12ª Lección Jesús Culebras. La alimentación y la nutrición en los enfermos con cáncer de cabeza y cuello: un reto permanente / 12th "Jesús Culebras" Lesson. Feeding and nutrition in patients with head and neck cancer - A permanent challenge

Los enfermos con cáncer de cabeza y cuello son una población en riesgo nutricional permanente. El motivo es, además de la presencia del tumor, la localización del mismo, que afecta a todas las estructuras implicadas en la deglución. Los efectos secundarios de los tratamientos oncológicos que deben recibir en el transcurso de su enfermedad —cirugía, quimio-radioterapia, etc.— no hacen sino gravar más aun un estado nutricional ya de por sí precario. Por todo ello es imprescindible que, desde el diagnóstico de su enfermedad, estén supervisados por un equipo multidisciplinar con especialistas en dietética y nutrición (AU)

Head and neck cancer patients are a population at permanent nutritional risk. In addition to the presence of the tumour, the reason for this is the tumour's location, which affects all structures involved in the swallowing process. The side effects of the oncological treatments they must receive during the course of their illness—surgery, chemo-radiotherapy, etc.—only further burden an already precarious nutritional status. For all these reasons, it is essential that, from the diagnosis of their disease, a multidisciplinary team including specialists in dietetics and nutrition supervises them (AU)

Baby led weaning, ¿seguro y eficaz? Una revisión narrativa / Baby led weaning, safe and effective? A narrative review

Introducción: el baby led weaning (BLW) o destete dirigido por el bebé es una técnica de alimentación complementaria que se ha puesto de moda en los últimos años gracias principalmente a su difusión por internet. Objetivo: determinar si dos de las principales críticas recibidas por este método (riesgo de atragantamiento y déficits nutricionales) son reales en comparación con otras técnicas de alimentación complementaria. Metodología: revisión narrativa de estudios de cohorte y diseños aleatorizados publicados en los últimos años en las bases de datos PubMed y Google Scholar. Resultados: once trabajos (siete relacionados con el atragantamiento y cuatro vinculados con los déficits nutricionales) fueron incluidos y analizados en esta revisión. Conclusiones: el BLW se presenta como una técnica de alimentación complementaria segura ya que no presenta más riesgo de atragantamiento que otras. En relación a su eficacia nutricional, no existe una evidencia sólida en relación a la exposición de alimentos ricos en hierro en niños que siguen el BLW con respecto a niños que siguen otra técnica (AU)

Introduction: the baby led weaning (BLW), or weaning directed by the baby, is a complementary feeding technique that has become fashionable in recent years thanks mainly to its diffusion on the internet. Objective: to determine if two of the main criticisms received by this method (risk of choking and nutritional deficits) are real compared to other complementary feeding techniques. Methodology: narrative review of cohort studies and randomized designs published in recent years in the PubMed and Google Scholar databases. Results: eleven works (seven related to choking and four related to nutritional deficits) were included and analyzed in this review. Conclusions: the BLW is presented as a safe complementary feeding technique since it presents no more choking risk than others. Regarding their nutritional efficacy, there is no solid evidence regarding the exposure of iron-rich foods in children who follow the BLW with respect to children who follow another technique (AU)

[Gastrointestinal manifestations of cystic fibrosis in children]. / Manifestaciones gastrointestinales en fibrosis quística en una población pediátrica.

