Management of disease-related malnutrition: a real-world experience with a novel concentrated high-protein energy-dense oral nutritional supplement

OBJECTIVE

Despite the availability of a wide range of oral nutritional supplements (ONS) offerings, individuals with malnutrition are still struggling to meet their nutritional targets. A new concentrated and high-protein energy-dense ONS (≥2.1 kcal/mL;32 g protein/200 mL) with high-quality protein (60% whey protein) has emerged as a pivotal formula to reach the patient's energy-protein requirements, enhance compliance, and maximize stimulation of muscle protein synthesis, key factors driving better nutritional, functional, and clinical outcomes. The purpose of this article is to provide our clinical experience using this new nutritionally concentrated ONS as a therapeutic strategy for patients with DRM.

METHODS

Three clinical cases have been examined using new assessment procedures and a new form of nutritional therapy, and their impact on the nutritional and functional outcomes in patients with moderate-to-severe DRM.

RESULTS

A tailored individualized nutritional interventions improved anthropometric, biochemical, and functional outcomes (Case 1,2, and 3) assessed using hand grip strength, bioimpedance and muscle ultrasound, and as well as good gastrointestinal tolerance (Case 1) and compliance to the ONS in patients with DRM (Case 1,2,3).

CONCLUSION

The use of this novel high-protein energy-dense formula with high-quality protein source (≥2.1 kcal/mL; 32 g protein/200 mL; 60% whey protein) overcome common practical challenges in the medical nutrition therapy of patients with DRM, either because these patients require a highly concentrated formulation to meet nutritional requirements due to loss of appetite, lack of interest in food, and high caloric-protein needs due to disease, and a large quantity and quality of protein to optimize muscle recovery due to sarcopenia, common in patients with moderate-severe malnutrition.

Nutritional therapy in chronic wound management for older adults

PURPOSE OF REVIEW

We provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.

RECENT FINDINGS

In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.

SUMMARY

Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.

Mediterranean Diet, Vitamin D, and Hypercaloric, Hyperproteic Oral Supplements for Treating Sarcopenia in Patients with Heart Failure-A Randomized Clinical Trial

BACKGROUND

Malnutrition and sarcopenia frequently affect patients with heart failure (HF), in which clinical outcomes and survival is decreased. Thus, appropriate nutritional screening and early nutrition support are highly recommended. Currently, nutritional support is not a standard of care in patients with HF, and the use of commercially available oral supplements (OSs) could provide an additional benefit to medical treatment in these patients.

AIM

To compare the effect of the Mediterranean diet in combination with hypercaloric, hyperproteic OS in patients with HF.

PATIENTS AND METHODS

An open label, controlled clinical study in which patients were randomly assigned to receive a Mediterranean diet (control group) vs. hypercaloric, hyperproteic OS (intervention group) for twenty-four weeks. Thirty-eight patients were included; epidemiological, clinical, anthropometric, ultrasound (muscle echography of the rectus femoris muscle of the quadriceps and abdominal adipose tissue), and biochemical evaluations were performed. All patients received additional supplementation with vitamin D.

RESULTS

Baseline malnutrition according to the GLIM criteria was observed in 30% of patients, while 65.8% presented with sarcopenia. Body cell mass, lean mass, and body mass increased in the intervention group (absolute increase of 0.5, p = 0.03, 1.2 kg, p = 0.03, and 0.1 kg, p = 0.03 respectively). In contrast, fat mass increased in the control group (4.5 kg, p = 0.05). According to the RF ultrasound, adipose tissue, muscle area, and circumference tended to decrease in the intervention group; it is probable that 24 weeks was too short a period of time for evaluating changes in muscle area or circumference, as previously observed in another group of patients. In contrast, functionality, determined by the up-and-go test, significantly improved in all patients (difference 12.6 s, p < 0.001), including the control (10 s improvement, p < 0.001) and the intervention group (improvement of 8.9 s, p < 0.001). Self-reported QoL significantly increased in all groups, from 68.7 ± 22.2 at baseline to 77.7 ± 18.7 (p = 0.01). When heart functionality was evaluated, LVEF increased in the whole cohort (38.7 ± 16.6 vs. 42.2 ± 8.9, p < 0.01); this increase was higher in the intervention group (34.2 ± 16.1 at baseline vs. 45.0% ± 17.0 after 24 weeks, p < 0.05). Serum values of NT-proBNP also significantly decreased in the whole cohort (p < 0.01), especially in the intervention group (p = 0.02). After adjusting by age and sex, nutritional support, baseline LVEF, NT-proBNP, and body composition parameters of functionality tests were not associated with mortality or new hospital admissions in this cohort.

CONCLUSION

Nutritional support with hypercaloric, hyperproteic OS, Mediterranean diet, and vitamin D supplementation were associated with decreased NT-proBNP and improvements in LVEF, functionality, and quality of life in patients with HF, despite a significant decrease in hospital admissions.

