Malnutrition and clinical outcomes post alloSCT.

BACKGROUND: Malnutrition has been linked with higher risk of poor outcomes post-allogeneic stem cell transplantation (alloSCT); however, few studies have used a validated nutrition assessment tool such as the Patient Generated Subjective Global Assessment (i.e., PG-SGA) to measure nutritional status and investigate associations with long-term clinical outcomes. The present study aimed to assess the incidence of malnutrition prior to alloSCT and determine whether there was an association between nutritional status pre-transplant and post-transplant clinical outcomes including acute kidney injury, graft-versus-host disease, intensive care admission, need for haemodialysis and survival. METHODS: A retrospective analysis of 362 patients (213 males:149 females, mean ± SD age = 47.8 ± 14.1 years) who underwent alloSCT from 2008 to 2013 was conducted. Data on clinical outcomes were obtained for 5 years post-transplant. RESULTS: Fifteen percent (n = 56) of patients were identified as malnourished pre-admission. Malnutrition was associated with longer hospital stay (p = 0.007), increased requirement for haemodialysis (p = 0.016) and increased admissions to the intensive care unit (p = 0.003). There was no association between malnutrition and acute kidney injury, graft-versus-host disease or survival. Following multivariate analyses, malnutrition remained significantly associated with increased admission rates to the intensive care unit (odds ratio = 3.8, 95% confidence interval = 1.3-10.5, p = 0.011) and increased length of hospital stay > 30 days (odds ratio = 3.6. 95% confidence interval = 1.8-7.4, p ≤ 0.001). CONCLUSIONS: These findings add importance to the need for nutrition screening and assessment to be routinely undertaken for patients prior to alloSCT and throughout hospitalisation to provide early nutrition intervention for the prevention of malnutrition, poor clinical outcomes and increased healthcare costs.

Effect of supplements/intensive nutrition on pressure ulcer healing: a multicentre, randomised controlled study.

OBJECTIVE: To investigate the effectiveness of an intensive nutrition intervention or use of wound healing supplements compared with standard nutritional care in pressure ulcer (PU) healing in hospitalised patients. METHOD: Adult patients with a Stage II or greater PU and predicted length of stay (LOS) of at least seven days were eligible for inclusion in this pragmatic, multicentre, randomised controlled trial (RCT). Patients with a PU were randomised to receive either: standard nutritional care (n=46); intensive nutritional care delivered by a dietitian (n=42); or standard care plus provision of a wound healing nutritional formula (n=43). Relevant nutritional and PU parameters were collected at baseline and then weekly or until discharge. RESULTS: Of the 546 patients screened, 131 were included in the study. Participant mean age was 66.1±16.9 years, 75 (57.2%) were male and 50 (38.5%) were malnourished at recruitment. Median length of stay was 14 (IQR: 7-25) days and 62 (46.7%) had ≥2 PUs at the time of recruitment. Median change from baseline to day 14 in PU area was -0.75cm2 (IQR: -2.9_-0.03) and mean overall change in Pressure Ulcer Scale for Healing (PUSH) score was -2.9 (SD 3.2). Being in the nutrition intervention group was not a predictor of change in PUSH score, when adjusted for PU stage or location on recruitment (p=0.28); it was not a predictor of PU area at day 14, when adjusted for PU stage or area on recruitment (p=0.89) or PU stage and PUSH score on recruitment (p=0.91), nor a predictor of time to heal. CONCLUSION: This study failed to confirm a significant positive impact on PU healing of use of an intensive nutrition intervention or wound healing supplements in hospitalised patients. Further research that focuses on practical mechanisms to meet protein and energy requirements is needed to guide practice.

The use of alternate vertebral levels to L3 in computed tomography scans for skeletal muscle mass evaluation and sarcopenia assessment in patients with cancer: a systematic review.

