The effects of enteral tube feeding and parenteral nutrition on appetite sensations and food intake in health and disease

Negative feedback control of hunger circuits by the taste of food

The rewarding taste of food is critical for motivating animals to eat, but whether taste has a parallel function in promoting meal termination is not well understood. Here we show that hunger-promoting AgRP neurons are rapidly inhibited during each bout of ingestion by a signal linked to the taste of food. Blocking these transient dips in activity via closed-loop optogenetic stimulation increases food intake by selectively delaying the onset of satiety. We show that upstream leptin receptor-expressing neurons in the dorsomedial hypothalamus (DMHLepR) are tuned to respond to sweet or fatty tastes and exhibit time-locked activation during feeding that is the mirror image of downstream AgRP cells. These findings reveal an unexpected role for taste in the negative feedback control of ingestion. They also reveal a mechanism by which AgRP neurons, which are the primary cells that drive hunger, are able to influence the moment-by-moment dynamics of food consumption.

The Phantom Satiation Hypothesis of Bariatric Surgery

The excitation of vagal mechanoreceptors located in the stomach wall directly contributes to satiation. Thus, a loss of gastric innervation would normally be expected to result in abrogated satiation, hyperphagia, and unwanted weight gain. While Roux-en-Y-gastric bypass (RYGB) inevitably results in gastric denervation, paradoxically, bypassed subjects continue to experience satiation. Inspired by the literature in neurology on phantom limbs, I propose a new hypothesis in which damage to the stomach innervation during RYGB, including its vagal supply, leads to large-scale maladaptive changes in viscerosensory nerves and connected brain circuits. As a result, satiation may continue to arise, sometimes at exaggerated levels, even in subjects with a denervated or truncated stomach. The same maladaptive changes may also contribute to dysautonomia, unexplained pain, and new emotional responses to eating. I further revisit the metabolic benefits of bariatric surgery, with an emphasis on RYGB, in the light of this phantom satiation hypothesis.

AdNut study: effectiveness of a high calorie and protein oral nutritional supplement with β-hydroxy-β-methylbutyrate in an older malnourished population in usual clinical practice

Objective

To evaluate the effectiveness of a high calorie and protein, β-hydroxy-β-methylbutyrate containing oral nutritional supplement (HP-HMB-ONS), on nutritional status, activities of daily living and quality of life (QoL) in old malnourished subjects.

Methods

We conducted an observational, prospective, open label, multicenter study. Participants were > 65 years, undernourished or at nutritional risk [Nutrition Risk Score (NRS) ≥ 3] and had been included on an ONS (HP-HMB-ONS twice daily for 12 weeks) per standard of care. Visits at baseline (V1), 6 weeks (V2) and 12 weeks (V3) were performed. The primary endpoints were gain of body weight, change in body mass index (BMI) and NRS 2002 index. Data from QoL (EQ-5D-3L) and activities of daily living (Katz index) were also collected.

Results

A total of 235 participants were included in the study. Of these 148 took at least a 75% of the HP-HMB-ONS and were included in the analysis (per protocol); median age was 80.0 (SD:8.3) years, 65.5% (n = 97) were female, 67.6% (n = 100) had 2 or more diseases. At V3, a statistically significant increase in weight (2.1 kg; SD: 3.8) (p < 0.001) and BMI (0.8 kg/m²; SD: 1.45) were found compared to V1, whereas NRS 2002 values decreased by 0.9 (SD: 1.2). A significant (p < 0.001) improvement in Katz index (mean change = 0.3; SD:1.4) and EQ-5D scoring (mean change = 0.5; SD:1.9) compared to V1, were also reported.

Conclusions

The results suggest that administration of a HP-HMB-ONS improve the nutritional status and may led to a significant improvement in patients' activities of daily living and QoL, independent of baseline BMI.

Making sense of the sensory regulation of hunger neurons

AgRP and POMC neurons are two key cell types that regulate feeding in response to hormones and nutrients. Recently, it was discovered that these neurons are also rapidly modulated by the mere sight and smell of food. This rapid sensory regulation "resets" the activity of AgRP and POMC neurons before a single bite of food has been consumed. This surprising and counterintuitive discovery challenges longstanding assumptions about the function and regulation of these cells. Here we review these recent findings and discuss their implications for our understanding of feeding behavior. We propose several alternative hypotheses for how these new observations might be integrated into a revised model of the feeding circuit, and also highlight some of the key questions that remain to be answered.

Unintended Adverse Effects of Enteral Nutrition Support: Parental Perspective

OBJECTIVES

The present study highlights the occurrence of unintended adverse effects of enteral nutrition in infancy and childhood, as viewed and reported from a parental perspective.

METHODS

Quantitative analysis of a standardized questionnaire, filled out online by parents of enterally fed children. The questions focused on the nutritive and nonnutritive adverse effects, and other medical and biometric data. Data were collected from January 1, 2009 to December 31, 2013.

RESULTS

The study cohort consisted of 425 infants and children with different underlying medical conditions and an average age of 2.17 (median = 1.63) years. Nasogastric tubes were used in 44.2% of all the patients, and 55.8% of the children were fed by percutaneous endoscopic gastrostomy tube. Nearly all of the children have been tube-fed since birth. A total of 56.0% of all tube-fed children showed regular gagging and retching episodes, 50.0% vomited frequently, 14.8% experienced nausea, 7.5% experienced extreme nervous perspiration during the feeding, 45.2% showed loss of appetite, 5.2% experienced local granulation tissue, and 1.9% had other skin irritations. No significant correlations could be found between age, sex, medical diagnoses, type of feeding tube, feeding schedules (bolus or continuous), and parental and child's behavior regarding the feeding situation and duration of tube feeding.

CONCLUSIONS

Enteral nutrition affects the child and the whole family system on more than just nutritional level. It is suggested that children and their families should be followed-up by health professionals periodically for nutritional optimization, growth documentation, and other aspects of tube management.

