria for malnutrition, 20% of the patients were diagnosed as malnourished. With the use of NRS 2002, 52.2% of the patients were found to be at high risk of malnutrition; with the use of MUST, 37.6% of the patients were found to be at moderate/high risk of malnutrition; and according to MNA-SF, 47.8% of the patients were found to be at nutritional risk. MUST was best correlated with the ESPEN diagnostic criteria (К=0.530, p Conclusions Among the tools, MUST was found to perform the best in identifyingmalnourished elderly patients with gastrointestinal cancer distinguished by the new ESPEN diagnostic criteria for malnutrition. Nevertheless, further studies are needed to verify our findings. Trial registration number ChiCTR-RRC-16009831; Pre-results.

Higher dietary magnesium intake is associated with lower body mass index, waist circumference and serum glucose in Mexican adults.

Abstract: Obesity and diabetes mellitus (DM) are public health concerns in Mexico of top-level priority due to their high prevalence and their growth rate in recent decades. The accumulation of adipose tissue leads to an unbalanced release of pro-oxidant factors, which causes cellular damage and favors the development of comorbidities. Recent evidence suggests that oxidative stress also promotes the accumulation of adipose tissue and the development of insulin resistance. The objective of this study is to evaluate the association between usual intake of antioxidant nutrients, specifically vitamins A, C, E and magnesium with body mass index (BMI), waist circumference (WC) and serum glucose concentrations in a representative sample of Mexican adults. We analyzed data on diet, BMI, WC and serum glucose from the Mexican National Health and Nutrition Survey 2012. Analysis included 20- to 65-year-old adults without a known diagnosis of DM (n = 1573). Dietary information was obtained using the five-step multiple-pass method developed by the United States Department of Agriculture and adapted to the Mexican context. Nutrient usual intake distributions were estimated using the Iowa State University method, through the “Software for Intake Distribution Estimation” (PC-Side) v.1.02. Associations were analyzed using multivariate regression models. Higher dietary magnesium intake was associated with lower markers of adiposity, so that an increase in 10 mg per 1000 kcal/day of magnesium was associated with an average decrease in BMI of 0.72% (95% CI: -1.36, − 0.08) and 0.49 cm (95% CI: -0.92, − 0.07) of WC. Additionally, in women with normal glucose concentrations, an increase in magnesium intake was associated with an average decrease in serum glucose by 0.59% (95% CI: -1.08, − 0.09). The results suggest that magnesium intake is associated with lower BMI, WC and serum glucose in Mexican population. However, more studies are required to elucidate the nature of this association.

Effects of nutrition therapy on HbA1c and cardiovascular disease risk factors in overweight and obese patients with type 2 diabetes.

Abstract: Nutrition Therapy (NT) is essential in type 2 diabetes (T2D) management. Standards of care recommend that each patient engages with a nutritionist (RDN) to develop an individualized eating plan. However, it is unclear if it is the most efficient method of NT. This study evaluates the effects of three different methods of NT on HbA1c and cardiovascular disease risk factors in overweight and obese patients with T2D. We randomized 108 overweight and obese patients with T2D (46 M/62F; age 60 ± 10 years; HbA1c 8.07 ± 1.05%; weight 101.4 ± 21.1 kg and BMI 35.2 ± 7.7 kg/m2) into three groups. Group A met with RDN to develop an individualized eating plan. Group B met with RDN and followed a structured meal plan. Group C did similar to group B and received weekly phone support by RDN. After 16 weeks, all three groups had a significant reduction of their energy intake compared to baseline. HbA1c did not change from baseline in group A, but decreased significantly in groups B (− 0.66%, 95% CI -1.03 to − 0.30) and C (− 0.61%, 95% CI -1.0 to − 0.23) (p value for difference among groups over time < 0.001). Groups B and C also had significant reductions in body weight, body fat percentage and waist circumference. Structured NT alone improves glycemia in comparison to individualized eating plans in overweight and obese patients with T2D. It also reduces other important cardiovascular disease risk factors like body fat percentage and waist circumference. The trial was retrospectively registered at clinicaltrials.gov( NCT02520050 ).

Lipid profiles in adolescents with and without asthma: Korea National Health and nutrition examination survey data

