Barriers and facilitators of improved nutritional support for patients newly diagnosed with cancer: a pre-implementation study.

BACKGROUND: Disease-related malnutrition affects a significant number of patients with cancer and poses a major social problem worldwide. Despite both global and national guidelines to prevent and treat malnutrition, the prevalence is high, ranging from 20 to 70% in all patients with cancer. This study aimed to explore the current practice of nutritional support for patients with cancer at a large university hospital in Norway and to explore potential barriers and facilitators of the intervention in the Green Approach to Improved Nutritional support for patients with cancer (GAIN), prior to implementation in a clinical setting. METHODS: The study used individual interviews and a focus group discussion to collect data. Study participants included different healthcare professionals and patients with cancer treated at a nutrition outpatient clinic. The Consolidated Framework for Implementation Research (CFIR) was used to guide the thematic data analysis. RESULTS: Barriers connected to the current nutritional support were limited resources and undefined roles concerning responsibility for providing nutritional support among healthcare professionals. Facilitators included a desire for change regarding the current nutritional practice. The GAIN intervention was perceived as feasible for patients and healthcare professionals. Potential barriers included limited knowledge of technology, lack of motivation among patients, and a potential added burden experienced by the participating patients. CONCLUSIONS: The identification of the potential barriers and facilitators of the current nutritional support to patients with cancer will be used to plan the implementation of improved nutritional support in a randomized controlled trial for patients with cancer prior to clinical implementation. The current findings may be of value to others trying to implement either or both nutritional support and digital application tools in a clinical healthcare setting. TRIAL REGISTRATION: The study was registered in the National Institutes of Health Clinical trials 08/09/22. The identification code is NCT05544318.

Validity of dietary intake methods in cancer cachexia.

PURPOSE OF REVIEW: Accurate assessment of dietary intake, especially energy and protein intake, is crucial for optimizing nutritional care and outcomes in patients with cancer. Validation of dietary assessment methods is necessary to ensure accuracy, but the validity of these methods in patients with cancer, and especially in those with cancer cachexia, is uncertain. Validating nutritional intake is complex because of the variety of dietary methods, lack of a gold standard method, and diverse validation measures. Here, we review the literature on validations of dietary intake methods in patients with cancer, including those with cachexia, and highlight the gap between current validation efforts and the need for accurate dietary assessment methods in this population. RECENT FINDINGS: We analyzed eight studies involving 1479 patients with cancer to evaluate the accuracy and reliability of 24-hour recalls, food records, and food frequency questionnaires in estimating energy and protein intake. We discuss validation methods, including comparison with biomarkers, indirect calorimetry, and relative validation of dietary intake methods. SUMMARY: Few have validated dietary intake methods against objective markers in patients with cancer. While food records and 24-hour recalls show potential accuracy for energy and protein intake, this may be compromised in hypermetabolic patients. Additionally, under- and overreporting of intake may be less frequent, and the reliability of urinary nitrogen as a protein intake marker in patients with cachexia needs further investigation. Accurate dietary assessment is important for enhancing nutritional care outcomes in cachexia trials, requiring validation at multiple time points throughout the cancer trajectory.

Attenuation of DNA base oxidation in post-surgery colorectal stage III patients at subsequent follow-ups.

DNA damage caused by oxidative reactions plays a crucial role in the pathogenesis of colorectal cancer (CRC). In a previous cross-sectional study, CRC patients diagnosed with regional disease (stage III) exhibited a higher level of DNA base oxidation in peripheral blood mononuclear cells (PBMCs) 2-9 months post-surgery compared to those with localized disease (stage I-II). To further explore this observation over time, the present study aimed to investigate DNA base oxidation in CRC patients with localized versus regional disease 6 and 12 months after the initial measurements. The present study included patients enrolled in the randomized controlled trial Norwegian Dietary Guidelines and Colorectal Cancer Survival (CRC-NORDIET). The standard comet assay, modified with the lesion-specific enzyme formamidopyrimidine DNA glycosylase (Fpg), was applied to measure DNA base oxidation in PBMCs at the 6- and 12-month follow-ups. Of the 255 patients assessed at baseline, 156 were included at the 6-month follow-up, with 89 of these patients included in the 12-month follow-up. In contrast to our observation at baseline, there were no significant differences in the levels of DNA base oxidation between patients diagnosed with localized disease and those with regional involvement at the 6- and 12-month follow-up visits (P = 0.81 and P = 0.09, respectively). Patients with stage III disease exhibited a significant decrease in the levels of DNA base oxidation from baseline to 6 months (P < 0.01) and baseline to 12 months (P = 0.03), but no significant difference from 6 to 12 months (P = 0.80). In conclusion, the initially elevated levels of DNA base oxidation in PBMCs, observed 2-9 months post-surgery in patients diagnosed with regional disease (stage III), subsequently decreased to levels comparable to patients with localized disease (stage I-II) at the 6- and 12-month follow-ups.

