Predictors of Skeletal Muscle Index for Patients Treated With Hemodialysis.

OBJECTIVE: There is an increased risk of skeletal muscle mass (SMM) loss among patients with stage 5 chronic kidney disease treated with maintenance hemodialysis (MHD). The reduced SMM considerably influences the development of protein-energy wasting (PEW). Patients who develop PEW have higher hospitalization and mortality rates than those without PEW. This study determined if key variables could predict SMM Index (SMM adjusted for height) in patients receiving MHD. METHODS: We conducted a secondary analysis of cross-sectional data obtained from the Rutgers Nutrition and Kidney Database (n = 178). Data were used to calculate both SMM and SMM Index. Univariate and multiple linear regression models explored the relationship between SMM Index and the following variables: serum albumin, urea clearance normalized treatment ratio, normalized protein catabolic rate, serum creatinine, and urea reduction ratio (URR). RESULTS: Most participants were Black/African American (82.9%), male (59.1%), and obese (39%), with a mean age of 55.9 ± 11.9 years. The median Subjective Global Assessment score was 5, indicating a lower risk of malnutrition. Participants had a mean SMM of 26.4 kg and a median SMM Index of 8.9 kg/m2. Univariate regression modeling found URR to be a significant predictor of SMM Index, with increases in the percentage of URR predicting lower SMM Index values. The adjusted regression modeling found similar results, with increases in URR percentage predicting declines in SMM Index. CONCLUSION: This study found that URR was a predictor of SMM Index in patients receiving MHD. Further research is required to explore these relationships and provide clinicians with a more extensive array of tools to recognize early signs of SMM loss to prevent the progression of PEW.

Nutrition Support for Older Adults With Pressure Injuries Receiving Maintenance Hemodialysis: A Case Study.

Hemodialysis (HD) and pressure injuries (PI) are both hypercatabolic states that may contribute to protein-energy wasting development. These conditions require increased energy and protein to prevent losses from HD and support wound healing. Nutrition support therapy using intradialytic parenteral nutrition (IDPN) with or without a combination of oral nutrition supplements has yielded positive outcomes among patients receiving HD with protein-energy wasting. However, IDPN is not a standard of care for patients with PI and receiving HD. No existing guidelines support its use with these combined complex medical conditions. We present a case of an older adult with PI receiving HD who required supplemental IDPN. This case demonstrated that IDPN helps wound healing, reduces the hospital length of stay, and enhances quality of life.

Dietary Intake Correlated to Waist-To-Hip Ratio in Patients on Maintenance Hemodialysis.

OBJECTIVE: Individuals with end-stage kidney disease (ESKD) receiving maintenance hemodialysis (MHD) are at risk for protein-energy wasting (PEW). Inadequate dietary intake and altered anthropometrics are two criteria of the PEW diagnosis. This study explored whether individuals with ESKD on MHD meet the National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF-KDOQI) 2020 guidelines for nutritional adequacy on a dialysis treatment day (DD) and explored the relationship between dietary energy [DEI] and protein [DPI] intake and anthropometrics. METHODS: This was a secondary analysis of clinical and demographic data for 142 adults from the Rutgers Nutrition and Kidney Disease database. The study assessed the relationships between DEI, DPI, and anthropometrics, including body mass index (BMI), BMI category, waist circumference, and waist-to-hip ratio (WHR) using Pearson's or Spearman's correlation and one-way ANOVA. RESULTS: The sample had a median age of 55.7 years; 58% were male, 83.8% were Black/African American, with a median dialysis vintage of 42.0 months (e.g., 3.5 years). Seventy-five percent of the data sample were overweight or obese. The WHR was 1.0 ± 0.8 cm for males and 0.9 ± 0.1 for females. DEI and DPI on a DD did not meet the NKF-KDOQI 2020 guidelines. Median DEI was 17.6 ± 8.4 kcal/kg and DPI was 0.7 ± 0.4 g/kg. In the total sample, significant positive correlations were found between DEI (r = 0.74, P = 0.03) and DPI (r = 0.18, P = 0.037) and WHR. In females, a significant positive correlation was identified between DPI and WHR (r = 0.26, P = 0.046). CONCLUSIONS: These findings suggest that the nutritional intake of individuals with ESKD receiving MHD is inadequate to meet NKF-KDOQI 2020 guidelines on a DD. WHR may be a useful tool to assess alterations in anthropometrics related to DEI or DPI in this population, but more research is warranted.

