Challenges in identifying malnutrition in obesity; An overview of the state of the art and directions for future research.

(Protein-energy) malnutrition in individuals living with obesity presents complex diagnostic challenges due to the distinctive physiological characteristics of obesity. This narrative review critically examines the identification of malnutrition within the population with obesity, distinguishing malnutrition in obesity from related conditions such as sarcopenic obesity. While noting some shared features, the review highlights key differences between these conditions. The review also highlights the limitations of current malnutrition screening tools, which are not designed for individuals living with obesity. These tools primarily rely on anthropometric measurements, neglecting (among others) nutrient intake assessment, which hinders accurate malnutrition detection. Additionally, this review discusses limitations in existing diagnostic criteria, including the Global Leadership Initiative on Malnutrition (GLIM) criteria, when applied to individuals living with obesity. Challenges include the identification of appropriate cut-off values for phenotypic criteria (unintentional weight loss, low body mass index and muscle mass) and aetiological criteria such as reduced food intake and inflammation for the population with obesity. Overall, this review emphasises the need for modified screening tools and diagnostic criteria to recognise and assess malnutrition in obesity, leading to improved clinical outcomes and overall wellbeing.

Nutritional problems of patients with COVID-19 receiving dietetic treatment in primary care.

BACKGROUND: The nutritional problems of patients who are hospitalised for COVID-19 are becoming increasingly clear. However, a large group of patients have never been hospitalised and also appear to experience persistent nutritional problems. The present study describes the nutritional status, risk of sarcopaenia and nutrition-related complaints of patients recovering from COVID-19 receiving dietetic treatment in primary care. METHODS: In this retrospective observational study, data were collected during dietetic treatment by a primary care dietitian between April and December 2020. Both patients who had and had not been admitted to the hospital were included at their first visit to a primary care dietitian. Data on nutritional status, risk of sarcopaenia and nutrition-related complaints were collected longitudinally. RESULTS: Data from 246 patients with COVID-19 were collected. Mean ± SD age was 57 ± 16 years and 61% of the patient population was female. At first consultation, two thirds of patients were classified as overweight or obese (body mass index >25 kg m-2 ). The majority had experienced unintentional weight loss because of COVID-19. Additionally, 55% of hospitalised and 34% of non-hospitalised patients had a high risk of sarcopaenia. Most commonly reported nutrition-related complaints were decreased appetite, shortness of breath, changed or loss of taste and feeling of being full. Nutrition-related complaints decreased after the first consultation, but remained present over time. CONCLUSIONS: In conclusion, weight changes, risk of sarcopaenia and nutrition-related complaints were prevalent in patients with COVID-19, treated by a primary care dietitian. Nutrition-related complaints improved over time, but remained prevalent until several months after infection.

Decision-making regarding oral nutritional supplements for nursing home residents with advanced dementia: A cross-sectional pilot study.

BACKGROUND: Surrogate decision-making regarding oral nutritional supplements (ONS) for nursing home residents with advanced dementia is a complex process. In this cross-sectional study, we assessed whether Dutch dietitians, elderly care physicians (physicians) and surrogate decision-makers (SDMs) differ in the factors that they regard important when considering ONS. We also investigated differences in opinion regarding whether or not ONS is a life-prolonging measure. METHODS: Through an online survey, 90 dietitians, 53 physicians and 70 SDMs of nursing home residents (all aged ≥ 65 years old with advanced dementia) rated the level of perceived influence of 11 pre-defined factors on their decision-making, ranked factors in order of importance and stated whether they considered ONS a life-prolonging measure or not. By statistical analysis, we tested differences in the mean sum of ranks for perceived influence differing between groups. We also tested differences in proportions between groups of those who considered ONS a life-prolonging measure. RESULTS: Rating of perceived influence significantly differed for six factors. Quality of life was ranked as the most influential factor by all groups. Dietitians significantly differed in their opinion on the life-prolonging effect of ONS from physicians (odds ratio = 0.29, 95% confidence interval = 0.13-0.65), as well as from SDMs (odds ratio = 0.22, 95% confidence interval = 0.10-0.45). CONCLUSIONS: Although all groups proclaimed quality of life to be first priority in decision-making, we found that Dutch dietitians, physicians and SDMs differed in what they regarded important when considering ONS for nursing home residents with advanced dementia. Regarding the life-prolonging effect of ONS, dietitians differed in opinion from physicians, as well as from SDMs.

