Patient-reported dietetic care post hospital for free-living patients: a Canadian Malnutrition Task Force Study.

BACKGROUND: Transitions out of hospital can influence recovery. Ideally, malnourished patients should be followed by someone with nutrition expertise, specifically a dietitian, post discharge from hospital. Predictors of dietetic care post discharge are currently unknown. The present study aimed to determine the patient factors independently associated with 30-days post hospital discharge dietetic care for free-living patients who transitioned to the community. METHODOLOGY: Nine hundred and twenty-two medical or surgical adult patients were recruited in 16 acute care hospitals in eight Canadian provinces on admission. Eligible patients could speak English or French, provide their written consent, were anticipated to have a hospital stay of ≥2 days and were not considered palliative. Telephone interviews were completed with 747 (81%) participants using a standardised questionnaire to determine whether dietetic care occurred post discharge; 544 patients discharged to the community were included in the multivariate analyses, excluding those who were admitted to nursing homes or rehabilitation facilities. Covariates during and post hospitalisation were collected prospectively and used in logistic regression analyses to determine independent patient-level predictors. RESULTS: Dietetic care post discharge was reported by 61/544 (11%) of participants and was associated with severe malnutrition [Subjective Global Assessment category C: odd's ratio (OR) 2.43 (1.23-4.83)], weight loss post discharge [(OR 2.86 (1.45-5.62)], comorbidity [(OR 1.09 (1.02-1.17)] and a dietitian consultation on admission [(OR 3.41 (1.95-5.97)]. CONCLUSIONS: Dietetic care post discharge occurs in few patients, despite the known high prevalence of malnutrition on admission and discharge. Dietetic care in hospital was the most influential predictor of post-hospital care.

Prevalence and predictors of weight change post discharge from hospital: a study of the Canadian Malnutrition Task Force.

BACKGROUND/OBJECTIVES: Little is known about factors associated with weight change post discharge from hospital; yet poor nutritional status in the transition from hospital to community can result in readmission. This exploratory study aimed to determine the factors associated with weight change 30 days post discharge defined as weight gain (WG; 5+ pounds), weight loss (WL; 5+pounds) or weight stable (WS). SUBJECTS/METHODS: A total of 922 medical or surgical patients were recruited from 16 acute care hospitals in 8 Canadian provinces. Telephone interviews were completed with 747 (81%) participants 30 days post discharge using a standardized questionnaire that included: self-reported weight change, assessment of appetite, usage of healthcare services and supports for food-related activities of daily living. Covariates collected during hospitalization, including nutritional status at discharge evaluated by subjective global assessment (SGA), were used in logistic regressions. RESULTS: Among the 747 patients, 26% reported WL, 16.7% had WG and 57.2% were WS. Those with WG were: younger (odds ratio (OR) 0.77 (0.69, 0.85)), male (OR 1.71 (1.12, 2.61)), malnourished at discharge (SGA B OR 2.13 (1.36, 3.33), SGA C OR 2.76 (1.19, 6.62)), and had a good appetite based on the low OR for fair/poor appetite (OR 0.28 (0.11, 0.66)). WL was associated with being on a special diet (OR 1.45 (1.07,1.96)) and reporting fair/poor appetite (OR 2.67 (1.76, 4.07)). CONCLUSIONS: Weight change was relatively common with WL predominating. Several variables were identified to be predictors of WL or weight gain, with appetite being common to both. Future work to further define and confirm these associations is warranted.

Barriers to food intake in acute care hospitals: a report of the Canadian Malnutrition Task Force.

