Resumen ejecutivo "Consenso sobre la evaluación y el tratamiento nutricional de los trastornos de la conducta alimentaria: anorexia nerviosa, bulimia nerviosa, trastorno por atracón y otros" / No disponible

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Consenso sobre la evaluación y el tratamiento nutricional de los trastornos de la conducta alimentaria: anorexia nerviosa / No disponible

La anorexia nerviosa es la enfermedad psiquiátrica más frecuente entre las mujeres jóvenes y se asume de origen multifactorial. Los criterios diagnósticos han sido recientemente modificados de forma que la amenorrea deja de formar parte de ellos. Esta enfermedad muestra una gran variabilidad en su presentación y gravedad, lo que condiciona diferentes abordajes terapéuticos y la necesidad de individualizar el tratamiento, haciéndose indispensable un enfoque multidisciplinar. Los objetivos persiguen restaurar el estado nutricional (a través de un plan dietético individualizado y basado en un patrón de consumo saludable), tratar las complicaciones y comorbilidades, la educación nutricional (basada en patrones alimentarios y nutricionales sanos), corrección de las conductas compensatorias y la prevención de recaídas. El tratamiento variará según la situación clínica del paciente, pudiendo realizarse en consultas externas (cuando existe estabilidad clínica), en hospital de día (modalidad intermedia entre el tratamiento ambulatorio tradicional y la hospitalización) o en hospitalización (fracaso del manejo ambulatorio o presencia de complicaciones médicas o psiquiátricas graves). La nutrición artificial a través del empleo de suplementos nutricionales orales, nutrición enteral y excepcionalmente nutrición parenteral puede ser necesaria en determinados escenarios clínicos. En pacientes severamente desnutridos se debe evitar el síndrome de realimentación. La anorexia nerviosa está asociada a numerosas complicaciones médicas que condicionan el estado de salud, la calidad de vida y que se relacionan estrechamente con la mortalidad. Existe poca evidencia clínica para evaluar los resultados de los distintos tratamientos en la anorexia nerviosa, estando basados la mayoría de las recomendaciones en consenso de expertos

Anorexia nervosa is the most common psychiatric disease among young women and it is assumed to be of multifactorial origin. Diagnostic criteria have recently been modified; therefore amenorrhea has ceased to be a part of them. This disease shows a large variability in its presentation and severity which conditions different therapeutic approaches and the need to individualize the treatment, thus it is indispensable a multidisciplinary approach. The goals are to restore nutritional status (through an individualized diet plan based on a healthy consumption pattern), treat complications and comorbidities, nutritional education (based on healthy eating and nutritional patterns), correction of compensatory behaviors and relapse prevention. The treatment will vary according to the patient's clinical situation, and it may be performed in outpatient clinics (when there is clinical stability), in a day hospital or ambulatory clinic (intermediate mode between traditional outpatient treatment and hospitalization) or hospitalization (when there is outpatient management failure or presence of serious medical or psychiatric complications). Artificial nutrition using oral nutritional supplements, enteral nutrition and exceptionally parenteral nutrition may be necessary in certain clinical settings. In severely malnourished patients the refeeding syndrome should be avoided. Anorexia nervosa is associated with numerous medical complications which determines health status, life quality, and is closely related to mortality. There is little clinical evidence to assess the results of different treatments in anorexia nervosa, when most of the recommendations are being based on expert consensus

Consenso sobre la evaluación y el tratamiento nutricional de los trastornos de la conducta alimentaria: bulimia nerviosa, trastorno por atracón y otros / No disponible

La bulimia nerviosa y el trastorno por atracón constituyen entidades nosológicas propias. Ambas muestran una gran variabilidad en su presentación y gravedad, lo que implica la individualización del tratamiento y la necesidad de equipos multidisciplinares. Los pacientes con bulimia nerviosa pueden presentar desde desnutrición y estados carenciales a exceso de peso, mientras que en los trastornos por atracón es habitual el sobrepeso u obesidad, que condiciona a su vez otras comorbilidades. Muchos de los síntomas y complicaciones derivan de las conductas compensatorias. Se dispone de diversas herramientas terapéuticas para el tratamiento de estos pacientes. El abordaje nutricional contempla el consejo dietético individualizado que garantice un adecuado estado nutricional y la correcta educación nutricional. Su objetivo es facilitar la adopción voluntaria de comportamientos alimentarios que fomenten la salud y que permitan la modificación a largo plazo de los hábitos alimentarios y el cese de conductas purgantes y atracones. El soporte psicológico es el tratamiento de primera línea y debe abordar el trastorno de la conducta alimentaria y las comorbilidades psiquiátricas que frecuentemente presentan. Los psicofármacos, aunque eficaces y ampliamente utilizados, no son imprescindibles. El manejo se realiza principalmente a nivel ambulatorio, siendo el hospital de día útil en pacientes seleccionados. Se debe reservar la hospitalización para corregir aquellas complicaciones somáticas o psiquiátricas graves o como medida de contención de las situaciones conflictivas no tratables de forma ambulatoria. La mayoría de las recomendaciones de las guías se basan en consensos de expertos, existiendo poca evidencia que evalúe los resultados clínicos y de coste-eficacia