Malnutrition in patients with COVID-19: assessment and consequences.

PURPOSE OF REVIEW: COVID-19 disease often presents with malnutrition and nutrition impact symptoms, such as reduced appetite, nausea and loss of taste. This review summarizes the most up-to-date research on nutritional assessment in relation to mortality and morbidity risk in patients with COVID-19. RECENT FINDINGS: Numerous studies have been published on malnutrition, muscle wasting, obesity, and nutrition impact symptoms associated with COVID-19, mostly observational and in hospitalized patients. These studies have shown a high prevalence of symptoms (loss of appetite, nausea, vomiting, diarrhea, dysphagia, fatigue, and loss of smell and taste), malnutrition, micronutrient deficiencies and obesity in patients with COVID-19, all of which were associated with increased mortality and morbidity risks. SUMMARY: Early screening and assessment of malnutrition, muscle wasting, obesity, nutrition impact symptoms and micronutrient status in patients with COVID-19, followed by pro-active nutrition support is warranted, and expected to contribute to improved recovery. There is limited research on nutritional status or nutrition impact symptoms in patients living at home or in residential care. RCTs studying the effects of nutrition intervention on clinical outcomes are lacking. Future research should focus on these evidence gaps.

Cachexia and Dietetic Interventions in Patients With Esophagogastric Cancer: A Multicenter Cohort Study.

BACKGROUND: Cachexia is common in patients with esophagogastric cancer and is associated with increased mortality. Nutritional screening and dietetic interventions can be helpful in preventing evolvement of cachexia. Our aim was to study the real-world prevalence and prognostic value of pretreatment cachexia on overall survival (OS) using patient-reported weight loss, and to explore dietetic interventions in esophagogastric cancer. MATERIALS AND METHODS: Patients with esophagogastric cancer (2015-2018), regardless of disease stage, who participated in the Prospective Observational Cohort Study of Esophageal-Gastric Cancer Patients (POCOP) and completed patient-reported outcome measures were included. Data on weight loss and dietetic interventions were retrieved from questionnaires before start of treatment (baseline) and 3 months thereafter. Additional patient data were obtained from the Netherlands Cancer Registry. Cachexia was defined as self-reported >5% half-year body weight loss at baseline or >2% in patients with a body mass index (BMI) <20 kg/m2 according to the Fearon criteria. The association between cachexia and OS was analyzed using multivariable Cox proportional hazard analyses adjusted for sex, age, performance status, comorbidities, primary tumor location, disease stage, histology, and treatment strategy. RESULTS: Of 406 included patients, 48% had pretreatment cachexia, of whom 65% were referred for dietetic consultation at baseline. The proportion of patients with cachexia was the highest among those who received palliative chemotherapy (59%) or best supportive care (67%). Cachexia was associated with decreased OS (hazard ratio, 1.52; 95% CI, 1.11-2.09). Median weight loss after 3-month follow-up was lower in patients with cachexia who were referred to a dietician at baseline compared with those who were not (0% vs 2%; P=.047). CONCLUSIONS: Nearly half of patients with esophagogastric cancer have pretreatment cachexia. Dietetic consultation at baseline was not reported in more than one-third of the patients with cachexia. Because cachexia was independently associated with decreased survival, improving nutritional screening and referral for dietetic consultation are warranted to prevent further deterioration of malnutrition and mortality.

Long-term quality of life and exocrine and endocrine insufficiency after pancreatic surgery: a multicenter, cross-sectional study.

