Who uses foodbanks and why? Exploring the impact of financial strain and adverse life events on food insecurity.

Background: Rising use of foodbanks highlights food insecurity in the UK. Adverse life events (e.g. unemployment, benefit delays or sanctions) and financial strains are thought to be the drivers of foodbank use. This research aimed to explore who uses foodbanks, and factors associated with increased food insecurity. Methods: We surveyed those seeking help from front line crisis providers from foodbanks (N = 270) and a comparison group from Advice Centres (ACs) (N = 245) in relation to demographics, adverse life events, financial strain and household food security. Results: About 55.9% of foodbank users were women and the majority were in receipt of benefits (64.8%). Benefit delays (31.9%), changes (11.1%) and low income (19.6%) were the most common reasons given for referral. Compared to AC users, there were more foodbank users who were single men without children, unemployed, currently homeless, experiencing more financial strain and adverse life events (P = 0.001). Food insecurity was high in both populations, and more severe if they also reported financial strain and adverse life events. Conclusions: Benefit-related problems appear to be a key reason for foodbank referral. By comparison with other disadvantaged groups, foodbank users experienced more financial strain, adverse life events, both increased the severity of food insecurity.

Validation of the Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) in patients with spinal cord injuries (SCIs).

OBJECTIVES: To validate the Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) in paediatric spinal cord injuries (SCIs) patients admitted to the tertiary SCI centre. METHODS: children's baseline clinical data, anthropometric measurements and STAMP score were assessed on admission. The validity of STAMP was assessed by (i) comparison with a full dietetic assessment (criterion validity); (ii) comparison with generic paediatric screening tools: the Paediatric Yorkhill Malnutrition Score (PYMS; concurrent validity); and (iii) completion of an additional STAMP to assess inter- and intra-rater reliability. The agreement was assessed using Cohen's κ-statistics. RESULTS: Fifty-one children were screened by STAMP. The prevalence of undernutrition risk was 58.8%. STAMP had moderate agreement with dietitian assessment (κ: 0.507) and a fair agreement with PYMS (κ: 0.314). The STAMP had substantial reliability (inter-rater reliability: κ: 0.752; intra-rater reliability: κ: 0.635). When compared with dietetic assessment as a reference standard, STAMP had a sensitivity of 83.3%, specificity of 66.7% and an overall agreement of 76.5%. CONCLUSION: The present study shows that undernutrition is common in children with SCI. The STAMP is an acceptable (valid and reliable) tool to identify paediatric SCI patients at risk of undernutrition.

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.

Meal provision in a UK National Spinal Injury Centre: a qualitative audit of service users and stakeholders.

STUDY DESIGN: A single centre survey. OBJECTIVES: The objective of this study is to (1) assess patients' food intake and (2) measure satisfaction with current food provision, as judged by patients and by stakeholders (medical and nursing staff, managers and catering staff). METHODS: Standardised questionnaires were used to record food intake over a 24-h period, and to evaluate the quality, ordering, delivery and overall acceptability of food provided. RESULTS: The food intake of 67 patients with spinal cord injury (SCI) was recorded (64% response rate) and 166 evaluations (50% response rate) were returned. Twenty-nine patients (48%) consumed three full meals a day, 17 (26%) received oral nutritional supplements, 22 (34%) received vitamin/mineral supplements, and 23 (35%) required assistance to eat. Some patients and stakeholders expressed satisfaction with the current food provision: taste good: 25 versus 17% (for patients and stakeholders, respectively); appropriate texture: 22 versus 21%; appropriate temperature: 55 versus 72% (P = 0.002); well presented: 43 versus 28%; good choice: 49 versus 59%; received meal ordered: 65 versus 37% (P < 0.001); meal served on time: 71 versus 58%; and no interruption during mealtimes: 62 versus 46%. Principal component analyses of item scores identified three main factors (food quality, food presentation and food delivery (logistics). CONCLUSION: The present study identified some areas where there appeared to have been improvement in SCI hospital catering, but with much still to be achieved. Hospital-catering systems should be tailored to meet the demands of the different patient groups to optimise nutritional intake. Periodic quality control is essential to meet recommendations and patients' expectations.

