Canadian Nutrition Society Dialogue on disease-related malnutrition: a commentary from the 2022 Food For Health Workshop.

This commentary represents a dialogue on key aspects of disease-related malnutrition (DRM) from leaders and experts from academia, health across disciplines, and several countries across the world. The dialogue illuminates the problem of DRM, what impact it has on outcomes, nutrition care as a human right, and practice, implementation, and policy approaches to address DRM. The dialogue allowed the germination of an idea to register a commitment through the Canadian Nutrition Society and the Canadian Malnutrition Task Force in the UN/WHO Decade of Action on Nutrition to advance policy-based approaches for DRM. This commitment was successfully registered in October 2022 and is entitled CAN DReaM (Creating Alliances Nationally for Policy in Disease-Related Malnutrition). This commitment details five goals that will be pursued in the Decade of Action on Nutrition. The intent of this commentary is to record the proceedings of the workshop as a stepping stone to establishing a policy-based approach to DRM that is relevant in Canada and abroad.

A paradigm shift in clinical nutrition.

The current clinical nutrition paradigm is that decreased caloric intake, resulting in a caloric deficit, is central to the development disease-related malnutrition (DRM). In following with this paradigm, one should assume that nutrition interventions with artificially administered nutrition (food substitution paradigm) aimed at preventing a caloric deficit should result in the prevention and/or successful treatment of DRM. However, clear evidence demonstrates that the DRM observed in diverse illnesses is at least partially resistant to nutrition interventions aimed at preventing the development of a caloric deficit. Simply put, DRM cannot be prevented nor resolved through a nutrition intervention aimed solely on replacing what the person cannot or will not eat. It is time to stop oversimplifying nutrition therapy in clinical nutrition interventions as a food substitution issue, focusing instead on developing and testing innovative hypotheses aimed at a mechanistic understanding of how DRM develops. Through this effort, new paradigms should evolve. The aim of this opinion paper is to provide an overview of why we need a shift in the current paradigm.

Nutrition care as a health policy in the 21st century: A phenomenological study.

BACKGROUND: Addressing the high prevalence of disease-related malnutrition (DRM) requires political will. The aim of this study is to define DRM as a health public policy issue from the point of view of the stakeholders. METHODS: We conducted a qualitative phenomenological study consisting of grey data search and individual semi-structured in-depth interviews with stakeholders (policy-makers, academics, and civil society organization representatives) from 17 Latin American countries. The analyzed themes reflected ideas repeatedly found across the interviews. RESULTS: 26 respondents were interviewed (5 policy-makers, 18 academics, 3 civil society organizations representatives). The grey data research and interviews showed that Brazil and Costa Rica were the only countries in the Region that had developed a specific public health policy addressing DRM and nutrition care issues. The rest of the Latin American countries had a nutrition policy which neither addressed DRM specifically nor included nutrition care, with important heterogeneity existing in terms of national regulation of selected nutritional care categories. Stakeholder opinions allowed to identify heterogeneity in the understanding of the nature and causes of DRM, confusing DRM with malnutrition caused by food insecurity and lack of food availability. Policy in the field of clinical nutrition can be addresses from two approaches: interdisciplinarity and a human rights-based approach. CONCLUSION: DRM is an unaddressed problem by health policy. Due to internal and external factor related to the health systems DRM has not been able to become a public policy issue. The study highlights the need for the development of public policy in clinical nutrition aimed at improving access to nutrition care.

Clinical Nutrition and Human Rights. An International Position Paper.

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political, and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Clinical nutrition and human rights. An international position paper.