BACKGROUND: Data regarding long-term quality of life and exocrine and endocrine insufficiency after pancreatic surgery for premalignant and benign (non-pancreatitis) disease are lacking. METHODS: This cross-sectional study included patients ≥3 years after pancreatoduodenectomy or left pancreatectomy in six Dutch centers (2006-2016). Outcomes were measured with the EQ-5D-5L, the EORTC QLQ-C30, an exocrine and endocrine pancreatic insufficiency questionnaire, and PAID20. RESULTS: Questionnaires were completed by 153/183 patients (response rate 84%, median follow-up 6.3 years). Surgery related complaints were reported by 72/153 patients (47%) and 13 patients (8.4%) would not undergo this procedure again. The VAS (EQ-5D-5L) was 76 ± 17 versus 82 ± 0.4 in the general population (p < 0.001). The mean global health status (QLQ-C30) was 78 ± 17 versus 78 ± 17, p = 1.000. Fatigue, insomnia, and diarrhea were clinically relevantly worse in patients. Exocrine pancreatic insufficiency was reported by 62 patients (41%) with relieve of symptoms by enzyme supplementation in 48%. New-onset diabetes mellitus was present in 22 patients (14%). The median PAID20 score was 6.9/20 (IQR 2.5-17.8). CONCLUSION: Although generic quality of life after pancreatic resection for pre-malignant and benign disease was similar to the general population and diabetes-related distress was low, almost half suffered from a range of symptoms highlighting the need for long-term counseling.

Interdisciplinary communication and collaboration as key to improved nutritional care of malnourished older adults across health-care settings - A qualitative study.

BACKGROUND: Malnutrition is a risk factor for impaired functionality and independence. For optimal treatment of malnourished older adults (OA), close collaboration and communication between all stakeholders involved (OA, their caregivers and health-care and welfare professionals) is important. This qualitative study assesses current collaboration and communication in nutritional care over the continuum of health-care settings and provides recommendations for improvement. METHODS: Eleven structured focus group interviews and five individual interviews took place in three regions across the Netherlands from November 2017 until February 2018, including OA, caregivers and health-care and welfare professionals. Various aspects of collaboration and communication between all stakeholders were discussed. Interviews were transcribed and analysed using a thematic approach. RESULTS: Six main themes emerged: causes of malnutrition, knowledge and awareness, recognition and diagnosis of malnutrition, communication, accountability and food preparation and supply. Physical and social aspects were recognized as important risk factors for malnutrition. Knowledge and awareness regarding malnutrition were acknowledged as being insufficient among all involved. This may impair timely recognition and diagnosis. Responsibility for nutritional care and its communication to other disciplines are low. Food preparation and supply in hospitals, rehabilitation centres and home care are below expected standards. CONCLUSION: Many stakeholders are involved in nutritional care of OA, and lack of communication and collaboration hinders continuity of nutritional care over health-care settings. Lack of knowledge is an important risk factor. Establishing one coordinator of nutritional care is suggested to improve collaboration and communication across health-care settings.

Higher Muscle Strength Is Associated with Prolonged Survival in Older Patients with Advanced Cancer.

BACKGROUND: Identifying predictors of treatment toxicity and overall survival (OS) is important for selecting patients who will benefit from chemotherapy. In younger patients with cancer, muscle mass and radiodensity are associated with treatment toxicity and OS. In this study, we investigated whether muscle mass, radiodensity, and strength were associated with treatment toxicity and OS in patients with advanced cancer aged 60 years or older. MATERIALS AND METHODS: Before starting palliative chemotherapy, muscle mass and radiodensity were assessed using computed tomography scans and muscle strength was assessed using a hydraulic hand grip dynamometer. Treatment toxicity was defined as any toxicity resulting in dose reduction and/or discontinuation of treatment. Multiple logistic and Cox regression analyses were performed to study potential associations of muscle mass, radiodensity, and strength with treatment toxicity and OS, respectively. RESULTS: The participants were 103 patients, with a mean age of 70 years, with advanced colorectal, prostate, or breast cancer. Muscle parameters were not significantly associated with treatment toxicity. Higher muscle strength was associated with longer OS (hazard ratio 1.03; 95% confidence interval 1.00-1.05). Muscle mass and radiodensity were not significantly associated with OS. CONCLUSION: Higher muscle strength at the start of palliative chemotherapy is associated with significantly better OS in older patients with advanced cancer. None of the investigated muscle parameters were related to treatment toxicity. Future studies are needed to evaluate whether muscle strength can be used for treatment decisions in older patients with advanced cancer. IMPLICATIONS FOR PRACTICE: This study in older patients with advanced cancer showed that adequate muscle strength is associated with longer overall survival. The results of this study imply that muscle strength might be helpful in estimating survival and therefore in identifying older patients who will benefit from anticancer treatment.