An audit to assess awareness and knowledge of nutrition in a UK spinal cord injuries centre.

STUDY DESIGN: A single centre survey. OBJECTIVES: To test: (i) awareness of nutrition screening tools and related care plans and; (ii) nutrition knowledge of doctors, nurses and dietitians working in spinal cord injuries (SCI) centres. METHODS: The 14-item questionnaire was sent to 102 nurses, 17 doctors and 15 dietitians working in UK SCI centres during January-March 2010. RESULTS: Sixty-two (46.5%) questionnaires were completed and returned for analysis. The present audit demonstrated that awareness of the need for nutritional screening is good: 83% of staff reported that they are aware there is a nutrition screening tool. This audit also demonstrated areas of poor knowledge, such as calorie content of intravenous fluids, indicators of malnutrition, and choice of nutritional support in malnourished patients. All doctors, but only 38% of nurses, knew how to calculate body mass index. Surprisingly, nearly half (49%) of the participants thought that at least 20% weight loss was required to indicate malnutrition. This high-perceived cut-off point suggests that malnutrition is likely to continue to be undetected and unmanaged. The overall scores (median) showed clear differences in nutritional knowledge between groups (median: dietitians 92.8%; doctors 53.5%; nurses 35.7; P<0.01). This suggests that dietitians could have an important role in training healthcare professionals about nutrition. CONCLUSION: This study highlights the need for further education in SCI medicine in order to improve the efficacy of feeding and nutrition therapy for SCI patients.

Dietary fat intake, body composition and blood lipids of university men and women.

BACKGROUND: Cardiovascular disease rates are high in the U.K., particular in men, and are related to dietary fat intake. We conducted a pilot study to investigate relationships between saturated and unsaturated dietary fat intakes, body composition and blood lipid parameters in Caucasian men and women at university. METHODS: Volunteers (52 men and 52 women; age range 20-50 years) were recruited from staff and students of London Metropolitan University. Dietary intake, body composition, blood pressure and fasting blood glucose and lipids were assessed. Gender differences between the measured variables and their relationships were assessed by Mann-Whitney U-test, and by multi-linear (stepwise) regression, respectively. RESULTS: Men consumed more saturated fat (29.5 vs. 20.5 g/day, p < 0.001), and had elevated levels of glucose (5.34 + 0.74 vs. 4.85 + 0.49 mmol/l, p < 0.001), low-density lipoprotein (LDL) cholesterol (2.99 + 1.5 vs. 2.62+ 0.74 mmol/l, p < 0.05), systolic blood pressure (126.4 + 11.0 vs. 112.6 + 17.2 mm/Hg, p < 0.001), and lower high-density lipoprotein (HDL) cholesterol (1.41 ± 0.34 vs. 1.83 ± 0.43, p < 0.001). Saturated fat was positively associated with total body fat ( p < 0.05), trunk fat ( p < 0.001), HDL cholesterol ( p < 0.05) and systolic blood pressure ( p < 0.001) in women, while in men docosahexaenoic acid and total cholesterol ( p < 0.05), total omega-3 fatty acids and LDL cholesterol ( p < 0.001), total omega-3 fatty acids and triglycerides ( p < 0.01) were positively related. Similar n-3 fatty acid intakes were reported in nutritionally aware students and other university subjects. CONCLUSIONS: The data of this study indicate gender-related differences in response to dietary fat, and widespread low compliance with n-3 fatty acid recommendations. Although the men are highly health conscious and physically active, their blood lipid levels are indicative of a risk of cardiovascular disease. In addition to enhanced nutritional education to increase seafood intakes in this age group of men and women, customised dietary and lifestyle advice may be required in the men.

How do spinal cord injury centres manage malnutrition? A cross-sectional survey of 12 regional centres in the United Kingdom and Ireland.