Abstract: Metabolic syndrome and dyslipidemia contribute to the development of a pro-inflammatory state in asthma. However, studies investigating the association between asthma and dyslipidemia have reported conflicting results. This study aimed to uncover the relationship between asthma and lipid profiles in adolescents using a national health and nutrition survey. This cross-sectional study analyzed the 2010–2012 Korea National Health and Nutrition Examination Survey data and included 2841 subjects aged 11–18 years with fasting blood sample data. Serum total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) levels were analyzed. We compared asthma prevalence between high-risk and low-risk lipid groups. There were 123 adolescents with asthma and 2718 without asthma (controls). The TC/HDL-C ratio, LDL-C/HDL-C ratio, and non-HDL-C levels were significantly higher in the asthma group than in the non-asthma group (P < 0.05). The high-risk groups displayed significantly higher asthma prevalence with higher TC, TG, LDL-C, and non-HDL-C levels and TG/HDL-C ratio than the low-risk groups (P < 0.05). After adjusting for potential confounding factors, the high-risk groups were associated with asthma according to their higher TC levels (adjusted odds ratio, 1.69; 95% confidence interval, 1.012–2.822) and TG/HDL-C ratios (adjusted odds ratio, 1.665; 95% confidence interval, 1.006–2.756). Asthma prevalence was greater in adolescents with a high TC level and TG/HDL-C ratio. In addition to the standard lipid profile, elevated TG/HDL-C ratio can be used as a useful additional lipid measure to evaluate interactions between dyslipidemia and asthma.

Nutritional variables predict chances of returning home and activities of daily living in post-acute geriatric care.

Abstract: Background Little is known about the association between malnutrition and the chances of returning home from post-acute facilities in older adult patients. This study aimed to understand whether malnutrition and malnutrition-related factors would be determinants for returning home and activities of daily living (ADL) at discharge after post-acute care. Methods Patients aged ≥65 years living at home before the onset of an acute disease and admitted to a post-acute ward were enrolled (n=207) in this prospective observational study. Malnutrition was defined based on the criteria of the European Society for Clinical Nutrition and Metabolism. Nutritional parameters included the nutritional intake at the time of admission and oral conditions evaluated by the Oral Health Assessment Tool (OHAT). The Barthel Index was used to assess daily activities. A Cox regression analysis of the length of stay was performed. Multivariable linear regression analyses to determine associations between malnutrition, returning home, and ADL at discharge were performed, after adjusting the variables of acute care setting. Results The mean patient age was 84.7±6.7 years; 38% were men. European Society for Clinical Nutrition and Metabolism-defined malnutrition was observed in 129 (62.3%) patients, and 118 (57.0%) of all patients returned home. Multivariable regression analyses showed that malnutrition was a negative predictor of returning home (hazard ratio: 0.517 [0.351-0.761], p=0.001), and an increase in the nutritional intake (kcal/kg/d) was a positive predictor of the Barthel Index at discharge (coefficient: 0.34±0.15, p=0.021). The OHAT was not associated with returning home and ADL. Conclusion Malnutrition and nutritional intake are associated with returning home and ADL at discharge, respectively, after post-acute care. Further studies investigating the effects of a nutritional intervention for post-acute patients would be necessary.

Nutrition therapy for critically ill patients across the Asia-Pacific and Middle East regions: A consensus statement.

Abstract: Summary Background & aims Guidance on managing the nutritional requirements of critically ill patients in the intensive care unit (ICU) has been issued by several international bodies. While these guidelines are consulted in ICUs across the Asia–Pacific and Middle East regions, there is little guidance available that is tailored to the unique healthcare environments and demographics across these regions. Furthermore, the lack of consistent data from randomized controlled clinical trials, reliance on expert consensus, and differing recommendations in international guidelines necessitate further expert guidance on regional best practice when providing nutrition therapy for critically ill patients in ICUs in Asia–Pacific and the Middle East. Methods The Asia–Pacific and Middle East Working Group on Nutrition in the ICU has identified major areas of uncertainty in clinical practice for healthcare professionals providing nutrition therapy in Asia–Pacific and the Middle East and developed a series of consensus statements to guide nutrition therapy in the ICU in these regions. Results Accordingly, consensus statements have been provided on nutrition risk assessment and parenteral and enteral feeding strategies in the ICU, monitoring adequacy of, and tolerance to, nutrition in the ICU and institutional processes for nutrition therapy in the ICU. Furthermore, the Working Group has noted areas requiring additional research, including the most appropriate use of hypocaloric feeding in the ICU. Conclusions The objective of the Working Group in formulating these statements is to guide healthcare professionals in practicing appropriate clinical nutrition in the ICU, with a focus on improving quality of care, which will translate into improved patient outcomes.

Nutrition therapy in esophageal cancer-Consensus statement of the Gastroenterological Society of Taiwan.

