Barriers and enablers in the implementation of a standardised process for nutrition care: findings from a multinational survey of dietetic professionals in 10 countries.

BACKGROUND: To explore the barriers and enablers experienced by nutrition and dietetic professionals in the implementation of the standardised Nutrition Care Process (NCP) across 10 different countries. NCP related beliefs, motivations and values were investigated and compared. METHODS: A validated online survey was disseminated to nutrition and dietetics professionals in 10 countries in the local language during 2017. Cross-sectional associations and differences between countries were explored for level of implementation, barriers/enablers and attitudes/motivation among the respondents. RESULTS: Higher NCP implementation was associated with greater occurrence of enabling aspects, as well as fewer occurrences of barriers. The most common enabler was 'recommendation by the national dietetic association' (69%) and the most common barrier was 'lack of time' (39%). A longer experience of NCP use was associated with a more positive attitude towards all NCP aspects. Differences between countries were identified, regarding both the occurrence of barriers/enablers and attitudes/motivations. CONCLUSIONS: Implementation efforts need to be tailored to country-specific contexts when implementing a new standard of care framework among nutrition and dietetic professionals. Additional research is needed to further assess the management and workplace strategies to support the development of nutrition and dietetics professionals in multidisciplinary healthcare organisations.

Dairy product consumption, dietary nutrient and energy density and associations with obesity in Australian adolescents.

BACKGROUND: Dairy intake is likely to influence dietary energy density (ED) and nutrient density (ND), which are factors representing aspects of dietary quality. Although evidence suggests dairy intake is unlikely to contribute to obesity, intake tends to decrease over adolescence, potentially as a result of concerns around weight gain. We examined associations between dairy intake, ED and ND, and investigated relationships with obesity in adolescents. METHODS: The present study comprised a cross-sectional study of 1613 14-year-olds in the Western Australian Pregnancy Cohort (Raine) Study. Adolescents completed a 212-item food frequency questionnaire. Nutrient Rich Food index 9.3 (NRF9.3) was used to estimate ND. Age-specific body mass index (BMI) and waist-height cut-offs were used to categorise obesity risk. RESULTS: Mean (SD) dairy intake was: 2.62 (1.51) servings daily; ED was 4.53 (0.83) (food and beverage) and 6.28 (1.33) (food only); ND was 373 (109). Dairy intake was inversely associated with ED and positively associated with ND. The odds of being overweight (as assessed by BMI) increased by 1.24 (95% confidence interval = 1.09-1.42) with each 100-point increase in ND, after adjustment for potential confounders and energy intake. ED measures and dairy intake were inversely associated with obesity after adjustment for confounders; associations became nonsignificant after energy adjustment. CONCLUSIONS: The NRF9.3 was originally designed to assess foods, not diets. Further research in other cohorts to determine whether similar findings exist, or investigations into alternate measures of dietary ND, may prove useful. Our findings may be the result of factors such as an excess consumption of refined but fortified foods. Although higher dairy intakes were associated with higher ND, intakes were not associated with higher obesity risk.

Dietary glycaemic carbohydrate in relation to the metabolic syndrome in adolescents: comparison of different metabolic syndrome definitions.

AIMS: High dietary glycaemic carbohydrate, as measured by the dietary glycaemic index and glycaemic load has been associated with increased risk of the metabolic syndrome in adults, but limited research exists for younger populations. We aimed to evaluate associations between dietary glycaemic carbohydrate and insulin resistance or the prevalence of the metabolic syndrome defined by three different criteria in a population-based adolescent cohort. METHODS: Diet was assessed using 3 day food records in 769 adolescents aged 13-15 years participating in the Western Australian Pregnancy Cohort (Raine) Study. The metabolic syndrome was identified using age-specific adolescent definitions from the International Diabetes Federation, the National Cholesterol Education Program Adult Treatment Panel III and a population-derived 'high-risk' metabolic cluster algorithm. Presence of a high waist circumference was mandatory only in the International Diabetes Federation definition. Insulin resistance was measured using homeostasis model assessment (HOMA-IR). RESULTS: The prevalence of the metabolic syndrome as defined by the International Diabetes Federation and the Adult Treatment Panel III was 3.6 and 4.0%, respectively; 25.9% of subjects were classified into the high-risk cluster. Significantly increased odds of International Diabetes Federation-defined metabolic syndrome were independently associated with a 20 unit glycaemic load increase (odds ratio 2.18; 95% confidence interval 1.26-3.78) and a 30 g carbohydrate increase (odds ratio 3.86; 95% confidence interval 1.80-8.28). No significant associations were observed when using the Adult Treatment Panel III, or the cluster-defined metabolic syndrome, or with HOMA-IR. CONCLUSIONS: This study supports the concept that high dietary glycaemic carbohydrate is associated with a higher prevalence of the metabolic syndrome in adolescents. However, relationships vary according to the definition of the metabolic syndrome used, with waist circumference a potentially relevant factor.