BACKGROUND: Poor food intake is common in acute care patients and can exacerbate or develop into malnutrition, influencing both recovery and outcome. Yet, research on barriers and how they can be alleviated is lacking. The present study aimed to (i) describe the prevalence of food intake barriers in diverse hospitals and (ii) determine whether patient, care or hospital characteristics are associated with the experience of these barriers. METHODS: Patients (n = 890; 87%) completed a validated questionnaire on barriers to food intake, including perceptions of food quality, just before their discharge from a medical or surgical unit in each of 18 hospitals across Canada. Scores were created for barrier domains. Associations between these barriers and selected patient characteristics collected at admission or throughout the hospital stay and site characteristics were determined using bivariate analyses. RESULTS: Common barriers were being interrupted at meals (41.8%), not being given food when a meal was missed (69.2%), not wanting ordered food (58%), loss of appetite (63.9%) and feeling too sick (42.7%) or tired (41.1%) to eat. Younger patients were more likely (P < 0.0001) to report being disturbed at meals (44.6%) than older patients (33.9%) and missing a meal for tests (39.0% versus 31.0%, P < 0.05). Patients who were malnourished, women, those with more comorbidity, and those who ate <50% of the meal reported several barriers across domains. CONCLUSIONS: The present study confirms that barriers to food intake are common in acute care hospitals. This analysis also identifies that specific patient subgroups are more likely to experience food intake barriers. Because self-reported low food intake in hospital was associated with several barriers, it is relevant to consider assessing, intervening and monitoring barriers to food intake during the hospital stay.

Validity and reliability of the new Canadian Nutrition Screening Tool in the 'real-world' hospital setting.

BACKGROUND/OBJECTIVES: Nutrition screening should be initiated on hospital admission by non-dietitians. This research aimed to validate and assess the reliability of the Canadian Nutrition Screening Tool (CNST) in the 'real-world' hospital setting. SUBJECTS/METHODS: Adult patients were admitted to surgical and medical wards only (no palliative patients). Study 1--Nutrition Care in Canadian Hospitals (n=1014): development of the CNST (3 items: weight loss, decrease food intake, body mass index (BMI)) and exploratory assessment of its criterion and predictive validity. Study 2--Inter-rater reliability and criterion validity assessment of the tool completed by untrained nursing personnel or diet technician (DT) (n=150). Subjective Global Assessment performed by site coordinators was used as a gold standard for comparison. RESULTS: Study 1: The CNST completed by site coordinators showed good sensitivity (91.7%) and specificity (74.8%). Study 2: In the subsample of untrained personnel (160 nurses; one DT), tool's reliability was excellent (Kappa=0.88), sensitivity was good (>90%) but specificity was low (47.8%). However, using a two-item ('yes' on both weight change and food intake) version of the tool improved the specificity (85.9%). BMI was thus removed to promote feasibility. The final two-item tool (study 1 sample) has a good predictive validity: length of stay (P<0.001), 30-day readmission (P=0.02; X(2) 5.92) and mortality (P<0.001). CONCLUSIONS: The simple and reliable CNST shows good sensitivity and specificity and significantly predicts adverse outcomes. Completion by several untrained nursing personnel confirms its utility in the nursing admission assessment.

Providing quality nutrition care in acute care hospitals: perspectives of nutrition care personnel.

BACKGROUND: Malnutrition is common in acute care hospitals worldwide and nutritional status can deteriorate during hospitalisation. The aim of the present qualitative study was to identify enablers and challenges and, specifically, the activities, processes and resources, from the perspective of nutrition care personnel, required to provide quality nutrition care. METHODS: Eight hospitals participating in the Nutrition Care in Canadian Hospitals study provided focus group data (n = 8 focus groups; 91 participants; dietitians, dietetic interns, diet technicians and menu clerks), which were analysed thematically. RESULTS: Five themes emerged from the data: (i) developing a nutrition culture, where nutrition practice is considered important to recovery of patients and teams work together to achieve nutrition goals; (ii) using effective tools, such as screening, evidence-based protocols, quality, timely and accurate patient information, and appropriate and quality food; (iii) creating effective systems to support delivery of care, such as communications, food production and delivery; (iv) being responsive to care needs, via flexible food systems, appropriate menus and meal supplements, up to date clinical care and including patient and family in the care processes; and (v) uniting the right person with the right task, by delineating roles, training staff, providing sufficient time to undertake these important tasks and holding staff accountable for their care. CONCLUSIONS: The findings of the present study are consistent with other work and provide guidance towards improving the nutrition culture in hospitals. Further empirical work on how to support successful implementation of nutrition care processes is needed.

Prescription of trace elements in adults on home parenteral nutrition: current practice based on the Canadian Home Parenteral Nutrition Registry.

