Dietary interventions for induction and maintenance of remission in inflammatory bowel disease.

BACKGROUND: Inflammatory bowel disease (IBD), comprised of Crohn's disease (CD) and ulcerative colitis (UC), is characterized by chronic mucosal inflammation, frequent hospitalizations, adverse health economics, and compromised quality of life. Diet has been hypothesised to influence IBD activity. OBJECTIVES: To evaluate the efficacy and safety of dietary interventions on IBD outcomes. SEARCH METHODS: We searched the Cochrane IBD Group Specialized Register, CENTRAL, MEDLINE, Embase, Web of Science, Clinicaltrials.gov and the WHO ICTRP from inception to 31 January 2019. We also scanned reference lists of included studies, relevant reviews and guidelines. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that compared the effects of dietary manipulations to other diets in participants with IBD. Studies that exclusively focused on enteral nutrition, oral nutrient supplementation, medical foods, probiotics, and parenteral nutrition were excluded. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, extracted data and assessed bias using the risk of bias tool. We conducted meta-analyses where possible using a random-effects model and calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes. We assessed the certainty of evidence using GRADE. MAIN RESULTS: The review included 18 RCTs with 1878 participants. The studies assessed different dietary interventions for active CD (six studies), inactive CD (seven studies), active UC (one study) and inactive UC (four studies). Dietary interventions involved either the consumption of low amounts or complete exclusion of one or more food groups known to trigger IBD symptoms. There was limited scope for data pooling as the interventions and control diets were diverse. The studies were mostly inadequately powered. Fourteen studies were rated as high risk of bias. The other studies were rated as unclear risk of bias.The effect of high fiber, low refined carbohydrates, low microparticle diet, low calcium diet, symptoms-guided diet and highly restricted organic diet on clinical remission in active CD is uncertain. At 4 weeks, remission was induced in: 100% (4/4) of participants in the low refined carbohydrates diet group compared to 0% (0/3) of participants in the control group (RR 7.20, 95% CI 0.53 to 97.83; 7 participants; 1 study; very low certainty evidence). At 16 weeks, 44% (23/52) of participants in the low microparticle diet achieved clinical remission compared to 25% (13/51) of control-group participants (RR 3.13, 95% CI 0.22 to 43.84; 103 participants; 2 studies; I² = 73%; very low certainty evidence). Fifty per cent (16/32) of participants in the symptoms-guided diet group achieved clinical remission compared to 0% (0/19) of control group participants (RR 20.00, 95% CI 1.27 to 315.40; 51 participants ; 1 study; very low certainty evidence) (follow-up unclear). At 24 weeks, 50% (4/8) of participants in the highly restricted organic diet achieved clinical remission compared to 50% (5/10) of participants in the control group (RR 1.00, 95% CI 0.39 to 2.53; 18 participants; 1 study; very low certainty evidence). At 16 weeks, 37% (16/43) participants following a low calcium diet achieved clinical remission compared to 30% (12/40) in the control group (RR 1.24, 95% CI 0.67 to 2.29; 83 participants; 1 study; very low certainty evidence).The effect of low refined carbohydrate diets, symptoms-guided diets and low red processed meat diets on relapse in inactive CD is uncertain. At 12 to 24 months, 67% (176/264) of participants in low refined carbohydrate diet relapsed compared to 64% (193/303) in the control group (RR 1.04, 95% CI 0.87 to 1.25; 567 participants; 3 studies; I² = 35%; low certainty evidence). At 6 to 24 months, 48% (24/50) of participants in the symptoms-guided diet group relapsed compared to 83% (40/48) participants in the control diet (RR 0.53, 95% CI 0.28 to 1.01; 98 participants ; 2 studies; I² = 54%; low certainty evidence). At 48 weeks, 66% (63/96) of participants in the low red and processed meat diet group relapsed compared to 63% (75/118) of the control group (RR 1.03, 95% CI 0.85 to 1.26; 214 participants; 1 study; low certainty evidence). At 12 months, 0% (0/16) of participants on an exclusion diet comprised of low disaccharides / grains / saturated fats / red and processed meat experienced clinical relapse compared to 26% (10/38) of participants on a control group (RR 0.11, 95% CI 0.01 to 1.76; 54 participants; 1 study; very low certainty evidence).The effect of a symptoms-guided diet on clinical remission in active UC is uncertain. At six weeks, 36% (4/11) of symptoms-guided diet participants achieved remission compared to 0% (0/10) of usual diet participants (RR 8.25, 95% CI 0.50 to 136.33; 21 participants; 1 study; very low certainty evidence).The effect of the Alberta-based anti-inflammatory diet, the Carrageenan-free diet or milk-free diet on relapse rates in inactive UC is uncertain. At 6 months, 36% (5/14) of participants in the Alberta-based anti-inflammatory diet group relapsed compared to 29% (4/14) of participants in the control group (RR 1.25, 95% CI 0.42 to 3.70; 28 participants; 1 study; very low certainty evidence). Thirty per cent (3/10) of participants following the carrageenan-free diet for 12 months relapsed compared to 60% (3/5) of the participants in the control group (RR 0.50, 95% CI 0.15 to 1.64; 15 participants; 1 study; very low certainty evidence). At 12 months, 59% (23/39) of milk free diet participants relapsed compared to 68% (26/38) of control diet participants (RR 0.83, 95% CI 0.60 to 1.15; 77 participants; 2 studies; I² = 0%; low certainty evidence).None of the included studies reported on diet-related adverse events. AUTHORS' CONCLUSIONS: The effects of dietary interventions on CD and UC are uncertain. Thus no firm conclusions regarding the benefits and harms of dietary interventions in CD and UC can be drawn. There is need for consensus on the composition of dietary interventions in IBD and more RCTs are required to evaluate these interventions. Currently, there are at least five ongoing studies (estimated enrollment of 498 participants). This review will be updated when the results of these studies are available.

