Compliance with preoperative oral nutritional supplements in patients at nutritional risk─only a question of will?

Motivational Interviewing improves postoperative nutrition goals within the Enhanced Recovery after Surgery (ERAS®) pathway in elective bowel surgery - A randomized clinical pilot trial

BACKGROUND & AIMS

Exploration whether Motivational Interviewing (MI) could be learned and implemented with ease within a surgical in-hospital setting and whether participation in the intervention led to significantly higher compliance with ERAS®-recommended protein intake goals. The individual healing process of many patients is delayed because they fail to cover their calorie requirement, which could be counteracted by a patient-centered conversational intervention that is new in perioperative practice.

METHODS

This patient-blinded pilot-RCT included 60 patients (≥18 years) following the certified ERAS® bowel protocol for colorectal surgery between March and August 2022. Five perioperative MI interventions were conducted by two health employees certified to perform MI. Key endpoints were the number of protein shakes drunk, calories of proteins ingested and overall calorie intake.

RESULTS

A total of 60 patients (34 men [56.7%]; mean [SD] age, 60.7 [13.3] years) were randomized. MI patient-group had significantly higher protein shake intake on all postoperative days except day 3. For days 0-3 MI group drank significantly more shakes overall (median 5.5 vs. 2.0; P = 0.004) and consumed more calories (median 1650.0 vs. 600.0 kcal; P = 0.004) and proteins (median 110.0 vs. 40.0 g; P = 0.005). Total calorie intake for each day by shakes and dietary intake was significantly higher in the MI-intervention group on day 2 (mean 1772.3 vs. 1358.9 kcal; P = 0.03).

CONCLUSIONS

MI may contribute to improve compliance with nutritional goals in the certified ERAS® protocol by increasing protein and calorie intake. The findings suggest further investigation of MI to help patients achieve their perioperative nutrition goals in different clinical settings.

TRIAL REGISTRATION

DRKS - Deutsches Register Klinischer Studien; DRKS-ID: DRKS00027863; https://drks.de/search/de/trial/DRKS00027863.

Adherence to Oral Nutrition Supplementation in Gastrointestinal Cancer Patients: A Systematic Review of the Literature

The prevalence of malnutrition is high in gastrointestinal (GI) cancer patients. The use of oral nutrition supplementation (ONS) as part of patients' nutritional therapy seems to be effective in the improvement of nutritional status. Nevertheless, oncology patients, experience several symptoms that negatively affect their compliance with ONS products. Τhe aim of this systematic review is to examine the factors affecting compliance with ONS in patients who underwent GI cancer surgery and/or adjuvant treatments. A systematic search was conducted to identify studies published until June 2023 that assessed compliance to ONS in GI cancer patients. Eleven studies fulfilled the eligibility criteria and were included in the analysis. Postoperative compliance with ONS among GI cancer surgery patients ranged between 26.2% and 71.1%, whereas in GI cancer patients receiving chemotherapy the average reported rate was 90.2%. The main reasons for noncompliance were the presence of GI symptoms, such as early satiety, bloating, and diarrhea after ONS consumption, as well as taste alterations that result in aversion to the provided ONS. Frequent monitoring of these patients is crucial in order to record adverse effects, identify patients that are in need of personalized guidance at an early stage and motivate them to follow their ONS plan.

Barriers and Facilitators of Adherence to Oral Nutritional Supplements Among People Living With Cancer: A Systematic Review

This study aims to synthesize the barriers and facilitators of oral nutritional supplement adherence in people with cancer and assess levels of adherence. Databases including Embase, PubMed, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure, Wanfang Database, and Chinese Scientific Journal Database, were used to search articles before January 4, 2021. Eighteen studies with 1,267 participants met the inclusion criteria. All studies reported rates of adherence, ranging from 6.0% to 96.9%. Gastrointestinal intolerances and disliked tastes were considered common barriers to cancer patients' adherence, whereas the ONS management strategy was considered the most crucial facilitator of adherence. Health professionals can improve adherence through regular monitoring and guidance and incentive strategies, and paying attention to the management and prevention of adverse reactions when prescribing nutritional products.

Opportunities for Patient Participation in Perioperative Malnutrition Care: A Qualitative Study

Introduction

In the perioperative period of hospitalization, barriers to food intake are common due to special nutritional needs, compromised nutritional status, and metabolic stress. Good nutritional care call for an interdisciplinary approach. And patients themselves may also play an essential role in managing nutritional care.

Objective

This study aimed to explore how patients with malnutrition experience nutritional care, their perspectives on patient participation, and their own role in malnutrition care in the perioperative period of hospitalization.

Methods

A qualitative study was conducted using an interpretive phenomenological approach. To follow patients' experiences, in-depth longitudinal interviews were undertaken before, during, and after hospitalization. Interview transcripts were analyzed thematically using open, axial, and selective coding and interpreted in an iterative process.

Results

Fifty-six interviews were undertaken with 26 patients with malnutrition scheduled for surgery and during the perioperative period of hospitalization. Four themes were identified: (1) unawareness and stigmata about being malnourished, (2) feasibility of optimal nutritional care, (3) needs and expectations for self-management, and (4) barriers and facilitators of taking own responsibilities in nutritional care.

Conclusion

Awareness and responsiveness to patients' perspectives, motivation, and compliance are prerequisites for patient participation in malnutrition care. This requires good communication between healthcare professionals and patients in all phases of hospitalization.

Bovine Colostrum Treatment of Specific Cancer Types: Current Evidence and Future Opportunities

Worldwide, the incidence of cancer is on the rise. Current cancer treatments include chemotherapy, radiation therapy, and surgery. Chemotherapy and radiation treatment are typically associated with severe adverse effects and a decline in patients' quality of life. Anti-cancer substances derived from plants and animals need to be evaluated therapeutically as it is cost-effective, have fewer side effects, and can improve cancer patients' quality of life. Recently, bovine colostrum (BC) has attracted the interest of numerous researchers investigating its anti-cancer potential in humans. Dressings loaded with BC are beneficial in treating chronic wounds and diabetic foot ulcers. Lactoferrin, a glycoprotein with potent anti-oxidant, anti-inflammatory, anti-cancer, and anti-microbial effects, is abundant in BC. The BC pills successfully promote the regression of low-grade cervical intraepithelial neoplasia when administered intravaginally. The biological, genetic, and molecular mechanisms driving BC remain to be determined. Oral BC supplements are generally well-tolerated, but some flatulence and nausea may happen. To evaluate the therapeutic effects, long-term safety, and appropriate dosages of BC drugs, well-designed clinical trials are necessary. The purpose of this article is to emphasize the anti-cancer potential of BC and its constituents.