BACKGROUND: Since the introduction of long-term parenteral nutrition (PN), morbidity due to inadequate replacement or toxicity of routinely administered trace elements has been well described. After decades of experience, much debate still exists about optimal supplementation. In practice, trace elements (TEs) seem to be frequently provided by prescribing an all-inclusive commercial multi-TE admixture with little dosage flexibility. AIM: Our goal was to review TE supplementation practice among 5 PN support centers across Canada, through a retrospective review of the Canadian Home PN Registry. METHODS: Baseline demographic, clinical, and biochemical parameters along with information regarding the PN prescription of 135 patients with complete records were retrieved from the registry database collected between 2005 and 2007. TE supplementation prescriptions were compared with recent guidelines as well as between groups of patients with different PN indications and dietary intake status. Consent was signed by all participating patients. RESULTS: The average daily PN concentrations of TE were as follows: zinc, 8.6 ± 5.5 mg (130.92 ± 84.23 µmol); manganese, 452 ± 184 µg (8.22 ± 3.34 µmol); selenium, 78 ± 45 µg (0.99 ± 0.57 µmol); chromium, 11 ± 5 µg (0.21 ± 0.10 µmol); copper, 0.64 ± 0.35 mg (10.11 ± 5.58 µmol); and iodine, 77 ± 42 µg (0.61 ± 0.33 µmol). The mean daily supplementation of zinc, manganese, copper, and selenium exceeded published recommendations. Patients' underlying anatomy or indication for PN did not significantly influence decisions regarding replacement standards. CONCLUSION: Parenteral TE supplementation in Canadian PN programs needs to be reviewed and adjusted according to most current guidelines. This may require a reevaluation of the commercial TE preparations currently available in Canada and potential new products worldwide to avoid oversupplementation and potential toxicity.

Canadian home parenteral nutrition (HPN) registry: validation and patient outcomes.

BACKGROUND: In Canada, there are an estimated 400 home parenteral nutrition (HPN) patients. In 2006, a registry was created to gather patient outcome information. The aim of this study was to validate the registry and report on HPN patient outcomes. METHODS: Several demographic, clinical parameters were collected. For the validation, paired t test and intraclass correlation coefficient (ICC) were used to assess agreement between repeat entries. For the outcome report, paired t test was used to assess changes, and survival analysis was performed using the Kaplan-Meier method. Results are expressed as mean ± SEM. RESULTS: On validation, there was high correlation/agreement (P < .05) for most parameters except vascular access/line sepsis, liver disease (ultrasound, biopsy, diagnoses), and hospitalizations. For the outcome report, 96 patients had their data entered at 2.24 ± 0.11 years after baseline. Over the period, there was a significant reduction in PN calories (P = .001) and proteins (P < .001). There were no significant changes in nutrition parameters and laboratory results except for lower platelet counts (P = .028), lower plasma potassium (P = .030), and a trend toward an increase in bilirubin from 19.29 ± 4.65 to 29.06 ± 8.73 µmol/L (P = .071). The QOL decreased significantly over time (P < .001) and the survival on HPN was 17.67 ± 1.89 years. CONCLUSIONS: The registry is a valid tool to assess several clinical parameters. On follow-up, HPN patients maintain good nutrition status while PN is reduced but do have a reduced quality of life.

Successful management of the short bowel syndrome.

Intestinal failure manifests as diarrhoea, fluid and electrolyte imbalance and malabsorption caused due to surgical resection of small intestine or very rarely due to nonfunctioning of large segment of bowel. Management of short bowel syndrome is quite challenging which requires better understanding of the site and extent of resected segment, pathophysiology of the remaining segment and the time of adaptation. Initial management includes control of diarrhoea with adequate fluid and electrolyte management which is critical for stabilization of the patient. Multidisciplinary approach to the patient is needed.

Renal effects of long-term treatment with 5-aminosalicylic acid.

