Lifestyle genomics and the metabolic syndrome: A review of genetic variants that influence response to diet and exercise interventions.

Metabolic syndrome (MetS) comprises a cluster of risk factors that includes central obesity, dyslipidemia, impaired glucose homeostasis and hypertension. Individuals with MetS have elevated risk of type 2 diabetes and cardiovascular disease; thus placing significant burdens on social and healthcare systems. Lifestyle interventions (comprised of diet, exercise or a combination of both) are routinely recommended as the first line of treatment for MetS. Only a proportion of people respond, and it has been assumed that psychological and social aspects primarily account for these differences. However, the etiology of MetS is multifactorial and stems, in part, on a person's genetic make-up. Numerous single nucleotide polymorphisms (SNPs) are associated with the various components of MetS, and several of these SNPs have been shown to modify a person's response to lifestyle interventions. Consequently, genetic variants can influence the extent to which a person responds to changes in diet and/or exercise. The goal of this review is to highlight SNPs reported to influence the magnitude of change in body weight, dyslipidemia, glucose homeostasis and blood pressure during lifestyle interventions aimed at improving MetS components. Knowledge regarding these genetic variants and their ability to modulate a person's response will provide additional context for improving the effectiveness of personalized lifestyle interventions that aim to reduce the risks associated with MetS.

Patient experiences of a lifestyle program for metabolic syndrome offered in family medicine clinics: a mixed methods study.

BACKGROUND: Patient perspectives on new programs to manage metabolic syndrome (MetS) are critical to evaluate for possible implementation in the primary healthcare system. Participants' perspectives were sought for the Canadian Health Advanced by Nutrition and Graded Exercise (CHANGE) study, which enrolled 293 participants, and demonstrated 19% reversal of MetS after 1 year. The main purpose of this study was to examine participants' perceptions of their experiences with the CHANGE program, enablers and barriers to change. METHODS: A convergent parallel mixed methods design combined patients' perspectives collected by questionnaires (n = 164), with insights from focus groups (n = 41) from three sites across Canada. Qualitative data were thematically analyzed using interpretative description. Insights were organized within a socio-ecologic framework. RESULTS: Key aspects identified by participants included intra-individual factors (personal agency, increased time availability), inter-individual factors (trust, social aspects) and organizational factors (increased mental health support, tailored programs). CONCLUSION: Results revealed participants' overall support for the CHANGE program, especially the importance of an extended program under the guidance of a family physician along with a skilled and supportive team. Team delivery of a lifestyle program in primary care or family medicine clinics is a complex intervention and use of a mixed methods design was helpful for exploring patient experiences and key issues on enablers and barriers to health behavior change.

A randomized trial of supplemental parenteral nutrition in underweight and overweight critically ill patients: the TOP-UP pilot trial.

BACKGROUND: Nutrition guidelines recommendations differ on the use of parenteral nutrition (PN), and existing clinical trial data are inconclusive. Our recent observational data show that amounts of energy/protein received early in the intensive care unit (ICU) affect patient mortality, particularly for inadequate nutrition intake in patients with body mass indices (BMIs) of <25 or >35. Thus, we hypothesized increased nutrition delivery via supplemental PN (SPN) + enteral nutrition (EN) to underweight and obese ICU patients would improve 60-day survival and quality of life (QoL) versus usual care (EN alone). METHODS: In this multicenter, randomized, controlled pilot trial completed in 11 centers across four countries, adult ICU patients with acute respiratory failure expected to require mechanical ventilation for >72 hours and with a BMI of <25 or ≥35 were randomized to receive EN alone or SPN + EN to reach 100% of their prescribed nutrition goal for 7 days after randomization. The primary aim of this pilot trial was to achieve a 30% improvement in nutrition delivery. RESULTS: In total, 125 patients were enrolled. Over the first 7 post-randomization ICU days, patients in the SPN + EN arm had a 26% increase in delivered calories and protein, whereas patients in the EN-alone arm had a 22% increase (both p < 0.001). Surgical ICU patients received poorer EN nutrition delivery and had a significantly greater increase in calorie and protein delivery when receiving SPN versus medical ICU patients. SPN proved feasible to deliver with our prescribed protocol. In this pilot trial, no significant outcome differences were observed between groups, including no difference in infection risk. Potential, although statistically insignificant, trends of reduced hospital mortality and improved discharge functional outcomes and QoL outcomes in the SPN + EN group versus the EN-alone group were observed. CONCLUSIONS: Provision of SPN + EN significantly increased calorie/protein delivery over the first week of ICU residence versus EN alone. This was achieved with no increased infection risk. Given feasibility and consistent encouraging trends in hospital mortality, QoL, and functional endpoints, a full-scale trial of SPN powered to assess these clinical outcome endpoints in high-nutritional-risk ICU patients is indicated-potentially focusing on the more poorly EN-fed surgical ICU setting. TRIAL REGISTRATION: NCT01206166.