INTRODUCTION: Cystic fibrosis (CF) is a multisystemic disease, with high morbidity and mortality, and its early diag nosis improves results. Lung conditions are the main cause of morbidity and mortality and are clo sely related to nutritional status and survival. There is little national information about the liver and gastrointestinal characteristics in pediatric patients with CF. OBJECTIVE: to describe at a gastrointes tinal level, the general, nutritional, and genetic characteristics and the evolution of CF carriers with/ without neonatal screening. PATIENTS AND METHOD: Retrospective study carried out in 4 public referral hospitals in the Metropolitan Region. The diagnosis of CF confirmed with two positive sweat tests (Gibson and Cooke method) was considered as an inclusion criterion. Those patients with unconfir med neonatal screening tests through Immunoreactive Trypsinogen (IRT) or with only one positive sweat test were excluded. Sex, age, nutritional status, date of diagnosis, clinical presentation at the onset, evolution, and therapies received were recorded as clinical variables, and as laboratory ones, genetic study by means of a diagnostic panel with 36 mutations. The STATA 12 software was used for statistical analysis. RESULTS: 127 patients were included. Respiratory manifestations (recurrent obstructive bronchial syndrome and pneumonia) were present in >60% and gastrointestinal ones (mainly malabsorption and malnutrition syndrome) in >80% of patients. On average, diagnostic confirmation took 4 months. The diagnosis guided by IRT was associated with better nutritional outcomes in the evolution of the patient. In 81.1% of the patients, the genetic study was performed. The most frequent mutations were those associated with DF508 (deletion of phenylalanine 508). 5.8% of the patients presented mutations not included in the gene panel used. CONCLUSIONS: Gas trointestinal CF appears with pancreatic, intestinal, and hepatic pathology throughout life. Malnutri tion is a frequently present factor, which worsens the prognosis. The management of gastrointestinal manifestations and malnutrition are relevant to improve the morbidity and mortality of CF patients.

Pretreatment Adherence to a Priori-Defined Dietary Patterns Is Associated with Decreased Nutrition Impact Symptom Burden in Head and Neck Cancer Survivors.

Dietary intake is understood to contribute to nutrition impact symptoms (NIS) in patients with head and neck squamous cell carcinoma (HNSCC). The purpose of this study was to evaluate the performance of four a priori-defined diet quality indices on the presence of NIS 1 year following diagnosis using data on 323 participants from the University of Michigan Head and Neck Specialized Program of Research Excellence (UM-SPORE). Pretreatment dietary intake was measured before treatment initiation using a food frequency questionnaire. NIS were measured along seven subdomains. Multivariable binary logistic regression models were constructed to evaluate relationships between pretreatment scores on a priori-defined diet quality indices (AHEI-2010, aMED, DASH, and a low-carbohydrate score) and the presence of individual symptoms in addition to a composite "symptom summary score" 1-year postdiagnosis. There were several significant associations between different indices and individual NIS. For the symptom summary score, there were significant inverse associations observed for aMED (ORQ5-Q1: 0.36, 95% CI: 0.14-0.88, ptrend = 0.04) and DASH (ORQ5-Q1: 0.38, 95% CI: 0.15-0.91, ptrend = 0.02) and the presence of NIS 1-year postdiagnosis. Higher adherence to the aMED and DASH diet quality indices before treatment may reduce NIS burden at 1-year postdiagnosis.

Energy Achievement Rate Is an Independent Factor Associated with Intensive Care Unit Mortality in High-Nutritional-Risk Patients with Acute Respiratory Distress Syndrome Requiring Prolonged Prone Positioning Therapy.

Early enteral nutrition (EN) and a nutrition target >60% are recommended for patients in the intensive care unit (ICU), even for those with acute respiratory distress syndrome (ARDS). Prolonged prone positioning (PP) therapy (>48 h) is the rescue therapy of ARDS, but it may worsen the feeding status because it requires the heavy sedation and total paralysis of patients. Our previous studies demonstrated that energy achievement rate (EAR) >65% was a good prognostic factor in ICU. However, its impact on the mortality of patients with ARDS requiring prolonged PP therapy remains unclear. We retrospectively analyzed 79 patients with high nutritional risk (modified nutrition risk in the critically ill; mNUTRIC score ≥5); and identified factors associated with ICU mortality by using a Cox regression model. Through univariate analysis, mNUTRIC score, comorbid with malignancy, actual energy intake, and EAR (%) were associated with ICU mortality. By multivariate analysis, EAR (%) was a strong predictive factor of ICU mortality (HR: 0.19, 95% CI: 0.07-0.56). EAR >65% was associated with lower 14-day, 28-day, and ICU mortality after adjustment for confounding factors. We suggest early EN and increase EAR >65% may benefit patients with ARDS who required prolonged PP therapy.