Body composition measurement using diagnostic computed tomography (CT) scans has emerged as a method to assess sarcopenia (low muscle mass) in oncology patients. Assessment of skeletal muscle mass (SMM) using the cross-sectional area of a single vertebral slice (at lumbar L3) in a CT scan is correlated with whole-body skeletal muscle volume. This method is used to assess CT-defined sarcopenia in patients with cancer, with low SMM effecting outcomes. However, as diagnostic scans are based on tumour location, not all include L3. We evaluated the evidence for the use of alternate vertebral CT slices for SMM evaluation when L3 is not available. Five electronic databases were searched from January 1996 to April 2020 for studies using CT scan vertebral slices above L3 for SM measurement in adults with cancer (solid tumours). Validation with whole-body SMM, rationale for the chosen slice and sarcopenia cut-off values were investigated. Thirty-two studies were included, all retrospective and cross-sectional in design. Cervical, thoracic and lumbar slices were used (from C3 to L1), with no validation of whole-body SMM using CT scans. Alternate slices were used in lung, and head and neck cancer patients. Sarcopenia cut-off values were reported in 75 % of studies, with differing methods, with or without sex-specific values, and a lack of consensus. Current evidence is inadequate to provide definitive recommendations for alternate vertebral slice use for SMM evaluation in cancer patients. Variation in sarcopenia cut-offs warrants more robust investigation, in order for risk stratification to be applied to all patients with cancer.

The changing face of head and neck cancer: are patients with human papillomavirus-positive disease at greater nutritional risk? A systematic review.

PURPOSE: Human papillomavirus (HPV) is now the primary cause of oropharyngeal head and neck cancer (OPC) worldwide; yet limited research has examined the effect of HPV-positive status (OPC+) on nutrition outcomes. This study aims to determine the impact of HPV status on nutritional outcomes for adult patients with OPC undergoing any treatment modality. METHODS: A systematic literature review was conducted up to and including July 2021 of PubMed, Embase, CENTRAL, CINAHL, and Web of Science to identify studies conducted in adults (>18 years) with known OPC reporting on any outcome(s) related to nutrition, according to HPV status (OPC+ versus OPC-). Bias was assessed using QUIPS tool, with certainty of evidence assessed using GRADE system. RESULTS: Six studies (total n = 635) all at moderate-high risk of bias were included. Three studies reported on weight change (n = 255), three feeding tube dependency (n = 380), three feeding tube timing of placement (prophylactic or reactive) and/or utilisation (n = 255), two nutritional (energy and/or protein) intake (n = 230), and one nutritional status (n = 83). Patients with OPC+ may experience greater weight loss, may have higher utilisation of reactive feeding tubes (both GRADE low certainty, downgraded due to serious bias and imprecision), and may have lower feeding tube dependency rates (GRADE low certainty, downgraded due to serious bias and inconsistency) versus OPC- . It is uncertain whether nutritional intake and nutritional status differed between populations (GRADE very low certainty, downgraded due to serious bias and very serious imprecision). CONCLUSION: Further, high-quality research is needed to understand optimal nutritional care practices for patients with OPC + to achieve positive health outcomes into survivorship.

Vitamin requirements during stem cell transplantation: a systematic review.

Patients undergoing stem cell transplantation (SCT) are at high risk of malnutrition during the acute post-transplantation period. This systematic review aimed to collate and analyse the evidence for vitamin requirements post-SCT. A systematic search of five databases was conducted to include studies published until March 2021. The review utilised the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) framework. Inclusion criteria consisted of adults undergoing SCT who received vitamin supplementation or had their vitamin levels monitored up to 100 days post-SCT. Studies with paediatric patients or those that looked at vitamin derivates such as folinic acid were excluded. Main outcomes included vitamin deficiency and relevant clinical outcomes. Eleven studies (n = 11) were eligible for inclusion with five rated as neutral quality and six as positive quality. Five studies focused on allogenic SCT, two on autologous SCT and the remaining included a mix of both. Eight studies monitored vitamins levels post-SCT, and seven studies provided vitamin supplementation. Three studies (one provided supplementation) found a high prevalence of vitamin D deficiency (23-60%) prior to SCT. Findings indicate an unclear association between vitamin deficiency and post-SCT complications including acute graft-versus-host-disease, oral mucositis, and mortality. The GRADE certainty of evidence across these outcomes was low or very low. It is unclear if supplementation is needed during SCT, though assessing vitamin D levels prior to transplant should be considered. Further large observational studies or randomised control trials are required to establish vitamin requirements and guide supplementation protocols during SCT.