The Impact of Medium Cut-Off Dialyzers on Malnutrition-Inflammation Scores in Maintenance Hemodialysis Patients

INTRODUCTION

Medium cut-off (MCO) membranes may be able to remove middle-large uremic toxins that are retained in the body, which has been linked to various risk factors including malnutrition-inflammation score (MIS). The effect of MCO dialyzers on MIS has been studied.

METHODS

This single-center exploratory prospective observational study enrolled maintenance hemodialysis patients who underwent dialysis using either MCO (Theranova 400) or high-flux (FX80) membranes as part of their regular care. Measurements of MIS, body weight, height, body mass index, and various biochemical markers were taken at the beginning and conclusion of the study.

RESULTS

This study included 50 patients who were treated with either the Theranova 400 (n = 25) or the FX80 (n = 25) for a period of 6 months. The two groups were similar in terms of demographics, duration of hemodialysis treatment, and baseline biochemical test results. Theranova 400 had no significant impact on the median MIS (6 [6-10] vs. 7 [5-10], p 0.575) and serum albumin levels (4.07 [3.92-4.22] vs. 4.04 [3.85-4.30], p 0.689), while the FX80 resulted in a significant increase in MIS (6 [5-8] vs. 8 [6-10], p 0.033) and a significant decrease in serum albumin levels (4.23 [4.03-4.36] vs. 3.98 [3.77-4.12], p 0.027) at the end of the study.

DISCUSSION/CONCLUSION

After 6 months of treatment, the MCO dialyzer did not demonstrate a statistically significant difference in the MIS when compared to the high-flux dialyzer. However, MIS worsening was significantly less in the MCO group, indicating the potential benefits of MCO membranes in maintaining nutritional status. Further research is required to validate these results.

Mapping the impact of malnutrition as defined by the Global Leadership Initiative on Malnutrition and nutrition impact symptoms on the possibility of returning to work after treatment for head and neck cancer

PURPOSE

This study aimed to investigate whether malnutrition or nutrition impact symptoms (NIS) affect the possibility of returning to work after treatment for head and neck cancer.

METHODS

Patients of working age with head and neck cancer were followed up from treatment initiation to 3 months (n = 238), 1 year (n = 182), and 2 years (n = 130) after treatment completion. The observed decrease in the number of patients over time was due to retirement, lack of follow-up, or death. Returning to work was dichotomised as yes or no. Malnutrition was diagnosed 7 weeks after treatment initiation using the Global Leadership Initiative on Malnutrition (GLIM) criteria. This time-point corresponds to the end of chemoradiotherapy or radiotherapy (with or without prior surgery), except for patients who underwent exclusive surgery. NIS were scored on a Likert scale (1-5) at each follow-up using the Head and Neck Patient Symptom Checklist© (HNSC©). Nonparametric tests were used to analyse the ability of patients with/without malnutrition and high/low NIS scores to return to work.

RESULTS

At 3 months, 1 year, and 2 years after treatment completion, 135/238 (56.7%), 49/182 (26.9%), and 23/130 (17.7%) patients had not returned to work. Patients with malnutrition at 7 weeks after treatment initiation were more likely to not return to work at 3 months than those without malnutrition, 70.5% compared to 47.1% (p < 0.001). At all three follow-up time-points, patients reporting high scores for a number of NIS had more often not returned to work, with this pattern being most distinct at 2 years.

CONCLUSION

Malnutrition according to the GLIM criteria at 7 weeks after treatment initiation and NIS assessed by the HNSC© at subsequent follow-ups were predictors of the return-to-work process after treatment for up to 2 years.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT03343236 (date of registration 17/11/2017).

Strengthening the Diagnosis and Treatment of Malnutrition Through Increased Nurse Involvement: A Quality Improvement Project From Pediatric Wards in Mozambique

BACKGROUND

Childhood acute malnutrition continues to be a serious health problem in many low-resource settings in Africa. On pediatric wards in Mozambique, missed opportunities for timely diagnosis and treatment of malnutrition may lead to poor health outcomes. To improve inpatient nutritional care, a quality improvement (QI) project was implemented that aimed to engage pediatric nurses in inpatient malnutrition diagnosis and treatment.

METHODS

In 2 Mozambican referral hospitals, for 6 months, the Plan-Do-Study-Act framework for QI was implemented to identify key drivers of the following measures: having complete anthropometric evaluation documented at admission, 3 or more weight measurements per hospitalization week, documentation of nutritional therapy for eligible patients, and documentation of referral for outpatient nutritional rehabilitation after discharge. Clinical data were abstracted from hospital charts and entered into an EpiInfo database, including a 3-month observation period after the project, and analyzed retrospectively.

