Energy Achievement Rate Is an Independent Factor Associated with Intensive Care Unit Mortality in High-Nutritional-Risk Patients with Acute Respiratory Distress Syndrome Requiring Prolonged Prone Positioning Therapy.

Early enteral nutrition (EN) and a nutrition target >60% are recommended for patients in the intensive care unit (ICU), even for those with acute respiratory distress syndrome (ARDS). Prolonged prone positioning (PP) therapy (>48 h) is the rescue therapy of ARDS, but it may worsen the feeding status because it requires the heavy sedation and total paralysis of patients. Our previous studies demonstrated that energy achievement rate (EAR) >65% was a good prognostic factor in ICU. However, its impact on the mortality of patients with ARDS requiring prolonged PP therapy remains unclear. We retrospectively analyzed 79 patients with high nutritional risk (modified nutrition risk in the critically ill; mNUTRIC score ≥5); and identified factors associated with ICU mortality by using a Cox regression model. Through univariate analysis, mNUTRIC score, comorbid with malignancy, actual energy intake, and EAR (%) were associated with ICU mortality. By multivariate analysis, EAR (%) was a strong predictive factor of ICU mortality (HR: 0.19, 95% CI: 0.07-0.56). EAR >65% was associated with lower 14-day, 28-day, and ICU mortality after adjustment for confounding factors. We suggest early EN and increase EAR >65% may benefit patients with ARDS who required prolonged PP therapy.

Food fortification with multiple micronutrients: impact on health outcomes in general population.