Exploration of current dietetic practices for patients with gynaecological cancers undergoing radiotherapy in Australia: a cross-sectional survey.

PURPOSE: Radiotherapy for gynaecological cancers often causes gastrointestinal (GI) toxicities such as diarrhoea. Evidence for the potential benefits of dietary interventions on the management of acute GI toxicities is inconclusive and of low quality, with no clear evidence-based guidelines to inform clinical practice. This study aims to provide an overview of current opinions and clinical practice of dietitians treating this cohort and to examine existing models of nutrition care in Australian cancer centres. METHODS: Semi-structured interviews were conducted over a video conferencing service to collect information relating to: demographic characteristics; referral protocol and post-treatment pathways; management strategies and interventions prescribed; and attitudes and confidence in service provided. Descriptive analysis was performed on quantitative data, and thematic analysis was performed on qualitative data. RESULTS: In total, 17 dietitians across Australia participated in the study. Almost all centres (94%) had dietetics services available for this patient cohort; however, most did not have an automatic referral pathway (94%) or post-treatment pathway (88%). The opinions and prescription of dietary interventions for symptom management had multiple variations of a 'low' or 'modified-fibre' diet with differing ratios of soluble and insoluble fibre. Over half of the respondents believed that practice was not standardized within their workplace (58%) or Australia (82%). CONCLUSION: There are variations in service provision with respect to opinions and prescription of dietary modifications within dietetic practice across Australia. The present study highlights the need to investigate the efficacy of dietary interventions on symptom management to better inform evidence-based models of care.

Pilot study investigating the effect of enteral and parenteral nutrition on the gastrointestinal microbiome post-allogeneic transplantation.

Nutrition support is frequently required post-allogeneic haematopoietic progenitor cell transplantation (HPCT); however, the impact of mode of feeding on the gastrointestinal microbiome has not been explored. This study aimed to determine if there is a difference in the microbiome between patients receiving enteral nutrition (EN) and parenteral nutrition (PN) post-allogeneic HPCT. Twenty-three patients received either early EN or PN when required. Stool samples were collected at 30 days post-transplant and analysed with shotgun metagenomic sequencing. There was no difference in microbial diversity between patients who received predominantly EN (n = 13) vs. PN (n = 10) however patients who received predominantly EN had greater abundance of Faecalibacterium (P < 0·001) and ruminococcus E bromii (P = 0·026). Patients who had minimal oral intake for a longer duration during provision of nutrition support had a different overall microbial profile (P = 0·044), lower microbial diversity (P = 0·004) and lower abundance of faecalibacterium prausnitzii_C (P = 0·030) and Blautia (P = 0·007) compared to patients with greater oral intake. Lower microbial diversity was found in patients who received additional beta lactam antibiotics (P = 0·042) or had a longer length of hospital stay (P = 0·019). Post-HPCT oral intake should be encouraged to maintain microbiota diversity and, if nutrition support is required, EN may promote a more optimal microbiota profile.

Nutrition support during allogeneic stem cell transplantation: evidence versus practice.

PURPOSE: Enteral (EN) or parenteral nutrition (PN) is frequently required during allogeneic haematopoietic progenitor cell transplantation (HPCT), however there is limited consensus on the appropriate mode and timing of nutrition support commencement. This study aimed to investigate current nutrition support practices in Australian allogeneic transplant units and explore barriers and enablers to the use of EN and PN. METHODS: All Australian adult allogeneic HPCT units were eligible to participate. A survey tool was developed, and phone interview with each unit dietitian was completed to explore current nutrition support and perceived barriers and enablers to provision of nutrition care. RESULTS: A total of 12 (100%) units agreed to participate. Six (50%) units reported using PN as standard care and six use EN routinely for one or more conditioning regimens. All units using EN place feeding tubes proactively with tolerance of EN reported at 50-95%. The most frequently reported barriers to the use of EN include perception of poor EN tolerance, medical team preference for PN, gastrointestinal symptoms and thrombocytopenia. Reported barriers to the use of PN include fluid overload, elevated liver enzymes, patient apprehension about PN commencement, medical team uncertainty if PN is required and patients approaching engraftment. CONCLUSION: There is wide variation in the mode and timing of nutrition support provided to patients undergoing allogeneic HPCT. Clinical guidelines should be updated to reflect recent findings on EN use and incorporate strategies to optimise EN tolerance. This will assist in standardising practice and facilitate evidence-based nutrition care.

