Joint action malnutrition in the elderly (MaNuEL) knowledge hub: summary of project findings.

PURPOSE: The Joint Action Malnutrition in the Elderly (MaNuEL) Knowledge Hub was established to extend scientific knowledge, strengthen evidence-based practice, build a sustainable, transnational network of experts and harmonize research and clinical practice in the field of protein-energy malnutrition in older persons. This paper aims to summarize the main scientific results achieved during the 2-year project and to outline the recommendations derived. METHODS: 22 research groups from seven countries (Austria, France, Germany, Ireland, Spain, The Netherlands and New Zealand) worked together on 6 relevant domains of malnutrition-i.e. prevalence, screening, determinants, treatment, policy measures and education for health care professionals-making use of existing datasets, evidence and expert knowledge. RESULTS: Four systematic reviews, six secondary data analyses of existing cohort and intervention studies, two web-based surveys and one Delphi study were performed. In addition, a scoring system to rate malnutrition screening tools and a theoretical framework on the aetiology of malnutrition in older persons were developed. Based on these activities and taking existing evidence into consideration, 13 clinical practice, 9 research and 4 policy recommendations were developed. The MaNuEL Toolbox was created and made available to effectively distribute and disseminate the MaNuEL results and recommendations. CONCLUSIONS: The MaNuEL Knowledge Hub successfully achieved its aims. Results and recommendations will support researchers, healthcare professionals, policy-makers as well as educational institutes to advance their efforts in tackling the increasing problem of protein-energy malnutrition in the older population.

Subjective and objective taste and smell changes in cancer.

CONTEXT: Malnutrition is highly prevalent in cancer patients and an important predictor of morbidity, mortality, treatment response, and toxicity. Taste and smell changes (TSCs) are common and may contribute to malnutrition. Research has previously focused on patients receiving chemotherapy (CT) or head and neck radiotherapy (RT). However, TSCs may occur pre-treatment, with other treatment modalities, and in cancer survivors. This review evaluates objective and subjective assessment of taste and smell, discusses the prevalence of TSCs in cancer, and reviews the clinical sequelae of TSCs in cancer patients. OBJECTIVES: To critically evaluate objective and subjective assessment of TSCs, and the prevalence and clinical sequelae of TSCs in cancer. METHODS: A literature search was conducted using PubMed, CINAHL and Embase for English-language articles published January 2009-June 2016. Search terms included combinations of the following: chemosensory, taste, smell, cancer, chemotherapy, radiotherapy, hormone therapy, immunotherapy, survivors. Reference lists of articles retrieved were also reviewed. RESULTS: Variation in objective and subjective assessment methodologies has resulted in difficulties interpreting the literature. TSC prevalence varies depending on stage of disease and treatment regimens, from 16% to 70% and 50% to 70% during CT and RT, respectively. TSCs in patients who are treatment-naïve, receiving hormone or immunotherapy treatment, post-treatment and cancer survivors have not been adequately studied. TSCs are associated with impaired nutritional status. The relationship between cancer-associated symptoms and nutritional status is not clearly defined. CONCLUSION: There is no gold standard assessment tool for TSCs. Heterogeneity in study methods hinders conclusive identification of the most appropriate way to measure TSCs. Subjective measures may reflect the patient experience and more reliably predict changes in dietary behaviour. Evaluation of TSCs should form part of all nutritional assessments in cancer patients. The true prevalence and severity of TSCs at all stages of cancer could then be established.

Subjective taste and smell changes in treatment-naive people with solid tumours.