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Lessons Learned in Nutrition Therapy in Patients With Severe COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic has reached worldwide, and until a vaccine is found, it will continue to cause significant morbidity and mortality. The clinical presentation of COVID-19 ranges from that of being asymptomatic to developing a fatal illness characterized by multiple organ involvement. Approximately 20% of the patients will require hospitalization; one-quarter of hospitalized patients will develop severe COVID-19 requiring admission to the intensive care unit, most frequently, with acute respiratory failure. An ongoing effort is being made to identify the patients that will develop severe COVID-19. Overall, patients present with 3 different phenotypes of nutrition risk: (1) the frail older patient, (2) the patient with severe ongoing chronic illness, and (3) the patient with severe and morbid obesity. These 3 phenotypes represent different nutrition risks and diverse nutrition interventions. This article explores the different potential approaches to nutrition intervention in patients with COVID-19, evaluating, in this process, the challenges faced in the implementation of guidelines written by different societies.

[Cartagena Declaration. The International Declaration on the Right to Nutritional Care and the Fight against Malnutrition]. / Declaración de Cartagena. Declaración Internacional sobre el Derecho al Cuidado Nutricional y la Lucha contra la Malnutrición.

INTRODUCTION: The need to promote the right to nutritional care, to fight against malnutrition and to advance in education and research in clinical nutrition has led all the FELANPE's societies to sign on May 3rd, during the 33rd Congress of the Colombian Clinical Nutrition Association (ACNC) in the city of Cartagena, the International Declaration on the Right to Nutritional Care and the Fight against Malnutrition, "Declaration of Cartagena". The Declaration provides a coherent framework of 13 principles which can serve as a guide for societies, schools and associations affiliated to FELANPE in the development of action plans. In addition, it will serve as an instrument to promote, through governments, the formulation of policies and legislation in the field of clinical nutrition. We believe that the general framework of principles proposed by the Declaration can contribute to raise awareness about the magnitude of this problem and to promote cooperation networks among Latin-American countries. Although this Declaration does not have a binding legal effect, it has an undeniable moral strength and it can provide practical guidance to States. An implementation program will allow developing a toolkit to transform principles into actions.

INTRODUCCIÓN: Frente a la necesidad de promover el derecho al cuidado nutricional, de luchar contra la malnutrición y de avanzar en temas de educación e investigación en nutrición clínica, las sociedades que constituyen la FELANPE firmaron la Declaración Internacional sobre el Derecho al Cuidado Nutricional y la Lucha contra la Malnutrición, "Declaración de Cartagena", el 3 de mayo del presente año en la ciudad de Cartagena, en el marco del 33º Congreso de la Asociación Colombiana de Nutrición Clínica. La Declaración proporciona un marco coherente de 13 principios, los cuales podrán servir de guía a las sociedades afiliadas a la FELANPE en el desarrollo de los planes de acción. Además, servirá como un instrumento para que promuevan, a través de los gobiernos, la formulación de políticas y legislaciones en el campo de la nutrición clínica. Consideramos que el marco general de principios propuesto por la Declaración puede contribuir a crear conciencia acerca de la magnitud de este problema y a forjar redes de cooperación entre los países de la región. Aunque esta Declaración no tiene un efecto jurídico vinculante (obligatorio), tiene una fuerza moral innegable y puede proporcionar orientación práctica a los estados. Un plan de implementación permitirá desarrollar la caja de herramientas necesaria para transformar los principios en acciones.

Is multi-level marketing of nutrition supplements a legal and an ethical practice?

BACKGROUND: Multi-level marketing (MLM) of nutrition products has experienced dramatic growth in recent decades. 'Wellness' is the second most popular niche in the MLM industry and represents 35% of sales among all the products in 2016. This category includes dietary supplements, weight management and sports nutrition products. The aim of this paper is to analyse whether this practice is legal and ethical. METHODS: An analysis of available documentary information about the legal aspects of Multi-level marketing business was performed. Ethical reflexion was based on the "principlism" approach. RESULTS: We argue that, while being a controversial business model, MLM is not fraudulent from a legal point of view. However, it is an unethical strategy obviating all the principles of beneficence, nonmaleficence and autonomy. What is at stake is the possible economic scam and the potential harm those products could cause due to unproven efficacy, exceeding daily nutrient requirements and potential toxicity. The sale of dietary and nutrition supplements products by physicians and dieticians presents a conflict of interests that can undermine the primary obligation of physicians to serve the interests of their patients before their own. CONCLUSION: While considering that MLM of dietary supplements and other nutrition products are a legal business strategy, we affirm that it is an unethical practice. MLM products that have nutritional value or promoted as remedies may be unnecessary and intended for conditions that are unsuitable for self-prescription as well.

