Global Leadership Initiative on Malnutrition (GLIM): Guidance on validation of the operational criteria for the diagnosis of protein-energy malnutrition in adults.

BACKGROUND: The Global Leadership Initiative on Malnutrition (GLIM) created a consensus-based framework consisting of phenotypic and etiologic criteria to record the occurrence of malnutrition in adults. This is a minimum set of practicable indicators for use in characterizing a patient/client as malnourished, considering the global variations in screening and nutrition assessment, and to be used across different health care settings. As with other consensus-based frameworks for diagnosing disease states, these operational criteria require validation and reliability testing as they are currently based solely on expert opinion. METHODS: Several forms of validation and reliability are reviewed in the context of GLIM, providing guidance on how to conduct retrospective and prospective studies for criterion and construct validity. FINDINGS: There are some aspects of GLIM criteria which require refinement; research using large data bases can be employed to reach this goal. Machine learning is also introduced as a potential method to support identification of the best cut-points and combinations of operational criteria for use with the different forms of malnutrition, which the GLIM criteria were created to denote. It is noted as well that the validation and reliability testing need to occur in a variety of sectors, populations and with diverse persons completing the criteria. CONCLUSION: The guidance presented supports the conduct and publication of quality validation and reliability studies for GLIM.

GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community.

RATIONALE: This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings. METHODS: In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee and a supporting working group with representatives bringing additional global diversity and expertise. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications. RESULTS: A two-step approach for the malnutrition diagnosis was selected, i.e., first screening to identify "at risk" status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among the GLIM core and supporting working group members. The top five ranked criteria included three phenotypic criteria (non-volitional weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present. Phenotypic metrics for grading severity as Stage 1 (moderate) and Stage 2 (severe) malnutrition are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories. CONCLUSION: A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure further collaboration and endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The diagnostic construct should be re-considered every 3-5 years.

GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community.

RATIONALE: This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings. METHODS: In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee and a supporting working group with representatives bringing additional global diversity and expertise. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications. RESULTS: A two-step approach for the malnutrition diagnosis was selected, i.e., first screening to identify "at risk" status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among the GLIM core and supporting working group members. The top five ranked criteria included three phenotypic criteria (weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present. Phenotypic metrics for grading severity as Stage 1 (moderate) and Stage 2 (severe) malnutrition are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories. CONCLUSION: A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure further collaboration and endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The diagnostic construct should be re-considered every 3-5 years.

ESPEN guidelines on definitions and terminology of clinical nutrition.

BACKGROUND: A lack of agreement on definitions and terminology used for nutrition-related concepts and procedures limits the development of clinical nutrition practice and research. OBJECTIVE: This initiative aimed to reach a consensus for terminology for core nutritional concepts and procedures. METHODS: The European Society of Clinical Nutrition and Metabolism (ESPEN) appointed a consensus group of clinical scientists to perform a modified Delphi process that encompassed e-mail communication, face-to-face meetings, in-group ballots and an electronic ESPEN membership Delphi round. RESULTS: Five key areas related to clinical nutrition were identified: concepts; procedures; organisation; delivery; and products. One core concept of clinical nutrition is malnutrition/undernutrition, which includes disease-related malnutrition (DRM) with (eq. cachexia) and without inflammation, and malnutrition/undernutrition without disease, e.g. hunger-related malnutrition. Over-nutrition (overweight and obesity) is another core concept. Sarcopenia and frailty were agreed to be separate conditions often associated with malnutrition. Examples of nutritional procedures identified include screening for subjects at nutritional risk followed by a complete nutritional assessment. Hospital and care facility catering are the basic organizational forms for providing nutrition. Oral nutritional supplementation is the preferred way of nutrition therapy but if inadequate then other forms of medical nutrition therapy, i.e. enteral tube feeding and parenteral (intravenous) nutrition, becomes the major way of nutrient delivery. CONCLUSION: An agreement of basic nutritional terminology to be used in clinical practice, research, and the ESPEN guideline developments has been established. This terminology consensus may help to support future global consensus efforts and updates of classification systems such as the International Classification of Disease (ICD). The continuous growth of knowledge in all areas addressed in this statement will provide the foundation for future revisions.