STUDY DESIGN: A multi-centre, cross-sectional survey. OBJECTIVES: To establish and compare the resources allocated against existing national standards, and to document current nutritional screening practices. SETTING: Spinal cord injury centres (SCICs) in the United Kingdom and the Republic of Ireland. METHODS: After obtaining research ethics committee approval, 12 SCICs in the United Kingdom and the Republic of Ireland were surveyed by a postal questionnaire. Data collected included the number of whole time equivalent (WTE) staff available, whether a nutrition team was present and the use of nutritional screening tools in the SCIC. RESULTS: Eleven (92%) SCICs responded. In total there were 482 allocated beds, and the average numbers of patients per WTE staff (s.d.), including consultants, nurses, dietitians, physiotherapists, occupational therapists and psychologists, were recorded. Eight centres used a nutritional screening tool, and only two centres had a clinical nutrition team. CONCLUSION: The resources allocated to nutritional care in SCICs appear to be very limited. This suggests that malnutrition will continue to be under-recognised and under-treated. There is a clear need for additional resources to address the nutritional needs of this special population group. Each SCIC should ensure regular access to nutritional advice, and the establishment of local nutrition support teams should be a priority.

Profile and prevalence of malnutrition in children with spinal cord injuries-assessment of the Screening Tool for Assessment of Malnutrition in Paediatrics (STAMP).

BACKGROUND: Data on the prevalence of malnutrition in paediatric patients with spinal cord injury (SCI) are limited. The present study aimed to establish the risk of (i) under-nutrition by using the Screening Tool for Assessment of Malnutrition in Paediatrics: STAMP (score ≥2) and (ii) over-nutrition by body mass index (BMI) centile (≥91st: overweight; ≥98th: obese). METHODS: After obtaining informed consent, a standardized questionnaire was used to collect baseline demographic data and nutrition risk score; BMI was measured and routine blood biochemistry was reviewed in every child (>6 months and <18 years) admitted to the SCI centre. RESULTS: Sixty-two children (mean age, 11.4 years; s.d., 4.9; median, 13 years; interquartile range, 7.8-15.6, 39.4% female) with SCI (46.5% tetraplegia, 53.4% complete SCI) were assessed. Prevalence of over-nutrition was high (BMI centile ≥91st, 41.1%; ≥98th, 25.5%). Under-nutrition risk was 47.1% (STAMP ≥2). Only 60% of these 'at risk' patients were referred for further nutritional assessment. Associated phenomena included previous intensive care (55.6 versus 20.8%, P<0.05), mechanical ventilation (58.3 versus 18.2%, P<0.01) and past need for artificial nutrition support (75 versus 12.8%, P<0.01). CONCLUSIONS: Both over- and under-nutrition appear common in children with SCI. Our data indicate, furthermore, that children at nutritional risk are under-managed. Future research is needed to complete the validation of the screening tools and to determine how effective intervention can be ensured.

Validation of the spinal nutrition screening tool (SNST) in patients with spinal cord injuries (SCI): result from a multicentre study.