Fasting plasma lactate as a possible early clinical marker for metabolic disease risk.

BACKGROUND AND AIM: Elevated fasting plasma lactate concentrations are evident in individuals with metabolic diseases. However, it has yet to be determined if these associations exist in a young, healthy population as a possible early marker for metabolic disease risk. The purpose of this study was to determine if indices of the metabolic syndrome are related to plasma lactate concentrations in this population. METHODS: Fifty (29 ± 7 yr) men (n = 19) and women (n = 31) classified as overweight (26.4 ± 1.8 kg/m2) participated in this observational study. Blood pressure and blood metabolites were measured after an overnight fast. Lactate was also measured before and after a three-day eucaloric high-fat (70 %) diet. The homeostatic model assessment for insulin resistance (HOMA-IR) was calculated as a measure of insulin resistance. Visceral adipose tissue mass was determined via dual X-ray absorptiometry. RESULTS: Triglycerides (r = 0.55, p=<0.0001), HOMA-IR (r = 0.53, p=<0.0001), and systolic and diastolic (both, r = 0.36, p = 0.01) blood pressures associated with fasting plasma lactate. No differences in visceral adipose tissue existed between the sexes (p = 0.41); however, the relationship between visceral adipose tissue and lactate existed only in females (r = 0.59, p = 0.02) but not in males (p = 0.53). Fasting lactate and HOMA-IR increased in males (p = 0.01 and p = 0.02, respectively), but not females, following a three-day high-fat diet. CONCLUSION: Indices of the metabolic syndrome associated with fasting plasma lactates in young relatively healthy individuals. Fasting lactate also increased in a sex-specific manner after a three-day high fat diet. Thus, lactate could become a clinical marker for metabolic disease risk.

Spontaneous weight change during chronic hepatitis C treatment: association with virologic response rates.

OBJECTIVE: We examined weight changes during chronic hepatitis C (CHC) therapy and association with virologic response. METHODS: Weight changes were compared between subjects achieving rapid, early, and sustained virologic response rates (RVR, EVR, and SVR). RVR, EVR and SVR were compared among patients with or without weight loss of ≥ 0.5 body mass index (BMI) units (kg/m²) at 4, 12, 48 weeks. RESULTS: CHC therapy was initiated in 184 cases. Median pretreatment BMI was 27.7 (18.4-51.3) with 38% overweight and 31% obese (BMI ≥25 and ≥ 30, respectively). Among patients with liver biopsies (n = 90), steatosis was present in 31.6%; fibrosis grade of 1-2/6 in 46%, 3-4 in 37.3% and 5-6 in 14.7%. Mean weight loss at 4, 12, 24 and 48 weeks of therapy were 1.2, 2.6, 3.8 and 3.3 kg, respectively. After 4 and 12 weeks of treatment, 38% and 54.3% had a BMI decrement of ≥ 0.5 kg/m². For genotype 1, weight loss at 4 weeks was associated with significantly higher EVR (90.0% vs. 70%, p = 0.01) and a tendency towards better RVR and SVR (42.9% vs. 26.0% and 55.2% vs. 34.8%, respectively, p = 0.08). In multivariate analysis, weight loss at 4 weeks was independently associated with EVR (OR 6.3, p = 0.02) but was not significantly associated with RVR or SVR. CONCLUSIONS: Spontaneous weight loss at 4 and 12 weeks of CHC therapy was associated with improved EVR. Weight loss at 4 weeks was an independent predictor of EVR but not SVR.

