[The role of dietitian in cardiac rehabilitation and secondary prevention]. / Ruolo del dietista nella riabilitazione e prevenzione secondaria cardiologica.

Rehabilitation and secondary prevention programs are recognized as an essential part of the overall care of patients with cardiovascular disease. They consist of multidisciplinary strategies aiming at the reduction of modifiable risk factors for cardiovascular disease. There are some evidence of the efficacy of nutritional care in modifying eating habits and behavior in patients undergoing cardiac rehabilitation. In 2007, the Italian Association of Dietitians (ANDID) appointed a working group of dietitians, skilled in nutrition applied in cardiovascular disease, with the aim to make an overview of the available scientific literature and to develop a Professional Position Paper on the role of Dietitian in cardiac rehabilitation and secondary prevention. The first Position Paper, developed in 2008, covered the available evidence about the dietitian professional role and contribution in the management of the topic. The working group has recently updated the contents by introducing, in agreement with the work done by ANDID, the methodology of the Nutrition Care Process and Model (NCP), a systematic problem-solving method intended to stimulate critical thinking, decision-making and address issues related to food and nutritional assistance, in order to provide a safe, effective and high quality care.

[First definition of minimal care model: the role of nurses, physiotherapists, dietitians and psychologists in preventive and rehabilitative cardiology]. / Documento preliminare alla definizione degli interventi Minimal Care infermieristici, fisioterapici, dietistici e psicologici attuabili nell'ambito della Cardiologia Riabilitativa e Preventiva.

Rehabilitative and preventive cardiology (CRP) is configured as intervention prevention to "gain health" through a process of multifactorial care that reduces disability and the risk of subsequent cardiovascular events. It makes use of an interdisciplinary team in which every professional needs to have multiple intervention paths because of the different levels of clinical and functional complexity of cardiac patients who currently have access to the rehabilitation. The document refers to the use of interventions by nurses, physiotherapists, dietitians and psychologists that are part of the rehabilitation team of CRP. Interventions of which have been documented, on scientific bases and clinical practice, empirical effectiveness and organizational efficiency. The methodological approach of this paper is a first attempt to define, through the model of consensus, the minimum standards for a CRP evidence based characterized by clearly defined criteria that can be used by operators of CRP. The document describes the activities to be carried out in each of the phases included in the pathways of care by nurses, physiotherapists, dietitians and psychologists. The routes identified were divided, according to the type of patients who have access to the CRP and to the phases of care, including the initial assessment, intervention, evaluation and final reporting, in high medium and low complexity. Examples of models of reporting, used by the operators of the team according to the principles of good clinical practice, are provided. This is made to allow traceability of operations, encourage communication inside the working group and within the patient and the caregiver. Also to give any possible indication for the post-rehabilitation.

The Assessment of the Risk of Malnutrition (Undernutrition) in Stroke Patients.

Malnutrition is common in stroke patients, as it is associated with neurological and cognitive impairment as well as clinical outcomes. Nutritional screening is a process with which to categorize the risk of malnutrition (i.e., nutritional risk) based on validated tools/procedures, which need to be rapid, simple, cost-effective, and reliable in the clinical setting. This review focuses on the tools/procedures used in stroke patients to assess nutritional risk, with a particular focus on their relationships with patients' clinical characteristics and outcomes. Different screening tools/procedures have been used in stroke patients, which have shown varying prevalence in terms of nutritional risk (higher in rehabilitation units) and significant relationships with clinical outcomes in the short- and long term, such as infection, disability, and mortality. Indeed, there have been few attempts to compare the usefulness and reliability of the different tools/procedures. More evidence is needed to identify appropriate approaches to assessing nutritional risk among stroke patients in the acute and sub-acute phase of disease or during rehabilitation; to evaluate the impact of nutritional treatment on the risk of malnutrition during hospital stay or rehabilitation unit; and to include nutritional screening in well-defined nutritional care protocols.