Response of appetite and potential appetite regulators following intake of high energy nutritional supplements

BACKGROUND

The net clinical benefit of high-energy nutritional supplements (HENSDs) consumption is lower than expected.

OBJECTIVES

To investigate the extent to which consumption of oral HENSD in the fasted state reduces energy intake in slim females during consecutive breakfast and lunch, and whether this relates to changes in appetite and metabolic appetite regulators.

DESIGN

Twenty three females of 24.4 ± 2.8 years with BMI of 18.2 ± 0.8 kg/m(2) consumed HENSD (2.5 MJ) or PLACEBO (0.4 MJ) in fasted state in a single blind randomized cross-over study. Appetite and metabolic rate measurements and blood collection were conducted prior to and during 240 min after the intake of the supplements. Energy intake was recorded during ad libitum buffet breakfast and lunch served 60 min and 240 min post supplementation respectively.

RESULTS

Energy intake during breakfast was significantly (P < 0.01) lower in the HENSD trial but the net cumulative effect on energy intake was 1.07 ± 0.34 MJ higher in the HENSD compared to PLACEBO. Plasma concentration of CCK and PYY and insulin and were significantly (P < 0.05) higher in the HENSD trial while appetite measures were not significantly different between HENSD and PLACEBO trials. Correlations for the within participant relations between the responses of plasma hormones and appetite scores were significant (P < 0.05) for PYY and insulin but not CCK. The energy expended above resting metabolic rate was significantly (P < 0.05) higher in the HENDS trial but relative increase in energy expenditure was not significantly different between the two trials.

CONCLUSION

Oral high-energy nutritional supplements have a partial and relatively short lived suppressive action on energy intake and can be expected to increase net energy intake by approximately half the energy value of the supplement consumed.

A practical approach to classifying and managing feeding difficulties

Many young children are thought by their parents to eat poorly. Although the majority of these children are mildly affected, a small percentage have a serious feeding disorder. Nevertheless, even mildly affected children whose anxious parents adopt inappropriate feeding practices may experience consequences. Therefore, pediatricians must take all parental concerns seriously and offer appropriate guidance. This requires a workable classification of feeding problems and a systematic approach. The classification and approach we describe incorporate more recent considerations by specialists, both medical and psychological. In our model, children are categorized under the 3 principal eating behaviors that concern parents: limited appetite, selective intake, and fear of feeding. Each category includes a range from normal (misperceived) to severe (behavioral and organic). The feeding styles of caregivers (responsive, controlling, indulgent, and neglectful) are also incorporated. The objective is to allow the physician to efficiently sort out the wide variety of conditions, categorize them for therapy, and where necessary refer to specialists in the field.

The consumption of omega-3 polyunsaturated fatty acids improves clinical outcomes and prognosis in pancreatic cancer patients: a systematic evaluation

This study was aimed to systematically evaluate results of trials examining the effects of omega-3 polyunsaturated fatty acid (n-3 PUFA) consumption on body weight, lean body mass, resting energy expenditure, and overall survival in pancreatic cancer patients. We searched Medline, Pubmed, Embase, and Cochrane databases. We selected randomized controlled trials of n-3 PUFA vs. conventional nutrition in unresectable pancreatic cancer patients. We analyzed our data using the Cochrane statistical package RevMan 5.1. Eleven trials met our inclusion criteria. There was a significant increase in body weight [weighted mean difference (WMD) = 0.62; 95% confidence interval (CI), 0.54-0.69, P < 0.00001) and lean body mass (WMD = 0.96; 95% CI, 0.86-1.06, P < 0.00001), a significant decrease in resting energy expenditure (WMD = -29.74; 95% CI, -55.89-3.59, P = 0.03), and an increase in overall survival (130-259 days vs. 63-130 days) in unresectable pancreatic cancer patients who consumed an oral nutrition supplement enriched with n-3 PUFAs compared to those who consumed conventional nutrition. This preliminary study suggests that n-3 PUFAs are safe and have a positive effect on clinical outcomes and survival in pancreatic cancer patients.

Nutrition and the circadian timing system

Life on earth has evolved under the daily rhythm of light and dark. Consequently, most creatures experience a daily rhythm in food availability. In this review, we first introduce the mammalian circadian timing system, consisting of a central clock in the suprachiasmatic nucleus (SCN) and peripheral clocks in various metabolic tissues including liver, pancreas, and intestine. We describe how peripheral clocks are synchronized by the SCN and metabolic signals. Second, we review the influence of the circadian timing system on food intake behavior, activity of the gastrointestinal system, and several aspects of glucose and lipid metabolism. Third, the circadian control of digestion and metabolism may have important implications for several aspects of food intake in humans. Therefore, we review the human literature on health aspects of meal timing, meal frequency, and breakfast consumption, and we describe the potential implications of the clock system for the timing of enteral tube feeding and parenteral nutrition. Finally, we explore the connection between type 2 diabetes and the circadian timing system. Although the past decade has provided exciting knowledge about the reciprocal relation between biological clocks and feeding/energy metabolism, future research is necessary to further elucidate this fascinating relationship in order to improve human health.

Neonatal short bowel syndrome as a model of intestinal failure: physiological background for enteral feeding

Intestinal failure (IF) is a well identified clinical condition, which is characterised by the reduction of functional gut capacity below the minimum needed for adequate digestion and absorption of nutrients for normal growth in children. Short bowel syndrome (SBS) is the leading cause of IF in neonates, infants and young children usually as a result of extensive intestinal resection during the neonatal period. Simultaneously maintaining optimal nutritional status and achieving intestinal adaptation is a clinical challenge in short bowel patients. Both growth and development of the child as well as gut adaptation should be considered synergistically as primary outcome parameters. Enteral nutrition (EN) can be introduced orally and/or by tube feeding (TF). Several controversies over nutritional treatment of children with SBS related intestinal failure remain. As reported from different centres around the world, most practices are more "experienced based" rather than "evidence based". This is partly due to the small number of patients with this condition. This review (based on a consensus) discusses the physiological principles and nutritional management, including the type of diet and route of delivery. Perspectives in optimizing intestinal adaptation and reducing the consequences of small intestinal bacterial overgrowth are also discussed.

