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.

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.

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.

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.

The role of cost-effectiveness analysis in developing nutrition policy.

Concern about the overconsumption of unhealthy foods is growing worldwide. With high global rates of noncommunicable diseases related to poor nutrition and projections of more rapid increases of rates in low- and middle-income countries, it is vital to identify effective but low-cost interventions. Cost-effectiveness studies show that individually targeted dietary interventions can be effective and cost-effective, but a growing number of modeling studies suggest that population-wide approaches may bring larger and more sustained benefits for population health at a lower cost to society. Mandatory regulation of salt in processed foods, in particular, is highly recommended. Future research should focus on lacunae in the current evidence base: effectiveness of interventions addressing the marketing, availability, and price of healthy and unhealthy foods; modeling health impacts of complex dietary changes and multi-intervention strategies; and modeling health implications in diverse subpopulations to identify interventions that will most efficiently and effectively reduce health inequalities.

Improving nutrition and health through non-timber forest products in Ghana.

Nutrition and health are fundamental pillars of human development across the entire life-span. The potential role of non-timber forest products (NTFPs) in improving nutrition and health and reduction of poverty has been recognized in recent years. NTFPs continue to be an important source of household food security, nutrition, and health. Despite their significant contribution to food security, nutrition, and sustainable livelihoods, these tend to be overlooked by policy-makers. NTFPs have not been accorded adequate attention in development planning and in nutrition-improvement programmes in Ghana. Using exploratory and participatory research methods, this study identified the potentials of NTFPs in improving nutrition and food security in the country. Data collected from the survey were analyzed using the SPSS software (version 16.0). Pearson's correlation (p < 0.05) showed that a significant association exists between NTFPs and household food security, nutrition, and income among the populations of Bibiani-Bekwai and Sefwi Wiawso districts in the western region of Ghana. NTFPs contributed significantly to nutrition and health of the poor in the two districts, especially during the lean seasons. The results of the survey also indicated that 90% of the sampled population used plant medicine to cure various ailments, including malaria, typhoid, fever, diarrhoea, arthritis, rheumatism, and snake-bite. However, a number of factors, including policy vacuum, increased overharvesting of NTFPs, destruction of natural habitats, bushfires, poor farming practices, population growth, and market demand, are hindering the use and development of NTFPs in Ghana. The study also provides relevant information that policy-makers and development actors require for improving nutrition and health in Ghana.

Assessment of dietary intake in an inner-city African American population and development of a quantitative food frequency questionnaire to highlight foods and nutrients for a nutritional invention.

PRIMARY OBJECTIVE: To characterize the diets of low-income inner-city African Americans to develop a population-specific quantitative food frequency questionnaire (QFFQ) that will be used to highlight foods and nutrients for a nutritional intervention program aimed at reducing the risk of chronic disease and to evaluate the program. METHODS AND PROCEDURES: A cross-sectional survey conducted in inner-city Baltimore, Maryland, USA. Twenty-four-hour dietary recalls were collected in 91 low-income African Americans aged between 18 and 74 years. MAIN OUTCOMES AND RESULTS: The average daily energy intake was approximately 2,165 kcal for women and 2,509 kcal for men. The percentages of energy from fat were approximately 34% and 33% for women and men, respectively. Sodas were the main contributor to energy and sugar intake. A 113-item QFFQ was developed. CONCLUSIONS: The results highlighted specific foods and nutrients that would be targeted in the nutritional intervention. The QFFQ developed is culturally appropriate and specific for low-income African Americans in inner-city Baltimore.

Lysine, arginine, and related amino acids: an introduction to the 6th amino acid assessment workshop.

The focus of the 6th workshop is on lysine, arginine, and related amino acids. Functions, metabolic pathways, clinical uses, and upper tolerance intakes are emphasized in the articles that follow. Lysine is arguably the most deficient amino acid in the food supply of countries where poverty exists, and since the discovery of the nitric oxide synthase pathway, arginine has come into prominence clinically because of the role of nitric oxide in cardiovascular physiology and pathophysiology.