Relationship between Nutritional Risk, Clinical and Demographic Characteristics, and Pressure Ulcers in Patients with Severe Acquired Brain Injuries Attending a Rehabilitative Program.

Preliminary evidence in the literature suggests a high prevalence of malnutrition (undernutrition) in patients with severe acquired brain injuries (sABI), with an expected negative impact on clinical outcomes and pressure ulcers (PUs) in particular. In a retrospective cohort study on patients discharged from intensive care units (ICU) and admitted to an intensive rehabilitation unit (IRU), the risk of malnutrition was systematically assessed, in addition to standard clinical procedures (including PUs evaluation), using two different tools: the Malnutrition Universal Screening Tool (MUST) and the Controlling Nutritional Status (CONUT) tool. Eighty-eight patients were included in the analysis. A high proportion (79.5%) of patients with sABI suffered from PUs, being older and more frequently men, with a longer ICU stay between the event and admission to IRU, and a greater MUST score. At discharge, when compared to patients whose PUs had healed, those with persisting PUs were more often men and had the worst cognitive performance at admission. As for nutritional risk, the baseline CONUT score was identified as an independent negative predictor of PUs at discharge by the logistic regression model. In conclusion, the assessment of nutritional risk using simple standard tools may be useful in the clinical evaluation of sABI patients with PUs.

[Mediterranean diet: not only food]. / Dieta mediterranea: non solo cibo.

The proposal of a Mediterranean way of life is much more than advise how to eat. The Mediterranean Diet, a model of Sustainable Diet, is an example of how to combine personal choices, economic, social and cultural rights, protective of human health and the ecosystem. There is in fact fundamental interdependence between dietary requirements, nutritional recommendations, production and consumption of food. In literature studies and nutritional and epidemiological monitoring activities at national and international level have found a lack of adherence to this lifestyle, due to the spread of the economy, lifestyles of the Western type and globalization of the production and consumption. To encourage the spread of a culture and a constant practice of the Mediterranean Diet, there are some tools that are presented in this article. The Mediterranean Diet Pyramid in addition to the recommendations on the frequency and portions of food, focuses on the choice of how to cook and eat food. The "Double Food Pyramid" encourages conscious food choices based on "healthy eating and sustainability. All the nutrition professionals and dietitians in particular should be constantly striving to encourage the adoption of a sustainable and balanced nutrition.

Predictors of Function, Activity, and Participation of Stroke Patients Undergoing Intensive Rehabilitation: A Multicenter Prospective Observational Study Protocol.

Background: The complex nature of stroke sequelae, the heterogeneity in rehabilitation pathways, and the lack of validated prediction models of rehabilitation outcomes challenge stroke rehabilitation quality assessment and clinical research. An integrated care pathway (ICP), defining a reproducible rehabilitation assessment and process, may provide a structured frame within investigated outcomes and individual predictors of response to treatment, including neurophysiological and neurogenetic biomarkers. Predictors may differ for different interventions, suggesting clues to personalize and optimize rehabilitation. To date, a large representative Italian cohort study focusing on individual variability of response to an evidence-based ICP is lacking, and predictors of individual response to rehabilitation are largely unexplored. This paper describes a multicenter study protocol to prospectively investigate outcomes and predictors of response to an evidence-based ICP in a large Italian cohort of stroke survivors undergoing post-acute inpatient rehabilitation. Methods: All patients with diagnosis of ischemic or hemorrhagic stroke confirmed both by clinical and brain imaging evaluation, admitted to four intensive rehabilitation units (adopting the same stroke rehabilitation ICP) within 30 days from the acute event, aged 18+, and providing informed consent will be enrolled (expected sample: 270 patients). Measures will be taken at admission (T0), at discharge (T1), and at follow-up 6 months after a stroke (T2), including clinical data, nutritional, functional, neurological, and neuropsychological measures, electroencephalography and motor evoked potentials, and analysis of neurogenetic biomarkers. Statistics: In addition to classical multivariate logistic regression analysis, advanced machine learning algorithms will be cross-validated to achieve data-driven prognosis prediction models. Discussion: By identifying data-driven prognosis prediction models in stroke rehabilitation, this study might contribute to the development of patient-oriented therapy and to optimize rehabilitation outcomes. Clinical Trial Registration: ClinicalTrials.gov, NCT03968627. https://www.clinicaltrials.gov/ct2/show/NCT03968627?term=Cecchi&cond=Stroke&draw=2&rank=2.

