Nutritional considerations for the management of the older person with hepato-pancreatico-biliary malignancy.

Malnutrition and cancer cachexia are prevalent in older people with hepato-pancreatico-biliary (HPB) malignancy, with the resultant loss of muscle mass and function accelerating normal age-associated losses. Unintentional weight loss may be missed in patients with pre-illness obesity, delaying diagnosis and limiting treatment potential and access. Sarcopenia and/or sarcopenic obesity increase the risk of dose-limiting chemotherapy toxicity, post-operative mortality and overall survival. The aetiology of malnutrition and weight loss is multi-factorial in patients with HPB malignancy, necessitating systematic evaluation of endocrine and exocrine function, and multi-modal therapeutic strategies. Prehabilitation aims to reduce the complications and side effects associated with treatment, aid recovery and improve quality of life, with the greatest benefits potentially being seen in high risk groups, such as people who are older and frail. Post-operatively, individualised nutritional support therapies targeting the preservation of weight and muscle indices are required to improve post-operative morbidity, and avoid delay or early cessation of any necessary adjuvant therapy.

Nutrition assessment in process-driven, personalized dietetic intervention - The potential importance of assessing behavioural components to improve behavioural change: Results of the EU-funded IMPECD project.

BACKGROUND & AIMS: Although up-to-date definitions for nutrition assessment integrate behavioural components, it is not clear what behavioural components are to be assessed. Since behavioural modification is linked to effective therapeutic dietetic interventions, assessing behaviour and factors influencing behaviour might be beneficial to improve personalized dietetic outcome. The aim of the following report is to emphasize the role of behavioural components and factors affecting behaviour at baseline nutrition assessment in personalized dietetic intervention. METHODS: The present work is part of the EU-funded project IMPECD ("Improvement of Education and Competences in Dietetics", www.impecd.eu). The project aims to improve the clarity and consistency of national dietetic process models to unify education and training of future dietitians. Experts from five European Universities of Applied Sciences (UAS) in Antwerp (BE), Fulda (DE), Groningen (NL), Neubrandenburg (DE) and St. Pölten (AT) developed a Massive Open Online Course (MOOC) consisting of several clinical cases. It warranted a detailed evaluation of all dietetic care process steps, starting with nutrition assessment. RESULTS: Results for motivation assessed during nutrition assessment are not consistently positively associated with outcome and the added value of assessing them at baseline is still unclear. However, depressive symptoms, emotional distress, and anxiety negatively affect eating and physical activity and therefore limit the efficacy of the dietetic intervention. Assessing behavioural components including nutrition literacy is an important precondition for influence on behavioural modification. CONCLUSION: Indisputably, baseline assessment of behavioural components and factors influencing behaviour are important to increase the therapeutic efficacy of personalized dietetic interventions.

Nutrition literacy predicts adherence to healthy/unhealthy diet patterns in adults with a nutrition-related chronic condition.

OBJECTIVE: To describe the relationship between adherence to distinct dietary patterns and nutrition literacy. DESIGN: We identified distinct dietary patterns using principal covariates regression (PCovR) and principal components analysis (PCA) from the Diet History Questionnaire II. Nutrition literacy was assessed using the Nutrition Literacy Assessment Instrument (NLit). Cross-sectional relationships between dietary pattern adherence and global and domain-specific NLit scores were tested by multiple linear regression. Mean differences in diet pattern adherence among three predefined nutrition literacy performance categories were tested by ANOVA. SETTING: Metropolitan Kansas City, USA. PARTICIPANTS: Adults (n 386) with at least one of four diet-related diseases. RESULTS: Three diet patterns of interest were derived: a PCovR prudent pattern and PCA-derived Western and Mediterranean patterns. After controlling for age, sex, BMI, race, household income, education level and diabetes status, PCovR prudent pattern adherence positively related to global NLit score (P < 0·001, ß = 0·36), indicating more intake of prudent diet foods with improved nutrition literacy. Validating the PCovR findings, PCA Western pattern adherence inversely related to global NLit (P = 0·003, ß = -0·13) while PCA Mediterranean pattern positively related to global NLit (P = 0·02, ß = 0·12). Using predefined cut points, those with poor nutrition literacy consumed more foods associated with the Western diet (fried foods, sugar-sweetened beverages, red meat, processed foods) while those with good nutrition literacy consumed more foods associated with prudent and Mediterranean diets (vegetables, olive oil, nuts). CONCLUSIONS: Nutrition literacy predicted adherence to healthy/unhealthy diet patterns. These findings warrant future research to determine if improving nutrition literacy effectively improves eating patterns.

