Malnutrition and cachexia may affect death but not functional improvement in patients with sarcopenic dysphagia.

PURPOSE: To investigate whether two factors, malnutrition and cachexia, affect swallowing function, activities of daily living (ADL), and death in sarcopenic dysphagia. METHODS: Of 467 patients enrolled in the Japanese Sarcopenic Dysphagia Database, 271 met the study eligibility criteria in a retrospective cohort study. Patients were divided into four groups based on whether they had cachexia according to the Asian Working Group for Cachexia (AWGC) criteria and malnutrition according to the Global Leadership Initiative on Malnutrition (GLIM) criteria. Multivariate analyses were performed to investigate the differences in changes in the Food Intake LEVEL Scale (FILS) and Barthel Index (BI) and death after follow-up between the malnutrition and cachexia group and the other groups. RESULTS: The mean age was 83.7 ± 8.3 years, 119 (44%) were men and 152 (56%) were women. The median FILS at baseline was 7 and the median BI was 25. A total of 120 (44%) had malnutrition only, 54 (20%) had neither cachexia nor malnutrition, 12 (4%) had cachexia only, and 85 (31%) had both cachexia and malnutrition. Multivariate analyses showed no significant difference between the change in BI (P = 0.688) and the change in FILS (P = 0.928) between the malnutrition and cachexia group and the other groups; however, death increased significantly (P = 0.010). CONCLUSION: Some patients diagnosed with cachexia were not malnourished, although many patients with cachexia were malnourished. While patients with both cachexia and malnutrition did not show significant improvement in ADL and swallowing function compared with patients without both conditions, the number of deaths increased significantly.

Cutoff value of the geniohyoid muscle mass to identify sarcopenic dysphagia by ultrasonography.

PURPOSE: Determining the strength and area of the swallowing muscles is important in patients with sarcopenic dysphagia. Although the normative data on the strength of the swallowing muscles have been reported, those of the area of the geniohyoid muscle are poorly investigated. We investigated the cross-sectional area of the geniohyoid muscle in Japanese subjects without dysphagia using ultrasonography to determine the normative and cut-off values. METHODS: 142 subjects without dysphagia were included. The older group (age ≥ 65 years) included 36 (women 27/men 9) subjects, and the younger group (age ≤ 39 years) included 106 (women 54/men 52) subjects. The cross-sectional area of the geniohyoid muscle was measured by ultrasound. The mean of the younger group-2 standard deviation (SD) was calculated and used as a cut-off value for low swallowing muscle mass. RESULTS: The mean (SD) of the area of the geniohyoid muscle of each group was as follows: older women group 167.2 (32.6) mm2, older men group 193.2 (49.5) mm2, younger women group 247.3 (37.4) mm2, younger men group 313.1 (59.2) mm2. The mean 2SD of the geniohyoid muscle area in the younger women group was 172.5 mm2 and in the younger men group 194.7 mm2. CONCLUSION: We found that the cut-off value of the ultrasonographic cross-sectional area of the geniohyoid muscle was 172.5 mm2 for women and 194.7 mm2 for men. These values could be used as cut-off values for the mass of the geniohyoid muscle to identify patients with sarcopenic dysphagia.

Prevention and Treatment of Malnutrition in Older Adults Living in Long-Term Care or the Community: an Evidence-based Nutrition Practice Guideline.

Malnutrition in older adults can decrease quality of life and increase risk of morbidities and mortality. Accurate and timely identification of malnutrition, as well as subsequent implementation of effective interventions, are essential to decrease poor outcomes associated with malnutrition in older adults. The Academy of Nutrition and Dietetics Evidence Analysis Center conducted a systematic review of the literature to develop an evidence-based nutrition practice guideline for the prevention and treatment of malnutrition in older adults. The objective of this guideline was to provide evidence-based recommendations to identify, prevent, or treat protein-energy malnutrition in older adults (mean age ≥65 years) living in long-term care and community settings. This guideline provides 11 nutrition recommendations to inform shared decision making among dietitians, members of the health care team, family members or caregivers, and older adults living in long-term care or the community to prevent or treat malnutrition. Topics include dietitian effectiveness, nutrition assessment tools, oral nutrition supplements, food fortification, and home-delivered and congregate meals. Guideline implementation should include consideration of the importance of comprehensive individualized nutrition care for older adults. Future research is needed to address gaps that were identified related to the validity, reliability, and feasibility of nutrition assessment tools, as well as the effectiveness of dietitian interventions on outcomes of interest in older adults living in long-term care and the community.