The effect of exercise training level on arterial stiffness after clinically significant weight loss.

Arterial stiffness is improved by weight loss. However, no data exist on the impact of aerobic exercise levels on arterial stiffness during weight maintenance. Adults who were  overweight or with obesity (N = 39) participated in a 10-week weight loss program. Participants who achieved ≥7% weight loss were randomized to aerobic training at the minimum physical activity guidelines (PA-REC, 550 MET min/week) or weight maintenance guidelines (WM-REC, 970 MET min/week) for 18 additional weeks. Arterial stiffness (carotid-to-femoral pulse wave velocity [cfPWV], augmentation index normalized for 75 beats/min [AIX75]) and blood pressure [aortic and brachial]) were assessed at baseline, the end of the weight loss phase (week 10), and follow-up (week 28). There was a reduction in cfPWV in participants who met the weight loss goal (-0.34 m/s, p = .02) and approached significance for the entire sample (p = .051). Similarly, there were reductions in AIX75, brachial blood pressure, and aortic blood pressure (p < .05) in the full sample. In the weight maintenance phase, no differences were observed between the PA-REC and the WM-REC groups for change in arterial stiffness or blood pressure (p > .05). However, changes in cfPWV were independently associated with changes in LDL (r2 : 0.45, p = .004) and exercise intensity (r2 : 0.17, p = .033). Aerobic exercise level at the minimum physical activity guidelines or weight maintenance guidelines does not affect the change in PWV or the change in cfPWV after clinically significant weight loss. However, interventions which limit increases in LDL cholesterol and promote high-intensity aerobic exercise may prevent increases in stiffness during weight maintenance.

Effects of weight loss and weight loss maintenance on cardiac autonomic function in obesity: a randomized controlled trial.

NOVELTY: Caloric restriction and exercise exert significant improvements in cardiac autonomic function as measured by HRV in overweight and obesity. Aerobic exercise training, within recommended guidelines coupled with weight loss maintenance, retains cardiac autonomic function benefits from weight loss in previously obese individuals.

Nutritional Care for Patients with Intestinal Failure.

Intestinal failure is a debilitating, complex disorder associated with loss of portions of intestine or loss of intestinal function. Short bowel syndrome is the most common form of intestinal failure and results in inability to maintain nutritional, fluid, and electrolyte status while consuming a regular diet. Nutrition interventions to treat short bowel syndrome include enteral and parenteral nutrition, intestinal rehabilitation techniques to enhance absorptive capacity of remnant bowel, and surgical reconstruction designed to provide more surface area for absorption. These therapies are interrelated services to restore nutritional status through the safest most effective therapy consistent with patient lifestyle and wishes.

Reduced mortality risk in malnourished hospitalized older adult patients with COPD treated with a specialized oral nutritional supplement: Sub-group analysis of the NOURISH study.

