Evidence supports nutritional support

The Outcomes of Nutritional Support Techniques in Patients with Gastrointestinal Cancers

Gastrointestinal cancers represent a major cause of morbidity and mortality worldwide. A significant issue regarding the therapeutic management of these patients consists of metabolic disturbances and malnutrition. Nutritional deficiencies have a negative impact on both the death rates of these patients and the results of surgical or oncological treatments. Thus, current guidelines recommend the inclusion of a nutritional profile in the therapeutic management of patients with gastrointestinal cancers. The development of digestive endoscopy techniques has led to the possibility of ensuring the enteral nutrition of cancer patients without oral feeding through minimally invasive techniques and the avoidance of surgeries, which involve more risks. The enteral nutrition modalities consist of endoscopy-guided nasoenteric tube (ENET), percutaneous endoscopic gastrostomy (PEG), percutaneous endoscopic gastrostomy with jejunal tube extension (PEG-J), direct percutaneous endoscopic jejunostomy (DPEJ) or endoscopic ultrasound (EUS)-guided gastroenterostomy.

Nutrition Support and the Gastrointestinal Microbiota: A Systematic Review

BACKGROUND

Low microbial diversity or altered microbiota composition is associated with many disease states. In the treatment of many conditions, enteral (EN) or parenteral (PN) nutrition is frequently required.

OBJECTIVE

This systematic review aimed to identify and evaluate the evidence of the effect of EN vs PN on the gastrointestinal microbiota.

METHOD

A comprehensive systematic literature search of 5 databases was completed to review studies published until February 2020. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were utilized in completion of the review with the Academy of Nutrition and Dietetics quality criteria checklist and Grading of Recommendations Assessment, Development and Evaluation to evaluate the included studies. The review was registered on PROSPERO (CRD42018091328). Studies were eligible for inclusion if participants were older than 3 years, patients received either EN, PN or both, with some patients receiving each mode of nutrition support. The main outcome was any assessment of the gastrointestinal microbiota, including diversity or taxa abundance.

RESULTS

Eleven articles (n = 367 patients) met the inclusion criteria and were evaluated. Seven studies (n = 237) reported greater abundance of Proteobacteria with the provision of PN compared to EN; 6 studies (n = 172) reported lower Firmicutes and 5 studies (n = 155) lower Bacteroidetes. In 7 studies (n = 282), microbial diversity was lower with provision of PN than EN. The Grading of Recommendations Assessment, Development and Evaluation certainty of evidence was very low.

CONCLUSIONS

Provision of PN may lead to greater abundance of Proteobacteria and reduced microbial diversity; however, there is limited literature on this topic and additional research is warranted to improve understanding of the impact of EN vs PN on the microbiota.

Nutrition Support Team Reconsultation During Nutrition Therapy in Korea

BACKGROUND

The aim of this study was to investigate the nutrition support team (NST) reconsultation practice and to evaluate reasons and describe risk factors for NST reconsultation during nutrition therapy (NT) in hospitalized patients.

METHODS

This study included 2505 patients aged >18 years who received NT through NST consultation between January 2016 and December 2016 at Seoul National University Hospital. NST reconsultation refers to consulting the NST more than twice during a single hospitalization period. Risk factors affecting NST reconsultation were included only when NST reconsultation occurred for specific reasons other than routine evaluations.

RESULTS

The NST reconsultation rate was 36.4% (913/2505) with 926 reasons, including 'changes in the nutrition provision method' (n = 474, 51.2%), 'NT-related complications' (n = 284, 30.7%), 'routine evaluations' (n = 137, 14.8%), and 'discharge planing including home NT' (n = 31, 3.3%). The reconsultation rate of enteral nutrition (EN) was 40.8% (n = 378) and that of parenteral nutrition (PN) was 59.2% (n = 548). Among the NT-related complications, diarrhea (n = 65, 49.2%) was the most common with EN, whereas electrolyte abnormality (n = 52, 34.2%) was the most common with PN. Performance of surgery (odds ratio [OR], 2.061; P < .001), low serum albumin levels (<3 mg/dL; OR, 1.672; P < .001), presence of comorbidities (OR, 1.556; P < .001), and low body mass index (kg/m² ) (<18.5; OR, 1.508; P < .001) were predictive risk factors for NST reconsultation.

CONCLUSIONS

Frequent evaluation of nutrition status through a multidisciplinary NST is important in patients with these risk factors.

Nutritional Support of Cancer Patients without Oral Feeding: How to Select the Most Effective Technique?