Community involvement in design, implementation and evaluation of nutrition interventions to reduce chronic diseases in indigenous populations in the U.S.: a systematic review.

BACKGROUND: Indigenous peoples of the United States disproportionately experience chronic diseases associated with poor nutrition, including obesity and diabetes. While chronic disease related health disparities among Indigenous people are well documented, it is unknown whether interventions adequately address these health disparities. In addition, it is unknown whether and to what extent interventions are culturally adapted or tailored to the unique culture, worldview and nutrition environments of Indigenous people. The aim of this review was to identify and characterize nutrition interventions conducted with Indigenous populations in the US, and to determine whether and to what degree communities are involved in intervention design, implementation and evaluation. METHODS: Peer-reviewed articles were identified using MEDLINE. Articles included were published in English in a refereed journal between 2000 and 2015, reported on a diet-related intervention in Indigenous populations in the US, and reported outcome data. Data extracted were program objectives and activities, target population, geographic region, formative research to inform design and evaluation, partnership, capacity building, involvement of the local food system, and outcomes. Narrative synthesis of intervention characteristics and the degree and type of community involvement was performed. RESULTS: Of 1060 records identified, 49 studies were included. Overall, interventions were successful in producing changes in knowledge, behavior or health (79%). Interventions mostly targeted adults in the Western region and used a pre-test, post-test design. Involvement of communities in intervention design, implementation, and evaluation varied from not at all to involvement at all stages. Of programs reporting significant changes in outcomes, more than half used at least three strategies to engage communities. However, formative research to inform the evaluation was not performed to a great degree, and fewer than half of the programs identified described involvement of the local food system. CONCLUSIONS: The extent of use of strategies to promote community engagement in programs reporting significant outcomes is notable. In planning interventions in Indigenous groups, researchers should consider ways to involve the community in intervention design, execution and evaluation. There is a particular need for studies focused on Indigenous youth in diverse regions of the US to further address diet-related chronic conditions.

Environmental and behavioural modifications for improving food and fluid intake in people with dementia.

