[Process of medical nutrition therapy]. / Proceso de tratamiento médico nutricional.

Introduction: Medical nutrition therapy is a very useful tool in maintaining and recovering the health of patients with disease-related malnutrition, although its implementation can be complex and is not without risks. Quality processes are understood as sets of activities that are related or interact to transform input elements into results. From the SENPE Management Work Group we present the process of medical nutrition therapy (PMNT), which aims to facilitate the management of clinical nutrition of a multidisciplinary nutrition support team in a hospital setting. This paper describes the seven sub-processes PMNT is comprised of, in addition to a previous nutritional screening sub-process. Each sub-process is divided into a first section with a technical sheet detailing its general aspects, while a second section proposes key objectives, quality indicators, and standards for their evaluation. .

Introducción: El tratamiento médico nutricional es de gran utilidad en el mantenimiento y recuperación de la salud de los pacientes con desnutrición relacionada con la enfermedad, aunque su implementación puede ser compleja y no está exenta de riesgos. Se entiende por proceso aquel conjunto de actividades que están mutuamente relacionadas o que interactúan para transformar elementos de entrada en resultados. Desde el Grupo de Trabajo de Gestión de la SENPE presentamos el Proceso de Tratamiento Médico Nutricional (PTMN), que tiene por objetivo facilitar la gestión de la nutrición clínica, pensando en un equipo de soporte nutricional multidisciplinar de atención al paciente hospitalizado. En este documento se describen los siete subprocesos que constituyen el PTMN, además de un subproceso previo de cribado nutricional. Cada subproceso se divide en una primera sección con una ficha técnica en la que se detallan sus aspectos generales, mientras que en la segunda sección se proponen objetivos clave, indicadores de calidad y estándares para su evaluación.

[Nutrition in palliative care: guidelines from the Working Group on Bioethics, Spanish Society of Clinical Nutrition and Metabolism (SENPE)]. / Nutrición en cuidados paliativos: resumen de recomendaciones del Grupo de Trabajo de Ética de la SENPE.

Introduction: Palliative care provides a holistic approach and care for patients with a terminal illness and their families. In palliative care physical complaints as well as emotional, social and spiritual aspects are considered. Nutritional care should be also considered within palliative support. For those working in the nutritional support field, to withhold or withdraw nutritional support may be an ethical dilemma in this scenario. The controversy starts when considering nutrition and hydration as basic care or a treatment. The goals of nutrition support in palliative care patients differ from common ones, aiming to improve quality of life, survival or both. The decision should be based on a consideration of prognosis (length of survival), quality of life, and risks-benefits ratio. Regarding oral nutrition (with or without oral supplements) the idea prevails of "comfort feeding", based on providing oral feeding till discomfort or avoidance develop. There is no evidence on the benefit of specific nutrients, despite the fact that omega-3 FAs may have some positive effects in patients with cancer. Regarding nutritional support (enteral or parenteral), no scientific evidence is present, so the decision needs to be agreed according to the desires and beliefs of the patient and their family, and based on a consensus with the interdisciplinary team on the aims of this support.

Introducción: Los cuidados paliativos proporcionan una atención integral que tiene en cuenta los aspectos físicos, emocionales, sociales y espirituales del paciente con enfermedad terminal y su entorno familiar. El tratamiento nutricional debe formar parte activa de los equipos de cuidados paliativos. La necesidad de iniciar o no un tratamiento nutricional sigue siendo, desde hace décadas, uno de los principales problemas éticos a los que se enfrentan los profesionales dedicados a la nutrición clínica. El origen de tal controversia radica, fundamentalmente, en cómo se consideran la nutrición y la hidratación: cuidado/soporte o tratamiento médico. Los objetivos fundamentales del tratamiento nutricional en los pacientes en cuidados paliativos deben ser otros: la mejoría de la calidad de vida, de la supervivencia o de ambas. La decisión de indicar o no el tratamiento nutricional en cuidados paliativos debe tomarse tras considerar el pronóstico, la calidad de vida y la relación "riesgo/beneficio". En relación a la alimentación por vía oral (con o sin suplementos orales), prevalece la idea de la "alimentación de confort", que se basa en intentos de alimentación oral hasta que se produzcan la incomodidad y/o el rechazo del paciente. No existen evidencias que justifiquen el uso de nutrientes específicos, aunque desde hace años se señala la posibilidad de lograr beneficios cuando se utilizan ácidos grasos omega-3 en los pacientes con cáncer. En cuanto al tratamiento nutricional (enteral o parenteral), en ausencia de evidencia, las decisiones sobre si iniciar una nutrición artificial en un paciente paliativo deben tomarse teniendo en cuenta los deseos y creencias del paciente y sus familiares, y basarse en el consenso del equipo interdisciplinar sobre los objetivos que se persiguen al iniciarla.