Preferences of oral nutritional supplement therapy among postoperative patients with gastric cancer: Attributes development for a discrete choice experiment

Background

Adherence to oral nutritional supplement therapy among postoperative patients with gastric cancer is low. There is little knowledge about patients’ priorities and needs regarding oral nutritional supplement therapy. The discrete choice experiment is an innovative method used to elicit patients’ preferences. Good practice guidelines emphasize that the development of attributes and levels is a fundamentally important process.

Objective

To comprehensively describe the identification, refinement, and selection of attributes and levels for a discrete choice experiment.

Methods

A mixed-methods approach, consisting of three consecutive steps: a literature review, in-depth interviews, and focus groups. First, the literature review allowed quick identification of attributes and levels. Then, 15 in-depth interviews were conducted to gather a rich description of the experience of patients taking oral nutritional supplements after gastrectomy and to verify and enrich the attributes and levels list. Finally, four focus group participants discussed the wording of the attributes and levels and reduced the number of attributes to manageable numbers through voting ranking methods.

Results

Following the literature review and qualitative data collection, eight attributes were finally generated, each with two to three levels. The following attributes were included: 1) information provider; 2) health guidance approach; 3) adverse reactions; 4) flavor; 5) follow-up method; 6) follow-up frequency; 7) psychological support; 8) cost. These attributes covered the important attributes of nutritional preparations and health guidance included in ONS therapy that were relevant to patients.

Conclusions

This study’s mixed-methods approach has been found highly suitable to identify, refine and select attributes and levels for a discrete choice experiment. The three methods have pros and cons, and they complement each other, especially the analysis of qualitative data led to a deeper and broader understanding of attributes and levels.

Study protocol for feasibility and safety of adopting early oral feeding in post total laparoscopic total gastrectomy (overlap esophagojejunostomy): A multicentre randomized controlled trial

Background

Total laparoscopic total gastrectomy (TLTG) for gastric cancer, especially with overlap esophagojejunostomy, has been verified that it has advantages of minimally invasion, less intraoperative bleeding, and faster recovery. Meanwhile, early oral feeding (EOF) after the operation has been demonstrated to significantly promote early rehabilitation in patients, particularly with distal gastrectomy. However, due to the limited application of TLTG, there is few related research proving whether it is credible or safe to adopt EOF after TLTG (overlap esophagojejunostomy). So, it is urgent to start a prospective, multicenter, randomized clinical trials to supply high level evidence.

Methods/design

This study is a prospective, multicenter, randomized controlled trial with 200 patients (100 in each group). These eligible participants are randomly allocated into two different groups, including EOF group and delay oral feeding (DOF) group after TLTG (overlap esophagojejunostomy). Anastomotic leakage will be carefully observed and recorded as the primary endpoints; the period of the first defecation and exhaust, postoperative length of stay and hospitalization expenses will be recorded as secondary endpoints to ascertain the feasibility and safety of adopting EOF after TLTG (overlap esophagojejunostomy).

Discussion

Recently, the adoption of TLTG was limited due to its difficult anastomotic procedure, especially in vivo esophagojejunostomy. With the innovation and improvement of operating techniques, overlap esophagojejunostomy with linear staplers simplified the anastomotic steps and reduced operational difficulties after TLTG. Meanwhile, EOF had received increasing attention from surgical clinicians as a nutrition part of enhanced recovery after surgery (ERAS), which had shown better results in patients after distal gastrectomy. Considering the above factors, we implemented EOF protocol to evaluate the feasibility and safety of adopting EOF after TLTG (overlap esophagojejunostomy), which provided additional evidence for the development of clinical nutrition guidelines.

Clinical trial registration

[www.chictr.org.cn], identifier [ChiECRCT20200440 and ChiCTR2000040692].

'Between foods and medicines': A qualitative interview study of patient experiences of the meaning and usage of oral nutritional supplements

The aim of this study was to deepen the understanding of what oral nutritional supplements mean to patients and how this meaning connects to supplement usage, by exploring patient experiences of such supplements. Qualitative interviews were conducted in June 2019-March 2020 with ten patients with malnutrition or at nutritional risk, prescribed oral nutritional supplements by dietitians. Data were thematically analysed using systematic text condensation. Two final categories were identified: 'Oral nutritional supplements are a one-dimensional remedy' and 'Everyday oral nutritional supplement usage is regulated autonomously'. The patients described the meaning of oral nutritional supplements as nutrition. While the supplements could compensate for nutrients not eaten or be part of a helpful compensation strategy, they could not lessen the burden of altered eating. Supplement usage was described as dependent on the acceptance of taste and the priority given to nutrition in everyday life. Usage was greater when nutrients were perceived as needed, such as when striving for higher bodyweight or disease recovery. Usage was lower when a patient's own goals were not increased nutrient intake or bodyweight or when other activities were perceived as more important. Patient experiences indicated that oral nutritional supplements could serve as a remedy for malnutrition, but not for a situation of altered eating. Supplement usage was described as being regulated autonomously based on patient views on the importance of nutrition. Those views were diverse, highlighting the importance of supplement prescribers discussing treatment goals with each patient. A deeper understanding of the meaning of oral nutritional supplements and reasons for their usage from a patient perspective is crucial in order for healthcare to provide appropriate, effective nutrition therapy for malnutrition.