Abstract: A number of clinical guidelines on nutrition therapy in cancer patients have been published by national and international societies; however, most of the reviewed data focused on gastrointestinal cancer or non-cancerous abdominal surgery. To collate the corresponding data for esophageal cancer (EC), a consensus panel was convened to aid specialists from different disciplines, who are involved in the clinical nutrition care of EC patients. The literature was searched using MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the ISI Web of Knowledge. We searched for the best evidence pertaining to nutrition therapy in the case of EC. The panel summarized the findings in 3 sections of this consensus statement, based on which, after the diagnosis of EC, an initial distinction is made between the patients, as follows: (1) Assessment; (2) Therapy in patients with resectable disease; patients receiving chemotherapy or chemoradiotherapy prior to resection, and patients with unresectable disease, requiring chemoradiotherapy or palliative therapy; and (3) Formula. The resulting consensus statement reflects the opinions of a multidisciplinary group of experts, and a review of the current literature, and outlines the essential aspects of nutrition therapy in the case of EC. The statements are: Patients with EC are among one of the highest risk to have malnutrition. Patient generated suggestive global assessment is correlated with performance status and prognosis. Nutrition assessment for patients with EC at the diagnosis, prior to definitive therapy and change of treatment strategy are suggested and the timing interval can be two weeks during the treatment period, and one month while the patient is stable. Patients identified as high risk of malnutrition should be considered for preoperative nutritional support (tube feeding) for at least 7-10 days. Various routes for tube feedings are available after esophagectomy with similar nutrition support benefits. Limited intrathoracic anastomotic leakage postesophagectomy can be managed with intravenous antibiotics and self-expanding metal stent (SEMS) or jejunal tube. Enteral nutrition in patients receiving preoperative chemotherapy or chemoradiation provides benefits of maintaining weight, decreasing toxicity, and preventing treatment interruption. Tube feeding or SEMS can offer nutrition support in patients with unresectable esophageal cancer, but SEMS is not recommended for those with neoadjuvant chemoradiation before surgery. Enteral immunonutrition may preserve lean body mass and attenuates stress response after esophagectomy. Administration of glutamine may decrease the severity of chemotherapy induced mucositis. Enteral immunonutrition achieves greater nutrition status or maintains immune functions during concurrent chemoradiation.

Resting energy expenditure and body composition: critical aspects for clinical nutrition.

Abstract: Under thermo-neutral conditions, 24-h energy expenditure or total energy expenditure (TEE) results from resting energy expenditure (REE), diet-induced thermogenesis (DIT), and physical activity-related energy expenditure (PA, also called activity-related energy expenditure, AEE) (Fig. 1). REE is the single largest component contributing about 55–75% to EE, while DIT (i.e. the postprandial increase in EE above REE) contributes about 7–15% and PA about 15–30% of EE [1–3]. The sum of DIT and PA are considered as non-resting energy expenditure (NREE). PA can be further subdivided into EE related to volitional, structured, or planned activities as observed in sports and fitness-related exercise (i.e. exercise activity thermogenesis (EAT)) and EE accompanying other than volitional activities like unplanned activities, spontaneous muscle contraction, fidgeting, etc. (i.e. non-exercise activity thermogenesis (NEAT)) [4]. In addition, growth, pregnancy and lactation add further components to EE during individual life periods. Smoking, stress and/or the thermic effect of certain components like caffeine, capsaicin, or drugs are also known to increase EE [3], but are not admissable under the strict pre-conditions for REE. Present day laboratories that measure TEE and its components utilise technology based on indirect calorimetry (IC) (Fig. 1). A key condition of the principle underlying IC is that individuals are measured within the thermo-neutral zone (TNZ), since it is within this zone that energy production (from IC) equals energy expenditure. It is generally accepted that the TNZ ranges from 23 to 27 °C for a lightly clothed person. However, defining the TNZ and the physiologicallyand behaviourally-related thermal comfort zone (TCZ) is difficult in practice since they can vary with age, gender, body composition, clothing, skin and core body temperatures [5]. It follows then that REE will increase when ambient temperature falls below the TNZ, though the magnitude of this increase is highly variable between-individuals. The primary aim of such nonshivering thermogenesis (NST) is to maintain core temperature, and any further decrease in air temperature beyond 14–16 °C (for a lightly clothed, lean person) will elicit shivering thermogenesis (ST). The latter temperatures are not precise cut-offs but depend on place of study, prior acclimatisation and method of cold exposure used, i.e. ambient air versus cold body suit [6–8]. There is currently not much evidence for a genetic effect, since heritability estimates of either REE or REE adjusted for body weight (or its composition) are around 0.3 [9–11]. The effect of several hormones and their functionality have been described as contributors to REE. These include insulin and insulin sensitivity, leptin and vitamin D status to name a few [12]. However, thyroid hormones, both thyroxine (T4) and triiodothyronine (T3) remain key regulators, since small changes in T3 modulate REE well before any changes in body weight or composition are apparent [13– 15]. Historically, before the advent of RIA, measurements of REE were used to clinically judge thyroid function, where measured REE minus predicted REE (based on body weight, height, age and sex) less than −10% and above +15%, signalled hypo and hyperthyroidism, respectively.

Nurses' prioritization of enteral nutrition in intensive care units: a national survey.