Chewing and taste increase blood velocity in the celiac but not the superior mesenteric arteries

To investigate the role of chewing and taste in the meal-induced rapid increase in splanchnic blood flow, we compared the blood flow responses in the celiac artery (CA) and superior mesenteric artery (SMA) to chewing solid food with a chocolate taste (FOOD) and paraffin wax without taste (WAX). After 5 min of baseline measurement, 15 healthy subjects repeated chewing and expectorating the FOOD or WAX every 20 s for 4 min followed by 10 min of recovery measurement. We measured the mean blood velocity (MBV) in the CA and SMA. The baseline MBVs in the CA and SMA did not differ between the FOOD and WAX trials. The MBV in the CA was lower than baseline at the 1st min of chewing in both trials. It was higher than baseline at the 3rd min of FOOD chewing, whereas it did not increase during and after WAX chewing. The MBV in the CA was higher in the FOOD trial than in the WAX trial at the 3rd min of chewing and thereafter. In contrast, the MBV in the SMA did not change throughout the protocols. These results suggest that the taste of food plays a role in meal-induced hyperemia in the CA but not the SMA.

Bolus tube feeding suppresses food intake and circulating ghrelin concentrations in healthy subjects in a short-term placebo-controlled trial

BACKGROUND

Previous investigations suggest continuous tube feeding (TF) schedules do not suppress appetite and food intake, but bolus TF has been little studied.

OBJECTIVE

We tested the hypothesis that 1) bolus TF does not suppress appetite and food intake and 2) there is no interrelation between food intake and appetite mediators (including ghrelin).

DESIGN

A single-blind, placebo-controlled trial within which 6 healthy men [body mass index (in kg/m(2)): 21.1 +/- 1.61] received 3 d of bolus TF (6.93 +/- 0.38 MJ/d of 4.18 kJ/mL multinutrient feed). For 2 d before and after TF, placebo boluses (<0.4 MJ/d) were given by tube. Hourly tracking of appetite, weighed measurements of daily ad libitum food intake, and metabolic and hormonal (including ghrelin) measurements were undertaken.

RESULTS

Total energy intake was significantly increased with bolus TF (18.2 +/- 1.86 MJ; P = 0.0005) despite a partial reduction in food intake compared with placebo periods (P = 0.013) and during the TF period (by 15%; P = 0.007). There was little change in hunger and fullness with bolus TF, and within-day temporal patterns did not differ whether TF or placebo was given. Changes in fasting concentrations of ghrelin (1003.6-756.0 pmol/L; P = 0.013) and other mediators (including leptin, insulin, and glucose) were significantly related to subsequent daily food intake (eg, ghrelin: r(2) = 0.81, P = 0.022).

CONCLUSIONS

In this short-term study, subjects maintained appetite ratings during bolus TF by a significant reduction in food intake and changes in ghrelin and some appetite mediators related to subsequent daily food intake. Longer-term studies are required to fully ascertain the effect of TF on appetite, food intake, and appetite mediators.

Cysteine-rich protein reverses weight loss in lung cancer patients receiving chemotherapy or radiotherapy

Oxidative stress plays a role in the tumor-cytotoxic effect of cancer chemotherapy and radiotherapy and also in certain adverse events. In view of these conflicting aspects, a double-blind trial over a 6-month period was performed to determine whether a cysteine-rich protein (IMN1207) may have a positive or negative effect on the clinical outcome if compared with casein, a widely used protein supplement low in cysteine. Sixty-six patients with stage IIIB-IV non-small cell lung cancer were randomly assigned to IMN1207 or casein. Included were patients with a previous involuntary weight loss of > or =3%, Karnofsky status > or =70, and an estimated survival of >3 months. Thirty-five lung cancer patients remained on study at 6 weeks. Overall compliance was not different between treatment arms (42-44% or 13 g/day). The patients treated with the cysteine-rich protein had a mean increase of 2.5% body weight, whereas casein-treated patients lost 2.6% (p = 0.049). Differences in secondary endpoints included an increase in survival, hand-grip force, and quality of life. Adverse events were mild or moderate. Further studies will have to show whether the positive clinical effects can be confirmed and related to specific parameters of oxidative stress in the host.

Prognostic factors in the resumption of oral dietary intake after allogeneic hematopoietic stem cell transplantation (HSCT) in children

BACKGROUND

Parenteral nutrition (PN) is a common supportive care therapy in patients undergoing hematopoietic stem cell transplantation (HSCT). Inadequate oral dietary intake may necessitate prolonged courses of PN, which have been associated with metabolic, infectious, and hepatobiliary complications. The objective of this study was to identify demographic, clinical, and nutrition factors associated with the resumption of oral dietary intake following HSCT.

METHODS

This was an observational cohort study of 37 children undergoing allogeneic HSCT. Repeated-measures regression analysis was performed to identify factors associated with the resumption and macronutrient composition of oral nutrient intake after HSCT.

RESULTS

Mean oral dietary intake during the first 2 weeks after HSCT was <280 kcal/d. At all times, oral carbohydrate intake was high, ranging from 58% to 74% of oral energy. Age, time since transplant, degree of oral mucositis, and severity of graft-vs-host disease (GVHD) were all significantly correlated with the resumption of oral energy intake, as well as oral intake of carbohydrates. Oral protein and fat intake were also associated with elapsed time since HSCT, severity of mucositis, and GVHD. Factors not associated with oral dietary intake included gender, pre-HSCT nutrition status, diagnosis, type of donor, and infections.