BACKGROUND

Digestive tumours are among the leading causes of morbidity and mortality. Many cancer patients cannot maintain oral feeding and develop malnutrition. The authors aim to: review the endoscopic, radiologic and surgical techniques for nutritional support in cancer patients; address the strategies for nutritional intervention according to the selected technique; and establish a decision-making algorithm to define the best approach in a specific tumour setting.

SUMMARY

This is a narrative non-systematic review based on an electronic search through the medical literature using PubMed and UpToDate. The impossibility of maintaining oral feeding is a major cause of malnutrition in head and neck (H&N) cancer, oesophageal tumours and malignant gastric outlet obstruction. Tube feeding, endoscopic stents and gastrojejunostomy are the three main nutritional options. Nasal tubes are indicated for short-term enteral feeding. Percutaneous endoscopic gastrostomy (PEG) is the gold standard when enteral nutrition is expected for more than 3-4 weeks, especially in H&N tumour and oesophageal cancer patients undergoing definite chemoradiotherapy. A gastropexy push system may be considered to avoid cancer seeding. Radiologic and surgical gastrostomy are alternatives when an endoscopic approach is not feasible. Postpyloric nutrition is indicated for patients intolerant to gastric feeding and may be achieved through nasoenteric tubes, PEG with jejunal extension, percutaneous endoscopic jejunostomy and surgical jejunostomy. Oesophageal and enteric stents are palliative techniques that allow oral feeding and improve quality of life. Surgical or EUS-guided gastrojejunostomy is recommended when enteric stents fail or prolonged survival is expected. Nutritional intervention is dependent on the technique chosen. Institutional protocols and decision algorithms should be developed on a multidisciplinary basis to optimize nutritional care.

CONCLUSIONS

Gastroenterologists play a central role in the nutritional support of cancer patients performing endoscopic techniques that maintain oral or enteral feeding. The selection of the most effective technique must consider the cancer type, the oncologic therapeutic program, nutritional aims and expected patient survival.

Bioelectrical impedance analysis (BIA)-derived phase angle (PA) is a practical aid to nutritional assessment in hospital in-patients

BACKGROUND

Nutritional status can be difficult to assess. Bioelectrical impedance analysis (BIA)-derived phase angle (PA), and the plasma markers citrulline and transthyretin (pre-albumin) have the potential to assist, but the protocol of fasting and resting for BIA renders the investigation impractical for routine use, especially so in populations at high risk of malnutrition.

AIMS

1 To clarify whether starving and resting are necessary for reliable measurement of PA. 2 To identify whether PA, citrulline and transthyretin correlate with nutritional status.

METHODS

Eighty consenting adult in-patients were recruited. Nutritional status was determined by subjective global assessment (SGA) used as gold standard. The Malnutrition Universal Screening Tool (MUST) was used and anthropometric measurements were performed. Serum was analysed for citrulline and transthyretin. PA was measured using Bodystat 4000. The PA was considered to define malnutrition when lower than reference ranges for sex and age, and severe malnutrition if more than 2 integers below the lower limit. Anthropometric measurements were categorised according to WHO reference centiles. Ordinal logistic regression estimated the strength of association of PA, citrulline and transthyretin with SGA. PA values in the different metabolic states were compared using paired t tests.

RESULTS

All 80 subjects completed the BIA and the nutritional assessments in the 3 different states; 14 declined to provide blood samples for the biochemical assays. Malnutrition was identified in 32 cases, severe malnutrition in 14 cases, the remaining 34 cases were deemed not to be malnourished. PA was strongly inversely associated with SGA (Odds Ratio [OR] per unit increase = 0.21, CI 0.12-0.37, p < 0.001). PA was not influenced by exercise (p = 0.134) or food intake (p = 0.184). Transthyretin was inversely associated with malnourished/severely malnourished states (OR = 0.98, 95% CI 0.97-0.99, p = 0.001), but had poorer predictive values than PA. There was no significant association between citrulline concentration and SGA (OR = 1.01, 95% CI 0.99-1.04, p = 0.348).

CONCLUSIONS

The BIA-derived PA reliably identifies malnutrition. It is strongly associated with SGA but requires less skill and experience, and out-performs circulating transthyretin, rendering it a promising and less operator-dependent tool for assessing nutritional status in hospital patients. Our novel demonstration that fasting and bed-rest are unnecessary consolidates that position.

Modified-Nutrition Index is a Significant Prognostic Factor for the Overall Survival of the Nasopharyngeal Carcinoma Patients who Undergo Intensity-modulated Radiotherapy

PURPOSE

To explore whether the modified-nutrition index (m-NI) is a prognostic factor for the overall survival (OS) in nasopharyngeal carcinoma (NPC) patients who undergo intensity-modulated radiotherapy (IMRT).