The Prediction of Deterioration of Nutritional Status during Chemoradiation Therapy in Patients with Esophageal Cancer.

Patients with esophageal cancer are at high risk of developing malnutrition during neoadjuvant chemoradiation therapy (CRT), which in turn is associated with postoperative morbidity. The aim of the study is to explore whether parameters of a complete pre-treatment nutritional status may predict deterioration of nutritional status during CRT in patients with esophageal cancer. In this prospective cohort study, 101 patients with esophageal cancer treated with CRT were included. Data of patient characteristics, tumor classification, performance score, %weight change, body mass index, fat (free) mass index, phase angle, handgrip strength, energy- and protein intake, and use of (additional) dietary supplements were collected. A prediction model was constructed to identify predictive parameters for deterioration in nutritional status (defined as weight loss of >5% and/or decline in fat free mass of ≥1.4 kg) during CRT. Nutritional status deteriorated in 49 patients (49%) during CRT. The only predictor for deterioration in nutritional status was fat free mass index (OR 1.21 (90% CI: 1.03 - 1.42)). Patients with a higher fat free mass index are at increased risk of deterioration in nutrition status during CRT. Results suggest that all patients should be carefully supervised during CRT, regardless of their nutritional status before start of CRT.

Cancer Cachexia: Identification by Clinical Assessment versus International Consensus Criteria in Patients with Metastatic Colorectal Cancer.

BACKGROUND: Cancer cachexia is associated with poorer outcomes and is often diagnosed by the Fearon criteria. Oncologists clinically identify cachexia based on a patient's presentation. In this study agreement between these identification methods was evaluated and associations with outcomes were studied in patients with metastatic colorectal cancer. METHODS: Fearon criteria comprised weight loss >5% OR weight loss >2% with either BMI <20 kg/m2 or sarcopenia (determined by CT-imaging). Clinical assessment by the oncologist was based on the patient's clinical presentation. Agreement was tested with Kappa. Associations with treatment tolerance and progression free survival (PFS) were tested with logistic regressions and Cox proportional hazards, respectively. RESULTS: Of 69 patients, 52% was identified as cachectic according to Fearon criteria and 9% according to clinical assessment. Agreement between both methods was slight (Kappa 0.049, P = 0.457). Clinically cachectic patients had a shorter PFS than clinically non-cachectic patients (HR 3.310, P = 0.016). No other differences in outcomes were found between cachectic vs. non-cachectic patients using both methods. CONCLUSIONS: The agreement between cancer cachexia identification by clinical assessment vs. Fearon criteria was slight. Further improvement of cachexia criteria is necessary to identify cachectic patients at risk of poorer outcomes, who may benefit from targeted cachexia interventions.

Ablation of Locally Advanced Pancreatic Cancer with Percutaneous Irreversible Electroporation: Results of the Phase I/II PANFIRE Study.

