The controversy continues: nutritional management of the pregnancy complicated by diabetes

Current controversies for medical nutrition therapy in pregnancies complicated by diabetes include the composition and amount of carbohydrates and fats as well as optimal gestational weight gain and energy restriction. Although carbohydrate is the macronutrient with the greatest effect on glycemic control, there is little evidence for a recommended amount and type of carbohydrate or its distribution. This lack of evidence prompts an issue of debate among practitioners over the type of carbohydrate and its percent distribution throughout the day. The best indicators at this time are the results of self-monitoring of blood glucose, ketone testing, food records, and weight gain. A review of the literature provides the most current information available for medical nutrition therapy during a pregnancy complicated by diabetes and reinforces the need for further research in the form of randomized controlled trials to answer questions regarding carbohydrate modification and distribution, energy needs, and weight gain.

Nutrition in heart failure: an update

PURPOSE OF REVIEW

Chronic heart failure (CHF) is increasingly recognized as a multisystem disease with important comorbidities such as anemia, insulin resistance, autonomic dysbalance, or cardiac cachexia.

RECENT FINDINGS

Apart from these perturbations, increasing evidence points to alterations in intestinal morphology, permeability, and absorption function in patients with CHF. This review provides an overview of the sonographic, histological, and functional abnormalities of different gastrointestinal regions. This intestinal dysfunction and disturbed intestinal barrier may lead to both the chronic inflammatory state and catabolic/anabolic imbalance as seen in cardiac cachexia, as a terminal stage of CHF, which carries a particularly poor prognosis. This review highlights the current knowledge of nutritional abnormalities that may occur in CHF, including fat, carbohydrates, proteins, water, and micronutrients. The regulation of feeding is discussed, as are nutritional strategies with potentially anti-inflammatory effects in the treatment of CHF.

SUMMARY

The gut and its role for inflammation and dietary interventions in heart failure patients are a crucial target of further heart failure research.

[Development of a program of nutritional education and valuation of the change of healthful nourishing habits in a population of students of Obligatory Secondary Education]

INTRODUCTION

Adolescence is a critical period for the acquisition and configuration of healthy dietary habits and lifestyle for the young future, which will likely persist throughout the adulthood. Paediatric and juvenile obesity is a public health problem which control necessarily implies prevention and nutritional education.

OBJECTIVES

To evaluate the nutritional status of the adolescents and determine the proportion with overweight or obesity, and to establish a Nutritional Intervention Programme and analyse the improvement in the pattern of dietary habits among the adolescents.

METHODS

The study has been carried out in a population of 372 Obligatory Secondary Education (OSE) students from the Institute of Secondary Education of Gandía (Valencia).

RESULTS

37.8% of the adolescents have improved the level of their diet quality. Those consuming a high quality diet have increased from 30.0% to 58.6%. Also significant is the number of students that have taken up having breakfast and those having discontinued taking industrial bakery with this meal. The decrease in the number of adolescents going to fast food places and of those that have discontinued eating candies regularly is statistically significant. The data from the KIDMED index show that 47.4% (p < 0.001) of de the students have improved the quality of their diet and in none of them it has worsened.

DISCUSSION

Before starting the programme, 30% of the students followed a high quality diet comparable to the traditional Mediterranean Diet, and after the education programme, this percentage increased to 58.6%. Forty-seven point four percent of overweighed or obese students receiving the Nutritional Education and Intervention have improved their diet quality and the percentage of those following a high quality diet varied from 28.9% to 71.0%.

Advancing from immunonutrition to a pharmaconutrition: a gigantic challenge

PURPOSE OF REVIEW

This review presents some difficulties encountered to develop and translate immunonutrition into clinical practice, and suggests moving forward to a pharmaconutrition approach.

RECENT FINDINGS

Immunonutrition suffers from inconclusive and contradictory data due to the design of many of experiments and clinical studies conducted so far. The concept of a single immunonutrient formula applicable to various types of patients has also contributed to leave the medical world in a state of uncertainty. We propose to move forward to the concept of pharmaconutrition where a disease-dedicated nutrition therapy is developed following a rigorous step-by-step procedure. Nutrients are selected according to their pharmacological properties and after an in-depth evaluation of their biological interactions when mixed together. The optimum administration schedule (i.e. dose, route, timing and duration) of the new formulae is then determined in well conducted projective clinical trials where it is administered apart from the standard nutrition to ensure full delivery of the expected doses.

SUMMARY

This review suggests moving forward to a pharmaconutrition approach where a rigorous step-by-step procedure would allow overcoming of the difficulties encountered to translate immunonutrition into clinical practice.

Weight loss and malnutrition in the elderly--the shared role of GPs and APDs

This article forms part of a series looking at the relationship between diet and good health, and the role of the dietician in the primary health care team. This review highlights some of the physical, social and medical factors that can indicate compromised nutritional status in the elderly, the screening tools available to detect malnutrition, and when to involve a dietician.

[Evaluation of the state intervention project to improve quality of life and reduce the complications associated with aging: "Add health to your years"]

OBJECTIVE

This paper evaluates the effectiveness of a Public Health program for the elderly based on health promotion and pathologies prevention, in order to avoid complications associated with illnesses and improves the quality of life (QOL) in elderly adults (EA).