BACKGROUND/OBJECTIVES: A disease-specific nutrition screening tool (NST): the spinal nutrition screening tool (SNST) has been developed for use in patients with spinal cord injury (SCI) but its reliability and agreement with other published tools requires investigation. The aims of this study were to assess the prevalence of malnutrition risk in SCI patients and to confirm the diagnostic accuracy of the SNST. SUBJECTS/METHODS: Patients' baseline clinical data, anthropometric measurements and NST scores were assessed. The validity of the SNST was assessed by (i) comparing with a full dietetic assessment (criterion validity); (ii) comparison with a generic NST: malnutrition universal screening tool (MUST) (concurrent validity); and (iii) completion of an additional SNST to assess inter- and intra-rater reliability. Agreement was assessed using Cohen's κ-statistics. RESULTS: Using the SNST, the prevalence of malnutrition risk ranged from 22 to 64% on admission to four SCI centres. The SNST had substantial agreement with MUST (κ: 0.723, 95% confidence interval (CI): 0.607-0.839) and dietitian assessment (κ: 0.567, 95% CI: 0.434-0.699). The SNST had a moderate to substantial reliability (inter-rater reliability: κ: 0.5, 95% CI: 0.2-0.8; intra-rater reliability: κ: 0.64, 95% CI: 0.486-0.802). When compared with dietetic assessment, the SNST had a numerically lower specificity (76.1% vs 80.4%) and similar agreement to MUST (κ: 0.57 vs 0.58) but SNST showed a numerically higher sensitivity (85.7% vs 80.4%) and a numerically higher negative predictive value (92% vs 89.2%) than MUST. CONCLUSIONS: This study shows that malnutrition is common in SCI patients. The SNST is an acceptable (valid and reliable) NST and may be a useful alternative to MUST in identifying SCI patients at risk of malnutrition.

A double-blind, randomized, controlled crossover trial of glutamine supplementation in home parenteral nutrition.

OBJECTIVE: Studies suggest clinical benefit of glutamine-supplemented parenteral nutrition. The aim was to determine if the inclusion of 10 g of glutamine as part of the nitrogen source of home parenteral nutrition (HPN) reduces infectious complications. SUBJECTS/METHODS: Thirty-five patients on HPN were recruited and 22 completed the study. Patients were randomized to receive either standard HPN or glutamine-supplemented HPN. Patients were assessed at randomization, 3 and 6 months later then they were crossed over to the alternative HPN and reassessed at 3 and 6 months. Assessments included plasma amino acid concentrations, intestinal permeability and absorption, nutritional status, oral and parenteral intake, quality of life, routine biochemistry and haematology. RESULTS: No difference was seen between the groups at randomization. No difference was detected between the treatment phases for infective complications (55% in the standard treatment phase and 36% in the glutamine-supplemented phase P=0.67). There were no differences in nutritional status, intestinal permeability, plasma glutamine concentrations or quality of life. CONCLUSION: Although limited by the sample size, the study has shown that glutamine as part of the nitrogen source of parenteral nutrition can be given to patients on HPN for 6 months without any adverse effects.

Nutritional support in critically ill children.

BACKGROUND & AIMS: Enteral nutrition is the feeding method of choice during critical illness, but in some cases as few as 25% are fed appropriately. The aim was to retrospectively review the administration of nutrition to critically ill children. METHODS: The notes of 95 children over the age of 1 year who were in PICU>or=3 days were reviewed and information related to the delivery of nutrition was obtained. RESULTS: Fifty-nine per cent were fed within 24h of admission. Enteral nutrition was administered 54% of the time, 10% required parenteral nutrition and 9.5% received no nutritional support. Children only received a median 58.8 (range 0-277)% of their energy requirements, which could not be optimised until the 10th intensive care day. Energy intake was greater when supplemented with parenteral nutrition. Parenteral nutrition administration was interrupted 3 times while enteral nutrition was stopped 264 times, mainly to allow other clinical procedures to take place. For 75% of the study time, children had abnormal bowel patterns. Seventy-nine per cent were constipated for 3-21 days and 43% had diarrhoea of unknown aetiology. CONCLUSION: This was a retrospective study to describe the efficiency of nutritional support in critically ill children. We have shown that it is possible to administer enteral nutrition safely. However, the difference between desirable intake and actual intake achieved suggests that a more pro-active approach should be adopted.

Methods for assessing intestinal absorptive function in relation to enteral nutrition.