Dietary patterns and markers for the metabolic syndrome in Australian adolescents.

BACKGROUND AND AIMS: Overweight and other risk factors for cardiovascular disease (CVD) as well as their clustering, are increasingly prevalent among adolescents. We examined dietary patterns, CVD risk factors, and the clustering of these risk factors in 1139 14-year-olds living in Western Australia. METHODS AND RESULTS: Usual dietary intake was assessed using a food frequency questionnaire. Two dietary patterns, 'Western' and 'Healthy', were identified using factor analysis. Associations between these dietary patterns and BMI, waist circumference, systolic blood pressure, fasting levels of serum glucose, insulin, total cholesterol, HDL-C, LDL-C, triglycerides and insulin resistance were assessed using ANOVA. Cluster analysis identified a high risk group (the 'high risk metabolic cluster') with features akin to adult metabolic syndrome. Belonging to the 'high risk metabolic cluster' was examined in relation to dietary patterns using logistic regression, adjusting for aerobic fitness and socio-demographic factors. Higher 'Western' dietary pattern scores were associated with greater odds for the 'high risk metabolic cluster' (p for trend=0.02) and greater mean values for total cholesterol (p for trend=0.03), waist circumference (p for trend=0.03) and BMI (p for trend=0.02) in girls, but not boys. Scores for the 'Healthy' dietary pattern were not related to the 'high risk metabolic cluster' but were inversely associated with serum glucose in boys and girls (p for trend=0.01 and 0.04, respectively) and were positively associated with HDL-C in boys (p for trend=0.02). CONCLUSIONS: Dietary patterns are associated with CVD risk factors and the clustering of these risk factors in adolescence.

Disposition of drugs in cystic fibrosis. II. Hepatic blood flow.

To determine whether the increased clearance of high extraction-ratio drugs in cystic fibrosis is caused by an increase in hepatic blood flow, the blood flow in main branches of the hepatic vein and portal vein was measured by use of noninvasive duplex ultrasound scanning in 10 adult subjects with cystic fibrosis and in 10 healthy age-, gender-, and height-matched control subjects. No statistically significant differences between subjects with cystic fibrosis and control subjects were detected in either the hepatic vein (217 +/- 103 ml/min for subjects with cystic fibrosis versus 211 +/- 135 ml/min for control subjects) or the portal vein (205 +/- 114 ml/min for subjects with cystic fibrosis versus 190 +/- 101 ml/min for control subjects) blood flows. These data indicate that a large (greater than or equal to 100%) increase in the clearance of high extraction-ratio drugs in patients with cystic fibrosis is unlikely to be primarily caused by an increase in hepatic blood flow. It is probable that alternative mechanisms such as enhanced secretory or metabolic pathways account in large part for increases in clearance of high extraction-ratio drugs.

Disposition of drugs in cystic fibrosis. IV. Mechanisms for enhanced renal clearance of ticarcillin.

To investigate the hypothesis that renal secretion of penicillins is enhanced in cystic fibrosis the maximal tubular secretion rate (Tmax) of ticarcillin and the serum concentration of ticarcillin at half-maximal secretion rate (TC50) were determined in patients with cystic fibrosis (n = 6) and control subjects (n = 6). Each subject received three consecutive constant-rate intravenous infusions of ticarcillin (4, 13, and 70 mg/kg/hr; 2 1/2 hours each) simultaneously with a constant-rate (30 mg/kg/hr) infusion of insulin. Urine samples were collected at 1/2-hour intervals and serum samples at the midpoint of the urine collections. Ticarcillin and inulin concentrations in serum and urine were determined by high-performance liquid chromatographic and a spectrophotometric method, respectively. Ticarcillin serum protein binding was determined by ultrafiltration. Steady-state ticarcillin serum concentrations were achieved at all three infusion rates. The TC50 was significantly lower (p < 0.05) in patients with cystic fibrosis (33.7 +/- 12.2 micrograms/ml) compared with that in control subjects (77.6 +/- 38.4 micrograms/ml). In contrast, the Tmax was similar (cystic fibrosis, 0.25 +/- 0.12 mg/min/kg; control, 0.22 +/- 0.14 mg/min/kg; p > 0.05). These data indicate that renal clearance of penicillins is enhanced in cystic fibrosis because of greater affinity of the renal secretory system for these drugs.