Unresolved issues in perioperative nutrition: A narrative review

Surgical patients are at an increased risk of negative outcomes if they are malnourished or at risk of malnutrition preoperatively. Optimisation of nutritional status should be a focus throughout the perioperative continuum to promote improved surgical outcomes. Enhanced Recovery after Surgery (ERAS) protocols are increasingly applied in the surgical setting but are not yet widespread. This narrative review focused on areas of perioperative nutrition that are perceived as controversial or are lacking in agreement. A search for available literature was conducted on 1 March 2022 and relevant high-quality articles published since 2015 were considered for inclusion. Most malnutrition screening tools are not specific to the surgical population except for the Perioperative Nutrition Screen (PONS) although more large-scale initiatives are needed to improve the prevalence of preoperative nutrition screening. Poor muscle health is common in patients with malnutrition and further exacerbates negative health outcomes indicating that prevention, detection and treatment is of high importance in this population. Although a lack of consensus remains for who should receive preoperative nutritional therapy, evidence suggests a positive impact on muscle health. Additionally, postoperative nutritional support benefits surgical outcomes, with some patients requiring enteral and/or parenteral feeding routes and showing benefit from immunonutrition. The importance of nutrition extends beyond the time in hospital and should remain a priority post-discharge. The impact of individual or personalised nutrition based on select patient characteristics remains to be further investigated. Overall, the importance of perioperative nutrition is evident in the literature despite select ongoing areas of contention.

Preferences for oral nutritional supplement therapy among postoperative patients with gastric cancer: a discrete choice experiment

Purposes

Patients after gastrectomy have poor compliance with oral nutritional supplement (ONS) therapy. Incorporating patient preferences into treatment decisions allows possible product improvements or treatment focus adjustments. The purpose of this research was to investigate the preferences for ONS therapy among postoperative patients with gastric cancer, and to provide person-centered oral nutrition management strategies.

Methods

A discrete choice experiment was designed and implemented within a Chinese cancer population. The survey was administered via paper-based questionnaires during face-to-face interviews with assistance from health professionals. A mixed logit model was used to estimate respondents’ preferences for different levels of nutrition therapy attributes.

Results

One hundred ninety respondents valued “Adverse reactions-almost none” (β 3.43 [SE, 0.28]) the most, followed by “Flavor-good taste” (β 0.68 [SE, 0.13]) and “Follow-up frequency-once every 2 weeks” (β 0.52 [SE, 0.13]), and were willing to pay more for these attribute levels. Respondents would be 93.73% more likely to accept a nutrition therapy program if there were almost no adverse reactions compared to the frequent adverse reactions.

Conclusions

Health professionals should pay attention to the management and prevention of adverse reactions when prescribing nutritional products, and provide diversified ONS products when necessary to meet patient preferences. When formulating intervention strategies, health professionals should also consider the different characteristics of patients, acknowledge the importance of the role of nurse specialists in a novel model of multidisciplinary nutritional care, standardize ONS information, follow up regularly, and encourage patients’ families to participate in daily nutrition care.

Supplementary information

The online version contains supplementary material available at 10.1007/s00520-022-07154-8.

Compliance with Oral Nutritional Supplementation among Gastric Cancer Patients at Nutritional Risk: A Cross-Sectional Study

AIMS

To explore compliance with oral nutritional supplementation (ONS) and to identify the risk factors for noncompliance among gastric cancer patients based on the health belief model (HBM).

METHODS

This prospective, observational study included gastric cancer patients at nutritional risk who were prescribed ONS from July to September 2020. Demographic factors, clinical factors, ONS-related factors, social factors and variables derived from the HBM were collected. The outcome of interest was compliance with ONS, which was measured by self-reported intake of ONS. Uni- and multivariate analyses of potential risk factors for noncompliance were performed.

RESULTS

A total of 162 gastric cancer patients in the preoperative and adjuvant chemotherapy periods were analyzed. The compliance rate with ONS was 24.7%. Univariate analysis identified thirteen variables as risk factors for decreased compliance. Multivariate logistic analysis indicated that ONS compliance was independently associated with the treatment period, perceived barriers to ONS, the motivation to take ONS, and the timing of taking ONS.

CONCLUSION

This study showed that overall ONS compliance among gastric cancer patients was notably low. Patients in the chemotherapy treatment period who took ONS at random times each day perceived more barriers to taking ONS and had a lower level of motivation were associated with lower compliance with ONS.

Low awareness of community-dwelling older adults on the importance of dietary protein: new insights from four qualitative studies

Meeting the recommended daily protein intake can be a challenge for community-dwelling older adults (CDOA). In order to understand why, we studied attitudes towards protein-rich products and healthy eating in general; identified needs and preferences, barriers and promotors and knowledge regarding dietary behaviour and implementation of high protein products. Attitudes towards protein-rich products and healthy eating were evaluated in focus groups (study 1, n 17). To gain insights in the needs and preferences of older adults with regard to meals and meal products (study 2, n 30), visual information on eating behaviour was assessed using photovoicing and verified in post-photovoice interviews. In studies 3 and 4, semi-structured interviews were conducted to identify protein consumption-related barriers, opportunities (n 20) and knowledge and communication channels (n 40), respectively. Risk of low protein intake was assessed using ProteinScreener55+ (Pro55+) in studies 2–4 (n 90). Focus groups showed that participants were unaware of potential inadequate dietary protein. Photovoicing showed that sixteen of thirty participants mainly consumed traditional Dutch products. In post-photovoice interviews, participants indicated that they were satisfied with their current eating behaviour. Barriers for adequate use of protein-rich products were ‘lack of knowledge’, ‘resistance to change habits’ and ‘no urge to receive dietary advice’. Promotors were ‘trust in professionals’ and ‘product offers’. Sixty-two percent had a low risk of low protein intake. CDOA feel low urgency to increase protein intake, possibly linked to low knowledge levels. A challenge for professionals would be to motivate older adults to change their eating pattern, to optimise protein intake.

Screening, assessment and management of perioperative malnutrition: a survey of UK practice

Background

Perioperative malnutrition is common and is associated with increased mortality, complications and healthcare costs. Patients having surgery for cancer and gastro-intestinal disease are at particular risk. It is a modifiable pre-operative risk factor and perioperative clinicians are well placed to identify those at risk and instigate interventions shown to improve outcome. Thus, we conducted a survey of Perioperative Medicine Leads with the aim of assessing the current provision of nutritional screening and intervention pathways in the UK.