Obesity among older persons: Screening for risk of adverse outcomes.

A research overview is presented that highlights the growing prevalence of obesity among older persons and the associated risks for medical co-morbidity, healthcare resource use, functional decline and homebound status. Findings reveal that even for obese individuals poor diet quality and micronutrient deficiencies are relatively common concerns. Currently available nutrition risk screening instruments lack validity for overweight / obese older persons. Development and preliminary testing of a new Nutrition Health Outcomes Questionnaire (NHOQ) for this application are presented.

Triacylglycerol lipase, monoacylglycerol lipase and phospholipase activities of highly purified rat hepatic lipase.

Highly purified rat hepatic lipase (NaCl-resistant, alkaline pH optimum) was studied to evaluate whether the enzyme has triacylglycerol lipase, monoacylglycerol lipase and phospholipase activities. Enzyme exhibiting a single band by SDS-polyacrylamide gel electrophoresis and having a specific activity eight times greater than that in any previous report was utilized. The ratios of the different lipolytic activities to each other remained constant throughout a multistep hepatic lipase purification. The lipolytic activities coeluted by gel filtration on Ultrogel AcA 34. Column isoelectric focusing of the highly purified enzyme revealed comigration of the lipolytic activities. Thermal inactivation produced similar decay curves for the different activities. Immune titration curves for the different activities with specific antibody against hepatic lipase were essentially identical. These findings indicate that hepatic lipase is a single enzyme molecule which has triacyglycerol lipase, monoacylglycerol lipase and phospholipase activities with artificial substrates. To study these lipolytic activities further, purified hepatic lipase was subjected to limited digestion by specific proteases. The triacylglycerol lipase activity was more sensitive to proteolytic destruction than either of the other two activities.

Nutrition risk screening characteristics of rural older persons: relation to functional limitations and health care charges.

This study was intended to characterize a rural population of older persons through nutrition screening and relate screening items to functional limitations and health care charges. There were 5373 participants (2522 males and 2851 females, mean age 71 y) screened over a 22-mo period by using a self-administered questionnaire adapted from the Nutrition Screening Initiative. Height and weight and cholesterol and albumin concentrations were measured, and health care claims data were obtained. The most frequent screening items reported were use of > or = 3 medications (41%) and food group intakes below recommended frequencies (> 50%). There were significant (P < 0.05) sex differences in affirmative responses to screening items and in likelihood of exceeding proposed threshold values for risk status assigned for body mass index (BMI; in kg/m2), albumin, or cholesterol. Overweight status was notable, with one-half of all subjects having BMIs > 27. Stepwise modeling procedures were used to identify screening items with the ability to predict self-reported functional limitation (logistic regression) and monthly average recorded health care charges (linear regression on logged charges). Age > or = 75 y, use of > or = 3 medications, and an albumin concentration < 35.0 g/L were significant predictors of both functional limitation and health care charges. Poor appetite, eating problems, income < $6000/y, eating alone, and depression were significant predictors of functional limitation but not health care charges. Being male, loss of 10 lb (4.5 kg), BMI > 27, cholesterol concentration < 4.14 or > 6.21 mmol/L, and functional limitation were significant predictors of health care charges only. These findings suggest that selected screening items may have be useful in the identification of subjects at potential risk for these outcomes.

Clinical nutrition: opportunity in a changing health care environment.

This article summarizes presentations from a satellite symposium, "Clinical Nutrition: Opportunity in a Changing Health Care Environment," held July 26, 1997, at the 37th annual meeting of the American Society for Clinical Nutrition in Montreal. The symposium was cosponsored by the American Society for Clinical Nutrition and the American Society for Parenteral and Enteral Nutrition. The diverse topics served as a practical forum for sharing information on innovative responses, concerns, and impediments in the rapidly evolving practice environment.