Disposition of drugs in cystic fibrosis. V. In vivo CYP2C9 activity as probed by (S)-warfarin is not enhanced in cystic fibrosis.

Enhanced metabolism of theophylline in subjects with cystic fibrosis suggests that the activity of certain cytochrome P450 isoforms is affected in subjects with this genetic disease. To determine whether this effect on the P450 enzymes is selective, the in vivo activity of the cytochrome P450 isoform CYP2C9 was determined in adult subjects with cystic fibrosis (n = 6) and in control subjects (n = 8). Subjects were administered (S)-warfarin as a single intravenous bolus dose (0.375 mg/kg), and urine and plasma samples were collected for 96 hours. Plasma (S)-warfarin concentrations were determined by HPLC; urinary concentrations of (S)-warfarin and its metabolites were determined by gas chromatography-mass spectrometry. The total plasma clearance of (S)-warfarin (subjects with cystic fibrosis, 3.6 +/- 0.48 ml/hr/kg; control subjects, 3.82 +/- 0.73 ml/hr/kg), elimination half-life (subjects with cystic fibrosis, 29.5 +/- 4.2 hours; control subjects, 25.9 +/- 5.4 hours); and steady-state volume of distribution (subjects with cystic fibrosis, 153 +/- 18 ml/kg; control subjects, 138 +/- 22 ml/kg) were similar in the two groups (p > 0.05). The metabolic clearance of (S)-warfarin to its major metabolites mediated by CYP2C9, 6-hydroxywarfarin and 7-hydroxywarfarin, was not significantly (p > 0.05) different between the two groups (6-hydroxywarfarin: subjects with cystic fibrosis, 0.33 +/- 0.1 ml/hr/kg; control subjects, 0.41 +/- 0.1 ml/hr/kg; 7-hydroxywarfarin: subjects with cystic fibrosis, 1.34 +/- 0.49 ml/hr/kg; control subjects, 1.8 +/- 0.45 ml/hr/kg). On the basis of these data, we conclude that the in vivo cytochrome P450 activity is selectively affected in persons with cystic fibrosis.

Disposition of drugs in cystic fibrosis. VI. In vivo activity of cytochrome P450 isoforms involved in the metabolism of (R)-warfarin (including P450 3A4) is not enhanced in cystic fibrosis.

OBJECTIVE: To determine whether the activity of cytochrome P450 isoforms involved in the metabolism of (R)-warfarin is enhanced in cystic fibrosis. DESIGN: Six adult subjects with cystic fibrosis and six healthy control subjects, matched by age and sex, were administered (R)-warfarin as a single intravenous bolus dose (0.375 mg/kg), and urine and plasma samples were collected for 192 hours. The concentration of (R)-warfarin in plasma and the concentration of (R)-warfarin and its metabolites in urine were determined by HPLC and GC/MS, respectively. Plasma protein binding of (R)-warfarin was measured by ultrafiltration. RESULTS: The unbound plasma clearance of (R)-warfarin was not significantly (p > 0.05) different between the cystic fibrosis and the control groups (cystic fibrosis, 997 +/- 483 ml/hr/kg; control, 788 +/- 219 ml/hr/kg). The unbound metabolic clearances of (R)-warfarin to its oxidative metabolites--6-hydroxywarfarin, 7-hydroxywarfarin, 8-hydroxywarfarin, and 10-hydroxywarfarin (mediated by P450 3A4)--were also similar (p > 0.05) in the two groups (6-hydroxywarfarin: cystic fibrosis: 124.2 +/- 72.8 ml/hr/kg, control: 99.4 +/- 37.3 ml/hr/kg; 7-hydroxywarfarin: cystic fibrosis: 43.8 +/- 32.2 ml/hr/kg, control: 34.5 +/- 10.6 ml/hr/kg; 8-hydroxywarfarin: cystic fibrosis: 80.4 +/- 85.4 ml/hr/kg, control: 69.5 +/- 39.5 ml/hr/kg; 10-hydroxywarfarin: cystic fibrosis: 4.38 +/- 2.72 ml/hr/kg, control: 16.28 +/- 13.71 ml/hr/kg). CONCLUSION: The in vivo activity of cytochrome P450 isoforms involved in the metabolism of (R)-warfarin, including P450 3A4, is not enhanced in cystic fibrosis.