Prevalence and prognosis of cachexia according to the Asian Working Group for Cachexia criteria in sarcopenic dysphagia: A retrospective cohort study.

OBJECTIVE: The aim to examine the prevalence and prognosis of cachexia according to the Asian Working Group for Cachexia (AWGC) criteria in patients with sarcopenic dysphagia. METHODS: A retrospective cohort study was conducted with 271 patients diagnosed with sarcopenic dysphagia out of 467 patients enrolled in the Japanese sarcopenic dysphagia database. Cachexia was diagnosed by the AWGC criteria. The AWGC criteria includes chronic diseases, either or both weight loss (2% or more over 3-6 mo) or low BMI (<21 kg/m2), and at least one of the following: anorexia, decreased grip strength (<28 kg in men and <18 kg in women), or elevated C-reactive protein levels (>0.5 mg/dL). Outcomes were death, swallowing function as assessed by the Food Intake LEVEL Scale (FILS), and activities of daily living as assessed by the Barthel Index (BI) at follow-up. RESULTS: The mean age was 84 (±8) y; 152 (56%) were female, and 97 (36%) had cachexia. In univariate analysis, death was significantly more common in the cachexia group (15% versus 2%, P ≤ 0.001). Logistic regression analysis showed that cachexia was independently associated with death (odds ratio: 3.557, 95% confidence interval: 1.010, 12.529). No significant differences were found in the presence or absence of cachexia in the FILS (7 versus 8, P = 0.849) and BI (55 versus 52.5, P = 0.892). CONCLUSIONS: Cachexia was found in 36% of patients with sarcopenic dysphagia, and death was significantly higher in cachexia.

Polypharmacy, Potentially Inappropriate Medications, and Dysphagia in Older Inpatients: A Multi-Center Cohort Study.

BACKGROUND: Although the relationship between medication status, symptomatology, and outcomes has been evaluated, data on the prevalence of polypharmacy and potentially inappropriate medications (PIMs) and the association of polypharmacy and PIMs with swallowing function during follow-up are limited among hospitalized patients aged ≥65 years with dysphagia. METHODS: In this 19-center cohort study, we registered 467 inpatients aged ≥65 years and evaluated those with the Food Intake LEVEL Scale (FILS) scores ≤8 between November 2019 and March 2021. Polypharmacy was defined as prescribing ≥5 medications and PIMs were identified based on the 2023 Updated Beers Criteria. We applied a generalized linear regression model to examine the association of polypharmacy and PIMs with FILS score at discharge. RESULTS: We analyzed 399 participants (median age, 83.0 years; males, 49.8%). The median follow-up was 51.0 days (interquartile range, 22.0-84.0 days). Polypharmacy and PIMs were present in 67.7% of and 56.1% of patients, respectively. After adjusting for covariates, neither polypharmacy (ß = 0.05; 95% confidence interval [CI], -0.04-0.13, p=0.30) nor non-steroidal anti-inflammatory medications (ß = 0.09; 95% CI, -0.02-0.19; p=0.10) were significantly associated with FILS score at discharge. CONCLUSION: The results of this study indicated a high proportion of polypharmacy and PIMs among inpatients aged ≥65 years with dysphagia. Although these prescribed conditions were not significantly associated with swallowing function at discharge, our findings suggest the importance of regularly reviewing medications to ensure the appropriateness of prescriptions when managing older inpatients.

Psychological aspects of rehabilitation nutrition: A position paper by the Japanese Association of Rehabilitation Nutrition (secondary publication).

Psychological aspects of rehabilitation nutrition affect physical, cognitive, and social rehabilitation nutrition. When depression is recognized, not only pharmacotherapy and psychotherapy, but also non-pharmacological therapies such as exercise, nutrition, psychosocial, and other interventions can be expected to improve depression. Therefore, accurate diagnosis and intervention without overlooking depression is important. Psychological aspects of preventive rehabilitation nutrition is also important because depression can be partially prevented by appropriate exercise and nutritional management. Even in the absence of psychological negatives, increasing more psychological positives from a positive psychology perspective can be useful for both patients and healthcare professionals. Positive rehabilitation nutrition interventions can increase more psychological positives, such as well-being, through cognitive-behavioral therapy and mindfulness on their own, as well as through interventions on environmental factors. Consequently, physical, cognitive, and social positives are also expected to be enhanced.

