[Impact of nutritional treatment in the evolution of inflammatory bowel disease]. / Impacto de la nutrición en la evolución de la enfermedad inflamatoria intestinal.

Inflammatory bowel disease is an entity with not wellknown pathogenesis, and important nutritional and metabolic implications because of the high prevalence of malnutrition, the possible implication of dietary factors in its pathogenesis and because of the hypothesis that nutritional intervention could be a primary treatment for the disease. Some nutrients could induce a low antigenic stimuli, regulate inflammatory and immunological responses and stimulate intestinal mucosal trophism. Present available evidence supports enteral nutrition in Crohn's disease as a primary treatment if treatment with steroids is not possible (failure or contraindication) (grade of recommendation A) or either combined treatment with drugs in malnourished patients or those with inflammatory bowel stenosis. In those patients with sustained clinical remission, no benefit of either enteral nutrition or supplements in the absence of nutritional deficits has been shown. Elemental or modified formula (glutamine, omega 3 fatty acids) could not be recommended. In ulcerative colitis, nutritional influence over the activity of the disease has not been shown, although there are some promising results regarding enteric coated W3 fatty acids and a possible role for probiotics. In the treatment and prevention of pouchitis, there could be a role for probiotics (VSL#3). Nutritional treatment should be considered an integral component in the Management of patients with inflammatory bowel disease.

[Effectiveness of dietetic treatment in nephrotic syndrome]. / Eficacia del tratamiento dietético en el síndrome nefrótico.

We present the case of a male patient suffering from a primary amyloidosis and a nephrotic syndrome who came to dietotherapy clinic. In the first visit we made a nutritional record including an anthropometric evaluation, body composition, biochemistry, and food intake. The patient had an excess of body water, proteinuria, low plasma protein, albumin, prealbumin and HDL cholesterol levels, and high concentrations of total cholesterol, LDL and triglycerides. The consumption of protein and sodium was higher than the recommendation. An individualized diet was made. Six months later, his weight and the excess of body water decreased, but the fat free mass remained unchanged. The levels of albumin and prealbumin increased, the proteinuria decreased. Total cholesterol, LDL and triglycerides decreased until normal levels. Dietetary treatment in nephrotic syndrome is effective to decrease proteinuria, improve cholesterol and triglycerides levels, and to prevent malnutrition.

Burden assessment in caregivers of patients with home artificial nutrition: a need and a challenge.

BACKGROUND/OBJECTIVES: Caregiving can be a stressful task with severe consequences on caregivers' health. Our aim was to evaluate the profile and the burden of caregivers of patients with home artificial nutrition (HAN) in our area. SUBJECTS/METHODS: We conducted a prospective observational study of patients who had started HAN over a period of a year (n=573) and their home caregivers (n=103). Epidemiological characteristics of the patients and the type of HAN were registered. Caregivers' profile data (gender, age and degree of kinship) and Zarit Burden Assessments were recorded. RESULTS: Care recipients had a median age of 79.0 (IQR 87) years, neurological and oncological diseases in 50% and a high rate of mobility limitations (80%). Oral supplements with high-calorie formulas were predominant (60%). The usual caregiver profile was a patient's daughter with a mean age of 53.1 (s.d. 13.4) years acting as the primary caregiver. Burden was absent in 49.5%, light in 18.4% and intense in 32% of caregivers. Intense burden was more frequent in oral over enteral nutrition (42% versus 22.6%; P=0.036). Supplementary nutrition was also associated with higher caregiver burden scores compared with complete diets. In patients with functional limitations, a tendency toward a slightly higher burden was observed. No differences in caregiver burden were detected according to other patient or caregiver characteristics. CONCLUSIONS: HAN type appears to be a factor influencing caregiver burden and therefore, evaluation of caregiver burden should be part of HAN programs.

Osteoporosis Management in a Real Clinical Setting: Heterogeneity in Intervention Approach and Discrepancy in Treatment Rates when Compared with the NOGG and NOF Guidelines.