Purpose To (a) investigate the safety of percutaneous irreversible electroporation (IRE) for locally advanced pancreatic cancer and (b) evaluate the quality of life (QOL), pain perception, and efficacy in terms of time to local progression, event-free survival, and overall survival (OS). Materials and Methods The study was approved by the local review board (NL42888.029.13). All patients provided written informed consent for study participation, the ablation procedure, and data usage. Between January 2014 and June 2015, 25 patients with histologically proved locally advanced pancreatic cancer 5 cm or smaller (13 women, 12 men; median age, 61 years; age range, 41-78 years) were prospectively included to undergo percutaneous computed tomographic-guided IRE. Patients with a metallic biliary Wallstent, epilepsy, or ventricular arrhythmias were excluded. Kaplan-Meier estimates were used to investigate time to local progression, event-free survival, and OS. Safety was assessed on the basis of adverse events, which were graded according to the Common Terminology Criteria for Adverse Events. Pain perception and QOL were evaluated by using specific questionnaires. Results All patients underwent IRE. The median largest tumor diameter was 4.0 cm (range, 3.3-5.0 cm). After a median follow-up of 12 months (interquartile range: 7-16 months), median event-free survival after IRE was 8 months (95% confidence interval [CI]: 4 months, 12 months); the median time to local progression after IRE was 12 months (95% CI: 8 months, 16 months). The median OS was 11 months from IRE (95% CI: 9 months, 13 months) and 17 months from diagnosis (95% CI: 10 months, 24 months). There were 12 minor complications (grade I or II) and 11 major complications (nine grade III, two grade IV) in 10 patients. There were no deaths within 90 days after IRE. Conclusion Percutaneous IRE for locally advanced pancreatic cancer is generally well tolerated, although major adverse events can occur. Preliminary survival data are encouraging and support the setup of larger phase II and III clinical trials to assess the efficacy of IRE plus chemotherapy in the neoadjuvant and adjuvant or second-line setting compared with more widely adopted regimens such as chemotherapy and/or radiation therapy. © RSNA, 2016 Online supplemental material is available for this article.

Prevalence of malnutrition and validation of bioelectrical impedance analysis for the assessment of body composition in patients with systemic sclerosis.

Objectives: The aims were to assess the prevalence of malnutrition and to validate bioelectrical impedance analysis (BIA) against whole-body DXA for the assessment of body composition in patients with SSc. Methods: Malnutrition was defined as BMI <18.5 kg/m 2 or unintentional weight loss >10% in combination with a fat-free mass index (FFMI) <15 kg/m 2 for women or <17 kg/m 2 for men or BMI <20.0 kg/m 2 (age <70 years) or <22 kg/m 2 (age >70 years). Body composition was assessed in 72 patients with whole-body DXA (Hologic, Discovery A) and BIA (Bodystat Quadscan 400). The manufacturer's equation and the Geneva equation were used to estimate FFM and fat mass. The agreement between BIA and whole-body DXA was assessed with Bland-Altman analysis and intraclass correlation coefficient. Results: Malnutrition was found in 8.3% (n = 6) and low FFMI in 20.8% (n = 15) of patients. The mean difference in FFM between BIA and DXA applying the Geneva equation was 0.02 ( s . d . 2.4) kg, intraclass correlation coefficient 0.97 (95% CI: 0.95, 0.98). Limits of agreement were ±4.6 kg. The manufacturer's equation was less adequate to predict FFM. Conclusion: This study shows a relatively low prevalence of malnutrition in comparison with other studies, but a high prevalence of low FFMI, underlining the necessity of measuring body composition in SSc patients with a standardized and validated method. A good validity of BIA in determining FFM was found at a group level, while at an individual level the FFM may vary by 4.6 kg.

The effect of individualized nutritional counseling on muscle mass and treatment outcome in patients with metastatic colorectal cancer undergoing chemotherapy: a randomized controlled trial protocol.