BACKGROUND: A number of case reports link the use of 5-aminosalicylic acid (5-ASA) to interstitial nephritis in patients with inflammatory bowel disease (IBD). OBJECTIVE: To investigate whether the long-term use of 5-ASA has harmful effects on renal function in patients with IBD. METHODS: A retrospective analysis of 171 consecutive outpatients with Crohn's disease or ulcerative colitis was conducted. Serum creatinine levels and body weight were measured before and after treatment to calculate the creatinine clearance (CrCl) rate. RESULTS: In 171 patients (93 women, 78 men), the mean (+/- SD) dose of 5-ASA was 3.65+/-0.85 g/day with a cumulative dose of 11+/-7.7 kg over an interval of 8.4+/-5.9 years. Serum creatinine concentrations increased from 76.8 micromol/L to 88.7 micromol/L (n=171; P<0.0001) and the CrCl rate fell significantly from 104.6 mL/min to 93.1 mL/min (n=81; P<0.0001). There was one case of interstitial nephritis reported. Treatment groups included mesalamine (74.3%), sulfasalazine (15.2%) and combination (sulfalsalazine/mesalamine [10.5%]) with treatment durations of 7.2+/-4.5, 12.3+/-8.7 and 11.2+/-6.7 years, respectively. The duration of treatment was the most important covariate for change in CrCl and when analyzed by treatment group, those treated with sulfasazine had a strong correlation (r=-0.54, P=0.0145), while nonsignificant in the mesalamine group (r=0.06, P=0.7017). The decline in CrCl was negatively correlated with the pretreatment CrCl rate (r=-0.34; P=0.0024) and positively correlated with the mean daily dose of 5-ASA (r=0.32; P=0.0034). CONCLUSION: The present study is the first to demonstrate a significant dose- and treatment duration-dependant decline in CrCl. The risks need to be further evaluated because 5-ASA is widely used for long-term maintenance therapy in patients with IBD.

Relationship between metabolism and peripheral blood mononuclear cell mitochondrial complex I activity before and after a short-term refeeding in weight-losing cancer patients.

BACKGROUND AND AIMS: Previous investigations showed that mitochondrial complex I activity seems to be a specific marker of dietary malnutrition in human. Since cancer has a more complex etiology than simple calorie deficiency, the aim of this study was to investigate the relationship between mitochondrial complex I activity and cancer. METHODS: Nine cancer patients (CaPs) with weight loss and 14 age-matched healthy volunteers (HVs) were recruited. Body mass index (BMI), body composition as well as resting energy expenditure (REE) and RQ were measured. Mitochondrial complex I activity was measured as described previously in isolated peripheral blood mononuclear cells. Six patients were investigated again after 7 days of refeeding. RESULTS: Weight loss in CaPs was mainly due to a loss of fat mass (FM), while fat-free mass (FFM) was preserved. The RQ was significantly lower in CaPs compared to HVs (P<0.001) and peripheral blood mononuclear cell complex I activity was significantly correlated with the %FM and RQ in CaPs. Furthermore, complex I activity increased significantly after 1 week of refeeding. CONCLUSIONS: Our study showed that mitochondrial complex I activity was inversely correlated to parameters of increased fat oxidation and reduced FM, which are indices of dietary insufficiency rather than loss of lean body mass, which is an index of increased catabolism in cancer.

Enteral and parenteral nutrition: evidence-based approach.

Nutrition support for patients in hospital has become an essential form of therapy. Total parenteral nutrition (TPN) was the preferred way of giving nutrition to hospital patients for many years but enteral nutrition (EN) is now the preferred route. EN is believed to promote gut function and prevent translocation of intestinal bacteria, thus reducing the incidence of sepsis in critically ill patients. In consequence, the use of TPN has been discouraged as a dangerous form of therapy. Critical review of the data suggests that in the human subject TPN does not cause mucosal atrophy or increase translocation of bacteria through the small intestine. However, overfeeding, which is easy with TPN, can explain the results of studies which have shown that TPN increases sepsis. Furthermore, the risks of TPN-induced complications have been exaggerated. When there is risk of malnutrition and EN is not tolerated, or there is gut failure, TPN is an equally effective and safe alternative.

Total parenteral nutrition: potion or poison?

The role of nutritional support in clinical care has burgeoned over the past 40 y. Initially, total parenteral nutri-tion (TPN) was considered to be the standard of care. Later, the concept that enteral nutrition (EN) promoted gut function and prevented the translocation of intestinal bacteria resulted in EN becoming the standard of care. Furthermore, TPN was consid-ered to be a dangerous form of therapy. Critical review of the data suggests that, in humans, TPN does not cause mucosal atrophy or increase bacterial translocation. Increased sepsis with TPN can be ascribed to overfeeding; the dangers of TPN-induced complications have been exaggerated. TPN is an equally effective alternative to EN when a risk of malnutrition is present and EN is not tolerated or when gut failure is present.

