A scoping review exploring the role of the dietitian in the identification and management of eating disorders and disordered eating in adolescents and adults with type 1 diabetes mellitus.

BACKGROUND: Eating disorder diagnoses and disordered eating behaviours are more prevalent in people living with Type 1 Diabetes Mellitus, in particular in adolescents. The role of the dietitian in this setting is not clearly outlined in the literature. AIM: This scoping review aims to outline the available information for the role of the dietitian in identifying and managing eating disorders in adolescents and adults with co-occurring Type 1 Diabetes Mellitus (T1DM) in a clinical setting. METHODS: The Johanna Briggs Institute was utilised to guide this scoping review and to develop a search strategy for relevant databases. Relevant organisations and societies websites and professional magazines were reviewed as part of the grey literature search. RESULTS: 38 peer reviewed journal articles, 5 professional articles, 5 book chapters and 11 clinical guidelines were included in this scoping review. Roles for the dietitian in identification, prevention and screening for eating disorders in Type 1 Diabetes Mellitus were identified and outlined in a visual workflow. The role of the dietitian in the management of eating disorder in both the outpatient/community and inpatient setting and as core member of the multidisciplinary team was detailed in the literature. CONCLUSION: This scoping review mapped the available information in the current literature on the role of the dietitian in the identification and management of eating disorders and disordered eating in adolescents and adults with a dual diagnosis of T1DM. The reviewed literature suggests there is a strong reliance on expert opinion and practice to inform the role of the dietitian. Further research is required in order to ensure more robust evidence-based practice in this area.

A comparison of a home parenteral nutrition service with the current European (ESPEN) guidelines on chronic intestinal failure in adults.

BACKGROUND & AIMS: Comprehensive evidenced based guidelines on appropriate and safe provision of home parenteral nutrition (HPN) have been developed by the European Society for Clinical Nutrition and Metabolism (ESPEN) in 2016 and 2020. These guidelines provide clinical standards of care against which the current practice of HPN services can be audited. The aim of this study was to audit a single center's current practice against 183 recommendations on supporting patients on HPN. The objective was to measure compliance and identify areas for quality improvement. METHODS: A retrospective audit of the HPN service received by patients from January 2019-May 2021 was conducted. The ESPEN guidelines were used as a benchmark to measure compliance of healthcare practice. Compliance was evaluated for the 13 subject areas included in the 2016 guideline and the 6 subject areas included in the 2020 guideline. Compliance was calculated as the percentage of criteria fully met for each subject area and an overall compliance rate with each guideline. RESULTS: Overall, compliance with the recommendations from 2016 was 80% and compliance with the recommendations from 2020 was 65%. Within the 2020 guideline there were 24 recommendations where noncompliance was found, 15 of these were due to the absence of a nutrition support team and dedicated intestinal failure unit. CONCLUSION: This audit and evaluation of current practice has identified areas of good evidence-based healthcare practice providing HPN. However, the absence of funding of a nutrition support team to provide a service to patients on HPN was identified as a major barrier to compliance with ESPEN recommendations in this study.

An evaluation of adherence to folic acid supplementation in pregnant women during early gestation for the prevention of neural tube defects.

OBJECTIVE: Neural tube defects (NTD) are potentially preventable by periconceptual folic acid supplementation. Women with obesity are at higher risk of NTD, therefore, are recommended a higher dose of 5 mg folic acid to mitigate this risk. The aim of this study was to evaluate maternal practice of folic acid supplementation amongst the antenatal population in relation to maternal obesity status. DESIGN: Prospective observational study. SETTING: Women ≤18 weeks' gestation at their first antenatal appointment attending University Maternity Hospital Limerick (Ireland) were recruited. Maternal height and weight were measured. Obesity was defined at a threshold of ≥30·0 kg/m2 and ≥27·5 kg/m2 when adjusting for ethnicity. A two-part questionnaire captured maternal characteristics and assessed supplementation compliance, commencement and dosage. Fisher's exact test for independence analysed differences in variables. A P value of <0·05 was considered significant. PARTICIPANTS: A total of 328 women participated over a duration of 6 weeks. RESULTS: Mean gestational age was 12·4 ± 1·4 weeks and mean BMI 26·7 kg/m2 ± 5·2 kg/m2. 23·8 % (n 78) were classified as obese. 96·5 % (n 315) were taking folic acid and 95·7 % (n 314) supplemented daily. 30·2 % (n 99) commenced supplementation 12 weeks prior to conception. Overall, 57·9 % (n 190) of women met folic acid supplementation dose requirements. 89·1 % (n 55) of women with obesity did not. Women with obesity were less likely to meet the higher folic acid supplementation dose requirements (P =< 0·001). CONCLUSION: Folic acid supplementation practices within this cohort were suboptimal to prevent their risk of NTD. This study showed inadequate compliance of folic acid supplementation, and inadequate dosage for women with obesity. Increased patient education and awareness are needed within the antenatal period of pregnancy to bring folic acid supplementation practices in line with best practice guidelines.