An algorithm for the clinical assessment of nutritional status in hospitalized patients.

Upon admission to hospital, 30-50 % of patients either are or become malnourished. There is no generally accepted definition of malnutrition or guidelines on the best way to establish nutritional status. We consider it self-evident that the nursing staff have an important role in screening patients at risk of malnutrition on admission and thereafter at regular times. This is why we developed the nursing nutritional screening form (NNSF). The NNSF was tested by nurses, dietitians and clinicians, in pairs, to establish the extent of agreement in two phases on sixty-nine and forty patients. Later, the form was used in practice by nursing staff on five wards (334 patients). Based on the results of the NNSF, patients were referred to a dietitian. The dietitian established whether the patient was indeed at risk, or was actually malnourished, using a complete nutritional history. The degree of concurrence within pairs was reasonable to good. The same applied to the concurrence between nursing staff and dietitians, but concurrence between clinicians and nursing staff was less. In total, 334 patients were screened and sixty-nine of them were referred to the dietitian. It was established that 86 % of the referred patients were potentially at risk of malnutrition or were malnourished. Without the NNSF, 39 % (n 27) of the patients referred to the dietitian would not have been referred, or would have been referred much later. The NNSF makes it possible for nurses to detect malnourished patients or patients at risk of malnutrition at an early stage of their hospitalization.

Tackling undernutrition through appropriate supplement prescribing.

Undernutrition has significant implications for patients' clinical condition and economical consequences for the NHS. However, due to continually increasing prescribing costs for sip feeds, treating undernutrition is often seen as very costly. An audit project in Lothian was undertaken to look at the appropriateness of sip feeds being prescribed. The project found there was a significant level of inappropriate prescribing with 30% of patients having their prescriptions for supplements stopped as they were deemed unnecessary. In view of this, the community dietitians involved developed and introduced a nutritional care pathway to allow a systematic and evidence-based approach to the identification and treatment of undernutrition.

Lysine requirements of chronically undernourished adult Indian men, measured by a 24-h indicator amino acid oxidation and balance technique.

BACKGROUND: In earlier studies with well-nourished subjects that used a 24-h indicator amino acid oxidation or balance approach, we concluded that the 1985 FAO/WHO/UNU requirement for lysine (12 mg x kg(-1) x d(-1)) was inadequate for healthy South Asian subjects and proposed a tentative requirement of 30 mg x kg(-1) x d(-1). OBJECTIVE: We assessed whether chronic undernutrition, with low habitual dietary protein and lysine intakes, leads to changed lysine requirements. DESIGN: Twenty-seven otherwise clinically healthy, chronically undernourished Indian men were studied during 2 randomly assigned 7-d diet periods supplying 12 and 30, 18 and 36, or 24 and 42 mg lysine x kg(-1) x d(-1), based on an L-amino acid diet. The subjects' leucine intake was 40 mg x kg(-1) x d(-1). At 1800 on day 6, a 24-h intravenous [(13)C]leucine tracer-infusion protocol was conducted to assess leucine oxidation and daily leucine balance at each test lysine intake. RESULTS: A breakpoint was not identified in the lysine intake-leucine oxidation or balance response over the range of intakes studied. Mixed-models linear regression analysis indicated a mean requirement of 44 mg lysine x kg(-1) x d(-1) (95% CI: 36, 63) for the lysine intake-leucine balance relation. CONCLUSIONS: The mean lysine requirement in chronically undernourished men is estimated to be higher than the value of 30 mg x kg(-1) x d(-1) proposed for well-nourished individuals. This may be related to body-composition differences. It also suggests that these subjects have not elicited a metabolic adaptation in response to their habitually low lysine intakes by substantially improving their efficiency of dietary lysine utilization.

Activating the community for nutritional improvement.