BACKGROUND: Weight loss, malnutrition and dehydration are common problems for people with dementia. Environmental modifications such as, change of routine, context or ambience at mealtimes, or behavioural modifications, such as education or training of people with dementia or caregivers, may be considered to try to improve food and fluid intake and nutritional status of people with dementia. OBJECTIVES: Primary: To assess the effects of environmental or behavioural modifications on food and fluid intake and nutritional status in people with dementia. Secondary: To assess the effects of environmental or behavioural modifications in connection with nutrition on mealtime behaviour, cognitive and functional outcomes and quality of life, in specific settings (i.e. home care, residential care and nursing home care) for different stages of dementia. To assess the adverse consequences or effects of the included interventions. SEARCH METHODS: We searched the Specialized Register of Cochrane Dementia and Cognitive Improvement (ALOIS), MEDLINE, Eembase, PsycINFO, CINAHL, ClinicalTrials.gov and the World Health Organization (WHO) portal/ICTRP on 17 January 2018. We scanned reference lists of other reviews and of included articles. SELECTION CRITERIA: We included randomised controlled trials (RCTs) investigating interventions designed to modify the mealtime environment of people with dementia, to modify the mealtime behaviour of people with dementia or their caregivers, or both, with the intention of improving food and fluid intake. We included people with any common dementia subtype. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, extracted data and assessed the risk of bias of included trials. We assessed the quality of evidence for each outcome using the GRADE approach. MAIN RESULTS: We included nine studies, investigating 1502 people. Three studies explicitly investigated participants with Alzheimer's disease; six did not specify the type of dementia. Five studies provided clear measures to identify the severity of dementia at baseline, and overall very mild to severe stages were covered. The interventions and outcome measures were diverse. The overall quality of evidence was mainly low to very low.One study implemented environmental as well as behavioural modifications by providing additional food items between meals and personal encouragement to consume them. The control group received no intervention. Differences between groups were very small and the quality of the evidence from this study was very low, so we are very uncertain of any effect of this intervention.The remaining eight studies implemented behavioural modifications.Three studies provided nutritional education and nutrition promotion programmes. Control groups did not receive these programmes. After 12 months, the intervention group showed slightly higher protein intake per day (mean difference (MD) 0.11 g/kg, 95% confidence interval (CI) -0.01 to 0.23; n = 78, 1 study; low-quality evidence), but there was no clear evidence of a difference in nutritional status assessed with body mass index (BMI) (MD -0.26 kg/m² favouring control, 95% CI -0.70 to 0.19; n = 734, 2 studies; moderate-quality evidence), body weight (MD -1.60 kg favouring control, 95% CI -3.47 to 0.27; n = 656, 1 study; moderate-quality evidence), or score on Mini Nutritional Assessment (MNA) (MD -0.10 favouring control, 95% CI -0.67 to 0.47; n = 656, 1 study; low-quality evidence). After six months, the intervention group in one study had slightly lower BMI (MD -1.79 kg/m² favouring control, 95% CI -1.28 to -2.30; n = 52, 1 study; moderate-quality evidence) and body weight (MD -8.11 kg favouring control, 95% CI -2.06 to -12.56; n = 52, 1 study; moderate-quality evidence). This type of intervention may have a small positive effect on food intake, but little or no effect, or a negative effect, on nutritional status.Two studies compared self-feeding skills training programmes. In one study, the control group received no training and in the other study the control group received a different self-feeding skills training programme. For both comparisons the quality of the evidence was very low and we are very uncertain whether these interventions have any effect.One study investigated general training of nurses to impart knowledge on how to feed people with dementia and improve attitudes towards people with dementia. Again, the quality of the evidence was very low so that we cannot be certain of any effect.Two studies investigated vocal or tactile positive feedback provided by caregivers while feeding participants. After three weeks, the intervention group showed an increase in calories consumed per meal (MD 200 kcal, 95% CI 119.81 to 280.19; n = 42, 1 study; low-quality evidence) and protein consumed per meal (MD 15g, 95% CI 7.74 to 22.26; n = 42, 1 study; low-quality evidence). This intervention may increase the intake of food and liquids slightly; nutritional status was not assessed. AUTHORS' CONCLUSIONS: Due to the quantity and quality of the evidence currently available, we cannot identify any specific environmental or behavioural modifications for improving food and fluid intake in people with dementia.

Emerging concepts on the role of epigenetics in the relationships between nutrition and health.

Understanding the physiological and metabolic underpinnings that confer individual differences in responses to diet and diet-related chronic disease is essential to advance the field of nutrition. This includes elucidating the differences in gene expression that are mediated through programming of the genome through epigenetic chromatin modifications. Epigenetic landscapes are influenced by age, genetics, toxins and other environmental factors, including dietary exposures and nutritional status. Epigenetic modifications influence transcription and genome stability are established during development with life-long consequences. They can be inherited from one generation to the next. The covalent modifications of chromatin, which include methylation and acetylation, on DNA nucleotide bases, histone proteins and RNA are derived from intermediates of one-carbon metabolism and central metabolism. They influence key physiological processes throughout life, and together with inherited DNA primary sequence, contribute to responsiveness to environmental stresses, diet and risk for age-related chronic disease. Revealing diet-epigenetic relationships has the potential to transform nutrition science by increasing our fundamental understanding of: (i) the role of nutrients in biological systems, (ii) the resilience of living organisms in responding to environmental perturbations, and (iii) the development of dietary patterns that programme physiology for life-long health. Epigenetics may also enable the classification of individuals with chronic disease for specific dietary management and/or for efficacious diet-pharmaceutical combination therapies. These new emerging concepts at the interface of nutrition and epigenetics were discussed, and future research needs identified by leading experts at the 26th Marabou Symposium entitled 'Nutrition, Epigenetics, Genetics: Impact on Health and Disease'. For a compilation of the general discussion at the marabou symposium, click here http://www.marabousymposium.org/.