The influence of lactation and its duration on bone mineral density in pregnancy and postpartum: A systematic review with meta-analysis.

BACKGROUND: There is a plethora of research on the association of parity and duration of lactation with bone mineral density (BMD) during and after pregnancy. However, there are no consensus conclusions on the impact of the duration of lactation on BMD. AIMS: The aim of this study was to examine the effect of pregnancy, and the duration of lactation on BMD during pregnancy, postpartum phase and 12 months post-delivery. METHODS: The search terms 'parity' 'lactation' 'BMD' were searched for using PubMed, CINAHL, SCOPUS and EMBASE databases in English language. Two independent reviewers assessed the quality of the included studies using Critical Appraisal Skills Program (CASP) appraisal tool and extracted data on BMD (g/cm2) in Excel. A meta-analysis was conducted with a random effect model using Cochrane Review Manager (Rev 5.4) to analyse the outcome. Heterogeneity was assessed with Chi Squared and I2 test. The duration of lactation was grouped into short lactation duration (SLD), ≤4 months and longer lactation duration (LLD) > 6 months. RESULTS: Twenty-one studies were included in this review with four studies included in the meta-analysis. BMD reduced during pregnancy and lactation. Recovery and net gains in BMD followed weaning. However, at 12 months postpartum, women in the LLD group had significant losses at the lumbar spine while those in the SLD recovered BMD. Between the SLD and LLD groups, the change in BMD was not significant 0.48 g/cm2 (95% CI -0.14, 1.10, p = 0.13). BMD losses were greater in primiparous women than multiparous women. CONCLUSION: Women who breastfed for >6 months had significantly reduced BMD. However, compared to women that breastfed for a ≤4 months there was no significant change in BMD. Further investigation is needed to clarify the association between lactation and BMD in a postpartum population in those women extending breastfeeding beyond one year.

A risk-prediction model using parameters of maternal body composition to identify gestational diabetes mellitus in early pregnancy.

BACKGROUND: Accurate early risk-prediction for gestational diabetes mellitus (GDM) would target intervention and prevention in women at the highest risk. We evaluated maternal risk-factors and parameters of body-composition to develop a prediction model for GDM in early gestation. METHODS: A prospective observational study was undertaken. Pregnant women aged between 18 and 50 y of age with gestational age between 10 and 16 weeks were included in the study. Women aged ≤18 y, twin-pregnancies, known foetal anomaly or pre-existing condition affecting oedema status were excluded. 8-point-skinfold thickness (SFT), mid-upper-arm-circumference (MUAC), waist, hip, weight and ultrasound measurements of subcutaneous (SAT) and visceral abdominal-adipose (VAT) were measured. Oral-glucose-tolerance-test (OGTT) for GDM diagnosis was undertaken at 28 weeks gestation. Binomial logistic-regression models were used to predict GDM. ROC-analysis determined discrimination and concordance of model and individual variables. RESULTS: 188 women underwent OGTT at ~28 weeks gestation. 20 women developed GDM. BMI (24.7 kg m-2 (±6.1), 29.9 kg m-2 (±7.8), p = 0.022), abdominal SAT(1.32 cm (CI 1.31, 1.53), 1.99 cm (CI 1.64, 2.31), p = 0.027), abdominal VAT(0.78 cm (CI 0.8, 0.96), 1.41 cm (CI 1.11, 1.65), p = 0.002), truncal SFT (84.8 mm (CI 88.2, 101.6), 130.4 mm (CI 105.1, 140.1), p = 0.010), waist (79.8 cm (CI 80.3, 84.1), 90.3 cm (CI 85.9, 96.2), p = 0.006) and gluteal hip (94.3 cm (CI 93.9, 98.0), 108.6 cm (CI 99.9, 111.6), p = 0.023) were higher in GDM vs. non-GDM. After screening variables for inclusion into the multivariate model, family history of diabetes, previous perinatal death, overall insulin resistant condition, abdominal SAT and VAT, 8-point SFT, MUAC and weight were included. The combined multivariate prediction model achieved an excellent level of discrimination, with an AUC of 0.860 (CI 0.774, 0.945) for GDM. CONCLUSIONS: An early gestation risk prediction model, incorporating known risk-factors, and parameters of body-composition, accurately identify pregnant women in their first-trimester who developed GDM later on in gestation. This methodology could be used clinically to identify at-risk pregnancies, and target specific treatment through referred services to those mothers who would most benefit.

Maternal obesity and degree of glucose intolerance on neonatal hypoglycaemia and birth weight: a retrospective observational cohort study in women with gestational diabetes mellitus.