Effect of a personalized intensive dietary intervention on base excision repair (BER) in colorectal cancer patients: Results from a randomized controlled trial.

DNA repair is essential to maintain genomic integrity and may affect colorectal cancer (CRC) patients' risk of secondary cancers, treatment efficiency, and susceptibility to various comorbidities. Bioactive compounds identified in plant foods have the potential to modulate DNA repair mechanisms, but there is limited evidence of how dietary factors may affect DNA repair activity in CRC patients in remission after surgery. The aim of this study was to investigate the effect of a 6-month personalized intensive dietary intervention on DNA repair activity in post-surgery CRC patients (stage I-III). The present study included patients from the randomized controlled trial CRC-NORDIET, enrolled 2-9 months after surgery. The intervention group received an intensive dietary intervention emphasizing a prudent diet with specific plant-based foods suggested to dampen inflammation and oxidative stress, while the control group received only standard care advice. The comet-based in vitro repair assay was applied to assess DNA repair activity, specifically base excision repair (BER), in peripheral blood mononuclear cells (PBMCs). Statistical analyses were conducted using gamma generalized linear mixed models (Gamma GLMM). A total of 138 CRC patients were included, 72 from the intervention group and 66 from the control group. The BER activity in the intervention group did not change significantly compared to the control group. Our findings revealed a substantial range in both inter- and intra-individual levels of BER. In conclusion, the results do not support an effect of dietary intervention on BER activity in post-surgery CRC patients during a 6-month intervention period.

The choice of diagnostic modality influences the proportion of low muscle strength, low muscle mass, and sarcopenia in colorectal cancer patients.

BACKGROUND AND AIMS: Low muscle strength, low muscle mass, and sarcopenia have a negative impact on health outcomes in colorectal cancer (CRC) patients. Different diagnostic modalities are used to identify these conditions but it is unknown how well the modalities agree. The aim of this study was to compare different diagnostic modalities by means of calculating the proportion of low muscle strength, low muscle mass, and sarcopenia in CRC patients, and to investigate the agreement for sarcopenia between the various modalities. METHODS: Men and women participating in the Norwegian Dietary Guidelines and colorectal cancer Survival (CRC-NORDIET) study were included in the analyses. Cut-off values for low muscle strength, low muscle mass, and sarcopenia were defined according to the second consensus set by the European Working Group on Sarcopenia in Older People (EWGSOP2). The diagnostic modalities used to assess muscle strength were handgrip strength and the sit-to-stand test. For muscle mass, computed tomography, dual-energy X-ray absorptiometry (DXA), multi-frequency bioelectrical impedance analysis (MF-BIA), and single-frequency BIA (SF-BIA) were applied. Cohen's kappa was calculated to determine the agreement for low muscle strength and confirmed sarcopenia between diagnostic modalities. RESULTS: Five hundred and three men and women (54 % men, mean age of 66 (range 50-80) years old) were included in the analysis. As much as 99 % (n = 70) of the population was identified with low muscle mass by MF-BIA, while the other modalities identified 9-49 % as having low muscle mass. Handgrip strength identified a lower proportion of low muscle strength as compared with the sit-to-stand test (4 % vs. 8 %). When applying various combinations of diagnostic modalities for low muscle strength and low muscle mass, the proportion of sarcopenia was found to be between 0.3 and 11.4 %. There was relatively poor agreement between the different diagnostic modalities with Cohen's Kappa ranging from 0.0 to 0.55, except for the agreement between SF-BIASergi and MF-BIASergi, which was 1. CONCLUSION: The proportion of low muscle strength, low muscle mass, and sarcopenia in CRC patients varied considerably depending on the diagnostic modalities used. Further studies are needed to provide modality-specific cut-off values, adjusted to sex, age and body size.

Malnutrition prevalence according to GLIM and its feasibility in geriatric patients: a prospective cross-sectional study.