Bulimia nervosa and binge eating disorder are unique nosological entities. Both show a large variability related to its presentation and severity which involves different therapeutic approaches and the need to individualize the treatment, thus it is indispensable a multidisciplinary approach. Patients with bulimia nervosa may suffer from malnutrition and deficiency states or even excess weight, while in binge eating disorders, it is common overweight or obesity, which determine other comorbidities. Many of the symptoms and complications are associated with compensatory behaviors. There are many therapeutic tools available for the treatment of these patients. The nutritional approach contemplates the individualized dietary advice which guarantees an adequate nutritional state and nutritional education. Its objective is to facilitate the voluntary adoption of eating behaviors that promote health and allow the long-term modification of eating habits and the cessation of purgatory and bingeing behaviors. Psychological support is a first-line treatment and it must address the frequent disorder of eating behavior and psychiatric comorbidities. Psychotropic drugs are effective and widely used although these drugs are not essential. The management is carried out mainly at an outpatient level, being the day hospital useful in selected patients. Hospitalization should be reserved to correct serious somatic or psychiatric complications or as a measure to contain non-treatable conflict situations. Most of the guidelines' recommendations are based on expert consensus, with little evidence which evaluates clinical results and cost-effectiveness

Nutritional supplements in eating disorders.

Eating disorders (EDs) are a series of differentiated nosological entities sharing the common link of a continuous alteration in food intake or in food intake-related behavior. Within this classification, the following disorders are noteworthy: anorexia nerviosa (AN) and bulimia nerviosa (BN). Anorexia nervosa is a chronic disorder characterized mainly by negative or decreased food intake accompanied by a distortion of body image and intense accompanying fear of weight gain. The estimated vital prevalence of this disorder in adolescence is approximately 0.5%-1%.1 The primary feature of BN is the presence of binge eating accompanied by compensatory behavior (in the form of intense exercise and the use of laxatives and diuretics, etc.). The prevalence of BN is estimated to be between 2% and 4% in young women, and it generally starts at somewhat later stages than AN. It is believed that biological, psychological, and environmental factors, as well as genetic vulnerability, influence the pathogenesis of EDs. A variety of therapies exist, both biological and psychological, whose effectiveness is supported by the scientific literature. Nonetheless, we find these therapies only partially effective and new targets as well as new treatments should be sought. Although the etiopathogenesis of EDs is unclear, some of the neurobiological dysfunction found suggests that diet and nutrient supplementation could be relevant in their treatment. We review in this article new treatments focusing on nutritional deficits.

Remote Healing of Bipolar Disorder, Eating Disorder Not Otherwise Specified, Posttraumatic Stress Disorder, Fibromyalgia, and Irritable Bowel Syndrome Through Lifestyle Change.

This case report illustrates the relationship between gut, hormonal, and brain function in that dietary change, mindfulness interventions, and detoxification led to resolution of disabling psychiatric symptoms. In this case, a single Caucasian female resolved her symptoms of bipolar disorder (BD) including psychotic features and suicidality, posttraumatic stress disorder symptoms from childhood torture, disordered eating, fibromyalgia, and irritable bowel syndrome through lifestyle interventions. This patient survived a severe trauma history only to develop alcohol dependence, disordered eating, and depressive symptoms, which were treated with a polypharmaceutical psychiatric approach. She was formally diagnosed with BD after being treated with antidepressants and went on to be treated with up to 15 medications in the ensuing years. Disabled by the side effects of her treatment, she worked with her treating psychiatrist to taper off of 4 medications before she learned of nutritional change through a book authored by the author. After completing 1 mo of these recommendations including dietary change, detox, and meditation, she enrolled in the author's online program and went on to resolve her symptoms, physical and psychiatric, to the extent that BD has been removed from her medical record. She has been symptom free for 1 y. This case is evidence of the potential for self-directed healing and resolution of chronic illness.