Methods

Perioperative Medicine Leads registered with the Royal College of Anaesthetists were asked to complete an online survey exploring current practice in screening, assessment and management of malnutrition in the perioperative period. The survey included a mixture of open and closed questions, graded response questions and options for free text. Where a response was not received, departments were phoned directly and e-mails sent to non-responders.

Results

We received 121 completed questionnaires from 167 Perioperative Medicine Leads (response rate of 72.5%). Seventy respondents (57.9%) reported using the Malnutrition Universal Screening Tool to screen patients; however, only 61 (50.4%) referred patients at nutritional risk onto a dietitian. Sixty (49.6%) lacked confidence in local ability to identify and manage malnutrition perioperatively, with 28 (23.1%) reporting having a structured pathway for managing malnourished patients. One hundred eleven respondents (91.7%) agreed that malnutrition impacts on quality of life after surgery and 105 (86.8%) felt adopting a standard protocol would improve outcomes for patients. Those reporting a lack of confidence in dealing with malnutrition perioperatively cited a lack of organisational support, patients being seen too close to surgery and lack of clarity around responsibility as key reasons for difficulties in managing this group of patients.

Conclusions

Malnutrition in the perioperative period is a modifiable risk factor which is common and results in increased morbidity for patients and increased cost to healthcare systems. This survey highlights areas of practice where perioperative clinicians can improve the assessment and management of patients at nutritional risk prior to elective surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-021-00196-2.

Oral Nutritional Supplements and Enteral Nutrition in Patients with Gastrointestinal Surgery

Nowadays, patients undergoing gastrointestinal surgery are following perioperative treatment in enhanced recovery after surgery (ERAS) protocols. Although oral feeding is supposed not to be stopped perioperatively with respect to ERAS, malnourished patients and inadequate calorie intake are common. Malnutrition, even in overweight or obese patients, is often underestimated. Patients at metabolic risk have to be identified early to confirm the indication for nutritional therapy. The monitoring of nutritional status postoperatively has to be considered in the hospital and after discharge, especially after surgery in the upper gastrointestinal tract, as normal oral food intake is decreased for several months. The article gives an overview of the current concepts of perioperative enteral nutrition in patients undergoing gastrointestinal surgery.

The Impact of Prehabilitation on Patient Outcomes in Hepatobiliary, Colorectal, and Upper Gastrointestinal Cancer Surgery: A PRISMA-Accordant Meta-analysis

OBJECTIVE

To determine the impact of prehabilitation on hospital length of stay, functional capacity, complications, and mortality after surgery in patients with hepatobiliary, colorectal, and upper gastrointestinal cancer.

BACKGROUND

"Prehabilitation" encompasses exercise, nutrition, and psychosocial interventions to optimize health before surgery. The benefits of prehabilitation are ill-defined.

METHODS

Medline, Embase and Cochrane Databases were searched systematically for the terms "prehabilitation AND exercise," "perioperative care AND cancer surgery," and "colorectal AND hepatobiliary AND hepatopancreatobiliary AND esophagogastric AND recovery AND outcomes." Primary outcomes analyzed were hospital length of stay, functional capacity, significant postoperative complications (Clavien Dindo ≥ III), and mortality. A meta-analysis was conducted on the effect of all-modality prehabilitation for patients with colorectal, hepatopancreatobiliary and upper gastrointestinal cancer surgery using the raw mean difference, risk difference, and a random-effects model.

RESULTS

Three hundred and seventy seven original titles were identified. Fifteen studies (randomized controlled trials; n = 9 and uncontrolled trials; n = 6) were included in the meta-analysis. Prehabilitation reduced hospital length of stay by 1.78 days versus standard care (95% CI: -3.36, -0.20, P < 0.05). There was no significant difference in functional capacity with prehabilitation determined using the 6-minute walk test (P = 0.816) and no significant reduction in postoperative complications (P = 0.378) or mortality rates (P = 0.114).

CONCLUSIONS

Prehabilitation was associated with reduced hospital length of stay but had no effect on functional capacity, postoperative complications, or mortality rates. Thus, prehabilitation should be recommended to accelerate recovery from cancer surgery, demonstrated by reduced hospital length of stay.

ESPEN practical guideline: Clinical nutrition in surgery

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.

Assessment of compliance with oral nutritional supplementation and exploration of barriers and facilitators for patients after gastrectomy: A mixed-methods study

AIMS

To evaluate the compliance of patients after gastrectomy in taking oral nutritional supplementation and to explore the promoting and hindering factors.

DESIGN

A mixed-methods design with an explanatory sequential approach was employed.

METHODS

We conducted a 12-week longitudinal study to evaluate the oral nutritional supplementation compliance of 122 patients after gastric cancer surgery and the factors that affected their compliance. After the quantitative phase, we selected the interview subjects and developed the interview outline based on the analysis of the quantitative results. In-depth interviews (n = 15) were conducted to explain and supplement the quantitative phase results. Data were collected from October 2019 to May 2020.

RESULTS

The average overall compliance rate of oral nutritional supplementation in patients with gastric cancer over 12 weeks was 30.59%. Adverse reactions to oral nutritional supplementation, the identity of the main caregivers and the patient's financial ability were independent factors that affected patient compliance. In subsequent interviews, we extracted four themes: social support plays an important role in patients taking oral nutritional supplementation, adverse reactions discourage patients from continuing to take oral nutritional supplementation, patients' attitudes affect their motivation to take oral nutritional supplementation, and the different needs of patients for oral nutritional supplementation affect patient compliance.

CONCLUSION

Patients' compliance with oral nutritional supplementation after gastric cancer surgery is very low. Health education should pay more attention to the management of adverse reactions and the role of patients' peers and family members. Oral nutritional supplementation products should be diversified to provide patients with more choices.

IMPACT

This study clarifies the factors that hinder and promote oral nutritional supplementation compliance and provides an important reference for the establishment and revision of health education strategies for patients after gastric cancer surgery.