Effects of nutritional support on short-term clinical outcomes and immune response in unresectable locally advanced oesophageal squamous cell carcinoma.

This retrospective study investigated the efficiency of nutritional support in unresectable locally advanced oesophageal squamous cell carcinoma (LAOSCC) patients who received concurrent chemoradiotherapy (CCRT) based on 5-fluorouracil and cisplatin. In the routine care group, 63 patients served as historical controls and received nutrition support in a reactive manner. In addition, 57 patients in the nutritional support group received timely diet counselling, oral nutritional supplements, enteral nutrition and/or parenteral nutrition during CCRT. This support was based on scores from nutritional risk screening 2002 (NRS-2002) after June 2014. The nutritional support group had significant advantages over the routine care group with respect to the incidence of neutropenia, the objective response rate, the change in serum albumin and the lengths of hospital stay. In addition, the nutritional support group had significantly higher levels of IgG and IL-2, higher proportions of NK, CD3+ and CD4+ cells as well as a higher ratio of CD4+ /CD8+ cells than the routine care group (p < .05). In contrast, the nutritional support group had a significantly lower level of IL-6. In conclusion, the current nutritional care programme could bring benefits of improving treatment compliance, reducing toxicity and lengths of hospital stay and enhancing the immune response.

Long-term nutritional impact of sleeve gastrectomy.

BACKGROUND: Sleeve gastrectomy (SG) has become a predominant bariatric procedure throughout the world. However, the long-term nutritional impact of this procedure is unknown. OBJECTIVES: To describe the nutritional deficiencies before and after SG and to analyze the influence of baseline weight on nutritional status. SETTING: University-affiliated tertiary care center. METHODS: All patients who underwent SG as a standalone procedure between 2008 and 2012 were included in this study. Patients were given multivitamin supplementation. Data were obtained from our prospectively maintained electronic database and are reported as mean ± standard deviation and percentage. Bivariate analyses were conducted to evaluate the influence of selected variables on outcomes. RESULTS: The mean age of the 537 patients was 48.0 ± 11.3 years, with an initial body mass index of 48.1 ± 8.7 kg/m2. Excess weight loss and total weight loss were 56.2% and 28.0% at 1 year and 43.0% and 21.1% at 5 years, respectively (P<.0001). Percentage of follow-up was 74% at 5 years (n = 79). The mean follow-up time was 34.3 ± 17.2 months. Hypoalbuminemia was present in 1.1% preoperatively and 4.2% at 5 years (P = .0043), low ferritin levels in 8.6% and 37.8% (P<.0001), low vitamin B12 in 30.3% and 16.4% (P<.0001), low vitamin D 63.2% and 24.3% (P<.0001), and hyperparathyroidism in 23.4% and 20.8% (P<.0001). There was no significant difference in the prevalence of anemia over time (P = 0.4301). The prevalence of vitamin A insufficiency peaked from 7.9% preoperatively to 28.7% at 3 months (P<.0001) and returned to baseline thereafter. Baseline weight was negatively correlated with vitamin B12 and vitamin D. CONCLUSION: Nutritional deficiencies are common in patients with morbid obesity before and after surgery. Preoperative supplementation and long-term nutritional follow-up are required to prevent nutritional deficiencies.

Nutritional Issues with Incremental Dialysis: The Role of Low-Protein Diets.