PRESENT 2020: texto que desarrolla la lista de verificación para el adecuado informe de la evidencia en ensayos clínicos de deporte y nutrición del ejercicio (Traducción Inglés-Español) / No disponible

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Transtheoretical model-based nutritional interventions in adolescents: a systematic review.

BACKGROUND: Literature has shown a tendency of inadequate dietary intake among youth, consequently, nutritional interventions are required. The transtheoretical model (TTM) classifies individuals based on their readiness to change. This model is widely used for health education interventions with proven efficacy. PURPOSE: This review aimed to weigh the strength of evidence about the TTM usage in nutritional interventions for adolescents and its effectiveness regarding dietary intake. METHODS: This study followed the PRISMA guidelines. Eligible studies were input into Mendeley software. The Adolec, Google Scholar, LILACS, PsycINFO, PubMed, Science Direct and Web of Science databases were searched. Only full original articles written in English, Spanish or Portuguese on randomized controlled trials and quasi-experimental designs that applied the TTM in the design of nutritional interventions targeting adolescents were included, with no restrictions on publication date. The quality and risk of bias was evaluated with the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. RESULTS: The initial search yielded 3779 results. Three studies were rated as strong, six as moderate and five as weak. The final sample of 14 articles included adolescents that were mostly recruited from schools, with interventions ranging from one month to three years. The TTM was used alone or combined with other behavior-change theories and most of the interventions involved digital technology. The nutritional topics covered included fruit and vegetable consumption, low-fat diet, and cooking skills. Four studies presented improvement in fruit and vegetable consumption and four progressed through stages of change. Participants from two interventions reduced fat intake. At the end of one intervention, all the participants were in action and maintenance stages. CONCLUSION: The TTM seems to be a successful strategy for nutritional intervention aiming at improving dietary intake in adolescents. Its application in different contexts shows that the TTM is flexible and possible to be implemented in many settings. The use of the model is shown to be restricted to the stage of change' construct. Further studies should use all constructs of the TTM in the design and compare the TTM with other behavior-change theories to better understand its effectiveness.

Effect of Bariatric Surgery on Weight Loss, Nutritional Deficiencies, Postoperative Complications and Adherence to Dietary and Lifestyle Recommendations: A retrospective cohort study from Bahrain.

OBJECTIVES: This study aimed to investigate the effect of bariatric surgery on degree of weight loss, as well as the prevalence of nutritional deficiencies, postoperative complications and adherence to dietary and lifestyle recommendations in a cohort of patients from Bahrain. METHODS: This retrospective cohort study took place between March and September 2018 at two hospitals in Bahrain. All adult patients who had undergone bariatric surgery between 2012-2017 were included. Sociodemographic and clinical information was collected from the patients' medical records and during phone interviews. RESULTS: A total of 341 patients participated in the study. The mean age was 39.82 ± 9.95 years and 67.7% were female. There was a significant relationship between postoperative body mass index and both the type of surgery and time since surgery (P = 0.025 and 0.008, respectively). While type of surgery had no significant effect on percent of excess weight loss (EWL) or percent of total weight loss (TWL), time since surgery significantly affected both of these weight loss measures (P = 0.006 and 0.001, respectively). Biochemical tests revealed haemoglobin, mean corpuscular volume, 25-hydroxy vitamin D, ferritin and iron deficiencies. Commonly reported complications included hair loss (59.5%), flatulence/abdominal pain (39.3%), dry skin (34.3%) and gastroesophageal reflux disease (33.1%). The level of adherence to dietary and lifestyle recommendations was high to moderate. CONCLUSION: Bariatric surgery was effective in accelerating EWL and TWL; however, it also resulted in complications such as nutritional deficiencies and gastrointestinal side-effects.