A comparison of fibrin sealant versus standard closure in the reduction of postoperative morbidity after groin dissection: A systematic review and meta-analysis.

BACKGROUND: Groin dissection is commonly performed in patients with lower limb malignant conditions such as malignant melanoma, vulvar, penile, anal and scrotal carcinomas with an associated high complication rate. Numerous surgical strategies have been suggested to reduce morbidity. We aimed to systematically review one of those methods - fibrin sealant (FS) - in comparison to standard closure (SC) in reducing postoperative morbidity from groin dissection. METHODS: A systematic search of the literature, study selection and data extraction using an independent screening process, assessment of risk of bias and statistical data analysis was performed. Only randomised controlled trials (RCTs) comparing fibrin sealant to standard care in patients with malignant disease undergoing groin dissection reporting at least one outcome measure relating to postoperative complications were included in the review. RESULTS: A total of 6 RCTs were included. There were no statistically significant differences in postoperative surgical site infection (SSI) rates between FS and SC. The overall incidence of wound infection in the FS group was 32% (43/133) compared to 34% (45/132) in the SC group. (Pooled risk ratio = 0.0.94 [0.68, 1.32]; 95% CI; P = 0.74). The incidence of seroma for the FS group (30/133) and the SC group (30/132) did not differ (Pooled risk ratio = 1.03 [0.67, 1.58]; 95% CI; P value = 0.90). Complication rates were similar between groups. CONCLUSION: Based on current evidence, fibrin sealant does not significantly reduce morbidity in patients undergoing groin dissection for the management of malignant disease when compared to standard closure techniques.

Dietary fructose in relation to blood pressure and serum uric acid in adolescent boys and girls.

Evidence that fructose intake may modify blood pressure is generally limited to adult populations. This study examined cross-sectional associations between dietary intake of fructose, serum uric acid and blood pressure in 814 adolescents aged 13-15 years participating in the Western Australian Pregnancy Cohort (Raine) Study. Energy-adjusted fructose intake was derived from 3-day food records, serum uric acid concentration was assessed using fasting blood and resting blood pressure was determined using repeated oscillometric readings. In multivariate linear regression models, we did not see a significant association between fructose and blood pressure in boys or girls. In boys, fructose intake was independently associated with serum uric acid (P<0.01), and serum uric acid was independently associated with systolic blood pressure (P<0.01) and mean arterial pressure (P<0.001). Although there are independent associations, there is no direct relationship between fructose intake and blood pressure. Our data suggest that gender may influence these relationships in adolescence, with significant associations observed more frequently in boys than girls.

Polyunsaturated fatty acid intake and blood pressure in adolescents.

Evidence that intake of polyunsaturated fatty acids (PUFAs) may modify blood pressure (BP) is generally limited to middle-aged or hypertensive populations. This study examined cross-sectional associations between BP and dietary intake of PUFAs in 814 adolescents aged 13-15 years participating in the Western Australian Pregnancy Cohort (Raine) Study. Fatty acid intakes were assessed using 3-day diet records and resting BP was determined using multiple oscillometric readings. In multivariate regression models, systolic BP was inversely associated with intakes of polyunsaturated (b=-0.436, P<0.01), omega-3 (b=-2.47, P=0.02), omega-6 (b=-0.362, P=0.04) and long chain omega-3 fatty acids (b=-4.37, P=0.04) in boys. Diastolic BP and mean arterial pressure were inversely associated with intakes of long chain omega-3 fatty acids in boys (b=-3.93, P=0.01, b=-4.05, P=0.01, respectively). For specific long-chain omega-3s, significant inverse associations were observed between eicosapentaenoic acid (EPA) and docosahexaenoic acid, such as systolic BP decreasing by 4.7 mm Hg (95% CI -9.3 to -0.1) for a quarter gram increase in EPA, but no significant associations were observed with docosapentaenoic acid. No significant associations were observed in girls, or with the omega-6 to omega-3 ratio. Our results suggest that gender may moderate relationships between fatty acid intake and BP in adolescence.