PURPOSE: Taste and smell changes (TSCs) are common in head and neck (H&N) cancer and during and after chemotherapy (CT) and radiotherapy (RT). It is an area that has been under-investigated, particularly in the treatment-naive, but can negatively impact nutritional status. This study examined the prevalence, severity and characteristics of TSCs in people with non-H&N solid tumours, before CT and RT, and their relationship with co-occurring symptoms. METHODS: A prospective, observational study was conducted. Forty consecutive pre-treatment cancer patients, referred to radiation oncology outpatients over 6 weeks, were recruited. Data on TSCs, symptoms and nutritional status were obtained using the 'Taste and Smell Survey' and the 'abridged Patient-Generated Subjective Global Assessment' (abPG-SGA). BMI was measured. SPSS® was used for statistical analysis. Two-sided P values <0.05 were considered statistically significant. RESULTS: Most patients were newly diagnosed (n = 28; 70 %). Nineteen (48 %) reported TSCs; nine noted a stronger sweet and seven a stronger salt taste. Of these, four reported a stronger and four a weaker smell sensation. Those at nutritional risk reported more TSCs (n = 13/20). TSCs were significantly associated with dry mouth (P < 0.01), early satiety (P < 0.05) and fatigue (P < 0.05). CONCLUSIONS: TSCs preceded CT or RT in almost half of treatment-naive patients with solid tumours, notably stronger sweet and salt tastes. Half of the study group were at nutritional risk; the majority of these reported TSCs. TSCs were significantly associated with other symptoms. Future research and clinical guidelines, with a common terminology for assessment, diagnosis and management of cancer TSCs, are needed.

A dietary survey of patients with irritable bowel syndrome.

BACKGROUND: Food is one of the most commonly reported triggers of irritable bowel syndrome (IBS) symptoms. However, the role of diet in the aetiology and management of IBS has not been clearly established. The present study aimed to examine the dietary practices of Irish patients with IBS and to determine whether these practices increased their vulnerability to nutritional inadequacies. METHODS: A questionnaire was completed by 135 IBS patients on their perceptions of the role of diet in their symptoms and whether they restrict their diet according to the symptoms experienced. A similar questionnaire was used to investigate the perceptions of 111 healthy subjects to the gastrointestinal symptoms experienced on the consumption of food. RESULTS: Food was considered to cause or worsen their gastrointestinal symptoms in 89.6% of IBS patients compared to 55% of healthy subjects (P < 0.001). Cereal-based foods, predominantly bread or its components, were the most frequently cited (53.3%), and spicy foods (39.3%), vegetables and fatty foods (35.6% for both) also featured prominently. A significantly greater number of patients with IBS reported changing their diet to minimise symptoms compared to healthy controls (91.9% versus 45.5%, P < 0.001). In relation to whole food groups, milk products (9.6%), fruit (7.4%) and vegetables (5.2%) were those most commonly restricted, with only a small number of IBS patients seeking professional healthcare advice. CONCLUSIONS: The majority of IBS patients consider their symptoms to be related to food, and change their diet by limiting the foods that they perceive as problematic, with some restricting whole food groups. Few patients sought professional healthcare advice when implementing dietary change, possibly exposing a considerable number to an increased risk of nutritional deficiency.

Reducing preoperative fasting in elective adult surgical patients: a case-control study.

BACKGROUND: The practice of fasting from midnight prior to surgery is an outdated one. AIMS: The aim of this study was to assess the impact of an evidence-based protocol for reduced preoperative fasting on fasting times, patient safety, and comfort. METHODS: A non-randomised case-control study of preoperative fasting times among adult surgical patients undergoing elective procedures was conducted. Consecutive patients were allocated to a reduced preoperative fasting protocol allowing fluids and solids up to 2 and 6 h prior to anaesthesia, respectively (n = 21). These were compared to control patients identified from an historic study of preoperative fasting times who followed the traditional fast from midnight (n = 29). Fasting times and details of patients' subjective comfort were collected using an interview-assisted questionnaire. Incidence of intraoperative aspirations was obtained from anaesthetic records. RESULTS: Significant reductions in fasting times for fluids (p = 0.000) and solids (p = 0.000) were achieved following implementation of the fasting protocol. Less preoperative thirst (0.000), headache (0.012) and nausea (0.015) were reported by those who had a shorter fast. Intraoperative aspiration did not occur in either group. CONCLUSION: Implementation of this protocol for reduced preoperative fasting achieved an appreciable reduction in fasting times and enhanced patient comfort. Patient safety was not compromised. Further modifications of our protocols are necessary to meet the international best practice. We recommend its implementation across all surgical groups in our institution.