BACKGROUND: Hospitalized, malnourished older adults with chronic obstructive pulmonary disease (COPD) have an elevated risk of readmission and mortality. OBJECTIVE: Post-hoc, sub-group analysis from the NOURISH study cohort examined the effect of a high-protein oral nutritional supplement (ONS) containing HMB (HP-HMB) in malnourished, hospitalized older adults with COPD and to identify predictors of outcomes. METHODS: The NOURISH study (n = 652) was a multicenter, randomized, placebo-controlled, double-blind trial. The COPD subgroup (n = 214) included hospitalized, malnourished (based on Subjective Global Assessment), older adults (≥65 y), with admission diagnosis of COPD who received either standard-of-care plus HP-HMB (n = 109) or standard-of-care and a placebo supplement (n = 105) prescribed 2 servings/day from within 3 days of hospital admission (baseline) and up to 90 days after discharge. The primary study outcome was a composite endpoint of incidence of death or non-elective readmission up to 90-day post-discharge, while secondary endpoints included changes in hand-grip strength, body weight, and nutritional biomarkers over time. Categorical outcomes were analyzed using Cochran-Mantel-Haenszel tests, longitudinal data by repeated measures analysis of covariance; and changes from baseline by analysis of covariance. p-values ≤ 0.05 were considered statistically significant. Multivariate logistic regression was used to model predictors of the primary outcome and components. RESULTS: In patients with COPD, 30, 60, and 90-day hospital readmission rate did not differ, but in contrast, 30, 60, and 90-day mortality risk was approximately 71% lower with HP-HMB supplementation relative to placebo (1.83%, 2.75%, 2.75% vs. 6.67%, 9.52% and 10.48%, p = 0.0395, 0.0193, 0.0113, resp.). In patients with COPD, compared to placebo, intake of HP-HMB resulted in a significant increase in handgrip strength (+1.56 kg vs. -0.34 kg, p = 0.0413) from discharge to day 30; increased body weight from baseline to hospital discharge (0.66 kg vs. -0.01 kg, p < 0.05) and, improvements in blood nutritional biomarker concentrations. The multivariate logistic regression predictors of the death, readmission or composite endpoints in these COPD patients showed that participants who were severely malnourished (p = 0.0191) and had a Glasgow prognostic score (GPS) Score of 1 or 2 had statistically significant odds of readmission or death (p = 0.0227). CONCLUSIONS: Among malnourished, hospitalized patients with COPD, supplementation with HP-HMB was associated with a markedly decreased mortality risk, and improved handgrip strength, body weight, and nutritional biomarkers within a 90-day period after hospital discharge. This post-hoc, subgroup analysis highlights the importance of early identification of nutritional risk and administration of high-protein ONS in older, malnourished patients with COPD after hospital admission and continuing after hospital discharge.

Health-Related Quality of Life in Weight Loss Interventions: Results from the OPTIWIN Trial.

Obesity is highly prevalent and associated with several adverse outcomes including health-related quality-of-life (HRQoL), work productivity, and activity impairment. The objective of this study is to examine group differences in HRQoL and labor-related health outcomes among participants in the OPTIWIN program, which compared the effectiveness of two intensive behavioral weight loss interventions. Participants (n = 273) were randomized to OPTIFAST®(OP) or food-based (FB) dietary interventions for 52 weeks. HRQoL and labor-related health outcomes were measured at baseline, week 26, and week 52, using two questionnaires. At baseline, there were no differences between groups on the Impact of Weight on Quality-of-Life Questionnaire (IWQOL-Lite). At week 26, the OP group had statistically significant differences towards better HRQoL for Physical Function, Self-Esteem, and the total score compared with the FB group. At week 52, the OP group showed better HRQoL in the total score (p = 0.0012) and in all but one domain. Moreover, the adjusted change-from-baseline normalized total score at week 52 was -5.9 points (p = 0.0001). Finally, the mean IWQOL-Lite normalized score showed that HRQoL improves by 0.4442 units (p < 0.0001) per kg lost, and that greater weight reduction was positively associated with better HRQoL. No statistically significant group differences were found with the Work Productivity and Activity Impairment (General Health) (WPAI-GH) Questionnaire. HRQoL improves with highly intensive, well-structured weight loss interventions. Greater weight loss lead to larger improvements. The lack of negative effect on productivity and activity suggests that these interventions may be compatible with an active work lifestyle.

Prescribed exercise to Reduce Recidivism After Weight Loss-Pilot (PREVAIL-P): Design, methods and rationale.