RESULTS

A total of 2,208 children from wards other than malnutrition were included in the analysis. Complete anthropometric evaluation at admission improved from 24.4% 2 months before the QI project to 80.1% during and 75.2% in the 3 months after the project (P<.001). The percentage of patients with 3 or more weight measurements per hospitalization week rose from 22.3% to 82.8% during and 75.0% after the project (P<.001). Documentation of nutritional therapy increased from 58.8% before to 67.1% during and 70.6% after the project (P=.54), and documentation of referral for outpatient nutritional rehabilitation after discharge decreased from 55.9% to 54.9% during and increased to 70.6% after the project, (P<.001).

CONCLUSION

Nurse engagement may lead to important advancements in the diagnosis and treatment of acute malnutrition in pediatric wards other than malnutrition in Mozambique. Task-sharing, particularly nurse engagement, in combination with QI methodology, may be considered for wards in similar settings with a high burden of malnutrition.

High-protein home parenteral nutrition in malnourished oncology patients: a systematic literature review

INTRODUCTION

Up to 83% of oncology patients are affected by cancer-related malnutrition, depending on tumour location and patient age. Parenteral nutrition can be used to manage malnutrition, but there is no clear consensus as to the optimal protein dosage. The objective of this systematic literature review (SLR) was to identify studies on malnourished oncology patients receiving home parenteral nutrition (HPN) where protein or amino acid delivery was reported in g/kg bodyweight/day, and to compare outcomes between patients receiving low (< 1 g/kg bodyweight/day), standard (1-1.5 g/kg/day), and high-protein doses (> 1.5 g/kg/day).

METHODS

Literature searches were performed on 5th October 2021 in Embase, MEDLINE, and five Cochrane Library and Centre for Reviews and Dissemination databases. Searches were complemented by hand-searching of conference proceedings, a clinical trial registry, and bibliographic reference lists of included studies and relevant SLRs/meta-analyses.

RESULTS

Nineteen publications were included; sixteen investigated standard protein, two reported low protein, and one included both, but none assessed high-protein doses. Only one randomised controlled trial (RCT) was identified; all other studies were observational studies. The only study to compare two protein doses reported significantly greater weight gain in patients receiving 1.15 g/kg/day than those receiving 0.77 g/kg/day.

CONCLUSION

At present, there is insufficient evidence to determine the optimal protein dosage for malnourished oncology patients receiving HPN. Data from non-HPN studies and critically ill patients indicate that high-protein interventions are associated with increased overall survival and quality of life; further studies are needed to establish whether the same applies in malnourished oncology patients.

Portal Hypertension in Malnutrition and Sarcopenia in Decompensated Cirrhosis-Pathogenesis, Implications and Therapeutic Opportunities

Malnutrition and sarcopenia are highly prevalent in patients with decompensated cirrhosis and are associated with poorer clinical outcomes. Their pathophysiology is complex and multifactorial, with protein-calorie malnutrition, systemic inflammation, reduced glycogen stores and hormonal imbalances all well reported. The direct contribution of portal hypertension to these driving factors is however not widely documented in the literature. This review details the specific mechanisms by which portal hypertension directly contributes to the development of malnutrition and sarcopenia in cirrhosis. We summarise the existing literature describing treatment strategies that specifically aim to reduce portal pressures and their impact on nutritional and muscle outcomes, which is particularly relevant to those with end-stage disease awaiting liver transplantation.

Frailty in end-stage liver disease: Understanding pathophysiology, tools for assessment, and strategies for management

Frailty and sarcopenia are frequently observed in patients with end-stage liver disease. Frailty is a complex condition that arises from deteriorations across various physiological systems, including the musculoskeletal, cardiovascular, and immune systems, resulting in a reduced ability of the body to withstand stressors. This condition is associated with declined resilience and increased vulnerability to negative outcomes, including disability, hospitalization, and mortality. In cirrhotic patients, frailty is influenced by multiple factors, such as hyperammonemia, hormonal imbalance, malnutrition, ascites, hepatic encephalopathy, and alcohol intake. Assessing frailty is crucial in predicting morbidity and mortality in cirrhotic patients. It can aid in making critical decisions regarding patients' eligibility for critical care and transplantation. This, in turn, can guide the development of an individualized treatment plan for each patient with cirrhosis, with a focus on prioritizing exercise, proper nutrition, and appropriate treatment of hepatic complications as the primary lines of treatment. In this review, we aim to explore the topic of frailty in liver diseases, with a particular emphasis on pathophysiology, clinical assessment, and discuss strategies for preventing frailty through effective treatment of hepatic complications. Furthermore, we explore novel assessment and management strategies that have emerged in recent years, including the use of wearable technology and telemedicine.