METHODS

Clinical data were prospectively collected from NPC patients who underwent IMRT at our hospital between October 2008 and December 2014. The patient nutritional status before radiotherapy was evaluated using the m-NI, based on eight nutrition indicators including body mass index, arm muscle circumference, albumin, total lymphocyte count, red blood cell count, hemoglobin, serum pre-albumin, and transferrin. The independent prognostic value of m-NI for the OS was evaluated.

RESULTS

A total of 323 patients (229 males, 94 females) were included in this study, and the follow-up rate was 99.7% (322/323). The 1-, 3-, and 5-yr OS rates between malnutrition and normal nutrition groups by using the m-NI were 93.0% vs. 96.9%, 76.4% vs. 82.8%, and 61.8% vs. 77.1%, respectively. A regression analysis showed that the m-NI was the significant prognostic value for the OS in NPC.

CONCLUSIONS

The m-NI before radiotherapy is a significant prognostic factor for the OS in NPC patients. Further validation of our instrument is needed in other NPC patients.

Benefits of early specialized nutritional support in malnourished patients

INTRODUCTION AND OBJECTIVE

Disease related malnutrition (DRM) is highly prevalent in Spain, affecting 23% of in-hospital patients, and is associated with clinical complications. Specialized nutritional support (SNS) can reduce these complications.

MATERIAL AND METHODS

Prospective study carried out in standard clinical practice conditions to test if SNS during the first 5 days of hospitalization, or subsequently, was associated to a lower length of stay or reduced complications in patients with a NRS-2002 score≥3 points.

RESULTS

In the group of patients who initiated early SNS, the length of stay was 8.83 days shorter than in the group with a later introduction (95% CI 3.55-14.10); nevertheless, the higher prevalence of male and oncological patients in this group could have impacted the results. A tendency towards a statistically significant lower mortality rate and a reduced amount of total complications was described.

CONCLUSION

The early introduction of SNS (within the first 5 days of hospitalization) in patients with DRM was associated with a 32.4% reduction in the length of stay.

Nutritional and microbiological quality of commercial and homemade blenderized whole food enteral diets for home-based enteral nutritional therapy in adults

BACKGROUND & AIMS

Serious nutritional and contamination risks may be involved in the preparation of blenderized tube-feeding diets and in the handling of commercial diets. Their nutritional and microbiological quality in home settings is unknown. The objective of this study was to assess the nutritional and microbiological quality of commercial enteral and homemade blenderized whole foods diets intended to adult patients in home nutritional therapy.

METHODS

In a cross sectional study, 66 samples of commercial (CD) and noncommercial (NCD) enteral diets were collected at the homes of patients in home enteral nutritional therapy, 33 of each type. Commercial diets were either powder (PCD; n = 13) or liquid (LCD; n = 20). The samples were analyzed in laboratory to assess their nutritional and microbiological quality. Anthropometric data of mid upper arm circumference (MUAC) and triceps skinfold (TST) thickness were obtained from the patients' medical records.

RESULTS

NCD presented significantly lower values for protein, fat, fiber, carbohydrate and energy while water content was significantly higher. PCD and LCD did not show any statistically significant differences between them. In the NCD, the values measured for macronutrients and energy corresponded to less than 50% of the prescribed values (except for fat). In CD, protein value was about 20% more than the prescribed value; fat and energy values corresponded to approximately 100% of the prescription, while carbohydrate corresponded to 92%. Regardless the type of the diet, prevalence of undernutrition was high in both groups though patients of the NCD presented a higher percentage. Samples of NCD complied significantly less with the microbiological standards; only 6.0% complied with the standard for coliform bacteria. Escherichia coli was detected in 10, 2, and 2 samples of NCD, PCD and LCD, respectively.

CONCLUSIONS

Homemade blenderized enteral diets showed low values of energy and macronutrients, delivered less than 50% of the prescribed values and had high levels of bacterial contamination.