Transitioning the eating experience in survivors of head and neck cancer.

PURPOSE: Applying the Social Cognitive Transition (SCT) Model of Adjustment as an interpretive framework, this mixed-methods case series explored how head and neck cancer (HNC) survivors participate in the dimensions of the eating experience (described as physiological, psychological, social, cultural). METHODS: This was a sub-study of a primary study, "The Natural History and Impact of Taste Change in Oncology Care." Qualitative interviews and quantitative data (questionnaires and exams) were intersected to examine and describe the complexities of transitioning the eating experience after treatment for HNC. Triangulation of qualitative and quantitative data within and across cases was examined to produce rich descriptions of the changes and transitions in the eating experience. RESULTS: Four case studies were detailed. All reported some taste and/or smell changes. Each case described worry about weight loss and the decreased ability to engage and finding meaning in the eating experience. Each expressed coping strategies that drew upon the social and cultural dimensions of their prior eating experience that brought meaning and purpose to the post-treatment eating experience. CONCLUSIONS: This case series explored the impact of taste and oral function and the participant's pre- and post-treatment mental model of the eating experience. Application of the SCT Model of Adjustment to the eating experience in adults with HNC provided a deeper insight into how cognitive adaptation and coping strategies supported transition in identity related to the eating experience following cancer therapy.

The Perceived Value of the Board-Certified Specialist in Renal Nutrition Credential Among Registered Dietitian Nutritionists Who Hold the Credential.

OBJECTIVE: Health care professionals who hold a specialist certification typically have a high perceived value of their credential. However, the perceived value of the board-certified specialist in renal nutrition (CSR) credential has not been studied. This study evaluated the perceived value of the CSR credential among registered dietitian nutritionists (RDNs) using the Perceived Value of Certification Tool (PVCT©) and explored differences in perceived values among those who did and did not receive reimbursement for taking the credentialing examination. METHODS: A cross-sectional internet-based survey was sent to 553 RDNs who held the CSR credential. The survey included the 18-item PVCT© including 12 intrinsic and 6 extrinsic value statements. Total, intrinsic, and extrinsic value scores and percent agreement were calculated. Value scores were compared using the Mann-Whitney U test to assess differences between those who received reimbursement and those who did not. RESULTS: The response rate was 33.3% (n = 184). Twelve of 18 value statements had >80% agreement. The median PVCT© scores were 61.0 of 72.0 for total, 43.5 of 48.0 for intrinsic, and 18.0 of 24.0 for extrinsic values. Those who received reimbursement had significantly higher perceived extrinsic value scores than those who did not (P = .041). Intrinsic and total value scores were higher but not significantly different in those who received reimbursement. The statements with the highest percent agreement were "validates specialized knowledge" and "provides evidence of professional commitment", and the lowest value statement was "increases salary". CONCLUSIONS: RDNs have a high perceived value of the CSR credential. Those who received reimbursement for their credential examination had higher extrinsic value. Future research should explore the value of the CSR credential among RDNs without the CSR credential and among stakeholders.

The effects of different IV fat emulsions on clinical outcomes in critically ill patients.

OBJECTIVE: To examine the effects of different IV fat emulsions on clinical outcomes in critically ill patients. DESIGN: Secondary analysis of data from a prospective multicenter study. SETTING: An international sample of ICUs. PATIENTS: Adult patients who were admitted to the ICU for more than 72 hours, were mechanically ventilated within 48 hours, received exclusive parenteral nutrition for more than or equal to 5 days, and did not change IV fat emulsion type during the data collection period. INTERVENTIONS: Demographic and clinical data were collected for up to 12 days, until death, or discharge from the ICU, whichever came first. Clinical outcomes were recorded at 60 days following ICU admission. MEASUREMENTS: Lipid-free, soybean, medium-chain triglyceride, olive, and fish oils in parenteral nutrition were compared using an adjusted Cox proportional hazard model to examine time to termination of mechanical ventilation alive, time to ICU discharge alive, and time to hospital discharge alive. MAIN RESULTS: A total of 451 patients were included in this study: 70 (15.5%) in the lipid-free group, 223 (49.5%) in the soybean oil group, 65 (14.4%) in the medium-chain triglyceride group, 74 (16.4%) in the olive oil group, and 19 (4.9%) in the fish oil group. When compared with lipid-free parenteral nutrition, patients who received fish oil had a faster time to ICU discharge alive (hazard ratio, 1.84; 95% CI, 1.01-3.34; p = 0.05). When compared with soybean oil, patients who received olive oil or fish oil had a shorter time to termination of mechanical ventilation alive (hazard ratio, 1.43; 95% CI, 1.06-1.93; p = 0.02 and hazard ratio, 1.67; 95% CI, 1.00-2.81; p = 0.05, respectively) and a shorter time to ICU discharge alive (hazard ratio, 1.76; 95% CI, 1.30-2.39; p < 0.001 and hazard ratio, 2.40; 95% CI, 1.43-4.03; p = 0.001, respectively). CONCLUSIONS: Use of alternative IV fat emulsions in parenteral nutrition, particularly olive and fish oil, was associated with improved clinical outcomes.