CONCLUSIONS

Children undergoing HSCT exhibit a marked reduction in oral dietary intake and a preference for a diet high in carbohydrates. Careful attention should be directed to the oral dietary intake and nutrient requirements of children during HSCT, especially in younger patients and those who experience severe mucositis or GVHD.

Strategies to improve ingestive behaviour with reference to critical illness

The complex interplay between neural and endocrine responses following food intake regulates ingestive behaviour and ultimately determines subsequent energy intake. These processes include cognitive, gastrointestinal-derived and metabolic mechanisms. Such physiological responses to the ingestion of food initiate short- to medium-term inhibition of intake (satiety). However, in clinical states in which systemic inflammation is evident there is a more profound satiety response and a clear absence of motivation to eat that is evident as loss of appetite. These negative influences on energy intake can contribute to poor nutritional status, and consequently poor physical function, and impact on rehabilitation and recovery. Cytokine mediators of the inflammatory response directly influence feeding behaviour at the hypothalamic nuclei and may explain the lack of motivation and desire for food. However, additional detrimental effects on appetite are brought about because of alterations in intermediary metabolism present in inflammation-induced catabolism. This process forms part of the host response to inflammation and may explain symptoms, such as early satiety, frequently reported in many patient groups. In clinical states, and cancer in particular, pharmacological strategies have been employed to ameliorate the inflammatory response in an attempt to improve energy intake. Some success of this approach has been reported following administration of substrates such as EPA. Novel strategies to improve intake through administration of anti-cytokine drugs such as thalidomide may also be of benefit. However, drugs that oppose the actions of neurotransmitter pathways involved in central induction of satiety, such as 5-hydroxytryptamine, have failed to improve intake but appear to enhance enjoyment of food. Such findings indicate that therapeutic nutritional targets can only be achieved where novel pharmacological therapies can be supported by more innovative and integrated dietary management strategies. Many of these strategies remain to be elucidated.

Assessment and monitoring of nutritional status in patients with advanced cancer: part 1

Using a qualitative approach, this study set out to explore nurses' management of patients with advanced cancer, weight loss and eating-associated problems. Extreme weight loss is commonly seen in patients with incurable solid tumour cancer and, to date, it has proved difficult to manage successfully. Currently, little is known about how nurses (often directly involved in the delivery of palliative care) assess weight loss and nutritional status in everyday practice in order to provide appropriate support. In this study, 14 semi-structured interviews were conducted with nurses from both hospital and community settings. The findings revealed that many nurses did not routinely provide early identification and assessment of nutritional status including weight loss, nor did they continue to monitor the patient's progress or deterioration. Many nurses were reluctant to initiate conversations with cancer patients about weight loss, but instead waited for patients and relatives to raise their concerns. As a result, it is likely that informal assessment may have resulted in the reactive style of nutritional management seen. However, nurses interviewed received limited training, but were keen to learn more about nutritional assessment and management.

Who benefits from nutritional support: what is the evidence?

Nutritional support, including oral nutritional supplements, enteral tube feeding and parenteral nutrition, can be an important part of the management of any patient. Malnutrition is common and costly, clinically and financially, if left untreated. In patients with, or at risk of, malnutrition, the appropriate use of nutritional support can prevent complications arising, produce other clinical, functional and financial benefits, and can be life saving in some situations. This article discusses the evidence from systematic reviews and meta-analyses of the effectiveness of nutritional support.

Elucidating effective ways to identify and treat malnutrition

There is a clear rationale for elucidating effective ways of identifying and treating disease-related malnutrition (DRM), given the physiological and financial consequences of this common condition and its treatability. Evidence indicates the efficacy of nutritional support methods (oral, tube and intravenous) in increasing total nutritional intake while having little effect on appetite, satiety, appetite mediators (e.g. leptin) and voluntary food intake. When used as the only source of nutrition, artificial nutrition can effectively maintain nutritional intake, and yet many patients find enteral or parenteral feeding alone is unable to relieve distressing appetite sensations, and unusual temporal patterns (including dissociation between hunger and desire to eat) occur. Despite the positive impact of these feeding methods on intake, controversy about whether nutritional support can affect patient outcome has remained. Systematic reviews and meta-analyses indicate that improvements in function and clinical (mortality, complication rates) outcome can occur in a number of patient groups (including hospitalised patients, the elderly, patients who have had gastrointestinal surgery, patients at risk of pressure ulcers). In order to target those patients who will benefit from nutritional support, and overcome the ongoing problem of poor detection and recognition of DRM, simple routine screening to identify risk followed by practical evidence-based treatment is recommended.

Appetite during consumption of enteral formula as a sole source of nutrition: the effect of supplementing pea-fibre and fructo-oligosaccharides

Liquid enteral formulas are commonly used as a sole source of nutritional support of patients in hospital and community settings. Their effect on appetite has important consequences for dietary management of such patients and is likely to be affected by the formula composition. The aim of the present study was to compare appetite within healthy subjects consuming both a standard formula and one supplemented with pea-fibre (10 g/l) and fructo-oligosaccharide (FOS; 5 g/l) as a sole source of nutrition. Eleven healthy subjects consumed a standard formula or a pea-fibre/FOS formula as a sole source of nutrition for 14 d in a double-blind, cross-over trial. Appetite was recorded using standard 100 mm lines anchored at each end by a phrase denoting the most extreme appetite sensation. Consumption of the pea-fibre/FOS formula resulted in higher mean fullness (46 v. 37 mm, P=0.035), minimum fullness (13 v. 9 mm, P=0.024) and minimum satiety (12 v. 8 mm, P=0.012) compared to the standard formula. As there were no differences in macronutrient intake between formulas, these differences are likely to be due to supplementation with pea-fibre and FOS. The effect on appetite of the composition of an enteral formula, both with respect to nutrient content and functional components such as pea-fibre and FOS, may be an important aspect to consider in the dietary management of patients consuming enteral formula as a sole source of nutrition.

