Importance of Nutritional Management in Comprehensive Diabetes Care

In this issue

Importance of nutritional management in comprehensive diabetes care

Clinical nutrition abstracts

Highlights of the ESPEN 2012 Congress

Science supporting better nutrition2012 • Volume 8, Issue 4

CLINICALNUTRITIONHIGHLIGHTS

ISSN 1815-7262

CLINICAL NUTRITION HIGHLIGHTSScience supporting better nutrition2012 • Volume 8, Issue 4

Feature article 2

Importance of nutritional management in comprehensive diabetes care Alice PS Kong, Lorena TF Cheung, Juliana CN Chan

Health economic perspective 9

Clinical nutrition abstracts 10 Cancer 10

Critical care 10

Dysphagia 13

Diabetes 14

Geriatrics 15

Immunonutrition 15

Medical nutrition therapy 16

Pediatrics 17

Highlights of the 34th ESPEN Congress 19 8–11 September 2012 Barcelona, Spain

Conference calendar 24

Sponsored as a service to the medical profession by the Nestlé Nutrition Institute.

Editorial development by UBM Medica. The opinions expressed in this publication are not necessarily those of the editor, publisher or sponsor. Any liability or obligation for loss or damage howsoever arising is hereby disclaimed. Although great care has been taken in compiling and checking the information herein to ensure that it is accurate, the editor, publisher and sponsor shall not be responsible for the continued currency of the information or for any errors, omissions or inaccuracies in this publication.

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Importance of nutritional management in

comprehensive diabetes careAlice PS Kong,1,2 Lorena TF Cheung3 and Juliana CN Chan1,2

1 Department of Medicine and Therapeutics 2 Li Ka Shing Institute of Health Sciences

The Chinese University of Hong Kong Hong Kong SAR, China

3 Nestlé Health Science, Asia, Oceania, Africa Region

Introduction

The global increase in the prevalence of diabetes and its

complications has made prevention and control of diabetes

a top public health priority. Globally in 2012, an estimated

371 million individuals had diabetes (8.3% of the total adult

population aged 20–79 years) and an additional 187 million

people were undiagnosed.1 In the United States (US) in 2010,

25.8 million people, or 8.3% of the entire population, had

diabetes; for those older than 65 years, the prevalence was

26.9%.2 In many Asian countries, the proportion of people

with type 2 diabetes has also surged dramatically due to

rapid socioeconomic development, and changes in lifestyle

and nutrition habits.3 Compared to Western populations,

people in Asia tend to develop diabetes at a younger age

and, hence, suffer longer with a higher chance of developing

diabetes-related complications.3 Obesity in childhood and

adolescence, an important predisposing factor for early

onset type 2 diabetes, has increased substantially4 and the

health consequences of this epidemic threaten to overwhelm

healthcare systems worldwide. Advocacy for lifestyle changes,

in particular nutritional management, is the first step in

comprehensive diabetes care.

Nutritional management, or medical nutrition therapy

(MNT), is a cornerstone in primary prevention of diabetes in

high-risk subjects, eg, individuals with obesity and pre-diabetes,

secondary prevention of diabetes complications and tertiary

prevention of further progression of diabetes complications.

Quality diabetes care requires a multidisciplinary approach

to promote patient self-management. The responsibility for

MNT should not be limited just to registered dietitians; all

healthcare professionals of the multidisciplinary diabetes

management team, including doctors, diabetes educators,

nurses and pharmacists, should be equipped with knowledge

about MNT to educate and reinforce to their patients the

importance of nutrition in order to optimize care and prevent

complications. There is no clear single approach to diabetes

MNT that applies to all patients with diabetes. Rather, the

approach and interventions should be customized, and

adapted to the patient’s needs and goals of therapy.

Burden of diabetes and its multiple comorbidities

Diabetes can be a silent and devastating disease and is often

associated with cardiovascular disease (CVD), which is

among the leading causes of mortality and morbidity in many

countries. In recent years there has been increasing recognition

of other frequent comorbidities of diabetes, such as cancer,

end-stage renal disease, sepsis and mental illnesses.5

In many developing countries, rapid socioeconomic,

cultural, information and technological changes have led

to changes in food supply, choices and consumption, which

promote unbalanced nutrition and positive energy balance.3

Taking China and India as examples, the traditional

high-carbohydrate, low-fat, high-fiber diets are being replaced

by high-fat, high-energy and low-fiber diets that contribute

to the rising trends of obesity and diabetes.6-8 In China, the

percentage of energy from dietary fat has increased from

19.3% in 1989 to 27.3% in 1997. These dietary changes

were particularly evident in urban compared with rural

populations (53% versus 40%, respectively).7 In India, the

respective figures were 32% and 17%.8 In addition, increased

urbanization and sedentary lifestyles have led to reduced

physical activity levels, contributing to the energy surplus and

development of obesity and type 2 diabetes.