Assessment of adherence to oral nutritional supplementation and exploration of barriers and facilitators in patients after gastric cancer surgery: a mixed methods study protocol

INTRODUCTION

Postoperative malnutrition is a major issue in patients with gastric cancer. The European Society for Clinical Nutrition and Metabolism recommends oral nutritional supplements (ONS) as a first-line nutritional therapy to prevent malnutrition in patients with cancer. However, adherence to ONS is unsatisfactory. The overall aim of this study was to evaluate the adherence of patients with gastric cancer to ONS and to explore the promoting and hindering factors.

METHODS AND ANALYSIS

In this study, we will use mixed methods with an explanatory sequential approach for data collection and analysis. In the first phase, a 12-week longitudinal study will be performed to identify changes in trends of oral nutritional supplementation adherence in 135 patients with gastric cancer, the impact of adherence on nutritional indicators and clinical outcomes and ONS adherence-related factors. The primary endpoints include patient adherence to ONS, weight, body mass index and grip strength followed by 30-day readmission rate, complications and adverse reactions. In the second stage, qualitative research will be implemented to provide in-depth insight into the quantitative results. Finally, quantitative and qualitative results will be combined for analysis and discussion to put forward suggestions for improving patients' ONS adherence.

ETHICS AND DISSEMINATION

This research protocol has been approved by the Ethics Committee of the School of Nursing, Jilin University, China (No. 2019101601). Results will be disseminated in peer-reviewed journals and conferences, and sent to participating practices.

TRIAL REGISTRATION NUMBER

ChiTR2000032425.

A qualitative exploration of dietitians' experiences of prescribing oral nutritional supplements to patients with malnutrition: A focus on shared tailoring and behaviour change support

BACKGROUND

Oral nutritional supplements (ONS) are commonly prescribed to patients with malnutrition. Dietitians have been suggested as preferred prescribers but generally lack ONS prescribing rights. How dietitians with prescribing rights experience their professional practice of prescribing ONS remains understudied. Thus, by exploring dietitians' experiences of prescribing ONS, the present study aimed to obtain a deeper understanding of specific aspects that are of importance for dietitians when providing a nutrition therapy including ONS.

METHODS

Qualitative individual interviews were conducted with 13 dietitians prescribing ONS to free-living adult outpatients with malnutrition or at nutritional risk in the hospital or primary care setting. Systematic text condensation was used for data analysis.

RESULTS

Two main categories signifying important aspects were identified and labelled: 'Shared tailoring of the ONS prescription' and 'Supporting and facilitating ONS use'. First, the dietitians described tailoring the ONS prescription together with the patient, having their acceptance as a prerequisite, and being flexible regarding products and amounts prescribed. Second, they described performing different communication strategies and organising of practical issues (e.g., ONS delivery and support from others) to support and facilitate patients' ONS usage.

CONCLUSIONS

The present study identifies patient involvement and the role of dietitians as behaviour change facilitators as two important aspects when dietitians prescribe ONS. These findings allow for dietitians' ideals and strategies on how to prescribe ONS to be made more visible, which can inform both clinical practice and clinical trials for future improvements in nutrition therapy to address malnutrition.

[Perioperative nutritional supplementation-what is really evidence based?]

For patients undergoing major surgery, perioperative management according to an early recovery after surgery (ERAS) protocol focusing on early oral food intake is the strategy of choice. So-called perioperative nutritional (artificial) support now seems to be very traditional and outdated. Nevertheless, even in an overweight and obese society the prevalence of combined malnutrition and/or sarcopenia should not be underestimated. This results in the necessity for identification of patients at metabolic risk and the indications for nutritional therapy. This article provides a review of the current concepts of perioperative nutritional supplementation and discusses the available evidence and guideline recommendations.

[A real-world study to evaluate a peptidic oral supplement in adults with altered intestinal function after parenteral nutrition]

Introduction

Objectives: in routine clinical practice many disorders are found that can disrupt the sequence of reactions in digestion and absorption, leading to malnutrition and requiring the use of oral nutritional supplements (ONS). The objective of our study was to evaluate in a real world setting the use of and compliance with a peptide-based ONS in malnourished adult patients with intestinal compromise after more than 14 days of parenteral nutrition. Material and methods: the study was carried out in 44 malnourished patients who required total parenteral nutrition for at least 14 days without using the oral route during their hospital stay. All patients were administered, on an outpatient basis, 1 brick per day of Vital 1.5® for 12 weeks. At the beginning of treatment and after the intervention period evaluated, the following variables were collected: weight, height, body mass index (BMI), global subjective assessment test, nutritional biochemistry, 3-day nutritional survey, adverse effects generated by the formula, and completion rate. Results: 44 patients were enrolled. Mean age was 70.4 ± 10.4 years (20 women & 24 men). After the intervention the following parameters had increased: BMI (0.51 ± 0.1 kg/m2; p = 0.02), weight (1.4 ± 0.3 kg; p = 0.03), prealbumin (3.5 ± 4.1 mg/dl; p = 0.01), albumin (1.3 ± 0.1 mg/dl; p = 0.03), and transferrin (71.5 ± 24.1 mg/dl; p = 0.02). Dietary intake of the ONS represented 14.4 % of the diet's total caloric intake at 3 months, 17.5 % of carbohydrates, 12.9 % of proteins, and 12.3 % of fats. Mean compliance was 87.7 ± 7.2 % of the prescribed intakes. In relation to the nutritional situation, at the beginning of the study, 52.3 % (n = 23) of patients were in the global subjective assessment test in category B (moderate malnutrition or nutritional risk), and 47.7 % (n = 21) in category C (severe malnutrition). After the intervention, 75 % of patients were in category A (n = 33), 13.6 % (n = 6) in category B, and 11.4 % (n = 5) in category C. Conclusions: the use of a peptide-based ONS with short-chain triglycerides in outpatients showed a beneficial effect on biochemical and anthropometric parameters, and improved the nutritional status of patients with high compliance and good tolerance rates.