BACKGROUND: Vitamins and minerals are essential for growth and maintenance of a healthy body, and have a role in the functioning of almost every organ. Multiple interventions have been designed to improve micronutrient deficiency, and food fortification is one of them. OBJECTIVES: To assess the impact of food fortification with multiple micronutrients on health outcomes in the general population, including men, women and children. SEARCH METHODS: We searched electronic databases up to 29 August 2018, including the Cochrane Central Register of Controlled Trial (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register and Cochrane Public Health Specialised Register; MEDLINE; Embase, and 20 other databases, including clinical trial registries. There were no date or language restrictions. We checked reference lists of included studies and relevant systematic reviews for additional papers to be considered for inclusion. SELECTION CRITERIA: We included randomised controlled trials (RCTs), cluster-RCTs, quasi-randomised trials, controlled before-after (CBA) studies and interrupted time series (ITS) studies that assessed the impact of food fortification with multiple micronutrients (MMNs). Primary outcomes included anaemia, micronutrient deficiencies, anthropometric measures, morbidity, all-cause mortality and cause-specific mortality. Secondary outcomes included potential adverse outcomes, serum concentration of specific micronutrients, serum haemoglobin levels and neurodevelopmental and cognitive outcomes. We included food fortification studies from both high-income and low- and middle-income countries (LMICs). DATA COLLECTION AND ANALYSIS: Two review authors independently screened, extracted and quality-appraised the data from eligible studies. We carried out statistical analysis using Review Manager 5 software. We used random-effects meta-analysis for combining data, as the characteristics of study participants and interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables, using the GRADE approach. MAIN RESULTS: We identified 127 studies as relevant through title/abstract screening, and included 43 studies (48 papers) with 19,585 participants (17,878 children) in the review. All the included studies except three compared MMN fortification with placebo/no intervention. Two studies compared MMN fortification versus iodised salt and one study compared MMN fortification versus calcium fortification alone. Thirty-six studies targeted children; 20 studies were conducted in LMICs. Food vehicles used included staple foods, such as rice and flour; dairy products, including milk and yogurt; non-dairy beverages; biscuits; spreads; and salt. Fourteen of the studies were fully commercially funded, 13 had partial-commercial funding, 14 had non-commercial funding and two studies did not specify the source of funding. We rated all the evidence as of low to very low quality due to study limitations, imprecision, high heterogeneity and small sample size. When compared with placebo/no intervention, MMN fortification may reduce anaemia by 32% (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.56 to 0.84; 11 studies, 3746 participants; low-quality evidence), iron deficiency anaemia by 72% (RR 0.28, 95% CI 0.19 to 0.39; 6 studies, 2189 participants; low-quality evidence), iron deficiency by 56% (RR 0.44, 95% CI 0.32 to 0.60; 11 studies, 3289 participants; low-quality evidence); vitamin A deficiency by 58% (RR 0.42, 95% CI 0.28 to 0.62; 6 studies, 1482 participants; low-quality evidence), vitamin B2 deficiency by 64% (RR 0.36, 95% CI 0.19 to 0.68; 1 study, 296 participants; low-quality evidence), vitamin B6 deficiency by 91% (RR 0.09, 95% CI 0.02 to 0.38; 2 studies, 301 participants; low-quality evidence), vitamin B12 deficiency by 58% (RR 0.42, 95% CI 0.25 to 0.71; 3 studies, 728 participants; low-quality evidence), weight-for-age z-scores (WAZ) (mean difference (MD) 0.1, 95% CI 0.02 to 0.17; 8 studies, 2889 participants; low-quality evidence) and weight-for-height/length z-score (WHZ/WLZ) (MD 0.1, 95% CI 0.02 to 0.18; 6 studies, 1758 participants; low-quality evidence). We are uncertain about the effect of MMN fortification on zinc deficiency (RR 0.84, 95% CI 0.65 to 1.08; 5 studies, 1490 participants; low-quality evidence) and height/length-for-age z-score (HAZ/LAZ) (MD 0.09, 95% CI 0.01 to 0.18; 8 studies, 2889 participants; low-quality evidence). Most of the studies in this comparison were conducted in children. Subgroup analyses of funding sources (commercial versus non-commercial) and duration of intervention did not demonstrate any difference in effects, although this was a relatively small number of studies and the possible association between commercial funding and increased effect estimates has been demonstrated in the wider health literature. We could not conduct subgroup analysis by food vehicle and funding; since there were too few studies in each subgroup to draw any meaningful conclusions. When we compared MMNs versus iodised salt, we are uncertain about the effect of MMN fortification on anaemia (R 0.86, 95% CI 0.37 to 2.01; 1 study, 88 participants; very low-quality evidence), iron deficiency anaemia (RR 0.40, 95% CI 0.09 to 1.83; 2 studies, 245 participants; very low-quality evidence), iron deficiency (RR 0.98, 95% CI 0.82 to 1.17; 1 study, 88 participants; very low-quality evidence) and vitamin A deficiency (RR 0.19, 95% CI 0.07 to 0.55; 2 studies, 363 participants; very low-quality evidence). Both of the studies were conducted in children. Only one study conducted in children compared MMN fortification versus calcium fortification. None of the primary outcomes were reported in the study. None of the included studies reported on morbidity, adverse events, all-cause or cause-specific mortality. AUTHORS' CONCLUSIONS: The evidence from this review suggests that MMN fortification when compared to placebo/no intervention may reduce anaemia, iron deficiency anaemia and micronutrient deficiencies (iron, vitamin A, vitamin B2 and vitamin B6). We are uncertain of the effect of MMN fortification on anthropometric measures (HAZ/LAZ, WAZ and WHZ/WLZ). There are no data to suggest possible adverse effects of MMN fortification, and we could not draw reliable conclusions from various subgroup analyses due to a limited number of studies in each subgroup. We remain cautious about the level of commercial funding in this field, and the possibility that this may be associated with higher effect estimates, although subgroup analysis in this review did not demonstrate any impact of commercial funding. These findings are subject to study limitations, imprecision, high heterogeneity and small sample sizes, and we rated most of the evidence low to very low quality. and hence no concrete conclusions could be drawn from the findings of this review.

Management of Exocrine Pancreatic Insufficiency in Children.

The diagnosis of exocrine pancreatic insufficiency (EPI) can be difficult, as symptoms may be nonspecific. A delayed diagnosis of EPI can negatively impact health through poor weight gain, impaired growth, and malabsorption of nutrients. Because of active growth and development, children are more vulnerable to the consequences of untreated EPI. Pancreatic enzyme replacement therapy is the cornerstone of management and offers both symptomatic relief and improvement in clinical outcomes. Additionally, a high-energy diet with unrestricted fat and supplementation with fat-soluble vitamins is often required to optimize growth and prevent nutrition deficiencies. Cystic fibrosis (CF) is the most common condition in children that causes EPI, and improvement in nutrition management is associated with improved pulmonary function and increased survival. Currently, the management of other conditions leading to EPI in children is not well studied, and inferences from the CF literature are often necessary in caring for these patients.