Cancer-Associated Cachexia and Underlying Biological Mechanisms

Cancer metastases (spread to distant organs from the primary tumor site) signify systemic, progressive, and essentially incurable malignant disease. Anorexia and wasting develop continuously throughout the course of incurable cancer. Overall, in Westernized countries nearly exactly half of current cancer diagnoses end in cure and the other half end in death; thus, cancer-associated cachexia has a high prevalence. The pathophysiology of cancer-associated cachexia has two principal components: a failure of food intake and a systemic hypermetabolism/hypercatabolism syndrome. The superimposed metabolic changes result in a rate of depletion of physiological reserves of energy and protein that is greater than would be expected based on the prevailing level of food intake. These features indicate a need for nutritional support, metabolic management, and a clear appreciation of the context of life-limiting illness.

The effect of different macronutrient infusions on appetite, ghrelin and peptide YY in parenterally fed patients

BACKGROUND & AIMS

Patients receiving parenteral nutrition (PN) still feel hungry despite adequate provision of calories intravenously. It is not known whether PN or its constituent macronutrients acutely affect appetite and to what degree this may be mediated by ghrelin and peptide YY (PYY).

METHODS

Six medically stable patients (four men) with intestinal failure receiving PN received an isocaloric 200 kcal infusion on three separate occasions following a 12 h fast. The infusions consisted of either carbohydrate (10% dextrose), fat (10% intralipid) or mixed protein/carbohydrate (PN). Changes in ghrelin and peptide YY levels and changes in subjective symptoms of hunger, satiety and nausea during each macronutrient infusion were assessed.

RESULTS

None of the three infusions acutely affected subjective symptoms of hunger, satiety and nausea (P>0.05 ANOVA). Ghrelin levels decreased significantly during dextrose [-19.1 (-35.9, -12.4), regression coefficient (95% CI), P<0.001] and parenteral nutrition infusions [-18.2 (-26.8, -9.6), P<0.001]. Lipid infusion had no effect on ghrelin levels but led to a significant decrease in PYY [-0.076 (-0.0123, -0.028), P=0.004]. Dextrose and PN infusion had no significant effect on PYY levels.

CONCLUSIONS

Dextrose and PN infusions decrease ghrelin levels. Lipid infusion does not affect ghrelin levels but in contrast to oral nutrients leads to a significant decrease in PYY. Despite these changes, in patients receiving PN, macronutrient infusions do no acutely affect appetite.

Nutritional care of Danish medical inpatients - patients' perspectives

Many patients do not eat and drink sufficiently during hospitalization. Surveys have shown that 30-50% of the elderly patients are undernourished when hospitalized, and for the majority of these patients their protein and energy requirements are not met during hospitalization. Diseased people often experience reduced appetite, aversion against certain types of food or nausea, and these symptoms are part of the explanation for insufficient consumption of food and drinks. In order to locate other possible explanations, this study investigate medical inpatients' experiences and satisfaction with the nutritional care. The patients included a total of 91 medical inpatients at two internal medical wards, Aarhus University Hospital, Denmark. Their average age was 72 +/- 11 years. They were individually interviewed about the food service and the nutritional care upon discharge. Patient satisfaction with the meals was overall high (90%). About 80% found the meals to be very important, but they lacked information about the food service, and the patients-staff communication about the food service was poor. The results indicate that the nursing staff was exercising a 'knowledge monopoly' in relation to the food service. In conclusion, a majority of the patients did not perceive the nutritional care as part of the therapy and nursing care during their hospitalization.

Evidence-based strategies for the use of oral nutritional supplements

Prescribable oral nutritional supplements are commonly used as a method of nutritional support in the prevention and treatment of malnutrition in adults. There is growing evidence to suggest that when used appropriately in treatment plans, individuals receiving them will benefit from functional and clinical improvements. The use of supplements in the community has increased over the last decade and questions about the increasing costs and efficacy of the products are often raised within health-care communities. The development of guidelines and protocols for the use of supplements in the community that are based on evidence of need and indicate a clear pathway of care, together with intended benefit, should help to address the issues of costly, inappropriate prescribing.

Nutrition intervention improves outcomes in patients with cancer cachexia receiving chemotherapy--a pilot study

GOALS OF THE WORK

The aim of this study was to examine the effect of nutrition intervention on outcomes of dietary intake, body composition, nutritional status, functional capacity and quality of life in patients with cancer cachexia receiving chemotherapy.

PATIENTS AND METHODS

Patients received weekly counselling by a dietitian and were advised to consume a protein- and energy-dense oral nutritional supplement with eicosapentaenoic acid for 8 weeks. The medical oncologist determined the chemotherapy protocol. Eight patients enrolled and seven completed the study.

MAIN RESULTS

There were significant improvements in total protein intake (median change 0.3 g/kg per day, range -0.1 to 0.8 g/kg per day), total energy intake (median change 36 kJ/kg per day, range -2 to 82 kJ/kg per day), total fibre intake (median change 6.3 g/day, range -3.4 to 20.1 g/day), nutritional status (patient-generated subjective global assessment score, median change 9, range -5 to 17), Karnofsky performance status (median change 10, range 0-30) and quality of life (median change 16.7, range 0-33.3). There were clinically significant improvements in weight (median change 2.3 kg; range -2.7 to 4.5 kg) and lean body mass (median change 4.4 kg, range -4.4 to 4.7 kg), although these were not statistically significant. Change in nutritional status was significantly associated with change in quality of life, change in Karnofsky performance status and change in lean body mass.

CONCLUSIONS

Nutrition intervention together with chemotherapy improved outcomes in patients with pancreatic and non-small-cell lung cancer over 8 weeks. Supplement intake does not inhibit meal intake.

Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area

Malnutrition occurs frequently in patients with cancer of the gastrointestinal (GI) or head and neck area and can lead to negative outcomes. The aim of this study is to determine the impact of early and intensive nutrition intervention (NI) on body weight, body composition, nutritional status, global quality of life (QoL) and physical function compared to usual practice in oncology outpatients receiving radiotherapy to the GI or head and neck area. Outpatients commencing at least 20 fractions of radiotherapy to the GI or head and neck area were randomised to receive intensive, individualised nutrition counselling by a dietitian using a standard protocol and oral supplements if required, or the usual practice of the centre (general advice and nutrition booklet). Outcome parameters were measured at baseline and 4, 8 and 12 weeks after commencing radiotherapy using valid and reliable tools. A total of 60 patients (51M : 9F; mean age 61.9±14.0 years) were randomised to receive either NI (n=29) or usual care (UC) (n=31). The NI group had statistically smaller deteriorations in weight (P<0.001), nutritional status (P=0.020) and global QoL (P=0.009) compared with those receiving UC. Clinically, but not statistically significant differences in fat-free mass were observed between the groups (P=0.195). Early and intensive NI appears beneficial in terms of minimising weight loss, deterioration in nutritional status, global QoL and physical function in oncology outpatients receiving radiotherapy to the GI or head and neck area. Weight maintenance in this population leads to beneficial outcomes and suggests that this, rather than weight gain, may be a more appropriate aim of NI.

Gut hormones in the control of appetite

Obesity is one of the greatest threats to the health of the developed world. In order to design effective drugs to treat the alarming increase in obesity, it is essential to understand the physiology of normal appetite control and the pathophysiology of obesity. The hypothalamus interprets and integrates neural and humoral inputs to provide a coordinated feeding and energy expenditure response. Recent evidence suggests that certain gut hormones - ghrelin, polypeptide YY, pancreatic polypeptide, glucagon-like-peptide 1 and oxyntomodulin - have a physiological role in governing satiety via the hypothalamus. Gut hormone appetite-regulatory systems represent a potential target for the design of antiobesity drugs.

Nutrition in the community - an exploratory study of oral nutritional supplements in a health board area in Ireland

BACKGROUND

A review of the General Medical (Payments) Scheme data in the Midland Health Board (MHB) Ireland identified a spend of just over euro 0.5 million on enteral nutritional supplements (oral and tube feeds) in an 11-month period in 1998 [General Medical Services (Payments) Board, 1998, MHB Clinical Nutritional Products: January-December 1998, Dublin]. In 2000, a figure of euro5 million was reported as the annual spend (oral and tube feeds) [General Medical Services (Payments) Board, 2000, MHB Clinical Nutritional Products: January-December 2000, Dublin]. Research has shown that a high proportion of Oral Nutritional Supplements (ONS) are inappropriately prescribed by primary care practitioners (Gall et al., 2001). The role of General Practitioners (GPs) and Public Health Nurses (PHNs) in prescribing ONS to patients aged 65 years and older was examined, as they are directly involved in the delivery of primary health care.

AIM

(i) Assess current trends, decision-making processes and monitoring procedures in the use of ONS for older patients in the community. (ii) Identify whether nutritional assessments and appropriate nutritional criteria are standard practice in determining selection of ONS.

METHODS

A study was conducted among 99 GPs and 120 PHNs in the MHB. All GPs were selected to participate and 50% (60) of PHNs were randomly selected. A telephone questionnaire was administered to each subject over a 2-week period.

RESULTS

Both GPs (78%) and PHNs (47%) reported that their prescription of/recommendations for ONS had increased in the last 4 years. None conducted a full nutritional assessment, but 25% of PHNs used a Nutrition Screening Tool when trying to ascertain whether a patient requires an ONS. Only 19.6% of GPs and 6.8% of PHNs surveyed were aware of the calorie content of a standard 200 mL ONS (sip-feed). In addition, a very significant proportion of both GPs and PHNs do not appear to give appropriate dietary advice to patients who may be at risk of malnutrition. Only 55% of GPs stated that they would specifically review a patient's ONS prescription. All GPs said that they would not conduct a full nutritional assessment at the review appointment.

CONCLUSION

The results of this study raise concerns as to the appropriateness of current ONS prescription and monitoring in the community. They also highlight the need for further intervention in the primary care setting in order to ensure that elderly malnourished patients are detected, treated and monitored in an appropriate and cost-effective manner.

Patient satisfaction is rated higher by radiation oncology outpatients receiving nutrition intervention compared with usual care

BACKGROUND

Satisfaction with services has been considered vital for the provision of quality health care, however, there are few published papers utilizing patient satisfaction with nutrition services as a measurable outcome.

METHOD

A randomized, controlled trial investigating the impact of nutrition intervention (NI) vs. usual care (UC) in 54 ambulatory oncology patients receiving radiotherapy to the gastrointestinal or head and neck area demonstrated beneficial impacts in terms of body weight, nutritional status, quality of life and bowel health. This study reports the changes in patient satisfaction that were associated with these improved outcomes for patients receiving NI compared with UC. The patient satisfaction with clinical nutrition services questionnaire was used to measure overall satisfaction and satisfaction with four components of nutrition services 12 weeks after patients commenced radiotherapy.

RESULTS

Patients receiving NI rated satisfaction higher for staff interpersonal skills (P < 0.001), perceived health benefits (P = 0.008), staff presentation skills (P = 0.044) and for overall patient satisfaction with nutrition services (P = 0.002). There were no significant differences between those patients receiving NI or UC for the nutrition supplements factor (P = 0.191).

CONCLUSIONS

These data suggest that patients receiving NI perceive nutrition as being beneficial and of higher importance to their health than those receiving UC. This may lead to increased compliance with the nutrition prescription and help explain the better outcomes observed in the NI group compared with the UC group. Patient satisfaction with nutrition services should be conducted regularly to act as a quality-control measure and target areas for improvement.