Sustained benefits of a community dietetics intervention designed to improve oral nutritional supplement prescribing practices.

BACKGROUND: Healthcare professionals working in the community do not always prescribe oral nutritional supplements (ONS) according to best practice guidelines for the management of malnutrition. The present study aimed to determine the impact of a community dietetics intervention on ONS prescribing practices and expenditure 1 year later. METHODS: The intervention involved general practitioners (GPs), practice nurses, nurses in local nursing homes and community nurses. It comprised an education programme together with the provision of a new community dietetics service. Changes in health care professionals' nutrition care practices were determined by examining community dietetics records. ONS prescribing volume and expenditure on ONS were assessed using data from the Primary Care Reimbursement Service of the Irish Health Service Executive. RESULTS: Seven out of 10 principal GPs participated in the nutrition education programme. One year later, screening for malnutrition risk was better, dietary advice was provided more often, referral to the community dietetics service improved and ONS were prescribed for a greater proportion of patients at 'high risk' of malnutrition than before (88% versus 37%; P < 0.001). There was a trend towards fewer patients being prescribed ONS (18% reduction; P = 0.074) and there was no significant change in expenditure on ONS by participating GPs (3% reduction; P = 0.499), despite a 28% increase nationally by GPs on ONS. CONCLUSIONS: The community dietetics intervention improved ONS prescribing practices by GPs and nurses, in accordance with best practice guidelines, without increasing expenditure on ONS during the year after intervention.

Nutritional practices in full-day-care pre-schools.

BACKGROUND: Full-day-care pre-schools contribute significantly to the nutritional intake and acquisition of dietary habits of the pre-school child. The present study investigated nutritional practices in full-day-care pre-schools in Dublin, Ireland, aiming to determine the nutritional support that pre-school managers deem necessary, thereby facilitating the amelioration of existing pre-school nutritional training and practices. METHODS: A telephone questionnaire completed by pre-school managers (n=54) examined pre-school dietary practices, food provision and the association between these and pre-school size, nutritional training attendance, possession of the Food and Nutrition Guidelines for Pre-school Services and having a healthy eating policy. Nutritional training needs were also investigated. RESULTS: Twenty-five pre-schools provided all food for attending children; parents were sole providers in six. Thirty-four pre-schools had a written healthy eating policy. Attendance at nutritional training was reported by 40. Possession of the Guidelines (n=40) did not consistently result in their use. Poor parental and staff involvement in policy and menu development was cited. Although the delayed introduction of iron-containing foods and a feeding beaker in infants was clearly evident, inappropriate beverages and snacks were served to children aged 1-5 years in 43 and 37 pre-schools, respectively. Training priorities cited by managers included parental education and the provision of information regarding menu planning and healthy food choices. CONCLUSIONS: Nutritional training should advocate whole staff familiarity with and use of current guidelines, in addition to encouraging nutritional policy development and enforcement. Parental education is warranted. Dietary education should focus specifically on appropriate weaning practices, healthy beverage and snack provision and menu planning.

Nutritional status of Irish older people in receipt of meals-on-wheels and the nutritional content of meals provided.