Current iodine nutrition status in Poland (2017): is the Polish model of obligatory iodine prophylaxis able to eliminate iodine deficiency in the population?

OBJECTIVE: The monitoring of the populations' iodine status is an essential part of successful programmes of iodine deficiency elimination. The current study aimed at the evaluation of current iodine nutrition in school children, pregnant and lactating women as a marker of the effectiveness and sustainability of mandatory iodine prophylaxis in Poland. DESIGN: The following iodine nutrition indicators were used: urinary iodine concentration (UIC) (all participants) and serum thyroglobulin (pregnant and lactating women). SETTING: The study was conducted in 2017 within the National Health Programme in five regions of Poland. PARTICIPANTS: The research included 300 pregnant women, 100 lactating women and 1000 school children (aged 6-12 years). RESULTS: In pregnant women, median UIC was 111·6 µg/l; there was no significant difference in median UIC according to the region of residence. In 8 % of pregnant women, thyroglobulin level was >40 ng/ml (median thyroglobulin 13·3 ng/ml). In lactating women, median UIC was 68·0 µg/l. A significant inter-regional difference was noted (P = 0·0143). In 18 % of breastfeeding women, thyroglobulin level was >40 ng/ml (median thyroglobulin 18·5 ng/ml). According to the WHO criteria, the investigated sample of pregnant and lactating women was iodine-deficient. Median UIC in school children was 119·8 µg/l (with significant inter-regional variation; P = 0·0000), which is consistent with iodine sufficiency. Ninety-four children (9·4 %) had UIC < 50 µg/l. CONCLUSIONS: Mandatory iodisation of household salt in Poland has led to a sustainable optimisation of iodine status in the general population. However, it has failed to assure adequate iodine nutrition during pregnancy and lactation.

Use of mobile applications to improve nutrition behaviour: A systematic review.

BACKGROUND AND OBJECTIVE: Mobile applications could be effectively used for dietary intake assessment, physical activity monitoring, behavior improvement, and nutrition education. The aim of this review is to determine the effectiveness of mobile applications in improving nutrition behaviors through a systematic review of literature. METHODS: The review protocol was registered with PROSPERO: registration number CRD42018118809, and followed PRISMA guidelines. We involved original articles including mobile electronic devices for improving dietary intake, physical activity, and weight management in adult populations in this review. Data were retrieved from January 2010 to December 2018 with PubMed, Web of Science, Excerpta Medica Database (Embase), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) as data sources. Authors individually screened the titles and abstracts, then full articles in order to obtain papers that met inclusion criteria. RESULTS: The database search yielded 2962 records. After removing the duplicates and analyzing the full text papers a total of 8 original articles were reviewed. Two articles showed obvious bias and were not included in our results or discussion. The remaining six articles with low to moderate bias risk were included in this systematic review. Three selected studies were randomized control trials (RCTs) with over 180 participants each. The other three studies were a nested trial, a case-control trial, and a pilot RCT with 36, 162, and 24 participants respectively. All larger RCTs and the small case control trail showed significant improvements in some nutritional-health objectives measured. The other two trials showed insignificant improvements in outcomes measured between groups. CONCLUSION: This study highlights the potential significant health benefits acquirable through mobile health application-assisted nutrition interventions. Some of these studies required significant financial and time input from providers for the application's utilization. Further studies, perhaps with multiple intervention arms, are required to compare across programs the elements that are essential for health benefits observed.

Medical reversals in low- and middle-income countries.

BACKGROUND: Low- to middle-income countries (LMICs) often have limited budgets for health care, and as such, they need to prioritize health care interventions that are evidence based. However, sometimes, interventions are implemented despite a lack of supporting evidence because of a perceived biologic plausibility or because they have worked in other populations. Later, some of these interventions are shown to either lack benefit or are harmful in randomized studies, which we call a medical reversal. MAIN BODY: In this paper, we discuss a variety of medical reversals in LMICs, ranging from tuberculosis to nutrition to malaria to septic shock. These practices were previously identified, but we wish to highlight those that are most relevant to LMICs. CONCLUSION: Identifying and eliminating these practices will help in better allocation of limited health care resources and dollars in LMICs.