PURPOSE: In 2019, the Global Leadership Initiative on Malnutrition (GLIM) suggested a 2-step diagnostic format for malnutrition including screening and diagnosis. Prospective validation and feasibility studies, using the complete set of the five GLIM criteria, are needed. The aims of this study were to determine the prevalence of malnutrition, and investigate how the prevalence varied with mode of screening. Furthermore, we assessed the feasibility of GLIM in geriatric patients. METHODS: Consecutive patients from two acute geriatric wards were included. For screening risk of malnutrition, the Mini Nutritional Assessment-Short Form (MNA-SF) or Malnutrition Screening Tool (MST) were used. In accordance with GLIM, a combination of phenotypic and etiologic criteria were required for the diagnosis of malnutrition. Feasibility was determined based on % data completeness, and above 80% completeness was considered feasible. RESULTS: One hundred patients (mean age 82 years, 58% women) were included. After screening with MNA-SF malnutrition was confirmed by GLIM in 51%, as compared with 35% after screening with MST (p = 0.039). Corresponding prevalence was 58% with no prior screening. Using hand grip strength as a supportive measure for reduced muscle mass, 69% of the patients were malnourished. Feasibility varied between 70 and 100% for the different GLIM criteria, with calf circumference as a proxy for reduced muscle mass having the lowest feasibility. CONCLUSION: In acute geriatric patients, the prevalence of malnutrition according to GLIM varied depending on the screening tool used. In this setting, GLIM appears feasible, besides for the criterion of reduced muscle mass.

Effect of a one-year personalized intensive dietary intervention on body composition in colorectal cancer patients: Results from a randomized controlled trial.

BACKGROUND & AIMS: Changes in body composition may affect colorectal cancer (CRC) patient's risk of cancer recurrence, secondary cancer, and other chronic diseases. The suggested interventions for changes in body composition such as low muscle mass or high fat mass, are diet and physical activity. Nevertheless, there is limited evidence of how dietary intervention alone can impact body composition. This study aimed to investigate the effect of a 6 and 12 month dietary intervention with a focus on healthy eating according to Norwegian food-based dietary guidelines on weight and body composition in patients with CRC stage I-III, post-surgery. METHODS: This study included participants from the randomized controlled trial CRC-NORDIET study 2-9 months after surgery. The intervention group received an intensive dietary intervention, while the control group underwent similar measurements, but no dietary intervention. Body composition was measured with Lunar iDXA, and the results were analyzed using linear mixed models. RESULTS: A total of 383 participants were included, 192 in the intervention group and 191 in the control group. After 6 months, the intervention group showed a 0.7 kg lower mean weight gain (p = 0.020) and 0.6 kg lower fat mass gain (p = 0.019) than the control group, but no difference at 12 months. Moreover, the fat mass increase was 0.5 percentage points lower at 6 months (p = 0.012), and 0.7 percentage points lower at 12 months (p = 0.011) in the intervention group compared to the controls. At 6 months, the intervention group had 63 g lower gain of visceral adipose tissue compared to the control group (p = 0.031). No differences were seen for fat-free mass or subcutaneous adipose tissue at any time point. The intervention group showed a lower increase in the ratio between fat mass and fat-free mass at both 6 months (p = 0.025) and 12 months (p = 0.021). CONCLUSION: The dietary intervention reduced the increases in total weight and fat masses, without changing fat-free mass. Although the individual changes are small, the dietary intervention may have resulted in an overall more favourable body composition profile. These findings suggest that dietary intervention may be part of a treatment strategy for prevention of weight and fat mass gain in CRC survivors.

Prevalence of malnutrition among older adults in a population-based study - the HUNT Study.