Screening for hospitalization and nutritional risks among community-dwelling older persons.

BACKGROUND: The potential for the use of nutritional screening to identify older persons at risk of hospitalization has not been contrasted with the use of tools developed for predicting hospital admissions. OBJECTIVE: Our goal was to compare the associations of items from the Level II Nutrition Screen (LII) and the Probability of Repeated Admissions (P(ra)) questionnaire with the outcome of hospitalization. DESIGN: This was a cohort study of participants in a Medicare managed-risk health plan who completed both the LII and P(ra) (n = 386). All hospitalizations within 1 y of screening were recorded. Hierarchical multivariate logistic regression was used to model associations with hospitalization. RESULTS: P(ra) items that retained significant associations with hospitalization were self-reported health, hospitalization in the past year, and >6 doctor visits in the past year (positive predictive value: 20%; sensitivity: 53.1; specificity: 69.7). LII items that retained significant associations with hospitalization were eating problems and polypharmacy (positive predictive value: 17.9%; sensitivity: 58.0; specificity: 56.3). Those persons designated by the P(ra) score as being at high risk of hospitalization (P(ra) > or = 0.30, 75th percentile) were also more likely to report weight loss, polypharmacy, consumption of a special diet, and functional limitation on the LII. CONCLUSIONS: Retained items from the P(ra) and the LII were comparable in identifying participants at risk of hospitalization. These observations suggest that nutritional risk factors such as eating problems, weight loss, and consumption of special diets should be considered in the management of older persons at risk of hospitalization, irrespective of the screening approach selected.

A double-blind, prospective, randomized study of glutamine-enriched compared with standard peptide-based feeding in critically ill patients.

Arterial and venous plasma amino acids were determined in 28 intensive care patients randomly assigned to receive 10 d of isoenergetic, isonitrogenous feedings that differed sixfold in glutamine content. Subjects were generally well-matched for age, injury severity, and disease diagnoses. Nasojejunal feedings were started within 48 h of admission. Data were analyzed from those 19 subjects still receiving > or = 50 mL feeding/h on day 5. Both groups had comparable gastric residuals, stool frequency, and delivered nitrogen and energy. At study initiation, all subjects had relative hypoaminoacidemia, with day 1 venous glutamine concentrations down 26% compared with reference values. Plasma glutamine rose to comparable concentrations with feeding of either diet. There were, however, significant (P < 0.05) increases in arterial or venous plasma total, indispensable, and branched-chain amino acids of 125-144% by day 5 only in patients fed the standard control diet. The phenylalanine-tyrosine ratio was elevated on day 1 in both groups (1.3-1.4) but decreased significantly only in the glutamine-supplemented group (1.1 compared with 1.4) by day 5. Glutamine supplementation blunted the hyperaminoacidemia and elevated aromatic amino acid response to injury.

Predicting early nonelective hospital readmission in nutritionally compromised older adults.

This study determined predictors of early nonelective hospital readmission in 92 (49 women and 43 men) nutritionally compromised Medicare patients. Subjects ranged in age from 65 to 92 y and represented patients hospitalized previously for medical or surgical services. The study used a repeated-measures design of multiple variables representing demographics, anthropometric and clinical values, and functional status. Data were collected during hospitalization and during home visits at 1 and 3 mo postdischarge. There were 26 readmissions, making the 4-mo nonelective readmission rate 26%. Subjects who were readmitted nonelectively were compared with those not readmitted. Univariate analyses suggested strong relations between readmission outcome and serum albumin, total lymphocyte count, change in weight, and change in white blood cell count. Sociodemographic variables were less useful in predicting readmission than were measurements of patients' clinical status. Measurements of change in clinical variables were generally more predictive of readmission than was any one single measurement. Multivariate-logistic-regression analyses suggested a model consisting of change in weight and change in serum albumin from hospitalization to 1 mo after discharge as being highly predictive of early nonelective readmission. Individuals with any amount of weight loss and no improvement in albumin concentrations during the first month after hospitalization were at a much higher risk of readmission than were those who maintained or increased their postdischarge weight and had repleted their serum albumin concentrations. More study is warranted to clarify whether routine monitoring of changes in weight and serum albumin after hospitalization is appropriate in older adults.