Food and Agricultural Approaches to Reducing Malnutrition (FAARM): protocol for a cluster-randomised controlled trial to evaluate the impact of a Homestead Food Production programme on undernutrition in rural Bangladesh.

INTRODUCTION: Chronic undernutrition affects over 150 million children worldwide and has serious consequences. The causes are complex and include insufficient dietary diversity and poor hygiene practices. Systematic reviews of nutrition-sensitive agricultural interventions concluded that while these hold promise, there is insufficient evidence for their impact on child growth. The Food and Agricultural Approaches to Reducing Malnutrition (FAARM) project is a 1:1 cluster-randomised trial aiming to evaluate the impact of a Homestead Food Production (HFP) programme implemented by Helen Keller International on women's and children's undernutrition. METHODS AND ANALYSIS: The HFP intervention comprises training of women's groups and asset distribution to support year-round home gardening, poultry rearing and improved nutrition and hygiene practices. Formal trainings are supplemented by behaviour change communication during household visits, and facilitated links between producer groups and market actors. The FAARM trial will examine if and how this complex intervention reduces undernutrition. In 2015, FAARM enrolled married women and their children (0-3 years) in 96 rural settlements of Habiganj district in Sylhet division, Bangladesh. Covariate-constrained randomisation was used to assign 48 settlements to receive a 3-year HFP intervention, with the other 48 acting as controls, targeting over 2700 women. To study impact pathways, a surveillance system collects data on all participants every 2 months. In late 2019, children 0-3 years of age (born during the intervention period) will be surveyed, thus capturing impact during the critical first 1000 days of life. Children's length/height-for-age z-scores will be compared between intervention and control arms using mixed-effects linear regression. Secondary outcomes include women's and children's micronutrient status, dietary intake, dietary diversity and other indicators of child growth, development and morbidity. ETHICS AND DISSEMINATION: Ethical approval was received in Bangladesh and Germany. Results will be disseminated through peer-reviewed publications and presentations in Bangladesh and internationally. TRIAL REGISTRATION NUMBER: NCT02505711; Pre-results.

Effects of current parenteral nutrition treatment on health-related quality of life, physical function, nutritional status, survival and adverse events exclusively in patients with advanced cancer: A systematic literature review.

BACKGROUND: The aim was to evaluate the effects of current parenteral nutrition (PN) treatment on clinical outcomes in patients with advanced cancer. METHODS: This review was conducted according to the PRISMA guidelines (PROSPERO ID: 4201707915). RESULTS: Two underpowered randomized controlled trials and six observational studies were retrieved (n = 894 patients). Health-related quality of life and physical function may improve during anti-neoplastic treatment in who PN treatment is the only feeding opportunity, but not necessarily in patients able to feed enterally. Nutritional status may improve in patients regardless of anti-neoplastic treatment and gastrointestinal function. PN treatment was neither superior to fluid in terminal patients nor to dietary counselling in patients able to feed enterally in regards to survival. The total incidence of adverse events was low. CONCLUSION: Current PN treatment in patients with advanced cancer is understudied and the level of evidence is weak.

Application of Acyzol in the Context of Zinc Deficiency and Perspectives.

Zinc is one of the most important essential trace elements. It is involved in more than 300 enzyme systems and is an indispensable participant in many biochemical processes. Zinc deficiency causes a number of disorders in the human body, the main ones being the delay of growth and puberty, immune disorders, and cognitive dysfunctions. There are over two billion people in the world suffering from zinc deficiency conditions. Acyzol, a zinc-containing medicine, developed as an antidote against carbon monoxide poisoning, demonstrates a wide range of pharmacological activities: Anti-inflammatory, reparative, detoxifying, immunomodulatory, bacteriostatic, hepatoprotective, adaptogenic, antioxidant, antihypoxic, and cardioprotective. The presence of zinc in the composition of Acyzol suggests the potential of the drug in the treatment and prevention of zinc deficiency conditions, such as Prasad's disease, immune system pathology, alopecia, allergodermatoses, prostate dysfunction, psoriasis, stomatitis, periodontitis, and delayed mental and physical development in children. Currently, the efficiency of Acyzol in the cases of zinc deficiency is shown in a large number of experimental studies. So, Acyzol can be used as a highly effective drug for pharmacologic therapy of a wide range of diseases and conditions and it opens up new perspectives in the treatment and prevention of zinc deficiency conditions.