BACKGROUND: Malnutrition is common in older adults and is associated with increased morbidity and mortality rates. AIM: The aim of the study is to describe the prevalence of malnutrition based on low BMI, involuntary weight loss, and reduced food intake, in a Norwegian population of community-dwelling older adults and older adults living in nursing homes. METHODS: This population-based study is part of the fourth wave of the Trøndelag Health Study (HUNT4) and includes participants ≥70 years from the HUNT4 70+ cohort. The HUNT4 70+ cohort consist of 9930 (response rate 51.2%) participants. In the current study 8127 older people had complete dataset for inclusion in the analyses. Participants completed a self-report questionnaire and standardised interviews and clinical assessments at field stations, in participants' homes or at nursing homes. Malnutrition was defined using the following criteria: low BMI, involuntary weight loss and severely reduced food intake. The standardised prevalence of malnutrition was estimated using inverse probability weighting (IPW) with weights for sex, age and education of the total population in the catchment area of HUNT. RESULTS: Of the 8127 included participants, 7671 (94.4%) met at field stations, 356 (4.4%) were examined in their home, and 100 (1.2%) in nursing homes. In total, 14.3% of the population were malnourished based on either low BMI, weight loss, or reduced food intake, of which low BMI was the most frequently fulfilled criterion. The prevalence of malnutrition was less common among men than among women (10.1 vs 18.0%, p < 0.001), also after adjustment for age (OR 0.53, 95% confidence interval (CI) 0.46-0.61). The prevalence increased gradually with increasing age and the regression analysis adjusted for sex showed that for each year increase in age the prevalence of malnutrition increased with 4.0% (OR 1.04, 95% CI 1.03-1.05). The prevalence was higher both among older adults examined in their homes (26.4%) and residents in nursing home (23.6%), as compared to community-dwelling older adults who met at field stations (13.5%). CONCLUSION: The prevalence of malnutrition is high in the older population. Special attention on prevention and treatment of malnutrition should be given to older women, the oldest age groups, and care-dependent community-dwelling older adults and nursing home residents.

Associations of the 2018 World Cancer Research Fund/American Institute of Cancer Research (WCRF/AICR) cancer prevention recommendations with stages of colorectal carcinogenesis.

BACKGROUND: While adherence to cancer prevention recommendations is linked to lower risk of colorectal cancer (CRC), few have studied associations across the entire spectrum of colorectal carcinogenesis. Here, we studied the relationship of the standardized 2018 World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) Score for cancer prevention recommendations with detection of colorectal lesions in a screening setting. As a secondary objective, we examined to what extent the recommendations were being followed in an external cohort of CRC patients. METHODS: Adherence to the seven-point 2018 WCRF/AICR Score was measured in screening participants receiving a positive fecal immunochemical test and in CRC patients participating in an intervention study. Dietary intake, body fatness and physical activity were assessed using self-administered questionnaires. Multinomial logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for screen-detected lesions. RESULTS: Of 1486 screening participants, 548 were free from adenomas, 524 had non-advanced adenomas, 349 had advanced lesions and 65 had CRC. Adherence to the 2018 WCRF/AICR Score was inversely associated with advanced lesions; OR 0.82 (95% CI 0.71, 0.94) per score point, but not with CRC. Of the seven individual components included in the score, alcohol, and BMI seemed to be the most influential. Of the 430 CRC patients included in the external cohort, the greatest potential for lifestyle improvement was seen for the recommendations concerning alcohol and red and processed meat, where 10% and 2% fully adhered, respectively. CONCLUSIONS: Adherence to the 2018 WCRF/AICR Score was associated with lower probability of screen-detected advanced precancerous lesions, but not CRC. Although some components of the score seemed to be more influential than others (i.e., alcohol and BMI), taking a holistic approach to cancer prevention is likely the best way to prevent the occurrence of precancerous colorectal lesions.

The Norwegian Directorate of Health recommends malnutrition screening tool (MST) for all adults.

BACKGROUND & AIMS: Malnutrition is underdiagnosed and undertreated in Norway. In a revision of a national guideline on malnutrition, the Norwegian Directorate of Health aimed for a harmonization and standardization of the malnutrition screening practice, including a recommendation of one malnutrition screening tool to be used among all adults in Norwegian health and care services. METHODS: A working group was appointed by the Norwegian Directorate of Health. Evidence-based practice, a pragmatic decision-making process based on a literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE), and the DECIDE decision-making model was used as a guidance in order to convert evidence into recommendations. RESULTS: The criteria and properties of the four most frequently validated malnutrition screening tools were identified and ranked by the working group. The tools were prioritized in the following order: 1: Malnutrition Screening Tool (MST), 2: Malnutrition Universal Screening Tool (MUST), 3: Nutritional Risk Screening 2002 (NRS-2002), and 4: Mini-Nutritional Assessment short form (MNA). CONCLUSIONS: The Norwegian Directorate of Health recommends use of MST for screening for malnutrition among all adults (≥18 years), across all health care settings, and diagnoses or conditions in Norway.

Harmonization and standardization of malnutrition screening for all adults - A systematic review initiated by the Norwegian Directorate of Health.

