An exploration of the experiences and attitudes of healthcare professionals towards enteral tube feeding for adults living in the community following stroke.

BACKGROUND: Guidelines recommend enteral feeding via gastrostomy should be considered for adult survivors of stroke with dysphagia who cannot eat or drink sufficiently for >4 weeks. Many people continue long-term tube-feeding via this route in the community where healthcare professionals contribute to their care and nutritional management, although little is known about their experiences of or attitudes towards enteral feeding in this situation. The present study aimed to explore the experiences and attitudes of healthcare professionals working with this patient group. METHODS: Healthcare professionals were invited to complete a questionnaire devised for the study which comprised closed and open questions about tube-feeding including their patients' participation in feeding processes and mealtimes and how these might be improved. Responses to closed questions were analysed descriptively and free-text responses analysed using thematic analysis. RESULTS: Fifty-seven participants met the inclusion criteria. They identified patients' quality of life (77% of respondents) and nutritional support (75%) as the most important aspects of tube-feeding. Good communication and training with healthcare teams and carers were considered important. Their patients' participation in tube-feed administration and mealtime involvement were described as variable and potentially beneficial, but both were related to patients' choice and health impairment. Blended tube-feeding was considered an option by 89% provided practical and safety conditions were met. CONCLUSIONS: Participants' experiences of and attitudes towards tube feeding in adults living with stroke in the community in the sample in the present study are varied and focussed on individual patients' needs, safety and professional standards.

Diet and physical activity interventions to improve cardiovascular disease risk factors in liver transplant recipients: Systematic review and meta-analysis.

BACKGROUND AND AIMS: Cardiovascular disease, associated risk factors and obesity are prevalent after liver transplant and modifiable through lifestyle changes. Understanding what lifestyle interventions and their respective components are effective is essential for translation to clinical practice. We aimed to investigate the effects of diet and physical activity interventions on weight, body mass index and other cardiovascular disease risk factors in liver transplant recipients, and systematically describe the interventions. METHODS: We systematically searched Embase, MEDLINE, Psycho Info, CINAHL, Cochrane central register of controlled trials, PeDro, AMED, BNI, Web of Science, OpenGrey, ClinicalTrials.gov and the international clinical trials registry from inception to 31 May 2023. Search results were screened by two independent reviewers: randomised control trials with interventions that targeted diet and physical activity behaviours in liver transplant recipients were considered eligible. Two independent reviewers extracted and synthesised data for study, participant and intervention details and results. We used the Revised Cochrane Risk of Bias Tool for Randomised Trials to assess risk of bias for outcomes and the GRADE approach to rate the quality of the body of evidence. When two or more studies reported findings for an outcome, we pooled data using random-effects meta-analysis. RESULTS: Six studies were included, reporting three physical activity and three combined diet and physical activity interventions. Participants were 2 months-4 years post-transplant. Interventions lasted 12 weeks-10 months and were delivered remotely and/or in-person, most commonly delivered to individual participants by health care or sports professionals. Five studies described individual tailoring, e.g. exercise intensity. Adherence to interventions ranged from 51% to 94%. No studies reported fidelity. Intervention components were not consistently reported. In meta-analysis, diet and physical activity interventions did not significantly reduce weight or body mass index compared to control groups, however no studies targeted participants with obesity. Diet and physical activity interventions reduced percentage body fat and triglycerides compared to control groups but did not reduce total cholesterol or increase activity. The GRADE quality of evidence was low or very low. CONCLUSION: Diet and physical activity interventions reduced percentage body fat and triglycerides in liver transplant recipients. Further good quality research is needed to evaluate their effect on other cardiovascular disease risk factors, including weight and BMI. Interventions need to be better described and evaluated to improve evidence base and inform patient care.

Modified dietary fat intake for treatment of gallstone disease in people of any age.