Screening of nutritional risk and nutritional support in general surgery patients: a survey from Shanghai, China

To determine the prevalence of nutritional risk in surgical departments and to evaluate the impact of nutritional support on clinical outcomes. The nutritional risk in different surgical diseases and the different way of nutritional support on clinical outcomes in patients at nutritional risk remain unclear. Hospitalized patients from general surgical departments were screened using the Nutritional Risk Screening (NRS) 2002 questionnaire on admission. Data were collected on nutritional risk, complications, and length of stay (LOS). Overall, 5034 patients were recruited; the overall prevalence of nutritional risk on admission were 19.2%. The highest prevalence was found among patients with gastric cancer. At-risk patients had more complications and longer LOS than nonrisk patients. Of the at-risk patients, the complication rate was significantly lower and LOS was significantly shorter in the nutritional-support group than in the no-support group (20.9 versus 30.0%, P < 0.05). Subgroup analysis showed reduced complication rates and LOS only in patients with gastric cancer, colorectal cancer, and hepato-pancreato-biliary (HPB) cancer. Significantly lower complication rates relative to nonsupported patients were found among patients who received enteral nutrition or who received support for 5 to 7 days, or daily support entailing 16 to 25 kcal/kg of nonprotein energy. Different surgical diseases have different levels of nutritional risk. The provision of nutritional support was associated with a lower complication rate and a shorter LOS for gastric, colorectal, and HPB cancer patients at nutritional risk. The improper use of nutritional support may not improve outcomes for at-risk patients.

NUTRITIONAL THERAPY IN THE TREATMENT OF ACUTE CORROSIVE INTOXICATION IN ADULTS

INTRODUCTION

Acute intoxications with corrosive substances can cause severe chemical injuries of the upper gastrointestinal tract, most often located in the mouth, pharynx, esophagus, stomach and duodenum. If a patient survives the acute phase of intoxication, regenerative response may result in esophageal and/or gastric stenosis, and increased risk of esophageal and gastric cancer. Such intoxication may be fatal due to perforation or tracheal necrosis. Enteral nutrition is a nutritional method when nutritional substances are administered through specially designed tubing placed through the nose or percutaneously, directly into the GIT.

AIM

The aim of this study is to describe the methods of artificial nutrition in patients with acute corrosive intoxications and the importance of nutritional support in the treatment of these intoxications.

DISCUSSION

Nutrition in the treatment of acute corrosive intoxications is one of the most important therapeutic processes that largely contribute to faster recovery of the post-corrosive injuries of upper GIT, stabilization of biologic, immunologic and metabolic parameters, and reduction of length of stay in hospital Aim of the treatment of acute corrosive intoxications is to prevent perforation and progressive fibrosis, and esophageal and gastric stenosis. There are different and often conflicting positions, on the conservative treatment of acute corrosive intoxications in adults. Such treatment mainly consists of anti-secretory treatment, antibiotics and intensive hyper-alimentation, aiming to prevent late post-corrosive intoxications.

CONCLUSION

It is considered that nutritional support plays a major role in maintenance of metabolic processes and prevention of severe metabolic complications that could additionally aggravate the condition and impair the treatment.

Nutritional management of the patient with Crohn's disease

Active Crohn's disease often co-exists with malnutrition and requires input from the inflammatory bowel disease multidisciplinary team in order to assess, prevent and treat the complications of both malnutrition and active disease.

Maintaining adequate hydration and nutrition in adult enteral tube feeding

Predicting the nutritional and fluid requirements of enterally-fed patients can be challenging and the practicalities of ensuring adequate delivery must be taken into consideration. Patients who are enterally fed can be more reliant on clinicians, family members and carers to meet their nutrition and hydration needs and identify any deficiencies, excesses or problems with delivery. Estimating a patient's requirements can be challenging due to the limitations of using predictive equations in the clinical setting. Close monitoring by all those involved in the patient's care, as well as regular review by a dietitian, is therefore required to balance the delivery of adequate feed and fluids to meet each patient's individual needs and prevent the complications of malnutrition and dehydration. Increasing the awareness of the signs of malnutrition and dehydration in patients receiving enteral tube feeding among those involved in a patient's care will help any deficiencies to be detected early on and rectified before complications occur.

Effects of soy protein and calcium levels on mineral bioaccessibility and protein digestibility from enteral formulas

Enteral formulas (EF) are complex food systems which have all the nutrients in their matrix for the complete human nourishment. However, there are components in EF which can interact with minerals, reducing their absorption, and thereof the EF nutritional quality. The effect of soy protein (SP) and Ca content on Fe, Zn, and Ca bioaccessibility and protein digestibility (%DP) was assessed using a response surface design in EF. Tested SP levels were 2.5-5.0 g/100 mL of total protein. Ca levels were adjusted with Ca citrate within a range between 50 and 100 mg/100 mL. SP content negatively influenced %DP and Fe, Zn and Ca bioaccessibility. As SP content increased, mineral bioaccessibility and %DP decreased, probably due to the increased levels of phytic acid and trypsin inhibitors from SP. Ca content only affected %DCa, which had a direct relationship with Ca levels, while did not affect Fe and Zn bioaccessibility or %DP. Since Ca citrate did not impair Fe and Zn bioaccessibility, it could be an appropriate Ca source for EF fortification.