Objective: The National Osteoporosis Guideline Group (NOGG) proposes intervention thresholds that vary by age. Instead, the National Osteoporosis Foundation (NOF) proposes a fixed threshold for decision. The aim of the present study was to compare the actual therapeutic decisions taken in a routine clinical practice setting with those recommended by the NOF and NOGG guidelines. Material and methods: A cross-sectional study was conducted in individuals referred to a densitometric unit who were not receiving antiresorptive therapy. The absolute risk of major and hip fracture was calculated using the British formula provided by the FRAX® tool. NOGG and NOF guidelines' therapeutic intervention thresholds were used. Agreement was calculated using Cohen's kappa. Results: A total of 640 individuals were included, of which 95% were women, with a median age of 59.4 (IQR=14) years. 31.7% of subjects who were analyzed received treatment for osteoporosis. The type of treatment that was mainly prescribed (71.9%) consisted of bisphosphonates. When applying the NOGG criteria, treatment was recommended in 22.7% of cases; this percentage increased to 42.2% with the NOF guidelines. According to both guidelines, 20.4% of patients would not have received treatment. The concordance, expressed as the kappa index, was low; 0.25 (CI 95% 0.17-0.34) and 0.49 (CI 95% 0.42-0.55), with the NOGG and NOF, respectively. Conclusions: Important heterogeneity exists in the treatment of osteoporosis in real practice. The choice of guideline has a major impact on the proportion and selection of individuals recommended for treatment and, subsequently, on treatment-related expenditures.

Clinical and financial implications of disease-related malnutrition in a department of Internal Medicine: prospective cohort study. / Repercusiones clínicas y económicas de la desnutrición relacionada con la enfermedad en un servicio de Medicina Interna: estudio de cohortes prospectivas.

BACKGROUND: Disease-related malnutrition is a challenge for Spanish hospitals. Our objective was to assess the feasibility and importance of establishing a nutritional screening strategy in our community. PATIENTS AND METHODS: A prospective cohort study was conducted in a department of internal medicine for 3 months. The nutritional screening was conducted at admission and was repeated weekly using the Malnutrition Universal Screening Tool. We analysed the clinical data, mean stay and expenses. RESULTS: The study included 330 patients (53.9% men), with a mean age of 77.8 years. The mean stay was 7 days, and the Charlson comorbidity index was 5.4. At admission, the Malnutrition Universal Screening Tool detected 26.9% of patients with a risk of malnutrition. Eighteen percent of the patients with a good nutritional state developed malnutrition during the hospitalisation. The patients with initially severe malnutrition had a longer mean stay. The patients whose nutritional state worsened during the hospitalisation had a significantly longer stay (2.5 days) compared with those whose state did not worsen. These cases of malnutrition caused a cost overrun of €767 per hospitalisation (35% greater), which entailed a malnutrition-related excess expenditure of €646,419.93 annually in the studied department. The appropriate coding resulted in an increase in mean weight from 2.11 to 2.81, which represented €82,568.52 and has not been previously quantified. CONCLUSION: The high prevalence and clinical and financial implications of Disease-related malnutrition in patients hospitalised in internal medicine warrants establishing protocols for its early detection and treatment.

Inflammatory status is different in relationship to insulin resistance in severely obese people and changes after bariatric surgery or diet-induced weight loss.

AIM: To assess if insulin resistance is related to a different inflammatory status (especially lymphocyte subpopulations) in severely obese people and to evaluate changes after weight loss either following a very-low calorie diet (VLCD) or bariatric surgery. RESEARCH METHODS & PROCEDURES: Severely obese patients were consecutively recruited in our Obesity Unit. Blood lymphocyte subpopulations and inflammatory parameters were measured baseline, after a VLCD during 6 weeks and one year after biliopancreatic diversion. Insulin resistance was evaluated by Homeostasis Model Assessment (HOMA) index. RESULTS: After excluding diabetic patients, 58 patients were studied. HOMA index classified 63.8% of them as insulin resistant (IR). Serum baseline levels of inflammatory cytokines were not significantly different between IR and insulinsensitive (IS) patients but, regarding lymphocyte subpopulations, Natural Killer (NK) cells were higher in IR patients [(305.0 (136.7) vs. 235.0 (80.7) cells/µL, p=0.047]. NK cells showed a significant positive correlation with HOMA index (r=0.484, p=0.000) and with the carbohydrate content of the diet (r=0.420, p=0.001). After VLCD, NK cells significantly decreased, but only in IR patients and in those losing more than 10% of their initial weight. After biliopancreatic diversion, total and CD8 T Lymphocytes, B lymphocytes and NK cells also decreased but only in IR individuals. CONCLUSION: NK cells are significantly increased in IR severely obese people in respect to IS, suggesting a slightly different immune status in these patients with a probable dietary relationship. Weight loss could reverse this increase either after VLCD or after bariatric surgery.