BACKGROUND: The prevalence of gallstones varies between less than 1% and 64% in different populations and is thought to be increasing in response to changes in nutritional intake and increasing obesity. Some people with gallstones have no symptoms but approximately 2% to 4% develop them each year, predominantly including severe abdominal pain. People who experience symptoms have a greater risk of developing complications. The main treatment for symptomatic gallstones is cholecystectomy. Traditionally, a low-fat diet has also been advised to manage gallstone symptoms, but there is uncertainty over the evidence to support this. OBJECTIVES: To evaluate the benefits and harms of modified dietary fat intake in the treatment of gallstone disease in people of any age. SEARCH METHODS: We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials in the Cochrane Library, MEDLINE ALL Ovid, Embase Ovid, and three other databases to 17 February 2023 to identify randomised clinical trials in people with gallstones. We also searched online trial registries and pharmaceutical company sources, for ongoing or unpublished trials to March 2023. SELECTION CRITERIA: We included randomised clinical trials (irrespective of language, blinding, or status) in people with gallstones diagnosed using ultrasonography or conclusive imaging methods. We excluded participants diagnosed with another condition that may compromise dietary fat tolerance. We excluded trials where data from participants with gallstones were not reported separately from data from participants who did not have gallstones. We included trials that investigated other interventions (e.g. trials of drugs or other dietary (non-fat) components) providing that the trial groups had received the same proportion of drug or other dietary (non-fat) components in the intervention. DATA COLLECTION AND ANALYSIS: We intended to undertake meta-analysis and present the findings according to Cochrane recommendations. However, as we identified only five trials, with data unsuitable and insufficient for analyses, we described the data narratively. MAIN RESULTS: We included five trials but only one randomised clinical trial (69 adults), published in 1986, reported outcomes of interest to the review. The trial had four dietary intervention groups, three of which were relevant to this review. We assessed the trial at high risk of bias. The dietary fat modifications included a modified cholesterol intake and medium-chain triglyceride supplementation. The control treatment was a standard diet. The trial did not report on any of the primary outcomes in this review (i.e. all-cause mortality, serious adverse events, and health-related quality of life). The trial reported on gallstone dissolution, one of our secondary outcomes. We were unable to apply the GRADE approach to determine certainty of evidence because the included trial did not provide data that could be used to generate an estimate of the effect on this or any other outcome. The trial expressed its finding as "no significant effect of a low-cholesterol diet in the presence of ursodeoxycholic acid on gallstone dissolution." There were no serious adverse events reported. The included trial reported that they received no funding that could bias the trial results through conflicts of interest. We found no ongoing trials. AUTHORS' CONCLUSIONS: The evidence about the effects of modifying dietary fat on gallstone disease versus standard diet is scant. We lack results from high-quality randomised clinical trials which investigate the effects of modification of dietary fat and other nutrient intakes with adequate follow-up. There is a need for well-designed trials that should include important clinical outcomes such as mortality, quality of life, impact on dissolution of gallstones, hospital admissions, surgical intervention, and adverse events.

Nature of the evidence base and approaches to guide nutrition interventions for individuals: a position paper from the Academy of Nutrition Sciences.

This Position Paper from the Academy of Nutrition Sciences is the third in a series which describe the nature of the scientific evidence and frameworks that underpin nutrition recommendations for health. This paper focuses on evidence which guides the application of dietary recommendations for individuals. In some situations, modified nutrient intake becomes essential to prevent deficiency, optimise development and health, or manage symptoms and disease progression. Disease and its treatment can also affect taste, appetite and ability to access and prepare foods, with associated financial impacts. Therefore, the practice of nutrition and dietetics must integrate and apply the sciences of food, nutrition, biology, physiology, behaviour, management, communication and society to achieve and maintain human health. Thus, there is huge complexity in delivering evidence-based nutrition interventions to individuals. This paper examines available frameworks for appraising the quality and certainty of nutrition research evidence, the development nutrition practice guidelines to support evidence implementation in practice and the influence of other sources of nutrition information and misinformation. The paper also considers major challenges in applying research evidence to an individual and suggests consensus recommendations to begin to address these challenges in the future. Our recommendations target three groups; those who deliver nutrition interventions to individuals, those funding, commissioning or undertaking research aimed at delivering evidence-based nutrition practice, and those disseminating nutritional information to individuals.

Nutritional Intake after Liver Transplant: Systematic Review and Meta-Analysis.

