Nutritional problems of patients with COVID-19 receiving dietetic treatment in primary care.

BACKGROUND: The nutritional problems of patients who are hospitalised for COVID-19 are becoming increasingly clear. However, a large group of patients have never been hospitalised and also appear to experience persistent nutritional problems. The present study describes the nutritional status, risk of sarcopaenia and nutrition-related complaints of patients recovering from COVID-19 receiving dietetic treatment in primary care. METHODS: In this retrospective observational study, data were collected during dietetic treatment by a primary care dietitian between April and December 2020. Both patients who had and had not been admitted to the hospital were included at their first visit to a primary care dietitian. Data on nutritional status, risk of sarcopaenia and nutrition-related complaints were collected longitudinally. RESULTS: Data from 246 patients with COVID-19 were collected. Mean ± SD age was 57 ± 16 years and 61% of the patient population was female. At first consultation, two thirds of patients were classified as overweight or obese (body mass index >25 kg m-2 ). The majority had experienced unintentional weight loss because of COVID-19. Additionally, 55% of hospitalised and 34% of non-hospitalised patients had a high risk of sarcopaenia. Most commonly reported nutrition-related complaints were decreased appetite, shortness of breath, changed or loss of taste and feeling of being full. Nutrition-related complaints decreased after the first consultation, but remained present over time. CONCLUSIONS: In conclusion, weight changes, risk of sarcopaenia and nutrition-related complaints were prevalent in patients with COVID-19, treated by a primary care dietitian. Nutrition-related complaints improved over time, but remained prevalent until several months after infection.

Hyperemesis gravidarum severity, enteral tube feeding and cardiometabolic markers in offspring cord blood.

This study aimed to investigate the association between hyperemesis gravidarum (HG) severity and early enteral tube feeding on cardiometabolic markers in offspring cord blood. We included women admitted for HG, who participated in the MOTHER randomised controlled trial (RCT) and observational cohort. The MOTHER RCT showed that early enteral tube feeding in addition to standard care did not affect symptoms/birth outcomes. Among RCT and cohort participants, we assessed how HG severity affected lipid, c-peptide, glucose and free thyroxine cord blood levels. HG severity measures were severity of vomiting at inclusion and 3 weeks after inclusion, pregnancy weight gain and 24-h energy intake at inclusion, readmissions and duration of hospital admissions. Cord blood measures were also compared between RCT participants allocated to enteral tube feeding and those receiving standard care. Between 2013-2016, 215 women were included: 115 RCT and 100 cohort participants. Eighty-one cord blood samples were available. Univariable not multivariable regression analysis showed that lower maternal weight gain was associated with higher cord blood glucose levels (ß: -0·08, 95% CI -0·16, -0·00). Lower maternal weight gain was associated with higher Apo-B cord blood levels in multivariable regression analysis (ß: -0·01, 95% CI -0·02, -0·01). No associations were found between other HG severity measures or allocation to enteral tube feeding and cord blood cardiometabolic markers. In conclusion, while lower maternal weight gain was associated with higher Apo-B cord blood levels, no other HG severity measures were linked with cord blood cardiometabolic markers, nor were these markers affected by enteral tube feeding.

Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults.