Online Education Improves Canadian Dietitians' Attitudes and Knowledge Regarding Recommending and Ordering Multivitamin/Mineral Supplements.

PURPOSE: To determine the attitudes and knowledge of Fraser Health registered dietitians (RDs) regarding recommending and ordering multivitamin/mineral supplements prior to and following an online education module. METHODS: The educational intervention consisted of narrated slides with electronic resources. After undergoing external review for face and content validity, 6 attitude questions and a 15-item knowledge test were administered pre- and postintervention. The attitude questionnaire utilized a 5-point Likert scale and had a maximum summative score of 30 points. The knowledge test was worth a maximum of 15 points. RESULTS: Of the eligible RDs (n = 123), 57 (46.3%) completed the study and 55 participants were included in the final analyses. Summative attitude scores were higher on the post-intervention questionnaire compared with the preintervention questionnaire (t = 92.5, P < 0.001). The proportion of correctly answered knowledge questions pre- (78.0% ± 10.0%) to postintervention (mean = 87.4% ± 6.0%) increased significantly (t = 7.16, P < 0.001). CONCLUSIONS: Postintervention, RD attitudes and knowledge improved confirming that the education strategy was effective. Future work should focus on optimizing the module and knowledge questions.

Registered dietitians' roles in decision-making processes for PEG placement in the elderly.

PURPOSE: The role of registered dietitians (RDs) in decision-making for percutaneous endoscopic gastrostomy (PEG) placement was explored. The ethical climate in their workplace and the relationship between decision-making and the ethical climate were examined. METHODS: The survey included 67 RDs in complex continuing care and long-term care settings in Ontario. Descriptive statistics were used to describe roles, ethical climate, and professional characteristics. Pearson's and nonparametric correlations were used to examine relationships between roles, ethical climate, and professional characteristics. RESULTS: Among the respondents, 97% thought RDs had a role in decision-making processes. The majority of RDs were usually or always involved in two roles: identifying relevant nutrition issues (91.2%) and discussing feeding options and alternatives (80.7%). Dietitians' roles in decision-making processes were more extensive when their relationship with physicians was positive (r=0.321, P=0.016), they had adequate knowledge (r=0.465, P<0.001) and adequate skills (r=0.520, P<0.001), and they were more satisfied with their role (r=0.554, P<0.001). CONCLUSIONS: Registered dietitians performed a variety of roles in decision-making processes concerning PEG placement in the elderly. A positive working relationship with physicians, knowledge, skills, and role satisfaction significantly increase RDs' involvement with patients and families.

Evidence-based practice attitudes and nutrition support guideline knowledge between holders and nonholders of the Certified Nutrition Support Clinician credential.