The effects of the administration of oral nutritional supplementation with medication rounds on the achievement of nutritional goals: a randomized controlled trial

BACKGROUND & AIMS

Oral nutritional supplements (ONS) are often considered for hospitalized patients with acute severe malnutrition, however the compliance to the supplements is known to be variable. The aim of our study was to investigate whether providing a lower volume of ONS at a higher frequency during medication rounds would improve the intake of the supplements.

METHODS

In this randomized controlled trial, 234 malnourished inpatients (mean age 71.2 years, 55% male, median LOS 10 days) were randomized to receive ONS (300 kcal and 12 g Protein per 125 ml serving) in one of three different schemes. The usual care group (n = 88) was offered ONS 125 ml twice per day in between meals. This was compared to two intervention groups that were offered ONS during medication rounds: intervention group 1 (n = 66) received 125 ml of ONS twice per day, at 12 and 17 o'clock, and intervention group 2 (n = 80) received 62 ml of ONS four times a day, at 8, 12, 17 and 20 o'clock. Follow-up was performed until discharge or until ONS was no longer needed, with a maximum follow-up period of 30 days. The primary outcome measure was the percentage of patients who consumed at least 75% of the prescribed volume of ONS.

RESULTS

No significant differences were observed between the control groups and intervention group 1 (risk difference of -16.0% (95% CI -33.2-1.2). However, the percentage of patients consuming at least 75% of the prescribed ONS was higher in intervention group 2, with a risk difference 23.4% (95% CI 7.8-39.0%) and a mean increased intake of 35 ml (84 kcal) per day, p < 0.001). Median time ONS were taken was 5 days (range 1-17).

CONCLUSION

A higher frequency of a lower volume of ONS during medication rounds increased the compliance of patients needing ONS. Clinical trial registration number NTR2535; www.trialregister.nl.

Advances in enteral nutrition research

Enteral nutrition (EN) has some advantages in maintaining physiological function in surgical patients, and gets more and more extensive applications. This paper carries out a comprehensive analysis of enteral nutrition in terms of evaluation before applying EN, the selection of application methods, application duration, the selection of preparations, and safety. The improvement measures are finally put forward.

Food matrix and cooking process affect mineral bioaccessibility of enteral nutrition formulas

BACKGROUND

When enteral formulas (EF) are administered orally as a supplement to the normal diet, they are often mixed with conventional foods or included in recipes in order to seek new flavors and textures and avoid monotony. The aims of this work were to study the bioaccessibility of Fe, Zn and Ca from commercial EF and the impact upon their incorporation into sweet preparations. Twenty commercial EF, before and after inclusion in sweet food (rice pudding, RP; banana smoothie, BS; tea, T; chocolate dessert, CD) were evaluated regarding Fe, Zn and Ca dialyzability (%DFe , %DZn , %DCa ) as an estimator of mineral bioaccessibility.

RESULTS

Fe, Zn and Ca dialyzability from EF was variable and generally low. Heating during EF-sweet food preparation (T and CD) lowered values to 44.1 %DFe , possibly due to degradation of vitamin C, and 52.7 %DZn and 25.3 %DCa , due to the interaction with food components.

CONCLUSION

EF and EF-sweet foods did not represent a good supply of Fe, Zn and Ca as recommended. This study demonstrated how the bioaccessibility of these minerals is affected by the food matrix in which EF is included as well as heating during food preparation.

Neonatal and pediatric parenteral nutrition

Parenteral nutrition is one of the most important therapeutic modalities invented in the last several decades. Since its introduction in the 1960s, this modality has saved thousands of lives by providing nutrients parenterally to sustain growth in premature neonates with severe intestinal immaturity and other pediatric patients with intestinal failure, such as a gastrointestinal fistula or short bowel syndrome. Although parenteral nutrition can be a lifesaving treatment, it is not benign. Many complications can result from either short- or long-term usage. This review discusses the nutritional requirements, common complications, medication additives, and special considerations for pediatric patients requiring parenteral nutrition.

Patient needs and research priorities in the enteral nutrition market - a quantitative prioritization analysis

BACKGROUND & AIMS

A quantitative systematic identification and prioritization of unmet needs and research opportunities in relation to enteral nutrition was conducted by means of a tailor-made health research prioritization process.