Awareness, perceptions and practices regarding cancer-related malnutrition and sarcopenia: a survey of cancer clinicians.

PURPOSE: Cancer-related malnutrition and sarcopenia have severe negative consequences including reduced survival and reduced ability to complete treatment. This study aimed to determine the awareness, perceptions and practices of Australian oncology clinicians regarding malnutrition and sarcopenia in people with cancer. METHODS: A national cross-sectional survey of Australian cancer clinicians was undertaken between November 2018 and January 2019. The 30-item online purpose-designed survey was circulated through professional organizations and health services. RESULTS: The 111 participants represented dietetic (38%), nursing (34%), medical (14%) and other allied health (14%) clinicians. Overall, 86% and 88% clinicians were aware of accepted definitions of malnutrition and sarcopenia, respectively. Perception of responsibility for identification of these conditions varied across participants, although 93% agreed this was a component of their role. However, 21% and 43% of clinicians had limited or no confidence in their ability to identify malnutrition and sarcopenia, respectively. Common barriers to the identification and management of malnutrition were access to the tools or skills required and a lack of services to manage malnourished patients. Common barriers to identification of sarcopenia were lack of confidence and lack of services to manage sarcopenic patients. Enablers for identification and management of malnutrition and sarcopenia were variable; however, training and protocols for management ranked highly. CONCLUSION: While awareness of the importance of cancer-related malnutrition and sarcopenia are high, participants identified substantial barriers to delivering optimal nutrition care. Guidance at a national level is recommended to strengthen the approach to management of cancer-related malnutrition and sarcopenia.

Lean body mass change over 6 years is associated with dietary leucine intake in an older Danish population.

Higher protein intake, and particularly higher leucine intake, is associated with attenuated loss of lean body mass (LBM) over time in older individuals. Dietary leucine is thought to be a key mediator of anabolism. This study aimed to assess this relationship over 6 years among younger and older adult Danes. Dietary leucine intake was assessed at baseline and after 6 years in men and women, aged 35-65 years, participating in the Danish cohort of the WHO-MONICA (Multinational MONItoring of trends and determinants in CArdiovascular disease) study (n 368). Changes in LBM over the 6 years were measured by bioelectrical impedance using equations developed for this Danish population. The association between leucine and LBM changes was examined using multivariate linear regression and ANCOVA analyses adjusted for potential confounders. After adjustment for baseline LBM, sex, age, energy intake and physical activity, leucine intake was associated with LBM change in those older than 65 years (n 79), with no effect seen in those younger than 65 years. Older participants in the highest quartile of leucine intake (7·1 g/d) experienced LBM maintenance, whereas lower intakes were associated with LBM loss over 6 years (for trend: ß=0·434, P=0·03). Sensitivity analysis indicated no effect modification of sex or the presence of CVD. Greater leucine intake in conjunction with adequate total protein intake was associated with long-term LBM retention in a healthy older Danish population. This study corroborates findings from laboratory investigations in relation to protein and leucine intakes and LBM change. A more diverse and larger sample is needed for confirmation of these results.

Quality of life after early enteral feeding versus standard care for proven or suspected advanced epithelial ovarian cancer: Results from a randomised trial.