The CHANGE program: Exercise intervention in primary care.

PROBLEM ADDRESSED: Primary care settings require a feasible program for integrating lifestyle interventions, which can reverse metabolic abnormalities, for patients in practice. OBJECTIVE OF PROGRAM: To integrate a lifestyle intervention program into existing primary care clinics with an interprofessional approach that includes dietitians and kinesiologists. PROGRAM DESCRIPTION: Canadian Health Advanced by Nutrition and Graded Exercise (CHANGE) provides a personalized approach to nutrition and exercise modification focusing on patients with metabolic syndrome. With CHANGE, exercise intervention is individualized (ie, tailored to individual preferences) and graded (ie, intensity is built up slowly over time); supervision and implementation of the program is conducted in a collaborative fashion between the family physician and the kinesiologist. Patients undergo an initial fitness assessment that determines their baseline aerobic, strength, and flexibility scores, and the same assessment is performed at 3 months and at 12 months. CONCLUSION: The CHANGE program demonstrates how interprofessional primary care teams can support patients with metabolic syndrome in achieving their health goals. By including dietitians and kinesiologists in primary care settings to work alongside family doctors, many barriers to lifestyle interventions can be overcome. The team's collaborative understanding of the patient combined with the patient's own sense of urgency for change creates the opportunity for the formation of new healthy lifestyle habits. Although results are preliminary, CHANGE appears to be a feasible, implementable, and effective program.

Enteral versus parenteral nutrition in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Enteral nutrition (EN) is recommended as the preferred route for early nutrition therapy in critically ill adults over parenteral nutrition (PN). A recent large randomized controlled trial (RCT) showed no outcome differences between the two routes. The objective of this systematic review was to evaluate the effect of the route of nutrition (EN versus PN) on clinical outcomes of critically ill patients. METHODS: An electronic search from 1980 to 2016 was performed identifying relevant RCTs. Individual trial data were abstracted and methodological quality of included trials scored independently by two reviewers. The primary outcome was overall mortality and secondary outcomes included infectious complications, length of stay (LOS) and mechanical ventilation. Subgroup analyses were performed to examine the treatment effect by dissimilar caloric intakes, year of publication and trial methodology. We performed a test of asymmetry to assess for the presence of publication bias. RESULTS: A total of 18 RCTs studying 3347 patients met inclusion criteria. Median methodological score was 7 (range, 2-12). No effect on overall mortality was found (1.04, 95 % CI 0.82, 1.33, P = 0.75, heterogeneity I(2) = 11 %). EN compared to PN was associated with a significant reduction in infectious complications (RR 0.64, 95 % CI 0.48, 0.87, P = 0.004, I(2) = 47 %). This was more pronounced in the subgroup of RCTs where the PN group received significantly more calories (RR 0.55, 95 % CI 0.37, 0.82, P = 0.003, I(2) = 0 %), while no effect was seen in trials where EN and PN groups had a similar caloric intake (RR 0.94, 95 % CI 0.80, 1.10, P = 0.44, I(2) = 0 %; test for subgroup differences, P = 0.003). Year of publication and methodological quality did not influence these findings; however, a publication bias may be present as the test of asymmetry was significant (P = 0.003). EN was associated with significant reduction in ICU LOS (weighted mean difference [WMD] -0.80, 95 % CI -1.23, -0.37, P = 0.0003, I(2) = 0 %) while no significant differences in hospital LOS and mechanical ventilation were observed. CONCLUSIONS: In critically ill patients, the use of EN as compared to PN has no effect on overall mortality but decreases infectious complications and ICU LOS. This may be explained by the benefit of reduced macronutrient intake rather than the enteral route itself.