[Perioperative nutritional support for surgical patients]

The article presents an algorithm for perioperative nutritional support of surgical patients operated on as planned. Today, planned surgical care is provided in accordance with the canons of the accelerated rehabilitation Program (ARP). The relevance of the problem of nutritional insufficiency, which is an important component of ARP, is due to the dependence of the results of surgical treatment on the initial nutritional status of the patient. Methods of screening for nutritional deficiency and options for correcting protein-energy disorders are described. The predominant method is the enteral delivery of nutrients and energy. Oral supplemental nutrition by sipping is a convenient way to correct nutritional disorders at all stages of the perioperative period.

Effect of Oral Nutritional Supplementation on the Prognostic Nutritional Index in Gastric Cancer Patients

This prospective study was undertaken to investigate whether preoperative oral nutritional supplementation (ONS) would increase the prognostic nutritional index (PNI) in gastric cancer patients undergoing gastrectomy. Before surgery for resectable gastric cancer, Racol® NF (Otsuka Pharmaceutical Factory, Japan) was administered orally at a recommended dose of 600 kcal/600 ml per day to patients with a PNI of <48. The primary endpoint was the change in the PNI, which was calculated as 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (per mm³). Forty-six patients received Racol^® NF. The mean PNI at baseline and before surgery was 44 ± 3.9 and 43 ± 4.4, respectively (p = 0.049). The mean serum albumin level was significantly decreased after the administration of Racol^® NF (p = 0.001), while the mean total lymphocyte count (p = 0.001) and body weight (p = 0.004) were significantly increased. The mean daily intake and duration of Racol^® NF administration were 340 ml and 22.6 day, respectively. Adverse events during the administration of Racol^® NF were observed in 12 (26.1%) patients. The present study indicated that preoperative ONS did not increase the PNI in gastric cancer patients with low PNI values.

Diet and weight management by people with nonmetastatic colorectal cancer during chemotherapy: mixed methods research

Aim: To investigate self-management of dietary intake by colorectal cancer patients receiving chemotherapy. Methods: A questionnaire was administered to 92 patients with nonmetastatic colorectal cancer receiving chemotherapy treatment at a UK cancer center in 2018–19. A maximum variation sample of 20 patients who completed the questionnaire were interviewed. Results: More than three in five patients were at nutritional risk but fewer than one in five were concerned about dietary intake or weight. Self-management of diet and weight was inconsistent with achieving the nutritional intake recommended by clinical guidelines on nutrition in cancer. Conclusion: There is potential for psychoeducation to support change in self-management of nutritional risk, with implications for better treatment tolerance and outcomes including quality of life.

Oral Nutritional Supplementation Following Upper Gastrointestinal Cancer Surgery: A Prospective Analysis Exploring Potential Barriers to Compliance

Objective: Malnutrition is common in patients who underwent upper gastrointestinal cancer surgery. Our goal was to explore postoperative compliance with oral nutritional supplementation and define barriers to consumption in patients with esophageal, gastroesophageal junction, and gastric cancer.Methods: Participants were prospectively recruited from September 2015 to November 2018. Preoperative nutritional status was assessed using the Patient Generated Subjective Global Assessment. Malnourished patients and patients at risk for malnutrition were offered oral nutritional supplementation at the time of hospital discharge. Compliance was evaluated 1 month after hospital discharge.Results: A total of 78 patients were analyzed. Mean patient age was 62.8 ± 10.7 years and 83.3% were males. Εsophagectomy and gastrectomy were performed in 60.3% and 39.7% of the patients respectively. Twenty-eight (35.9%) participants reported consuming all prescribed supplements, whereas 50 (64.1%) patients were noncompliant with their prescribed oral nutritional supplementation regimen. The main barriers to oral nutritional supplementation compliance were bloating (compliant vs. noncompliant patients: 17.9% vs. 58%, p < 0.001), early satiety (compliant vs. noncompliant patients: 25% vs. 52.32%, p < 0.001), flavor or texture dislike (compliant vs. noncompliant patients: 7.1% vs. 34%, p < 0.001), and diarrhea (compliant vs. noncompliant patients: 10.7% vs. 24%, p < 0.001). No other statistically significant differences were identified between the two groups.Conclusions: Postoperative compliance to oral nutritional supplementation is low in patients who underwent upper gastrointestinal cancer surgery. Patient education and support as well as providing a range of oral nutrition supplement flavors, texture, and compositions may be useful in increasing adherence to oral nutritional supplementation regimens.

Effects of enteral nutritional rich in n-3 polyunsaturated fatty acids on the nutritional status of gastrointestinal cancer patients: a systematic review and meta-analysis

Postoperative malnutrition is a major issue among gastrointestinal cancer patients. Because n-3 polyunsaturated fatty acids (n-3 PUFAs) have immunological benefits, n-3 PUFAs are widely used in oral nutritional supplements (ONS). However, n-3 PUFAs in ONS reduced patients' compliance with ONS and affected the role of ONS in maintaining the postoperative nutritional status of patients. The aim of this study was to systematically explore the benefits of enteral nutrition rich in n-3 PUFAs in maintaining the nutritional status of patients after gastrointestinal surgery. Databases including PubMed, Web of Science, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang, and VIP databases were searched through March 16, 2019. The references of related reviews and studies were assessed up to March 16, 2019. The effect sizes from individual studies were calculated as the standardized mean difference (SMD), mean difference (MD), and risk ratio (RR) with 95% confidence intervals (95% CIs). A total of 11 studies (n = 977) were included. In this systematic review and meta-analysis, we observed that enteral supplementation of n-3 PUFAs had no significant effect on weight (MD, 1.09; 95% CI, -0.90, 3.08), body mass index (MD, 0.55; 95% CI, -1.45, 2.54), albumin (SMD, 0.39; 95% CI, -0.10, 0.87), wound infections (RR, 0.87, 95% CI, 0.57, 1.33), or pneumonia (RR, 0.98; 95% CI, 0.60, 1.59) in gastrointestinal cancer patients. Thus, compared with enteral nutritional without n-3 PUFAs, enteral nutritional rich in n-3 PUFAs has no significant effects on nutritional status, incidence of pneumonia, or wound infections among gastrointestinal cancer patients during postoperative convalescence.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Nutrition Screening and Therapy Within a Surgical Enhanced Recovery Pathway