Lymphatic absorption of enterally fed structured triacylglycerol vs physical mix in a canine model.

The lymphatic absorption of a structured triacylglycerol vs an equivalent physical mixture of the constituent medium-chain triacylglycerol and fish oils was studied. Each of four canines served as its own control in a crossover feeding design with the investigators unaware of diet contents. Lymphatic absorption of n-3 and medium-chain fatty acids peaked within 4-8 h of feeding either diet. The lymph contained more 10:0 fatty acids than 8:0 despite an overall ratio of 10:0 to 8:0 of 0.3 for the diets. The mass of medium-chain fatty acids absorbed in the lymph at measured time points was 2.6 +/- 0.5-fold higher (mean +/- SE of 12 determinations) for the structured triacylglycerol compared with the physical mix. Molecular species analyses revealed that the medium-chain fatty acids in lymph were present as mixed triacylglycerols. The unique molecular structure of these mixed triacylglycerols and the fatty acids at the 2-position may account for the improved absorption.

A prospective randomized study of glutamine-enriched parenteral compared with enteral feeding in postoperative patients.

Plasma amino acids were measured in 17 postoperative subjects randomly assigned to receive for > or = 5 d tube feeding or total parenteral nutrition (TPN) that had identical energy, nitrogen, and glutamine contents. Subjects required gastric or pancreatic surgery for malignancy and were well-matched for age and body mass index. Tube feeding or TPN began on postoperative day 1 and advanced in daily 25% increments to meet goals of 105 kJ . kg body wt-1 . d-1, 1.5 g protein . kg body wt-1 . d-1, and 0.3 g glutamine . kg body wt-1 . d-1. Delivered energy, nitrogen, and glutamine were closely matched on day 4. Nitrogen balance and plasma proteins did not differ significantly between feeding groups. Total indispensable amino acids, branched-chain amino acids, and glutamine declined 25% on postoperative day 1 compared with preoperative day 0. Indispensable and branched-chain amino acid concentrations were restored with 5 d of either tube feeding or TPN. Glutamine concentrations did not differ significantly by feeding group, though a trend suggested that glutamine recovered more slowly in the tube-fed than in the TPN-fed subjects. Plasma amino acids otherwise reflected formula composition with ratios of valine to leucine of 1.24 and 3.69 mumol/L in subjects receiving 5 d of tube feeding or TPN, respectively. These findings suggest that glutamine-enriched tube feeding and TPN can result in similar profiles for most plasma amino acids at carefully matched doses.

The relationship between body mass index and self-reported functional limitation among older adults: a gender difference.

OBJECTIVES: To determine whether there is a gender difference in how body mass index (BMI) relates to self-reported functional limitation. Also, to evaluate whether the method of categorizing BMI changes the observed results. DESIGN: Cross-sectional cohort study. SETTING: Rural Pennsylvania. PARTICIPANTS: A total of 7,120 male (n = 3,312) and female (n = 3,808) community-dwelling older adults enrolled in a Medicare managed-risk contract. MEASUREMENTS: All subjects completed a modified Level II Nutrition Risk Screen upon enrollment in the health plan. Height and weight were obtained by nursing personnel during an enrollment clinic visit. Subjects who reported 10 or more pounds weight loss in the previous 6 months were excluded. Logistic regression was used to evaluate the relationship between BMI and self-reported functional limitation separately for each sex, adjusting for age, depression, and polypharmacy. Two schemes were used to categorize BMI: equally distributed sex-specific quintiles and arbitrary division based on National Institutes of Health (NIH) Obesity Guidelines. RESULTS: How BMI relates to functional limitation depends upon both sex and method of categorizing BMI. When BMI was considered in gender-specific quintiles, women in the highest quintile of BMI had increased risk of functional impairment; there was no relationship between BMI and functional limitation for men. When BMI was categorized by the NIH obesity guidelines, both men and women with BMI >40 had significantly increased risk of functional limitation. CONCLUSIONS: The mechanisms behind gender discrepancy in self-reported functional limitation remain unclear. Studies may need to consider men and women separately, because how BMI relates to function depends on gender. Further research is needed to evaluate how changes in weight and body composition during middle and old age affect functional status.