Multidisciplinary consensus on nutritional and metabolic therapy in enhanced recovery after abdominal surgery programs: NutRICA Project.

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) care pathways include evidence-based items designed to accelerate recovery after surgery. Interdisciplinarity is one of the key points of ERAS programs. OBJECTIVE: To prepare a consensus document among the members of the Nutrition Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Group for Multimodal Rehabilitation (GERM), in which the goal is to homogenize the nutritional and metabolic management of patients included in an ERAS program. METHODS: 69 specialists in Endocrinology and Nutrition and 85 members of the GERM participated in the project. After a literature review, 79 statements were proposed, divided into 5 sections: 17 of general characteristics, 28 referring to the preoperative period, 4 to the intraoperative, 13 to the perioperative and 17 to the postoperative period. The degree of consensus was determined through a Delphi process of 2 circulations that was ratified by a consistency analysis. RESULTS: Overall, in 61 of the 79 statements there was a consistent agreement, with the degree of consensus being greater among members of the SEEN (64/79) than members of the GERM (59/79). Within the 18 statements where a consistent agreement was not reached, we should highlight some important nutritional strategies such as muscle mass assessment, the start of early oral feeding or pharmaconutrition. CONCLUSION: Consensus was reached on the vast majority of the nutritional measures and care included in ERAS programs. Due to the lack of agreement on certain key points, it is necessary to continue working closely with both societies to improve the recovery of the surgical patients.

Multidisciplinary consensus on nutritional and metabolic therapy in enhanced recovery after abdominal surgery programs: NutRICA Project. / Consenso multidisciplinar sobre la terapia nutricional y metabólica en los programas de recuperación intensificada en cirugía abdominal: Proyecto NutRICA.

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) care pathways include evidence-based items designed to accelerate recovery after surgery. Interdisciplinarity is one of the key points of ERAS programs. OBJECTIVE: To prepare a consensus document among the members of the Nutrition Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Group for Multimodal Rehabilitation (GERM), in which the goal is to homogenize the nutritional and metabolic management of patients included in an ERAS program. METHODS: 69 specialists in Endocrinology and Nutrition and 85 members of the GERM participated in the project. After a literature review, 79 statements were proposed, divided into 5 sections: 17 of general characteristics, 28 referring to the preoperative period, 4 to the intraoperative, 13 to the perioperative and 17 to the postoperative period. The degree of consensus was determined through a Delphi process of 2 circulations that was ratified by a consistency analysis. RESULTS: Overall, in 61 of the 79 statements there was a consistent agreement, with the degree of consensus being greater among members of the SEEN (64/79) than members of the GERM (59/79). Within the 18 statements where a consistent agreement was not reached, we should highlight some important nutritional strategies such as muscle mass assessment, the start of early oral feeding or pharmaconutrition. CONCLUSION: Consensus was reached on the vast majority of the nutritional measures and care included in ERAS programs. Due to the lack of agreement on certain key points, it is necessary to continue working closely with both societies to improve the recovery of the surgical patients.

Fish Oil Enriched Intravenous Lipid Emulsions Reduce Triglyceride Levels in Non-Critically Ill Patients with TPN and Type 2 Diabetes. A Post-Hoc Analysis of the INSUPAR Study.

There are no studies that have specifically assessed the role of intravenous lipid emulsions (ILE) enriched with fish oil in people with diabetes receiving total parenteral nutrition (TPN). The objective of this study was to assess the metabolic control (glycemic and lipid) and in-hospital complications that occurred in non-critically ill inpatients with TPN and type 2 diabetes with regard to the use of fish oil emulsions compared with other ILEs. We performed a post-hoc analysis of the Insulin in Parenteral Nutrition (INSUPAR) trial that included patients who started with TPN for any cause and that would predictably continue with TPN for at least five days. The study included 161 patients who started with TPN for any cause. There were 80 patients (49.7%) on fish oil enriched ILEs and 81 patients (50.3%) on other ILEs. We found significant decreases in triglyceride levels in the fish oil group compared to the other patients. We did not find any differences in glucose metabolic control: mean capillary glucose, glycemic variability, and insulin dose, except in the number of mild hypoglycemic events that was significantly higher in the fish oil group. We did not observe any differences in other metabolic, liver or infectious complications, in-hospital length of stay or mortality.