BACKGROUND: Research has suggested that meals-on-wheels recipients can be at risk for poor nutritional status. Despite this, few countries have statutory minimum requirements for the nutrient content of meals-on-wheels. This study examined both the nutritional status of a sample of Irish recipients and the nutrient content of a sample of meals provided to determine whether Irish recipients would benefit from statutory minimum nutritional standards. METHODS: The study had two phases. First, a nutritional assessment was carried out to analyse the nutritional status of a sample of Irish meals-on-wheels recipients (Mini Nutritional Assessment and 24-h dietary recall with 63 self-selected respondents). Second, an assessment of the nutrient content of a sample of 46 meals from eight meals-on-wheels services was undertaken to characterise the nutritional content of the meals. RESULTS: Over one-third of recipients (38.5%) were malnourished or at-risk of malnutrition and over half (52.3%) were overweight or obese. The mean (SD) energy [kJ (kcal)] content of the meals assessed was 3008 (498) kJ [719 (119.1) kcal], contributing 35-40% of the recommended dietary allowance (RDA) for males aged 65 years and over and 42-45% of the RDA for females aged 65 years and over. In the meals assessed, the levels of vitamin C (25.3%), vitamin D (11.6%), folate (24.8%) and calcium (20.9%) were below one-third of the Irish RDA for these nutrients. CONCLUSIONS: Irish recipients may not be receiving adequate micronutrients from meals-on-wheels. Legislation that sets out minimum standards for the nutrient content of meals-on-wheels and greater variation in the portion sizes offered may benefit recipients.

Comparison of nutritional risk screening tools in patients on admission to hospital.

BACKGROUND AND AIMS: Under nutrition has been frequently reported in patients on admission to hospital. Because this is not always detected promptly, screening for nutritional risk on admission has been widely advocated. Although there is no universally accepted 'gold standard' for defining undernutrition, the definition used by McWhirter, J.P. & Pennington, C.R. [(1994) Br. Med. J.308, 945] has been widely used by clinical nutrition specialists. This study aimed to compare the efficacy of two frequently used nutritional risk screening tools in detecting undernutrition according to this definition. METHODS: Both the Nutrition Risk Index [Veterans Affairs Total Parenteral Nutrition Co-operative Study Group (1991) N. Engl. J. Med.325, 525] and the Nutrition Risk Score [Reilly H.M. et al. (1995) Clin. Nutr.14, 269] were used to screen for undernutrition in 359 admissions to two acute teaching hospitals in Dublin. Undernutrition was defined as a Body Mass Index below 20 kg m(-2) and a triceps skinfold thickness or mid-arm muscle circumference below the 15th percentile. Comparison of stratification of nutritional risk by the two screening tools was carried out. RESULTS: Both screening tools identified over 40% (Nutrition Risk Index, 44%; Nutrition Risk Score, 46%) of all patients assessed as at nutritional risk on admission. However, one-third of the undernourished patients were classified as at no nutrition risk by the Nutrition Risk Index, while almost one-fifth of those undernourished were classified as at low risk by the Nutrition Risk Score. The degree of nutritional risk differed with the screening tool used, the Nutrition Risk Score classifying 29% of all patients as high risk while the Nutrition Risk Index classified only 5% as in the high risk category. CONCLUSIONS: Although a large proportion of patients on admission were classified as being at nutritional risk, the degree of risk was significantly different depending on the screening tool used. Both nutritional risk screening tools evaluated in this study failed to recognize many cases of undernutrition. Evaluation of the efficacy of nutritional screening tools should be promoted as seriously as the development of such tools.

Pre-operative nutritional assessment in the elderly.

Nutritional depletion has been frequently documented in adult surgical patients admitted to hospital with nutritional status being known to deteriorate over the course of the hospital stay. In the elderly in particular, undernutrition has serious implications for health and for recovery from illness or surgery. This, in turn, has cost implications for the health service and the efficient distribution of health care. Because nutritional depletion is often insidious, nutritional problems frequently go unrecognised and untreated. Nutritional screening and assessment of nutritional status should therefore form an essential part of the health care of any elderly patient who requires surgical intervention. This paper aims to review the screening and assessment techniques currently available and their applicability to the elderly surgical patient.

Apparent low frequency of undernutrition in Dublin hospital in-patients: should we review the anthropometric thresholds for clinical practice?