Time and cost for recruiting older adults.

OBJECTIVES: The purpose of this study was to examine the time requirements and costs of recruiting older adults for participation in a medical center-/university-sponsored, home-based nutrition education study. A two-step recruitment strategy consisting of an introductory letter followed by a telephone call was used. DESIGN: A random selection of 1300 individuals aged 60 to 74 years was drawn from a patient database of a large, rural, tertiary care hospital to receive introductory letters and recruitment telephone calls. One week after the mailing, potential subjects were contacted by trained interviewers and asked to participate in a home-based nutrition education study. PARTICIPANTS: Men and women, aged 60 to 74 years, whose names appeared in a rural, tertiary care hospital database. MEASUREMENTS: Recruitment rate, time required for recruitment by telephone, and cost of the combined mailing and telephone recruitment effort. RESULTS: Of the 1300 individuals selected, 1077 (83%) people were contacted by phone and 223 (17%) people were unable to be reached. A total of 2895 calling attempts were required to determine the recruitment status of those identified as potential participants. Of those reached by phone, the recruitment rate was 45%. The total cost (mailing, telephone, and database management) per recruited subject was $8.56. CONCLUSION: This study has helped to establish the costs of recruitment for home-based education interventions using a two-step strategy of an introductory mailing and follow-up telephone interview.

Overzealous resuscitation of an extremely malnourished patient with nutritional cardiomyopathy.

Overzealous resuscitation of the severely malnourished patient may be associated with life-threatening complications. A variety of electrolyte, hemodynamic, septic, and nutritional derangements may result in sudden decompensation and even death. We present a case that dramatically illustrates these complications and focuses on the key role of underlying nutritional cardiomyopathy.

Obesity in older persons.

The prevalence of obesity among older persons is growing. This trend has adverse medical, functional, psychosocial, and health care resource consequences. Many obese older persons were obese middle-aged adults. A sedentary lifestyle may be the dominant contributing factor. Intervention should focus on moderate weight reduction through the modification of diet, exercise, and behavior. Improvements in health and quality of life can be achieved with moderate weight reduction. Strategies tailored to the older population will facilitate successful interventions. Dietitians must be key participants in the effort to raise awareness of obesity as a serious health concern for older persons. The focus must be on achieving a more healthful weight.

Evaluation of a food label nutrition intervention for women with type 2 diabetes mellitus.

OBJECTIVE: To evaluate an educational intervention about the food label designed specifically for women with type 2 diabetes mellitus. DESIGN: A pretest-posttest control group design. Participants received random group assignment. SUBJECTS/SETTING: Forty-three women aged 40 to 60 years with type 2 diabetes living in a rural community in Pennsylvania participated. Forty participants (93%) completed the program. INTERVENTION: Nine weekly group sessions were developed on the basis of findings from previous research among this sample. Principles from Ausubel's learning theory were also incorporated into program design and evaluation. MAIN OUTCOME MEASURES: The effectiveness of the food label education program on participants' knowledge was determined using a multiple-choice test designed to measure declarative and procedural knowledge. A skills inventory assessed participants' perceived confidence in using the food label. The validity and reliability of the instruments had been established previously. STATISTICAL ANALYSES: Analysis of variance was performed to compare groups. Paired t tests compared pretest and posttest results. RESULTS: The experimental group showed a greater gain than the control group in total knowledge (P < .001), declarative knowledge (P < .001), and procedural knowledge (P < .01) at posttest. Posttest data showed a significant increase (P < .01) in experimental participants' perceived confidence in using the food label. CONCLUSIONS: Women with diabetes need more education about the food label. This intervention is an effective outpatient education program. Participant knowledge and perceived confidence in using the food label improved significantly as a result of the intervention. Future research should assess retention of knowledge gained and the impact of the intervention on metabolic measures of diabetes management and control.