[9th Jesús Culebras Lecture: "The value of clinical nutrition"]. / 9.ª Lección Jesús Culebras: "El valor de la nutrición clínica".

The word "value" encompasses different concepts but it is probably the importance we give to something and its usefulness that best brings us conceptually closer to its meaning. In this text we analyze the reasons why it is necessary to value the usefulness of nutritional therapy. The development of a new discipline, Nutrition Economics, should help us to create value in Clinical Nutrition by incorporating economic evaluation into their research. It also reviews the importance of economic analysis in decision-making and in more detail the very useful tools also used in the field of nutrition economics, such as cost-of-disease studies, cost-effectiveness studies and budget impact. We analyze different works that have allowed us to advance in these fields in recent years. Finally, the difficulties related to the financing of nutrition in the centers as well as the regulation of enteral nutrition in the home are analyzed. The creation of value in clinical nutrition is a task for everyone (healthcare professionals, patients, managers and the pharmaceutical industry).

La palabra "valor" engloba distintos conceptos, pero probablemente sea la importancia que damos a algo y su utilidad lo que mejor nos acerca conceptualmente a su significado. En este texto se analizan las razones por las que se hace necesario poner en valor la utilidad de la terapia nutricional. El desarrollo de una nueva disciplina, la nutrieconomía, debe ayudarnos a crear valor en nutrición clínica mediante la incorporación de la evaluación económica en su investigación. También se revisan la importancia del análisis económico en la toma de decisiones y, con más detalle, las herramientas de gran utilidad también empleadas en el campo de la economía de la nutrición, como son los estudios de coste de la enfermedad, los de coste-efectividad y los de impacto presupuestario. Se analizan distintos trabajos que nos han permitido avanzar en estos campos en los últimos años. Por último, se analizan las dificultades relacionadas con la financiación de la nutrición en los centros así como la regulación de la nutrición enteral en el ámbito domiciliario. La creación de valor en nutrición clínica es una tarea de todos (profesionales sanitarios, pacientes, gestores e industria farmacéutica).

Cribrado nutricional en aras de la eficiencia / Nutrition screening: looking for the efficiency

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Malnutrition secondary to gastrojejunal stricture after biliopancreatic diversion.

CONTEXT: Bariatric surgery has beneficial effects on obesity and associated comorbidities such as glycaemic control in type 2 diabetes, dyslipidaemia, hypertension, and renal and hepatic function. Nevertheless, this surgery is not free of complications and possible side effects due to restrictive and/or malabsorptive related components. CASE DESCRIPTION: We report the case of a 60-year-old woman whose past medical history included morbid obesity, hypertension and Scopinaro biliopancreatic diversion (BPD) with duodenal switch in 1998. In 2015, she attended the emergency department hypotensive with bad general condition and reporting chronic constitutional symptoms. A wide variety of tests were performed including endoscopic studies as her symptoms were not immediately correlated with the BPD surgery. Finally, she was diagnosed from gastrojejunal stricture which caused her severe malnutrition. The patient underwent successful surgical management. DISCUSSION: BPD is one of the most effective surgical procedures for obesity, with an overall 5-year loss of excess body weight higher than 72%. Nonetheless, it is associated with long-term complications such as protein malnutrition and vitamin deficiencies due to malabsorption. Being surgically challenging, with high risk of nutritional complications and lifelong needed for the follow-up, BPD is rarely performed nowadays. CONCLUSIONS: Bariatric Surgery is a well-known effective therapeutic measure to improve obesity and cardiovascular related disease. However, this case highlights the importance of robust multidisciplinary lifelong surgical and medical follow-up in all BPD patients. BPD complications can be minimised and recognised early with patient and healthcare staff education on the importance of lifetime follow-up and adherence to dietary and supplement regimes.