Suplementos nutricionales en trastornos de la conducta alimentaria / Nutritional supplements in eating disorders

Se consideran Trastornos de la Conducta Alimentaria (TCA) a una serie de entidades nosológicas diferenciadas que tienen como nexo común una alteración continuada en la ingesta o bien en la conducta relacionada con la ingesta. Dentro de dicha clasificación destacan los siguientes trastornos: Anorexia Nerviosa (AN) y Bulimia Nerviosa (BN). La AN es un trastorno de curso crónico caracterizado principalmente por una negativa o disminución de la ingesta acompañado de una distorsión de la imagen corporal con el consecuente miedo intenso a la ganancia de peso. Se estima una prevalencia vital en la adolescencia de dicho trastorno de aproximadamente el 0,5-1%1. En la BN la presencia de atracones de comida y la posterior conducta compensatoria (en forma de ejercicio intenso, uso de laxantes, diuréticos...) es lo que prima en el paciente. La prevalencia se estima entre un 2 y un 4% en mujeres jóvenes, iniciándose generalmente en etapas algo posteriores que la AN. Se cree que en su patogenia influyen factores biológicos, psicológicos y ambientales así como una cierta vulnerabilidad genética. Existen distintos tratamientos con eficacia avalada por parte de literatura científica, tanto terapias biológicas como psicológicas, a pesar de ello, nos encontramos con una efectividad parcial de dichas terapias siendo necesaria la búsqueda de nuevas dianas así como de nuevos tratamiento. Aunque la etiopatogenia de los TCA no esté clara, algunas de las disfunciones neurobiológicas encontradas permitirían considerar que la dieta y la administración de nutrientes podría ser relevante en el tratamiento de estos trastornos. Proponemos en este artículo una revisión de nuevos tratamientos enfocados al déficit nutricional (AU)

Eating disorders (EDs) are a series of differentiated nosological entities sharing the common link of a continuous alteration in food intake or in food intake-related behavior. Within this classification, the following disorders are noteworthy: anorexia nerviosa (AN) and bulimia nerviosa (BN). Anorexia nervosa is a chronic disorder characterized mainly by negative or decreased food intake accompanied by a distortion of body image and intense accompanying fear of weight gain. The estimated vital prevalence of this disorder in adolescence is approximately 0.5%-1%.1 The primary feature of BN is the presence of binge eating accompanied by compensatory behavior (in the form of intense exercise and the use of laxatives and diuretics, etc.). The prevalence of BN is estimated to be between 2% and 4% in young women, and it generally starts at somewhat later stages than AN. It is believed that biological, psychological, and environmental factors, as well as genetic vulnerability, influence the pathogenesis of EDs. A variety of therapies exist, both biological and psychological, whose effectiveness is supported by the scientific literature. Nonetheless, we find these therapies only partially effective and new targets as well as new treatments should be sought. Although the etiopathogenesis of EDs is unclear, some of the neurobiological dysfunction found suggests that diet and nutrient supplementation could be relevant in their treatment. We review in this article new treatments focusing on nutritional déficits (AU)

Severe vitamin C deficiency in a child newly diagnosed with T-cell ALL due to nutrient gap.

A 10-year-old boy developed a perifollicular rash during interim maintenance of T-Cell acute lymphoblastic leukaemia. Differential diagnoses included drug reaction and inflammatory process. Before diagnosis, the patient had a limited diet--low in vegetables and fruits--due to selective eating, with later anorexia and taste aversions due to chemotherapy treatment. Despite nutritional counselling and starting a multivitamin, the patient incurred severe weight loss (18.5% of his usual body weight). Serum levels of ascorbic acid were non-detectable, at <5 µmol/L, indicative of vitamin C deficiency. The patient began vitamin C supplementation containing 125 mg ascorbic acid three times a day for 7 days, then 125 mg once daily for 3 months to normalise serum vitamin C. After ascorbic acid treatment was completed, the patient started a complete multivitamin and made efforts to eat fruits and vegetables rich in vitamin C. His serum ascorbic acid concentrations normalised to 52 µmol/L 3 months after receiving supplementation.