BACKGROUND: Disease-related malnutrition has been reported in 10% to 55% of people in hospital and the community and is associated with significant health and social-care costs. Dietary advice (DA) encouraging consumption of energy- and nutrient-rich foods rather than oral nutritional supplements (ONS) may be an initial treatment. OBJECTIVES: To examine evidence that DA with/without ONS in adults with disease-related malnutrition improves survival, weight, anthropometry and quality of life (QoL). SEARCH METHODS: We identified relevant publications from comprehensive electronic database searches and handsearching. Last search: 01 March 2021. SELECTION CRITERIA: Randomised controlled trials (RCTs) of DA with/without ONS in adults with disease-related malnutrition in any healthcare setting compared with no advice, ONS or DA alone. DATA COLLECTION AND ANALYSIS: Two authors independently assessed study eligibility, risk of bias, extracted data and graded evidence. MAIN RESULTS: We included 94, mostly parallel, RCTs (102 comparisons; 10,284 adults) across many conditions possibly explaining the high heterogeneity.  Participants were mostly older people in hospital, residential care and the community, with limited reporting on their sex. Studies lasted from one month to 6.5 years.  DA versus no advice - 24 RCTs (3523 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.87 (95% confidence interval (CI) 0.26 to 2.96), or at later time points. We had no three-month data, but advice may make little or no difference to hospitalisations, or days in hospital after four to six months and up to 12 months. A similar effect was seen for complications at up to three months, MD 0.00 (95% CI -0.32 to 0.32) and between four and six months. Advice may improve weight after three months, MD 0.97 kg (95% CI 0.06 to 1.87) continuing at four to six months and up to 12 months; and may result in a greater gain in fat-free mass (FFM) after 12 months, but not earlier. It may also improve global QoL at up to three months, MD 3.30 (95% CI 1.47 to 5.13), but not later. DA versus ONS - 12 RCTs (852 participants) All outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.66 (95% CI 0.34 to 1.26), or at later time points. Either intervention may make little or no difference to hospitalisations at three months, RR 0.36 (95% CI 0.04 to 3.24), but ONS may reduce hospitalisations up to six months. There was little or no difference between groups in weight change at three months, MD -0.14 kg (95% CI -2.01 to 1.74), or between four to six months. Advice (one study) may lead to better global QoL scores but only after 12 months. No study reported days in hospital, complications or FFM. DA versus DA plus ONS - 22 RCTs (1286 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.92 (95% CI 0.47 to 1.80) or at later time points. At three months advice may lead to fewer hospitalisations, RR 1.70 (95% CI 1.04 to 2.77), but not at up to six months. There may be little or no effect on length of hospital stay at up to three months, MD -1.07 (95% CI -4.10 to 1.97). At three months DA plus ONS may lead to fewer complications, RR 0.75 (95% CI o.56 to 0.99); greater weight gain, MD 1.15 kg (95% CI 0.42 to 1.87); and better global QoL scores, MD 0.33 (95% CI 0.09 to 0.57), but this was not seen at other time points. There was no effect on FFM at three months. DA plus ONS if required versus no advice or ONS - 31 RCTs (3308 participants) Evidence was moderate- to low-certainty. There may be little or no effect on mortality at three months, RR 0.82 (95% CI 0.58 to 1.16) or at later time points. Similarly, little or no effect on hospitalisations at three months, RR 0.83 (95% CI 0.59 to 1.15), at four to six months and up to 12 months; on days in hospital at three months, MD -0.12 (95% CI -2.48 to 2.25) or for complications at any time point. At three months, advice plus ONS probably improve weight, MD 1.25 kg (95% CI 0.73 to 1.76) and may improve FFM, 0.82 (95% CI 0.35 to 1.29), but these effects were not seen later. There may be little or no effect of either intervention on global QoL scores at three months, but advice plus ONS may improve scores at up to 12 months. DA plus ONS versus no advice or ONS - 13 RCTs (1315 participants) Evidence was low- to very low-certainty. There may be little or no effect on mortality after three months, RR 0.91 (95% CI 0.55 to 1.52) or at later time points. No study reported hospitalisations and there may be little or no effect on days in hospital after three months, MD -1.81 (95% CI -3.65 to 0.04) or six months. Advice plus ONS may lead to fewer complications up to three months, MD 0.42 (95% CI 0.20 to 0.89) (one study). Interventions may make little or no difference to weight at three months, MD 1.08 kg (95% CI -0.17 to 2.33); however, advice plus ONS may improve weight at four to six months and up to 12 months. Interventions may make little or no difference in FFM or global QoL scores at any time point. AUTHORS' CONCLUSIONS: We found no evidence of an effect of any intervention on mortality. There may be weight gain with DA and with DA plus ONS in the short term, but the benefits of DA when compared with ONS are uncertain. The size and direction of effect and the length of intervention and follow-up required for benefits to emerge were inconsistent for all other outcomes.  There were too few data for many outcomes to allow meaningful conclusions. Studies focusing on both patient-centred and healthcare outcomes are needed to address the questions in this review.

The Impact of Combined Nutrition and Exercise Interventions in Patients with Chronic Kidney Disease.

Combined nutrition and exercise interventions potentially improve protein-energy wasting/malnutrition-related outcomes in patients with chronic kidney disease (CKD). The aim was to systematically review the effect of combined interventions on nutritional status, muscle strength, physical performance and QoL. MEDLINE, Cochrane, Embase, Web of Science and Google Scholar were searched for studies up to the date of July 2023. Methodological quality was appraised with the Cochrane risk-of-bias tool. Ten randomized controlled trials (nine publications) were included (334 patients). No differences were observed in body mass index, lean body mass or leg strength. An improvement was found in the six-minute walk test (6-MWT) (n = 3, MD 27.2, 95%CI [7 to 48], p = 0.008), but not in the timed up-and-go test. No effect was found on QoL. A positive impact on 6-MWT was observed, but no improvements were detected in nutritional status, muscle strength or QoL. Concerns about reliability and generalizability arise due to limited statistical power and study heterogeneity of the studies included.

More than 10% weight loss in head and neck cancer patients during radiotherapy is independently associated with deterioration in quality of life.