Factors associated with nutritional decline in hospitalised medical and surgical patients admitted for 7 d or more: a prospective cohort study.

This prospective cohort study was conducted in eighteen Canadian hospitals with the aim of examining factors associated with nutritional decline in medical and surgical patients. Nutritional decline was defined based on subjective global assessment (SGA) performed at admission and discharge. Data were collected on demographics, medical information, food intake and patients' satisfaction with nutrition care and meals during hospitalisation; 424 long-stay (≥7 d) patients were included; 38% of them had surgery; 51% were malnourished at admission (SGA B or C); 37% had in-hospital changes in SGA; 19·6% deteriorated (14·6% from SGA A to B/C and 5% from SGA B to C); 17·4% improved (10·6% from SGA B to A, 6·8% from SGA C to B/A); and 63·0 % patients were stable (34·4% were SGA A, 21·3% SGA B, 7·3% SGA C). One SGA C patient had weight loss ≥5%, likely due to fluid loss and was designated as stable. A subset of 364 patients with admission SGA A and B was included in the multiple logistic regression models to determine factors associated with nutritional decline. After controlling for SGA at admission and the presence of a surgical procedure, lower admission BMI, cancer, two or more diagnostic categories, new in-hospital infection, reduced food intake, dissatisfaction with food quality and illness affecting food intake were factors significantly associated with nutritional decline in medical patients. For surgical patients, only male sex was associated with nutritional decline. Factors associated with nutritional decline are different in medical and surgical patients. Identifying these factors may assist nutritional care.

The Integrated Nutrition Pathway for Acute Care (INPAC): Building consensus with a modified Delphi.

BACKGROUND: Malnutrition is commonly underdiagnosed and undertreated in acute care patients. Implementation of current pathways of care is limited, potentially as a result of the perception that they are not feasible with current resources. There is a need for a pathway based on expert consensus, best practice and evidence that addresses this crisis in acute care, while still being feasible for implementation. METHODS: A modified Delphi was used to develop consensus on a new pathway. Extant literature and other resources were reviewed to develop an evidence-informed background document and draft pathway, which were considered at a stakeholder meeting of 24 experts. Two rounds of an on-line Delphi survey were completed (n = 28 and 26 participants respectively). Diverse clinicians from four hospitals participated in focus groups to face validate the draft pathway and a final stakeholder meeting confirmed format changes to make the pathway conceptually clear and easy to follow for end-users. Experts involved in this process were researchers and clinicians from dietetics, medicine and nursing, including management and frontline personnel. RESULTS: 80% of stakeholders who were invited, participated in the first Delphi survey. The two rounds of the Delphi resulted in consensus for all but two minor components of the Integrated Nutrition Pathway for Acute Care (INPAC). The format of the INPAC was revised based on the input of focus group participants, stakeholders and investigators. CONCLUSIONS: This evidence-informed, consensus based pathway for nutrition care has greater depth and breadth than prior guidelines that were commonly based on systematic reviews. As extant evidence for many best practices is absent, the modified Delphi process has allowed for consensus to be developed based on better practices. Attention to feasibility during development has created a pathway that has greater implementation potential. External validation specifically with practitioner groups promoted a conceptually easy to use format. Test site implementation and evaluation is needed to identify resource requirements and demonstrate process and patient reported outcomes resulting from embedding INPAC into clinical practice.