Individually prescribed diet is fundamental to optimize nutritional treatment in geriatric patients.

BACKGROUND & AIMS: Malnutrition is a well-recognized problem in geriatric patients. Individually prescribed diet is fundamental to optimize nutritional treatment in geriatric patients. The objective of this study was to investigate routines regarding dietary prescriptions and monitoring of food intake in geriatric patients and to see how well the prescribed diet conforms to the patients' nutritional status and ability to eat. A further aim was to identify the most common reasons and factors interacting with patients not finishing a complete meal. METHODS: This study combines two methods using both qualitative and quantitative analysis. Patients (n = 43; 82.5 ± 7.5 yrs; 60% females) at four geriatric wards performed a two-day dietary record, assisted by a dietician. Nurses and assistant nurses at each ward participated in a semi-structured interview regarding prescription of diets and portion size for the patients. RESULTS: The prescribed diet differed significantly (P < 0.01) from a diet based upon the patient's nutritional status and ability to eat. Only 30% of the patients were prescribed an energy-enriched diet in contrast to 60% that was in need of it. The most common reason for not finishing the meal was lack of appetite. Diet prescription for the patient was based upon information about eating difficulties identified in the Mini Nutritional Assessment-Short Form (MNA-SF) at admission and the type of diet that was prescribed on a previous ward. Monitoring of the patients' food intake was described as a continuous process discussed daily between the staff. CONCLUSION: Patients' nutritional status and to what extent they were able to eat a complete meal was not routinely considered when prescribing food and monitoring food intake in this study. By making use of this information the diet could be tailored to the patients' needs, thereby improving their nutritional treatment.

Hypomagnesemia in adolescents with eating disorders hospitalized for medical instability.

BACKGROUND: Hypomagnesemia in patients with eating disorders is poorly characterized, particularly among adolescents. METHODS: To determine the prevalence of hypomagnesemia (Mg ≤ 1.7 mg/dL) and clinical characteristics of adolescents hospitalized with a DSM-IV-diagnosed eating disorder who developed hypomagnesemia, a retrospective chart review was conducted on all adolescents aged 10-21 years with an eating disorder were hospitalized at a tertiary care children's hospital from 2007 to 2010. Patients were refed orally with standard nutrition and high-energy liquid supplements. Serum magnesium and phosphorus were obtained on admission, every 24-48 hours for the first week, and thereafter as clinically indicated. Clinical characteristics of patients with hypomagnesemia were compared with those of individuals with normal magnesium levels and those with hypophosphatemia. RESULTS: Eighty-six of 541 eligible participants (15.9%) developed hypomagnesemia. Forty (47%) with hypomagnesemia admitted to purging in the year before admission, with 88% purging during the prior month. Compared with those with normal serum magnesium levels, patients with hypomagnesemia were older (P = .0001), ill longer (P = .001), more likely to be purging (P = .04), and more likely to have an alkaline urine (P = .01). They did not differ in eating disorder diagnosis, BMI, or other electrolyte disturbances. Hypomagnesemia developed 4.9 ± 5.5 days after refeeding was initiated, significantly later than the onset of hypophosphatemia, 0.95 ± 2.6 days (P < .001). CONCLUSIONS: Hypomagnesemia is prevalent in adolescents hospitalized for an eating disorder and is associated with purging and alkaline urine. Hypomagnesemia develops later in the course of refeeding than hypophosphatemia. Magnesium levels should continue to be monitored after the more immediate risk of hypophosphatemia has passed, especially in those with alkaline urine.

Omega-3 essential fatty acid status is improved during nutritional rehabilitation of adolescent girls with eating disorders and weight loss.

AIM: Essential fatty acid status is altered in eating disorders with weight loss, and deficiencies in polyunsaturated omega-3 essential fatty acids have been implicated in the development of depression and other psychopathologies. Presently, recovery of essential fatty status during the treatment of adolescent girls with eating disorders has been investigated. METHODS: Fatty acids were analysed in erythrocyte membranes of 24 adolescents girls with eating disorders of short duration, and on the average >10 kg weight loss at presentation. Blood samples were obtained at presentation and following weight recovery on standard diet without supplementation with essential fatty acids. RESULTS: Alterations of essential fatty status observed at presentation largely normalized during treatment. Omega-3 status improved following weight gain. CONCLUSION: Adequate nutrition, normalization of eating behaviours, weight gain and the consequent return to normalization of metabolism and endocrine function are sufficient to ensure normalization of essential fatty acid status. Supplementation with omega-3 polyunsaturated fatty acids does not appear warranted.