Effect of hypoenergetic feeding and refeeding on muscle and mononuclear cell activities of mitochondrial complexes I--IV in enterally fed rats.

BACKGROUND: Previous studies suggested that cell energetics are altered by malnutrition. OBJECTIVE: We hypothesized that nutritional manipulations influence mitochondrial enzyme activities of the electron transport chain in both skeletal muscle and blood mononuclear cells. DESIGN: After a gastrostomy tube was inserted, 44 rats were randomly assigned to 1 of 4 experimental groups: control fed (CF; 364 kJ/d for 7 d), hypoenergetic fed (HF; 92 kJ/d for 7 d), hypoenergetic protein refed (HPR; 92 kJ/d for 7 d and then 129 kJ/d for 1 d), and hypoenergetic glucose refed (HGR; 92 kJ/d for 7 d and then 129 kJ/d for 1 d). The protein and glucose contents of the liquid formulas were different for the HPR and HGR groups. After mitochondria were isolated from the soleus muscle, the activities of complexes I--IV were measured spectrophotometrically. Because of the lack of available tissue, only the activity of complex I was measured in the mononuclear cell extract. RESULTS: The recovery of complex activities in the CF and HF groups was not significantly different in the mitochondrial fraction of the soleus muscle. Compared with that in the CF group, the activities of complexes I--III in the mitochondrial fraction of the soleus muscle and the activity of complex I in mononuclear cells were significantly lower in the HF group. The activities of complexes I--III in the mitochondrial fraction of the soleus muscle and the activity of complex I in mononuclear cells were significantly higher in the HPR than in the HF group. The activity of complex IV was generally not affected by nutritional manipulations. CONCLUSION: Malnutrition decreases activities of mitochondrial complexes, which are restored by protein but not glucose refeeding.

Conditioned nutritional deficiencies in the cardiomyopathic hamster heart.

BACKGROUND: Evidence indicates that nutritional factors may be important in the maintenance of myocyte structure and energetics. The failing myocardium has been reported to exhibit a depletion of several nutrients that are important for the maintenance of intracellular calcium homeostasis and cellular energetics, and levels of oxidative stress. This nutrient depletion may contribute to the progressive deterioration in myocardial structure and function observed in heart failure. OBJECTIVE: To examine the extent to which advanced cardiomyopathy results in a depletion of nutrients and/or metabolites and antioxidants, and whether supplementation with these nutrients may influence cellular structure or function. SUBJECTS AND METHODS: Cardiomyopathic hamsters were randomly placed to one of the three following diet groups: chow; control gelled diet; or a supplemented gelled diet that provided taurine, carnitine, coenzyme Q10, selenium, vitamins E and C, creatine, thiamine and L-cysteine. After approximately three months of supplementation, one group of hamsters underwent functional testing using a modified Langendorff technique with biopsy samples taken for electron microscopy. Myocardial nutrient concentrations were determined in a second group of diseased and nondiseased hamsters of the same age. RESULTS: Cardiomyopathy resulted in a depletion of vitamin E, creatine, carnitine, taurine and coenzyme Q10. Supplementation resulted in improved cardiac ultrastructure, function and contractility compared with nonsupplemented hamsters. CONCLUSIONS: These studies suggest that heart failure results in 'condition-related nutrient deficiencies' that, once corrected, can significantly impact on heart function and structure.

A controlled clinical trial of vitamin E supplementation in patients with congestive heart failure.

BACKGROUND: Oxidative stress is increased in patients with congestive heart failure and can contribute to the progressive deterioration observed in these patients. Increased oxidative stress is the result of either an increased production of free radicals or a depletion of endogenous antioxidants, such as vitamin E. OBJECTIVE: We aimed to determine whether vitamin E supplementation of patients with advanced heart failure would modify levels of oxidative stress, thereby preventing or delaying the deterioration associated with free radical injury. DESIGN: Fifty-six outpatients with advanced heart failure (New York Heart Association functional class III or IV) were enrolled in a double-blind randomized controlled trial for 12 wk. At a baseline visit and at 2 follow-up visits, blood and breath samples were collected for the measurement of indexes of heart function and disease state, including malondialdehyde, isoprostanes, and breath pentane and ethane. Quality of life was also assessed at baseline and after 12 wk of treatment. RESULTS: Vitamin E treatment significantly increased plasma concentrations of alpha-tocopherol in the treatment group but failed to significantly affect any other marker of oxidative stress or quality of life. In addition, concentrations of atrial natriuretic peptide (a humoral marker of ventricular dysfunction), neurohormonal-cytokine markers of prognosis, tumor necrosis factor, epinephrine, and norepinephrine were unchanged with treatment and were not significantly different from those in the control group. CONCLUSION: Supplementation with vitamin E did not result in any significant improvements in prognostic or functional indexes of heart failure or in the quality of life of patients with advanced heart failure.