Nutritional management in renal transplant recipients: A transplant team opportunity to improve graft survival.

AIMS: The nutritional management of renal transplant recipients (RTR) represents a complex problem either because the recovery of renal function is not complete and for the appearance of "unavoidable" metabolic side effects of immunosuppressive drugs. Nevertheless, it remains a neglected problem, whereas an appropriate dietary intervention could favorably affect graft survival. DATA SYNTHESIS: Renal transplantation is associated with steroids and calcineurin inhibitors administration, liberalization of diet after dialysis restrictions, and patients' better quality of life. These factors predispose, from the first months after surgery, to body weight gain, enhanced post transplant diabetes, hyperlipidemia, metabolic syndrome, with negative consequences on graft outcome. Unfortunately, specific guidelines about this topic and nutritional counseling are scarce; moreover, beyond the low adherence of patients to any dietary plan, there is a dangerous underestimation of the problem by physicians, sometimes with inadequate interventions. A prompt and specific nutritional management of RTR can help prevent or minimize these metabolic alterations, mostly when associated with careful and repeated counseling. CONCLUSIONS: A correct nutritional management, possibly tailored to enhance patients' motivation and adherence, represents the best preventive maneuver to increase patients' life and probably improve graft survival, at no cost and with no side effects.

Alternative Ernährungsformen: Allgemeine Aspekte und vegetarische Kostformen.

Alternative diets (AD) differ from the current common mixed diet; AD are recommended as a permanent diet. These diets are based on ethical, philosophical and health promoting principles and lead to very different recommendations for food selection. Even within a particular AD there is usually a broad spectrum of versions, so that a general evaluation is only possible to a limited extent. This is also true for single AD. Vegetarian diets and partly paleo-diets have been investigated to a reasonable extent. Plant based diets are appropriate as permanent diets and offer health benefits as compared with currently practiced diets (risk reduction of cancers by 10-18% and of heart diseases by 30%; favorable effect on blood pressure and lipid profile; no risk reduction on cancer and total mortality). Vegan diets have to be critically assessed: they are linked to an increased risk of deficits for single nutrients (vitamin B12, iodine and as the case may be. calcium and long chain omega-3 fatty acids), if suitable supplements or fortified foods are not consumed.

Considerations for Secondary Prevention of Nutritional Deficiencies in High-Risk Groups in High-Income Countries.

Surveys in high-income countries show that inadequacies and deficiencies can be common for some nutrients, particularly in vulnerable subgroups of the population. Inadequate intakes, high requirements for rapid growth and development, or age- or disease-related impairments in nutrient intake, digestion, absorption, or increased nutrient losses can lead to micronutrient deficiencies. The consequent subclinical conditions are difficult to recognize if not screened for and often go unnoticed. Nutrient deficiencies can be persistent despite primary nutrition interventions that are aimed at improving dietary intakes. Secondary prevention that targets groups at high risk of inadequacy or deficiency, such as in the primary care setting, can be a useful complementary approach to address persistent nutritional gaps. However, this strategy is often underestimated and overlooked as potentially cost-effective means to prevent future health care costs and to improve the health and quality of life of individuals. In this paper, the authors discuss key appraisal criteria to consider when evaluating the benefits and disadvantages of a secondary prevention of nutrient deficiencies through screening.

Long-term nutritional impact of sleeve gastrectomy.