Cardiovascular disease and its concurrent risk factors are prevalent after liver transplant (LT). Most of these risk factors are modifiable by diet. We aimed to synthesise the literature reporting the nutritional intake of liver transplant recipients (LTR) and the potential determinants of intake. We performed a systematic review and meta-analyses of studies published up until July 2021 reporting the nutritional intake of LTR. The pooled daily mean intakes were recorded as 1998 (95% CI 1889, 2108) kcal, 17 (17, 18)% energy from protein, 49 (48, 51)% energy from carbohydrates, 34 (33, 35)% energy from total fat, 10 (7, 13)% energy from saturated fat, and 20 (18, 21) g of fibre. The average fruit and vegetable intake ranged from 105 to 418 g/day. The length of time post-LT and the age and sex of the cohorts, as well as the continent and year of publication of each study, were sources of heterogeneity. Nine studies investigated the potential determinants of intake, time post-LT, gender and immunosuppression medication, with inconclusive results. Energy and protein requirements were not met in the first month post-transplant. After this point, energy intake was significantly higher and remained stable over time, with a high fat intake and low intake of fibre, fruits and vegetables. This suggests that LTR consume a high-energy, low-quality diet in the long term and do not adhere to the dietary guidelines for cardiovascular disease prevention.

Undertaking a research project improves confidence in research skills among student dietitians.

BACKGROUND: Research is a cornerstone of evidence-based dietetic practice. Research skills are often taught at university through experiential learning during a final-year research project. The present study aimed to investigate attitudes towards research and confidence in research skills among student dietitians before and after a research project. METHODS: A questionnaire survey of student dietitians' attitudes to research and confidence in research skills was undertaken before and after completing a research project at two universities in London, UK. Dichotomous data were compared before and after the research project using a McNemar's test. Factors associated with 'high confidence' or 'improved confidence' in overall research skills at the end of the research project were investigated using multivariable logistic regression. RESULTS: In total, 160 student dietitians completed a questionnaire before and after their research project. The majority had positive attitudes to research both before and after their research project. There was an increase in numbers with 'high confidence' in overall research skills before (13; 8.1%) and after (79; 49.4%) the research project (p < 0.001), and 113 (70.6%) reported 'improved confidence' in overall research skills. The only factor associated with 'high confidence' in overall research skills was having 'high levels of involvement in the overall research process' (odds ratio = 6.13, 95% confidence interval = 2.03-18.49, p = 0.001). CONCLUSIONS: Student dietitians have positive attitudes towards research and undertaking a research project significantly improves confidence in their research skills. A higher level of involvement in the research project is the single most significant factor associated with high confidence in research skills.

Nutritional supplementation for nonalcohol-related fatty liver disease: a network meta-analysis.