Home enteral nutrition in Spain; NADYA registry 2011-2012.

OBJECTIVE: To describe the results of the home enteral nutrition (HEN) registry of the NADYA-SENPE group in 2011 and 2012. MATERIAL AND METHODS: We retrieved the data of the patients recorded from January 1st 2011 to December 31st 2012. RESULTS: There were 3021 patients in the registry during the period from 29 hospitals, which gives 65.39 per million inhabitants. 97.95% were adults, 51.4% male. Mean age was 67.64 ± 19.1, median age was 72 years for adults and 7 months for children. Median duration with HEN was 351 days and for 97.5% was their first event with HEN. Most patients had HEN because of neurological disease (57.8%). Access route was nasogastric tube for 43.5% and gastrostomy for 33.5%. Most patients had limited activity level and, concerning autonomy, 54.8% needed total help. Nutritional formula was supplied from chemist's office to 73.8% of patients and disposables, when necessary, was supplied from hospitals to 53.8% of patients. HEN was finished for 1,031 patients (34.1%) during the period of study, 56.6% due to decease and 22.2% due to recovery of oral intake. CONCLUSIONS: Data from NADYA-SENPE registry must be explained cautiously because it is a non-compulsory registry. In spite of the change in the methodology of the registry in 2010, tendencies regarding HEN have been maintained, other than oral route.

Objetivos: Describir los resultados del registro de nutrición enteral domiciliaria (NED) del grupo NADYASENPE de los años 2011 y 12. Material y métodos: Se recopilaron los datos introducidos en el registro desde el 1 de enero de 2011 al 31 de diciembre de 2012. Resultados: Hubo 3021 pacientes en el registro durante el periodo, procedentes de 29 hospitales, lo que da una prevalencia de 65,39 casos por millón de habitantes. 97.95% fueron adultos, 51,4% varones. La edad media fue 67,64 ± 19,1 años y la mediana 72 años para los adultos y 7 meses para los niños. La duración media de la NED fue 351 días y para el 97,5% fue el primer episodio con NED. La mayoría de pacientes tenían NED por una enfermedad neurológica (57,8%). La vía de acceso fue sonda nasogástrica para el 43,5% y gastrostomía para el 33,5%. La mayoría de pacientes tuvieron un nivel de actividad física limitado y, respecto a la autonomía, 54,8% necesitaba ayuda total. La fórmula de nutrición se suministró desde las oficinas de farmacia para el 73,8% y los fungibles, cuando fueron necesarios, desde los hospitales para el 53,8%. La NED se suspendió en 1.031 pacientes (34,1%) durante el periodo de estudio, 56,6% debido a fallecimiento y 22,2% debido a recuperación de la vía oral. Conclusiones: Los datos del registro NADYA-SENPE deben ser interpretados con precaución ya que se trata de un registro voluntario. A pesar del cambio de metodología del registro en 2010, las tendencias en NED se han mantenido, salvo la importancia cuantitativa de la vía oral.

[Effects of preoperative weight loss with a very low calorie diet (VLCD) on weight loss after biliopancreatic diversion in patients with severe obesity]. / Efectos de la pérdida de peso mediante una dieta muy baja en calorías (VLCD) sobre la pérdida de peso tras derivación biliopancreática en pacientes con obesidad severa.