Nutrition and dietetic practice in eating disorder management.

BACKGROUND: This review examines the current literature that is available on nutrition and dietetic practice in the treatment of eating disorders. Evidence-based guidelines on nutrition and dietetic practice in the management of eating disorder patients are lacking, as is detailed information on how to implement existing recommendations into day-to-day practice. METHODS: A search of databases was undertaken, with articles on nutrition and eating disorders being reviewed for strength of evidence, content and relevance to dietetic practice. Core dietetic skills used at the graduate level, such as dietary assessment, were not included in the literature review. RESULTS: There were a total of 61 references reviewed that discussed nutrition and dietetic practice in the management of eating disorder patients. Most papers were descriptive papers, with few examining the effectiveness of nutrition intervention. Three papers were surveys that assessed the professional needs and challenges of dietitians who work with eating disorder clients. CONCLUSIONS: Dietetic practice in the treatment of eating disorder patients is not well defined. Most publications are descriptions of practice, with few evaluating the effectiveness of dietetic work. Dietitians need to move from the clinical arena alone and become more involved in research, evaluating practice and defining a gold standard of nutritional treatment strategies that are best delivered by the dietitian. There is also a need for manualised approaches that can be prospectively examined.

[Nutritional treatment or feeding? Problems in child feeding]. / Leczenie zywieniowe czy karmienie? Trudnosci w karmieniu dzieci.

Eating disorders affect nutritional status and psycho-mental development of the child. When the child is ill, such disorders may be exacerbated, leading to malnutrition and thus affecting the course of underlying disease and its duration, the number and type of complications, as well as the prognosis. The risk of malnutrition is most commonly observed in chronically ill children or in patients with dysphagia secondary to CNS damage. Symptoms of dysphagia and/or malnutrition indicate the need for developing an individual nutritional protocol, and in malnourished patients--for initiating aggressive nutritional treatment. The report analyzes the decision-making algorithm employed in nutritional interventions, types of diets and routes of their administration.

Hepatocellular injuries observed in patients with an eating disorder prior to nutritional treatment.

BACKGROUND/AIMS: Although hepatocellular injuries are occasionally observed in patients with an eating disorder, such as anorexia nervosa (AN), it remains unclear how malnutrition in patients with AN causes hepatocellular damage. In this retrospective study, we aimed to reveal the characteristics of hepatocellular injuries in patients with an eating disorder without any nutritional treatment, to eliminate the possible hepatotoxic effects of nutritional support. SUBJECTS AND METHODS: Twenty-five patients with an eating disorder who visited St. Luke's International Hospital were enrolled. No nutritional treatment had been performed for these patients. The diagnosis of eating disorder as well as typing (anorexia nervosa or bulimia nervosa) was made according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-4). We reviewed the charts of these patients and examined the clinical parameters. RESULTS: Elevation of serum alanine aminotransferase (ALT) was found in 13 out of 25 (52%), all of whom were categorized as AN. In 13 AN patients with elevated ALT, the median of serum ALT values was 92 [39-438] IU/L. The body mass index (BMI) was significantly lower (13.5 vs. 17.3, p=0.011), and the duration since the onset of AN was shorter (4.2 years vs. 8.9 years, p=0.037) in patients with elevated ALT. The age was younger in patients with elevated ALT, even though not significant (24.5 vs. 29.8, p=0.139). Logistic regression analysis revealed that only BMI was a significant determinant for the development of hepatocellular injuries (OR=3.46; 95% CI 1.06-11.34, p=0.041). Imaging studies failed to demonstrate any abnormalities, including fatty liver. CONCLUSION: The current study indicated that lower BMI might significantly contribute to the development of hepatocellular injuries in AN patients prior to any nutritional treatments.