Abstract: Background Enteral nutrition is important in critically ill patients to improve patient outcomes, with nurses playing a pivotal role in the delivery and ongoing care of enteral nutrition. A significant deficit in nurses' knowledge and education relating to enteral nutrition has been identified, leading to iatrogenic malnutrition and potentially compromising patient care. Enteral nutrition appears to be prioritized lower than many other aspects of care. However, there is scant research to show how nurses prioritize enteral nutrition. Aim This study aimed to explore how nurses prioritize enteral nutrition when caring for a critically ill patient. Method A descriptive online questionnaire, administered in May 2014, was utilized to explore the study aim. Descriptive statistics were performed to evaluate quantitative data. Content analysis was used to evaluate qualitative data. Results A total of 359 responses were included in data analysis (response rate 20.8%). All respondents were registered nurses working within an Australian intensive care unit or high dependency unit. Nurses agreed that enteral nutrition was very important and should be commenced as soon as possible. However, life-saving procedures always took priority and there were often multiple barriers that hindered optimal delivery of enteral nutrition. Conclusion Respondents relied on their clinical judgement to inform decisions in relation to enteral nutrition in critically ill patients. Most respondents agreed that enteral nutrition was an important aspect of patient care, but acknowledged that other aspects of care were prioritized more highly. Despite this, some delays to enteral nutrition were perceived to be avoidable, and nurses recognized a need to advocate on the patient's behalf to increase the visibility of enteral nutrition. Relevance to clinical practice The findings of this study demonstrate that enteral nutrition is often prioritized lower than other competing care needs in the critically ill patient. Given the importance of enteral nutrition to patient recovery, changes to clinical practice to improve enteral nutrition management are necessary.

Integral nutritional approach to the care of cancer patients: results from a Delphi panel

Abstract: Malnutrition is a common complication in cancer patients and can negatively affect the outcome of treatments. This study aimed to reach a consensus on nutritional needs and optimize nutritional care in the management of cancer patients at a national level. A qualitative, multicenter, two-round Delphi study involving 52 specialists with experience in nutritional support in cancer patients was conducted. Regarding the presence of malnutrition, 57.7% of the participants stated that 50% at the end of the treatment. Forty percent of participants believed that the main objective of nutritional treatment was to improve quality of life and 34.6% to improve tolerability and adherence to chemotherapy. The quality nutritional care provided at their centers was rated as medium–low by 67.3%. Enteral and parenteral nutrition was administered to less than 10% and less than 5% of patients in 40.4 and 76.9% of cases, respectively. In relation to nutritional screening at the time of diagnosis, 62.9% of participants considered than screening to assess the risk of malnutrition was performed in < 30% of patients. There is an important variability in the management of cancer patient nutrition, which is associated with the absence of a national consensus on nutritional support in this field. Given the incidence of nutritional disorders in cancer patients, a specialist in clinical nutrition (regardless of his/her specialty) should be integrated into the strategic cancer plan.

Advanced practice nursing: Nutrition Nurse Specialist role and function.

Abstract: Summary Background Different disciplines should be represented in Nutritional Support Teams, e.g. a physician, dietician, pharmacist and a nurse. The latter one can function as an Advanced Practice Nurse, which implicates that he or she must have sufficiently thorough knowledge, attitudes and competences to fulfill the profile of a nutritional expert in the field of clinical nutrition. Methods Description of the scope of practice, education and added value related to a Nutrition Support Nurse, based on detailed published competency profiles. Results The described competencies reflect the advanced role and clinical expertise of a Nutrition Support Nurse. She can make a significant contribution to the overall quality of nutritional care, uncover the multidimensional aspects of nutrition, monitor effectiveness/ appropriateness of nutrition therapy and improve clinical outcomes. Conclusions A Nutrition Support Nurse can incorporate nutrition nursing in the overall nutrition support, acting as an important player for users, carers and the healthcare organization in general.

Observation about phosphorus and protein supply in cats and dogs prior to the diagnosis of chronic kidney disease

Abstract: There is evidence that nutritional phosphorus (P) excess may be a risk factor for chronic kidney disease (CKD) in humans and pets (Advances in Nutrition: An International Review Journal (2014), 5, 104;The American Journal of Clinical Nutrition, (2013), 98, 6;Journal of Feline Medicine and Surgery, (2017);The source of phosphorus influences serum PTH, apparent digestibility and blood levels of calcium and phosphorus in dogs fed high phosphorus diets with balanced Ca/P ratio. Proc. Waltham International Nutritional Sciences Symposium, USA;Clinical aspects of natural and added phosphorus in foods, 2017, Springer Science+Business, Media). A retrospective study was conducted in order to gather data about P and protein intake in the feeding history of dogs and cats prior to the diagnosis of CKD. Cases of 75 dogs and 16 cats with CKD with comprehensive nutritional history presented to the nutrition consultation service of the Chair of Animal Nutrition and Dietetics, Ludwig-Maximilians-University Munich, between October 2009 and March 2016, were evaluated. Cases of age-matched dogs (n=57) and cats (n=18) without diagnosed or suspected CKD served as controls. The most frequent type of diet used in the four groups (cats CKD, cats control, dogs CKD and dogs control) was home-made. In all groups, P and protein supply was in excess (>150%) of the recommended daily allowances (RDA;Nutrient requirements of dogs and cats (2006), National Research Council, National Academy Press). Between the dog groups, no differences regarding P and protein intake existed. The P and protein intake relative to the RDA was altogether higher in cats than in dogs. Cats with CKD showed significantly higher P and protein intakes prior to diagnosis than the control cats (170 +/- 36 vs. 123 +/- 34mg P/kg BW0.67;p<.05). These observations call for further investigations into the long-term effects of P excess.