Effect of a personalized nutritional intervention program on nutritional status, quality of life and mortality in hemodialysis patients

Introduction

Objective: dietary advice provided through a nutritional intervention program (NIP) is recommended by renal clinic guidelines to prevent or treat malnutrition, that could improve quality of life (QoL) and survival in hemodialysis (HD) patients. This study set out to evaluate the effect of a personalized NIP on the nutritional status and its impact on QoL and mortality in dialyzed patients. Material and methods: this was a 12-month intervention study with regular follow-up in which nutritional parameters were measured at baseline and after 6 and 12 months. QoL was assessed by the Kidney Disease Quality of Life version 1.2 (KDQOL-SF) at baseline and at the end of the study. All dialyzed patients received individualized consultations with a trained dietitian. The content of the nutritional education program included a personalized meal plan and educational materials addressing nutrition to manage fluids, electrolytes, and vitamin D. Results: a total of 75 patients were included. After the NIP, visceral proteins, phosphorous, potassium and vitamin D levels had improved significantly (p < 0.001). The percentage of well-nourished patients increased by 30 % (p < 0.001). At the end of the study, the well-nourished patients had significantly improved scores on the general summary areas of the KDQOL-SF, reduced worry concerning fluid and dietary restrictions (p < 0.001), and the survival rate was 12 months longer (p < 0.01). Conclusion: the results of this study suggest that personalized NIP contributed to improved nutritional status, QoL and survival in HD patients.

High Protein Oral Nutritional Supplements Enable the Majority of Cancer Patients to Meet Protein Intake Recommendations during Systemic Anti-Cancer Treatment: A Randomised Controlled Parallel-Group Study

ESPEN guidelines recommend a minimum protein intake of 1.0 g/kg body weight (BW) per day to maintain or restore lean body mass in patients with cancer. During anti-cancer treatment, optimal protein intake is difficult to achieve. We investigated whether a high-protein, low-volume oral nutritional supplement (ONS) supports patients in meeting recommendations. A multi-centre, randomised, controlled, open-label, parallel-group study was carried out in nine hospitals (five countries) between January 2019 and July 2021 in colorectal and lung cancer patients undergoing first-line systemic treatment with chemo(radio-) or immunotherapy. Subjects were randomised (2:1) to receive Fortimel Compact Protein® or standard care. Protein intake was assessed with a 3-day food diary (primary outcome). BW was a secondary outcome. Due to challenges in recruitment, the study was terminated prematurely with 42 patients randomised (intervention group (IG) 28; control group (CG) 14). At T1 and T2, protein intake was statistically significantly higher in the IG compared to the CG (1.40 vs. 1.07 g/kg/day at T1, p = 0.008; 1.32 vs. 0.94 g/kg/day at T2, p = 0.002). At baseline, only 65% (IG) and 45% (CG) of patients met ESPEN minimum protein intake recommendations. However, at T1 and T2 in the IG, a higher proportion of patients met recommendations than in the CG (88% vs. 55% and 40%). No statistically significant difference between study groups was observed for BW. Mean compliance to the ONS was 73.4%. A high-protein, low-volume ONS consumed twice daily enables the majority of patients to reach minimal ESPEN protein recommendations.

Refeeding Syndrome in Pediatric Age, An Unknown Disease: A Narrative Review

Refeeding syndrome (RS) is characterized by electrolyte imbalances that can occur in malnourished and abruptly refed patients. Typical features of RS are hypophosphatemia, hypokalemia, hypomagnesemia, and thiamine deficiency. It is a potentially life-threatening condition that can affect both adults and children, although there is scarce evidence in the pediatric literature. The sudden increase in food intake causes a shift in the body's metabolism and electrolyte balance, leading to symptoms such as weakness, seizures, and even heart failure. A proper management with progressive increase in nutrients is essential to prevent the onset of this condition and ensure the best possible outcomes. Moreover, an estimated incidence of up to 7.4% has been observed in pediatric intensive care unit patients receiving nutritional support, alone or as an adjunct. To prevent RS, it is important to carefully monitor feeding resumption, particularly in severely malnourished individuals. A proper strategy should start with small amounts of low-calorie fluids and gradually increasing the calorie content and amount of food over several days. Close monitoring of electrolyte levels is critical and prophylactic use of dietary supplements such as thiamine may be required to correct any imbalances that may occur. In this narrative review, we aim to provide a comprehensive understanding of RS in pediatric clinical practice and provide a possible management algorithm.

Factors influencing the selection of oral healthcare providers in multidisciplinary Nutrition Support Team for malnourished inpatients: A cross-sectional study

BACKGROUND

Oral health management involving dental professionals in a multidisciplinary Nutritional Support Team (NST) is effective collaborative care. However, the indicators for the triage of oral health management requirements and selection of oral healthcare providers remain unclear.

OBJECTIVE

This cross-sectional study included inpatients with malnutrition and aimed to investigate the factors associated with determining the need for oral health management involving dental professionals and selecting primary oral healthcare providers when needed.