[Validation of the Italian version of the questionnaire on nutrition knowledge by Moynihan]. / Validazione della versione italiana del questionario di Moynihan sulle conoscenze alimentari.

BACKGROUND AND AIMS: A series of validation studies was performed on the Moynihan questionnaire to obtain data on nutrition knowledge, translated and adapted to Italian eating habits. Higher scores mean lower knowledge. METHODS: Test-retest reliability was assessed administering the questionnaire at a 15-day interval in 52 inpatients. Factor structure and correlation with demographic and anthropometric characteristics were studied on a larger sample, which included a number of health professionals. Finally, sensitivity to change induced by an educational program was verified in a sample of 11 patients with type 1 diabetes. RESULTS: Test-retest reliability was satisfactory; factor structure suggested one single principal component. Test scores were inversely correlated with age (r = 0.24; p = 0.02), but not with body mass index or waist circumference. Patients with higher education show a greater degree of nutrition knowledge. Among type 1 diabetic patients, an educational program induces a significant improvement of test scores (from 20.6 [18.6-22.8] to 16.6 [15.5-17.7], p = 0.003). CONCLUSIONS: The Italian version of the questionnaire appears to be psychometrically adequate for its use in clinical research.

Effect of Mediterranean Diet Enriched in High Quality Extra Virgin Olive Oil on Oxidative Stress, Inflammation and Gut Microbiota in Obese and Normal Weight Adult Subjects.

Introduction: The Mediterranean Diet (MD) is useful in the prevention of overweight, obesity and metabolic disease. High Quality-Extra Virgin Olive Oil (HQ-EVOO), an essential component of this diet, exerts protective effects against chronic diseases. Gut Microbiota (GM), recognized as a key factor in driving metabolic activities, is involved in the regulation of host immunity. Lactic Acid Bacteria (LAB) and their probio-active cellular substances produce beneficial effects in the gastrointestinal tract. Materials and Methods: Eighteen overweight/obese subjects (cases, BMI ≥25 kg/m2) and 18 normal weight controls (BMI 18.5-24.9 kg/m2) were fed with MD enriched with 40 g/die HQ-EVOO for three months. Feces and blood samples were collected at time 0 (T0) and after three months (T1) for LAB composition, oxidative stress, metabolic and inflammation parameter determinations. Results: Myeloperoxidase and 8-hydroxy-2-deoxyguanosine, markers of inflammation and oxidative stress, were significantly decreased after MD rich in HQ-EVOO both in controls and in cases. Proinflammatory cytokines levels were significantly decreased in cases in comparison to controls, while IL-10 and adiponectin were significantly increased in cases. LAB's rpoB copies/ng of DNA increased 55.6 folds in cases compared to their baseline after MD rich in HQ-EVOO. MD rich in HQ-EVOO increased adiponectin and IL-10 concentration in overweight/obese subjects and decreased oxidative stress and inflammation parameters and at the same time, increased LAB number in GM. Discussion: Our results indicate that MD rich in HQ-EVOO induces an increase of LAB in GM and could have a potential role in the prevention of inflammation. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03441802.

[The role of dietitian in cardiac rehabilitation and prevention]. / Ruolo del dietista nella riabilitazione e prevenzione cardiologica.