The authors prospectively assessed the independent association between weight loss and deterioration in quality of life (QOL) in patients treated by radiotherapy for head and neck cancer. In 533 head and neck cancer patients treated by curative radiotherapy, changes in weight and QOL were assessed between baseline (before radiotherapy) and follow-up (12 wk after the start of radiotherapy). Patients were categorized into 4 weight loss categories: 0%, 0.1%-5.0%, 5.1%-10.0%, and >10% weight loss. The association between weight loss and change in QOL was analyzed by linear regression analysis, adjusted for sociodemographic and tumor-related characteristics, and additionally for disease specific symptoms and tube feeding. Thirty percent of patients lost 0.1%-5.0% weight, 26% lost 5.1%-10.0% weight, and 24% lost >10% weight. Adjusted regression analyses showed a significant association between weight loss and deterioration of global QOL, physical functioning, social functioning, social eating, and social contact. After additional adjustment for disease-specific symptoms and tube feeding, weight loss (>10%) remained significantly associated with global QOL, social eating, and social contact (P < 0.05). More than 10% weight loss during and directly after radiotherapy has a significant impact on social eating, social contact, and QOL in head and neck cancer patients.

Effects of a dietetic treatment in older, undernourished, community-dwelling individuals in primary care: a randomized controlled trial.

PURPOSE: Undernutrition is a prevalent problem in older, community-dwelling individuals. Aim of this study was to determine the effects of a dietetic treatment in older, undernourished, community-dwelling individuals. METHODS: A parallel randomized controlled trial was performed in 146 non-institutionalized, undernourished individuals aged ≥65 years in primary care. Participants were randomly assigned to the intervention (referral to and treatment by a trained dietitian) or control group (no referral). Body weight, physical performance, handgrip strength, energy intake, protein intake and fat-free mass were assessed at baseline, after 3 months and after 6 months. RESULTS: All randomized participants (n = 146) were included in the intention-to-treat generalized estimating equations analysis (72 in intervention and 74 in control group). No treatment effect was found on the primary outcomes body weight (ß = 0.49 kg, 95% CI: -0.15-1.12), physical performance (ß = 0.15 points, 95% CI: -0.33-0.64) and handgrip strength (ß = 0.49 kg, 95% CI: -0.62-1.60). Furthermore, no treatment effect was found for the secondary outcomes. Predefined subgroup analyses showed a treatment effect on body weight in physically active participants (ß = 1.25 kg, 95% CI: 0.70-2.11) and not in inactive participants (ß = -0.20 kg, 95% CI: -1.16-0.75). CONCLUSIONS: After 6 months, a dietetic treatment by trained dietitians does not lead to increases in body weight and physical functioning in older, undernourished, community-dwelling individuals.

Minerals and Sarcopenia in Older Adults: An Updated Systematic Review.

OBJECTIVE: This systematic review aims to reevaluate the role of minerals on muscle mass, muscle strength, physical performance, and the prevalence of sarcopenia in community-dwelling and institutionalized older adults. DESIGN: Systematic review. SETTING AND PARTICIPANTS: In March 2022, a systematic search was performed in PubMed, Scopus, and Web of Sciences using predefined search terms. Original studies on dietary mineral intake or mineral serum blood concentrations on muscle mass, muscle strength, and physical performance or the prevalence of sarcopenia in older adults (average age ≥65 years) were included. METHODS: Eligibility screening and data extraction was performed by 2 independent reviewers. Quality assessment was performed with the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies. Risk of bias was evaluated using the Risk Of Bias In Non-randomized Studies-of Exposure (ROBINS-E) tool. RESULTS: From the 15,622 identified articles, a total of 45 studies were included in the review, mainly being cross-sectional and observational studies. Moderate quality of evidence showed that selenium (n = 8) and magnesium (n = 7) were significantly associated with muscle mass, strength, and physical performance as well as the prevalence of sarcopenia. For calcium and zinc, no association could be found. For potassium, iron, sodium, and phosphorus, the association with sarcopenic outcomes remains unclear as not enough studies could be included or were nonconclusive (low quality of evidence). CONCLUSIONS AND IMPLICATIONS: This systematic review shows a potential role for selenium and magnesium on the prevention and treatment of sarcopenia in older adults. More randomized controlled trials are warranted to determine the impact of minerals on sarcopenia in older adults.

Malnutrition Screening Tools Are Not Sensitive Enough to Identify Older Hospital Patients with Malnutrition.

This study evaluates the concurrent validity of five malnutrition screening tools to identify older hospitalized patients against the Global Leadership Initiative on Malnutrition (GLIM) diagnostic criteria as limited evidence is available. The screening tools Short Nutritional Assessment Questionnaire (SNAQ), Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST), Mini Nutritional Assessment-Short Form (MNA-SF), and the Patient-Generated Subjective Global Assessment-Short Form (PG-SGA-SF) with cut-offs for both malnutrition (conservative) and moderate malnutrition or risk of malnutrition (liberal) were used. The concurrent validity was determined by the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the level of agreement by Cohen's kappa. In total, 356 patients were included in the analyses (median age 70 y (IQR 63-77); 54% male). The prevalence of malnutrition according to the GLIM criteria without prior screening was 42%. The conservative cut-offs showed a low-to-moderate sensitivity (32-68%) and moderate-to-high specificity (61-98%). The PPV and NPV ranged from 59 to 94% and 67-86%, respectively. The Cohen's kappa showed poor agreement (k = 0.21-0.59). The liberal cut-offs displayed a moderate-to-high sensitivity (66-89%) and a low-to-high specificity (46-95%). The agreement was fair to good (k = 0.33-0.75). The currently used screening tools vary in their capacity to identify hospitalized older patients with malnutrition. The screening process in the GLIM framework requires further consideration.