METHODS

Participants included 255 inpatients (154 males and 101 females, mean age 69.7 ± 14.4 years) aged ≥20 years who underwent oral assessment by the NST between April 2016 and July 2019. Participants were assigned to the following groups: good oral health group, oral health management by nurses under the supervision of dental professionals group, and oral health management by dental professionals group. The comprehensive oral health status was investigated using the Oral Health Assessment Tool (OHAT). The total OHAT score ranges from 0 to 16, with a higher score indicating a poorer oral environment.

RESULTS

The total OHAT score had a significant correlation with the need for oral health management by dental professionals. Inpatients with denture problems required oral health management from dental professionals. The optimal cutoff value of the total OHAT score for determining the need for oral health management was four.

CONCLUSION

The need for oral health management by dental professionals increased with worsening oral health status, especially denture problems. The OHAT score could be used to triage inpatients who require oral health management collaborated with dental professionals.

What do patients and oncologists think about the evaluation and management of cancer-related anorexia-cachexia? The Quasar_SEOM study

INTRODUCTION

Cancer patients often suffer from malnutrition and early detection and raising awareness of nutritional issues is crucial in this population.

METHODS

The Spanish Oncology Society (SEOM) conducted the Quasar_SEOM study to investigate the current impact of the Anorexia-Cachexia Syndrome (ACS). The study employed questionnaires and the Delphi method to gather input from both cancer patients and oncologists on key issues related to early detection and treatment of ACS. A total of 134 patients and 34 medical oncologists were surveyed about their experiences with ACS. The Delphi methodology was used to evaluate oncologists' perspectives of ACS management, ultimately leading to a consensus on the most critical issues.

RESULTS

Despite widespread acknowledgement of malnutrition in cancer as a significant issue by 94% of oncologists, the study revealed deficiencies in knowledge and protocol implementation. A mere 65% of physicians reported being trained to identify and treat these patients, with 53% failing to address ACS in a timely manner, 30% not monitoring weight, and 59% not adhering to any clinical guidelines. The lack of experience was identified as the primary hindrance to the use of orexigens in 18% of cases. Furthermore, patients reported concerns and a perception of inadequate attention to malnutrition-related issues from their physicians.

CONCLUSION

The results of this study point to a gap in the care of this syndrome and a need to improve education and follow-up of cancer patients with anorexia-cachexia.

Perioperative Malnutrition

CASE SUMMARY

A 61-year-old man presented with penetrating Crohn's ileocolitis and neoterminal ileal fibrostenotic stricture. He developed an anastomotic leak after a redo ileocolic resection and now has a chronic low-output enterocutaneous fistula. He was transferred from an outside institution for further management and is currently without Crohn's disease (CD)-related medical therapy. The fistula output is 25 to 50 mL/day of GI contents. His weight dropped by 25 pounds in 6 months after surgery with a current BMI of 19.1, albumin of 2.0 g/dL, and hemoglobin of 9.7 g/dL. During a 3-month period, he was optimized for surgery with local wound care, initiation of infliximab, and nutritional support with exclusive enteral nutrition (EEN). He gained 9 pounds (BMI 20.4). Albumin improved to 3.4 g/dL and hemoglobin to 12.1 g/dL. He underwent a successful open takedown of the enterocutaneous fistula with ileocolic anastomosis.

Probiotic Supplementation for Promotion of Growth in Undernourished Children: A Systematic Review and Meta-Analysis

OBJECTIVES

Probiotic supplementation has been proposed as a therapeutic intervention to improve growth outcomes in children with undernutrition. The objective of this review is to synthesize the current evidence on probiotic supplementation for promotion of growth in undernourished children.

METHODS

We searched MEDLINE, Cochrane CENTRAL, CINAHL, Embase, LILACS, and Scopus for randomized controlled trials (RCTs) that administered probiotics or eligible comparators to undernourished children below 5 years of age. Our primary outcomes of interest were weight-for-age, height-for-age, and weight-for-height at the longest follow-up points reported. Random-effects meta-analysis was used to calculate standardized mean differences (SMD) for continuous outcomes and risk ratios for dichotomous outcomes. The Grading of Recommendations Assessment, Development and Evaluation criteria were used to assess certainty of the evidence.

RESULTS

Nine RCTs with 5295 children in total were included. Durations of treatment ranged from 1 month to 1 year. Pooled analyses from 7 studies showed that probiotics may have little to no effect on weight-for-age (SMD 0.05 standard deviation [SD], 95% CI: -0.04 to 0.13, n = 2115 children; low-certainty evidence) and height-for-age (SMD -0.04 SD, 95% CI: -0.14 to 0.07, n = 1357 children; low-certainty evidence). The evidence was very uncertain about the effect on weight-for-height.