METHODS

The research objectives were reached by conducting qualitative interviews followed by quantitative questionnaires targeting enteral nutrition key opinion leaders (KOLs). (1) Define disease areas that deserve more research attention; (2) Rank importance of product characteristics of tube feeding (TF) and oral nutritional supplements (ONS); (3) Assess involvement of KOLs in enteral nutrition R&D process. KOLs ranked three product characteristics and three disease areas that deserve additional research attention. From these, overall priority scores were calculated by multiplying ranks for both product characteristics and disease areas.

RESULTS

17 qualitative interviews were conducted and 77 questionnaires (response rate 35%) were completed and returned. (1) Disease areas in ONS and TF with highest priorities are: ONS: general malnutrition & geriatrics, TF: intensive care. (2) TF product characteristics with highest priorities are: composition and clinical evidence from a KOL perspective; tolerance and ease of use from a patient perspective. ONS product characteristics with highest priorities are: composition, clinical evidence and taste from a KOL perspective; taste from a patient perspective. We find a high discrepancy between product characteristic prioritization from a KOL and patient perspective. (3) Although 62% of all KOLs give advice to enteral nutrition companies on patient needs, they under-influence the setting of research priorities by enteral nutrition companies.

CONCLUSIONS

This study provides a systematic approach to achieve research prioritization in enteral nutrition. In addition to providing new directions for enteral nutrition research and development, this study highlights the relevance of involving KOLs in the identification of research priorities as they have the ability to provide a balanced view of the unmet patient needs.

Does documentation in nursing records of nutritional screening on admission to hospital reflect the use of evidence-based practice guidelines for malnutrition?

PURPOSE

To describe the documentation of nutrition-related data and wards referral to dieticians in a Belgian university hospital.

METHOD

Retrospective analysis of 506 nursing records.

FINDINGS

Body weight and height are documented in 22%. "Feeding assistance" and "usual food intake pattern" are documented in 68% of all cases, and in 71% it is marked whether the patient is on a diet. Eight percent of the patients are referred to a dietician, but the indications for these referrals are not clear.

CONCLUSION

Given the poor documentation, most likely these patients are not adequately screened for malnutrition as recommended.

IMPLICATIONS FOR NURSING PRACTICE

Nurses' documentation of nutrition-related data should be improved to facilitate treatment of malnutrition with tailored multidisciplinary interventions.

Hypokalemia during the early phase of refeeding in patients with cancer

OBJECTIVE

Refeeding syndrome occurs in patients with severe malnutrition when refeeding begins after a long period of starvation. This syndrome increases the risk of clinical complications and mortality. Hypophosphatemia is considered the primary characteristic of the syndrome. The aim of our study was to investigate the presence of other electrolyte alterations in patients with cancer during the early stage of refeeding.

METHODS

In this observational study, we enrolled 34 patients with cancer of the upper aerodigestive tract receiving upfront radiotherapy who were also enrolled in a nutrition program. A caloric intake assessment, anthropometric measurements and biochemical laboratory tests were performed.

RESULTS

Significant weight loss (∼20%) was found in these patients. In the patients receiving artificial nutrition, we found lower levels of potassium and total protein compared with those who were fed orally (p = 0.03 for potassium and 0.02 for protein, respectively). Patients on enteral tube feeding had a higher caloric intake compared with those who were fed orally (25±5 kcal/kg/day vs. 10±2 kcal/kg/day).

CONCLUSION

Hypokalemia, like hypophosphatemia, could be a complication associated with refeeding in patients with cancer. Hypokalemia was present in the early stages of high-calorie refeeding.

Self-reported body weight and height on admission to hospital: a reliable method in multi-professional evidence-based nutritional care?

Screening patients' nutritional status on admission to hospital is recommended by evidence-based guidelines on malnutrition. In practice, self-reported values for body weight and height are often used by nurses and dieticians. This study assessed the accuracy of self-reported body weight and height and whether these self-reported values might be influenced by the nature of the health-care worker involved. Patients (n = 611) on admission reported their body weight and height to a nurse and a dietician. Reported values were analysed and compared with the measured values. Self-reported values for body weight and height on admission are not always accurate. Patients do report different values to different health-care workers. Self-reported values for body weight to nurses were more accurate as compared with dieticians. Self-reported values for body weight and height are subject to observer bias and should be used with caution in nutritional screening and multi-professional nutritional care.

Patients' lived experiences of a reduced intake of food and drinks during illness: a literature review

AIM

This study aims to identify patients' lived experiences of having a reduced intake of food and drink during illness, through a literature review.