Comparison of nutritional risk screening tools in patients on admission to hospital

BACKGROUND AND AIMS

Under nutrition has been frequently reported in patients on admission to hospital. Because this is not always detected promptly, screening for nutritional risk on admission has been widely advocated. Although there is no universally accepted 'gold standard' for defining undernutrition, the definition used by McWhirter, J.P. & Pennington, C.R. [(1994) Br. Med. J.308, 945] has been widely used by clinical nutrition specialists. This study aimed to compare the efficacy of two frequently used nutritional risk screening tools in detecting undernutrition according to this definition.

METHODS

Both the Nutrition Risk Index [Veterans Affairs Total Parenteral Nutrition Co-operative Study Group (1991) N. Engl. J. Med.325, 525] and the Nutrition Risk Score [Reilly H.M. et al. (1995) Clin. Nutr.14, 269] were used to screen for undernutrition in 359 admissions to two acute teaching hospitals in Dublin. Undernutrition was defined as a Body Mass Index below 20 kg m(-2) and a triceps skinfold thickness or mid-arm muscle circumference below the 15th percentile. Comparison of stratification of nutritional risk by the two screening tools was carried out.

RESULTS

Both screening tools identified over 40% (Nutrition Risk Index, 44%; Nutrition Risk Score, 46%) of all patients assessed as at nutritional risk on admission. However, one-third of the undernourished patients were classified as at no nutrition risk by the Nutrition Risk Index, while almost one-fifth of those undernourished were classified as at low risk by the Nutrition Risk Score. The degree of nutritional risk differed with the screening tool used, the Nutrition Risk Score classifying 29% of all patients as high risk while the Nutrition Risk Index classified only 5% as in the high risk category.

CONCLUSIONS

Although a large proportion of patients on admission were classified as being at nutritional risk, the degree of risk was significantly different depending on the screening tool used. Both nutritional risk screening tools evaluated in this study failed to recognize many cases of undernutrition. Evaluation of the efficacy of nutritional screening tools should be promoted as seriously as the development of such tools.

Tackling undernutrition through appropriate supplement prescribing

Undernutrition has significant implications for patients' clinical condition and economical consequences for the NHS. However, due to continually increasing prescribing costs for sip feeds, treating undernutrition is often seen as very costly. An audit project in Lothian was undertaken to look at the appropriateness of sip feeds being prescribed. The project found there was a significant level of inappropriate prescribing with 30% of patients having their prescriptions for supplements stopped as they were deemed unnecessary. In view of this, the community dietitians involved developed and introduced a nutritional care pathway to allow a systematic and evidence-based approach to the identification and treatment of undernutrition.

Short-term continuous enteral tube feeding schedules did not suppress appetite and food intake in healthy men in a placebo-controlled trial

Tube feeding (TF) provides a model with which to study appetite when nutrient delivery bypasses the upper gastrointestinal (GI) tract and associated cephalic phase response. Nocturnal, diurnal and 24-h TF schedules are used clinically, but their effects on satiety have not been distinguished. This study tested two hypotheses: 1) bypassing the upper GI tract with TF has little satiating effect, and 2) diurnal TF suppresses appetite and food intake more than nocturnal or 24-h schedules. Six healthy men, residing in a metabolic suite, each received three continuous TF schedules (diurnal 12-h, nocturnal 12-h and 24-h; 6.86 +/- 0.51 MJ/d) in random order for 3 d over separate 10-d periods. Two days before and after TF, a placebo feed (<0.4 MJ/d) was given. Weighed measurements of ad libitum food consumption, hourly tracking of appetite and metabolic and hormonal measurements were undertaken. Compared with placebo feeding, there was a nonsignificant reduction in oral intake (1.01-2.49 MJ reduction), little change in appetite sensations with TF and an increase in total energy intake from 14.88 to 20.42 +/- 3.25 MJ. The schedules did not differ although diurnal TF was the most satiating. Changes in a variety of mediators (including leptin, insulin, cholecystokinin, metabolites and respiratory quotient) did not relate to immediate assessments of appetite and food intake. This trial suggests that continuous TF has little effect on satiety in healthy men over a period of 3 d, irrespective of the timing of the schedule. This could not be explained by changes in a variety of metabolic and hormonal signals within the time frame studied.

Introduction of a community nutrition risk assessment tool

This article describes the introduction of a community nutrition risk assessment (CNRA) initiative in liaison with a local primary care trust (PCT). A pilot was undertaken in order to produce local evidence of the benefits of nutrition risk screening and thus gain support from the PCT for full implementation of the CNRA. The results from the pilot, which indicated that a substantial financial saving for the PCT was possible with a corresponding improvement in patient care, were sufficiently convincing for the PCT to sanction the introduction of the CNRA throughout the local community. Seven steps for success are recommended which may be of use to other healthcare professionals who are considering such a process for their own community patients or indeed any other multiprofessional initiative which requires PCT support. Such steps include identification of those who may help or hinder the process and a thorough preparation of a concise evidence-based proposal which should assist in persuading those less enthusiastic to accept and support the vision.

Prolonged effects of modified sham feeding on energy substrate mobilization

BACKGROUND

Vagal stimulation in response to nutrients is reported to elicit an array of digestive and endocrine responses, including an alteration in postprandial lipid metabolism.

OBJECTIVE

The objective of this study was to assess whether neural stimulation could alter hormone and substrate metabolism during the late postprandial phase, with implications for body fat mobilization.

DESIGN

Vagal stimulation was achieved by using the modified sham feeding (MSF) technique, in which nutrients are chewed and tasted but not swallowed. Ten healthy subjects were studied on 3 separate occasions, 4 wk apart. Five hours after a high-fat breakfast (56 g fat), the subjects were given 1 of 3 test meals allocated in random order: water, a lunch containing a modest amount of fat (38 g), or MSF (38 g fat). Blood was collected for 3 h poststimulus for hormone and metabolite analyses.