BACKGROUND: Sleeve gastrectomy (SG) has become a predominant bariatric procedure throughout the world. However, the long-term nutritional impact of this procedure is unknown. OBJECTIVES: To describe the nutritional deficiencies before and after SG and to analyze the influence of baseline weight on nutritional status. SETTING: University-affiliated tertiary care center. METHODS: All patients who underwent SG as a standalone procedure between 2008 and 2012 were included in this study. Patients were given multivitamin supplementation. Data were obtained from our prospectively maintained electronic database and are reported as mean ± standard deviation and percentage. Bivariate analyses were conducted to evaluate the influence of selected variables on outcomes. RESULTS: The mean age of the 537 patients was 48.0 ± 11.3 years, with an initial body mass index of 48.1 ± 8.7 kg/m2. Excess weight loss and total weight loss were 56.2% and 28.0% at 1 year and 43.0% and 21.1% at 5 years, respectively (P<.0001). Percentage of follow-up was 74% at 5 years (n = 79). The mean follow-up time was 34.3 ± 17.2 months. Hypoalbuminemia was present in 1.1% preoperatively and 4.2% at 5 years (P = .0043), low ferritin levels in 8.6% and 37.8% (P<.0001), low vitamin B12 in 30.3% and 16.4% (P<.0001), low vitamin D 63.2% and 24.3% (P<.0001), and hyperparathyroidism in 23.4% and 20.8% (P<.0001). There was no significant difference in the prevalence of anemia over time (P = 0.4301). The prevalence of vitamin A insufficiency peaked from 7.9% preoperatively to 28.7% at 3 months (P<.0001) and returned to baseline thereafter. Baseline weight was negatively correlated with vitamin B12 and vitamin D. CONCLUSION: Nutritional deficiencies are common in patients with morbid obesity before and after surgery. Preoperative supplementation and long-term nutritional follow-up are required to prevent nutritional deficiencies.

[Nutrition of Polymorbid Patients - Data or Opinions?] / Ernährung bei multimorbiden Patienten ­ Daten oder Meinungen?

Polymorbidity and old age are rather the rule than the exception in hospitalised patients. Malnutrition is common in such patients and should be identified by appropriate screening and assessment measures in order to devise a nutrition plan and act accordingly. Unlike in the UK or The Netherlands, malnutrition screening and nutrition teams are not mandatory for German hospitals. Malnutrition and, in particular, sarcopenia are indicators of a nutrition associated risk or increased morbidity and mortality. Malnutrition can affect patients of any medical discipline and, therefore, is managed most efficiently by the interdisciplinary and multiprofessional nutrition team. By this approach goal directed nutrition therapy can improve morbidity and mortality of hospitalised patients.

Critical Care Nutrition: Where's the Evidence?

The surgical critically ill patient is subject to a variable and complex metabolic response, which has detrimental effects on immunity, wound healing, and preservation of lean body muscle. The concept of nutrition support has evolved into nutrition therapy, whereby the primary objectives are to prevent oxidative cell injury, modulate the immune response, and attenuate the metabolic response. This review outlines the metabolic response to critical illness, describes nutritional risk; reviews the evidence for the role, dose, and timing of enteral and parenteral nutrition, and reviews the evidence for immunonutrition in the surgical intensive care unit.

The low-FODMAP diet for irritable bowel syndrome: Lights and shadows / Dieta con bajo contenido en FODMAP para el síndrome del intestino irritable: luces y sombras

Irritable bowel syndrome (IBS) affects 10-15% of the western population. Drug therapy for this entity has shown limited efficacy. The low Fermentable Oligo-, Di-, Monosaccharides And Polyols (FODMAP) diet has recently emerged as an effective intervention for reducing gastrointestinal symptoms in IBS. Currently, several mechanistic studies have proven the rational basis of carbohydrate restriction. In addition, high-quality evidence (prospective studies and randomized controlled trials) from a variety of countries supports the high effectiveness of a low-FODMAP diet for IBS symptoms (70%), especially abdominal bloating, pain, and diarrhea. Importantly, this diet seems to be superior to a gluten-free diet for patients with non-celiac gluten sensitivity. The most controversial features of the low FODMAP diet are its short- and long-term limitations (a high level of restriction, the need for monitoring by an expert dietitian, potential nutritional deficiencies, significant gut microbiota reduction, lack of predictors of response), as well as the potential lack of advantage over alternative dietary, pharmacological and psychological interventions for IBS. Although liberalization of carbohydrate intake is recommended in the long-term, the reintroduction process remains to be clarified as, theoretically, global carbohydrate restriction is deemed to be necessary to avoid additive effects