Knowledge and practices of medical oncologists concerning nutrition therapy: A survey study.

Abstract: Summary Background and aims Despite the identification of malnutrition and administration of nutrition therapy being increasingly recognised as integral to the treatment of cancer patients, this is not always translated into routine clinical practice. The aim of this study was to determine medical oncologists’ awareness of, and ability to assess, nutritional status and when to initiate nutrition therapy, to identify their educational status concerning clinical nutrition and their perceived barriers to the routine use of nutrition therapy in their patients through a survey study. Methods 155 medical oncologists were invited to complete a digital questionnaire. The questionnaire included information regarding the participants demographic and professional information, clinical nutrition education status, attitudes towards malnutrition and nutrition therapy, and barriers to using nutrition therapy. The questionnaire also included two case scenarios designed to assess ability to diagnose malnutrition/assess nutritional status and identify when nutrition therapy might be indicated. Results Of 109 medical oncologists who agreed to participate, 43.1% declared that they received clinical nutrition education and 33.9% declared that they followed the oncology sections in the European Society of Clinical Nutrition and Metabolism (ESPEN) Guidelines. The medical oncologists were divided into two groups according to their knowledge score (31 medical oncologists with a knowledge score of Conclusions Our results emphasize the association between clinical nutrition education and higher knowledge scores in medical oncologists, but reveal a mis-match between knowledge and awareness and what happens in clinical practice. Nutrition therapy might be used more frequently in routine practice when medical oncologists’ lack of knowledge is resolved.

Refeeding syndrome in the gastroenterology practice: how concerned should we be?

Abstract: Clinical nutrition is emerging as a major area in gastroenterology practice. Most gastrointestinal disorders interfere with digestive physiology and compromise nutritional status. Refeeding syndrome (RS) may increase morbidity and mortality in gastroenterology patients. Literature search using the keywords "Refeeding Syndrome", "Hypophosphatemia", "Hypomagnesemia" and "Hypokalemia". Data regarding definition, pathophysiology, clinical manifestations, risk factors, management and prevention of RS were collected. Most evidence comes from case reports, narrative reviews and scarse observational trials. RS results from the potentially fatal shifts in fluid and electrolytes that may occur in malnourished patients receiving nutritional therapy. No standard definition is established and epidemiologic data is lacking. RS is characterized by hypophosphatemia, hypomagnesemia, hypokalemia, vitamin deficiency and abnormal glucose metabolism. Oral, enteral and parenteral nutrition may precipitate RS. Awareness and risk stratification using NICE criteria is essential to prevent and manage malnourished patients. Nutritional support should be started using low energy replacement and thiamine supplementation. Correction of electrolytes and fluid imbalances must be started before feeding. Malnourished patients with inflammatory bowel disease, liver cirrhosis, chronic intestinal failure and patients referred for endoscopic gastrostomy due to prolonged dysphagia present high risk of RS, in the gastroenterology practice. RS should be considered before starting nutritional support. Preventive measures are crucial, including fluid and electrolyte replacement therapy, vitamin supplementation and use of hypocaloric regimens. Gastroenterology patients must be viewed as high risk patients but the impact of RS in the outcome is not clearly defined in current literature.

Changes in nutritional care after implementing national guidelines—a 10-year follow-up study

Abstract: In 2004, a survey conducted in Scandinavia documented insufficient knowledge in nutrition care among doctors and nurses. The survey also revealed a significant discrepancy in nutritional practice, where Norway ranked lowest, thus leading to several actions including elaboration of national guidelines. The aim of this study was to evaluate potential changes in nutritional practice, as well as assessing barriers to nutrition therapy, 10 years after the former study. In the first half of 2014, a total of 4000 doctors and nurses received a questionnaire, similar to the one used in 2004. The questions dealt with nutritional practice, routines, knowledge, barriers, and use of clinical dietitians (CDs) in the hospitals. The response rate was 22%. Routines in nutritional practice were significantly improved. The level of knowledge among respondents were increased, but lack of knowledge and lack of assignment of responsibility were still important barriers. The patients’ contradiction could be a barrier to the use of enteral nutrition. CDs are used in a small amount of patients, and wards with good nutritional routines have a better cooperation with CDs than wards with insufficient routines. Routines in clinical nutrition have improved from 2004 to 2014. Barriers in the daily practice among health care workers like lack of knowledge and lack of assignment of responsibility are still important, and health care professionals seem to let the patient himself or herself be a barrier to the use of enteral nutrition.