Protein-energy undernutrition, or the possibility of its development, has been documented to occur frequently in patients on admission to hospital. Deterioration in nutritional status is known to occur in hospital. In a prospective study of 594 sequential hospital admissions, we aimed to assess the prevalence of undernutrition among patients on admission to two acute teaching hospitals in Dublin, Republic of Ireland using the widely-accepted anthropometric criteria applied in a large study from Dundee, Scotland, UK (McWhirter & Pennington, 1994) and to determine changes in nutritional status in hospital. The mean prevalence of undernutrition (11 %) was considerably lower than was reported from Dundee (40 %). Unintentional weight loss before admission and functional impairment on admission occurred to a similar extent in both centres. Weight loss in hospital occurred in the same proportion of patients, but less frequently among those undernourished on admission to hospital, in Dublin compared with Dundee. The patients found to be undernourished on admission in this study had a mortality rate in hospital (6.5 %) over three times that of the adequately nourished group (2 %). The magnitude of the difference in prevalence of undernutrition between the two centres cannot be explained by ethnicity, case-mix or age distribution. With the secular increase in BMI in the population, the thresholds for classifying patients as undernourished or at risk of nutritional deterioration may need to be reviewed. For clinical use, recent weight loss and functional status may be more appropriate variables to use in the evaluation of nutritional status on admission to hospital.

Protein-energy undernutrition in hospital in-patients.

Impaired nutritional status has been frequently reported in surveys estimating its prevalence amongst patients in hospital. While there is no doubt that protein-energy undernutrition has serious implications for health, recovery from illness or surgery and hospital costs, lack of nationally or internationally accepted cut-off points and guidelines for most nutrition-related variables make nutritional assessment difficult and proper comparisons between studies impossible. In reviewing published work in which the prevalence of undernutrition has been assessed, it can be seen that each study defined undernutrition, or nutritional risk, using different methodology. This present review aims to highlight the problems which arise when deciphering these studies, and the resulting difficulty in determining the true prevalence of undernutrition and nutritional risk, amongst both general and specific groups of hospital in-patients. It is widely agreed that routine hospital practices can further adversely affect the nutritional status of sick patients in hospital. How this occurs, and the potential effects of impaired nutritional status on clinical outcome are examined. The methods currently available to assess nutritional status are evaluated in the knowledge that such assessments are difficult in clinical practice. The review concludes by proposing that if we want the medical and nursing professions to consider the nutritional status of hospital patients seriously, definitions of undernutrition and nutritional risk, and cut-off values for the nutritional variables measured must be agreed to allow evidence-based practice. Outcome measures which allow clear comparisons between groups and treatments must be used in studies assessing the effects of nutritional interventions.

Pre-operative nutritional assessment.

Protein-energy undernutrition, or the possibility of its development, has been documented to occur frequently in surgical patients admitted to hospital. Nutritional status is known to deteriorate over the course of the hospital stay, with poor awareness by medical and nursing staff as to the deleterious effects of impaired nutritional status on clinical outcome and hospital costs. While there is no consensus on the best method for assessment of the nutritional status of surgical patients pre-operatively, there are a number of techniques available. These techniques can be divided into two types, those suitable for screening for nutrition risk on admission to hospital and those used to fully assess nutritional status. Both techniques have their limitations, but if used correctly, and their limitations recognized, should identify the appropriate degree of nutritional intervention for an individual patient in a timely and cost-effective manner. The techniques currently available for nutritional screening and nutritional assessment are reviewed, and their applicability to the Irish setting are discussed in the present paper.

Cardiac surgery and women.

Coronary heart disease is just as serious a problem for women as it is for men, yet historically women have been significantly underrepresented in research studies related to the disease and treatment options, including cardiac surgery. Cardiac surgery is a proven therapy for the management of coronary heart disease in women. Research addressing the physical, psychosocial, and emotional issues women face during the preoperative, postoperative, and recovery phases of surgery is limited. Nurses play a pivotal role in the education and management of women undergoing cardiac surgery and need to be aware of unique issues related to the experience. This article reviews the literature pertaining to women's issues during the perioperative and recovery phases of cardiac surgery.