BACKGROUND: Clinical practice frequently changes, and professionals should stay abreast of evidence-based practice (EBP) guidelines. Negative attitudes towards EBP are a barrier to guideline adoption. This study explored EBP attitudes and knowledge of a complex nutrition support clinical case scenario of individuals holding or not holding the Certified Nutrition Support Clinician (CNSC) credential. METHODS: This cross-sectional study used an online survey sent to American Society for Parenteral and Enteral Nutrition (ASPEN) members with and without the CNSC credential and all CNSC credential holders from the National Board of Nutrition Support Certification email list. The survey included the Evidence-Based Practice Attitude Scale Score (EBPAS-15) and eight knowledge questions using a nutrition support case scenario. An independent samples t test compared knowledge and EBPAS-15 total scores and subscores between CNSC holders and nonholders. Pearson correlation determined the correlation between knowledge and EBPAS-15 scores. RESULTS: The response rate was 7.8% (N = 706). CNSC holders (n = 536) had significantly higher mean knowledge scores (4.7 ± 1.6 out of 8) than nonholders (n = 159, 4.1 ± 1.7) (P < 0.001). Total EBPAS-15 scores were not significantly different between CNSC holders (n = 542, 2.9 ± 0.4 out of 4) and nonholders (n = 164, 2.8 ± 0.7) (P = 0.434), and knowledge scores and total EBPAS-15 scores (P = 0.639) or subscores were not significantly correlated. CONCLUSIONS: Regardless of holding the CNSC credential, EBPAS-15 scores indicated respondents had positive EBP attitudes. CNSC holders had significantly higher knowledge scores of recent nutrition support EBP guidelines compared with non-CNSC credential holders. Positive EBP attitudes are a precursor to clinical decision-making, but future research should determine the use of guidelines in clinical practice.

Small-bore feeding tubes placed with an electromagnetic imaging device leads to cost avoidance and decreased time to initiation of enteral nutrition.

BACKGROUND: The Cortrak Enteral Access System (CEAS) was previously approved by the United States Food and Drug Administration (FDA) to be used in lieu of radiographic confirmation imaging for feeding tubes placed by trained clinicians. Following an institutional protocol change in 2016, our registered dietitians had the option to forgo radiographic confirmation imaging for tubes placed using the CEAS. Our research aimed to determine the difference in the number of radiographic confirmation images for feeding tubes placed using the CEAS between preprotocol and postprotocol environments and the associated cost avoidance after the institutional policy change. METHODS: We retrospectively reviewed data from 506 tube placements (n = 253 per protocol environment) in adult patients with diverse diagnoses admitted to various in-patient care units. RESULTS: There was a significant reduction in the mean number of radiographic images per tube placement (preprotocol = 1.10 [95% CI, 1.05-1.15]; postprotocol = 0.36 [95% CI, 0.30-0.41]; P < 0.001), leading to a cost avoidance of $67,282.80 for the 253 tube placements and a potential cost avoidance of $279,236 over the 5-year postprotocol environment. Additionally, the mean time to initiation of enteral nutrition was significantly reduced by 2.65 h in the postprotocol environment (P < 0.001). CONCLUSION: Our findings suggest that using the CEAS can reduce the number of radiographic images, provide cost avoidance, and improve nutrition outcomes. However, updated 2022 FDA regulatory changes to the use of the CEAS for tube confirmation lead to an uncertain future for this practice because of safety concerns.

Oral Urea Supplementation in the Treatment of Acute Hyponatremia among Hospitalized Adults: A Systematic Review.

Hyponatremia is the most common electrolyte disturbance among hospitalized adults. Oral urea is currently recommended in Europe in the treatment of chronic hyponatremia; no published systematic review investigating oral urea for acute hyponatremia among hospitalized adults exists. An oral urea supplement became available in the United States in 2016. This was a systematic review investigating the use of oral urea in the treatment of acute hyponatremia among hospitalized adults. Pubmed, CINAHL, Scopus, Web of Science, and Cochrane databases were searched for studies published between 1998 and 2021. Risk of bias was assessed using the ROBINS-I tool; strength of the evidence was assessed using GRADE criteria. Changes in serum sodium and measures of safety and tolerance were reported. Eight studies were identified that met inclusion criteria, which included a total of 296 patients. Seven studies were retrospective. All studies found an increase in serum sodium levels associated with oral urea supplementation. Side effects were minimal; one patient discontinued urea due to a side effect (dysgeusia). Urea dose/duration varied among the studies. Based on the serious risk of bias and GRADE criteria, the strength of the evidence was considered low. Oral urea supplementation was associated with increases in serum sodium concentrations among hospitalized adults with hyponatremia, and appears to be safe and well tolerated in this population. Prospective controlled trials are needed to establish the efficacy, comparative effectiveness, and potential cost savings of this therapy.Key teaching pointsHyponatremia is associated with negative clinical outcomes among hospitalized adults.Oral urea is now available in the United States, and is currently recommended in Europe to treat chronic hyponatremia.This systematic review shows that oral urea supplementation may be associated with increases in serum sodium levels among hospitalized adults with hyponatremia, and appears safe and well-tolerated; however, the studies reviewed here are at high risk of bias and the available evidence is of low quality, making any recommendation drawn from this data weak.Prospective controlled trials are needed to establish the efficacy, comparative effectiveness, and potential cost savings of oral urea supplementation for hyponatremia.