Development of a Dietary Management Care Map for Metabolic Syndrome.

Metabolic syndrome (MetS) refers to a particular cluster of metabolic abnormalities (hypertension, dyslipidemia, type 2 diabetes, and visceral fat deposition) that can lead to a 1.5- to 2-fold increased relative risk of cardiovascular disease. Various combinations of healthier eating patterns and increased physical activity have been shown to improve metabolic abnormalities and reduce MetS prevalence. Dietitians who counsel MetS patients are challenged to integrate guidance from various medical management guidelines and research studies with effective behavioural change strategies and specific advice on what food and eating pattern changes will be most effective, feasible, and acceptable to clients. As part of a demonstration project that is currently underway, we developed a care map (decision aid) that represents the key decision processes involved in diet counselling for MetS. The care map is based on evidence from both clinical and health behaviour change studies and expert consensus and has undergone limited dietitian review. It is being used to help project dietitians clearly articulate their specific food intake change goals. Additional studies to directly compare counselling strategies could inform future development of the map. In the meantime, dietitians may find this care map helpful in clarifying counselling goals and strategies in this client group.

Malnutrition, fatigue, frailty, vulnerability, sarcopenia and cachexia: overlap of clinical features.

PURPOSE OF REVIEW: Malnutrition, fatigue, frailty, vulnerability, sarcopenia and cachexia all phenotypically present with the same features because they are subject to the operation of similar mechanistic factors. However, the conditions referred to above differ by which mechanism dominates the cause of the clinical condition. This review discusses the overlap and differences, which distinguish as well as unite these different conditions and allow a rationale for treatment. RECENT FINDINGS: In the continuum of malnutrition, cachexia, sarcopenia and frailty the recent activities focus on two areas. The first is a better understanding of the mechanisms of cachexia and sarcopenia and frailty. In particular, the differential effects of cytokines on muscle and on the hypothalamic system. The effects of inactivity promoting the loss of body mass in cachexia and sarcopenia as well as the positive effects of exercise. The second is the development of a synthesis of available literature to develop consensus documents about the definition, causes, diagnosis and treatment of cachexia, sarcopenia and frailty. SUMMARY: Loss of body tissues resulting in wasting is a common phenotype for several different conditions which can be caused by a combination of reduced food intake, excessive requirements, altered metabolism, sepsis, trauma, ageing and inactivity. They have been referred to loosely as malnutrition but in not all will respond to simply providing nutrients. In this review the common features and the differences as they relate to cause and response to treatment are discussed.

Key process features of personalized diet counselling in metabolic syndrome: secondary analysis of feasibility study in primary care.

BACKGROUND: Personalized diet counselling, as part of lifestyle change programs for cardiometabolic risk conditions (combinations of prediabetes or type 2 diabetes, hypertension, dyslipidemia and high waist circumference) has been shown to reduce progression to type 2 diabetes overall. To identify key process of care measures that could be linked to changes in diet, we undertook a secondary analysis of a Canadian pre-post study of lifestyle treatment of metabolic syndrome (MetS). Diet counselling process measures were documented and association with diet quality changes after 3 months were assessed. Results of the primary study showed 19% reversal of MetS after 1 year. METHODS: Registered dietitians (RDs) reported on contact time, specific food behaviour goals (FBG), behaviour change techniques (BCT; adapted from the Michie CALO-RE taxonomy) and teaching resources at each contact. Diet quality was measured by 2005 Canadian Healthy Eating Index (HEI-C) and assessed for possible associations with individual BCT and FBG. RESULTS: Food behaviour goals associated with improved HEI-C at 3 months were: poultry more than red meat, increased plant protein, increased fish, increased olive oil, increased fruits and vegetables, eating breakfast, increased milk and alternatives, healthier fats, healthier snacks and increased nuts, with an adverse association noted for more use (> 2 times/ 3 months) of the balanced meal concept (F test; p < 0.001). Of 16 BCT, goal setting accounted for 15% of all BCT recorded, yet more goal setting (> 3 times/3 months) was associated with poorer HEI-C at 3 months (F test; p = 0.007). Only self-monitoring, feedback on performance and focus on past success were associated with improved HEI-C. CONCLUSIONS: These results identify key aspects of process that impact diet quality. Documentation of both FBG and BCT is highly relevant in diet counselling and a summary diet quality score is a promising target for assessing short-term counselling success.