Dietary intakes in Ireland of a healthy elderly population.

The aim of this paper is to assess the adequacy of the diet of individuals over 60 yr of age, participating in the 1990 Irish National Nutritional Survey. A nationwide random sample based on the most recently updated electoral register was used. Demographic information was collected. Anthropometric measurements were taken and nutrient intake was assessed using the 7-day dietary history method. The randomly selected sample of 1213 subjects was considered to be representative of the Irish population. Of those selected, 163 individuals were over 60 yr of age, 79 of whom were male and 84 female. Mean energy intakes including alcohol for males and females were 9.55 +/- 3.09MJ and 7.07 +/- 2.39MJ respectively. The main sources of energy were bread, meat and meat products, potatoes and milk. As percentage energy, protein, fat and carbohydrate intakes were 14.90 per cent, 33.97 per cent and 48.22 per cent for men and 15.39 per cent, 34.09 per cent and 49.37 per cent for women respectively. Except for vitamin D and folate, micronutrient intakes were adequate. The body mass index (BMI [weight/height2] kg/m2) for men was 25.6 and for women 26.4. Fewer than 27.8 per cent of the males and 20.2 per cent of females take part in regular physical activity. In conclusion, the diet of a healthy elderly population in Ireland is nutritionally adequate with macronutrient intake in keeping with the recommended guidelines. Overall energy intakes are lower than those of a younger age group and may account for the lower intakes of certain micronutrients. An increase in fruit and vegetable consumption would improve vitamin and mineral intake. In order to allow for a higher energy intake an increase in physical activity is desirable.

Evaluation of lifestyle, food consumption and nutrient intake patterns among Irish teenagers.

Lifestyle, food consumption and nutrient intake patterns from a randomly selected group of 390 secondary pupils aged between 12-18 were evaluated. Demographic information and anthropometric measurements included weight, height, and skinfold thickness were taken. Nutrient intake was assessed using the 7-day dietary history method, using a photographic atlas as an aid. Mean energy intakes for boys and girls aged 12-15 and 15-18 were 11.3MJ and 14MJ and 9.1MJ and 8.9MJ respectively. As percentage energy, protein fat and carbohydrate intakes varied little between the different age-sex groupings and were approximately 13.7-14.5, 35.4-37 and 46.8-50 per cent respectively. For boys micronutrient intake for iron and folate achieving only 83 and 78 per cent and 98 and 90 per cent of the recommended nutrient intake (R.N.I.) for ages 12-15 and 15-18 respectively. Mean dietary fibre intakes were approximately 19.6-25g/day for boys aged 12-18 and 17g/day for girls of a similar age. The main sources of energy were bread, meat and meat products, potatoes/chips, confectionery and preserves. Fruit and vegetable consumption was low for all groups. The majority of those surveyed consumed the traditional main meals. Snacking was also common practice. The snack foods consumed were generally of a high fat/high sugar content. 1.1 per cent boys and 2.6 per cent of girls aged 12-15 and 5.5 per cent and 8.2 per cent of boys and girls aged 15-18 respectively had a BMI greater than 26 indicating a risk of overweight. Greater than 68 per cent of girls and 79.5 per cent of boys surveyed participated in some form of sport. Boys were more physically active than girls and older girls less active than younger. In conclusion, changes from present day practices would be beneficial to reduce incidence of chronic disease for present day teenagers.

Nutrition and liver disease.

Although the normal liver has considerable ability to regenerate, advanced liver disease can significantly reduce this ability. In compensated liver disease, all efforts should be made to maintain nutrition status. In decompensated liver disease, symptoms of decompensation may require therapeutic dietetic intervention. Early nutrition assessment and dietetic intervention in the management of malnutrition, ascites, encephalopathy, and esophageal varices are mandatory and have shown reduced morbidity and mortality in these patients.