The efficacy of a blended intervention to improve physical activity and protein intake for optimal physical recovery after oncological gastrointestinal and lung cancer surgery, the Optimal Physical Recovery After Hospitalization (OPRAH) trial: study protocol for a randomized controlled multicenter trial.

BACKGROUND: Improving physical activity, especially in combination with optimizing protein intake, after surgery has a potential positive effect on recovery of physical functioning in patients after gastrointestinal and lung cancer surgery. The aim of this randomized controlled trial is to evaluate the efficacy of a blended intervention to improve physical activity and protein intake after hospital discharge on recovery of physical functioning in these patients. METHODS: In this multicenter single-blinded randomized controlled trial, 161 adult patients scheduled for elective gastrointestinal or lung cancer surgery will be randomly assigned to the intervention or control group. The purpose of the Optimal Physical Recovery After Hospitalization (OPRAH) intervention is to encourage self-management of patients in their functional recovery, by using a smartphone application and corresponding accelerometer in combination with coaching by a physiotherapist and dietician during three months after hospital discharge. Study outcomes will be measured prior to surgery (baseline) and one, four, eight, and twelve weeks and six months after hospital discharge. The primary outcome is recovery in physical functioning six months after surgery, and the most important secondary outcome is physical activity. Other outcomes include lean body mass, muscle mass, protein intake, symptoms, physical performance, self-reported limitations in activities and participation, self-efficacy, hospital readmissions and adverse events. DISCUSSION: The results of this study will demonstrate whether a blended intervention to support patients increasing their level of physical activity and protein intake after hospital discharge improves recovery in physical functioning in patients after gastrointestinal and lung cancer surgery. TRIAL REGISTRATION: The trial has been registered at the International Clinical Trials Registry Platform at 14-10-2021 with registration number NL9793. Trial registration data are presented in Table 1.

Evaluation of Primary Allied Health Care in Patients Recovering From COVID-19 at 6-Month Follow-up: Dutch Nationwide Prospective Cohort Study.

BACKGROUND: Patients recovering from COVID-19 often experience persistent problems in their daily activities related to limitations in physical, nutritional, cognitive, and mental functioning. To date, it is unknown what treatment is needed to support patients in their recovery from COVID-19. OBJECTIVE: This study aimed to evaluate the primary allied health care of patients recovering from COVID-19 at 6-month follow-up and to explore which baseline characteristics are associated with changes in the scores of outcomes between baseline and 6-month follow-up. METHODS: This Dutch nationwide prospective cohort study evaluated the recovery of patients receiving primary allied health care (ie, dietitians, exercise therapists, occupational therapists, physical therapists, and speech and language therapists) after COVID-19. All treatments offered by primary allied health professionals in daily practice were part of usual care. Patient-reported outcome measures on participation, health-related quality of life, fatigue, physical functioning, and psychological well-being were assessed at baseline and at 3- and 6-month follow-up. Linear mixed model analyses were used to evaluate recovery over time, and uni- and multivariable linear regression analyses were used to examine the association between baseline characteristics and recovery. RESULTS: A total of 1451 adult patients recovering from COVID-19 and receiving treatment from 1 or more primary allied health professionals were included. For participation (Utrecht Scale for Evaluation of Rehabilitation-Participation range 0-100), estimated mean differences of at least 2.3 points were observed at all time points. For the health-related quality of life (EuroQol Visual Analog Scale, range 0-100), the mean increase was 12.3 (95% CI 11.1-13.6) points at 6 months. Significant improvements were found for fatigue (Fatigue Severity Scale, range 1-7): the mean decrease was -0.7 (95% CI -0.8 to -0.6) points at 6 months. However, severe fatigue was reported by 742/929 (79.9%) patients after 6 months. For physical functioning (Patient-Reported Outcomes Measurement Information System-Physical Function Short Form 10b, range 13.8-61.3), the mean increase was 5.9 (95% CI 5.9-6.4) points at 6 months. Mean differences of -0.8 (95% CI -1.0 to -0.5) points for anxiety (Hospital Anxiety and Depression Scale range 0-21) and -1.6 (95% CI -1.8 to -1.3) points for depression were found after 6 months. A worse baseline score, hospital admission, and male sex were associated with greater improvement between baseline and 6-month follow-up, whereas age, the BMI, comorbidities, and smoking status were not associated with mean changes in any outcome measures. CONCLUSIONS: Patients recovering from COVID-19 who receive primary allied health care make progress in recovery but still experience many limitations in their daily activities after 6 months. Our findings provide reference values to health care providers and health care policy makers regarding what to expect from the recovery of patients who receive health care from 1 or more primary allied health professionals. TRIAL REGISTRATION: ClinicalTrials.gov NCT04735744; https://tinyurl.com/3vf337pn. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2340/jrm.v54.2506.