BACKGROUND: Malnutrition is common in patients with advanced epithelial ovarian cancer (EOC), and is associated with impaired quality of life (QoL), longer hospital stay and higher risk of treatment-related adverse events. This phase III multi-centre randomised clinical trial tested early enteral feeding versus standard care on postoperative QoL. METHODS: From 2009 to 2013, 109 patients requiring surgery for suspected advanced EOC, moderately to severely malnourished were enrolled at five sites across Queensland and randomised to intervention (n=53) or control (n=56) groups. Intervention involved intraoperative nasojejunal tube placement and enteral feeding until adequate oral intake could be maintained. Despite being randomised to intervention, 20 patients did not receive feeds (13 did not receive the feeding tube; 7 had it removed early). Control involved postoperative diet as tolerated. QoL was measured at baseline, 6weeks postoperatively and 30days after the third cycle of chemotherapy. The primary outcome measure was the difference in QoL between the intervention and the control group. Secondary endpoints included treatment-related adverse event occurrence, length of stay, postoperative services use, and nutritional status. RESULTS: Baseline characteristics were comparable between treatment groups. No significant difference in QoL was found between the groups at any time point. There was a trend towards better nutritional status in patients who received the intervention but the differences did not reach statistical significance except for the intention-to-treat analysis at 7days postoperatively (11.8 intervention vs. 13.8 control, p 0.04). CONCLUSION: Early enteral feeding did not significantly improve patients' QoL compared to standard of care but may improve nutritional status.

The muscle mass, omega-3, diet, exercise and lifestyle (MODEL) study - a randomised controlled trial for women who have completed breast cancer treatment.

BACKGROUND: Loss of lean body mass (LBM) is a common occurrence after treatment for breast cancer and is related to deleterious metabolic health outcomes [Clin Oncol, 22(4):281-288, 2010; Appl Physiol Nutr Metab, 34(5):950-956, 2009]. The aim of this research is to determine the effectiveness of long chain omega-3 fatty acids (LCn-3s) and exercise training alone, or in combination, in addressing LBM loss in breast cancer survivors. METHODS/DESIGN: A total of 153 women who have completed treatment for breast cancer in the last 12 months, with a Body Mass Index (BMI) of 20 to 35 kg/m2, will be randomly assigned to one of 3 groups: 3g/d LCn-3s (N-3), a 12-week nutrition and exercise education program plus olive oil (P-LC) or the education program plus LCn-3s (EX+N-3). Participants randomised to the education groups will be blinded to treatment, and will receive either olive oil placebo (OO+N-3) or LCn-3 provision, while the N-3 group will be open label. The education program includes nine 60-75 min sessions over 12 weeks that will involve breast cancer specific healthy eating advice, plus a supervised exercise session run as a resistance exercise circuit. They will also be advised to conduct the resistance training and aerobic training 5 to 7 days per week collectively. Outcome measures will be taken at baseline, 12-weeks and 24-weeks. The primary outcome is % change in LBM as measured by the air displacement plethysmograhy. Secondary outcomes include quality of life (FACT-B + 4) and inflammation (C-Reactive protein: CRP). Additional measures taken will be erythrocyte fatty acid analysis, fatigue, physical activity, menopausal symptoms, dietary intake, joint pain and function indices. DISCUSSION: This research will provide the first insight into the efficacy of LCn-3s alone or in combination with exercise in breast cancer survivors with regards to LBM and quality of life. In addition, this study is designed to improve evidence-based dietetic practice, and how specific dietary prescription may link with appropriate exercise interventions. TRIALS REGISTRATION: ACTRN12610001005044; and World Health Organisation Universal trial number: U1111-1116-8520.

Current Oncology Nutrition Care Practice in Southeast Asia: A Scoping Review.

Although evidence-based nutrition care is recommended for patients with cancer, current nutrition care practices provided by nutritionists and dietitians in Southeast Asian countries are not clearly reported. The aim of this scoping review was to describe nutritionists' and dietitians' current oncology nutrition care practice within Southeast Asia by identifying access to dietetic services, tools or strategies used in providing care, and barriers and enablers to implementing nutrition care practices. Five databases (Ovid MEDLINE, Global Health, Embase, Cochrane Central Register of Controlled Trials, and Proquest) were searched through structured search strategies, in addition to strategic searching of grey literature. A total of 4261 sources of evidence were retrieved. After full-text screening, 18 studies from Southeast Asian countries met the inclusion criteria and were included in this review. The provision and reporting of nutrition care practices provided by nutritionists and dietitians were limited. Access to dietetic services, including nutritional screening tools and reason to be referred, were varied within studies. Barriers and enablers to nutrition care provision were unique and related to each country's specific resources and guidelines. In summary, there was varied reporting of nutrition care practices provided to patients with cancer in Southeast Asia and a lack of clarity on the actual standardized processes. Future research is warranted to further explore the barriers and enablers to providing nutrition care by local nutritionists and dietitians in Southeast Asia.