METHODS

A 12 month intervention studies used 700 EA randomized in 2 groups: intervention and control. Each group was submitted to pre-post intervention measurements that included weight, height, blood pressure (BP), cholesterol, lipids, glycaemia, cardiovascular (infarct, stroke) and bone fractures events, hospitalization, and a QOL survey. Intervention consisted of periodic physical activity to fortify muscular groups, as well as recreational activities, nutritional and food manipulation training visits. A medical student was assigned to each participant from the intervention group to assure periodical contact and to share activities. The control group continued with their normal activities during observational period.

RESULTS

The intervention group showed a significant reduction in the BP, lipids and cholesterol values compared to control group. Reduction on cardiovascular events (-31%), hip fractures (-18.2%) and number of hospital admittance (-21.1%) were obtained for group A in relation to B. The QOL survey showed 28.7% improvement for group A compared with 33.4% improvement compared with control group.

CONCLUSION

The health program with exhaustive follow-up administration, significantly reduced risk factors and complications associated with aging.

Nutrition therapy for acute renal failure: a new approach based on 'risk, injury, failure, loss, and end-stage kidney' classification (RIFLE)

PURPOSE OF REVIEW

Critically ill patients are hypermetabolic and have increased nutrient requirements. Although it is assumed that nutritional support is beneficial in this group of patients there are no well designed clinical trials to test this hypothesis. The rationale for nutritional support, therefore, is based upon clinical judgement. Although it is not known how long a critically ill patient can tolerate what is effectively starvation, the loss of lean tissue which occurs in catabolic patients (20-40 g nitrogen/day) suggests that depletion to a critical level may occur after 14 days.

RECENT FINDINGS

Acute kidney injury (AKI) is a syndrome commonly seen in the ICU. It is usually multifactorial rather than the result of a primary renal disease. The difficulty of adequately defining the syndrome has been addressed by the acute dialysis quality initiative, leading to the risk, injury, failure, loss, and end-stage kidney (RIFLE) criteria.

SUMMARY

Broad consensus in the diagnosis and management of AKI in critical illness is achievable. Standardization of nutritional support by RIFLE classification is urgently needed.

Recent insights on chronic heart failure, cachexia and nutrition

PURPOSE OF REVIEW

To provide recent observations on the interrelation between chronic heart failure (CHF), cachexia and human nutrition and updating epidemiological issues in CHF.

RECENT FINDINGS

Present evidence suggests that impairment in cardiac muscle energetics plays an important role in the pathogenesis of heart failure. New concepts such as microRNA expression are emerging as potential agents in heart failure. Recent research suggests mechanisms by which inflammatory catabolic states may persist in the presence of adequate growth factors and nutrition. A consensus panel has recently designed a definition for general cachexia and its stratification. Together with classicals, new nutrients and substrates are showing efficacies in the malnutrition associated with CHF. Although still promising, ghrelin, growth factors and other biological compounds maintain emergent therapeutical positions for heart failure or associated catabolic states or both.

SUMMARY

Altered intestinal function as an agent for CHF is rising in evidence. New techniques to well diagnose and stratify malnutrition and cardiac cachexia in CHF are needed. Treatment of cachexia in CHF appears to be a combination of different approaches, in which metabolic, nutritional, immunological and hormonal strategies may play an important role. Although the current experimental research is of great help, well designed randomized controlled trials are needed to test these hypothesis and generate clinical evidence.

[Rate of undernutrition and response to specific nutritional therapy in Crohn's disease]

OBJECTIVES

to determine the rate of malnutrition in patients with Crohn's disease in our area (Substudy A). We assess in long-term the response of malnourished patients to treatment of nutritional supplement with TGF-beta2 (Substudy B).

SUBJECTS

ninety-eight (51% females) patients with Crohn's disease without selection, ages: 39.2 +/- 15.19 years, range: 18-81 years were included in Substudy A. In Substudy B thirty-nine malnourished patients (52% females) were included with an average age of 36.41 +/- 5.2 years and range: 19-45 (Substudy B).

METHODS

the design of the Substudy A was an observational and cross sectional study. Whereas, the Substudy B was a longitudinal, open intervention study with active (historical) control. The variables were anthropometric parameters, electrical bioimpedance, biochemical measures, index of disease activity, subjective global assessment and the kind of treatment that every patient has received.

MAIN RESULTS

the malnutrition rate was 52%, being the most frequent the caloric malnutrition, followed by mixed malnutrition. Thirty four per cent of the patients had iron deficiency. Twelve months of nutritional therapy with supplement specifically enriched in TGF-beta2 improved the evolution of the disease determined by a decrease in CDAI.

CONCLUSIONS

The rate of malnutrition was similar to that of previous studies realized in Spain. Our study confirms the high rate of iron deficiency that the patients suffer with Crohn's disease. The response to the treatment is favorable, especially regarding the natural history of the disease.

[Management of phosphate in nutrition therapy for chronic kidney disease]

Abnormality of serum phosphate levels, which is one of CKD-Mineral and Bone Disorder (CKD-MBD) , causes many complications such as cardiovascular disease and affects quality of life and prognosis. In CKD patients, phosphate uptake including food intake is one of the most important factor of phosphate control because ability of phosphate excretion is impaired. Concerning management of serum phosphate levels, regulation of protein intake, appropriate administration of phosphate binder, and prevention of constipation are essential.