Measures for Identifying Malnutrition in Geriatric Rehabilitation: A Scoping Review.

Malnutrition is a common condition in geriatric rehabilitation settings; however, the accuracy and predictive validity of the measures to identify malnutrition have not been established. The current scoping review followed the Joanna Briggs Institute's evidence synthesis manual and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews checklist. Literature published through September 2023 was searched using MEDLINE and CINAHL. The inclusion criteria selected studies reporting malnutrition measures, which include static body weight and weight loss. Identified tools were classified as nutritional screening tools, nutritional assessment tools, or diagnostic criteria. The domains of each tool/criterion and their accuracy and predictive validity were extracted. Fifty-six articles fulfilled the inclusion criteria, and six nutritional screening tools, three nutritional assessment tools, and three diagnostic criteria for malnutrition were identified. These measures consisted of various phenotypes, e.g., weight loss, causes such as inflammation/disease, and risk factors of malnutrition, e.g., functional impairment. The predictive validity of nutritional screening tools (n = 6) and malnutrition diagnostic criteria (n = 5) were inconsistently reported, whereas those for nutritional assessment tools were scarce (n = 1). These findings highlight the need to distinguish the functional impairment of nutritional origin from that of non-nutritional origin in nutritional assessment procedures, and the need to study the accuracy and the predictive validity of these measures in geriatric rehabilitation patients.

Ultrasound utilized by registered dietitians for body composition measurement, nutritional assessment, and nutritional management.

BACKGROUND AND AIMS: Ultrasound has been used primarily as a tool for body composition measurement in the field of clinical nutrition. Although many recent reports have demonstrated that ultrasound could be a useful tool for nutritional assessment, it is not well incorporated into registered dietitians' (RDs) practice. The aim of this review was to summarize the usefulness of ultrasound in assessing body composition and nutritional status and in nutritional management by RDs. METHODS: Studies on ultrasonography, nutritionists, body composition, nutritional assessment, and diet therapy was searched using the MEDLINE databases. RESULTS: After reviewing the articles, we categorized them into the following topics; 1) principles of muscle measurement using the ultrasound, types of muscle that can be measured, 2) indices of muscle and muscle mass and quality as assessed using ultrasound and its relationship to nutritional indicator, 3) diagnosis of the Global Leadership Initiative on Malnutrition (GLIM) criteria malnutrition using ultrasound, 4) practical nutritional management using ultrasound and 5) education and issues for ultrasound implementation. Ultrasound can evaluate low body mass index, unintentional loss of body weight, low skeletal muscle mass index, decreased food intake/assimilation, and disease burden/inflammation, all which are essential items of the phenotypic and etiologic criteria of the GLIM. CONCLUSION: Ultrasound may be useful for RDs to perform body composition measurement, nutritional assessment, and nutritional management. It will be important to identify the cutoff values for ultrasound-based measurements of muscle mass. In order for RDs to perform a body composition measurement, nutritional assessment, and nutritional management using ultrasound, educational issues need to be addressed.

Impact of registered dietitian and dental hygienist involvement on functional outcomes in patients with dysphagia: triad of rehabilitation, nutrition, and oral management.

PURPOSE: To investigate whether the involvement of both registered dietitians and dental hygienists results in greater improvement in swallowing function and activities of daily living (ADL) in patients with dysphagia undergoing rehabilitation. METHODS: Of 467 patients enrolled in the Japanese Sarcopenic Dysphagia database, 433 met the study eligibility criteria in a retrospective cohort study. Patients were divided into two groups based on whether or not they received intervention by both registered dietitians and dental hygienists. Outcomes were changes in the Food Intake Level Scale (FILS) and the Barthel Index (BI) at initial and follow-up assessments. Multiple regression analyses adjusted for age, sex, sarcopenia, dwelling, Charlson comorbidity index, malnutrition diagnosed by the Global Leadership Initiative on Malnutrition, and initial FILS or BI were conducted to examine the relationship between the involvement of both registered dietitians and dental hygienists. RESULTS: The mean age was 80.5 and ± 10.7 years, and 222 were female. Both registered dietitians and dental hygienists were involved in 242 (57%) patients. Median and interquartile range changes in FILS and BI were 1 (0, 2) and 15 (0, 32.5), respectively. In multiple regression analyses, the change in the FILS was significantly higher in the involvement of both registered dietitians and dental hygienists (standardized coefficient = 0.075, P = 0.033), however, the change in the BI was not significantly different between the groups. CONCLUSION: The involvement of both registered dietitians and dental hygienists improved swallowing function, but not ADL. Triad of rehabilitation, nutrition, and oral management may be useful for patients with dysphagia.