Effect of milk-honey mixture on the sleep quality of coronary patients: A clinical trial study.

Abstract: Background: Admission of patients in coronary care units can lead to sleep disorders due to advanced monitoring and interventions. Inappropriate sleep quality in cardiac patients may be influenced by their health status. So, this study was performed to detect the effect of Milk-honey mixture on sleep status of acute coronary syndrome patients in the coronary care unit. Methods: A clinical trial study (registered under IRCT.ir with identifier no. IRCT201309285134N7) was conducted with 68 hospitalized patients with the acute coronary syndrome in the coronary care unit of a referral hospital in Semnan, Iran. After hospitalization of patients and selected eligible patients, sleep status of them was measured by Richards–Campbell Sleep Questionnaire in range of 0 to 100 score. Then patients were divided into the intervention and control groups randomly. Patients in the intervention group were received milk-honey mixture twice a day for three days. The control group patients were received routine care. In the third day, sleep quality of patients in the two groups was measured again. Finally, the data were analyzed by descriptive and inferential statistics. Results: The mean and standard deviation of patients’ age was 63.12 ± 32.63. There was no significant difference in sleep scores on the first day of admission between the two groups (P = 0.914). But, on the third day of admission, there was a significant difference in sleep scores between the intervention and the control groups (P = 0.001). Conclusion: The mixture of milk and honey improves the sleep status of patients. So, it can be considered as an effective and affordable intervention to enhance the sleep quality of patients with the acute coronary syndrome in coronary care units. © 2018 European Society for Clinical Nutrition and Metabolism

Improving the standard of nutrition care in hospital: mealtime barriers reduced with implementation of the Integrated Nutrition Pathway for Acute Care

Abstract: Summary Background Poor food intake is common in hospital patients and is associated with adverse patient and healthcare outcomes; diverse mealtime barriers to intake often undermine clinical nutrition care. Aim This study determines whether implementation of locally adaptable nutrition care activities as part of uptake of the Integrated Nutrition Pathway for Acute Care (INPAC) reduced mealtime barriers and improved other patient outcomes (e.g. length of stay; LOS) when considering other covariates. Methods 1250 medical patients from 5 Canadian hospitals were recruited for this before-after time series design. Mealtime barriers were tallied with the Mealtime Audit Tool after a meal, while proportion of the meal consumed was assessed with the My Meal Intake Tool. Implementation of new standard care activities occurred over 12 months and three periods (pre-, early, and late) of implementation were compared. Regression analyses determined the effect of time period while adjusting for key covariates. Results Mealtime barriers were reduced over time periods (Period 1 = 2.5 S.D. 2.1; Period 3 = 1.8 S.D. 1.7) and site differences were noted. This decrease was statistically significant in regression analyses (−0.28 per time period; 95% CI -0.44, −0.11). Within and across site changes were also observed over time in meal intake and LOS; however, after adjusting for covariates, time period of implementation was not significantly associated with these outcomes. Discussion Mealtime barriers can be reduced and sustained by implementing improved standard care procedures for patients. The More-2-Eat study provides an example of how to implement changes in practice to support the prevention and treatment of malnutrition. Trial registration Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304 , June 7, 2016.

Exploring the views of young women and their healthcare professionals on dietary habits and supplementation practices in adolescent pregnancy: a qualitative study.

Abstract: Nutrition is a modifiable factor affecting foetal growth and pregnancy outcomes. Inadequate nutrition is of particular concern in adolescent pregnancies with poor quality diet and competing demands for nutrients. The aim of this study was to explore knowledge and understanding of nutrition advice during adolescent pregnancy, and identify barriers and facilitators to dietary change and supplementation use in this vulnerable population. Semi-structured interviews were conducted with young women and key antenatal healthcare providers: midwives, family nurses and obstetricians. Doncaster, Manchester and London were chosen as sites offering different models of midwifery care alongside referral to the Family Nurse Partnership programme. A total of 34 young women (adolescents aged 16–19 years) and 20 health professionals were interviewed. Young women made small changes to their dietary intake despite limited knowledge and social constraints. Supplementation use varied; the tablet format was identified by few participants as a barrier but forgetting to take them was the main reason for poor adherence. Health professionals provided nutrition information but often lack the time and resources to tailor this appropriately. Young women’s prime motivator was a desire to have a healthy baby; they wanted to understand the benefits of supplementation and dietary change in those terms. Pregnancy is a window of opportunity for improving nutrition but often constrained by social circumstances. Health professionals should be supported in their role to access education, training and resources which build their self-efficacy to facilitate change in this vulnerable population group beyond the routine care they provide.