This presentation provides information on community-oriented action research conducted under the leadership of Dr. Rajammal P. Devadas, the recipient of the IUNS International Nutrition Award for 2001. Educating, activating, and energizing the community with empowerment have been the focus of the action-oriented research. In the four decades of work presented, massive efforts have been made in the areas of infant and preschool child nutrition; nutritious noon meal programs for children; integration of nutrition, health, and sanitation concepts in the primary school curriculum; use of local foods to eradicate malnutrition; introduction of novel and underexploited foods; food-based approaches to overcome micronutrient malnutrition; equipping women for food and nutrition security; and nutrition education. These efforts have been activated through development of relevant food and educational materials, their introduction to the community, impact evaluation, follow-up, and implementation of the concepts in relevant national programs with massive training efforts. Many of the efforts outlined have formed the basis for regional and nationwide nutrition intervention strategies. The experiences gained and training efforts developed have gone beyond the country-level exposure to training and equipping nutrition workers in other countries.

Testing mediating variables in a school-based nutrition intervention program.

This study identified mediators of a school-based nutrition intervention for 4th graders and their parents. Nine variables were tested for satisfying 4 conclusions necessary to establish mediation of intervention effects on changes in fruit and vegetable consumption (FVC) in 4th graders (N = 1,676). FVC was measured in children by the use of 24-hr dietary recalls. Mediators were assessed by the use of questionnaires completed by children and parents. All 4 conclusions were met for positive outcome expectancies. Knowledge, self-efficacy, and parent consumption satisfied the first 3 conclusions for mediation but the mediating effects were not statistically significant (Conclusion 4). Future mediational analyses and the creation of a national database of mediators are crucial for increasing strength and efficiency of school-based nutrition programs.

[Role of nutritional care in hospitals in the prevention of disease-related malnutrition]. / A kórházi betegélelmezés szerepe a kóros tápláltsági állapot kivédésében.

The prevalence of undernutrition is about 30% at admission to hospitals, and in many cases the nutritional risk is not recognized and significantly increases in patients during hospitalisation in Hungary. Undernutrition and acute rapid weight loss of as little as 2-3 kg (cc. 5%) in combination with disease increases the risk of complications, lowers resistance to infection, impairs physical and mental functioning and delays recovery. Undernourished patients are at greater risk for adverse medical outcomes than well-nourished ones. In most hospitals the nutritional risk of patients is not determined and nutritional treatment plan isn't developed; fewer than 10 Nutritional Support Teams are established in hospitals. Nutritional care of ill patients is considered as a part of clinical treatment in very few hospitals in Hungary. There is no adequate recognition of the problem of undernutrition. The simplest and safest way to provide nutritional support is the adequate energy rich oral nutrition. If the oral nutrition fails or is inappropriate then artificial nutritional support becomes necessary. Nutrition is the most cost effective measure to prevent the complications of diseases. To improve the intolerable situation it would be necessary to increase the nutritional knowledge and the awareness of health care teams of the real importance of nutritional status in illnesses, and improve the quality of hospital food and eating conditions and environment.

[Help to children and adolescents with malnutrition or eating disorders. Percutaneous endoscopic gastrostomy with button: simple, safe and cost-effective]. / Hjälp för barn och ungdomar med malnutrition eller ätstörning. Perkutan endoskopisk gastrostomi och knapp enkelt, säkert och billigt.

Percutaneous endoscopic gastrostomy (PEG) has gained great popularity for children with malnutrition and eating disorders secondary to chronic illness. However, the procedure is not without risks. We report on 62 infants and children, median age 4 years (1 month-20 years), who underwent PEG placement. Cerebral palsy with or without mental retardation was the most common diagnosis (50%). No complications related to the PEG procedure itself occurred, but postoperative pneumonia was seen in 10%. Late complications were few: intraperitoneal migration of the button in one child and prolapse of the stoma in another. At the time of button placement, after median 14 weeks, mean weight had increased from a standard deviation score of -2.7 to -2.2 (P < 0.001). We consider PEG to be a safe procedure for children with malnutrition requiring enteral feeding. Due to potential risks and complications related to this method, a multidisciplinary approach, as found in a "nutritional support team", is recommended.

Treatment of malnutrition in Brazil: simple solutions to common problems.