Gestational diabetes mellitus (GDM) is an increasing problem worldwide. Postnatal hypoglycaemia and excess foetal growth are known important metabolic complications of neonates born to women with diabetes. This retrospective cohort study aims to determine the influence of obesity and glucose intolerance on neonatal hypoglycaemia and birth weight over the 90th percentile (LGA). Data were abstracted from 303 patient medical records from singleton pregnancies diagnosed with GDM. Data were recorded during routine hospital visits. Demographic data were acquired by facilitated questionnaires and anthropometrics measured at the first antenatal appointment. Blood biochemical indices were recorded. Plasma glucose area under the curve (PG-AUC) was calculated from OGTT results as an index of glucose intolerance. OGTT results of 303 pregnant women aged between 33.6 years (29.8-37.7) diagnosed with GDM were described. Neonates of mothers with a BMI of over 30 kg/m2 were more likely to experience neonatal hypoglycaemia (24 (9.2%) vs. 23 (8.8%), p = 0.016) with odds ratio for neonatal hypoglycaemia significantly higher at 2.105, 95% CI (1.108, 4.00), p = 0.023. ROC analysis showed poor strength of association (0.587 (95% CI, .487 to .687). Neonatal LGA was neither associated with or predicted by PG-AUC nor obesity; however, multiparous women were 2.8 (95% CI (1.14, 6.78), p = 0.024) times more likely to have a baby born LGA.Conclusion: Maternal obesity but not degree of glucose intolerance increased occurrence of neonatal hypoglycaemia. Multiparous women had greater risk of neonates born LGA.What is Known:•Excess foetal growth in utero has long-term metabolic implications which track into adulthood.•Neonatal hypoglycaemia is detrimental to newborns in the acute phase with potential long-term implications on the central nervous system.What is New:•Maternal obesity but not degree of glucose intolerance in a GDM cohort increased occurrence of neonatal hypoglycaemia.•Multiparous women diagnosed had greater risk of neonates born LGA.

Inter and intra-reliability of ultrasonography for the measurement of abdominal subcutaneous & visceral adipose tissue thickness at 12 weeks gestation.

BACKGROUND: Excess abdominal adiposity cause metabolic disturbances, particularly in pregnancy. Methods of accurate measurement are limited in pregnancy due to risks associated with these procedures. This study outlines a non-invasive methodology for the measurement of adipose tissue in pregnancy and determines the intra- and inter-observer reliability of ultrasound (US) measurements of the two components of adipose tissue (subcutaneous (SAT) and visceral adipose tissue (VAT)) within a pregnant population. METHODS: Thirty pregnant women were recruited at the end of their first trimester, from routine antenatal clinic at the University Maternity Hospital Limerick, Ireland. Measurements of adipose tissue thickness were obtained using a GE Voluson E8 employing a 1-5 MHz curvilinear array transducer. Two observers, employing methodological rigour in US technique, measured thickness of adipose tissue three times, and segmented the US image systematically in order to define measurements of SAT and VAT using specifically pre-defined anatomical landmarks. RESULTS: Intra-observer and inter-observer precision was assessed using Coefficient of Variation (CV). Measurements of SAT and total adipose for both observers were < 5% CV and < 10% CV for VAT in measures by both observers. Inter-observer reliability was assessed by Limits of Agreement (LoA). LoA were determined to be - 0.45 to 0.46 cm for SAT and - 0.34 to 0.53 cm for VAT values. Systematic bias of SAT measurement was 0.01 cm and 0.10 cm for VAT. Inter-observer precision was also assessed by coefficient of variation (CV: SAT, 3.1%; VAT, 7.2%; Total adipose, 3.0%). CONCLUSION: Intra-observer precision was found to be acceptable for measures of SAT, VAT and total adipose according to anthropometric criterion, with higher precision reported in SAT values than in VAT. Inter-observer reliability assessed by Limits-Of-Agreement (LoA) confirm anthropometrically reliable to 0.5 cm. Systematic bias was minimal for both measures, falling within 95% confidence intervals. These results suggest that US can produce reliable, repeatable and accurate measures of SAT and VAT during pregnancy.

Body composition analysis of inter-county Gaelic athletic association players measured by dual energy X-ray absorptiometry.

Gaelic Football and Hurling are two sporting codes within the Gaelic Athletic Association. The purpose of this study was to report the body composition phenotype of inter-county Gaelic athletic association players, comparing groups by code and field position. 190 senior, male, outfield inter-county players (144 hurlers and 46 Gaelic footballers) were recruited. Stature and body mass was measured, estimates of three components of body composition, i.e., lean mass, fat mass and bone mineral content was obtained by dual energy X-ray absorptiometry (DXA), and normative data for Gaelic athletic association athletes by code and position was compared. Other than in the midfield, there was limited difference in body composition between codes or playing position. Stature-corrected indices nullified any existing group differences between midfielders for both codes. Further comparisons with a non-athletic control group (n = 431) showed no difference for body mass index (BMI); however, the athletic group has a lower fat mass index, with a greater lean mass in accounting for the matched BMI between groups. In addition to providing previously unknown normative data for the Gaelic athletic association athlete, a proportional and independent tissue evaluation of body composition is given.