BACKGROUND: The prevalence of non-alcohol-related fatty liver disease (NAFLD) varies between 19% and 33% in different populations. NAFLD decreases life expectancy and increases risks of liver cirrhosis, hepatocellular carcinoma, and the requirement for liver transplantation. Uncertainty surrounds relative benefits and harms of various nutritional supplements in NAFLD. Currently no nutritional supplement is recommended for people with NAFLD. OBJECTIVES: • To assess the benefits and harms of different nutritional supplements for treatment of NAFLD through a network meta-analysis • To generate rankings of different nutritional supplements according to their safety and efficacy SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Science Citation Index Expanded, Conference Proceedings Citation Index-Science, the World Health Organization International Clinical Trials Registry Platform, and trials registers until February 2021 to identify randomised clinical trials in people with NAFLD. SELECTION CRITERIA: We included only randomised clinical trials (irrespective of language, blinding, or status) for people with NAFLD, irrespective of method of diagnosis, age and diabetic status of participants, or presence of non-alcoholic steatohepatitis (NASH). We excluded randomised clinical trials in which participants had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS: We performed a network meta-analysis with OpenBUGS using Bayesian methods whenever possible and calculated differences in treatments using hazard ratios (HRs), odds ratios (ORs), and rate ratios with 95% credible intervals (CrIs) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. MAIN RESULTS: We included in the review a total of 202 randomised clinical trials (14,200 participants). Nineteen trials were at low risk of bias. A total of 32 different interventions were compared in these trials. A total of 115 trials (7732 participants) were included in one or more comparisons. The remaining trials did not report any of the outcomes of interest for this review. Follow-up ranged from 1 month to 28 months. The follow-up period in trials that reported clinical outcomes was 2 months to 28 months. During this follow-up period, clinical events related to NAFLD such as mortality, liver cirrhosis, liver decompensation, liver transplantation, hepatocellular carcinoma, and liver-related mortality were sparse. We did not calculate effect estimates for mortality because of sparse data (zero events for at least one of the groups in the trial). None of the trials reported that they measured overall health-related quality of life using a validated scale. The evidence is very uncertain about effects of interventions on serious adverse events (number of people or number of events). We are very uncertain about effects on adverse events of most of the supplements that we investigated, as the evidence is of very low certainty. However, people taking PUFA (polyunsaturated fatty acid) may be more likely to experience an adverse event than those not receiving an active intervention (network meta-analysis results: OR 4.44, 95% CrI 2.40 to 8.48; low-certainty evidence; 4 trials, 203 participants; direct evidence: OR 4.43, 95% CrI 2.43 to 8.42). People who take other supplements (a category that includes nutritional supplements other than vitamins, fatty acids, phospholipids, and antioxidants) had higher numbers of adverse events than those not receiving an active intervention (network meta-analysis: rate ratio 1.73, 95% CrI 1.26 to 2.41; 6 trials, 291 participants; direct evidence: rate ratio 1.72, 95% CrI 1.25 to 2.40; low-certainty evidence). Data were sparse (zero events in all groups in the trial) for liver transplantation, liver decompensation, and hepatocellular carcinoma. So, we did not perform formal analysis for these outcomes. The evidence is very uncertain about effects of other antioxidants (antioxidants other than vitamins) compared to no active intervention on liver cirrhosis (HR 1.68, 95% CrI 0.23 to 15.10; 1 trial, 99 participants; very low-certainty evidence). The evidence is very uncertain about effects of interventions in any of the remaining comparisons, or data were sparse (with zero events in at least one of the groups), precluding formal calculations of effect estimates. Data were probably because of the very short follow-up period (2 months to 28 months). It takes follow-up of 8 to 28 years to detect differences in mortality between people with NAFLD and the general population. Therefore, it is unlikely that differences in clinical outcomes are noted in trials providing less than 5 to 10 years of follow-up. AUTHORS' CONCLUSIONS: The evidence indicates considerable uncertainty about effects of nutritional supplementation compared to no additional intervention on all clinical outcomes for people with non-alcohol-related fatty liver disease. Accordingly, high-quality randomised comparative clinical trials with adequate follow-up are needed. We propose registry-based randomised clinical trials or cohort multiple randomised clinical trials (study design in which multiple interventions are trialed within large longitudinal cohorts of patients to gain efficiencies and align trials more closely to standard clinical practice) comparing interventions such as vitamin E, prebiotics/probiotics/synbiotics, PUFAs, and no nutritional supplementation. The reason for the choice of interventions is the impact of these interventions on indirect outcomes, which may translate to clinical benefit. Outcomes in such trials should be mortality, health-related quality of life, decompensated liver cirrhosis, liver transplantation, and resource utilisation measures including costs of intervention and decreased healthcare utilisation after minimum follow-up of 8 years (to find meaningful differences in clinically important outcomes).

Lifestyle modifications for nonalcohol-related fatty liver disease: a network meta-analysis.