FACTORS ASSOCIATED WITH INADEQUATE MILK CONSUMPTION AMONG ADOLESCENTS: NATIONAL SCHOOL HEALTH SURVEY - PENSE 2012.

OBJECTIVE: To identify the prevalence and factors associated with inadequate milk consumption among adolescents. METHODS: This was a cross-sectional study based on secondary data from the National School Health Survey (2012), a Brazilian survey carried out using a self-administered questionnaire in a representative sample of 9th-grade students from public and private schools. The frequency of milk intake and its association with socio-demographic characteristics, food consumption and physical activity were estimated. A descriptive and inferential analysis of factors associated with inadequate milk consumption (no consumption at least one of the seven days of the week) was performed. A multiple logistic model was adjusted to control confounders. RESULTS: The sample included 108,828 adolescents and inadequate milk consumption ocurred in 58.9%. The final model included nine variables independently associated with inadequate milk intake: breakfast frequency less than 4 days per week (odds ratio [OR]=2.40; p<0.001), unprocessed or minimally processed foods intake less than 5 days per week (OR=1.93; p<0.001), living in the northeast region (OR=1.39; p<0.001), less maternal schooling (OR=1.35; p<0.001), physical inactivity (OR=1.33; p<0.001), attending public school (OR=1.26; p<0.001), not being white (OR=1.14; p<0.001), being older than 14 years old (OR=1.13; p<0.001) and having a habit of eating meals while watching TV or studying (OR=1.04; p=0.036). CONCLUSIONS: Inadequate milk consumption is prevalent among Brazilian adolescents. The identification of associated factors suggests the need to develop nutritional guidance strategies for the prevention of diseases that result from low calcium intake.

Factors associated with inadequate milk consumption among adolescents: national school health survey - pense 2012 / Fatores associados ao consumo inadequado de leite em adolescentes: pesquisa nacional de saúde do escolar - pense 2012

ABSTRACT Objective: To identify the prevalence and factors associated with inadequate milk consumption among adolescents. Methods: This was a cross-sectional study based on secondary data from the National School Health Survey (2012), a Brazilian survey carried out using a self-administered questionnaire in a representative sample of 9th-grade students from public and private schools. The frequency of milk intake and its association with socio-demographic characteristics, food consumption and physical activity were estimated. A descriptive and inferential analysis of factors associated with inadequate milk consumption (no consumption at least one of the seven days of the week) was performed. A multiple logistic model was adjusted to control confounders. Results: The sample included 108,828 adolescents and inadequate milk consumption ocurred in 58.9%. The final model included nine variables independently associated with inadequate milk intake: breakfast frequency less than 4 days per week (odds ratio [OR]=2.40; p<0.001), unprocessed or minimally processed foods intake less than 5 days per week (OR=1.93; p<0.001), living in the northeast region (OR=1.39; p<0.001), less maternal schooling (OR=1.35; p<0.001), physical inactivity (OR=1.33; p<0.001), attending public school (OR=1.26; p<0.001), not being white (OR=1.14; p<0.001), being older than 14 years old (OR=1.13; p<0.001) and having a habit of eating meals while watching TV or studying (OR=1.04; p=0.036). Conclusions: Inadequate milk consumption is prevalent among Brazilian adolescents. The identification of associated factors suggests the need to develop nutritional guidance strategies for the prevention of diseases that result from low calcium intake.