Perioperative malnutrition has proven to be challenging to define, diagnose, and treat. Despite these challenges, it is well known that suboptimal nutritional status is a strong independent predictor of poor postoperative outcomes. Although perioperative caregivers consistently express recognition of the importance of nutrition screening and optimization in the perioperative period, implementation of evidence-based perioperative nutrition guidelines and pathways in the United States has been quite limited and needs to be addressed in surgery-focused recommendations. The second Perioperative Quality Initiative brought together a group of international experts with the objective of providing consensus recommendations on this important topic with the goal of (1) developing guidelines for screening of nutritional status to identify patients at risk for adverse outcomes due to malnutrition; (2) address optimal methods of providing nutritional support and optimizing nutrition status preoperatively; and (3) identifying when and how to optimize nutrition delivery in the postoperative period. Discussion led to strong recommendations for implementation of routine preoperative nutrition screening to identify patients in need of preoperative nutrition optimization. Postoperatively, nutrition delivery should be restarted immediately after surgery. The key role of oral nutrition supplements, enteral nutrition, and parenteral nutrition (implemented in that order) in most perioperative patients was advocated for with protein delivery being more important than total calorie delivery. Finally, the role of often-inadequate nutrition intake in the posthospital setting was discussed, and the role of postdischarge oral nutrition supplements was emphasized.

Bovine Colostrum Against Chemotherapy-Induced Gastrointestinal Toxicity in Children With Acute Lymphoblastic Leukemia: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

The toxic effect of chemotherapy on the gastrointestinal tract may lead to mucositis and is associated with the pathogenesis of other treatment-related complications. We hypothesized that nutrition supplementation with bovine colostrum, rich in bioactive factors, would ameliorate gastrointestinal toxicity and reduce the incidence of fever and infectious complications during induction treatment for childhood acute lymphoblastic leukemia (ALL).

METHODS

Children with newly diagnosed ALL were included in a 2-center, randomized, double-blind, placebo-controlled clinical trial. Patients were randomized to receive a daily colostrum or placebo supplement during 4 weeks of induction treatment. Data on fever, bacteremia, need for antibiotics, and mucosal toxicity were prospectively collected. (Trial registration: www.clinicaltrials.gov NCT01766804).

RESULTS

Sixty-two patients were included. No differences were found for the primary outcome (number of days with fever). No difference was observed for neutropenic fever, intravenous antibiotics, or incidence of bacteremia. Peak severity of oral mucositis was significantly reduced by colostrum (7/29 patients, 24% mild; 6/29, 21% moderate; 1/29, 3% severe) compared with placebo (12/31, 39% mild; 1/31, 3% moderate; 7/31, 23% severe) (P = 0.02). Among patients receiving at least 1 dose of supplement (colostrum: n = 22; placebo: n = 30), the peak weekly self-reported oral mucositis score was overall significantly less severe in the colostrum group (P = 0.009).

CONCLUSION

The use of prophylactic bovine colostrum showed no effect on fever, infectious morbidity, or inflammatory responses. Nevertheless, these data may suggest protective effects on the oral mucosa during induction therapy in childhood ALL, encouraging additional studies confirming these findings.

High Adherence to Oral Nutrition Supplements Prescribed by Dietitians: A Cross-Sectional Study on Hospital Outpatients

Background

This study aimed to assess adherence to oral nutrition supplements (ONS) among hospital outpatients and to assess patient characteristics, experiences of ONS, and the characteristics of ONS prescriptions in clinical practice.

Methods

Hospital outpatients aged ≥18 years and prescribed ONS by a dietitian at a Swedish hospital were referred to the study from September 2016 to February 2017. Data were collected from structured telephone interviews, medical records, and a register of ONS delivered. Adherence to ONS was measured by dividing self‐reported intake of ONS (frequency question and 24‐hour recall question) by the amount prescribed and using the medication possession ratio (MPR).

Results

Of the 96 patients included (mean age 67 ± 13 years), 52% were male. The 2 most frequent medical diagnoses were malignancy and digestive system disease. Mean adherence to ONS was 93% measured by the frequency question, 87% measured by the 24‐hour recall question, and 76% according to MPR. The majority of the patients (83%) were prescribed 1–3 bottles of ONS/day. The average number of flavors of ONS delivered was 4.2. Before prescription, 69% of the patients had been allowed to taste the ONS and 92% had chosen the flavors to be prescribed. Over 75% liked the taste of the ONS and considered them to be good for their health.

Conclusions

Adherence to ONS was high in this population, which might be explained by the individual tailoring of ONS prescriptions by a dietitian, positive experiences of ONS, and the relatively young mean age of the participants.

Preoperative serum pre-albumin as an independent prognostic indicator in patients with localized upper tract urothelial carcinoma after radical nephroureterectomy

Purpose

To investigate the prognostic value of preoperative pre-albumin and albumin level in patients with localized upper tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy.

Methods and Materials

Between January 2003 and June 2013, we evaluated data on 425 patients with nonmetastatic UTUC (Ta-4N0/+M0) who underwent radical nephroureterectomy at our institution. Low pre-albumin level was defined as <20 mg/dl, while hypoalbuminemia was defined as albumin <35 g/L. The associations of preoperative low pre-albumin level and hypoalbuminemia with clinical and pathologic variables were assessed. Univariable and multivariable analyses using the Cox regression model were performed to determine prognostic factors that were associated with cancer specific survival (CSS) and overall survival (OS). The Harrell concordance index with variables only or combined pre-albumin data were used to evaluate the prognostic accuracy.

Results

Compared with patients with high pre-albumin level, patients with low pre-albumin level were more likely to have older age, higher tumor stage, higher rate of diabetes, regional lymph node metastasis and lymphovascular invasion. Meanwhile, hypoalbuminemia was only associated with diabetes. Multivariate analysis identified decreased preoperative pre-albumin level as an independent prognostic factor for CSS (HR 1.85, 95% CI 1.14-3.00, p=0.013) and OS (HR 1.73, 95% CI 1.12-2.70, p=0.015), but not preoperative hypoalbuminemia. The estimated c-index of the multivariate model for CSS and OS increased from 0.771 and 0.760 without pre-albumin to 0.775 and 0.765 when pre-albumin added.