Pre-existing sarcopenia and swallowing outcomes in acute stroke patients.

BACKGROUND & AIMS: This study aimed to investigate the associations of pre-existing sarcopenia with swallowing function, oral intake level, and aspiration pneumonia in patients with acute stroke. METHODS: This observational study included patients (≥60 years of age) with acute ischemic stroke or intracerebral hemorrhage within 7 days of onset who were screened for sarcopenia, malnutrition, and swallowing difficulties in a stroke-care unit within 48 h of admission. Sarcopenia was defined by the Asian Working Group on Sarcopenia 2019 as having a low calf circumference, handgrip strength, and appendicular muscle mass index. The primary outcome was impaired oral intake (functional oral intake scale <5 points) at 3, 7, and 14 days after admission, and the secondary outcome was aspiration pneumonia during hospitalization. RESULTS: We enrolled 350 patients (median age of 77 years; 63% males) who underwent the aforementioned screening. Sarcopenia was diagnosed in 34% of patients, and malnutrition was found in 66% of patients with sarcopenia. When compared with the comparison group (defined as patients with either or both normal calf circumference and handgrip strength), the sarcopenia group had significantly lower tongue pressure and a higher prevalence of dysphagia. Sarcopenia was associated with functional oral intake scale <5 at 7 days (adjusted odds ratio [OR], 4.72; 95% confidence interval [CI], 1.91-11.71); p = 0.002) and 14 days (adjusted OR, 3.93; 95% CI, 1.47-10.53; p = 0.006) and with aspiration pneumonia during hospitalization (adjusted OR, 6.12; 95% CI, 1.63-22.94; p = 0.007). CONCLUSION: Acute stroke patients with sarcopenia may have weakness of the swallowing-related muscles which may lead to impaired oral intake and aspiration pneumonia.

Impact of energy intake on the activities of daily living in patients with cervical spinal cord injury undergoing post-acute rehabilitation.

OBJECTIVE: To investigate the association between sufficient energy intake and improvement in activities of daily living (ADL) after hospitalization in patients with cervical spinal cord injury (CSCI) undergoing post-acute rehabilitation. DESIGN: Retrospective cohort study. SETTING: Post-acute care hospital from September 2013 to December 2020. PARTICIPANTS: Patients with CSCI admitted to a post-acute care hospital for rehabilitation. INTERVENTION: Not applicable. OUTCOME MEASURE(S): Multiple regression analysis was performed to investigate the relationship of sufficient energy intake to Motor Functional Independence Measure (mFIM) gain, mFIM score at discharge, and body weight change during hospitalization. RESULTS: In total, 116 patients (104 men and 12 women), median age: 55 (interquartile range [IQR] 41-65) years were included in the analysis. Then, 68 (58.6%) were in the energy-sufficient group, and 48 (41.4%) patients were classified under the energy-deficient group. The two groups did not significantly differ in terms of mFIM gain and mFIM score at discharge. The energy-sufficient group maintained body weight change during hospitalization than the energy-deficient group (0.6 [-2.0-2.0] vs. -1.9 [-4.0--0.3], P < 0.001). Multiple regression analysis showed no association between sufficient energy intake and outcomes. CONCLUSION: Sufficient energy intake within the first 3 days of admission did not affect ADL improvement during hospitalization in patients with a post-cute CSCI undergoing rehabilitation.

Current Understanding of Sarcopenia and Malnutrition in Geriatric Rehabilitation.

Malnutrition and sarcopenia are different but common conditions in older adults that share some underlying causes, including age-related physiological changes, decreased food intake, acute or chronic inflammation [...].

Effects of Undernutrition on Swallowing Function and Activities of Daily Living in Hospitalized Patients: Data from the Japanese Sarcopenic Dysphagia Database.