BACKGROUND & AIMS: The Norwegian Directorate of Health has identified a need to harmonize and standardize the malnutrition screening practice in Norwegian hospitals and primary health care settings, in order to provide a seamless communication of malnutrition screening along the patient pathway. Our aim was to perform a systematic review of the validity and reliability of screening tools used to identify risk of malnutrition across health care settings, diagnoses or conditions and adult age groups, as a first step towards a national recommendation of one screening tool. METHODS: A systematic literature search for articles evaluating validity, agreement, and reliability of malnutrition screening tools, published up to August 2020, was conducted in: MEDLINE, Embase, APA PsycInfo, Cinahl, Cochrane Databases, Web of Science, Epistemonikos, SveMed+, and Norart. The systematic review was registered in PROSPERO (CRD42022300558). For critical appraisal of each included article, the Quality Criteria Checklist by The Academy of Nutrition and Dietetics was used. RESULTS: The review identified 105 articles that fulfilled the inclusion and exclusion criteria. The most frequently validated tools were Mini Nutritional Assessment short form (MNA), Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST), and Nutritional Risk Screening 2002 (NRS-2002). MNA, MST and NRS-2002 displayed overall moderate validity, and MUST low validity. All four tools displayed low agreement. MST and MUST were validated across health care settings and age groups. In general, data on reliability was limited. CONCLUSIONS: The screening tools MST and NRS-2002 displayed moderate validity for the identification of malnutrition in adults, of which MST is validated across health care settings. In addition, MNA has moderate validity for the identification of malnutrition in adults 65 years or older.

Low inter-rater reliability between nurses and researchers for the NRS-2002 screening tool for malnutrition in a hematological hospital ward.

BACKGROUND & AIMS: NRS-2002 is one of the recommended tools to screen hospitalized patients for malnutrition. NRS-2002 is considered as valid and reliable, but little is known about the inter-rater reliability between different groups of healthcare professionals. The aim of this study was to test the inter-rater reliability of the NRS-2002 tool between department nurses and researchers. METHODS: Inter-rater reliability was measured between the NRS-2002 scores given by department nurses and researchers, using data from a randomized controlled trial (RCT) at a hematological department in a Norwegian hospital. RESULTS: The mean NRS-2002 score was significantly higher when using researchers' scores compared to the department nurses' scores. The total agreement between the two groups of raters was 59%, kappa = 0.27. CONCLUSION: The inter-rater reliability of the NRS-2002 scores given by nurses and researchers was low. More research is needed to study if this is applicable also to other patient groups and in other wards.

Agreement between GLIM and PG-SGA for diagnosis of malnutrition depends on the screening tool used in GLIM.

BACKGROUND & AIM: The Global Leadership Initiative on Malnutrition (GLIM) has suggested a process for the diagnosis of malnutrition. The process consists of applying an existing screening tool for malnutrition screening, followed by malnutrition diagnostics, and finally categorization of malnutrition severity (moderate or severe) according to specific GLIM criteria. However, it is not known how well the GLIM process agrees with other diagnostic tools used in the current clinical practice. The aim of this study was to validate the GLIM process against the Patient Generated-Subjective Global Assessment (PG-SGA) when different screening tools were applied in the screening step of the GLIM process. METHODS: Colorectal cancer (CRC) patients from the ongoing CRC-NORDIET study were included. For the GLIM process, the patients were first screened for malnutrition using either 1) Nutritional risk screening, first 4 questions (NRS-2002-4Q), 2) Malnutrition Screening Tool (MST), 3) Malnutrition Universal Screening Tool (MUST) or 4) the PG-SGA short form (PG-SGA-SF). The GLIM malnutrition diagnosis was then based on combining the result from each of the screening methods with the etiological and phenotypic GLIM-criteria including weight loss, BMI and fat free mass. In parallel, the patients were diagnosed using the PG-SGA methodology categorizing the patients into either A: well nourished, B: moderately malnourished or C: severely malnourished. The four different GLIM based diagnoses were then validated against the diagnosis obtained by the PG-SGA tool. Sensitivity, specificity and positive predictive value (PPV) were calculated to evaluate validity. RESULTS: In total, 426 patients were included (mean age: 66, ±8 years) at a mean time of 166 (±56) days after surgery. The GLIM diagnosis based on the four different screening tools identified 10-24% of the patients to be malnourished, of which 3-8% were severely malnourished. The PG-SGA method categorized 15% as moderately malnourished (PG-SGA: category B) and no patients as severely malnourished (PG-SGA: category C). The agreement between the PG-SGA and GLIM process was in general low, but differed according to the tools: PG-SGA SF (sensitivity 47%, PPV 71%), MST (sensitivity 56%, PPV 47%), NRS-2002-4Q (sensitivity 63%, PPV 53%) and MUST (sensitivity 53%, PPV 34%). CONCLUSION: In this cross-sectional study of patients with CRC, the concordance between the GLIM-criteria and PG-SGA depended on the screening tool used in the GLIM process. Malnutrition frequency based on the GLIM process schould be reported with and without the use of a screening tool.