Clinically significant weight loss is associated with health benefits for overweight and obese adults. Participation in adequate amounts of physical activity is critical for weight maintenance. However, the recommended amount of physical activity needed to promote weight maintenance is based primarily on retrospective studies that quantified physical activity levels through questionnaires which tend to overestimate physical activity levels. In addition, the present literature has provided little data on the impact of these physical activity levels on cardiovascular and diabetes risk factors, which may have equal or more clinical importance than weight changes. The Prescribed Exercise to Reduce Recidivism After Weight Loss-Pilot (PREVAIL-P) study will evaluate the effect of aerobic exercise training amount on weight maintenance following clinically significant weight loss in overweight and obese adults (BMI 25-40 kg/m2) age 30-65 years. Participants (N = 39) will complete a 10-week OPTIFAST® weight loss program with supervised aerobic exercise training. Individuals who achieve ≥7% weight loss from baseline will be subsequently randomized to levels of aerobic training consistent with physical activity recommendations (PA-REC) or weight maintenance recommendations (WM-REC) for 18 additional weeks. The primary outcome of the PREVAIL-P study will be change in weight from the completion of OPTIFAST® program to the end of the study. Notable secondary measures include changes in clinically relevant cardiometabolic risk factors between study groups (e.g. blood lipids concentrations, oral glucose tolerance, arterial stiffness). This pilot study will be used to estimate the effect sizes needed for a randomized controlled trial on this topic.

Specialized High-Protein Oral Nutrition Supplement Improves Home Nutrient Intake of Malnourished Older Adults Without Decreasing Usual Food Intake.

BACKGROUND: Reduced nutrient intake is common in patients after hospitalization, contributing to increased risk for readmission and mortality. Oral nutrition supplements can improve nutrition status and clinical outcomes, but intake of food is prioritized by clinicians. This study examines the impact of a high-protein oral nutrition supplement (S-ONS) on nutrient intake post discharge. METHODS: In a subset of patients (14 S-ONS and 16 placebo) from the NOURISH (Nutrition effect On Unplanned ReadmIssions and Survival in Hospitalized patients) trial, 24-hour dietary recalls were conducted on 3 randomly selected days during the weeks of 30, 60, and 90 days post discharge. Nutrient intake was estimated using Nutrition Data System for Research software. Adequate energy and protein intake were defined as 30 kcal/kg/d and 1.2 g/kg/d, respectively. Dietary Reference Intakes (DRIs) were used for other nutrients. RESULTS: Less than half of patients met the requirements for energy, protein, and 12 micronutrients from food intake alone during the study. Energy and protein intakes from food were not diminished relative to placebo. Considering nutrient intake from both food and S-ONS, 50% and 71% of patients receiving S-ONSs met energy and protein goals respectively at 90 days (compared with 29% and 36%, in the placebo group), and 100% met the DRI for total carbohydrate, iron, phosphorus, copper, selenium, thiamin, and riboflavin at all time points, all of which were consumed at higher amounts vs placebo. CONCLUSION: Three months of S-ONS consumption increases intake of numerous nutrients without decreasing nutrient intake from food in older malnourished adults post discharge.

Practice audit of nutrition support certification.

The National Board of Nutrition Support Certification (NBNSC) is an independent credentialing board responsible for administering certification programs in nutrition support. The NBNSC conducted a study (practice audit) of Nutrition Support Professionals (NSP), with the purposes of defining the role of the nutrition support professional and determining the current elements (knowledge or functions) required for competent NSP practice. This article describes the development of the study, results of the study, and use of the information for future certification in nutrition support. A list of the elements required for competent practice was gleaned from a variety of sources. A rating scale was developed to measure the importance of elements required for competent practice and frequency of practice. From this, an online survey instrument was prepared. Surveys were sent to 5964 NSPs; a total of 891 surveys were completed (return rate of 16.8%). There was 98% agreement among the disciplines of the perceived importance of the elements required of competent entry-level NSP practice; that the survey either completely or adequately described these elements; and that it reflected practice by region as well as among various disciplines and work settings. The results of the practice audit demonstrate a common core of practice (95%) across the nutrition support disciplines as well as a universal core of elements believed to be important for competent nutrition support practice. As a result, the NBNSC has developed 1 examination for future nutrition support certification testing and will confer 1 credential, Certified Nutrition Support Clinician (CNSC), to those who pass the exam.

Bacteria, Bones, and Stones: Managing Complications of Short Bowel Syndrome.