A gentle start of dialysis is a welcome possibility for both patients and physicians. Incident dialysis patients often maintain residual kidney function (RKF) for a considerable period of time; the start of dialysis is often driven mainly by uremic symptoms. Recently, the combination of a low-protein diet, along with a less-frequent dialysis schedule, has regained interest as an alternative option in selected and motivated patients. In addition, there is renewed interest in a low-protein diet in patients with moderate to advanced chronic kidney disease (CKD). Dietary regimens have additional objectives now: obtaining better control of phosphate and potassium levels; preventing or reducing metabolic acidosis, protein catabolism, and malnutrition; and reducing uremic symptoms. In the eighties and early nineties, data from uncontrolled studies showed that combining a very low-protein diet with once weekly hemodialysis was a feasible approach. However, these diets were very demanding with poor patient compliance and had a high risk of smoldering malnutrition. However, recent experience has shown that the new protein-free foods have better palatability and nutritional properties; this has increased adherence to dietary prescriptions. Dietary regimens are now tailored to the patient's needs and habits. A multidisciplinary approach is considered crucial for updating medical needs and dietary prescriptions, ensuring adherence to the combined program, and avoiding the development of malnutrition and inadequate dialysis. Monitoring RKF is another key factor for the success of the program due to the importance of optimal timing of the transition to twice-weekly regimens and, eventually, thrice-weekly hemodialysis.

Nutritional rehabilitation for children with congenital heart disease with left to right shunt.

El-Koofy N, Mahmoud AM, Fattaouh AM. Nutritional rehabilitation for children with congenital heart disease with left to right shunt. Turk J Pediatr 2017; 59: 442-451. Children with congenital heart disease (CHD) are prone to malnutrition. We aimed to assess the nutritional status of infants with CHD and evaluate the role of nutritional counseling. A cohort study included 50 patients with acyanotic CHD causing increased pulmonary blood flow consecutively enrolled from the cardiology clinic in Cairo University Children Hospital. The patients were subjected to clinical evaluation, nutritional assessment with detailed nutritional history, anthropometric measurements and subjective global assessment (SGA) score and complete blood count, serum albumin and total protein assessment. Degree of failure to thrive (FTT) was assessed and nutritional counselling was offered to those patients; followed up for 3 months then re-evaluated. The mean age was (8.6±4.8 months) with male: female ratio 1:1. The overall prevalence of malnutrition was 62%. Fourteen patients had mild FTT and 17 patients had severe FTT [47.1% with mild heart failure (HF) and 47.1% had moderate or severe HF]. All patients with moderate to severe HF had severe FTT and 80% of those with mild HF had severe FTT. Anemia was present in 96% of the patients. Patients with moderate or severe FTT had more severe degree of HF (p < 0.001), more complications (p < 0.001), more frequent hospital admission (p < 0.001) and less optimum breast feeding (p < 0.001). It was found that 76.5% of those with moderate to severe FTT were formula fed (p 0.002) and significantly lower rate of optimum weaning among (p 0.037). There was significant improvement in the anthropometry, the SGA and degree of FTT, level of albumin with decrease in the percent of anemia among the included patients after nutritional rehabilitation. Malnutrition represents serious problem to children with CHD. Nutritional assessment and proper counseling help to improve the nutritional status of those patients.

Validation of a search strategy to identify nutrition trials in PubMed using the relative recall method.

OBJECTIVES: To develop, assess, and maximize the sensitivity of a search strategy to identify diet and nutrition trials in PubMed using relative recall. STUDY DESIGN AND SETTING: We developed a search strategy to identify diet and nutrition trials in PubMed. We then constructed a gold standard reference set to validate the identified trials using the relative recall method. Relative recall was calculated by dividing the number of references from the gold standard our search strategy identified by the total number of references in the gold standard. RESULTS: Our gold standard comprised 298 trials, derived from 16 included systematic reviews. The initial search strategy identified 242 of 298 references, with a relative recall of 81.2% [95% confidence interval (CI): 76.3%, 85.5%]. We analyzed titles and abstracts of the 56 missed references for possible additional terms. We then modified the search strategy accordingly. The relative recall of the final search strategy was 88.6% (95% CI: 84.4%, 91.9%). CONCLUSION: We developed a search strategy to identify diet and nutrition trials in PubMed with a high relative recall (sensitivity). This could be useful for establishing a nutrition trials register to support the conduct of future research, including systematic reviews.

Dietary alterations and restrictions following surgery for upper gastrointestinal cancers: Key components of a health-related quality of life intervention.