Relationship between Cardiometabolic Factors and the Response of Blood Pressure to a One-Year Primary Care Lifestyle Intervention in Metabolic Syndrome Patients.

Systemic hypertension has been recognized as a modifiable traditional cardiovascular risk factor and influenced by many factors such as eating habits, physical activity, diabetes, and obesity. The objective of this cross-sectional study was to identify factors that predict changes in blood pressure induced by a one-year lifestyle intervention in primary care settings involving a collaboration between family physicians, dietitians, and exercise specialists. Patients with metabolic syndrome diagnosis were recruited by family physicians participating in primary care lifestyle intervention among several family care clinics across Canada. Participants for whom all cardiometabolic data at the beginning (T0) and the end (T12) of the one-year intervention were available were included in the present analysis (n = 101). Patients visited the dietitian and the exercise specialist weekly for the first three months and monthly for the last nine months. Diet quality, exercise capacity, anthropometric indicators, and cardiometabolic variables were evaluated at T0 and at T12. The intervention induced a statistically significant decrease in waist circumference (WC), systolic (SBP) and diastolic (DBP) blood pressure, and plasma triglycerides, and an increase in cardiorespiratory fitness (estimated VO2max). Body weight (p < 0.001), body mass index (BMI) (p < 0.001), and fasting blood glucose (p = 0.006) reduction, and VO2max increase (p = 0.048) were all related to changes in SBP. WC was the only variable for which changes were significantly correlated with those in both SBP (p < 0.0001) and DBP (p = 0.0004). Variations in DBP were not associated with changes in other cardiometabolic variables to a statistically significant extent. Twelve participants were identified as adverse responders (AR) in both SBP and DBP and displayed less favorable changes in WC. The beneficial effects of the primary care lifestyle intervention on blood pressure were significantly associated with cardiometabolic variables, especially WC. These findings suggest that a structured lifestyle intervention in primary care can help improve cardiometabolic risk factors in patients with metabolic syndrome and that WC should be systematically measured to better stratify the patient's hypertension risk.

Evaluation of Nutrition Status Using the Subjective Global Assessment: Malnutrition, Cachexia, and Sarcopenia.

The subjective global assessment (SGA) is a nutrition assessment tool that refers to an overall evaluation of a patient's history and physical examination and uses structured clinical parameters to diagnose malnutrition. The SGA is known to be a reliable and valid tool that predicts morbidity and mortality associated with malnutrition. The objective of SGA is to identify patients likely to benefit from nutrition intervention and therefore to identify persons in whom inadequate nutrition intake or absorption explain features of malnutrition, including body wasting. There are other conditions that cause weight loss, muscle wasting, and fat loss, including cachexia and sarcopenia. Acknowledging that these 2 last conditions differ in their mechanism of body wasting and consequently in the outcomes of nutrition intervention, the practitioner needs a tool to identify when malnutrition is the dominating factor to explain body wasting. The SGA form has been revised to clearly reflect the key concepts behind the diagnosis of malnutrition and help to distinguish this condition from other wasting conditions. This review presents the revised SGA form and guidance document. Using case studies, it illustrates the 3 wasting conditions, their overlap, and how the SGA identifies malnutrition as a dominating factor of body wasting and thus individuals who require nutrition intervention.

Evaluation of Latent Models Assessing Physical Fitness and the Healthy Eating Index in Community Studies: Time-, Sex-, and Diabetes-Status Invariance.