Expert Consensus Statement: Management of Dysphagia in Head and Neck Cancer Patients.

OBJECTIVE: To develop an expert consensus statement (ECS) on the management of dysphagia in head and neck cancer (HNC) patients to address controversies and offer opportunities for quality improvement. Dysphagia in HNC was defined as swallowing impairment in patients with cancers of the nasal cavity, paranasal sinuses, nasopharynx, oral cavity, oropharynx, larynx, or hypopharynx. METHODS: Development group members with expertise in dysphagia followed established guidelines for developing ECS. A professional search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements targeted at providers managing dysphagia in adult HNC populations. The development group prioritized topics where there was significant practice variation and topics that would improve the quality of HNC patient care if consensus were possible. RESULTS: The development group identified 60 candidate consensus statements, based on 75 initial proposed topics and questions, that focused on addressing the following high yield topics: (1) risk factors, (2) screening, (3) evaluation, (4) prevention, (5) interventions, and (6) surveillance. After 2 iterations of the Delphi survey and the removal of duplicative statements, 48 statements met the standardized definition for consensus; 12 statements were designated as no consensus. CONCLUSION: Expert consensus was achieved for 48 statements pertaining to risk factors, screening, evaluation, prevention, intervention, and surveillance for dysphagia in HNC patients. Clinicians can use these statements to improve quality of care, inform policy and protocols, and appreciate areas where there is no consensus. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to dysphagia in HNC patients.

Research Involvement Among Registered Dietitian Nutritionist Graduates of Three Clinical Nutrition Graduate Programs.

BACKGROUND: Rutgers University, in the northeast region of the US, offers three levels of clinical nutrition graduate programs with a strong focus on practice-based research competencies. However, the level of research involvement (RI) among alumni had not been assessed. METHODS: This study assessed RI among registered dietitian nutritionist (RDN) graduates of three clinical nutrition graduate programs (entry-level Master's of Science in Clinical Nutrition, post-professional Master's of Science in Clinical Nutrition, and Doctor of Clinical Nutrition) and evaluated if there was a relationship between RI scores and years of employment as an RDN. This was a cross-sectional study using the validated Practice-Based Dietitian Research Involvement Survey (PBDRIS) tool and included questions about sociodemographic and professional characteristics. Data were collected via an online survey, and the sample included 94 alumni from the past 25 years (usable response rate of 32.5%). Descriptive statistics, Mann-Whitney U and Spearman correlation tests were conducted. RESULTS: The median PBDRIS total score was 54.0 (out of 80.0). Level 1, consisting of applying evidence-based practice (EBP), was the highest median subscore (19.0 out of 20.0). The lowest median subscore was level 4 (11.0 out of 20.0), involving activities about leadership in research. The most and least frequently reported activities were "applying EBP" (83.0%) and "applying for grant funding" (62.8%), respectively. There was a statistically significant medium, positive correlation between years of employment as an RDN and PBDRIS total scores (r = 0.396, p < 0.001). CONCLUSIONS: RDN alumni from three clinical nutrition graduate programs had RI which likely reflects the unique research-based focus of the program curricula. With more years of experience as an RDN, RI scores increased.

Integration of patient-centered care in nutrition support decision-making: A case report.

Patient-centered care considers a patient's unique needs, values, preferences, and the psychosocial situation at the heart of decisions related to healthcare. Dietitians have reported several barriers to the practice of patient-centered care, including a lack of time and support and a perception that patients are unable to participate. This is meaningful as decisions regarding nutrition therapy, specifically in adult populations with cancer, influence patient morbidity and mortality and a patient's quality of life. Patient-centered care is associated with improved decision-making, patient-provider communication, and quality of life in patients with cancer. This case report discusses and applies patient-centered care in conjunction with the best available evidence for an adult patient with a history of head and neck cancer admitted to a critical care unit. Nutrition support clinicians are equipped to use a patient-centered and evidence-based approach to help patients navigate through nutrition therapy decisions that may influence both clinical and quality of life outcomes. Further research should be done to determine the association between patient-centered care and quality of life outcomes in nutrition support practice.

Risk factors and assessment considerations for essential fatty acid deficiency in nonparenterally fed patients using a case example.