Short bowel syndrome (SBS) occurs in patients who have had extensive resection. The primary physiologic consequence is malabsorption, resulting in fluid and electrolyte abnormalities and malnutrition. Nutrient digestion, absorption, and assimilation may also be diminished by disturbances in the production of bile acids and digestive enzymes. Small bowel dilation, dysmotility, loss of ileocecal valve, and anatomical changes combined with acid suppression and antimotility drugs increase the risk of small intestinal bacterial overgrowth, further contributing to malabsorption. Metabolic changes that occur in SBS due to loss of colonic regulation of gastric and small bowel function can also lead to depletion of calcium, magnesium, and vitamin D, resulting in demineralization of bone and the eventual development of bone disease. Persistent inflammation, steroid use, parenteral nutrition, chronic metabolic acidosis, and renal insufficiency may exacerbate the problem and contribute to the development of osteoporosis. Multiple factors increase the risk of nephrolithiasis in SBS. In the setting of fat malabsorption, increased free fatty acids are available to bind to calcium, resulting in an increased concentration of unbound oxalate, which is readily absorbed across the colonic mucosa where it travels to the kidney. In addition, there is an increase in colonic permeability to oxalate stemming from the effects of unabsorbed bile salts. The risk of nephrolithiasis is compounded by volume depletion, metabolic acidosis, and hypomagnesemia, resulting in a decrease in renal perfusion, urine output, pH, and citrate excretion. This review examines the causes and treatments of small intestinal bacterial overgrowth, bone demineralization, and nephrolithiasis in SBS.

Therapeutic efficacy of intestinal and multivisceral transplantation: survival and nutrition outcome.

The clinical introduction of intestinal transplantation has added a new dimension and offered a valid therapeutic option for patients with irreversible intestinal failure. In the year 2000, the Center for Medicare & Medicaid Services (CMS) recognized intestinal, combined liver-intestinal, and multivisceral transplantation as the standard of care for patients with irreversible intestinal and parenteral nutrition (PN) failure. Accordingly, the indications for the procedure are currently limited to those who develop life-threatening PN complications. However, a recent improvement in survival similar to other solid organ transplant recipients should justify lifting the current restricted criteria, and the procedure should be considered before the development of PN failure. Equally important is the awareness of the recent evolution in nutrition management and outcome after transplantation. Early and progressive enteral feeding using a complex polymeric formula is safe and effective after successful transplantation. Full nutrition autonomy is universally achievable among most intestinal and multivisceral recipients, with enjoyment of unrestricted oral diet. Such a therapeutic benefit is commonly maintained among long-term survivors, with full rehabilitation and restoration of quality of life.

Dietary fatty acids modulate chronic colitis, colitis-associated colon neoplasia and COX-2 expression in IL-10 knockout mice.

OBJECTIVE: The effects of different dietary oils on the development of colitis-associated colon cancer have not been studied. The present study examined the effect of different dietary oils on the severity of chronic colitis, development of colitis-associated premalignant changes, and colonic expression of cyclooxygenase-2 (COX-2) in interleukin-10 knockout (IL-10-/-) mice. METHODS: IL-10-/- mice were fed chow supplemented with corn oil (CO; control, n=28), olive oil (OO; n=29), or fish oil (FO; n=35) for 12 wk and their colons were studied for colitis score, premalignant changes, and COX-2 expression. RESULTS: The average colitis score was higher in the FO than in the CO group. Similarly, the incidence of severe colitis (score>or=3) was significantly higher in the FO than in the CO and OO groups (50% versus 7.7% and 3.7%, respectively, P<0.05). Dysplasia was more frequent in the FO and less frequent in the OO than in the CO group (47% and 4% versus 15%, respectively, P<0.05). Conversely, aberrant crypt foci and crypt index were significantly higher in the FO than in the CO group. Colitis score, aberrant crypt foci, and crypt index did not differ between the OO and CO groups. COX-2 immunostaining was significantly lower in the OO than in CO group (P<0.05) but not different between the FO and CO groups. CONCLUSIONS: In IL-10-/- mice, fish oil exacerbates chronic colitis and colitis-associated premalignant changes. Conversely, olive oil inhibits COX-2 immunostaining and decreases the risk of neoplasia associated with chronic colitis.

Evaluating Evidence-Based Nutrition Support Practice Among Healthcare Professionals With and Without the Certified Nutrition Support Clinician Credential.