Rehabilitation and secondary prevention programs are recognized as an essential part of the overall care of patients with cardiovascular disease. They consist of multidisciplinary strategies aiming at the reduction of modifiable risk factors for cardiovascular disease. Cardiac rehabilitation includes non-pharmacological interventions as: Patients' evaluation. Nutritional counseling. Risk factors management (serum lipids, blood pressure, weight, diabetes, smoking). Psychosocial interventions. Physical activity and cardiovascular physical training counseling. Their effectiveness in the reduction of mortality through the decrease of risk factors has been proven in the last twenty years. Guidelines on appropriate and well-framed interventions have been released and nutritional interventions have a ringside seat in all programs. During 2007, the Italian Association of Dietitians, ANDID, created a working group of expert dietitians, with the goals of making a review of available scientific literature and of elaborating a Professional Position Papers on the role of Dietitian in cardiac rehabilitation and prevention. This Position Paper retrieves and remarks the available evidence that are important for the dietitians, according to their professional role and their contribution in the management of the topic.

What constitutes the 'Minimal Care' interventions of the nurse, physiotherapist, dietician and psychologist in Cardiovascular Rehabilitation and secondary prevention: A position paper from the Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology.

BACKGROUND: In cardiovascular prevention and rehabilitation, care activities are carried out by different professionals in coordination, each with their own specific competence. This GICR-IACPR position paper has analysed the interventions performed by the nurse, physiotherapist, dietician and psychologist in order to identify what constitutes minimal care, and it lists the activities that are fundamental and indispensable for each team member to perform in clinical practice. RESULTS: In analysing each type of intervention, the following dimensions were considered: the level of clinical care complexity, determined both by the disease and by environmental factors; the 'area' complexity, i.e. the specific level of competence required of the professional in each professional section; organisational factors, i.e. whether the care is performed in an inpatient or outpatient setting; duration of the rehabilitation intervention. The specific contents of minimal care have been identified for each professional area together with the specific goals, the assessment tools and the main essential interventions. For the assessments, only a few validated tools have been indicated, leaving the choice of which instrument to use to the individual professional based on experience and usual practice. CONCLUSION: For the interventions, attention has been focused on conditions of major complexity requiring special care, taking into account the different care settings, the clinical conditions secondary to the disease event, and the distinct tasks of each area according to the operator's specific role. The final report performed by each professional has also been included.

[Nutritional care in the cardiac rehabilitation program]. / Percorso di assistenza nutrizionale in riabilitazione cardiologica.

There is some evidence of the efficacy of nutritional care in modifying eating habits and behavior in patients undergoing cardiac rehabilitation: nutritional care has a relevant role in the secondary prevention of cardiovascular disease. The dietitian is the qualified sanitary professional for nutritional care. The aim of this study was to define the role of dietitians within a health care team in programs of cardiac rehabilitation. In this setting, nutritional care starts with a dietary assessment, which includes a measurement of the anthropometric parameters, and a survey of the patient knowledge and eating habits. If there is no need for change in the patient lifestyle, the patient is addressed to the normal cardiac rehabilitation program with no further nutritional intervention except one session of counseling. When lifestyle changes are needed, the dietitian defines, together with the patient, therapeutic aims and expected results. The following phase is represented by group session with patients and their relatives during which nutritional topics are discussed and nutritional education is provided Afterwards, self-monitoring sheets of eating habits are individually discussed in one visit; a last individual visit is used for a final assessment of nutritional knowledge, dietary habits, and anthropometric parameters. In case of unsatisfactory results, patients are invited to participate to three group session to be held biweekly, during which they interact with the dietitian and take part to exercises and group discussions. When the established targets are reached, the nutritional program includes individual follow up visits at six and twelve months for further assessment of medium term results.

Efficacy of a nutritional education program to improve diet in patients attending a cardiac rehabilitation program: outcomes of a one-year follow-up.