Agreement between the GLIM criteria and PG-SGA in a mixed patient population at a nutrition outpatient clinic.

BACKGROUND & AIMS: The Global Leadership Initiative on Malnutrition (GLIM) criteria is a step-wise process including a screening tool of choice for risk assessment of malnutrition before assessment of diagnosis and grading of malnutrition severity. The agreement between GLIM and the established malnutrition assessment method Patient Generated-Subjective Global Assessment (PG-SGA) is uncertain. Also, several aspects of GLIM remain to be clearly defined. In this study, we compared diagnosis of malnutrition with the GLIM criteria to the PG-SGA, and explored the differences between the methods. METHODS: This cross-sectional study was conducted at the Nutrition Outpatient Clinic at Oslo University Hospital, Norway. Patients were included from September-December 2019. Nutritional Risk Screening 2002 (NRS-2002) was used as the screening tool in the GLIM process before diagnosing and grading the severity of malnutrition. Results are presented with and without the initial risk screening. The diagnostic results from the GLIM process were compared to the malnutrition diagnosis using the PG-SGA. RESULTS: In total, 144 patients, median age 58 years, participated in the study. The full GLIM process identified 36% of the patients as malnourished, while the PG-SGA identified 69% of the patients as malnourished. Comparison of GLIM and PG-SGA showed fair agreement, however the agreement was better when the NRS-2002 screening was excluded. Considering the PG-SGA a gold standard, GLIM had a sensitivity of 51% and a specificity of 98%. The introduction of new cut-off values for fat-free mass did not considerably alter the diagnosis of malnutrition within GLIM. CONCLUSIONS: The GLIM criteria showed only fair agreement with the PG-SGA, however the agreement was better when the initial NRS-2002 screening was excluded. A joint consensus on how to perform the GLIM process is needed for comparisons of future studies, and before routine use in clinical practice.

Quantification of adipose tissues by Dual-Energy X-Ray Absorptiometry and Computed Tomography in colorectal cancer patients.

BACKGROUND & AIMS: Excess adipose tissue may affect colorectal cancer (CRC) patients' disease progression and treatment. In contrast to the commonly used anthropometric measurements, Dual-Energy X-Ray Absorptiometry (DXA) and Computed Tomography (CT) can differentiate adipose tissues. However, these modalities are rarely used in the clinic despite providing high-quality estimates. This study aimed to compare DXA's measurement of abdominal visceral adipose tissue (VAT) and fat mass (FM) against a corresponding volume by CT in a CRC population. Secondly, we aimed to identify the best single lumbar CT slice for abdominal VAT. Lastly, we investigated the associations between anthropometric measurements and VAT estimated by DXA and CT. METHODS: Non-metastatic CRC patients between 50-80 years from the ongoing randomized controlled trial CRC-NORDIET were included in this cross-sectional study. Corresponding abdominal volumes were acquired by Lunar iDXA and from clinically acquired CT examinations. Also, single CT slices at L2-, L3-and L4-level were obtained. Agreement between the methods was investigated using univariate linear regression and Bland-Altman plots. RESULTS: Sixty-six CRC patients were included. Abdominal volumetric VAT and FM measured by DXA explained up to 91% and 96% of the variance in VAT and FM by CT, respectively. Bland-Altman plots demonstrated an overestimation of VAT by DXA compared to CT (mean difference of 76 cm3) concurrent with an underestimation of FM (mean difference of -319 cm3). A higher overestimation of VAT (p = 0.015) and underestimation of FM (p = 0.036) were observed in obese relative to normal weight subjects. VAT in a single slice at L3-level showed the highest explained variance against CT volume (R2 = 0.97), but a combination of three slices (L2, L3, L4) explained a significantly higher variance than L3 alone (R2 = 0.98, p < 0.006). The anthropometric measurements explained between 31-65% of the variance of volumetric VAT measured by DXA and CT. CONCLUSIONS: DXA and the combined use of three CT slices (L2-L4) are valid to predict abdominal volumetric VAT and FM in CRC patients when using volumetric CT as a reference method. Due to the poor performance of anthropometric measurements we recommend exploring the added value of advanced body composition by DXA and CT integrated into CRC care.