El síndrome de intestino irritable (SII) es una entidad clínica que afecta al 10-15% de la población occidental, para la que los fármacos disponibles han demostrado una eficacia limitada. La dieta con bajo contenido en oligo, di, monosacáridos y polioles (FODMAP) ha surgido recientemente como una medida eficaz para el control de los síntomas gastrointestinales del SII. En la actualidad, los estudios fisiopatológicos han confirmado la base racional de la restricción de carbohidratos en el SII y existe evidencia científica de alta calidad (estudios prospectivos y ensayos clínicos controlados) proveniente de diversos países confirmado la eficacia de la dieta con bajo contenido en FODMAP para el SII (70%), especialmente para la hinchazón y dolor abdominal, así como la diarrea. Cabe destacar que esta dieta parece ser más eficaz que la dieta sin gluten para los pacientes con sensibilidad al gluten no celíaca. Los aspectos más controvertidos de esta dieta son las limitaciones que implica a corto y largo plazo (nivel alto de restricción alimentaria, la necesidad de monitorización por dietistas, riesgo de déficits nutricionales, una descenso marcado de la microbiota intestinal, la ausencia de herramientas predictoras de respuesta), al igual que una eficacia similar a otras intervenciones dietéticas menos restrictivas, farmacológicas y psicológicas en recientes estudios. Pese a que se recomienda liberalizar el consumo de carbohidratos a largo plazo, queda por dilucidar con exactitud la estrategia de reintroducción, ya que teóricamente el éxito de la dieta reside en una restricción global de carbohidratos para evitar efectos aditivos

Optimizing Performance, Health, and Well-being: Nutritional Factors.

Nutrition is essential for maintaining peak health and performance of Warfighters. This review will focus on a series of nutrients of concern for female Warfighters. Biological function, dietary sources, and requirements will be reviewed, and recommendations for women in combat roles will be provided. Iron, essential for physical and cognitive performance, is critical for female Warfighters because of elevated dietary requirements as compared to male Warfighters, as well as declines in iron status that may occur in response to physical activities, such as military training. Calcium and vitamin D are essential for bone health, and should be considered in efforts to prevent stress fractures, which occur with greater frequency in female Warfighters as compared to their male counterparts. Folate, essential for the prevention of neural tube defects during pregnancy and gestation, is critical for female Warfighters because of elevated dietary requirements before pregnancy. Providing optimal levels of these nutrients will facilitate readiness as women prepare to serve in combat roles.

[Vitamin and mineral supplements: regulation, consumption, and health implications]. / Suplementos vitamínicos e/ou minerais: regulamentação, consumo e implicações à saúde.

Micronutrient supplementation to reduce nutritional deficiencies has grown in recent years due to changes in the population's dietary patterns. Widespread preoccupation with health, ease in marketing vitamin and mineral supplements, and strong advertising appeal have encouraged increasing consumption of these products, thereby posing health risks. The current study addresses legislation, consumption, and health risks related to vitamin and mineral supplements in Brazil. The Brazilian legislation on dietary supplements is complex. Studies on their consumption by the Brazilian population are limited, and inappropriate use due to gaps in knowledge poses a potential health risk to the population. The study concludes that public policies are needed to raise awareness on this topic among the general public, health professionals, and sales personnel.

Suplementos vitamínicos e/ou minerais: regulamentação, consumo e implicações à saúde / Vitamin and mineral supplements: regulation, consumption, and health implications / Suplementos de vitaminas y/o minerales: normativas, consumo e implicaciones en la salud

Em decorrência das mudanças no padrão alimentar da população, a suplementação da dieta com micronutrientes é prática comum. A preocupação com a saúde e a facilidade de comercialização dos suplementos vitamínicos e/ou minerais, aliadas ao forte apelo publicitário, têm estimulado a população ao consumo indiscriminado desses produtos, o que pode acarretar riscos à saúde. Este trabalho teve como objetivo avaliar a legislação relativa ao cenário do consumo e segurança do uso de suplementos vitamínicos e/ou minerais no Brasil. Verificou-se que as legislações brasileiras a esse respeito são complexas, dificultando o entendimento das normas e a aplicação destas. Estudos sobre o consumo de suplementos pela população brasileira são limitados, e o consumo inadequado por falta de conhecimento é um potencial risco à saúde da população. Concluiu-se que há necessidade de implementação de políticas públicas que promovam o esclarecimento da população, dos profissionais da área de saúde e do comércio sobre o assunto.