Accurate measurement requires assessment of measurement equivalence/invariance (ME/I) to demonstrate that the tests/measurements perform equally well and measure the same underlying constructs across groups and over time. Using structural equation modeling, the measurement properties (stability and responsiveness) of intervention measures used in a study of metabolic syndrome (MetS) treatment in primary care offices, were assessed. The primary study (N = 293; mean age = 59 years) had achieved 19% reversal of MetS overall; yet neither diet quality nor aerobic capacity were correlated with declines in cardiovascular disease risk. Factor analytic methods were used to develop measurement models and factorial invariance were tested across three time points (baseline, 3-month, 12-month), sex (male/female), and diabetes status for the Canadian Healthy Eating Index (2005 HEI-C) and several fitness measures combined (percentile VO2 max from submaximal exercise, treadmill speed, curl-ups, push-ups). The model fit for the original HEI-C was poor and could account for the lack of associations in the primary study. A reduced HEI-C and a 4-item fitness model demonstrated excellent model fit and measurement equivalence across time, sex, and diabetes status. Increased use of factor analytic methods increases measurement precision, controls error, and improves ability to link interventions to expected clinical outcomes.

Zinc: an essential trace element for parenteral nutrition.

Zinc is an essential trace element for human nutrition that is an integral part of many enzyme systems, including DNA polymerase complex. Zinc deficiency has been associated with stunting of growth and sexual immaturity. In children, deficiency causes a fatal condition called acrodermatitis enteropathica. The same syndrome has been observed in patients on total parenteral nutrition (TPN) who do not receive zinc. In TPN the requirements have been estimated by balance studies to be 3 mg/d in patients without gastrointestinal losses and a mean of 12 mg/d in patients with diarrhea and fistula losses.

GLIM criteria has fair sensitivity and specificity for diagnosing malnutrition when using SGA as comparator.

BACKGROUND & AIMS: The Global Leadership Initiative on Malnutrition (GLIM) proposed a new framework for diagnosing malnutrition based on combinations of phenotypic and etiologic criteria. The aim of this study was to compare GLIM criteria to Subjective Global Assessment (SGA) judged to be the most validated standardized assessment of malnutrition. METHODS: This is a retrospective analysis of variables extracted from a prospective cohort study assessing malnutrition at admission, in 18 Canadian hospitals. Based on the available parameters, GLIM was compared to SGA using the following combinations of one phenotypic and one etiologic criteria: A. weight loss and low intake; B. weight loss and high C-reactive protein (CRP); C. low body mass index (BMI) and low intake; D. low BMI, high CRP. Data were not available for fat-free mass. Since all patients had acute or chronic active disease as per GLIM etiologic criterion, CRP was used as a more specific measure to define inflammation. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were calculated. Data are expressed as mean and Clopper-Pearson exact 95% confidence interval (CI). RESULTS: From 1022 patients in the original dataset, 784 had all considered parameters with a prevalence of malnutrition (SGA B or C) of 45.15% (CI 41.60, 48.70), where severe malnutrition (SGA C) was 11.73% (CI 9.57, 14.20). Using the available GLIM parameters with the above combinations of two-criteria, the prevalence of malnutrition was 33.29% (CI 30.00, 36.71) and severe malnutrition was 19.77% (CI 17.00, 22.70). For all criteria combinations of GLIM together versus SGA, sensitivity was 61.30% (CI 56.0, 66.4), specificity was 89.77% (CI 86.5, 92.5) and PPV was 83.14% (CI 78.0, 87.5) while NPV was 73.80 (CI 69.8, 77.5). Sensitivity was improved when only SGA C for severe malnutrition was used as the criterion (82.61%; CI 73.3, 89.7) but PPV was greatly reduced (29.12%; CI 23.7, 35.0). Similarly, when using GLIM criteria for severe malnutrition only, sensitivity improved (76.09%; CI 66.1, 84.4). Any two criteria combinations of GLIM had much poorer sensitivity with the highest being weight loss + high CRP (46.33%) with a specificity of 93.02% (PPV: 84.54%; NPV: 67.80%), while the combination of low BMI + low intake had the highest specificity (98.84%) but with a sensitivity of 15.54% (PPV 91.67%; NPV: 58.70%). CONCLUSIONS: Based on the CMTF dataset and using SGA as the most validated tool for diagnosing malnutrition, the two criteria combinations used for GLIM in the present study had fair criterion validity for the diagnosis of malnutrition, regardless of severity status. The best combinations were weight loss and high CRP or weight loss and low intake, both having high specificity at diagnosing malnutrition but unacceptably low sensitivity, and thus were considered poor. There may be potential for the full framework to be used to diagnose malnutrition, but individual combinations of two criteria when used exclusively will miss malnourished patients, as defined by SGA.