BACKGROUND: The prevalence of nonalcohol-related fatty liver disease (NAFLD) varies between 19% and 33% in different populations. NAFLD decreases life expectancy and increases the risks of liver cirrhosis, hepatocellular carcinoma, and requirement for liver transplantation. There is uncertainty surrounding the relative benefits and harms of various lifestyle interventions for people with NAFLD. OBJECTIVES: To assess the comparative benefits and harms of different lifestyle interventions in the treatment of NAFLD through a network meta-analysis, and to generate rankings of the different lifestyle interventions according to their safety and efficacy. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, Conference Proceedings Citation Index - Science, World Health Organization International Clinical Trials Registry Platform, and trials registers until February 2021 to identify randomised clinical trials in people with NAFLD. SELECTION CRITERIA: We included only randomised clinical trials (irrespective of language, blinding, or status) in people with NAFLD, whatever the method of diagnosis, age, and diabetic status of participants, or presence of non-alcoholic steatohepatitis (NASH). We excluded randomised clinical trials in which participants had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS: We planned to perform a network meta-analysis with OpenBUGS using Bayesian methods and to calculate the differences in treatments using hazard ratios (HRs), odds ratios (ORs), and rate ratios (RaRs) with 95% credible intervals (CrIs) based on an available-participant analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. However, the data were too sparse for the clinical outcomes. We therefore performed only direct comparisons (head-to-head comparisons) with OpenBUGS using Bayesian methods. MAIN RESULTS: We included a total of 59 randomised clinical trials (3631 participants) in the review. All but two trials were at high risk of bias. A total of 33 different interventions, ranging from advice to supervised exercise and special diets, or a combination of these and no additional intervention were compared in these trials. The reference treatment was no active intervention. Twenty-eight trials (1942 participants) were included in one or more comparisons. The follow-up ranged from 1 month to 24 months. The remaining trials did not report any of the outcomes of interest for this review. The follow-up period in the trials that reported clinical outcomes was 2 months to 24 months. During this short follow-up period, clinical events related to NAFLD such as mortality, liver cirrhosis, liver decompensation, liver transplantation, hepatocellular carcinoma, and liver-related mortality were sparse. This is probably because of the very short follow-up periods. It takes a follow-up of 8 years to 28 years to detect differences in mortality between people with NAFLD and the general population. It is therefore unlikely that differences by clinical outcomes will be noted in trials with less than 5 years to 10 years of follow-up. In one trial, one participant developed an adverse event. There were no adverse events in any of the remaining participants in this trial, or in any of the remaining trials, which seemed to be directly related to the intervention. AUTHORS' CONCLUSIONS: The evidence indicates considerable uncertainty about the effects of the lifestyle interventions compared with no additional intervention (to general public health advice) on any of the clinical outcomes after a short follow-up period of 2 months to 24 months in people with nonalcohol-related fatty liver disease. Accordingly, high-quality randomised clinical trials with adequate follow-up are needed. We propose registry-based randomised clinical trials or cohort multiple randomised clinical trials (a study design in which multiple interventions are trialed within large longitudinal cohorts of participants to gain efficiencies and align trials more closely to standard clinical practice), comparing aerobic exercise and dietary advice versus standard of care (exercise and dietary advice received as part of national health promotion). The reason for the choice of aerobic exercise and dietary advice is the impact of these interventions on indirect outcomes which may translate to clinical benefit. The outcomes in such trials should be mortality, health-related quality of life, decompensated liver cirrhosis, liver transplantation, and resource use measures including costs of intervention and decreased healthcare use after a minimum follow-up of eight years, to find meaningful differences in the clinically important outcomes.

Diet and physical activity after liver transplant: A qualitative study of barriers and facilitators to following advice.

BACKGROUND: Liver transplant recipients are given diet and physical activity advice to aid recovery and promote long-term health. The present study aimed to explore patients' experiences of receiving and implementing diet and physical activity advice after liver transplant and identify barriers and facilitators to following recommendations. METHODS: A qualitative descriptive design included purposive sampling of 13 liver transplant recipients. Semi-structured audio-recorded interviews and inductive thematic analysis using a framework were undertaken concurrently to enable recruitment until saturation of themes occurred. RESULTS: Overall experiences varied between participants and settings, as well as over time. Seven themes emerged, all representing both barriers and facilitators to implementing advice. Poor capability and loss of confidence were barriers that improved in hospital because healthcare professionals enabled participants to set and achieve goals but remained key barriers after discharge from hospital. The format and consistency of advice influenced participants' confidence in the healthcare team. Social support helped participants to return to and implement advice, although social networks could also have a negative influence. Advice and modelling of behaviour from other transplant recipients were facilitators. Symptoms, side effects, comorbidities and the environment presented barriers and facilitators. The desire to return to normal and coping strategies were drivers of behaviours, which were also influenced by participants' beliefs and values. CONCLUSIONS: The variation in experiences indicates a need for individually tailored advice that is consistent across the multidisciplinary team. Interventions for behaviour change that merit further investigation include goal setting, improving coping strategies, peer support and modifying the hospital and home environment.

Improved prediction equations for estimating height in adults from ethnically diverse backgrounds.