LOFIT (Lifestyle front Office For Integrating lifestyle medicine in the Treatment of patients): a novel care model towards community-based options for lifestyle change-study protocol.

BACKGROUND: A healthy lifestyle is indispensable for the prevention of noncommunicable diseases. However, lifestyle medicine is hampered by time constraints and competing priorities of treating physicians. A dedicated lifestyle front office (LFO) in secondary/tertiary care may provide an important contribution to optimize patient-centred lifestyle care and connect to lifestyle initiatives from the community. The LOFIT study aims to gain insight into the (cost-)effectiveness of the LFO. METHODS: Two parallel pragmatic randomized controlled trials will be conducted for (cardio)vascular disorders (i.e. (at risk of) (cardio)vascular disease, diabetes) and musculoskeletal disorders (i.e. osteoarthritis, hip or knee prosthesis). Patients from three outpatient clinics in the Netherlands will be invited to participate in the study. Inclusion criteria are body mass index (BMI) ≥25 (kg/m2) and/or smoking. Participants will be randomly allocated to either the intervention group or a usual care control group. In total, we aim to include 552 patients, 276 in each trial divided over both treatment arms. Patients allocated to the intervention group will participate in a face-to-face motivational interviewing (MI) coaching session with a so-called lifestyle broker. The patient will be supported and guided towards suitable community-based lifestyle initiatives. A network communication platform will be used to communicate between the lifestyle broker, patient, referred community-based lifestyle initiative and/or other relevant stakeholders (e.g. general practitioner). The primary outcome measure is the adapted Fuster-BEWAT, a composite health risk and lifestyle score consisting of resting systolic and diastolic blood pressure, objectively measured physical activity and sitting time, BMI, fruit and vegetable consumption and smoking behaviour. Secondary outcomes include cardiometabolic markers, anthropometrics, health behaviours, psychological factors, patient-reported outcome measures (PROMs), cost-effectiveness measures and a mixed-method process evaluation. Data collection will be conducted at baseline, 3, 6, 9 and 12 months follow-up. DISCUSSION: This study will gain insight into the (cost-)effectiveness of a novel care model in which patients under treatment in secondary or tertiary care are referred to community-based lifestyle initiatives to change their lifestyle. TRIAL REGISTRATION: ISRCTN ISRCTN13046877 . Registered 21 April 2022.

Weight loss of 5% or more predicts loss of fat-free mass during palliative chemotherapy in patients with advanced cancer: a pilot study.

The cutoff value of critical weight loss is still subject of discussion. In this pilot study, we investigated whether ≥ 5% weight loss in the past year predicts changes in nutritional status in patients with advanced cancer during treatment with palliative chemotherapy. In 20 patients with advanced cancer undergoing palliative (combination) chemotherapy, body weight, fat free mass (FFM), and cachexia were measured prior to the start and at 9 wk of treatment. History of weight loss was used to test differences in development of nutritional parameters during chemotherapy with use of independent sample t-tests. At baseline, 10 of 20 patients had lost ≥ 5% body weight during the past year and 5 patients were cachectic. The change in FFM in the first 9 wk of chemotherapy was significantly worse in patients with ≥ 5% weight loss compared to patients with <5% weight loss [mean difference: 3.5 kg (P = 0.001)]. Data also suggest that ≥ 5% weight loss predicts shorter survival (P = 0.03). We found that patients with ≥ 5% weight loss prior to chemotherapy have a deterioration in nutritional status during chemotherapy and may have a shorter survival. These results have to be confirmed in a larger study including a robust survival analysis.

Calculation of protein requirements; a comparison of calculations based on bodyweight and fat free mass.