RESUMO Objetivo: Identificar a prevalência e os fatores associados ao consumo inadequado de leite em adolescentes. Métodos: Estudo transversal com base em dados secundários da Pesquisa Nacional de Saúde do Escolar (PeNSE; 2012), inquérito brasileiro realizado por meio de questionário autoaplicável em amostra representativa de alunos do nono ano do ensino fundamental de escolas públicas e privadas. Estimou-se a frequência da ingestão de leite e sua associação com características sociodemográficas, consumo alimentar e prática de atividade física. Foi realizada análise descritiva e inferencial dos fatores associados ao consumo inadequado de leite (ausência em pelo menos um dos sete dias da semana). Um modelo logístico múltiplo foi ajustado para controle das variáveis de confusão. Resultados: A amostra incluiu 108.828 adolescentes e o consumo inadequado de leite foi de 58,9%. O modelo final incluiu 9 variáveis independentemente associadas à ingestão inadequada de leite: frequência de desjejum inferior a 4 dias semanais (odds ratio [OR]=2,40; p<0,001), consumo de alimentos in natura e minimamente processados inferior a 5 dias semanais (OR=1,93; p<0,001), residir na Região Nordeste (OR=1,39; p<0,001), menor escolaridade materna (OR=1,35; p<0,001), inatividade física (OR=1,33; p<0,001), frequentar escola pública (OR=1,26; p<0,001), não ser da raça branca (OR=1,14; p<0,001), ter idade superior a 14 anos (OR=1,13; p<0,001) e possuir o hábito de realizar as refeições assistindo à TV ou estudando (OR=1,04; p=0,036). Conclusões: O consumo inadequado de leite é frequente entre adolescentes brasileiros. A identificação de fatores associados sugere a necessidade do desenvolvimento de estratégias de orientação nutricional para a prevenção de doenças resultantes da baixa ingestão de cálcio.

Food fortification with multiple micronutrients: impact on health outcomes in general population.