Nutrición en anorexia nerviosa / Nutrition in anorexia nervosa

La anorexia nerviosa es la enfermedad psiquiátrica más frecuente entre las mujeres jóvenes, y se caracteriza por la realización de dietas estrictas con pérdida significativa de peso y un miedo desproporcionado a su ganancia. Esta enfermedad conlleva múltiples complicaciones derivadas tanto de la desnutrición que origina como de los métodos empleados para la pérdida de peso. El tratamiento de esta afección exige un abordaje multidisciplinario y especializado, que se puede efectuar en distintos niveles asistenciales tanto ambulatorio como hospitalario, dependiendo de la situación clínica de los pacientes. Durante el proceso de renutrición, en cualquiera de los niveles asistenciales, se pretende la recuperación de un peso mínimo saludable, la normalización de la conducta alimentaria así como la corrección de las secuelas físicas y psicológicas de la malnutrición. El tratamiento inicial debe enfocarse hacia la restauración del peso, y para alcanzar los objetivos propuestos se seleccionará la vía de acceso de alimentación más apropiada; la vía oral siempre será la de elección, y se optará por la nutrición artificial sólo en situaciones de falta de cooperación o de incorrecta progresión ponderal durante el tratamiento. Si es preciso puede recurrirse a la nutrición artificial, y la nutrición enteral es preferible a la parenteral. Una vez iniciada la realimentación, la progresión en la alimentación se realizará de manera individualizada, y se incrementará progresivamente el aporte calórico hasta alcanzar los objetivos de peso propuestos. Es imprescindible el estricto control hidroelectrolítico, metabólico y físico durante la fase inicial de la realimentación para evitar y diagnosticar complicaciones que pueden aparecer, como el síndrome de renutrición

Anorexia nervosa is the most frequent psychiatric disorder among young women and is characterized by strict dieting with significant weight loss accompanied by a inordinate fear of weight gain. The disorder produces multiple complications arising from both malnutrition and from the methods used to lose weight. Treatment involves a multidisciplinary and specialized approach, which can be carried out in distinct health care levels, both inpatient and outpatient, depending on the patient's clinical status. In all levels of healthcare, during the renutrition process the aim is to recover a minimum healthy weight, achieve normal eating behavior in the patient, and correct the physical and psychological sequelae of malnutrition. Initial treatment should focus on weight gain. To achieve this goal, the most appropriate route of feeding should be selected; the route of choice is always oral, while artificial nutrition is reserved when the patient is uncooperative or there is insufficient weight gain during treatment. If artificial nutrition is unavoidable, enteral nutrition should always be preferred over parenteral nutrition. Once refeeding has been initiated, feeding progression should be individualized, progressively increasing calorie intake until the target weight has been achieved. Strict monitoring of hydroelectrolyte, metabolic and physical status is essential during the initial refeeding phase to prevent or diagnose possible complications, such as refeeding syndrome

Tratamento nutricional dos transtornos alimentares / Nutritional treatment of eating disorders

Pacientes com transtornos alimentares possuem inadequaçäes profundas no consumo, padrão e comportamento alimentar, além de diversas crenças equivocadas sobre alimentação, o que geralmente acarreta piora do estado nutricional. O tratamento nutricional visa a reverter tais alteraçäes e promover hábitos alimentares saudáveis e melhor relação para com o alimento. Os objetivos e características do tratamento diferem para a anorexia nervosa e a bulimia nervosa, contudo, usualmente, a abordagem é dividida em duas fases: a educacional, cujas principais metas são a regularização do hábito alimentar e o aumento do conhecimento nutricional, e a experimental, que visa a propiciar maior reabilitação nutricional e mudanças mais profundas no comportamento alimentar. As evidências existentes sugerem que o tratamento nutricional promove a melhora de tais parâmetros, porém, alguns comportamentos alimentares, como a sensação de incompetência ao lidar com os alimentos, permanecem. Desta forma, mais estudos são necessários para que se possa de fato avaliar a eficácia da abordagem nutricional.

[Nutrition counseling in tumor cachexia so patients will eat better]. / Ernährungsberatung bei Tumorkachexie damit Ihre Patienten wieder besser essen.

With the aim of preventing, or at least limiting, malnutrition in patients suffering from cancer, they should receive appropriate nutritional advice before, during and after treatment. Such problems as loss of appetite, nausea, gustatory disturbances, dry mouth, etc., may be ameliorated by specific counseling. Enteral liquid diets and commercially available baby food products offer a good alternative to normal diet, or may be used to supplement it. Such supplements as vitamin and/or mineral tablets, and vegetable and fruit concentrates should only be used selectively and for well-founded indications. The metabolic situation in cachectic patients is not particularly amenable to oral nutritional measures. A fat-rich diet is recommended. The administration of pharmacological doses of omega-3 fatty acids may offer some benefit.