CONCLUSIONS

Probiotics may have little to no effect on anthropometry in undernourished children, though there is considerable heterogeneity among the trials reviewed thus far. The interaction between gut microbiota and human nutrition is complex, and further research is needed to determine how the gut microbiome may contribute to undernutrition and how probiotics may affect growth in this vulnerable population.

Protocol for a randomized clinical trial comparing the efficacy of Structured Diet (SD) and Regular Therapy (RT) for adolescents with malnutrition having Autism Spectrum Disorder (ASD)

BACKGROUND

Autism spectrum disorders (ASD) have a lifelong impact on behavior, communication, cognitive function, education, physical functioning, and personal, or social life. Separate studies suggest, Therapeutic and dietary interventions are effective to some extent in managing these issues. No study integrated the nutrition and therapeutic approaches and examined the outcome on disease severity, overall health, and behavioral status in ASD. The proposed study is designed to evaluate the combined effect of regular therapy (RT) and structured diet (SD) compared to the usual diet (UD) for Adolescents with ASD.

METHODS

The proposed study will be a randomized clinical trial (RCT) with the assessor, therapist, and participants blinded to group allocation. Seventy ASD children with malnutrition will be enrolled in two different facilities of the Centre for the Rehabilitation of the Paralysed (CRP) between January 2023 and June 2023. Participants will be enrolled through a hospital-based randomization process from a population-based screening dataset, and with a concealed group allocation to either RT+ SD or RT+ UD group with a 1:1 ratio. The outcome measures are the Childhood Autism Rating Scale as per DSM-5 to determine the severity of ASD, Mid-upper arm circumference (MUAC), and BMI for nutritional status, and Gilliam Autism Rating Scale (GARS-2) to assess the behavioral status. Post-test will be performed after 12 weeks of intervention, and Follow-up will be taken after 6 months of post-test.

PERSPECTIVES

The result of the study will contribute to the provision of a comprehensive approach to malnourished Adolescents with ASD, and manage the issues related to the severity of ASD, stereotypical behavior, and anticipated health hazards.

CLINICAL TRIAL IDENTIFIER

CTRI/2022/11/047653.

A Prospective Comparison of Standard and Modified Acute Malnutrition Treatment Protocols during COVID-19 in South Sudan

A non-randomized prospective cohort study was conducted in 2022 to compare recovery rate and length of stay (LoS) for acutely malnourished children treated under South Sudan's standard Community Management of Acute Malnutrition (CMAM) protocol and a COVID-modified protocol. Children aged 6-59 months received acute malnutrition (AM) treatment under the standard or modified protocol (mid-upper-arm circumference-only entry/exit criteria and simplified dosing). Primary (recovery rate and LoS) were compared for outpatient therapeutic (OTP) and therapeutic supplementary feeding programs (TSFP) using descriptive statistics and mixed-effects models. Children admitted to OTP under both protocols were similar in age and sex; children admitted to TSFP were significantly older under the modified protocol than the standard protocol. Shorter LoS and higher recovery rates were observed under the modified protocol for both OTP (recovery: 93.3% vs. 87.2%; LoS: 38.3 vs. 42.8 days) and TSFP (recovery: 79.8% vs. 72.7%; LoS: 54.0 vs. 61.9 days). After adjusting for site and child characteristics, neither differences in adjusted odds of recovery [OTP: 2.63; TSFP 1.80] nor LoS [OTP -10.0; TSFP -7.8] remained significant. Modified protocols for AM performed well. Adjusted models indicate similar treatment outcomes to the standard protocol. Adopting simplified protocols could be beneficial post-pandemic; however, recovery and relapse will need to be monitored.

Association of admission cortisol levels with outcomes and treatment response in patients at nutritional risk : A secondary analysis of a randomized clinical trial

INTRODUCTION

Cortisol is a metabolically active stress hormone that may play a role in the pathogenesis of malnutrition. We studied the association between admission cortisol levels and nutritional parameters, disease severity, and response to nutritional support among medical inpatients at nutritional risk.

METHODS

Admission cortisol was measured in a subset of 764 patients participating in the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a multicentre, randomized-controlled trial that compared individualized nutritional support with usual nutritional care.

RESULTS

Overall, mean cortisol levels were 570 (± 293) nmol/L and significantly higher in patients with high nutritional risk (NRS ≥ 5) and in patients reporting loss of appetite. Cortisol levels in the highest quartile (> 723 nmol/l) were associated with adverse outcomes including mortality at 30 days and 5 years (adjusted HR 2.31, [95%CI 1.47 to 3.62], p = 0.001 and 1.51, [95%CI 1.23 to 1.87], p < 0.001). Nutritional treatment tended to be more effective regarding mortality reduction in patients with high vs. low cortisol levels (adjusted OR of nutritional support 0.54, [95%CI 0.24 to 1.24] vs. OR 1.11, [95%CI 0.6 to 2.04], p for interaction = 0.134). This effect was most pronounced in the subgroup of patients with severe malnutrition (NRS 2002 ≥ 5, p for interaction = 0.047).