Nutrition and health for older persons in rural America: a managed care model.

Health care services and resources for older persons living in rural areas may be highly variable, and integrated service-delivery models are often lacking. This article presents a managed-care model of nutrition risk screening and intervention for older persons in rural areas. Nutrition risk screening was implemented by the Geisinger Health Care System, Danville, Pa, to target all eligible enrollees in a regional Medicare risk program. A single remote clinic site participating in the managed health care system was chosen for further study of a linked screening and case-management effort for undernourished persons. Screening and intervention at the clinic site selected for this study were guided by centralized expertise and resources. Individualized evaluation and intervention plans were developed with the aid of a dietitian and implemented by the clinic case manager. Of the 417 subjects who completed screening at the remote site, 68 met the risk criteria for undernutrition and were selected for case management. Many of the targeted persons received interventions that included evaluations by a physician or physician extender (eg, physician assistant, nurse practitioner) at the clinic and consultations with nutrition, mental health, or social services professionals. Twenty-six of the subjects who took part in the intervention completed a follow-up screening 6 months later. Ten of those persons no longer exhibited risk criteria. This demonstrates the feasibility of a linked screening and case management program for nutrition risk in the managed-care setting.

Responses of older adults to theory-based nutrition newsletters.

OBJECTIVE: To evaluate the effect of a theory-based newsletter on knowledge, attitude, and behavior change in older adults. DESIGN: Pretest-posttest, random assignment, and treatment-control design with 2 treatment groups: 1 that received newsletters only and 1 that received newsletters with follow-up telephone interviews. Control group completed pretest-posttest surveys only. SUBJECTS/SETTING: Four hundred eighty men and women, aged 60 to 74 years, were recruited to participate in a home-based educational intervention using a patient list generated from a rural tertiary care hospital database, Geisinger Medical Center in Danville, Pa. INTERVENTION: Five nutrition newsletters designed using the nutrition communication model and adult learning theory principles were mailed biweekly. Telephone interviews followed each of the 5 newsletters 10 to 14 days after distribution. OUTCOME MEASURES: Nutrition knowledge and interest, food behavior related to dietary fat, and stages of change for dietary fat and fiber. STATISTICAL ANALYSES PERFORMED: Analysis of covariance was used to determine group differences in posttest outcome measures using pretest as covariate. RESULTS: In addition to achieving higher scores than the control group, the treatment groups were significantly different from each other in correct and perceived nutrition knowledge at posttest. Those in the treatment group receiving telephone calls scored higher (mean change = 19.0% for correct and 20.3% for perceived) than those who received the newsletters only (mean change = 12.5% for correct and 14.3% for perceived; P < .05). Treatment groups also rated their interest in nutrition higher than the control group did; there was no between-treatment difference. Treatment groups performed significantly better than the control group for dietary fiber stage of change (P < .05). Those receiving only newsletters scored significantly better than the control for the "avoid fat" food behavior (P < .05). APPLICATIONS/CONCLUSIONS: This study provides an example of the incorporation of a theoretical model in development and evaluation of newsletters. Home-delivered nutrition newsletters based on this model can communicate health and nutrition information to older adults. Consumers today have more opportunities than ever before to access nutrition information quickly and inexpensively. Newsletters can help dietetics professionals filter and limit what consumers must process, saving clients time and improving the accuracy of information obtained. Dietetics professionals in both clinical and community practice are uniquely positioned to provide highly focused and understandable information to consumers via a newsletter format.