BACKGROUND & AIMS: When body height cannot be measured, it can be predicted from ulna length (UL). However, commonly used published prediction equations may not provide useful estimates in adults from all ethnicities. This study aimed to evaluate the relationship between UL and height in adults from diverse ethnic groups and to consider whether this can be used to provide useful prediction equations for height in practice. METHODS: Standing height and UL were measured in 542 adults at seven UK locations. Ethnicity was self-defined using UK Census 2011 categories. Data were modelled to give two groups of height prediction equations based on UL, sex and ethnicity and these were tested against an independent dataset (n = 180). RESULTS: UL and height were significantly associated overall and in all groups except one with few participants (P = 0.059). The new equations yielded predicted height (Hp) that was closer to measured height in the Asian and Black subgroups of the independent population than the Malnutrition Universal Screening Tool (MUST) equations. For Asian men, (Hp (cm) = 3.26 UL (cm) + 83.58), mean difference from measured (95% confidence intervals) was -0.6 (-2.4, +1.2); Asian women, (Hp = 3.26 UL + 77.62), mean difference +0.5 (-1.4, 2.4) cm. For Black men, Hp = 3.14 UL + 85.80, -0.4 (-2.4, 1.7); Black women, Hp = 3.14 UL + 79.55, -0.8 (-2.8, 1.2). These differences were not statistically significant while predictions from MUST equations were significantly different from measured height. CONCLUSIONS: The new prediction equations provide an alternative for estimating height in adults from Asian and Black groups and give mean predicted values that are closer to measured height than MUST equations.

Evaluating the ≤10:1 wholegrain criterion in identifying nutrient quality and health implications of UK breads and breakfast cereals.

OBJECTIVE: To evaluate the nutrient quality of breads and breakfast cereals identified using the wholegrain definition of ≤10:1 carbohydrate:fibre ratio. DESIGN: Following a cross-sectional study design, nutritional information was systematically gathered from food labels of breads and breakfast cereals that met the ≤10:1 carbohydrate:fibre criterion. The median nutrient content was compared with the UK Food Standards Agency's nutrient profiling standards and the associations between carbohydrate:fibre ratio and other nutrients were analysed. Subgroup analyses were undertaken for products with and without fruit, nuts and/or seeds. SETTING: Products from four major supermarket stores in the UK. SUBJECTS: Breads (n 162) and breakfast cereals (n 266). RESULTS: Breads which met the ≤10:1 criterion typically contained medium fat, low saturated fat, low sugar and medium Na. Breakfast cereals typically contained medium fat, low saturated fat, high sugar and low Na. In both groups, as the carbohydrate:fibre ratio decreased, fat content increased (bread: P=0·029, r=-0·171; breakfast cereal: P=0·033, r=-0·131) and, in breakfast cereals, as the ratio increased, sugar content increased (P<0·0005, r=0·381). Breakfast cereals with fruit, nuts and/or seeds contained, per 100 g, more energy (P=0·002), fat, saturated fat and sugar (all P<0·0005), while seeded breads had more energy, fat and saturated fat (all P<0·0005). CONCLUSIONS: Overall, breads and breakfast cereals meeting the ≤10:1 criterion have good nutritional quality, suggesting that the criterion could be useful in public health and/or food labelling. The utility of applying the ≤10:1 criterion to products containing fruit, nuts and/or seeds is less clear and requires further research.

Patients' preferences for nutrition-related health outcomes in liver disease: a preliminary study using an electronic questionnaire.

BACKGROUND: Patients with liver disease frequently have nutritional problems but intervening to improve these is challenging. Healthcare interventions that respond to patients' needs are associated with better health outcomes but no studies investigating patients' preferences for nutrition-related outcomes in liver disease have been published. The present study aimed to identify nutrition-related health outcomes that are important to patients with liver disease. METHODS: An electronic questionnaire was devised and reviewed by patients and dietitians with relevant experience. It comprised a Likert scale and open questions focussing on six domains considered pertinent to patients with liver disease. An invitation to participate was posted on the website of a national liver charity and sent to liver patient support groups. RESULTS: Fifty-one patients participated (22 men and 29 women). Responses indicated a wide range of preferred nutrition-related outcomes, with those identified as very important most frequently focussing on gaining knowledge about which foods to eat more or less of, as well as on understanding why nutrition is important in liver disease. Women tended to score outcomes as more important than did men. Participants who considered themselves overweight scored outcomes on body size and shape as more important than those with other nutritional problems. Additional outcomes were identified and included an increased knowledge of healthy eating, interactions between medication and food, and supplementation. CONCLUSIONS: The present study identified a wide range of nutrition-related outcomes that were important to this small sample of patients with liver disease and these may be useful to guide the direction of future nutrition-related management.