Special clinical nutrition formula for postoperative children

Abstract: The invention relates to a special clinical nutrition formula for postoperative children. The special clinical nutrition formula comprises the following components in parts by weight: protein, fat, carbohydrate, water-soluble dietary fiber, macroelement, microelement, fat-soluble vitamin, water-soluble vitamin, dietary essence, homology components of medicine and food, natural plant compounds andnew-resource foods. The invention also relates to a preparation method of the clinical nutrition formula. All the components are prepared into powder in advance; the homology components of medicine and food are prepared into powder by alcohol extraction and water extraction concentration, spraying and drying; the vitamin and the fat are prepared into powder by microencapsulation treatment; or emulsification homogenizing, spraying and drying are performed on each component for preparing powder through wet processes. Through screening and proportioning of the components, the nutrition formula provided by the invention provides reasonable and comprehensive nutrition support for patients suffering from postoperative child diseases, and the homology components of medicine and food with an anti-infection function and an immunity enhancing function are added, so that the incidence probability of infectious complications is reduced, and the patients can be promoted to recover as soon as possible.

Dietary management and supplementation with branched-chain amino acids in cirrhosis of the liver.

Abstract: One of the most important characteristics of malnutrition is the loss of muscle mass and the severe depletion of the protein reserve, secondarily affecting energy metabolism. That impacts nutritional status and the progression of disease-related complications. Nutritional treatment is one of the main factors in the comprehensive management of those patients. Achieving adequate energy intake that provides the macronutrients and micronutrients necessary to prevent or correct malnutrition is attempted through dietary measures. ESPEN, the European Society for Clinical Nutrition and Metabolism, recommends a caloric intake of 30-40kcal/kg/day, in which carbohydrates provide 45-60% of the daily energy intake and proteins supply 1.0-1.5g/kg/day. The remaining portion of the total energy expenditure should be covered by lipids. The administration of branched-chain amino acids has been shown to be beneficial not only in counteracting malnutrition, but also as a coadjuvant treatment in specific complications, thus playing a favorable role in outcome and quality of life. Therefore, branched-chain amino acids should be considered part of nutritional treatment in patients with advanced stages of cirrhosis of the liver, particularly in the presence of complications.

Nutritional knowledge, dietary practice and associated factors among adults on antiretroviral therapy in Felege Hiwot referral hospital, Northwest Ethiopia.

Abstract: Nutritional support is identified as one of the most critical and immediate needs for people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Adequate nutrition is vital to optimize response to medical treatment, manage opportunistic infections, maintain the immune system, and support optimal quality of life for people living with HIV/AIDS (PLWHA). Evidence has shown that the progression of the disease could be slowed with good nutrition. Nutrition interventions increase compliance with treatment regimens and optimize the benefits of antiretroviral drugs. The nutritional knowledge, dietary practice and associated factors among adults on antiretroviral therapy are not well understood generally in Ethiopia and particularly in Bahir Dar City. Therefore, the aim of this study was to assess the nutritional knowledge, dietary practice and associated factors among adult PLWHA on anti-retroviral therapy (ART) in Felege Hiwot Referral Hospital. Institution based cross-sectional study was conducted from April 13 to May 18, 2017 in Felege Hiwot Referral Hospital. Systematic random sampling technique was used to select 539 adults on highly active antiretroviral treatment (HAART). Data were collected using a semi-structured and pretested questionnaire. Bivariate and multivariate logistic regression analyses were carried out to identify factors associated with nutritional knowledge and dietary practice. This study shows that 25.8, 52.5 and 21.7% of respondents had poor, average and good nutritional knowledge scores respectively. Ever heard about good nutrition and received dietary counselling were significant factors for nutritional knowledge. This study also reveals that 3.2, 66.4 and 30.4% of respondents had poor, average and good dietary practice scores respectively. Presence of gastrointestinal symptom, ever heard about good nutrition and good nutritional knowledge were significant factors for dietary practice. This study found that the magnitude of good nutritional knowledge and good dietary practice were 21.7 and 30.4%. Nutrition education and counseling should be given by health care workers for patients on ART to improve their nutritional knowledge. The media should also strengthen its role in disseminating nutrition information. The health professionals should routinely diagnose and treat gastrointestinal symptoms to maintain patients’ appetite for food their by increasing dietary intake.

Identifying children at risk of malnutrition.