METHODS

Scientific studies were selected through a systematic search of CINAHL, PubMed, SweMed, British Nursing Index, Psycinfo and EMBASE. A deductive thematic analysis was performed on the studies included. The analysis provided three main themes: (i) serving of food and drink - patient experiences. (ii) Modifications related to illness - patient experiences. (iii) Nutritional care provided by healthcare professionals nutritional care - patient experiences.

FINDINGS

Generally speaking, the findings showed high satisfaction with the food served at hospitals. However, patients' individual tastes and preferences as to when and where to eat were found to affect their intake of food and drink. Physical changes because of illness were stated as the main reason for the patients' lived experiences of a reduced intake of food and drink. These experiences seemed to be related to negative feelings, such as anxiety and shame during meals. Furthermore, the literature review revealed a lack of professional assistance during meals and insufficient guidance on how to handle specific nutritional problems.

CONCLUSIONS

Patients expect committed nursing care in regard to nutritional advice during illness and assistance in meal-related situations. Nurses need to refocus on fundamental caring.

Factors leading to discrepancies between prescription and intake of enteral nutrition therapy in hospitalized patients

OBJECTIVE

We investigated factors leading to a reduction in enteral nutrition (EN) prescribed by a nutritional support team (NST) at a general hospital in Brazil.

METHODS

In this prospective, observational study, hospitalized adults receiving only EN therapy via tube feeding were followed for up to 21 d from July to October 2008.

RESULTS

The 152 subjects analyzed included 38 (23.5%) ward patients and 124 (76.5%) intensive care unit (ICU) patients. Eighty percent of the targeted feeding volume was achieved on day 4 by 80% of the patients. Reasons for not receiving the total amount of EN prescribed included delay in EN administration (3.1%), abdominal distention (5.6%), patient refusal of treatment (6.8%), feeding tube obstruction (8.6%), vomiting (10.5%), diarrhea (17.9%), unknown causes (17.9%), interference by a non-NST physician (25.9%), accidental feeding tube loss (34%), presence of high gastric residual (34%), and operational logistics at the hospital's Nutrition and Dietetics Service (99.4%). There was a significant association between patients who received <60% of the prescribed EN and external physician interference (P < 0.016). ICU patients also received inadequate EN (P < 0.025). Neurologic patients had a greater chance of receiving >81% of the prescribed EN amount than cardiac patients (odds ratio 3.75, P < 0.01).

CONCLUSION

Major reasons for inadequate EN intake are (in decreasing order) operational logistical problems, gastric stasis, accidental loss of enteral feeding tube, and interference by an external physician (not an NST member). Cardiologic patients and ICU patients are at a higher risk for inadequacy than neurologic patients.

Nutritional screening and mortality in newly institutionalised elderly: a comparison between the geriatric nutritional risk index and the mini nutritional assessment

BACKGROUND & AIMS

Several tools are available for nutritional screening. We evaluated the risk of mortality associated with the Geriatric Nutritional Risk Index (GNRI) and the Mini Nutritional Assessment (MNA) in newly institutionalised elderly.

METHODS

A prospective observational study involving 358 elderly newly admitted to a long-term care setting. Hazard ratios (HR) for mortality among GNRI categories and MNA classes were estimated by multivariable Cox's model.

RESULTS

At baseline, 32.4% and 37.4% of the patients were classified as being malnourished (MNA <17) and at severe nutritional risk (GNRI <92), respectively, whereas 57.5% and 35.2%, respectively, were classified as being at risk for malnutrition (MNA 17-23.5) and having low nutritional risk (GNRI 92-98). During a median follow-up of 6.5 years [25th-75th percentile, 5.9-8.6], 297 elderly died. Risk for all-cause mortality was significantly associated with nutritional risk by the GNRI tool (GNRI<92 HR = 1.99 [95%CI, 1.38-2.88]; GNRI 92-98 HR = 1.51 [95%CI, 1.04-2.18]) but not with nutritional status by the MNA. A significant association was also found with cardiovascular mortality (GNRI <92 HR = 1.79 [95%CI, 1.23-2.61]).

CONCLUSIONS

Nutritional risk by GNRI but not nutritional status by MNA was associated with higher mortality risk. Present data suggest that in the nutritional screening of newly institutionalised elderly the use of the GNRI should be preferred to that of the MNA.

How nutritional risk is assessed and managed in European hospitals: a survey of 21,007 patients findings from the 2007-2008 cross-sectional nutritionDay survey

BACKGROUND & AIMS

Recognition and treatment of undernutrition in hospitalized patients are not often a priority in clinical practice.

OBJECTIVES

We investigated how the nutritional risk of patients is determined and whether such assessment influences daily nutritional care across Europe and in Israeli hospitals.