Marketing foods to children: a comparison of nutrient content between children's and non-children's products.

OBJECTIVE: The predominance of marketing of products high in fat, sugar and/or salt to children has been well documented and implicated in the incidence of obesity. The present study aimed to determine whether foods marketed to children in UK supermarkets are nutritionally similar to the non-children's equivalent, focusing on food categories that may be viewed as healthier options. DESIGN: Nutritional data were collected on yoghurts (n 147), cereal bars (n 145) and ready meals (n 144) from seven major UK supermarkets and categorised as children's or non-children's products based on the characteristics, promotional nature or information on the product packaging. Fat, sugar and salt content was compared per 100 g and per recommended portion size. SETTING: UK. RESULTS: Per 100 g, children's yoghurts and cereal bars were higher in total sugars, fat and saturated fat than the non-children's; this was significant for all except sugar and total fat in cereal bars. Per portion these differences remained, except for sugars in yoghurts. Conversely children's ready meals were significantly lower in these nutrients per portion than non-children's, but not when expressed per 100 g. Children's yoghurts and ready meals had significantly lower sodium content than non-children's both per portion and per 100 g. CONCLUSIONS: Significant differences between the nutritional composition of children's and non-children's products were observed but varied depending on the unit reference. A significant number of products marketed towards children were higher in fat, sugar and salt than those marketed to the general population.

Evaluation of a phosphate management protocol to achieve optimum serum phosphate levels in hemodialysis patients.

OBJECTIVE: To evaluate the effectiveness of a protocol designed to optimize serum phosphate levels in patients undergoing regular hemodialysis (HD). DESIGN: Randomized, controlled trial. SETTING: Hemodialysis units at Barts and the London NHS Trust and satellite units. PATIENTS: Thirty-four clinically stable adults undergoing regular HD with a serum phosphate level >1.8 mmol/L on at least one occasion within 4 months of starting the study. INTERVENTION: Management of serum phosphate using a specially designed phosphate management protocol during a 4-month study period implemented by a renal dietitian and renal pharmacist compared with standard practice. MAIN OUTCOME MEASURE: Change in serum phosphate levels in both groups after 4 months. RESULTS: Patients managed using the phosphate management protocol had a significantly greater reduction in serum phosphate levels compared with patients receiving standard practice (-0.22 +/- 0.67 mmol/L vs. +0.19 +/- 0.32 mmol/L, P = 0.03). CONCLUSION: The phosphate management protocol was effective, and its implementation was associated with significantly better serum phosphate control in patients undergoing regular HD.

Student research projects: the experiences of student dietitians, university faculty members, and collaborators.

Two universities in the United Kingdom made systematic attempts to increase the number of student dietitians' research projects that are supervised by university faculty members in conjunction with external collaborators (collaborative projects), rather than by faculty alone (faculty-only projects). A questionnaire survey was used to evaluate the experiences of student dietitians (n=110), university faculty members (n=38), and collaborators (n=31) involved in a student research project, comparing those involved in a faculty-only project with those involved in a collaborative project. Students undertaking collaborative projects reported greater involvement in most areas of the research process and greater skill development in obtaining research ethics approval (P=0.005), data collection (P=0.05), and statistical analysis (P=0.004) than students undertaking faculty-only projects. In addition, collaborative projects were more frequently considered to produce results that would change dietetics practice than faculty-only projects by both student dietitians (60% vs 30%, P=0.01) and university faculty members (62% vs 19%, P<0.001). The collaborators also considered that in the majority of instances (61%) their involvement helped them to organize their own time to do research. The type of project did not appear to influence student's expectations of future involvement in research and audit. In general, both types of projects resulted in positive experiences for student dietitians, university faculty members, and collaborators. We recommend that those involved in dietetics education, practice, and management consider the potential value of senior-level student dietitian involvement in collaborative research projects.

Two-component models are of limited value for the assessment of body composition in patients with cirrhosis.