Essential fatty acid deficiency (EFAD) has most commonly been reported in parenterally fed individuals but may also present in patients receiving fat-restricted diets and in patients with fat-malabsorption disorders. This article reviews the physical and biochemical assessment for EFAD in clinical practice and disorders of fat malabsorption as potential risk factors for EFAD. A case report is included to describe the fatty acid profile of a patient with exocrine pancreatic insufficiency receiving low-dose pancreatic enzyme replacement therapy after a self-imposed fat-restricted diet. The current challenges with laboratory interpretation of essential fatty acid status are also discussed.

Current methods for developing predictive energy equations in maintenance dialysis are imprecise.

PURPOSE: For individuals receiving maintenance dialysis, estimating accurate resting energy expenditure (REE) is essential for achieving energy balance, and preventing protein-energy wasting. Dialysis-specific, predictive energy equations (PEEs) offer a practical way to calculate REE. Three PEEs have been formulated via similar methods in different demographic samples; the Maintenance Haemodialysis Equation (MHDE REE), Vilar et al. Equation (Vilar REE) and the Fernandes et al. Equation (Cuppari REE). We compared them in a US cohort and assessed precision relative to measured REE (mREE) from indirect calorimetry. Because of expected imprecision at the extremes of the weight distribution, we also assessed the PEEs stratified by body mass index (BMI) subgroups. METHODS: This analysis comprised of 113 individuals from the Rutgers Nutrition and Kidney Database. Estimated REE (eREE) was calculated for each PEE, and agreement with mREE was set at > 50% of values within the limits of ±10%. Reliability and accuracy were determined using intraclass correlation (ICC) and a Bland Altman plot, which analysed the percentage difference of eREE form mREE. RESULTS: Participants were 58.4% male and 81.4% African American. Mean age was 55.8 ± 12.2 years, and the median BMI was 28.9 (IQR = 25.3 - 34.4) kg/m2. The MHDE REE achieved 58.4% of values within ±10% from mREE; Cuppari REE achieved 47.8% and Vilar REE achieved 46.0% agreement. Reliability was good for the MHDE REE (ICC = 0.826) and Cuppari REE (ICC = 0.801), and moderate for the Vilar REE (ICC = 0.642) (p < .001 for all). The equations performed poorly at the lowest and highest BMI categories. CONCLUSION: Dialysis-specific energy equations showed variable accuracy. When categorized by BMI, the equations performed poorly at the extremes, where individuals are most vulnerable. Innovation is needed to understand these variances and correct the imprecision in PEEs for clinical practice.KEY MESSAGESPotentially impacting over millions of patients worldwide, our long-term goal is to understand energy expenditure (EE) across the spectrum of CKD (stages 1-5) in adults and children being treated with dialysis or transplantation, with the intent of providing tools for the health professional that will improve the delivery of quality care.Our research has identified and focussed on disease-specific factors which account for 60% of the variance in predicting EE in patients on MHD, but significant gaps remain.Thus, our central hypotheses are that (1) there are unique disease-specific determinants of EE and (2) prediction of EE for individuals diagnosed with CKD can be vastly improved with a model that combines these factors with more sophisticated approaches.

Contributions of Structural Racism to the Food Environment: A Photovoice Study of Black Residents With Hypertension in Baltimore, MD.

BACKGROUND: Disproportionate exposure to poor food environments and food insecurity among Black Americans may partially explain critical chronic disease disparities by race and ethnicity. A complex set of structural factors and interactions between Black residents and their food environments, including store types, quantity, proximity, and quality of goods and consumer interactions within stores, may affect nutritional behaviors and contribute to higher cardiovascular and kidney disease risk. METHODS: We used the Photovoice methodology to explore the food environment in Baltimore, MD, through the perspectives of Black residents with hypertension between August and November 2019. Twenty-four participants were enrolled in the study (mean age: 65.1 years; 67% female). After a brief photography training, participants captured photos of their food environment, which they discussed in small focus groups over the course of 5 weeks. Discussions were audiotaped and analyzed for emergent themes using a line-by-line inductive approach. Themes were, then, organized into a collective narrative. RESULTS: Findings describe physical and social features of the food environment as well as participants' perceptions of its origins and holistic and generational health effects. The study illustrates the interrelationships among the broader socio-political environment, the quality and quantity of stores in the food landscape, and the ways in which they engage with the food environment as residents and consumers who have been marginalized due to their race and/or social class. The following meta-themes emerged from the data: (1) social injustice; (2) structural racism and classism; (3) interpersonal racism; (4) generational effects; (5) mistrust; (6) social programs; and (7) community asset-based approaches, including advocacy and civic engagement. CONCLUSIONS: Understanding residents' perceptions of the foundations and effects of the food environment on their health may help stakeholders to cocreate multilevel interventions alongside residents to improve access to healthy food and health outcomes among disparities affected populations.