BACKGROUND: The National Board of Nutrition Support Certification credentials healthcare professionals and certifies that holders of the Certified Nutrition Support Clinician (CNSC) credential have specialized knowledge of safe and effective nutrition support therapy. The purpose of this pilot study was to survey healthcare professionals affiliated with the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) regarding their approaches to nutrition support practice using a complex patient case scenario in accordance with established clinical guidelines. MATERIALS AND METHODS: An electronic survey was emailed to individuals affiliated with A.S.P.E.N. Eight multiple-choice knowledge questions addressed evidence-based nutrition support practice issues for a patient with progressing pancreatitis. Demographic and clinical characteristic data were collected. RESULTS: Of 48,093 email invitations sent, 4455 (9.1%) responded and met inclusion criteria. Most respondents were dietitians (70.8%) and in nutrition support practice for 10.3 years, and 29.3% held the CNSC credential. Respondents with the CNSC credential answered 6.18 questions correctly compared with 4.56 for non-CNSC respondents (P < .001). For all 8 questions, CNSC respondents were significantly more likely to choose the correct answer compared with non-CNSC respondents (P < .001). CONCLUSION: Professionals with the CNSC credential scored significantly higher on a complex case-based knowledge assessment of guideline recommendations for the nutrition support treatment of pancreatitis compared with those without a credential.

Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: A randomized clinical trial.

BACKGROUND: Hospitalized, malnourished older adults have a high risk of readmission and mortality. OBJECTIVE: Evaluation of a high-protein oral nutritional supplement (HP-HMB) containing beta-hydroxy-beta-methylbutyrate on postdischarge outcomes of nonelective readmission and mortality in malnourished, hospitalized older adults. DESIGN: Multicenter, randomized, placebo-controlled, double-blind trial. SETTING: Inpatient and posthospital discharge. PATIENTS: Older (≥65 years), malnourished (Subjective Global Assessment [SGA] class B or C) adults hospitalized for congestive heart failure, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease. INTERVENTIONS: Standard-of-care plus HP-HMB (n = 328) or a placebo supplement (n = 324), 2 servings/day. MEASUREMENTS: Primary composite endpoint was 90-day postdischarge incidence of death or nonelective readmission. Other endpoints included 30- and 60-day postdischarge incidence of death or readmission, length of stay (LOS), SGA class, body weight, and activities of daily living (ADL). RESULTS: The primary composite endpoint was similar between HP-HMB (26.8%) and placebo (31.1%). No between-group differences were observed for 90-day readmission rate, but 90-day mortality was significantly lower with HP-HMB relative to placebo (4.8% vs. 9.7%; relative risk 0.49, 95% confidence interval [CI], 0.27 to 0.90; p = 0.018). The number-needed-to-treat to prevent 1 death was 20.3 (95% CI: 10.9, 121.4). Compared with placebo, HP-HMB resulted in improved odds of better nutritional status (SGA class, OR, 2.04, 95% CI: 1.28, 3.25, p = 0.009) at day 90, and an increase in body weight at day 30 (p = 0.035). LOS and ADL were similar between treatments. LIMITATIONS: Limited generalizability; patients represent a selected hospitalized population. CONCLUSIONS: Although no effects were observed for the primary composite endpoint, compared with placebo HP-HMB decreased mortality and improved indices of nutritional status during the 90-day observation period. CLINICAL TRIAL REGISTRATION: www.ClinicalTrials.govNCT01626742.

Practical guide to intestinal rehabilitation for postresection intestinal failure: a case study.

After massive small-intestinal resection or combined small-intestinal and colonic resection, diarrhea with resulting dehydration, electrolyte abnormalities, and malnutrition occur. Many patients become dependent on IV fluids and nutrition. An adaptation process manifested clinically by decreased diarrhea and improved nutrient absorption according to decreased parenteral nutrition and fluid requirements has been noted to occur over time. In some patients, adaptation is inadequate and may require special techniques to enhance and augment this process. This is a case of a 52-year-old woman who experienced increased stoma output 1 week after major intestinal resection, resulting in dehydration. She required IV fluids in order to maintain hydration. After the initiation of an intestinal rehabilitation program, which included modified diet, soluble fiber, oral rehydration solution (ORS), and medications, IV fluids were successfully weaned off in 3 months. She continues not to receive IV fluids and continues to follow the intestinal rehabilitation plan.

Short bowel syndrome: clinical guidelines for nutrition management.