Micronutrient supplementation to reduce nutritional deficiencies has grown in recent years due to changes in the population’s dietary patterns. Widespread preoccupation with health, ease in marketing vitamin and mineral supplements, and strong advertising appeal have encouraged increasing consumption of these products, thereby posing health risks. The current study addresses legislation, consumption, and health risks related to vitamin and mineral supplements in Brazil. The Brazilian legislation on dietary supplements is complex. Studies on their consumption by the Brazilian population are limited, and inappropriate use due to gaps in knowledge poses a potential health risk to the population. The study concludes that public policies are needed to raise awareness on this topic among the general public, health professionals, and sales personnel.

Como resultado de los cambios en los hábitos alimenticios de la población, el consumo de suplementos alimenticios con micronutrientes es una práctica común. La preocupación sobre la salud y la comercialización de suplementos de vitaminas y/o minerales, combinadas con el fuerte atractivo de la publicidad, han animado a la población al consumo indiscriminado de estos productos, que pueden ocasionar riesgos a la salud. Este trabajo tuvo como objetivo evaluar la legislación existente, en relación con el consumo y seguridad en el uso de suplementos de vitaminas y/o minerales. Se descubrió que la legislación brasileña -en materia de suplementos alimenticios- es compleja y difícil de entender, así como la aplicación de la normativa. Los estudios de su consumo por parte de la población son limitados, y el consumo inadecuado por falta de conocimientos es un riesgo potencial para la salud pública. Se concluye que existe la necesidad de implementar políticas públicas que promuevan la transparencia de la información a la población, profesionales de la salud y comercio sobre este tema.

The epidemiology of global micronutrient deficiencies.

Micronutrients are essential to sustain life and for optimal physiological function. Widespread global micronutrient deficiencies (MNDs) exist, with pregnant women and their children under 5 years at the highest risk. Iron, iodine, folate, vitamin A, and zinc deficiencies are the most widespread MNDs, and all these MNDs are common contributors to poor growth, intellectual impairments, perinatal complications, and increased risk of morbidity and mortality. Iron deficiency is the most common MND worldwide and leads to microcytic anemia, decreased capacity for work, as well as impaired immune and endocrine function. Iodine deficiency disorder is also widespread and results in goiter, mental retardation, or reduced cognitive function. Adequate zinc is necessary for optimal immune function, and deficiency is associated with an increased incidence of diarrhea and acute respiratory infections, major causes of death in those <5 years of age. Folic acid taken in early pregnancy can prevent neural tube defects. Folate is essential for DNA synthesis and repair, and deficiency results in macrocytic anemia. Vitamin A deficiency is the leading cause of blindness worldwide and also impairs immune function and cell differentiation. Single MNDs rarely occur alone; often, multiple MNDs coexist. The long-term consequences of MNDs are not only seen at the individual level but also have deleterious impacts on the economic development and human capital at the country level. Perhaps of greatest concern is the cycle of MNDs that persists over generations and the intergenerational consequences of MNDs that we are only beginning to understand. Prevention of MNDs is critical and traditionally has been accomplished through supplementation, fortification, and food-based approaches including diversification. It is widely accepted that intervention in the first 1,000 days is critical to break the cycle of malnutrition; however, a coordinated, sustainable commitment to scaling up nutrition at the global level is still needed. Understanding the epidemiology of MNDs is critical to understand what intervention strategies will work best under different conditions.

Understanding healthy pregnancies: the perspective of Inuit midwives in northwestern Quebec.