PURPOSE: The surgical treatment of upper gastrointestinal (GI) cancers, specifically esophageal and gastric cancers, often result in extensive health-related quality of life (HRQOL) concerns, particularly those associated with dietary adjustments. This paper provides a review of HRQOL changes following esophagectomy and gastrectomy, and describes key components of an intervention to improve dietary adjustments following surgery. METHODS: Intervention development was informed by 1) current published evidence on HRQOL changes for patients following upper GI surgery, 2) examination of usual post-operative care related to dietary restrictions to identify areas for continued education and support and 3) the inclusion of a conceptual framework (the Chronic Care Model) to guide intervention design and inform the selection of appropriate outcome measures. RESULTS: Three key components of an HRQOL intervention are identified, and should focus on HRQOL concerns associated with dietary alterations and restrictions following treatment, involve family caregivers, and be tailored and flexible to patient and family caregiver's needs and preferences. CONCLUSIONS: Evidence-based interventions to support long-term dietary alterations and restrictions following upper GI surgery are lacking, despite evidence confirming its impact on morbidity and mortality. Interventions are needed to support dietary adjustments, prevent malnutrition and excessive weight loss, and enhance HRQOL following surgery for upper GI cancers.

Nutritional status in chronic obstructive pulmonary disease and systemic sclerosis: two systemic diseases involving the respiratory system.

This study aimed to assess and compare the nutritional status and life quality of patients with chronic obstructive pulmonary disease (COPD) and systemic sclerosis (SSc). Thirty patients with stable COPD and 32 patients with SSc were examined. In all patients, the following parameters were measured: fat mass, fat-free mass, total body water, FEV1, and blood gases. COPD patients' life quality was assessed with St. George's Respiratory Questionnaire, and in SSc patients with a Quality of Life Questionnaire. The results show that among COPD patients 13% had normal body weight, 60% were obese, and 27% were overweight. In SSc patients, 59% had normal body weight, 31% were overweight, 1 patient was obese, and 2 were underweight. The mean life quality score in COPD patients was 57.3±16.5, while that in SSc patients was 35.8±18.2. COPD patients had a statistically significant lower life quality than SSc patients. The mean value of FEV1 was 45.5±12.2% pred. in COPD patients, and 86.8±21.2% pred. in the SSc group. We conclude that nutritional disorders are more frequent in COPD patients compared to those with SSc.

Nutritional assessment and therapy in COPD: a European Respiratory Society statement.

Nutrition and metabolism have been the topic of extensive scientific research in chronic obstructive pulmonary disease (COPD) but clinical awareness of the impact dietary habits, nutritional status and nutritional interventions may have on COPD incidence, progression and outcome is limited. A multidisciplinary Task Force was created by the European Respiratory Society to deliver a summary of the evidence and description of current practice in nutritional assessment and therapy in COPD, and to provide directions for future research. Task Force members conducted focused reviews of the literature on relevant topics, advised by a methodologist. It is well established that nutritional status, and in particular abnormal body composition, is an important independent determinant of COPD outcome. The Task Force identified different metabolic phenotypes of COPD as a basis for nutritional risk profile assessment that is useful in clinical trial design and patient counselling. Nutritional intervention is probably effective in undernourished patients and probably most when combined with an exercise programme. Providing evidence of cost-effectiveness of nutritional intervention is required to support reimbursement and thus increase access to nutritional intervention. Overall, the evidence indicates that a well-balanced diet is beneficial to all COPD patients, not only for its potential pulmonary benefits, but also for its proven benefits in metabolic and cardiovascular risk.

Prescription diets for rabbits.

Dietary management can be used with drug therapy for the successful treatment of many diseases. Therapeutic nutrition is well-recognized in dogs and cats and is beginning to increase among other pet species, including rabbits. The nutritional component of some rabbit diseases (eg, urolithiasis) is not completely understood, and the clinician should evaluate the use of prescription diets based on the scientific literature and individual needs. Long-term feeding trials are needed to further evaluate the efficacy of prescription diets in rabbits. Prescription diets are available for selected diseases in rabbits, including diets for immediate-term, short-term, and long-term management.