Proactive enteral nutrition for patients undergoing allogeneic stem cell transplantation- implementation and clinical outcomes.

BACKGROUND/ OBJECTIVES: Nutrition support is frequently required post allogeneic haematopoietic progenitor cell transplantation (HPCT) however the tolerance of enteral nutrition (EN) can vary. This mixed methods study aimed to explore staff perceptions, barriers and enablers to the use of EN post HPCT and report the implementation and outcomes of a nutrition protocol. SUBJECT/ METHODS: A survey on barriers and enablers to the use of EN was developed and distributed to medical and nursing staff. Data on nutrition and clinical outcomes was collected for 12 months post implementation of a new nutrition protocol. RESULTS: Thirty staff completed the survey, key barriers identified included uncertain EN tolerance, lack of confidence in nasogastric tube placement and insufficient training and resources. Eighty-four patients commenced EN, 23 changed to PN (27%) and 61 received EN only (73%). In total 36 patients received PN and eight patients oral nutrition support only. There was a difference in type of conditioning (p = 0.025) and nutritional status (p = 0.016) between patients who received PN vs EN only, with a higher proportion of malnourished patients receiving PN (23% vs 5%). Patients who received PN had a longer length of hospital stay (median 22 vs 19 days, p = 0.012) and lower rate of survival to day 100 (81% vs 95%, p = 0.036) than patients who received EN. CONCLUSION: The use of EN may lead to improved clinical outcomes compared to PN therefore should be implemented as first line nutrition support.

Incidence and outcomes of in-hospital nutritional decline: A prospective observational cohort study in adult patients.

BACKGROUND AND AIMS: Hospital malnutrition is associated with higher healthcare costs and worse outcomes. Only a few prospective studies have evaluated trends in nutritional status during an acute stay, but these studies were limited by the short timeframe between nutrition assessments. The aim of this study was to investigate changes in nutritional status, incidence of hospital-acquired malnutrition (HAM), and the associated risk factors and outcomes in acute adult patients admitted for >14 days. METHODS: A prospective observational cohort study was conducted in two medical and two surgical wards in a tertiary hospital in Brisbane, Australia. Nutrition assessments were performed using the Subjective Global Assessment at baseline (day eight) and weekly until discharge. Nutritional decline was defined as a change from well-nourished to moderate/severe malnutrition (HAM) or from moderate to severe malnutrition (further decline) >14 days after admission. RESULTS: One hundred and thirty patients were included in this study (58.5% male; median age 67.0 years (IQR 24.4), median length of stay 23.5 days (IQR 14)). At baseline, 70.8% (92/130) of patients were well-nourished. Nutritional decline occurred in 23.8% (31/130), with 28.3% (26/92) experiencing HAM. Of the patients with moderate malnutrition on admission (n = 30), 16% (5/30) continued to decline to severe malnutrition. Improvement in nutritional status from moderate and severe malnutrition to well-nourished was 18.4% (7/38). Not being prescribed the correct nutrition care plan within the first week of admission was an independent predictor of in-hospital nutritional decline or remaining malnourished (OR 2.3 (95% CI 1.0-5.1), p = 0.039). In-hospital nutritional decline was significantly associated with other hospital-acquired complications (OR 3.07 (95% CI 1.1-8.9), p = 0.04) and longer length of stay (HR 0.63 (95% CI 0.4-0.9), p = 0.044). CONCLUSION: This study found a high rate of nutritional decline in acute patients, highlighting the importance of repeated nutrition screening and assessments during hospital admission and proactive interdisciplinary nutrition care to treat or prevent further nutritional decline.

A Conceptual Study on Characterizing the Complexity of Nutritional Interventions for Malnourished Older Adults in Hospital Settings: An Umbrella Review Approach.