BACKGROUND: Weight loss before bariatric surgery, achieved by means of a very low calorie diet (VLCD) has been recently reported to be related to a lower rate of postoperative complications. However, it is controversial if preoperative weight loss after VLCD could improve postoperative weight loss. AIMS: To assess the effectiveness of a preoperative VLCD for 6 weeks in weight loss one year after bariatric surgery. To evaluate the changes obtained in anthropometric measures and biochemical parameters after VLCD. METHODS: Prospective uncontrolled study including severely obese patients undergoing biliopancreatic diversion in our Obesity Unit in 2008-2010. Patients included followed a VLCD providing 840 kcal and 60 g of protein (Optisource®). Descriptive data are presented as mean (standard deviation) and after checking a normal distribution is followed, they were analyzed by Student s T test, ANOVA or Pearson correlation. RESULTS: We evaluated 107 obese patients, 43.5 (10.2) years-old, 72% women, with initial weight 122.4 (18.6) Kg and BMI 46.8 (5.5) kg/m(2). 24.5% of them lost more than 10 % of initial weight and 73.5% more than 5% after following VLCD. Mean percentage of excess weight loss (% PSP) one year after surgery was 59.6 (13.4)%, and although it was higher for those patients losing more weight after VLCD, a significant correlation was not found: those who lost more than 5% showed %PSP 59.5 (13.8) % after twelve months and 68.4 (16.2) % of percentage of excess BMI loss (%PEIMC), vs 57,9 (13,1) % and 68.5 (16.6) % if they didn t lose that amount of weight. Those patients losing more than 10% achieved %PSP 63.3 (13.7) and %PEIMC 70.9 (14.7) vs 58.2 (14.0) y 67.7 (16.7) vs those not losing that amount. Significant correlations between preoperative loss with VLCD and %PSP or %PEIMC at 3,6,9 and 12 months were not found, and only %PSP 1 month after surgery correlated with %PSP after VLCD (r = 0.454, p = 0.003). CONCLUSIONS: Preoperative weight loss with VLCD in severely obese patients did not show to improve either %PSP or %PEIMC one year after bariatric surgery.

Introducción: Se ha comunicado recientemente que la reducción de peso previa a cirugía bariátrica mediante dieta muy baja en calorías (VLCD) durante 2 semanas supone menor tasa de complicaciones postoperatorias. Es debatido, sin embargo, si la pérdida de peso preoperatoria con VLCD puede favorecer pérdida de peso postoperatoria. Objetivos: Valorar la eficacia de una VLCD, seguida durante 6 semanas preoperatorias, en el descenso de peso conseguido al 2013 de la cirugía bariátrica. Evaluar los cambios en parámetros antropométricos y bioquímicos conseguidos con dicha dieta. Metodología: Estudio prospectivo no controlado en los pacientes obesos sometidos a derivación biliopancréatica en la Unidad de Obesidad de referencia en el periodo 2008-2010. Los pacientes recibieron durante 6 semanas previas a la intervención una VLCD que aportaba diariamente 840 kcal y 60 g de proteínas (Optisource®). Los datos descriptivos se presentan como media y desviación estándar (DS), y tras comprobar su distribución normal, fueron analizados mediante prueba t de Student, ANOVA o correlación de Pearson. Resultados: Fueron valorados 107 pacientes obesos, de 43,5 (10,2) 2013s, el 72 % fueron mujeres con peso inicial 122,4 (18,6) Kg e IMC de 46,8 (5,5) kg/m2. Un 24,5% perdieron más de 10 % de su peso inicial y un 73,5% más de 5% tras VLCD. La media de porcentaje pérdida de exceso de peso (% PSP) a los 12 meses de la intervención fue 59,6 (13,4)%, y aunque fue mayor en los pacientes que habían perdido peso con VLCD, no se asoció de forma significativa: aquellos pacientes con pérdida mayor de 5% perdieron a los 12 meses 59,5 (13,8)% de PSP y 68,4 (16,2) % de exceso de IMC (%PEIMC), frente a 57,9 (13,1) % y 68,5 (16,6) % si no conseguían esa pérdida. El grupo de pacientes con pérdida mayor de 10 % consiguió %PSP de 63,3 (13,7) y %PEIMC de 70,9 (14,7) vs 58,2 (14,0) y 67,7 (16,7) si no perdieron >10% del peso inicial. No se encontró correlación entre la pérdida preoperatoria con VLCD y %PSP ni de exceso de IMC (%PEIMC) a 3,6,9 y 12 meses, sólo el %PSP a 1 mes se correlacionó con %PSP con VLCD (r = 0,454, p = 0,003). Conclusiones: La pérdida de peso preoperatoria mediante VLCD en pacientes obesos mórbidos no hademostrado favorecer la pérdida de exceso de peso ni de exceso de IMC al 2013 de la cirugía bariátrica.