Intestinal failure is a condition in which inadequate digestion or absorption of fluid, electrolytes, and nutrients leads to dehydration or malnutrition. The most common cause of intestinal failure is short bowel syndrome (SBS) defined as <200 cm of functional small intestine. SBS may result from congenital abnormalities or from surgical resection. For the past 3 decades, patients with severe SBS were managed with home parenteral nutrition (HPN). With the emergence of new therapies, the clinician now has multiple options to treat these patients. These include intestinal rehabilitation regimens whereby patients are treated with specialized oral diets, soluble fiber, oral rehydration solutions (ORS), and trophic factors to enhance absorption. There are also a variety of surgical techniques available to preserve intestinal length. Small bowel and multivisceral transplantation has evolved during the last decade to be a valid therapeutic option for those patients who cannot be rehabilitated or who fail HPN. These are interrelated services designed to offer the patient the best therapeutic options to meet their individual needs. This article reviews the principles associated with the nutrition management of this very complex and diverse group of patients.

Growth hormone, glutamine, and modified diet for intestinal adaptation.

Many patients who undergo extensive resection of the gastrointestinal tract develop intestinal failure from short-bowel syndrome that results in significant malabsorption of fluid, electrolytes, and other nutrients. This may result in dependence on long-term parenteral nutrition. It has been almost a decade since Byrne and colleagues published their research demonstrating enhanced absorption of nutrients, improved weight gain, and reduction in parenteral nutrition requirements with the administration of a combination of growth hormone, glutamine, and a modified diet. Other researchers have conducted similar studies with inconsistent results. A systematic search on electronic databases and the Internet for the purpose of identifying the evidence published to date on this subject was performed. The analysis suggests administering recombinant human growth hormone alone or together with glutamine with or without a modified diet may be of benefit when the appropriate patients are selected for treatment.

Body composition changes in cachectic patients receiving home parenteral nutrition.

BACKGROUND: The purpose of this study was to evaluate the initial body compositional changes experienced by malnourished patients requiring home parenteral nutrition (HPN) for repletion. METHODS: Eight patients were prospectively studied for 3 months. Body composition was determined by dual-energy X-ray absorptiometry (DXA), and a comprehensive nutrition assessment was performed including body weight, visceral proteins, triceps skinfold (TSF), midupper arm circumference (MUAC), midupper arm muscle circumference (MUAMC), body mass index (BMI), delayed hypersensitivity skin tests (DHST), and diet history. RESULTS: Body composition measured by DXA showed an increase in (mean +/- SD) total fat from 5770 +/- 2805 to 10581 +/- 1980 g (p < .001) and bone mineral content from 2155 +/- 429 to 2190 +/- 443 g (p = .047). Lean soft tissue remained unchanged. Body weight and BMI increased from 47.7 +/- 6.6 to 53.6 +/- 8.2 kg (p = .006) and from 16.6 +/- 1.5 to 18.6 +/- 1.5 kg/m2 (p = .005), respectively. TSF increased from 6.3 +/- 3.1 to 10.4 +/- 4.0 mm (p < .001), and MUAMC remained stable. There was a significant improvement in transferrin from 191 +/- 82 to 326 +/- 128 mg/dL (p = .043), and a trend toward improvement in albumin and DHST. Body weight was highly correlated with DXA weight at baseline (r = .997; 95% confidence interval [CI], 0.98 to 1.00; p < .001) and at 3 months (r = .988; 95% CI, 0.93 to 1.00; p <.001). TSF correlated with total fat as measured by DXA at baseline (r = .839; 95% CI, 0.33 to 0.97; p = .009) but not at 3 months (r = .693; 95% CI, -0.02 to 0.94; p = .057). MUAMC correlated with lean soft tissue measured by DXA both at baseline (r = .739; 95% CI 0.07 to 0.95; p = .036) and at 3 months (r = .870; 95% CI, 0.43 to 0.98; p = .005). Physical activity, on a subjective scale of 1 (low activity) to 3 (high activity), improved over the 3-month period from 1.3 +/- 0.5 to 2.2 +/- 0.8 (p = .031). CONCLUSIONS: Initial weight gain experienced by malnourished HPN patients is primarily fat. Bone mineral content increases, but lean soft tissue does not change. Overall nutritional status is improved as exhibited by significant improvements in body weight and serum transferrin and a trend toward improvement in albumin and delayed hypersensitivity skin tests.