BACKGROUND & AIMS: In dietary practice, it is common to estimate protein requirements on actual bodyweight, but corrected bodyweight (in cases with BMI <20 kg/m2 and BMI ≥30 kg/m2) and fat free mass (FFM) are also used. Large differences on individual level are noticed in protein requirements using these different approaches. To continue this discussion, the answer is sought in a large population to the following question: Will choosing actual bodyweight, corrected bodyweight or FFM to calculate protein requirements result in clinically relevant differences? METHODS: This retrospective database study, used data from healthy persons ≥55 years of age and in- and outpatients ≥18 years of age. FFM was measured by air displacement plethysmography technology or bioelectrical impedance analysis. Protein requirements were calculated as 1) 1.2 g (g) per kilogram (kg) actual bodyweight or 2) corrected bodyweight or 3) 1.5 g per kg FFM. To compare these three approaches, the approach in which protein requirement is based on FFM, was used as reference method. Bland-Altman plots with limits of agreement were used to determine differences, analyses were performed for both populations separately and stratified by BMI category and gender. RESULTS: In total 2291 subjects were included. In the population with relatively healthy persons (n = 506, ≥55 years of age) mean weight is 86.5 ± 18.2 kg, FFM is 51 ± 12 kg and in the population with adult in- and outpatients (n = 1785, ≥18 years of age) mean weight is 72.5 ± 18.4 kg, FFM is 51 ± 11 kg. Clinically relevant differences were found in protein requirement between actual bodyweight and FFM in most of the participants with overweight, obesity or severe obesity (78-100%). Using corrected bodyweight, an overestimation in 48-92% of the participants with underweight, healthy weight and overweight is found. Only in the Amsterdam UMC population, protein requirement is underestimated when using the approach of corrected bodyweight in participants with severe obesity. CONCLUSION: The three approaches in estimation of protein requirement show large differences. In the majority of the population protein requirement based on FFM is lower compared to actual or corrected bodyweight. Correction of bodyweight reduces the differences, but remain unacceptably large. It is yet unknown which method is the best for estimation of protein requirement. Since differences vary by gender due to differences in body composition, it seems more accurate to estimate protein requirement based on FFM. Therefore, we would like to advocate for more frequent measurement of FFM to determine protein requirements, especially when a deviating body composition is to be expected, for instance in elderly and persons with overweight, obesity or severe obesity.

Evaluation of Allied Healthcare in Patients Recovering from Covid-19: Study Protocol and Baseline Data of s National Prospective Cohort Study.

OBJECTIVE: To report the study protocol and baseline characteristics of a prospective cohort study to evaluate longitudinal recovery trajectories of patients recovering from COVID-19 who have visited a primary care allied health professional. DESIGN: Report of the protocol and baseline characteristics for a prospective cohort study with a mixed-methods approach. PATIENTS: Patients recovering from COVID-19 treated by primary care dietitians, exercise therapists, occupational therapists, physical therapists and/or speech and language therapists in the Netherlands. METHODS: The prospective study will measure primary outcome domains: participation, health-related quality of life, fatigue, physical functioning, and costs, at baseline, 3, 6, 9 and 12 months. Interviews, on the patients' experiences with allied healthcare, will be held with a subsample of patients and allied health professionals. RESULTS: The cohort comprises 1,451 patients (57% female, mean age 49 (standard deviation 13) years). Preliminary results for the study cohort show that 974 (67%) of the participants reported mild/moderate severity symptoms during the infection period and patients reported severe restrictions in activities of daily living compared with previous research in other patient populations. Both quantitative and qualitative, will provide insight into the recovery of patients who are treated by allied health professionals. CONCLUSION: In conclusion, this will be the first comprehensive study to longitudinally evaluate the recovery trajectories and related costs of patients recovering from COVID-19 who are treated by allied health professionals in the Netherlands. This study will provide evidence for the optimal strategy to treat patients recovering from COVID-19 infection, including which patients benefit, and to what extent, from treatment, and which factors might impact their recovery course over time. The preliminary results of this study demonstrated the severity of restrictions and complaints at the start of therapy are substantial.

Comparison of five malnutrition screening tools in one hospital inpatient sample.

AIMS AND OBJECTIVES: The purpose of this study is to compare five commonly used malnutrition screening tools against an acknowledged definition of malnutrition in one hospital inpatient sample. BACKGROUND: Early identification and intervention of malnutrition in hospital patients may prevent later complications. Several screening tools have reported their diagnostic accuracy, but the criterion validity of these tools is unknown. DESIGN: A cross sectional study. METHODS: We compared quick-and easy screening tools [Malnutrition Screening Tool (MST), Short Nutritional Assessment Questionnaire (SNAQ) and Mini-Nutritional Assessment Short Form (MNA-SF)] and more comprehensive malnutrition screening tools [Malnutrition Universal Screening Tool (MUST) and Nutritional Risk Screening 2002 (NRS-2002)] to an acknowledged definition of malnutrition (including low Body Mass Index and unintentional weight loss) in one sample of 275 adult hospital inpatients. Sensitivity, specificity, positive predictive value and negative predictive value were determined. A sensitivity and specificity of ≥ 70% was set as a prerequisite for adequate performance of a screening tool. RESULTS: According to the acknowledged definition of malnutrition 5% of patients were at moderate risk of malnutrition and 25% were at severe risk. The comprehensive malnutrition screening tools (MUST, NRS-2002) and the quick-and-easy malnutrition screening tools (MST and SNAQ) showed sensitivities and specificities of ≥70%. However, 47% of data were missing on the MUST questionnaire and 41% were missing on MNA-SF. The MNA-SF showed excellent sensitivity, but poor specificity for the older subpopulation. CONCLUSIONS: The quick-and-easy malnutrition screening tools (MST and SNAQ) are suitable for use in an hospital inpatient setting. They performed as well as the comprehensive malnutrition screening tools (MUST and NRS-2002) on criterion validity. However, MUST was found to be less applicable due to the high rate of missing values. The MNA-SF appeared to be not useful because of it low specificity. RELEVANCE TO CLINICAL PRACTICE: Insight in what is the most valid and practical nutritional screening tool to use in hospital practice will increase effective recognition and treatment of malnutrition.