INTRODUCTION: For 25 years, Inuit midwives have provided perinatal and newborn care for about 90% of the pregnancies in northwestern Quebec. Patients in this region continue to have high rates of preventable nutritional deficiencies. The objective of this study was to explore the perceptions of professional midwives and students about what makes a healthy pregnancy and a healthy newborn. METHODS: We convened, via teleconference, a semistructured focus group with the local midwives and students. The conversation focused on local understanding of a healthy pregnancy and a healthy newborn, and the role of midwives in the communities. RESULTS: Four midwives and 6 students took part in the focus group, representing 80% of local midwives and students. All of the participants were women, and their professional experience ranged from 3 to 25 years. Through inductive thematic analysis, it became apparent that personal experiences and professional training were important determinants of opinions. Midwives believed that the health of women and infants could be improved through better food selection, particularly reliance on traditional nutrient-rich food. They were aware that iron deficiency was a problem and that infants required vitamin D; however, they reported that supplement uptake was poor. CONCLUSION: Concern was expressed about a decline in traditional beliefs and about unhealthy behaviours. Participants advanced strategies to promote knowledge locally (e.g., visual aids, local radio) to attempt to reduce rates of nutritional deficiencies.

INTRODUCTION: Pendant 25 ans, les sages-femmes inuites ont prodigué les soins périnataux et néonataux requis pour environ 90 % des grossesses dans le Nord-Ouest du Québec. Les patientes de cette région continuent de présenter des taux élevés de carences nutritionnelles évitables. L'objectif de cette étude était d'explorer les perceptions des sages-femmes professionnelles et des étudiantes sur ce qu'elles considèrent comme une grossesse saine et un nouveau-né en bonne santé. MÉTHODES: Nous avons organisé un groupe de discussion semi-structuré par téléconférence avec des sages-femmes et des étudiantes locales. L'entrevue a porté sur leur conception d'une grossesse saine et d'un nouveau-né en bonne santé et sur le rôle des sages-femmes dans les communautés. RÉSULTATS: Quatre sages-femmes et 6 étudiantes ont participé au groupe de discussion, représentant 80 % des sages-femmes et étudiantes locales. Toutes les participantes étaient des femmes et leur expérience professionnelle variait de 3 à 25 ans. Une analyse thématique inductive a fait ressortir que les expériences personnelles et la formation professionnelle étaient d'importants déterminants des opinions formulées. Les sages-femmes se sont dites d'avis que la santé des femmes et des nouveau-nés pouvait être améliorée par de meilleurs choix alimentaires, particulièrement en ce qui concerne l'alimentation traditionnelle, riche en éléments nutritifs. Elles étaient conscientes du fait qu'une carence en fer constitue un problème et que les nourrissons ont besoin de vitamine D. Elles ont toutefois mentionné que dans les faits, les suppléments sont peu utilisés. CONCLUSION: Les participantes ont exprimé leur inquiétude face au déclin des connaissances traditionnelles et face aux comportements malsains. Elles ont proposé des stratégies pour promouvoir la transmission des connaissances à l'échelle locale (p. ex., aides visuelles, radio locale) pour tenter de remédier aux carences nutritionnelles.

Evidence-based recommendations for addressing malnutrition in health care: an updated strategy from the feedM.E. Global Study Group.

The prevalence of malnutrition ranges up to 50% among patients in hospitals worldwide, and disease-related malnutrition is all too common in long-term and other health care settings as well. Regrettably, the numbers have not improved over the past decade. The consequences of malnutrition are serious, including increased complications (pressure ulcers, infections, falls), longer hospital stays, more frequent readmissions, increased costs of care, and higher risk of mortality. Yet disease-related malnutrition still goes unrecognized and undertreated. To help improve nutrition care around the world, the feedM.E. (Medical Education) Global Study Group, including members from Asia, Europe, the Middle East, and North and South America, defines a Nutrition Care Pathway that is simple and can be tailored for use in varied health care settings. The Pathway recommends screen, intervene, and supervene: screen patients' nutrition status on admission or initiation of care, intervene promptly when needed, and supervene or follow-up routinely with adjustment and reinforcement of nutrition care plans. This article is a call-to-action for health caregivers worldwide to increase attention to nutrition care.