The success of nasoenteral nutrition support can be limited by intestinal impairment. In particular, reduced absorptive area, mucosal atrophy and abnormal motility may reduce absorption of macronutrients and micronutrients, and diarrhoea remains a commonly encountered complication. We review how basic physiological techniques can be used to investigate such pathophysiology. Lumenal nutrients control mucosal growth, expression of mucosal transporters and regional gut motility. Cell biology techniques now complement classical intestinal perfusion methods in determining the 'safety factor' of excess absorptive capacity. The controversial role of the sodium-glucose linked transporter in dietary glucose assimilation is described in terms of its control, its true function and its role in uptake of other solutes. Techniques that involve brush-border membrane vesicles, Caco-2 cells, mucosal immunohistochemistry and gene expression probes are described. Together, these techniques describe a picture of an organ with remarkable ability to maintain digestive and absorptive function in response to a wide variety of nutritional intakes, often in the face of inflammatory illness.

Nucleotides as immunomodulators in clinical nutrition.

Dietary nucleotides, like glutamine, have attracted attention as a key ingredient missing from nutritional formulae for many years. They are the building blocks of tissue RNA and DNA and of ATP and their presence in breast milk has stimulated research in babies which has indicated that supplementation of infant formula milk leads to improved growth and reduced susceptibility to infection. Animal studies have confirmed some of these data. In particular, dietary nucleotides modulate immune function, promote faster intestinal healing and have trophic effects on the intestine of parenterally-fed rats which are similar to those resulting from glutamine supplementation, but at much lower intakes. Nucleotide supplementation has also been shown to improve some aspects of tissue recovery from ischaemia/reperfusion injury or radical resection. There is, however, a fundamental paradox. The intestine and liver possess powerful homeostatic mechanisms which degrade intake of purines and pyrimidines (i.e. salvage) and replace it with de novo synthesised output. It is possible that peripheral tissues receive only small amounts of nucleotides of dietary origin. Previously, nucleotides have been proposed as being conditionally-essential nutrients that provide an adequate supply of purines and pyrimidines for nucleic acid synthesis in neonates or in the stressed patient. This review explores this puzzle in the light of recent data from nutritional studies and from research into purinergic signalling in the intestine, heart and cells of the immune system. We propose that dietary nucleotides should be considered within a pharmacological and metabolic framework.

Methods for measuring tissue RNA turnover.

Measuring RNA turnover is important because of the significance of rRNA, tRNA and mRNA in tissue protein synthesis. Changes in turnover of each of these species precede important cellular events such as hormone or cytokine action or cell-division itself. Isotopic methods have relied on decay of pulse-labelled RNA or on incorporation of isotopically-labelled precursors. However, recycling of labels may lead to under or overestimation of synthesis rates respectively. The labelling of the intracellular precursor pool must be known if accurate RNA synthesis rates are to be calculated from the degree of incorporation. However, the intracellular nucleotide pools may be anatomically or metabolically compartmented (i.e. via de novo or salvage synthesis routes) and this complicates many study designs. The use of[methyl-14C]- or [methyl-3H]methionine as a means of labelling methylated nucleosides in RNA and protein simultaneously is described in addition to new stable isotopic techniques based on 13C-glycine as a de novo label. Urinary excretion of the numerous modified nucleosides in cellular RNA can be used to calculate whole-body turnover rates of each of the major RNA species. Examples of the effects of critical-illness and glutamine supplementation on RNA turnover are given. We conclude by suggesting that whole-body RNA turnover rates have been significantly underestimated and that this has implications for nutritional therapy, especially with regard to nucleotide supplementation.

Enteral nutrition in intensive care patients: a practical approach.

Severe protein-calorie malnutrition is a major problem in many intensive care (ICU) patients, due to the increased catabolic state often associated with acute severe illness and the frequent presence of prior chronic wasting conditions. Nutritional support is thus an important part of these patient's management. Over the years, enteral nutrition (EN) has gained considerable popularity, due to its favorable effects on the digestive tract and its lower cost and rate of complications compared to parenteral nutrition. However, clinicians caring for ICU patients are often faced with contradictory data and difficult decision-making when having to determine the optimal timing and modalities of EN administration, estimation of patient requirements and choice of formulas. The purpose of this paper is to provide practical guidelines on these various aspects of enteral nutritional support, based on presently available evidence.