Nutritional treatment is associated with longer survival in patients with pancreatic disease and concomitant risk of malnutrition.

BACKGROUND: Pancreatic diseases involve complex nutritional challenges. Despite this, conflicting evidence exists regarding the clinical relevance of detecting the risk of malnutrition and implementing systematic nutrition support for these patients. Thus, our aims were to investigate whether screening for malnutrition risk and initiating nutrition support are predictive of mortality for hospitalized patients with pancreatic diseases. DESIGN: From 2008 to 2018, 34 prevalence surveys of nutrition were conducted at Haukeland University Hospital (HUH), Norway. Risk of malnutrition was defined by a score of ≥3 in Nutritional Risk Screening 2002 (NRS 2002). Primary outcomes included overall, one-year, and one-month mortality, and were compared according to malnutrition risk and nutrition support for adult patients with ICD-10 codes of K85: acute pancreatitis, K86: other diseases of pancreas, and C25: malignant neoplasm of pancreas. Length of hospital stay (LOS) was included as a secondary outcome. RESULTS: Of the 283 patients investigated, risk of malnutrition was present in 61.5%. Risk of malnutrition was associated with higher overall mortality (Hazard Ratio (HR) = 1.67, 95% confidence interval (CI): 1.2-2.4, P = 0.003) and one-year mortality (HR = 1.89, 95% CI: 1.2-2.9, P = 0.004) compared to patients not at risk. Not receiving nutrition support for at-risk patients was associated with higher overall mortality (HR = 1.60, 95% CI: 1.1-2.4, P = 0.019) and one-year mortality (HR = 1.64, 95% CI: 1.04-2.6, P = 0.034) compared to patients at risk who received nutrition support. Patients at risk of malnutrition had increased LOS (20.5 nights vs 15.2 nights, P = 0.044) compared to patients not at risk of malnutrition. CONCLUSION: This study of hospitalized patients with pancreatic disease suggests that risk of malnutrition may be associated with higher mortality rates, whereas nutrition support may decrease mortality rates. CLINICAL TRIAL REGISTRY: Not registered.

Dietary Adjustments to Altitude Training in Elite Endurance Athletes; Impact of a Randomized Clinical Trial With Antioxidant-Rich Foods.

Background: Altitude training stresses several physiological and metabolic processes and alters the dietary needs of the athletes. International Olympic Committee (IOC)'s Nutrition Expert Group suggests that athletes should increase intake of energy, carbohydrate, iron, fluid, and antioxidant-rich foods while training at altitude. Objective: We investigated whether athletes adjust their dietary intake according to the IOC's altitude-specific dietary recommendations, and whether an in-between meal intervention with antioxidant-rich foods altered the athletes' dietary composition and nutrition-related blood parameters (mineral, vitamin, carotenoid, and hormone concentrations). Design: The dietary adjustments to altitude training (3 weeks at 2,320 m) were determined for 31 elite endurance athletes (23 ± 5 years, 23 males, 8 females) by six interviewer-administered 24-h dietary recalls on non-consecutive days; three before and during the altitude camp. The additional effect of in -between meal intervention with eucaloric antioxidant-rich or control snacks (1,000 kcal/day) was tested in a randomized controlled trial with parallel design. Results: At altitude the athletes increased their energy intake by 35% (1,430 ± 630 kcal/day, p < 0.001), the provided snacks accounting for 70% of this increase. Carbohydrate intake increased from 6.5 ± 1.8 g/kg body weight (BW) (50 E%) to 9.3 ± 2.1 g/kg BW (53 E%) (p < 0.001), with no difference between the antioxidant and control group. Dietary iron, fluid, and antioxidant-rich food intake increased by 37, 38, and 104%, respectively, in the whole cohort. The intervention group had larger increases in polyunsaturated fatty acids (PUFA), ω3 PUFA (n-3 fatty acids), ω6 PUFA (n-6 fatty acids), fiber, vitamin C, folic acid, and copper intake, while protein intake increased more among the controls, reflecting the nutritional content of the snacks. Changes in the measured blood minerals, vitamins, and hormones were not differentially affected by the intervention except for the carotenoid; zeaxanthin, which increased more in the intervention group (p < 0.001). Conclusions: Experienced elite endurance athletes increased their daily energy, carbohydrate, iron, fluid, and antioxidant-rich food intake during a 3-week training camp at moderate altitude meeting most of the altitude-specific dietary recommendations. The intervention with antioxidant-rich snacks improved the composition of the athletes' diets but had minimal impact on the measured nutrition-related blood parameters. Clinical Trial Registry Number: NCT03088891 (www.clinicaltrials.gov), Norwegian registry number: 626539 (https://rekportalen.no/).