Dietary habits are widely reported to play a primary role in the occurrence of coronary artery disease (CAD). Cardiac rehabilitation is a multidisciplinary intervention that includes nutritional education. Proper nutrition plays an important role in cardiovascular health outcomes and in decreasing morbidity and mortality of cardiovascular diseases (CVD) as highlighted in the literature. The aim of this study was to assess the efficacy of an educational program to improve the diet of cardiac rehabilitation patients compared to usual treatment. 160 patients with CAD, (124 M, 36 F) were randomized into two groups. Data analysis was conducted on 133 patients (11 % dropped out). All enrolled patients attended two educational seminars about proper nutrition and cardiovascular prevention, and completed a questionnaire about dietary habits (before CAD). The Body Mass Index (BMI) was calculated, and basal glycaemia and plasma lipids were assessed at the beginning and at the end of the study (12 months after hospital discharge). The intervention group patients underwent a mid-term evaluation of nutrient intakes, BMI, and received a personalized educational reinforcement by a dietitian. At the end of the study, the intervention group was shown to have significantly reduced their daily caloric intake (reduction of total proteins, total fat, carbohydrate, alcohol), and showed a significant reduction of weight and BMI compared to the control group. Individual nutritional counseling session as a reinforcement of a standard educational program is effective in reducing caloric intake and BMI, which may reduce cardiovascular risk factors in cardiovascular patients.

Targeting educational therapy for type 2 diabetes: identification of predictors of therapeutic success.

Patient education is a key component of diabetes care. Limits in resources often prevent the participation of many patients with type 2 diabetes to structured education programs. The identification of predictors of response to group education could help in selecting those patients in whom the intervention is more cost-effective. A structured interactive group program was proposed to a consecutive series of 150 type 2 diabetes patients, who were then followed prospectively in 24 months, with measurements of HbA1c, BMI, quality of life, eating habits. For comparison, another consecutive series of 113 patients who had received no intervention was also observed for 12 months. A significant reduction in HbA1c was observed in the intervention group at 12 and 24 months (from 7.5 ± 1.4 to 6.9 ± 1.2 and 6.6 ± 1.1% at 12 and 24 months, respectively, both P < 0.01), with no variation in BMI and quality of life. A sustained reduction in total energy, protein, and fat intake was observed after education. The proportion of success (HbA1c < 7% and/or HbA1c reduction from baseline > 1%) in the intervention group was 60.7% (vs. 38.1% in controls) and 63.3% at 12 and 24 months, respectively. In the intervention group, patients with success at 12 months showed lower baseline HbA1c, BMI, duration of diabetes, protein, and cholesterol intake. Patients with a lower duration of diabetes appear to have a greater response to structured group education, whereas age is not a predictor of response. Therefore, educational intervention should be planned in the earlier phases of the disease.

Fit and motivated: outcome predictors in patients starting a program for lifestyle change.

BACKGROUND: In previous pilot studies we have demonstrated that the Treatment Motivation and Readiness Test (TRE-MORE) is capable of predicting the outcome of obesity therapy and that a higher muscle mass (MM) is associated with a greater weight loss. Purposes of the present study were: to confirm the predictive value of TRE-MORE scores and MM, using a standardized non-pharmacologic intervention for weight loss; to explore the relationship between TRE-MORE and MM; to discriminate predictors of attendance from predictors of final therapeutic success. METHODS: A consecutive series of 331 patients was enrolled and addressed to a standardized treatment protocol. RESULTS: Mean weight loss at 6 months was -5.03%. Among participants, 48.7% lost at least 5% initial body weight after 6 months and had significantly higher TRE-MORE total scores and MM. Weight loss was significantly associated with baseline MM, TRE-MORE-3, and a lower number of previous diets. Significantly lower TRE-MORE-3 scores were associated with drop-out. CONCLUSION: The present study confirms that therapeutic success is predicted by TRE-MORE scores and, independently from these, by estimated MM (after adjustment for BMI). TRE-MORE total score is a predictor of failure, but not of attendance, whereas drop-out patients showed a lower score only in TREMORE-3 subscale which investigates lifestyle habits.