Are we overfeeding hemodialysis patients with protein? Exploring an alternative method to estimate protein needs.

BACKGROUND & AIMS: Sufficient protein intake is of great importance in hemodialysis (HD) patients, especially for maintaining muscle mass. Daily protein needs are generally estimated using bodyweight (BW), in which individual differences in body composition are not accounted for. As body protein mass is best represented by fat free mass (FFM), there is a rationale to apply FFM instead of BW. The agreement between both estimations is unclear. Therefore, the aim of this study is to compare protein needs based on either FFM or BW in HD patients. METHODS: Protein needs were estimated in 115 HD patients by three different equations; FFM, BW and BW adjusted for low or high BMI. FFM was measured by multi-frequency bioelectrical impedance spectroscopy and considered the reference method. Estimations of FFM x 1.5 g/kg and FFM x 1.9 g/kg were compared with (adjusted)BW x 1.2 and x 1.5, respectively. Differences were assessed with repeated measures ANOVA and Bland-Altman plots. RESULTS: Mean protein needs estimated by (adjusted)BW were higher compared to those based on FFM, across all BMI categories (P < 0.01) and most explicitly in obese patients. In females with BMI >30, protein needs were 69 ± 17.4 g/day higher based on BW and 45 ± 9.3 g/day higher based on BMI adjusted BW, compared to FFM. In males with BMI >30, protein needs were 51 ± 20.4 g/day and 23 ± 20.9 g/day higher compared to FFM, respectively. CONCLUSIONS: Our data show large differences and possible overestimations of protein needs when comparing BW to FFM. We emphasize the importance of more research and discussion on this topic.

Poor nutritional status, risk of sarcopenia and nutrition related complaints are prevalent in COVID-19 patients during and after hospital admission.

BACKGROUND AND AIMS: Patients with COVID-19 infection presents with a broad clinical spectrum of symptoms and complications. As a consequence nutritional requirements are not met, resulting in weight- and muscle loss, and malnutrition. The aim of the present study is to delineate nutritional complaints, the (course of the) nutritional status and risk of sarcopenia of COVID-19 patients, during hospitalisation and after discharge. METHODS: In this prospective observational study in 407 hospital admitted COVID-19 patients in four university and peripheral hospitals, data were collected during dietetic consultations. Presence of nutrition related complaints (decreased appetite, loss of smell, changed taste, loss of taste, chewing and swallowing problems, nausea, vomiting, feeling of being full, stool frequency and consistency, gastric retention, need for help with food intake due to weakness and shortness of breath and nutritional status (weight loss, BMI, risk of sarcopenia with SARC-F ≥4 points) before, during hospital stay and after discharge were, where possible, collected. RESULTS: Included patients were most men (69%), median age of 64.8 ± 12.4 years, 60% were admitted to ICU at any time point during hospitalisation with a median LOS of 15 days and an in-hospital mortality rate of 21%. The most commonly reported complaints were: decreased appetite (58%), feeling of being full (49%) and shortness of breath (43%). One in three patients experienced changed taste, loss of taste and/or loss of smell. Prior to hospital admission, 67% of the patients was overweight (BMI >25 kg/m2), 35% of the patients was characterised as malnourished, mainly caused by considerable weight loss. Serious acute weight loss (>5 kg) was showed in 22% of the patents during the hospital stay; most of these patients (85%) were admitted to the ICU at any point in time. A high risk of sarcopenia (SARC-F ≥ 4 points) was scored in 73% of the patients during hospital admission. CONCLUSION: In conclusion, one in five hospital admitted COVID-19 patients suffered from serious acute weight loss and 73% had a high risk of sarcopenia. Moreover, almost all patients had one or more nutritional complaints. Of these complaints, decreased appetite, feeling of being full, shortness of breath and changed taste and loss of taste were the most predominant nutrition related complaints. These symptoms have serious repercussions on nutritional status. Although nutritional complaints persisted a long time after discharge, only a small group of patients received dietetic treatment after hospital discharge in recovery phase. Clinicians should consider the risks of acute malnutrition and sarcopenia in COVID-19 patients and investigate multidisciplinary treatment including dietetics during hospital stay and after discharge.