Conclusions

Low preoperative pre-albumin level but not preoperative hypoalbuminemia is a negative independent prognostic factor for survival outcome in patients with UTUC undergoing radical nephroureterectomy.

Normal Diet within Two Postoperative Days-Realistic or Too Ambitious?

Enhanced Recovery After Surgery (ERAS) protocols advocate early postoperative resumption of normal diet to decrease surgical stress and prevent excessive catabolism. The aim of the present study was to identify reasons for delayed tolerance of normal postoperative diet. This was a retrospective analysis including all consecutive colorectal surgical procedures since May 2011 until May 2017. Data was prospectively recorded by an institutional data manager in a dedicated database. Uni- and multivariate risk factors associated with delayed diet (beyond POD 2) were identified by multiple logistic regression among demographic, surgery- and modifiable pre- and intraoperative ERAS-related items. In a second step, univariate analysis was performed to compare surgical outcomes for patients with early vs. delayed oral intake. The study cohort consisted of 1301 consecutive colorectal ERAS patients. Herein, 691 patients (53%) were able to resume normal diet within two days of surgery according to ERAS protocol, while in 610 patients (47%), a delay in tolerance of normal diet was observed. Male gender was independently correlated to early tolerance (Odds Ratio (OR) 0.66; 95% Confidence Interval (CI) 0.46–0.84, p = 0.002), while ASA score ≥ 3 (OR 1.60; 95% CI 1.12–2.28, p = 0.010), abdominal drains (OR 1.80; 95% CI 1.10–2.49, p = 0.020), right colectomy (OR 1.64; 95% CI 1.08–2.49, p = 0.020) and Hartmann reversal (OR 2.61; 95% CI 1.32–5.18, p = 0.006) constituted risk factors for delayed tolerance of normal diet. Patients with delayed resumption of normal diet experienced more overall (Clavien grade I–V) (47% vs. 21%, p < 0.001) and major (Clavien grade IIIb–V) (11% vs. 4%, p < 0.001) complications and had a longer length of stay (9 ± 5 vs. 5 ± 4 days, p < 0.001). Over half of patients could not tolerate early enteral realimentation and were at higher risk for postoperative complications. Prophylactic drain placement was the only independent modifiable risk factor for delayed oral intake.

Serum Pre-Albumin Predicts the Clinical Outcome in Metastatic Castration-Resistant Prostate Cancer Patients Treated With Abiraterone

Objective To determine the prognostic utility of serum pre-albumin in metastatic castration-resistant prostate cancer (mCRPC) patients treated with abiraterone (AA).

Patients and Methods 112 chemotherapy pretreated or chemotherapy-naive patients were scheduled for systemic treatment with AA. Serum pre-albumin levels were measured before and after 3 months of AA treatment. Univariate and multivariate analyses were performed to determine prognostic factors that were associated with PSA progression-free survival (PSA-PFS), radiographic PFS (rPFS) and overall survival (OS). The Harrell concordance index with variables only or combined pre-albumin data were used to evaluate the prognostic accuracy.

Results The group of patients with baseline pre-albumin value ≥20mg/dL had a longer OS, PSA-PFS, rPFS than those with pre-albumin value <20mg/dL. Based on the values of pre-albumin before and after 3 months of AA treatment, we divided these patients into 4 groups: high-high, high-low, low-high and low-low group. High- high group showed a significantly better OS, PSA-PFS, rPFS than other 3 groups. In multivariate analysis, low pre-albumin level remained significant predictors of OS (HR, 13.2; P<0.001), rPFS (HR, 3.7; P=0.003) and PSA-PFS (HR, 8.7; P<0.001). The estimated c-index of the multivariate model for OS increased from 0.814 without pre-albumin to 0.845 when pre-albumin added.

Conclusion Low pretreatment serum pre-albumin is a negative independent prognosticator of survival outcomes in mCRPC treated with AA and also increases the accuracy of established prognostic model. Serial pre-albumin evaluation might help clinicians guide clinical treatment of mCRPC patients.

Optimizing the electronic health record to standardize administration and documentation of nutritional supplements

Malnutrition in hospitalized patients is a major cause for hospital re-admission, pressure ulcers and increased hospital costs. Methods to improve the administration and documentation of nutritional supplements for hospitalized patients are needed to improve patient care, outcomes and resource utilization. Staff at a medium-sized academic health science center hospital in the southeastern United States noted that nutritional supplements ordered for patients at high risk for malnutrition were not offered or administered to patients in a standardized manner and/or not documented clearly in the electronic health record as per prescription. This paper reports on a process improvement project that redesigned the ordering, administration and documentation process of oral nutritional supplements in the electronic health record. By adding nutritional products to the medication order sets and adding an electronic nutrition administration record (ENAR) tab, the multidisciplinary team sought to standardize nutritional supplement ordering, documentation and administration at prescribed intervals. This process improvement project used a triangulated approach to evaluating pre- and post-process change including: medical record reviews, patient interviews, and nutrition formula room log reports. Staff education and training was carried out prior to initiation of the system changes. This process change resulted in an average decrease in the return of unused nutritional formula from 76% returned at baseline to 54% post-process change. The process change resulted in 100% of nutritional supplement orders having documentation about nutritional medication administration and/or reason for non-administration. Documentation in the ENAR showed that 41% of ONS orders were given and 59% were not given. Significantly more patients reported being offered the ONS product (p=0.0001) after process redesign and more patients (5% before ENAR and 86% after ENAR reported being offered the correct type, amount and frequency of nutritional products (p=0.0001). ENAR represented an effective strategy to improve administration and documentation of nutritional supplements for hospitalized patients.

The use of oral nutritional supplements in the acute care setting

Oral nutritional supplements offer support to patients in acute care who are undernourished or at risk of malnutrition. Yet doubts remain over cost and compliance. Omorogieva Ojo, Senior Lecturer in Primary Care at University of Greenwich weighs up the evidence.