Study Exploring the Effects of Daily Supplementation with 400 µg of Folic Acid on the Nutritional Status of Folate in Women of Reproductive Age.

BACKGROUND: This investigation determines the nutritional state of serum and red blood cell (RBC) folate concentration and their relation with intake of folate, B6 ,and B12 , with serum vitamin B12 , and with genetic variants after provision of 400 µg/day of folic acid for 3 months to a group of 34 Colombian women of reproductive age. METHODS: We evaluated nutrient intake using 24-hr recall, assessing the levels of serum folate, RBC folate, serum B12 , and homocysteine, as well as determining genetic variants of the enzyme MTHFR (C677T and A1298C) and CßS (844ins68pb). RESULTS: The results show that following intake of 400 µg/day of folic acid, the risk of folate deficiency as seen in regular dietary intake disappears and the nutritional status of this nutrient is increased (p < 0.001). With respect to vitamin B12, the risk of serum deficiency with folic acid consumption increased slightly, and those that were found to be B12 deficient after supplementation also had decreased levels of serum homocysteine. Genetic factors did not influence the nutritional status of folate, although an association was found between the intake of nutrients and biochemical indicators. CONCLUSION: Given the results of our study, subsequent studies evaluating folic acid supplementation should also consider evaluating the status of B12 and B6 , and serum and RBC folate, as they participate interdependently in the cycle of folate and methionine and in homocysteine metabolism.Birth Defects Research 109:564-573, 2017.© 2017 Wiley Periodicals, Inc.

Encuesta de satisfacción con el cuidado de la salud en las personas con enfermedad crónica / Survey of satisfaction with health care in people with chronic disease

Objetivo Desarrollar y validar la Encuesta de satisfacción con el cuidado de la salud para personas con enfermedad crónica no trasmisible (ECNT), para ser utilizada en el contexto Latinoamericano. Método: Estudio metodológico desarrollado entre 2012 y 2014. Para ello se cumplieron tres fases: 1) Revisión de la literatura relacionada con la satisfacción con el cuidado en situaciones de ECNT. 2) Estructuración de la propuesta preliminar de la «Encuesta de satisfacción con el cuidado de personas con enfermedad crónica», conocida como GCPC-UN-ESU. 3) validez fácil y de contenido con expertos 4) Prueba de campo en la aplicación a 111 personas con ECNT. Resultados: La encuesta GCPC-UN-ESU contiene 19 ítems y 4 dimensiones: satisfacción con los cuidados, con la educación en salud, con la calidad en el servicio prestado y el nivel de fidelización con el servicio. La encuesta en conjunto valora de manera integral la percepción de satisfacción con el cuidado de la salud por parte de las personas con ECNT, puede ser autodiligenciada. Conclusiones. La encuesta CPC-UN ESU fue validada y mostró contar con las variables necesarias para determinar el nivel de satisfacción de las personas con ECNT en el contexto de América Latina. Esta herramienta constituye una respuesta a las demandas de acreditación de los servicios en esta región (AU)