METHODS

1217 units from 325 hospitals in 25 countries with 21,007 patients participated in a longitudinal survey "nutritionDay" 2007/2008 undertaken in Europe and Israel. Screening practice, the type of tools used and whether energy requirements and intake are assessed and monitored were surveyed using standardized questionnaires.

RESULTS

Fifty-two percent (range 21-73%) of the units in the different regions reported a screening routine which was most often performed with locally developed methods and less often with national tools, the Nutrition Risk Screening-2002, or the Malnutrition Universal Screening Tool. Twenty-seven percent of the patients were subjectively classified as being "at nutritional risk", with substantial differences existing between regions. Independent factors influencing the classification of nutritional risk included age, BMI <18.5 kg/m(2), unintentional weight loss, reduced food intake in the previous week and on nutritionDay (for all parameters, p < 0.0001). The energy goal was defined as >=1500 kcal in 76% of the patients, but 43% of patients did not reach this goal.

CONCLUSIONS

The process of nutrition risk assessment varied between units and countries. Additionally, energy goals were frequently not met. More effort is needed to implement current guidelines within daily clinical practice.

The Geriatric Nutritional Risk Index

PURPOSE OF REVIEW

A new nutrition-related risk assessment tool, the Geriatric Nutritional Risk Index (GNRI), has been recently proposed. The aim of this review is to summarize current evidences on the use of this tool with particular focus on the rationales of its application in elderly healthcare.

RECENT FINDINGS

Structured as a dichotomous index, based on serum albumin values and the discrepancy between real and ideal weight, the GNRI seems to account for both acute and chronic reasons of nutrition-related complications. It allows us to face the frequent difficulties in obtaining a profitable participation of the old patient to nutritional assessment. Its application appears feasible in all healthcare settings in which it shows adequacy to discriminate different profiles of nutritional risk. A GNRI less than 92 might be suggested as clinical trigger for routine nutritional support.

SUMMARY

In maths of nutrition 'recognize and treat' has become a clinical imperative. Actually, clinical judgement by an expert is still considered the reference standard to diagnose malnutrition but the use of simplified tools profitably assists in nutritional risk screening process. The GNRI is easy to use and preliminary results show that it is promising. Its routine application, next to the other validated tools already available, might be enforced in the assessment of the old patient.

Feeding the injured intestine: enteral nutrition in the critically ill patient

PURPOSE OF REVIEW

The utilization of enteral nutrition in critically ill patients is frequently suboptimal. This may be due, in part, to ongoing controversies regarding appropriate use of enteral support, but there are also perceived barriers to its use even when there is good evidence that it can be given. This review was undertaken to outline some of these controversies and barriers to use of enteral nutrition in the ICU.

RECENT FINDINGS

Although the advantages of enteral nutrition may have been overstated, it remains preferable to parenteral nutrition for support of critically ill patients. Early initiation of enteral support is a reasonable approach. Many patients with perceived contraindications to enteral therapy are actually good candidates for its use. Frequent interruptions in enteral nutrition lead to suboptimal nutrient delivery, but might be overcome by use of specific protocols emphasizing safe and effective utilization of enteral support.

SUMMARY

Use of enteral nutritional support is recommended for critically ill patients requiring specialized nutritional support. Barriers to its use could be overcome by better educating providers about indications for use and by developing methods to avoid undue interruption of therapy.

Economic impact and quality of life as endpoints of nutritional therapy

PURPOSE OF REVIEW

The present review exposes why considering primary endpoints such as cost-effectiveness and quality of life in wasting disease research is critical for promoting medical nutrition therapy.

RECENT FINDINGS

Despite growing evidence that nutritional support improves patients' clinical outcome, its use is not widely considered as a routine by most healthcare professionals. Many factors, depending on physicians, patients and institutions, could explain such a resistance to implement nutritional therapy in routine care. One of these factors is the lack of indisputable evidence that nutritional intervention improves patients' quality of life and is cost-effective.

SUMMARY

In today's resource-constrained environment, disease management strategies are judged in terms of not only clinical efficacy and safety but also patient satisfaction and economic dimensions. The demonstration of a positive costs/saving ratio is crucial to obtain the political backing of health administrators and sustain further investment in research. Moreover, improving patients' quality of life promotes their capacity to cope with psychological distress, increases their tolerance and response to treatments, and enhances the global image of the healthcare system. In wasting diseases research, there is a need for well designed clinical trials from which cost-utility performance of nutritional interventions could be assessed in order to convince all the stakeholders and to get support from clinicians and patients themselves.