BACKGROUND: Vitamins and minerals are essential for growth and maintenance of a healthy body, and have a role in the functioning of almost every organ. Multiple interventions have been designed to improve micronutrient deficiency, and food fortification is one of them. OBJECTIVES: To assess the impact of food fortification with multiple micronutrients on health outcomes in the general population, including men, women and children. SEARCH METHODS: We searched electronic databases up to 29 August 2018, including the Cochrane Central Register of Controlled Trial (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register and Cochrane Public Health Specialised Register; MEDLINE; Embase, and 20 other databases, including clinical trial registries. There were no date or language restrictions. We checked reference lists of included studies and relevant systematic reviews for additional papers to be considered for inclusion. SELECTION CRITERIA: We included randomised controlled trials (RCTs), cluster-RCTs, quasi-randomised trials, controlled before-after (CBA) studies and interrupted time series (ITS) studies that assessed the impact of food fortification with multiple micronutrients (MMNs). Primary outcomes included anaemia, micronutrient deficiencies, anthropometric measures, morbidity, all-cause mortality and cause-specific mortality. Secondary outcomes included potential adverse outcomes, serum concentration of specific micronutrients, serum haemoglobin levels and neurodevelopmental and cognitive outcomes. We included food fortification studies from both high-income and low- and middle-income countries (LMICs). DATA COLLECTION AND ANALYSIS: Two review authors independently screened, extracted and quality-appraised the data from eligible studies. We carried out statistical analysis using Review Manager 5 software. We used random-effects meta-analysis for combining data, as the characteristics of study participants and interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables, using the GRADE approach. MAIN RESULTS: We identified 127 studies as relevant through title/abstract screening, and included 43 studies (48 papers) with 19,585 participants (17,878 children) in the review. All the included studies except three compared MMN fortification with placebo/no intervention. Two studies compared MMN fortification versus iodised salt and one study compared MMN fortification versus calcium fortification alone. Thirty-six studies targeted children; 20 studies were conducted in LMICs. Food vehicles used included staple foods, such as rice and flour; dairy products, including milk and yogurt; non-dairy beverages; biscuits; spreads; and salt. Fourteen of the studies were fully commercially funded, 13 had partial-commercial funding, 14 had non-commercial funding and two studies did not specify the source of funding. We rated all the evidence as of low to very low quality due to study limitations, imprecision, high heterogeneity and small sample size. When compared with placebo/no intervention, MMN fortification may reduce anaemia by 32% (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.56 to 0.84; 11 studies, 3746 participants; low-quality evidence), iron deficiency anaemia by 72% (RR 0.28, 95% CI 0.19 to 0.39; 6 studies, 2189 participants; low-quality evidence), iron deficiency by 56% (RR 0.44, 95% CI 0.32 to 0.60; 11 studies, 3289 participants; low-quality evidence); vitamin A deficiency by 58% (RR 0.42, 95% CI 0.28 to 0.62; 6 studies, 1482 participants; low-quality evidence), vitamin B2 deficiency by 64% (RR 0.36, 95% CI 0.19 to 0.68; 1 study, 296 participants; low-quality evidence), vitamin B6 deficiency by 91% (RR 0.09, 95% CI 0.02 to 0.38; 2 studies, 301 participants; low-quality evidence), vitamin B12 deficiency by 58% (RR 0.42, 95% CI 0.25 to 0.71; 3 studies, 728 participants; low-quality evidence), weight-for-age z-scores (WAZ) (mean difference (MD) 0.1, 95% CI 0.02 to 0.17; 8 studies, 2889 participants; low-quality evidence) and weight-for-height/length z-score (WHZ/WLZ) (MD 0.1, 95% CI 0.02 to 0.18; 6 studies, 1758 participants; low-quality evidence). We are uncertain about the effect of MMN fortification on zinc deficiency (RR 0.84, 95% CI 0.65 to 1.08; 5 studies, 1490 participants; low-quality evidence) and height/length-for-age z-score (HAZ/LAZ) (MD 0.09, 95% CI 0.01 to 0.18; 8 studies, 2889 participants; low-quality evidence). Most of the studies in this comparison were conducted in children. Subgroup analyses of funding sources (commercial versus non-commercial) and duration of intervention did not demonstrate any difference in effects, although this was a relatively small number of studies and the possible association between commercial funding and increased effect estimates has been demonstrated in the wider health literature. We could not conduct subgroup analysis by food vehicle and funding; since there were too few studies in each subgroup to draw any meaningful conclusions. When we compared MMNs versus iodised salt, we are uncertain about the effect of MMN fortification on anaemia (R 0.86, 95% CI 0.37 to 2.01; 1 study, 88 participants; very low-quality evidence), iron deficiency anaemia (RR 0.40, 95% CI 0.09 to 1.83; 2 studies, 245 participants; very low-quality evidence), iron deficiency (RR 0.98, 95% CI 0.82 to 1.17; 1 study, 88 participants; very low-quality evidence) and vitamin A deficiency (RR 0.19, 95% CI 0.07 to 0.55; 2 studies, 363 participants; very low-quality evidence). Both of the studies were conducted in children. Only one study conducted in children compared MMN fortification versus calcium fortification. None of the primary outcomes were reported in the study. None of the included studies reported on morbidity, adverse events, all-cause or cause-specific mortality. AUTHORS' CONCLUSIONS: The evidence from this review suggests that MMN fortification when compared to placebo/no intervention may reduce anaemia, iron deficiency anaemia and micronutrient deficiencies (iron, vitamin A, vitamin B2 and vitamin B6). We are uncertain of the effect of MMN fortification on anthropometric measures (HAZ/LAZ, WAZ and WHZ/WLZ). There are no data to suggest possible adverse effects of MMN fortification, and we could not draw reliable conclusions from various subgroup analyses due to a limited number of studies in each subgroup. We remain cautious about the level of commercial funding in this field, and the possibility that this may be associated with higher effect estimates, although subgroup analysis in this review did not demonstrate any impact of commercial funding. These findings are subject to study limitations, imprecision, high heterogeneity and small sample sizes, and we rated most of the evidence low to very low quality. and hence no concrete conclusions could be drawn from the findings of this review.

Management of Exocrine Pancreatic Insufficiency in Children.