Objective: To develop and validate the survey of satisfaction with health care in people with non-communicable chronic diseases(NCDs), for use in the Latin American context. Method: This is a methodological study developed between 2012 and 2014, as part of the Latin American Network for Chronic Patient Care, under the Program for the Reduction of the burden of chronic disease in Colombia. Three stages were met: 1) Review of the literature on satisfaction with care in chronic diseases situations. 2) Structuring the preliminary proposal of the «Survey of satisfaction with health care in people with chronic disease» known as GCPC-UN-ESU and 3) facial validity and experts review 4) Test application to 111 people with NCDs. Results: The GCPC-UN-ESU, survey contains 19 items and 4 dimensions: satisfaction with care, with health education and with the quality of the service provided and the level of loyalty to the service. The survey holistically perceived satisfaction with health care by people with NCDs and it can be personally developed. Conclusions: The CPC-A ESU survey was validated and it had the necessary variables in order to determine the level of satisfaction of people with NCDs in the Latin American context. This tool is a response to the demands of accreditation services in this región (AU)

What is clinical nutrition? Understanding the epistemological foundations of a new discipline.

BACKGROUND: Although the therapeutic and economic efficacy of nutrition has been proven, optimal nutritional care is still scarce among hospital and ambulatory patients. Thus malnutrition is still highly prevalent. We identify as an underlying cause the absence of a common understanding of clinical nutrition as a discipline. The aim of this paper is to establish the epistemological foundations of clinical nutrition and to characterize it as a science. METHODS AND RESULTS: From the standpoint of historical epistemology, we examine the historical conditions that determine i) the main object of knowledge, ii) the nature and iii) domain of this science. Our hypothesis is that clinical nutrition as a science was formed in the second half of the twentieth century as an outcome of the integration of medicine and nutrition and underpinned by a primary transformation of the "nutrient" concept. We identify malnutrition as the primary practical and research domain of knowledge. CONCLUSION: Clinical nutrition is an autonomous empirical science that can be characterized as a basic and applied science. Its wide multi-disciplinarity guarantees its future.

Microbial carbon metabolism associated with electrogenic sulphur oxidation in coastal sediments.

Recently, a novel electrogenic type of sulphur oxidation was documented in marine sediments, whereby filamentous cable bacteria (Desulfobulbaceae) are mediating electron transport over cm-scale distances. These cable bacteria are capable of developing an extensive network within days, implying a highly efficient carbon acquisition strategy. Presently, the carbon metabolism of cable bacteria is unknown, and hence we adopted a multidisciplinary approach to study the carbon substrate utilization of both cable bacteria and associated microbial community in sediment incubations. Fluorescence in situ hybridization showed rapid downward growth of cable bacteria, concomitant with high rates of electrogenic sulphur oxidation, as quantified by microelectrode profiling. We studied heterotrophy and autotrophy by following (13)C-propionate and -bicarbonate incorporation into bacterial fatty acids. This biomarker analysis showed that propionate uptake was limited to fatty acid signatures typical for the genus Desulfobulbus. The nanoscale secondary ion mass spectrometry analysis confirmed heterotrophic rather than autotrophic growth of cable bacteria. Still, high bicarbonate uptake was observed in concert with the development of cable bacteria. Clone libraries of 16S complementary DNA showed numerous sequences associated to chemoautotrophic sulphur-oxidizing Epsilon- and Gammaproteobacteria, whereas (13)C-bicarbonate biomarker labelling suggested that these sulphur-oxidizing bacteria were active far below the oxygen penetration. A targeted manipulation experiment demonstrated that chemoautotrophic carbon fixation was tightly linked to the heterotrophic activity of the cable bacteria down to cm depth. Overall, the results suggest that electrogenic sulphur oxidation is performed by a microbial consortium, consisting of chemoorganotrophic cable bacteria and chemolithoautotrophic Epsilon- and Gammaproteobacteria. The metabolic linkage between these two groups is presently unknown and needs further study.

Phospholipid-derived fatty acids and quinones as markers for bacterial biomass and community structure in marine sediments.