Validity of the "Rate-a-Plate" Method to Estimate Energy and Protein Intake in Acutely Ill, Hospitalized Patients.

BACKGROUND: Prevalence of malnutrition in hospitals has been reported around 20% and increases during hospitalization. The "Rate-a-Plate" method has been developed to monitor dietary intake and identify patients whose nutrition status deteriorates during hospitalization, but has not yet been validated. The objective was to study the validity and reliability of the method (phase 1) and redesign and revalidate a revised version (phase 2). METHODS: Detailed food records provided a reference method. A priori difference of >20% in energy or protein between the reference and the "Rate-a-Plate" method was determined as clinically relevant. Intraclass correlation coefficients were used to determine the reliability. RESULTS: In phase 1, 24 patients were included with a total 67 test days. In phase 2, 14 patients were included, 28 test days. In phase 1, the "Rate-a-Plate" method underestimated intake by 422 kcal (29%, ICC 0.349, 95% CI 304-541) and 5.7 g protein (10%, ICC 0.511, 95% CI 0.0-11.5). Underestimation was found in 65% and 23% for energy and protein intake, respectively. Underestimation was higher when patients had higher intake. In phase 2, underestimation was 109 kcal (7%, ICC 0.788, 95% CI -273 to 56) and 3.7 g protein (6%, ICC 0.905, 95% CI -8.4 to 1.0). In 32% and 21% of the cases, energy and protein intake were underestimated. CONCLUSION: The revised version of the "Rate-a-Plate" method is a valid method to monitor energy and protein intake of hospitalized patients and can be filled out by nutrition assistants. A larger validation study is required.

Fructo-oligosaccharides and fibre in enteral nutrition has a beneficial influence on microbiota and gastrointestinal quality of life.

OBJECTIVE: Intestinal microbiota is important in health and disease. The aim of this study was to evaluate the effect of fructo-oligosaccharides (FOS) and fibre-enriched tube feeding on quality of life and intestinal microbiota (faecal Bifidobacteria). MATERIAL AND METHODS: Nineteen out of 59 home-living, tube-feeding-dependent, adult patients and matched healthy controls were included in this randomized, double-blind study. After a washout period, patients received either no residue tube feeding (non-FOS group) or FOS and fibre-enriched tube feeding (FOS group). Quality of life as defined by the Gastrointestinal Quality of Life Index (GIQLI) and quantification of faecal Bifidobacteria were determined. RESULTS: At baseline, GIQLI scores in controls and patients were 88+/-12 and 67+/-14, respectively (p=0.001). Following 6 weeks' intervention, GIQLI scores remained stable (65+/-14 versus 67+/-17) in the FOS group, whereas the non-FOS group values decreased (68+/-17 versus 64+/-19). Baseline faecal samples contained 2. 1x 10(7)+/-3.5 x 10(7) and 2.1 x 10(6)+/-5.6 x10(6)Bifidobacteria (p=0.002) in controls and patients, respectively, with no differences between patient groups. During the intervention, this number remained stable in the FOS group (0.7 x 10(6)+/-1.3 x 10(6) versus 1.0 x 10(6)+/-1.3 x 10(6) baseline versus end-point), but decreased in the non-FOS group (3.6 x1 0(6)+/-8.0 x 10(6) versus 2.5 x 10(4)+/-4.0 x 10(4)). GIQLI scores were correlated with the number of faecal Bifidobacteria (r=0.41, p=0.007). CONCLUSIONS: The GIQL score for the tube-fed patients increased with the number of faecal Bifidobacteria, although in a non-linear way, and addition of FOS increased the number of Bifidobacteria. This suggests that prebiotic tube feeding may lead to a change in intestinal microbiota that could induce an increased quality of life in these patients.

[Personalised nutrition care or standard care?] / Gepersonaliseerde voedingszorg of standaardzorg?

Optimal nutrition is an important condition for optimal recovery from illness, both in and outside the hospital setting. In addition, in developed countries hospital-related malnutrition remains a major problem which can lead to complications, longer hospital stays and increased costs. The EFFORT study investigated if individualised nutritional support targeted at reaching protein and caloric goals, would reduce the risk of adverse outcomes. Achieving optimal nutrition is difficult due to illness-induced anorexia, inadequate education of medical doctors and little financial incentive. Guidelines focus on protein and energy, negating those illness-induced anorexia and individual patient aspects such as taste, portion size and eating habits. Although the EFFORT study showed benefit on the composite and individual endpoints, we should point out that the intervention group received standard care. Malnutrition needs multidisciplinary and transmural care including physiotherapy/exercise. As such, a more holistic approach is needed; optimal care as described by the EFFORT study should be the standard.