BACKGROUND: A low muscle mass is prevalent in patients with metastatic colorectal cancer (mCRC) and has been associated with poor treatment outcome. Chemotherapeutic treatment has an additional unfavorable effect on muscle mass. Sufficient protein intake and physical activity are known to induce muscle protein anabolism in healthy individuals, however it is unclear whether optimal nutrition is effective to preserve muscle mass in patients with mCRC during first-line chemotherapy as well. We hypothesize that individual nutritional counseling by a trained dietitian during first-line chemotherapy is effective in preserving muscle mass and may improve clinical outcomes in patients with mCRC. METHODS/DESIGN: In this multi-center single-blind randomized controlled trial, patients with mCRC scheduled for first-line combination chemotherapy consisting of oxaliplatin and fluoropyrimidine, with or without bevacizumab (n = 110), will be randomized to receive either individualized nutritional counseling by a trained dietitian to achieve a sufficient dietary intake and an adequate physical activity level, or usual care. Outcome measures will be assessed at baseline and after two and four months of treatment. The primary endpoint will be the change in skeletal muscle area (measured by CT-scan) at the first treatment evaluation. Secondary endpoints will be quality of life, physical functioning, treatment toxicity, treatment intensity and survival. Statistical analyses include one-sided t-tests for the primary endpoint and mixed models and the Kaplan-Meier method for secondary endpoints. DISCUSSION: This randomized controlled trial will provide evidence whether individualized nutritional counseling during chemotherapy is effective in preventing loss of muscle mass in patients with mCRC. TRIAL REGISTRATION: ClinicalTrials.gov NCT01998152 ; Netherlands Trial Register NTR4223.

Effect of Early Individualized Dietary Counseling on Weight Loss, Complications, and Length of Hospital Stay in Patients With Head and Neck Cancer: A Comparative Study.

Patients with head and neck cancer (HNC) are at risk for undernutrition. Dietary counseling during treatment has positive effects on nutritional status and quality of life, however, the effects of dietary counseling started before initiation of treatment are currently unknown. Therefore we assessed the effect of early individualized dietary counseling (DC) on weight loss, major complications, and length of hospital stay (LOS) in patients with HNC. Ninety-five newly diagnosed HNC patients with (risk of) undernutrition receiving DC were compared to 95 matched HNC patients receiving usual nutritional care (UC). Difference in weight change over time was analyzed by generalized estimating equations (GEE). Differences in complications and LOS were studied by Pearson chi-squared and student's t-tests. Weight change between diagnosis and end of treatment was -6.0 ± 6.9% (DC) and -5.4 ± 5.7% (UC; GEE: -0.4kg, 95% confidence interval: -1.2 to 0.5; P = 0.44). Less DC patients experienced overall postoperative complications (44%/70%, P = 0.04). No effect on major postoperative or (chemo)radiotherapy complications or LOS was found. This study showed a lower prevalence of overall postoperative complications in HNC patients receiving DC but could not demonstrate an effect on weight loss, other complications, and LOS.

The Impact of Different Diagnostic Criteria on the Prevalence of Sarcopenia in Healthy Elderly Participants and Geriatric Outpatients.

BACKGROUND: A consensus on the diagnostic criteria for sarcopenia, a common syndrome in the elderly, has not been reached yet. Prevalence rates vary between studies due to the use of different criteria encompassing different measures, correction factors and cutoff points. OBJECTIVE: This study compared prevalence rates of sarcopenia using nine sets of diagnostic criteria applied in two different elderly populations. METHODS: The study population encompassed 308 healthy elderly participants (152 males, 156 females; mean age 74 years) and 123 geriatric outpatients (54 males, 69 females; mean age 81 years). Diagnostic criteria included relative muscle mass, absolute muscle mass, muscle strength and physical performance. RESULTS: Prevalence rates of sarcopenia varied between 0 and 15% in healthy elderly participants and between 2 and 34% in geriatric outpatients. CONCLUSION: This study clearly demonstrates the dependency of sarcopenia prevalence rates on the applied diagnostic criteria.

A vegan dietary pattern is associated with high prevalence of inadequate protein intake in older adults; a simulation study.