Phospholipid-derived fatty acids (PLFA) and respiratory quinones (RQ) are microbial compounds that have been utilized as biomarkers to quantify bacterial biomass and to characterize microbial community structure in sediments, waters, and soils. While PLFAs have been widely used as quantitative bacterial biomarkers in marine sediments, applications of quinone analysis in marine sediments are very limited. In this study, we investigated the relation between both groups of bacterial biomarkers in a broad range of marine sediments from the intertidal zone to the deep sea. We found a good log-log correlation between concentrations of bacterial PLFA and RQ over several orders of magnitude. This relationship is probably due to metabolic variation in quinone concentrations in bacterial cells in different environments, whereas PLFA concentrations are relatively stable under different conditions. We also found a good agreement in the community structure classifications based on the bacterial PLFAs and RQs. These results strengthen the application of both compounds as quantitative bacterial biomarkers. Moreover, the bacterial PLFA- and RQ profiles revealed a comparable dissimilarity pattern of the sampled sediments, but with a higher level of dissimilarity for the RQs. This means that the quinone method has a higher resolution for resolving differences in bacterial community composition. Combining PLFA and quinone analysis as a complementary method is a good strategy to yield higher resolving power in bacterial community structure.

Pain after spinal cord injury: a review of classification, treatment approaches, and treatment assessment.

Pain is a prevalent consequence of spinal cord injury (SCI) that can persist for years after the injury and can have a significant impact on physical and emotional function and quality of life. There are a variety of types of pain that may develop after a SCI, including those of primarily nociceptive origin and those of primarily neuropathic origin. Recommendations for diagnostic and treatment strategies have been varied in part because of the lack of a universal classification system and in part because of the biopsychosocial nature of pain. The most recent taxonomy for pain after SCI is described herein. Pain-management strategies, including pharmacological, interventional, and psychological treatments, also are described. For neuropathic pain in SCI, anticonvulsant agents and tricyclic antidepressants often are tried, but these treatments have had limited success in many patients, and alternative interventions (eg, massage therapy, acupuncture, meditation) often are just as successful. Treatment of nociceptive pain after SCI often includes nonsteroidal antiinflammatory agents and acetaminophen, but correction of underlying etiologies and behavior adjustments also should be implemented if possible. An overview of self-report pain questionnaires and scales is also presented to provide the clinician and researcher with a set of tools to evaluate the efficacy of pain interventions.

Effects of self-hypnosis training and EMG biofeedback relaxation training on chronic pain in persons with spinal-cord injury.

Thirty-seven adults with spinal-cord injury and chronic pain were randomly assigned to receive 10 sessions of self-hypnosis (HYP) or EMG biofeedback relaxation (BIO) training for pain management. Participants in both treatment conditions reported substantial, but similar, decreases in pain intensity from before to after the treatment sessions. However, participants in the HYP condition, but not the BIO condition, reported statistically significant decreases in daily average pain pre- to posttreatment. These pre- to posttreatment decreases in pain reported by the HYP participants were maintained at 3-month follow-up. Participants in the HYP condition, but not the BIO condition, also reported significant pre- to posttreatment increases in perceived control over pain, but this change was not maintained at the 3-month follow-up.

Long-term outcome of hypnotic-analgesia treatment for chronic pain in persons with disabilities.

Data from 26 participants in a case series of hypnotic analgesia for chronic pain were examined to determine the long-term effects of hypnosis treatment. Statistically significant decreases in average daily pain intensity, relative to pretreatment values, were observed at posttreatment and at 3- and 9-month follow-up but not at 6- or 12-month follow-up. The percent of participants who reported clinically meaningful decreases in pain were 27%, 19%, 19%, and 23%, at the 3-, 6-, 9-, and 12-month follow-up points, respectively. Moreover, at 12-months posttreatment, 81% of the sample reported that they still used the self-hypnosis skills learned in treatment. Overall, the results indicate that about 20% of the sample obtained substantial and lasting long-term reductions in average daily pain following hypnosis treatment and that many more continue to use self-hypnosis up to 12 months following treatment.