INTRODUCTION: Malnutrition is a widespread and intricate issue among hospitalized adults, necessitating a wide variety of nutritional strategies to address its root causes and repercussions. The primary objective of this study is to systematically categorize nutritional interventions into simple or complex, based on their resource allocation, strategies employed, and predictors of intervention complexity in the context of adult malnutrition in hospital settings. METHODS: A conceptual evaluation of 100 nutritional intervention studies for adult malnutrition was conducted based on data from a recent umbrella review (patient population of mean age > 60 years). The complexity of interventions was categorized using the Medical Research Council 2021 Framework for Complex Interventions. A logistic regression analysis was employed to recognize variables predicting the complexity of interventions. RESULTS: Interventions were divided into three principal categories: education and training (ET), exogenous nutrient provision (EN), and environment and services (ES). Most interventions (66%) addressed two or more of these areas. A majority of interventions were delivered in a hospital (n = 75) or a hospital-to-community setting (n = 25), with 64 studies being classified as complex interventions. The logistic regression analysis revealed three variables associated with intervention complexity: the number of strategies utilized, the targeted areas, and the involvement of healthcare professionals. Complex interventions were more likely to be tailored to individual needs and engage multiple healthcare providers. CONCLUSIONS: The study underlines the importance of considering intervention complexity in addressing adult malnutrition. Findings advocate for a comprehensive approach to characterizing and evaluating nutritional interventions in future research. Subsequent investigations should explore optimal balances between intervention complexity and resource allocation, and assess the effectiveness of complex interventions across various settings, while considering novel approaches like telehealth.

A Cost-Consequence Analysis of Nutritional Interventions Used in Hospital Settings for Older Adults with or at Risk of Malnutrition.

BACKGROUND: Malnutrition is a significant and prevalent issue in hospital settings, associated with increased morbidity and mortality, longer hospital stays, higher readmission rates, and greater healthcare costs. Despite the potential impact of nutritional interventions on patient outcomes, there is a paucity of research focusing on their economic evaluation in the hospital setting. This study aims to fill this gap by conducting a cost-consequence analysis (CCA) of nutritional interventions targeting malnutrition in the hospital setting. METHODS: We performed a CCA using data from recent systematic reviews and meta-analyses, focusing on older adult patients with or at risk of malnutrition in the hospital setting. The analysis included outcomes such as 30-day, 6-month, and 12-month mortality; 30-day and 6-month readmissions; hospital complications; length of stay; and disability-adjusted life years (DALYs). Sensitivity analyses were conducted to evaluate the impact of varying success rates in treating malnutrition and the proportions of malnourished patients seen by dietitians in SingHealth institutions. RESULTS: The CCA indicated that 28.15 DALYs were averted across three SingHealth institutions due to the successful treatment or prevention of malnutrition by dietitians from 1 April 2021 to 31 March 2022, for an estimated 45,000 patients. The sensitivity analyses showed that the total DALYs averted ranged from 21.98 (53% success rate) to 40.03 (100% of malnourished patients seen by dietitians). The cost of implementing a complex nutritional intervention was USD 218.72 (USD 104.59, USD 478.40) per patient during hospitalization, with additional costs of USD 814.27 (USD 397.69, USD 1212.74) when the intervention was extended for three months post-discharge and USD 638.77 (USD 602.05, USD 1185.90) for concurrent therapy or exercise interventions. CONCLUSION: Nutritional interventions targeting malnutrition in hospital settings can have significant clinical and economic benefits. The CCA provides valuable insights into the costs and outcomes associated with these interventions, helping healthcare providers and policymakers to make informed decisions on resource allocation and intervention prioritization.

Five-Year Mortality Outcomes for Eating As Treatment (EAT), a Health Behavior Change Intervention to Improve Nutrition in Patients With Head and Neck Cancer: A Stepped-Wedge, Randomized Controlled Trial.