The diagnosis of exocrine pancreatic insufficiency (EPI) can be difficult, as symptoms may be nonspecific. A delayed diagnosis of EPI can negatively impact health through poor weight gain, impaired growth, and malabsorption of nutrients. Because of active growth and development, children are more vulnerable to the consequences of untreated EPI. Pancreatic enzyme replacement therapy is the cornerstone of management and offers both symptomatic relief and improvement in clinical outcomes. Additionally, a high-energy diet with unrestricted fat and supplementation with fat-soluble vitamins is often required to optimize growth and prevent nutrition deficiencies. Cystic fibrosis (CF) is the most common condition in children that causes EPI, and improvement in nutrition management is associated with improved pulmonary function and increased survival. Currently, the management of other conditions leading to EPI in children is not well studied, and inferences from the CF literature are often necessary in caring for these patients.

Food and Agricultural Approaches to Reducing Malnutrition (FAARM): protocol for a cluster-randomised controlled trial to evaluate the impact of a Homestead Food Production programme on undernutrition in rural Bangladesh.

INTRODUCTION: Chronic undernutrition affects over 150 million children worldwide and has serious consequences. The causes are complex and include insufficient dietary diversity and poor hygiene practices. Systematic reviews of nutrition-sensitive agricultural interventions concluded that while these hold promise, there is insufficient evidence for their impact on child growth. The Food and Agricultural Approaches to Reducing Malnutrition (FAARM) project is a 1:1 cluster-randomised trial aiming to evaluate the impact of a Homestead Food Production (HFP) programme implemented by Helen Keller International on women's and children's undernutrition. METHODS AND ANALYSIS: The HFP intervention comprises training of women's groups and asset distribution to support year-round home gardening, poultry rearing and improved nutrition and hygiene practices. Formal trainings are supplemented by behaviour change communication during household visits, and facilitated links between producer groups and market actors. The FAARM trial will examine if and how this complex intervention reduces undernutrition. In 2015, FAARM enrolled married women and their children (0-3 years) in 96 rural settlements of Habiganj district in Sylhet division, Bangladesh. Covariate-constrained randomisation was used to assign 48 settlements to receive a 3-year HFP intervention, with the other 48 acting as controls, targeting over 2700 women. To study impact pathways, a surveillance system collects data on all participants every 2 months. In late 2019, children 0-3 years of age (born during the intervention period) will be surveyed, thus capturing impact during the critical first 1000 days of life. Children's length/height-for-age z-scores will be compared between intervention and control arms using mixed-effects linear regression. Secondary outcomes include women's and children's micronutrient status, dietary intake, dietary diversity and other indicators of child growth, development and morbidity. ETHICS AND DISSEMINATION: Ethical approval was received in Bangladesh and Germany. Results will be disseminated through peer-reviewed publications and presentations in Bangladesh and internationally. TRIAL REGISTRATION NUMBER: NCT02505711; Pre-results.

Effects of current parenteral nutrition treatment on health-related quality of life, physical function, nutritional status, survival and adverse events exclusively in patients with advanced cancer: A systematic literature review.

BACKGROUND: The aim was to evaluate the effects of current parenteral nutrition (PN) treatment on clinical outcomes in patients with advanced cancer. METHODS: This review was conducted according to the PRISMA guidelines (PROSPERO ID: 4201707915). RESULTS: Two underpowered randomized controlled trials and six observational studies were retrieved (n = 894 patients). Health-related quality of life and physical function may improve during anti-neoplastic treatment in who PN treatment is the only feeding opportunity, but not necessarily in patients able to feed enterally. Nutritional status may improve in patients regardless of anti-neoplastic treatment and gastrointestinal function. PN treatment was neither superior to fluid in terminal patients nor to dietary counselling in patients able to feed enterally in regards to survival. The total incidence of adverse events was low. CONCLUSION: Current PN treatment in patients with advanced cancer is understudied and the level of evidence is weak.