CONCLUSION

This secondary analysis of a randomized nutritional trial suggests that cortisol levels are linked to nutritional and clinical outcome among multimorbid medical patients at nutritional risk and may help to improve risk assessment, as well as response to nutritional treatment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02517476.

Impact of a specialized oral nutritional supplement on quality of life in older adults following hospitalization: Post-hoc analysis of the NOURISH trial

BACKGROUND & AIMS

Both during and after hospitalization, nutritional care with daily intake of oral nutritional supplements (ONS) improves health outcomes and decreases risk of mortality in malnourished older adults. In a post-hoc analysis of data from hospitalized older adults with malnutrition risk, we sought to determine whether consuming a specialized ONS (S-ONS) containing high protein and beta-hydroxy-beta-methylbutyrate (HMB) can also improve Quality of Life (QoL).

METHODS

We analyzed data from the NOURISH trial-a randomized, placebo-controlled, multi-center, double-blind study conducted in patients with congestive heart failure, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease. Patients received standard care + S-ONS or placebo beverage (target 2 servings/day) during hospitalization and for 90 days post-discharge. SF-36 and EQ-5D QoL outcomes were assessed at 0-, 30-, 60-, and 90-days post-discharge. To account for the missing QoL observations (27.7%) due to patient dropout, we used multiple imputation. Data represent differences between least squares mean (LSM) values with 95% Confidence Intervals for groups receiving S-ONS or placebo treatments.

RESULTS

The study population consisted of 622 patients of mean age ±standard deviation: 77.9 ± 8.4 years and of whom 52.1% were females. Patients consuming placebo had lower (worse) QoL domain scores than did those consuming S-ONS. Specifically for the SF-36 health domain scores, group differences (placebo vs S-ONS) in LSM were significant for the mental component summary at day 90 (-4.23 [-7.75, -0.71]; p = 0.019), the domains of mental health at days 60 (-3.76 [-7.40, -0.12]; p = 0.043) and 90 (-4.88 [-8.41, -1.34]; p = 0.007), vitality at day 90 (-3.33 [-6.65, -0.01]; p = 0.049) and social functioning at day 90 (-4.02 [-7.48,-0.55]; p = 0.023). Compared to placebo, differences in LSM values for the SF-36 general health domain were significant with improvement in the S-ONS group at hospital discharge and beyond: day 0 (-2.72 [-5.33, -0.11]; p = 0.041), day 30 (-3.08 [-6.09, -0.08]; p = 0.044), day 60 (-3.95 [-7.13, -0.76]; p = 0.015), and day 90 (-4.56 [-7.74, -1.38]; p = 0.005).

CONCLUSIONS

In hospitalized older adults with cardiopulmonary diseases and evidence of poor nutritional status, daily intake of S-ONS compared to placebo improved post-discharge QoL scores for mental health/cognition, vitality, social functioning, and general health. These QoL benefits complement survival benefits found in the original NOURISH trial analysis.

CLINICAL TRIAL REGISTRATION

NCT01626742.

Dietitians' perceptions of identifying and managing malnutrition and frailty in the community: A mixed-methods study

AIM

This study aimed to explore dietitians' perceptions of their current practice for identifying and managing malnutrition/frailty in the community, to fill an evidence gap.

METHODS

This mixed-methods study involved an online survey distributed to dietitians practising in Australia and New Zealand, and semi-structured interviews with a subset of survey participants. The 34-item survey and interviews explored dietitians' practices for identifying/managing malnutrition and frailty, focusing on the community setting. Survey data were analysed descriptively and some simple association tests were conducted using statistical software. Interview data were analysed thematically.

RESULTS

Of the 186 survey respondents, 18 also participated in an interview. Screening and assessment for malnutrition varied in the community and occurred rarely for frailty. Dietitians reported practising person-centred care by involving clients/carers/family in setting goals and selecting nutrition interventions. Key barriers to providing nutrition care to community-dwelling adults included a lack of awareness/understanding of nutrition by clients and other health professionals (leading to them not participating in or valuing nutrition care), lack of time and resources in the community, and client access to foods/supplements. Enablers included engaging family members/carers and coordinating with other health professionals in nutrition care planning.

CONCLUSION

Reported practices for identifying malnutrition and frailty vary in the community, suggesting guidance may be needed for health professionals in this setting. Dietitians reported using person-centred care with malnourished and frail clients but encountered barriers in community settings. Engaging family members/carers and multidisciplinary colleagues may help overcome some of these barriers.