Prediction modelling of 1-year outcomes to a personalized lifestyle intervention for Canadians with metabolic syndrome.

Metabolic syndrome (MetS) comprises a cluster of risk factors that includes central obesity, hypertension, dyslipidemia, and impaired glucose homeostasis. Although lifestyle interventions reduce MetS risk, not everyone responds to the same extent. The primary objective of this study was to identify variables that could predict 1-year changes in MetS risk in individuals participating in the Canadian Health Advanced by Nutrition and Graded Exercise (CHANGE) program. Participants were allocated into training (n = 157) and test (n = 29) datasets by availability of genetic data. A linear mixed-effect model revealed that age, medication, fasting glucose, triglycerides, high-density lipoprotein cholesterol, waist circumference, systolic blood pressure, and fibre intake were associated with continuous MetS (cMetS) score across all time points. Multiple linear regressions were then used to build 2 prediction models using 1-year cMetS score as the outcome variable. Model 1 included only baseline variables and was 38% accurate for predicting cMetS score. Model 2 included both baseline variables and the 3-month change in cMetS score and was 86% accurate. As a secondary objective, we also examined if we could build a model to predict a person's categorical response bin (i.e., positive responder, nonresponder, or adverse responder) at 1 year using the same variables. We found 72% concordance between predicted and observed outcomes. These various prediction models need to be further tested in independent cohorts but provide a potentially promising new tool to project patient outcomes during lifestyle interventions for MetS. Novelty Short-term changes in cMetS score improve prediction model performance compared with only baseline variables. Predictive models could potentially facilitate clinical decision-making for personalized treatment plans.

Effect of teduglutide on restoring oral autonomy for magnesium in two patients with short bowel.

It is not known whether Teduglutide can allow patients with Short bowel syndrome, previously dependent on continuous or periodic intravenous (IV) magnesium, to attain oral autonomy with or without supplementation. Here, we report on two patients previously dependent on continuous or intermittently administered IV magnesium to achieve autonomy from IV, one with and one without oral supplementation that was previously ineffective in both patients.

Variations in practice patterns for adult cancer patients on home parenteral nutrition in Canada.

OBJECTIVES: Cancer has become a major indication for home parenteral nutrition (HPN). However, the use of HPN in adult cancer patients is highly variable between countries and may also differ within each country. The aim of the present study was to characterize regional variations in practice patterns for cancer patients on HPN using data from the Canadian HPN Registry. METHODS: This retrospective analysis included all cancer patients (n = 164) enrolled in the registry from 2005 to 2016. Patient demographic and clinical characteristics were described. Differences in baseline characteristics were evaluated by province and duration of HPN therapy. Survival was estimated with the Kaplan-Meier method and compared among different tumor types and provinces using the log-rank test. RESULTS: The most common tumors were gastrointestinal (54.2%) and gynecologic (31.8%). Most patients were from the provinces of Ontario (54.3%) and Alberta (41.5%). Patients who received HPN for ≥3 mo (64.6%) had a higher baseline Karnofsky Performance Status (80 versus 50) and albumin (35 versus 26 mmol/L) compared with those on HPN for <3 mo. There were no differences in survival based on tumor category. Patients in Ontario programs had a longer median survival (11.3 versus 7.1 mo) and higher proportion of secondary indications for HPN relative to patients in Alberta programs. CONCLUSIONS: Most cancer patients on HPN have gastrointestinal or gynecologic cancers. Those surviving for ≥3 mo have better baseline characteristics. Regional variability in the prevalence, selection, and survival of cancer patients receiving HPN suggests the need for consensus on the use of HPN in this population.