This retrospective cohort study examined the effects of undernutrition on swallowing function and activities of daily living in hospitalized patients. Data from the Japanese Sarcopenic Dysphagia Database were used, and hospitalized patients aged ≥20 years with dysphagia were included in the analysis. Participants were assigned to the undernutrition or normal nutritional status group based on the Global Leadership Initiative on Malnutrition criteria. The primary outcome was the Food Intake Level Scale change, and the secondary outcome was the Barthel Index change. Among 440 residents, 281 (64%) were classified under the undernutrition group. The undernutrition group had a significantly higher Food Intake Level Scale score at baseline and Food Intake Level Scale change (p = 0.001) than the normal nutritional status group. Undernutrition was independently associated with the Food Intake Level Scale change (B = -0.633, 95% confidence interval = -1.099 to -0.167) and the Barthel Index change (B = -8.414, 95% confidence interval = -13.089 to -3.739). This was defined as the period from the date of admission to the hospital until discharge or 3 months later. Overall, our findings indicate that undernutrition is associated with reduced improvement in swallowing function and the ability to perform activities of daily living.

The Relationship between Low Skeletal Muscle Mass and Subsequent Oral Intake Ability among the Aged Population.

This study aimed to determine the relationship between skeletal muscle mass in an aged population with limited oral intake upon admission and functional oral intake at the subsequent 3-month follow-up. Methods: This was a retrospective cohort study using the Japanese Sarcopenia Dysphagia Database involving older adults (≥60 years) with limited oral intake (Food Intake Level Scale [FILS] level of ≤8). People without skeletal muscle mass index (SMI) data, unknown methods of SMI evaluation, and SMI evaluation by DXA were excluded. Data for 76 people (47 women, 29 men) were analyzed (mean [standard deviation] age: 80.8 [9.0] years; median SMI: women, 4.80 kg/m2; men, 6.50 kg/m2). There were no significant differences in age, FILS upon admission and methods of nutrition intake between the low (n = 46) and the high skeletal muscle mass groups (n = 30), although the proportion of sex between the two groups was different. The FILS level at the time of follow-up differed significantly between the groups (p < 0.01). The SMI upon admission (odds ratio: 2.99, 95% confidence interval: 1.09-8.16) were significantly associated with the FILS level at the time of follow-up after adjustment for sex, age, and history of stroke and/or dementia (p < 0.05, power = 0.756). Conclusion: A low skeletal muscle mass is a disadvantage for achieving a subsequent fully functional oral intake ability among the aged population with limited oral intake upon admission.

Association of poor oral health status and faecal incontinence in patients with dysphagia: A cross-sectional analysis from the Sarcopenic Dysphagia Database.

BACKGROUND: Poor oral health status may alter oral and gut microbiota. Previous studies have shown that poor oral health can exacerbate gut inflammation. Therefore, poor oral health status may be related to faecal incontinence via changes in the gut. OBJECTIVE: To investigate the association between poor oral health status and faecal incontinence in inpatients with dysphagia. METHODS: This multicentre cross-sectional study included 423 patients (mean age 79.8 ± 11.5 years, 48.2% female) with dysphagia. Oral health status was assessed at each facility using the Oral Health Assessment Tool (OHAT) or the Revised Oral Assessment Guide (ROAG). Poor oral health status was defined as an OHAT score of ≥3 or a ROAG score of ≥13. A multivariate logistic model was used to analyse the association between poor oral health status and faecal incontinence. RESULTS: A total of 351 (83.0%) patients had poor oral health and 97 (22.7%) had faecal incontinence. Patients with poor oral health status had a higher proportion of faecal incontinence than those with normal oral health status (25.4% vs. 11.1%, p = .009). A multivariate logistic model revealed an association between faecal incontinence and poor oral health status (adjusted odds ratio = 2.501, 95% confidence interval = 1.065-5.873, p = .035). CONCLUSIONS: Poor oral health status assessed by OHAT or ROAG in inpatients with dysphagia may adversely affect faecal incontinence. Further studies are needed to determine the causal relationship between poor oral health status and faecal incontinence.

Association between board-certified physiatrist involvement and functional outcomes in sarcopenic dysphagia patients: a retrospective cohort study of the Japanese Sarcopenic Dysphagia Database.