Utilization of indirect calorimetry to assist in determining undiagnosed hypothyroidism in a patient on mechanical ventilation.

Published predictive equations are required when indirect calorimetry (IC) is unavailable in the clinical setting. Several medical conditions that are not accounted for by published predictive equations can impact a patient's resting energy expenditure, such as adrenal changes or alterations in thyroid-stimulating hormone (TSH). TSH levels significantly impact a patient's resting energy expenditure, with hypothyroidism decreasing and hyperthyroidism increasing energy requirements. Clinical hypothyroidism has been correlated with increased ventilator dependency in patients with critical illness and malnutrition. The following case study describes the utilization of IC to trigger a full evaluation for the diagnosis of hypothyroidism in an adult patient with multiple myeloma who was mechanically ventilated. IC results for this patient were 39% lower than estimated by predictive energy equations. TSH, thyroxine, and triiodothyronine serum assays were obtained to rule out hypothyroidism. Based on elevated TSH and low thyroxine, the patient was found to have undiagnosed hypothyroidism. Appropriate pharmaceutical and nutrition interventions were made based upon these results. This case demonstrates the impact hormonal changes can have on resting energy expenditure and how the utilization of IC can provide additional information other than energy requirements.

Food Insecurity Among Health Sciences Graduate Students at a Large Northeastern University.

OBJECTIVE: To determine the prevalence of food insecurity and the factors associated with it among health sciences graduate students. METHODS: A cross-sectional web-based survey conducted in 2019 on an urban health sciences campus of a large, public northeastern university among health sciences graduate students. Food security status was assessed using the US Department of Agriculture validated 6-item short-form food security module. RESULTS: Of the 302 respondents (response rate, 8.8%), the mean age ± SD was 28.8 ± 7.30 years; 28.5% were food insecure. After adjusting for other covariates, receiving loans was independently associated with higher odds of being food insecure (P < 0.001). CONCLUSIONS AND IMPLICATIONS: Universities may consider screening graduate students for food insecurity risk, especially those receiving student loans. Future research on this topic with graduate students and program administrators in other universities may help identify potential interventions. The impacts of the coronavirus disease 2019 pandemic on food insecurity among graduate students merit exploration to develop context-specific interventions.

Volume-Based vs Rate-Based Enteral Nutrition in the Intensive Care Unit: Impact on Nutrition Delivery and Glycemic Control.

BACKGROUND: Underfeeding with enteral nutrition (EN) is prevalent in intensive care units (ICUs) and associated with negative outcomes. This study evaluated the impact of volume-based EN (VBEN) vs rate-based EN (RBEN) on delivery of prescribed energy and protein, and glycemic control (GC). METHODS: This retrospective study included adult patients who require mechanical ventilation within 48 hours of ICU admission and with an RBEN (n = 85) or VBEN (n = 86) order for ≥3 consecutive days during the first 12 ICU days. RESULTS: Patients receiving VBEN, vs RBEN, received more prescribed energy (RBEN, 67.6%; VBEN, 79.6%; P < .001) and protein (RBEN, 68.6%; VBEN, 79.3%; P < .001). Multiple linear regression analyses confirmed VBEN was significantly associated with an 8.9% increase in energy (P = .002) and 7.7% increase in protein (P = .004) received, after adjusting for age, Acute Physiology and Chronic Health Evaluation II score, duration of and initiation day for EN, and ICU admission location. Presence of hyperglycemia (P = .40) and glycemic variability (GV) (P = .99) were not different between the 2 groups. After adjusting for age, body mass index, diabetes history, primary diagnosis, and percent of days receiving corticosteroids, GC outcomes (presence of hyperglycemia, P = .27; GV, P = .67) remained unrelated to EN order type in multivariable regression models. CONCLUSION: VBEN, compared with RBEN, was associated with increased energy and protein delivery without adversely affecting GC. These results suggest VBEN is an effective, safe strategy to enhance EN delivery in the ICU.