Nutrient intake and dietary quality changes within a personalized lifestyle intervention program for metabolic syndrome in primary care.

A team-based 12-month lifestyle program for the treatment of metabolic syndrome (MetS) (involving physicians, registered dietitians (RDs), and kinesiologists) was previously shown to reverse MetS in 19% of patients (95% confidence interval, 14% to 24%). This work evaluates changes in nutrient intake and diet quality over 12 months (n = 205). Individualized diet counselling was provided by 14 RDs at 3 centres. Two 24-h recalls, the Canadian Healthy Eating Index (HEI-C), and the Mediterranean Diet Score (MDS) were completed at each time point. Total energy intake decreased by 145 ± 586 kcal (mean ± SD) over 3 months with an additional 76 ± 452 kcal decrease over 3-12 months. HEI-C improved from 58 ± 15 to 69 ± 12 at 3 months and was maintained at 12 months. Similarly, MDS (n = 144) improved from 4.8 ± 1.2 to 6.2 ± 1.9 at 3 months and was maintained at 12 months. Changes were specific to certain food groups, with increased intake of fruits, vegetables, and nuts and decreased intake of "other foods" and "commercial baked goods" being the most prominent changes. There was limited change in intake of olive oil, fish, and legumes. Exploratory analysis suggested that poorer diet quality at baseline was associated with greater dietary changes as assessed by HEI-C. Novelty Multiple dietary assessment tools provided rich information on food intake changes in an intervention for metabolic syndrome. Improvements in diet were achieved by 3 months and maintained to 12 months. The results provide a basis for further dietary change implementation studies in the Canadian context.

The development of a novel intracolonic occlusion balloon for transcolonic natural orifice transluminal endoscopic surgery: description of the technique and early experience in a porcine model (with videos).

BACKGROUND: Transgastric and transvaginal approaches in natural orifice transluminal endoscopic surgery (NOTES) are the most commonly used, although the transcolonic approach may have some advantages. OBJECTIVE: To develop a workable technique for transcolonic NOTES. DESIGN: A nonsurvival study followed by a survival study in a porcine model. Transcolonic peritoneoscopy was performed with the use of a novel intracolonic occlusion balloon. The colotomy was closed with endoclips. A necropsy and histologic evaluation were performed 2 weeks after surgery. SETTING: Academic hospital, health science research center. SUBJECTS: Fifteen female Yorkshire pigs (5 nonsurvival, 10 survival). INTERVENTIONS: A balloon-tipped catheter was placed proximal to the colotomy site. The balloon was inflated to occlude the colonic lumen. An endoscope was inserted through the anus. Colonic incision was created with an endoscopic needle-knife at 15 to 20 cm from the anal verge. Peritoneoscopy was performed. The colotomy was closed with endoclips. MAIN OUTCOME MEASUREMENTS: Rates of complications, survival, healing, and adhesions. RESULTS: Two initial experiments were complicated by bowel distension and contamination of the incision area by colonic content. In the remaining 13 pigs, the experiments were performed with the use of the intracolonic occlusion balloon. No complications were documented. Necropsies were performed 2 weeks after surgery. Gross and histologic evaluations demonstrated near complete healing. Minimal adhesions were identified in 4 of 10 pigs. LIMITATION: Imperfection of the prototype balloon. CONCLUSIONS: Excessive bowel distension and fecal contamination because of spillage from the proximal bowel may be barriers to performing transcolonic NOTES. Isolation of the operative area by splitting the bowel and sealing the colonic lumen with the balloon above the colonic incision may overcome these problems and optimize the technique.