Objective: Dysphagia rehabilitation is an important area in geriatric nutrition due to the commonality of sarcopenic dysphagia in older adults. However, there have been no reports on the efficacy of treatment by board-certified physiatrists (BCP) in patients with sarcopenic dysphagia. This study therefore aimed to investigate whether intervention by board-certified physiatrists affects the functional prognosis of patients with sarcopenic dysphagia. Materials and Methods: Of 467 patients enrolled in the Japanese Sarcopenic Dysphagia database between November 2019 and March 2021, 433 met the study eligibility criteria. The patients were divided into two groups based on whether or not they received intervention by a BCP. The clinical characteristics and outcomes of the two groups were compared. Statistical analyses were performed by inverse probability weighting (IPW). Results: BCPs were involved in the management of 57.0% of patients with sarcopenic dysphagia. These patients had a significantly higher increase in the Barthel index both before and after IPW correction than those not managed by a BCP (P=0.001 and P=0.016, respectively). However, sarcopenic dysphagia significantly improved in the non-BCP group before IPW correction (P<0.001), although there was no significant difference after IPW correction (P=0.301). Conclusion: BCP management was significantly associated with higher activities of daily living (ADL), but not with an improvement in sarcopenic dysphagia. To provide and manage effective rehabilitation, it is necessary to familiarize patients with the management and training of sarcopenic dysphagia rehabilitation for BCP in order to cope in regions with few rehabilitation units.

Interaction between malnutrition and physical disability in older adults: is there a malnutrition-disability cycle?

Malnutrition and physical disability are urgent issues in super-aging societies and the 2 phenomena are closely linked in older adults. Both conditions have common underlying causes, including physiological changes due to aging and burdens imposed by disease or injury. Accordingly, a concept of the malnutrition-disability cycle was generated and a comprehensive literature search was performed. There was insufficient evidence to prove an interrelationship between malnutrition and physical disabilities, because of the study design and poor quality, among other factors. However, some evidence exists for the interaction between low body mass index and swallowing disorders, and the effects of some malnutrition and disability components. This review provides the rationale for this interaction, the concept of a malnutrition-disability cycle is proposed, and the available evidence is critically appraise.

Impact of Poor Oral Health Status on Swallowing Function Improvement in Older Dysphagic Patients.

Background This study aimed to explore the relationship between poor oral health status and improvement in swallowing function in older patients with dysphagia across various clinical settings, including acute and post-acute care environments. Methods This retrospective cohort study encompassed patients aged 65 years and older with dysphagia. Oral health status was assessed using the oral health assessment tool (OHAT) or the revised oral assessment guide (ROAG). In this study, an OHAT score of ≥3 or an ROAG score of ≥13 indicated poor oral health status. The primary outcome measured was the change in the food intake level scale (FILS) score, which reflects swallowing function, during the observation period. The association between changes in FILS score and poor oral health status was analyzed using a multivariable linear regression model. Results The study included 361 older patients with dysphagia (mean age 82.7 ± 7.7 years; 47.3% male), of whom 82.5% had poor oral health. A negative association was found between poor oral health status and improvement in FILS score at the endpoint (partial regression coefficient: -0.523, 95% confidence interval: -0.99 to -0.06, P=0.026). Conclusions Our findings underscore the negative impact of poor oral health status on the improvement of swallowing function and emphasize the importance of oral health interventions for older patients. Further study on oral health interventions' effects on improving swallowing function in older patients with dysphagia is warranted.

The concept of aggressive nutrition therapy and clinical indication: A position paper.

Aggressive nutrition therapy is a nutritional management method that sets energy intake requirements by adding the amount of energy accumulated to energy consumption. It is used to treat patients with undernutrition and sarcopenia. However, evidence for aggressive nutrition therapy is insufficient, and validation through high-quality clinical research is essential. Therefore, this paper aimed to clarify the concept of aggressive nutrition therapy, present indications and contraindications; and describe the effects, limitations, and the need to individualize aggressive nutrition therapy for different pathological conditions. Aggressive nutrition therapy should be accompanied by the etiology of undernutrition, sarcopenia, and nutritional metabolism in various states. In addition to calculating nutritional requirements, the nutritional management methods of oral intake, tube feeding, and parenteral nutrition should be appropriately selected. A nutrition plan with the amount of energy accumulated should also be a vital issue. This position paper was authored by the Registered Dietitian Subcommittee of the Japanese Association of Rehabilitation Nutrition and was approved by the Japanese Association of Rehabilitation Nutrition.