BACKGROUND: A more sustainable diet with fewer animal-based products has a lower ecological impact but might lead to a lower protein quantity and quality. The extent to which shifting to more plant-based diets impacts the adequacy of protein intake in older adults needs to be studied. OBJECTIVES: We simulated how a transition towards a more plant-based diet (flexitarian, pescetarian, vegetarian, or vegan) affects protein availability in the diets of older adults. SETTING: Community. PARTICIPANTS: Data from the Dutch National Food Consumption Survey 2019-2021 of community-dwelling older adults (n = 607) was used MEASUREMENTS: Food consumption data was collected via two 24 -h dietary recalls per participant. Protein availability was expressed as total protein, digestible protein, and utilizable protein (based on digestibility corrected amino acid score) intake. The percentage below estimated average requirements (EAR) for utilizable protein was assessed using an adjusted EAR. RESULTS: Compared to the original diet (∼62% animal-based), utilizable protein intake decreased by about 5% in the flexitarian, pescetarian and vegetarian scenarios. In the vegan scenario, both total protein intake and utilizable protein were lower, leading to nearly 50% less utilizable protein compared to the original diet. In the original diet, the protein intake of 7.5% of men and 11.1% of women did not meet the EAR. This slightly increased in the flexitarian, pescetarian, and vegetarian scenarios. In the vegan scenario, 83.3% (both genders) had a protein intake below EAR. CONCLUSIONS: Replacing animal-based protein sources with plant-based food products in older adults reduces both protein quantity and quality, albeit minimally in non-vegan plant-rich diets. In a vegan scenario, the risk of an inadequate protein intake is imminent.

Sex disparities in parenteral and enteral nutrition societies' leadership worldwide: a 20-year retrospective analysis.

BACKGROUND: Despite advancements in the global dialog surrounding sex and gender equity, an important gap persists with women markedly underrepresented in major roles within health care leadership. OBJECTIVES: We examined the extent of women's representation in prominent positions within parenteral and enteral nutrition (PEN) societies worldwide over a span of 2 decades. DESIGN: This retrospective analysis explored the sex distribution of society chairs, conference presidents, and editor-in-chief positions across 64 PEN societies between 2003 and 2022. Additionally, data on the first and last authors of endorsed clinical guidelines were collected from the 2 leading societies. RESULTS: Over the past 20 y, women held society chair positions in 34.4% of cases. The representation shifted from 30% during the decade from 2003 to 2012 to 40.5% from 2013 to 2022. Throughout these years, the numbers consistently ranged from 0 to 10; however, the median shifted upward from 1 during the first decade to 4 in the subsequent decade (P = 0.04). Of 420 congress presidencies, ∼30% were women. In endorsed guidelines, women were the first authors in 27.1% of cases (P < 0.001) and the last in 28.9% (P < 0.001) compared with men. Of the 123 journal editor-in-chief positions, women occupied 23 (18.7%). CONCLUSION: Over the last 2 decades, women have been consistently underrepresented in prominent leadership roles in PEN societies globally. Although there has been a noticeable shift toward more women in chair positions, true sex equality remains elusive. Moreover, sex disparities are even more pronounced in positions, such as conference presidents, authors of major guidelines, and editors-in-chief of society-affiliated journals. These data underscore the pressing need to enhance efforts toward sex equality across these domains.

Understanding recovery of people recovering from COVID-19 receiving treatment from primary care allied health professionals: a mixed-methods study.

PURPOSE: To quantitatively assess changes in recovery of people recovering from COVID-19 treated by a primary care allied health professional, and to qualitatively describe how they dealt with persistent complaints. MATERIALS AND METHODS: This mixed-methods study is part of a Dutch prospective cohort study, from which thirty participants were selected through purposive sampling. Quantitative data on recovery were collected at start of treatment and 6 months. Additionally, by use of semi-structured interviews participants were asked on how persistent complaints influenced their lives, and how they experienced received primary care allied health treatment. RESULTS: Despite reported improvements, most participants still experienced limitations at 6 months. Hospital participants reported a higher severity of complaints, but home participants reported more diverse complaints and a longer recovery. Most participants were satisfied with the primary care allied healthcare. Tender loving care and a listening ear, learning to manage limits, and support and acceptance of building up in small steps were perceived as contributing most to participants' recovery. CONCLUSION: Although improvements were reported on almost all outcomes, most participants suffered from persistent complaints. Despite these persistent complaints, many participants reported being better able to cope with persistent complaints because they had decreased substantially in their intensity. TRIAL REGISTRATION: Clinicaltrials.gov registry (NCT04735744).