Use of bioelectrical impedance analysis to monitor changes in fat-free mass during recovery from colorectal cancer- a validation study.

BACKGROUND & AIMS: Although previous research show high correlation between fat-free mass (FFM) measured by bioelectrical impedance analysis (BIA) and dual-energy X-ray absorptiometry (DXA), the validity of BIA to track longitudinal changes in FFM is uncertain. Thus, the aim of this study was to validate the ability of BIA to assess changes in FFM during 6 months of recovery from non-metastatic colorectal cancer (CRC). METHODS: A total of 136 women and men (50-80 years) with stage I-III CRC and a wide range of baseline FFM (35.7-73.5 kg) were included in the study. Body composition was measured at study baseline within 2-9 months of surgery and again 6 months later. Whole-body BIA FFM estimates (FFMBIA) were calculated using three different equations (manufacturer's, Schols' and Gray's) before comparison to FFM estimates obtained by DXA (FFMDXA). RESULTS: Correlation between changes in FFMBIA and FFMDXA was intermediate regardless of equation (r ≈ 0.6). The difference in change of FFMBIA was significant compared to FFMDXA, using all three equations and BIA overestimated both loss and gain. However, BIA showed 100% sensitivity and about 90% specificity to identify individuals with ≥5% loss in FFM, using all three equations. Sensitivity of FFMBIA to detect a smaller loss of FFM (60-76%) or a gain in FFM of ≥5% (33-62%) was poor. CONCLUSION: In a well-nourished population of non-metastatic CRC patients, a single-frequency whole-body BIA device yielded imprecise data on changes in FFM, regardless of equation. BIA is thus not a valid option for quantifying changes in FFM in individuals. However, BIA could be used to identify patients with loss in FFM ≥5% in this population. The validity of BIA to monitor changes in FFM warrants further investigation before implementation in clinical praxis.

Effects of using the MyFood decision support system on hospitalized patients' nutritional status and treatment: A randomized controlled trial.

BACKGROUND & AIMS: Compliance to guidelines for disease-related malnutrition is documented as poor. The practice of using paper-based dietary recording forms with manual calculation of the patient's nutritional intake is considered cumbersome, time-consuming and unfeasible among the nurses and does often not lead to appropriate nutritional treatment. We developed the digital decision support system MyFood to deliver a solution to these challenges. MyFood is comprised of an app for patients and a website for nurses and includes functions for dietary recording, evaluation of intake compared to requirements, and a report to nurses including tailored recommendations for nutritional treatment and a nutritional care plan for documentation. The study aimed to investigate the effects of using the MyFood decision support system during hospital stay on adult patients' nutritional status, treatment and hospital length of stay. The main outcome measure was weight change. METHODS: The study was a parallel-arm randomized controlled trial. Patients who were allocated to the intervention group used the MyFood app during their hospital stay and the nurses were encouraged to use the MyFood system. Patients who were allocated to the control group received routine care. RESULTS: We randomly assigned 100 patients (51.9 ± 14 y) to the intervention group (n = 49) and the control group (n = 51) between August 2018 and February 2019. Losses to follow-up were n = 5 in the intervention group and n = 1 in the control group. No difference was found between the two groups with regard to weight change. Malnutrition risk at discharge was present in 77% of the patients in the intervention group and 94% in the control group (p = 0.019). Nutritional treatment was documented for 81% of the patients in the intervention group and 57% in the control group (p = 0.011). A nutritional care plan was created for 70% of the intervention patients compared to 16% of the control patients (p < 0.001). CONCLUSIONS: The intervention had no effect on weight change during hospital stay. A higher proportion of the patients in the control group was malnourished or at risk of malnutrition at hospital discharge compared to the patients in the intervention group. The documentation of nutritional intake, treatment and nutritional care plans was higher for the patients using the MyFood system compared to the control group. This trial was registered at clinicaltrials.gov (NCT03412695).