Early diet quality in a longitudinal study of Australian children: associations with nutrition and body mass index later in childhood and adolescence.

Obesity has origins extending to antenatal and early postnatal periods; however, the relationship between early postnatal diet and subsequent obesity is not well defined. The aims of this study were to determine whether early childhood dietary quality was associated with (a) infant and adolescent nutrition and (b) body mass index (BMI) in childhood and adolescence. The degree to which early nutrition and growth factors determine BMI throughout childhood and adolescence was also explored. This research was conducted using the Raine Study, a longitudinal survey of Australian children assessed from mid-gestation to 17 years of age. A dietary quality index, the Raine Eating Assessment in Toddler score, was assigned to 2562 participants to assess early nutrition. Linear regression determined that breastfeeding was associated with dietary quality at 1-3 years. Dietary elements at 14 years of age were related to earlier dietary quality. There were no consistent associations between early diet and BMI at 3, 5, 8, 10, 14 or 17 years. In contrast, birth weight and infant weight gain were significantly associated with BMI at these ages. This study suggests that early dietary patterns are associated with aspects of diet in adolescence, likely reflecting the influence of maternal reporting. Birth weight and early growth appear to be more important determinants of adolescent BMI than early diet and nutrition. While optimizing early diet by maternal nutritional education has potential to influence later nutrition, interventions focussing on early weight gain may have a greater impact on the obesity epidemic.

Glycaemic load is associated with insulin resistance in older Australian women.

BACKGROUND/OBJECTIVES: Diets with a high postprandial glycaemic response may contribute to the long-term development of insulin resistance and diabetes; however, earlier epidemiological studies are conflicting on whether glycaemic index (GI) or glycaemic load (GL) are dietary factors associated with the progression. Our objectives were to estimate GI and GL in a group of older women, and evaluate cross-sectional associations with insulin resistance. SUBJECTS/METHODS: The subjects were 329 Australian women aged 42-81 years participating in year 3 of the Longitudinal Assessment of Ageing in Women study. Dietary intakes were assessed by diet history interviews and analysed using a customized GI database. Insulin resistance was defined as a homeostasis model assessment value of >3.99, based on fasting blood glucose and insulin concentrations. RESULTS: GL was significantly higher in the 26 subjects who were classified as insulin resistant compared with subjects who were not (134+/-33 versus 114+/-24, P<0.001). In a logistic regression model, an increment of 15 GL units increased the odds of insulin resistance by 2.09 (95% confidence interval (1.55, 2.80), P<0.001) independently of potential confounding variables. No significant associations were found when insulin resistance was assessed as a continuous variable. CONCLUSIONS: The results of this cross-sectional study support the concept that diets with a higher GL are associated with an increased risk of insulin resistance. Further studies are required to determine whether reducing the glycaemic intake, either by consuming lower GI foods or through smaller serves of carbohydrate, can contribute to a reduction in development of insulin resistance and long-term risk of type II diabetes.

The reliability of a food frequency questionnaire for use among adolescents.

BACKGROUND: Accurate measurement of dietary intake is essential for understanding the long-term effects of adolescent diet on chronic disease risk. However, adolescents may have limited food knowledge and ability to quantify portion sizes and recall dietary intake. Therefore, food frequency questionnaires (FFQs) deemed appropriate for use among adults may not be suitable for adolescents. OBJECTIVES: To evaluate an FFQ in comparison with a 3-day food record (FR) in 14-year olds participating in a population-based cohort study in Western Australia. METHODS: Nutrient intakes estimated by a semi-quantitative FFQ were compared with those from a 3-day FR using Bland & Altman limits of agreement (LOA), tertile classifications and Pearson's correlation coefficients. RESULTS: A total of 785 adolescents provided data from both dietary methods. Mean agreement between the FR and FFQ ranged from 73 (starch) to 161% (vitamin C). The LOA ranged from 27 (retinol) to 976% (carotene), with most nutrients being overestimated by the FFQ. For most nutrients, agreement between the two methods varied significantly with the magnitude of intake. Pearson's r ranged from 0.11 (polyunsaturated fats) to 0.52 (riboflavin). The FFQ classified 80 to 90% of subjects' nutrient intakes into the same or adjacent tertile as their FR. Boys performed slightly better for all of these indices. CONCLUSIONS: Agreement between individual FFQ and FR nutrient intakes was less than ideal. However, the FFQ was able to correctly rank a reasonable proportion of adolescents.