Soporte nutricional y nutrición parenteral en el paciente oncológico: informe de consenso de un grupo de expertos / Nutritional support and parenteral nutrition in cancer patients: An expert consensus report

La desnutrición es un problema médico frecuente de los pacientes oncológicos que impacta de forma negativa en la calidad de vida. El objetivo de este trabajo es analizar y dar respuesta a diferentes cuestiones relacionadas con el manejo nutricional de un paciente oncológico en la práctica clínica. Un grupo multidisciplinar de expertos en Oncología Médica, Endocrinología y Nutrición y Farmacia elaboró una lista de temas relacionados con el estado nutricional del paciente oncológico agrupados en 3 bloques: soporte nutricional, nutrición parenteral (NP) y NP domiciliaria (NPD). Se realizó una revisión de la literatura que incluyó artículos publicados en español, inglés y francés hasta abril de 2017. Este consenso destaca diferentes elementos clave que ayudarán a los médicos a normalizar el manejo del estado nutricional del paciente oncológico en la práctica clínica, estableciendo pautas comunes de indicación, monitorización, requerimientos nutricionales y vías de acceso a la NP

Malnutrition is a common medical problem in cancer patients with a negative impact on quality of life. The aim of this study was to address different issues related to nutritional management of cancer patients in clinical practice. A multidisciplinary group of experts in Medical Oncology, Pharmacy, and Endocrinology and Nutrition prepared a list of topics related to the nutritional status of cancer patients and grouped them into three blocks: nutritional support, parenteral nutrition (PN), and home PN (HPN). A literature review was made of articles published in Spanish, English and French until April 2017. This consensus emphasizes several key elements that help physicians standardize management of the nutritional status of cancer patients in clinical practice, and establishes common guidelines for indication, monitoring, nutritional requirements, and access routes to PN

Terms, concepts and definitions in clinical artificial nutrition. The ConT-SEEN Project. / Términos, conceptos y definiciones en nutrición clínica artificial. Proyecto ConT-SEEN.

BACKGROUND: Imprecision in terms used in the field of clinical nutrition may lead to misinterpretations among professionals. OBJECTIVE: For this reason, the Spanish Society of Endocrinology and Nutrition (SEEN) promoted this document on the terms and definitions used in clinical artificial nutrition (enteral and parenteral), establishing an agreement between Spanish experts of this specialty. METHODS: Forty-seven specialists in endocrinology and nutrition, members of the Nutrition Area of the SEEN, participated between April and September 2016. After a systematic literature review, 52 concepts were proposed. The coordinators included two additional concepts, and 57were finally selected by the working group: 13 of a general nature, 30 referring to enteral nutrition and 14 to parenteral nutrition. The degree of agreement was subsequently determined using a two-round Delphi process. It was finally ratified by consistency and concordance analysis. RESULTS: Fifty-four of the 57 terms had a very consistent agreement and were concordant. Only three showed no concordance, of whom two were very consistent and one inconsistent. In conclusion, there was consensus in the definition of 54 basic terms in the practice of clinical nutrition.

Organization and management of clinical nutrition in Spain. How do we assess the quality of our activities?

INTRODUCTION: Among the objectives of the SENPE Management Working Group is the development of knowledge and tools related to the evaluation of health outcomes. OBJECTIVES: To obtain an approximate profile of clinical nutrition in hospitals in Spain, specifically concerning its organization, endowment, activities and quality indicators. METHODS: A cross-sectional study conducted in 2013 through a structured survey sent to a random sample of 20% of hospitals from the network of the National Health System of Spain, stratified by the number of hospital beds. RESULTS: The overall response rate was 67% (83% in hospitals with over 200 beds). In 65% of hospitals, clinical nutrition is run by a coordinated team or unit, with a doctor working full time in only 50% of centers. Other professionals are often not recognized as part of the team or unit. There is a specialized monographic nutrition clinic in 62% of centers and 72% have more than 40 new inpatient consultations per month (27% with more than 80 per month). Among the centers with a clinical nutrition team or unit, there is a greater tendency to monitor quality indicators related to clinical practice. CONCLUSIONS: There is widespread addition of clinical nutrition teams and units in hospitals in Spain. However, truly multidisciplinary organization is not often found. High workloads are assumed in relation to staffing levels. The existence of well-organized structures may be associated with benefits that directly affect attendance.