[Comparative study of total energy expenditure estimated by Sense Wear Armband and Harris-Benedict equation in healthy ambulatory population; utility in clincal practice]. / Estudio comparativo del cálculo del gasto energético total mediante Sense Wear Armband y la ecuación de Harris-Benedict en población sana ambulatoria; utilidad en la práctica clínica.

INTRODUCTION: Different methodologies for estimating total energy expenditure (TEE) are currently used. OBJECTIVE: To know which tool is most useful to estimate TEE in healthy subjects: SenseWearArmband (SWA) or Harris-Benedict (HB). METHODOLOGY: Cross-sectional study in 32 volunteers. SWA was placed for 24 hours and TEE was estimated with HB and the activity factor calculated with a 24-h activity questionnaire. RESULTS: The difference between both estimates of TEE was 351.9 (95% CI 222.2 to 481.6) kcal/day (p < 0.001). This difference was associated with obesity, but not with sex. The value of ICC was 65.0% (95% CI 7.8% to 86.2%) being statistically significant (p < 0.001). There was a significant difference in the estimation of the activity between both techniques [0.4 (CI 95% 0.1 to 0.7) hours (p = 0.007)]. CONCLUSIONS: A significant difference in the estimation of TEE using HB and SWA has been found.

One-year effectiveness of two hypocaloric diets with different protein/carbohydrate ratios in weight loss and insulin resistance.

BACKGROUND: The maintenance of weight loss may be influenced by the distribution of macronutrients in the diet and insulin sensitivity. OBJECTIVE: The objective of the study was to evaluate the longterm effect of two hypocaloric diets with different protein/carbohydrate ratios in overweight and obese individuals either with insulin resistance (IR) or without insulin resistance (IS). DESIGN: Prospective, randomized, clinical intervention study. Forty patients were classified as IR/IS after a 75 g oral glucose tolerance test and then randomized to a diet with either 40% carbohydrate/30% protein/30% fat (diet A) or 55% carbohydrate/15% protein/30% fat (diet B). RESULTS: After one year of follow-up there was no difference in weight loss between diets A and B in each group, but the IS group maintained weight loss better than the IR group [-5.7 (3.9) vs. -0.6 (4.1); P = 0.04]. No differences were found in either Homeostasis Model Assessment (HOMA) or other metabolic glucose parameters except lower insulin at 120 minutes with diet A [21.40 (8.30) vs. 71.40 (17.11); P = 0.02]. CONCLUSIONS: The hypocaloric diets with different protein/carbohydrate ratios produced similar changes in weight. Insulin resistance may play a negative role in maintaining weight loss.

Comparison of different body composition measurements in severely obese patients in the clinical setting.

BACKGROUND AIMS: Body composition measurements seem to be not reliable enough in obese patients. Our aim was to compare single frequency-bioelectrical impedance (SF-BIA) analysis; foot-to-foot impedance meters (FFI) or upper body fat analysers (UBFA) and DXA (Dual-energy X-ray absorptiometry) in severely obese patients. PATIENTS AND METHODS: Cross-sectional study including 40 severely obese patients. Bioelectrical impedance was performed for SF-BIA (Holtain (H) and OMRON BF 500 (O500)), FFI (Tanita TBF-300 (T)) and UBFA (Omron BF 300 (O300)). DXA scans were performed using a Lunar iDXA. The data were analysed using Pearson's correlation and Bland Altman plots were also drawn to evaluate any agreements. RESULTS: The percentage and total body fat values were 49.2% and 55.2 kg measured with DXA, 44.3%/53.4 kg with O300, 50.6%/58.3 kg with O500, 45.4%/55.4 kg with H and 49.1%/60.3 kg with T. The Holtain BIA showed the worst correlation with DXA for both %BF and FFM. Although the measurements of % body fat, fat mass and fat-free mass were significantly correlated with DXA, each method showed wide limits of agreement, although T was most closely correlated with DXA. CONCLUSION: Compared to DXA, FFI and UBFA could be useful for assessing body composition in severely obese people, although they appeared to underestimate %BF and FM and their limits of agreement were too wide.