At the largest rehabilitation centre in Ceará, Brazil, the World Health Organization (WHO) guidelines for improved dietary management of severe malnutrition were implemented. Rates of weight gain increased fourfold, daily food costs were reduced, and staff time was saved. Implementation was achieved within 1 week, including training. Other centres are encouraged to adopt similar measures.

Influence of liver failure, ascites, and energy expenditure on the response to oral nutrition in alcoholic liver cirrhosis.

The influence of liver failure, ascites, and energy expenditure on the response to oral nutrition was assessed in a group of 55 alcoholic cirrhotic patients. Caloric intake, nutritional status, resting energy expenditure (REE), and Child-Pugh score were evaluated before and after 1 mo of oral nutrition. Patients were severely malnourished, 73% had muscular midarm circumference (MMAC) below the 5th percentile of a reference population, 51% had triceps skinfold thickness below the 25th percentile. Eleven patients were in class A of Child, 19 in class B, and 25 in class C. Twenty-six patients were nonascitic, whereas ascites was resolved in 10 ascitic patients by the end of the study and 19 patients had refractory ascites. Liver damage was more pronounced and did not improve during the study in patients with refractory ascites. Caloric intake was approximately 40 kcal/kg of body weight and was in the same range in the three groups according to Child classification. Fat mass (FM) increased, respectively, from 17.4% +/- 1.7% to 19.5% +/- 1.4%, P < 0.01, in Child A patients; from 17.1% +/- 1.4% to 19.3% +/- 1.4%, P < 0.001, in Child B patients; and from 17.6% +/- 1.5% to 18.8% +/- 1.5%, P < 0.05, in Child C patients. The increase in FM was comparable in the three groups, whereas MMAC and the creatinine/height ratio did not change significantly. FM was lower and did not increase in patients with refractory ascites. Child C patients were characterized by an increase in the rate of glucose oxidation (P < 0.02) and a decrease in the rate of lipid oxidation (P < 0.05). High-density lipoprotein cholesterol and apolipoprotein (Apo) A1 were reliable indices of improvement of liver function in patients with severe liver failure, ApoA1 was also a marker of improvement of metabolic impairment. With respect to the measured REE/predicted REE ratio calculated according to Harris-Benedict equation (r), 19 patients were considered hypermetabolic (r < 1.1), 30 normometabolic (0.9 < r < 1.1), and 6 hypometabolic (r < 0.9). An increase in FM correlated with r (P < 0.01) and was more marked in hypermetabolic patients. In contrast to the other two groups, Child-Pugh score and nutritional status remained unchanged in the hypometabolic patients. These results show that severe liver failure did not preclude improvement of nutritional status provided caloric intake was high. In Child C patients, improvement of nutritional status paralleled improvement of liver function and normalization of oxidative metabolism. Refractory ascites had negative effects on changes in nutritional status and liver function. Despite adequate caloric intake to energy requirements, hypometabolism has a poor prognosis regarding both nutritional status and liver function.

High-quality nutritional interventions reduce costs.

Numerous clinical studies have documented improved clinical outcomes and cost savings when patients at risk for malnutrition receive high-quality nutritional care. A survey of 19 hospitals found that patients who received high-quality nutritional care averaged 12.2 days in the hospital. Patients who received medium nutritional care averaged 14.0 days in the hospital. Patients who received low-quality nutritional care were hospitalized an average of 14.4 days. The survey further revealed that only 7.5 percent of patients at risk for malnutrition actually received the type of nutritional care that was associated with the shortest average length of stay. If all patients in the at-risk population had received high-quality nutritional care, the estimated net savings potential would have been $1,064 per patient. Financial managers can determine the financial consequences of clinical nutritional policies and practices from information and analytical tools that are readily available.

Malnutrition of the hospitalised patient--assessment of provision of diet and dietary intake.

Malnutrition is a common problem amongst hospitalised patients leading to an increased risk of mortality and morbidity. Malnutrition occurs when a patient's nutrient intake is insufficient to meet their requirements.