RESULTS

Plasma insulin and pancreatic polypeptide concentrations peaked at 250% and 209% of baseline concentrations within 15 min of MSF. The plasma glucose concentration increased significantly (P = 0.038) in parallel with the changes observed in the plasma insulin concentration. The nonesterified fatty acid concentration was significantly suppressed (P: = 0.006); maximum suppression occurred at a mean time of 114 min after MSF. This fall in nonesterified fatty acid was accompanied by a fall in the plasma glucagon concentration from 122 to 85 pmol/L (P = 0.018) at a mean time of 113 min after MSF.

CONCLUSIONS

Effects on substrate metabolism after MSF in the postprandial state differ from those usually reported in the postabsorptive state. The effects of MSF were prolonged beyond the period of the cephalic response and these may be relevant for longer-term metabolic regulation.

Hunger disease

This paper examines three aspects of hunger disease: the effect of initial fat stores on macronutrient fuel selection during total starvation (no energy) and how it influences survival; the effects of different rates of weight loss on tissue and body function; and the importance of appetite sensations, including hunger, during malnutrition and during enteral and parenteral nutritional support. Long-term starvation studies in humans reveal major differences in fat carbohydrate and protein metabolism between lean and obese subjects, including a 2-4-fold lower contribution of protein oxidation to energy expenditure in obese subjects, which ensures that more of the excess body fat is oxidized. The rate of weight loss, determined by recent dietary intake, can have major effects on tissue and body function, including wound healing, the acute phase protein response, muscle fatigue and psychological/behavioural function in both clinical and non-clinical settings. In depleted states uncomplicated by disease, changes in appetite sensations can result in energy intakes as high as 6000 to 10,000 kcal/day ( 25-42 MJ/day). Long-term enteral tube feeding and parenteral nutrition are associated with frequent disturbances in appetite sensations, and in those able to eat normally they tend to add rather than replace oral intake to an extent that appears to depend on the regimen. It is concluded that 1) differences between lean and obese subjects in macronutrient fuel selection during starvation are adaptive because they optimize survival in both groups of subjects; 2) the rate of weight loss in health and disease has a major effect on certain tissue and body functions, independently of the magnitude of weight loss; and 3) clinically relevant disturbances in appetite sensations are common subjects receiving long-term enteral and parenteral nutrition. The clinical modulation of all these variables would be aided by greater knowledge of the mechanisms involved.

Serum leptin concentrations in patients with short-bowel syndrome

BACKGROUND

Short-bowel syndrome is a state of severe malabsorption resulting from absence or removal of the small bowel for several causes. A number of short-bowel patients develop hyperphagia. Leptin, a protein secreted from adipose tissue, signals the amount of energy stores to the brain.

OBJECTIVE

To study body composition and leptin regulation in short-bowel patients and to determine whether or not leptin concentrations are linked with hyperphagia.

DESIGN

We studied 25 short-bowel patients (remnant bowel less than 150 cm) and 31 controls and 10 oral nutrition. Fifteen patients received total parenteral nutrition and 10 oral nutrition. Anthropometric measurements, body composition (by bioelectrical impedance), and cholesterol, triacylglycerol and leptin concentrations were studied in all subjects.

RESULTS

There were no differences between short-bowel patients and controls in anthropometric variables, body composition, or leptin concentrations. Leptin concentrations were higher in short-bowel women than men (9.21+/-8.54 vs. 3.22+/-1.86 ng/ml, P=0.01). Leptin concentrations correlated positively with age (r=0.4, P=0.045), body mass index (r=0.52, P=0.007), fat mass (r=0.67, P=0.001) and body fat (r=0.68, P=0.0001); there were no correlations with other body composition parameters. We found no correlations between parenteral or oral nutrition and body composition parameters, or between leptin concentrations and the presence of hyperphagia. Logistic regression analysis showed that body fat correctly identified leptin concentrations in 60% of patients.

CONCLUSIONS

Body composition, leptin concentrations and leptin regulation in patients with short-bowel syndrome are similar to those of controls. Leptin concentrations do not correlate with hyperphagia in short bowel-patients.

Summary of a systematic review on oral nutritional supplement use in the community

Despite a marked increase in the prescription of oral nutritional supplements (ONS) in the community (Department of Health, 1991-7), there is still uncertainty about the value of their use in patients with different diseases. To answer questions about the effects on ONS on body weight and structure, spontaneous food intake and body function, a critical systematic review was undertaken (Stratton & Elia, 1999a). Eighty-four trials were reviewed (forty-five randomized, thirty-nine non-randomized: 2,570 patients; diagnoses including chronic obstructive pulmonary disease, Crohn's disease, cystic fibrosis, human immunodeficiency virus and acquired immune deficiency syndrome and cancer). Most studies (83 %) were conducted in patients living at home. The supplements were typically mixed macronutrients in liquid form, providing < 0.42-10.5 MJ/d for 1 week-2 years. The studies reviewed in patients with predominantly chronic conditions living in the community suggested that: (1) ONS produce demonstrable clinical (including functional) benefits, but the nature and extent of these benefits varies with the underlying chronic condition; (2) ONS increase total energy intake with > 50 % of the energy from ONS typically additional to that from habitual food intake; (3) improvements in body weight, total energy intake and body function following ONS appear to occur more frequently in individuals with a BMI < 20 kg/m2 than in those with a BMI > 20 kg/m2.

Are oral nutritional supplements of benefit to patients in the community? Findings from a systematic review

Although the use of oral nutritional supplements has increased in the community setting, no consensus exists about the benefits of their use in patients with different diseases and conditions. This article highlights new findings from a critical, systematic review of 84 trials, which has led to a rationale for the use of supplements in patients with chronic conditions in the community and has identified key areas for future research.