[The registry of home artificial nutrition and ambulatory of the Spanish Society of Parenteral and Enteral Nutrition; SWOT analysis]. / El registro de Nutrición Artificial Domiciliaria y Ambulatoria de la Sociedad Española de Nutrición Parenteral y Enteral; análisis DAFO.

OBJECTIVE: To evidence by means of a SWOT-R analysis performed by an expert consensus the most worrying characteristics of the register on Home-based and Outpatient Artificial Nutrition. MATERIAL AND METHODS: SWOT-R analysis with expert consensus. We requested the participation of the active members of the NADYA group within the last 5 years with the premise of structuring the SWOT-R based on the characteristics of the NADYA registry from its beginning. RESULTS: 18 experts from hospitals all over Spain have participated. The internal analysis seems to be positive, presenting the registry as having important resources. The external analysis did not show a great number of threats, there are very potent factors, "the voluntariness" of the registry and the "dependence on external financing". The opportunities identified are important. The recommendations are aimed at stabilizing the system by decreasing the threats as one of the main focus of the strategies to develop as well as promoting the items identified as opportunities and strengths. CONCLUSIONS: The analysis shows that the NADYA register shows a big potentiality for improvement. The proposed recommendations should be structured in order to stay on the track of development and quality improvement that has characterized the NADYA register from the beginning.

[Effect of nutritional support on survival in patients with amyotrophic lateral sclerosis]. / Efecto del soporte nutricional sobre la supervivencia en pacientes con esclerosis lateral amiotrófica.

INTRODUCTION: Malnutrition affects morbidity and mortality of patients with ALS. The nutrition unit should evaluate these patients early and regularly providing the necessary steps in the evolution of the disease. METHODS: A retrospective cohort study in which we analyzed 46 patients diagnosed with ALS, 21 of them received nutritional therapy. We studied age, mode of onset, date of entry into a nutritional protocol, placement of PEG and survival. We performed a test of Breslow comparing patients who were at nutritional protocol with those not receiving nutritional support, and those who received early nutritional therapy with those with delayed nutrition. RESULTS: There was an increase in median survival for patients in nutritional therapy in bulbar ALS (452 vs 55 days) and in spinal ALS (1,798 vs 357 days) (p = 0.002). The median delay in the initiation of nutritional therapy in spinal ALS was 557 days while in bulbar ALS was 230 days. The survival in the spinal ALS of those who entered into nutritional protocol before the median survival was 325 days to 181 days (p = 0.09) while in bulbar ALS those who entered before had a median survival of 435 days to 177 days (p = 0.38). CONCLUSIONS: The entry of patients with ALS in a nutritional protocol increases survival. There is an advantage in the evolution of patients with early nutritional treatment.

[Changes on dietary habits of the late-breakfast in a school population]. / Modificación de los hábitos alimentarios del almuerzo en una población escolar.

BACKGROUND: The establishment of healthy eating habits in children at school and in family life is very important for preventing obesity in children. AIMS: To know the habits of late-breakfast in a scholar population, the prevalence of overweight and obesity, and establish healthy dietary habits through the late-breakfast. METHODS: A prospective interventional study was performed in a school group. Children from 10 to 13 years-old were included. The study had three phases: pre-intervention (anthropometric assessment and questionnaire of late-breakfast frequency), intervention (parents and teachers received information about "the importance of proper nutrition in school" focused on the transcendence of a healthy and balanced diet that includes a suitable late-breakfast every day at school, and the students received the late-breakfast during two weeks that included milk, fruit and a traditional sandwich), and post-intervention (questionnaire of late-breakfast frequency). RESULTS: Frequency of overweight was 10.6% and obesity 2.6%. After the intervention the proportion of children who had late-breakfast increased by 9.2%, and the kind of food which they ate changed. CONCLUSION: Dietary habits can be modified in a scholar population with an easy nutritional intervention.