BACKGROUND: Most techniques for measuring body composition are based on 2-component models (2-CMs) and depend on assumptions relating to the constancy of the density (D(FFM)) and hydration fraction (HF(FFM)) of fat-free mass (FFM). OBJECTIVES: The objectives were to determine whether these assumptions are systematically violated in patients with cirrhosis and to assess the validity of the estimates of body composition obtained in these patients by using 2-CM techniques. DESIGN: Body composition was assessed by using a 4-component model (4-CM), which was based on data obtained from densitometry, deuterium dilution, and dual-energy X-ray absorptiometry, in 20 patients with cirrhosis who had no evidence of fluid retention and in 20 pair-matched healthy control subjects. The results were compared with those obtained by using "reference" and "bedside" 2-CM techniques. RESULTS: The mean (+/-SD) D(FFM) was significantly lower in the patients with cirrhosis (1.091 +/- 0.008 compared with 1.100 +/- 0.006 kg/L; P < 0.001); no significant difference in HF(FFM) was observed between the patients and control subjects (74.5 +/- 2.6 compared with 73.5 +/- 2.1), although there was greater variability in the patients. Significant differences were observed in the body-composition variables obtained by using the "reference" 2-CM techniques compared with the 4-CM-the 95% limits of agreement in the patients with cirrhosis exceeded 5% body fat and 3 kg FFM; the corresponding values for the "bedside" 2-CM techniques were 11% body fat and 7.5 kg FFM. CONCLUSIONS: Assumptions relating to the constancy of the D(FFM) and HF(FFM) are violated in patients with cirrhosis. Thus, standard 2-CM techniques provide inaccurate body composition estimates in this patient population.

Derivation and validation of a new global method for assessing nutritional status in patients with cirrhosis.

Accurate assessments of nutritional status are difficult to obtain in patients with cirrhosis. The aim of this study was to devise and validate a global nutritional assessment scheme for use in this patient population. Measures of body mass index (BMI) and mid-arm muscle circumference (MAMC) were combined with details of dietary intake in a semistructured, algorithmic construct to provide a nutritional assessment scheme for use in patients with cirrhosis; evaluated individuals were classified as adequately nourished, moderately malnourished (or suspected to be), or severely malnourished. There was good interobserver agreement in the nutritional categorization of 50 patients with cirrhosis (34 men, 16 women) using this scheme (kappa = 0.79) and significant associations with the contributing objective variables--namely, BMI (Spearman's correlation r = -0.78; P < .001) and relative MAMC (r = -0.69; P < .001)--confirming its internal validity. There was a significant association between nutritional categorization in 20 patients with cirrhosis (10 men, 10 women) and estimates of total body protein obtained using a four-component model (r = -0.45; P = .046), confirming the external validity of the scheme. Finally, a significant association was found between poor nutritional status in 116 patients with cirrhosis (65 men, 51 women), followed for 14 to 52 months, and shorter subsequent survival (P = .0005), confirming the scheme's predictive validity. In conclusion, a global assessment scheme has been devised that provides a simple, reproducible, valid, and predictive method of assessing nutritional status in patients with cirrhosis.

Changing perspectives in the nutritional management of disease.

There have been substantial changes in the nutritional management of many diseases in the last 20 years, which have been accompanied by a growing recognition of its importance. Many of the changes in clinical nutrition have been associated with the introduction of standards, clinical audit and the implementation of evidence-based practice, which has led to a re-evaluation of some established dietary interventions using a hierarchy-of-evidence approach. Although there are few randomised controlled trials on which to base such work, the examination of other, often less-robust, evidence has led to some traditional dietary interventions being modified. Examples in gastroenterology include the use of low-fat diets in gall bladder disease and the restriction of protein in hepatic encephalopathy, where the current evidence suggests that neither should be used routinely in clinical practice. Where therapeutic dietary restrictions are required, as with low-Na diets in ascites, there is very little information on how these restrictions influence total nutrient intake and, if intake is impaired, how the detrimental effects of an inadequate intake should be balanced with the therapeutic effects of restriction. Studies are required to ensure that nutritional interventions are not only effective but also free from undesirable side effects. The mode and timing of the delivery of nutritional support has also been re-evaluated and the benefits of early enteral feeding have been recognised. The delivery of dietary advice is a new area that is being considered, with practitioners in clinical nutrition using behaviour-change skills to facilitate optimum nutrition rather than simply providing patients with advice. For such developments to continue in clinical nutrition it is essential that all practice should be systematically evaluated and, where necessary, modified in the light of sound current research findings, and that gaps in our present knowledge base are identified and addressed.