Participants recovering from COVID-19 receiving treatment from primary care allied health professionals reported improvements after 6 months, but still experienced persistent complaints.Home participants reported more persistent complaints and a longer recovery from COVID-19 than hospital participants.Personal attention for patients recovering from COVID-19 is necessary. Next to implementing a treatment plan (e.g. physical exercise), primary care allied health professionals should also pay attention to listening to the patient's story and offering support.Interprofessional collaboration between primary care allied health professionals, with a unified message to patients, is essential.

One-year evaluation of people recovering from COVID-19 receiving allied primary healthcare: A nationwide prospective cohort study.

BACKGROUND: A Dutch nationwide prospective cohort study was initiated to investigate recovery trajectories of people recovering from coronavirus disease 2019 (COVID-19) and costs of treatment by primary care allied health professionals. OBJECTIVES: The study described recovery trajectories over a period of 12 months and associated baseline characteristics of participants recovering from COVID-19 who visited a primary care allied health professional. It also aimed to provide insight into the associated healthcare and societal costs. METHODS: Participants completed participant-reported standardized outcomes on participation, health-related quality of life, fatigue, physical functioning, and costs at baseline (ie, start of the treatment), 3, 6, 9 and 12 months. RESULTS: A total of 1451 participants (64 % women, 76 % mild/moderate severity) with a mean (SD) age of 49 (12) years were included. Linear mixed models showed significant and clinically relevant improvements over time in all outcome measures between baseline and 12 months. Between 6 and 12 months, we found significant but not clinically relevant improvements in most outcome measures. Having a worse baseline score was the only baseline factor that was consistently associated with greater improvement over time on that outcome. Total allied healthcare costs (mean €1921; SEM €48) made up about 3% of total societal costs (mean €64,584; SEM €3149) for the average participant in the cohort. CONCLUSIONS: The health status of participants recovering from COVID-19 who visited an allied health professional improved significantly over a 12-month follow-up period, but nearly the improvement occurred between baseline and 6 months. Most participants still reported severe impairments in their daily lives, and generated substantial societal costs. These issues, combined with the fact that baseline characteristics explained little of the variance in recovery over time, underscore the importance of continued attention for the management of people recovering from COVID-19. TRIAL REGISTRATION: clinicaltrials.gov (NCT04735744).

Malnutrition assessment by Global Leadership Initiative on Malnutrition criteria in patients with amyotrophic lateral sclerosis.

Malnutrition can play an important prognostic role in terms of survival in patients with amyotrophic lateral sclerosis (ALS). In this clinical context, applying criteria defining malnutrition requires particular attention, especially in the initial stage of the disease. This article discusses the application of the most recent criteria used for the definition of malnutrition when applied to patients with ALS. Currently, the Global Leadership Initiative on Malnutrition (GLIM) criteria, which have received a worldwide consensus, are based on parameters such as unintentional weight loss, low body mass index (BMI), and reduced muscle mass (phenotypic criteria) in combination with reduced food intake and assimilation or inflammation and disease (etiologic criteria). However, as discussed in this review, the initial unintentional weight loss and the consequent BMI reduction could be attributed, at least in part, to muscle atrophy, which also alters the reliability of muscle mass assessment. Moreover, the condition of hypermetabolism, which is observed in up to 50% of these patients, may complicate the calculation of total energy requirements. Finally, it remains to be established if the presence of neuroinflammation can be considered a type of inflammatory process able to induce malnutrition in these patients. In conclusion, the monitoring of BMI, associated with body composition evaluation by bioimpedance measurement or specific formulas, could be a practicable approach to the diagnosis of malnutrition in patients with ALS. In addition, attention should be given to dietary intake (e.g., in patients with dysphagia) and excessive involuntary weight loss. On the other hand, as suggested by GLIM criteria, a single assessment of BMI resulting in <20 kg/m2 or <22 kg/m2 in patients aged <70 y and ≥70 y, respectively, should always be considered a sign of malnutrition.