The tissue distribution of tumor necrosis factor-alpha in rats: a compartmental model.

Tumor necrosis factor (TNF) is widely accepted to be the mediator of the cascade of metabolic abnormalities associated with both critical and chronic illness. TNF binding to cell surface receptors mediates its physiologic actions, although the exact mechanism of TNF action is unknown. Therefore, this study was designed to investigate the in vivo metabolism of TNF using a mathematical model to examine tissue uptake and loss of TNF over time. Two distinct patterns of TNF uptake were observed. Muscle tissues were found to accumulate TNF over the entire experimental period, whereas the visceral organs were found to have a rapid initial accumulation of TNF followed by a rapid loss of TNF back to the plasma or out into the bile or the urine. These patterns of TNF binding and retention may reflect the number of TNF receptors or their affinity for TNF, as well as the balance between cell surface and soluble TNF receptors. Furthermore, TNF binding patterns provide insight into the biologic action of TNF at these sites.

Conditioned nutritional requirements and the pathogenesis and treatment of myocardial failure.

The majority of symptomatic patients with congestive heart failure have been shown to be significantly malnourished. Myocardial and skeletal muscle energy reserves are also diminished. Total daily energy expenditure in these patients is less than that in control individuals, and high protein-calorie feeds do not reverse the abnormalities; thus, the wasting that occurs in patients with congestive heart failure is metabolic rather than because of negative protein-calorie balance. Several specific deficiencies have been found in the failing myocardium: a reduction in the content of L-carnitine, coenzyme Q10, creatine and thiamine, nutrient cofactors that are important for myocardial energy production; a relative deficiency of taurine, an amino acid that is integral to the modulation of intracellular calcium levels; and an increase in myocardial oxidative stress, and a reduction of both endogenous and exogenous antioxidant defences. In addition, these processes may influence skeletal muscle metabolism and function. Cellular nutritional requirements conditioned by metabolic abnormalities in heart failure are important considerations in the pathogenesis of the skeletal and cardiac muscle dysfunction. A comprehensive restoration of adequate myocyte nutrition would seem to be essential to any therapeutic strategy designed to benefit patients suffering from this disease.

Nutritional and metabolic effects of the endotoxin bacterial lipopolysaccharide in orally and parenterally fed rats.

BACKGROUND: Animals treated with tumor necrosis factor alpha (TNF-alpha) developed severe metabolic abnormalities despite receiving sufficient protein and energy by total parenteral nutrition (TPN). OBJECTIVE: We sought to investigate the nutritional and metabolic effects of bacterial lipopolysaccharide (LPS) in rats. DESIGN: Rats were randomly allocated to 5 groups: oral nutrition (ON control; n = 7), TPN control (n = 7), ON+LPS (n = 6), TPN+LPS (n = 9), and pair fed (PF) in relation to ON+LPS (n = 6). RESULTS: Body weight decreased significantly as diet consumption decreased in the ON+LPS and PF groups compared with the ON control group. Relative carcass weights were significantly lower in the TPN+LPS and ON+LPS groups than in their respective control groups. Diaphragm and extensor digitorum longus weights were significantly lower in the ON+LPS and PF rats, but not in the TPN+LPS rats, compared with their respective controls. Biochemical abnormalities and plasma corticosterone concentrations were greater in the TPN+LPS group than in the other groups. CONCLUSIONS: These data suggest that provision of sufficient protein and energy by TPN does not prevent general carcass wasting induced by LPS but may protect individual muscles. However, compared with an oral ad libitum diet, TPN providing sufficient protein and energy worsens the biochemical abnormalities induced by LPS. More rapid clearance of TNF-alpha and low corticosterone concentrations in weight-losing animals may help reduce the severity of the metabolic effects of LPS.