Abstract: This issue of Nutrition Journal includes three papers by Grellety and Golden, which explore comparisons between the use of mid-upper arm circumference (MUAC) and the use of weight in relation to height (WH) to screen for and identify children with severe acute malnutrition at risk of death [1–3]. This important debate is the most recent in a long history of attempts to understand the nature of a condition of varied geographical distribution with a complex aetiopathology in which the risk of mortality is high and effective care needs can appear counterintuitive. The condition is common where resources are limited and hence identification and effective care requires simple approaches that can be delivered at community level, but more complex problems need to be securely identified and manged in a facility [4, 5]. Grellety and Golden [1–3] present data that suggest that the current balance of effort allows unacceptable mortality because groups of children at greatest risk based upon WH or the presence of oedema are not adequately identified when using MUAC, and hence, not offered appropriate care. If the authors are correct, the problem needs to be acknowledged in order for better approaches to be considered and put in place. One of the great marks of the progress of society over the past 50 years has been the considerable improvements in the life opportunity for children, marked as significant reductions in post-neonatal mortality for children under 5 years of age [6]. A wide range of players can be credited with making contributions to these singular achievements [4–6]: contributions which embrace a rights-based approach to health and consideration of social factors and also the biomedical interventions required to save life and enable normal development in children at risk [4, 5, 7, 8]. One of the major challenges in efficiently facilitating progress has been the extent to which the problem of malnutrition is conceived of as a social problem or a medical problem. The reality is of course that social progress itself is often manifest as changing patterns of ill-health, which present as medical problems [4, 5, 9]. Given that malnutrition is prevalent in many widely different contexts [4, 5, 10], its genesis and any approach to its alleviation has always excited strong differences of opinion about how it might best be tackled. The priority given to any of the widely different approaches that might be adopted has often depended upon the particular interests and direction of concern of those immediately involved. The model articulated by UNICEF of immediate, underlying, and basic causes acknowledges multiple levels of concern, each of which has to be the focus and responsibility of different groups, but each of which has implications for the other levels; therefore, all have to be addressed with some measure of balance [11, 12]. At times, differences among approaches have evoked fierce controversies that have challenged our scientific insights, intellectual understanding, and our ability to translate theory into practice. These uncertainties have been particularly evident when the problems being addressed appear intractable, and hence, there is uncertainty about how best to proceed [7]. Further insights based upon advancement in technology, its application to health care, and the understanding generated from the available data have enabled resolution of differences, thereby clarifying the most appropriate approaches that not only embrace differences in viewpoints but draw strength from their resolution. At its heart, resolution of these uncertainties and differences reflects the importance of research and its application to the delivery of improved health care [4, 6, 8]. For example, the development of ready-to-use therapeutic foods derived from milk-based products for managing severely malnourished children has been informed by results of physiological and metabolic studies carried out in hospital, but has enabled a high standard of care in the community [13–16]. By applying the same principles, the further development of products based upon locally-available foods have made possible backward food production and employment opportunities and a move to local sustainability [17, 18]. The important underlying principle is that the nutrient composition of the therapeutic food seeks to correct Correspondence: aaj@soton.ac.uk Emeritus Professor of Human Nutrition, University of Southampton, Southampton General Hospital (MP 113), Tremona Road, Southampton SO16 6YD, UK

[Metabolic management and nutrition in critically ill patients with renal dysfunction : Recommendations from the renal section of the DGIIN, ÖGIAIN, and DIVI].

Abstract: Background Intensive care patients with renal failure or insufficiency comprise a heterogeneous group of subjects with widely differing metabolic patterns and nutritional requirements. They include subjects with various stages of acute kidney injury (AKI), acute-on-chronic renal failure (A-CKD), without/with renal replacement therapy (RRT), chronic kidney disease (CKD), and subjects on regular hemodialysis or peritoneal dialysis therapy (HD/PD). Goals Development of recommendations by the renal section of DGIIN (Deutsche Gesellschaft fur Internistische Intensivmedizin und Notfallmedizin), OGIAIN (Osterreichische Gesellschaft fur Internistische und Allgemeine Intensivmedizin und Notfallmedizin) and DIVI (Deutsche Interdisziplinare Vereinigung fur Intensiv- und Notfallmedizin) for the metabolic management and the planning, indication, implementation, and monitoring of nutrition therapy in this heterogeneous group of patients. Materials and methods The recommendations are based on recent evidence and current recommendations of DGEM (Deutsche Gesellschaft fur Ernahrungsmedizin), ASPEN (American Society for Parenteral and Enteral Nutrition) and ESPEN (European Society for Clinical Nutrition and Metabolism) and also the KDGIO (Kidney Disease: Improving Global Outcomes) clinical practice guidelines for AKI and the expert knowledge and clinical experience of the authors. Results Nutrition support in these patient groups is not fundamentally different from that in other disease states but must consider the multiple variations in metabolism and nutrient requirements. Nutrition therapy must be adapted to the stage of disease and especially, in those patients on RRT. Nutritional needs can differ widely between patients but also in the same patient during the course of the disease. Conclusions Thus, the patient with renal failure requires an individualized approach in nutrition support and because of the altered metabolism of many nutrients and intolerances for electrolytes and fluids, the nutrition support in patients with renal insufficiency requires close clinical and laboratory monitoring.