PURPOSE: Malnutrition affects up to 80% of patients with head and neck cancer (HNC) and is associated with higher burden of disease, poorer treatment outcomes, and greater mortality. The Eating As Treatment (EAT) intervention is a behavioral intervention previously demonstrated to be effective in improving nutritional status, depression, and quality of life in patients with HNC. This article examines the effects of the EAT intervention on 5-year mortality among participants. METHODS AND MATERIALS: A multicenter, stepped-wedge, randomized controlled trial was conducted in 5 Australian hospitals. Dietitians were trained to deliver EAT, a combination of motivational interviewing and cognitive behavior therapy strategies, to patients with HNC receiving radiation therapy. Secondary analyses of survival benefit on an intention-to-treat basis were performed. Differences in proportions of 5-year all-cause mortality between the control and EAT intervention arms were analyzed using multivariable logistic regression, and 5-year survival rates were analyzed using Cox proportional hazards regression. Analyses controlled for temporal effects (study duration), hospital site (clustering), and baseline nutritional status differences. RESULTS: Overall, there were 64 deaths in the 5 years after enrollment, 36 (24%) among those assigned to the control condition and 28 (18%) among those assigned to EAT. Logistic regression showed statistically significant reduced odds in favor of EAT (odds ratio, 0.33; 95% CI, 0.11-0.96), with an absolute risk reduction of 17% (95% CI, 0.01-0.33) and a relative risk reduction of 55% (95% CI, 0.22-0.92), resulting in a number needed to treat of 6 (95% CI, 4-13). Survival analysis revealed that risk of death was significantly reduced by the EAT intervention (hazard ratio, 0.39; 0.16-0.96). CONCLUSIONS: Participation in EAT provided a statistically and clinically meaningful survival benefit, likely via improved nutrition during radiation therapy. This survival benefit strengthens the finding of the main trial, showing that a behavioral intervention focused on nutrition could improve HNC outcomes. Replication studies using stepped-wedge designs for implementation into clinical practice may be warranted.

Dietetics student contribution to addressing malnutrition in residential aged care facilities.

AIMS: To test a model of malnutrition screening and assessment conducted by dietetics students on placement in residential aged care facilities. The secondary aim was to identify possible facilitators and barriers to the implementation of the model. METHOD: The type 1 hybrid effectiveness-implementation trial study design and reporting outcomes were developed using the Consolidated Framework for Implementation Research. An innovative placement model was developed, where students on voluntary placement visited three residential aged care facilities to identify residents at risk of malnutrition using currently available screening tools for older people. Students completed malnutrition assessments for all residents using the subjective global assessment tool. RESULTS: Thirty-two students participated; 31 completed all three sessions, with malnutrition screening completed for 207 residents and malnutrition assessment for 187 residents (July and September 2022). Based on the subjective global assessment, 31% (n = 57) of residents were mildly/moderately malnourished, and 3% (n = 5) were severely malnourished. The Innovation Domain of the Framework was the most important consideration before implementation. CONCLUSION: Whilst previous research documented student learning opportunities in residential aged care facilities, this study provides the first available evidence of the direct contribution students can make to the health of aged care residents through malnutrition screening and assessment. The model enables students to conduct malnutrition screening and assessment feasibly and efficiently in facilities that do not routinely collate and act on these data. With a limited nursing aged care workforce to undertake this vital task, the potential role of student dietitians to fulfil this role must be considered.

Omega-3 fatty acids and changes in LBM: alone or in synergy for better muscle health?

Myopenia or muscle wasting due to ageing, chronic disease, and various medical interventions has been associated with increased mortality, morbidity, and poorer physical function. Attempts through nutrient and exercise interventions have been made to prevent this deterioration. In addition, while a measure of lean body mass (LBM) is associated with health outcomes, LBM function may be a better prognostic tool. Long-chain omega-3 fatty acids (LCn-3s) are nutrients that may mitigate LBM losses in noncancer populations. The purpose of this review is to determine whether LCn-3s have a role in LBM sparing in noncancer populations, to establish a minimum dose and duration of LCn-3s that will result in LBM change, and to summarise the potential effects of LCn-3s on LBM function when combined with an anabolic stimulus. Overall, in noncancer populations, LCn-3s have limited utility in sparing LBM during energy balance, energy restriction, or in conjunction with aerobic exercise. Further investigations are required to determine the appropriate dose and duration of LCn-3s for optimal LBM function. Finally, compelling evidence exists for LCn-3s in conjunction with an anabolic stimulus to improve LBM function and quality. Functionality of LBM tissue is an important outcome for population health, and LCn-3s show some promise, albeit pending further study.