A - 102 Neuropsychological Findings in a Patient Diagnosed with Wernicke's Encephalopathy Due to Chemoradiation and Malnutrition: a Case Presentation

OBJECTIVE

Wernicke's Encephalopathy (WE) is a rare neuropsychiatric syndrome caused by thiamine deficiency. WE is characterized by inattention, incoherence, confusion, eye-movement disorders, and ataxia. However, scarce information exists on neurocognitive outcomes, particularly stemming from oncology-related etiologies, (e.g., malnutrition caused by chemoradiation). In hopes of elucidating consequential deficits, a case presenting the neurocognitive profile of WE in a 71-year-old female cancer survivor is reported.

METHOD

Patient underwent standard chemoradiation for squamous cell carcinoma of the oropharynx in 2021 followed by frequent nutritional deficiency resulting from decreased appetite, mouth sores, and nausea/vomiting. She developed increased weakness, confusion, difficulty walking, nystagmus, and altered mental state. Completion of chemoradiation and onset of WE saw her experience altered mental status, confusion, gait instability, dysarthric speech, and memory difficulties. Imaging indicated a linear chronic infarct in the left cerebellar hemisphere and frontal predominant brain volume loss.

RESULTS

Patient was referred for neuropsychological evaluation after beginning treatment for WE and psychotherapy to assess barriers to improving nutrition. Primary deficits were observed on verbal learning and memory, verbal fluency, executive functioning, attention, and visuomotor functioning. Comprehension and visual memory skills were intact. Both basic and higher order cognitive processes were impacted resulting in declining quality of life and activities of daily living.

CONCLUSION

This study highlights the need to consider chemoradiation as an etiological risk factor for the development of WE and associated neurocognitive sequelae. Neuropsychological dysfunction is an important consideration given the acute nature of this life-threatening disease. The key elements in treatment involve thiamine replacement, nutrition, appropriate rehabilitation, and medical follow-up.

Successful Use of an Exclusion Diet with Partial Enteral Nutrition in a Patient After Total Gastrectomy: A Case Report

BACKGROUND Gastric cancer is the 5th most common malignancy worldwide. Treatment consists of excision of the entire stomach. Malnutrition is a common problem in patients diagnosed with gastric cancer and has a negative impact on the course of treatment and the quality of life. CASE REPORT The paper presents a case report of a patient after total gastrectomy performed on 11/04/2016 due to G3 mucocellulare carcinoma. The patient had been on home parenteral nutrition for 2.5 years due to chronic malnutrition. After this period of time, an attempt was made to introduce an exclusion diet with the addition of Modulen IBD (Nestle Health Science), which is routinely used in the nutritional treatment of patients with Crohn's disease, with simultaneous discontinuation of parenteral nutrition. After 3 months, the patient was readmitted to the hospital to assess his nutritional status. He continued the diet as recommended. He maintained his body weight and reported improvement in eating habits. CONCLUSIONS In the described case, the patient presented with symptoms of impaired bowel function resulting from long-term cessation of oral nutrition. It is possible that the nutritional and immunomodulatory effect of Modulen, in combination with the anti-inflammatory elimination diet, resulted in better nutrition of intestinal epithelial cells and gradual improvement of intestinal motility and absorption, which in turn enabled the patient to completely withdraw from parenteral nutrition. We propose that this type of nutritional management could also be considered in other cases of intestinal dysfunction.

Inclusion of nutritional counseling and mental health services in HIV/AIDS management: A paradigm shift

Human immunodeficiency virus (HIV) infection is a public health challenge that can degenerate into acquired immunodeficiency syndrome (AIDS) if not properly managed. HIV infection shortens life expectancy to about 5 to 10 years compared to noninfected individuals. People living with HIV/AIDS (PLWHA) are prone to several health challenges as a result of a deranged immune system culminating in high morbidity and mortality. Depression is a common feature of PLWHA. Depression heightens the emergence of opportunistic infections in HIV-infected individuals, accelerates the progression to AIDS, and increased suicidal tendencies, morbidity, and mortality. Food insecurity with its resultant undernutrition contributes to HIV/AIDS-related deaths. Undernourished PLWHA are more prone to opportunistic infections due to poor immunity. Interestingly, proper diet intake can boost immunity, slow the progression of AIDS and opportunistic infections, enhance body weight, and retard depression tendencies. Undernutrition can also be ameliorated by incorporating nutritional counseling and oral nutrient supplementation in routine HIV/AIDS checkups. Therefore, to increase HIV/AIDS management outcomes, the integration of nutrition counseling, dietary supplements, and mental health services should be embraced. Thus, HIV/AIDS care centers should amplify these services. In this article, we isolated relevant studies from various databases, illuminated the interwoven relationship between HIV/AIDS, depression, and undernutrition, and also reemphasized the need for adequate nutritional intervention in the battle against HIV/AIDS. Thus, this study provides a reawakening call to focus on incorporating nutritional guides and mental health care in HIV/AIDS management protocols.