Multifaceted role of MNT in the management of diabetes

MNT in primary prevention of diabetesAll diabetes associations recognize MNT as an integral

component in a comprehensive diabetes care program. There is

conclusive evidence from different populations, including those

in the US, China and Europe, which support the importance

of MNT in primary prevention of type 2 diabetes.9-12 In these

structured lifestyle modification programs, MNT was often

given in conjunction with advice on physical activity to achieve

significant weight loss. Compared with the control group,

lifestyle modification in subjects with impaired glucose tolerance

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CLINICAL NUTRITION HIGHLIGHTS • 2012 • Volume 8, Issue 4

resulted in an average 7% reduction in body weight. This delayed

incident type 2 diabetes by 11 years, representing an absolute risk

reduction of 20%.9,13 In the US Diabetes Prevention Program

(DPP), the benefit of lifestyle modification was greater and more

cost-effective than treatment with the oral anti-diabetic agent

metformin.9,13 Of note, while lifestyle modification was effective

in all age groups, the effect of metformin was less evident in

persons older than 65 years.9 In a recent study from Spain, a

Mediterranean diet reduced the incidence of diabetes in high-risk

subjects by 52% compared with a low-fat diet, despite the lack

of weight reduction, increased physical activity and caloric

restriction.10 These data support the importance of quality of diet

on disease prevention, in addition to caloric restriction.

MNT in secondary prevention of diabetes complicationsOptimal glycemic control prevents complications in both type

1 and type 2 diabetes.11,12,14 In the United Kingdom Prospective

Diabetes Study (UKPDS), which enrolled newly diagnosed

type 2 diabetes patients, HbA1c was 7.9% in the conventional

treatment group versus 7.0% in the intensive treatment group

over 10 years.12 This 0.9% reduction in HbA1c reduced the

risk of microvascular complications by 25% and all diabetes

endpoints by 12%. Similar to the long-term follow-up data of

the Diabetes Control and Complications Trial (DCCT)15 and

the Kumamoto study,16 this early and intensive glycemic control

had a legacy effect in reducing the risk of onset and progression

of all-diabetes events, including CVD and death, in the 10-year

post-trial period.17

In this context, MNT has been shown to reduce HbA1c

by an average of 1–2% in type 2 diabetes patients18-20 with

some studies reporting 0.25–2.9% reduction at 3–6 months. In

most of these studies, short disease duration and availability of

a registered dietitian to provide dietary advice were associated

with greater glycemic improvements.21-28 In other studies,

MNT was also found to reduce blood pressure and improve

lipid profiles.29-31

MNT has been shown to reduce

HbA1c by an average of 1–2% in

type 2 diabetes patients

Many conventional anti-diabetic agents, such as sulphonylureas

and insulin, can cause weight gain. In obese type 2 diabetes

patients, adiposity can worsen insulin resistance due to increased

release of free fatty acids, adipokines and cytokines, resulting

in increased drug usage; thus, setting up a vicious cycle.32 In a

6-month study, type 2 diabetes patients treated with intensive

insulin therapy had a reduction in HbA1c of 2.6%, but gained

an average of 8.7 kg.33 In the UKPDS, most patients gained

body weight over 10 years, particularly those treated with

insulin.34 Thus, glycemic control by increasing doses of insulin

and anti-diabetic agents (eg, sulphonylureas) may be offset by

weight gain with increased blood pressure and dyslipidemia.

The Look AHEAD (Action for Health in Diabetes) was

a multicenter, randomized trial comparing the effects of an

intensive lifestyle intervention (ILI) and diabetes support and

education (DSE) in 5,145 overweight or obese individuals with

type 2 diabetes mellitus in the US. The ILI participants had a

greater percentage weight loss than DSE participants (-6.15%

vs -0.88%; P < 0.001), which was associated with improved

control of blood glucose, blood pressure and blood lipids.

Based on the interim 4-year study results, adherence rates to

the program, percentage of weight loss and improvement in

cardiovascular risk factors were similar between severely and

mildly obese participants.35 However, to the dismay of many

clinicians, the Look AHEAD study was halted prematurely

in October 2012 because of futility.36 Although the study

found weight loss had many positive health benefits in type 2

diabetes patients, the weight loss did not reduce the number

of cardiovascular events at 11 years’ follow-up (5% vs -1%

weight loss in ILI and DSE participants, respectively).

MNT in tertiary prevention of progression of diabetes complicationsIn patients with diabetic nephropathy, salt (sodium) and

protein restrictions are recommended to reduce fluid

retention, blood pressure and rate of decline of renal function

(Tables 1 and 2). In type 1 and type 2 diabetes patients with

microalbuminuria,37-40 restriction of daily protein intake

(0.8–1.0 g per kg body weight) attenuated the rate of increase

in urinary albumin excretion and decline in glomerular

filtration rate. In type 1 diabetes with macroalbuminuria,

restriction of daily protein intake to 0.8 g per kg body weight

slowed the rate of decline in renal function.41

Nutritional recommendations of international diabetes associations

Professional diabetes associations from the US, Canada,

United Kingdom (UK) and Europe recognize the importance

of MNT and provide nutritional recommendations in their

diabetes management guidelines. Table 1 summarizes the

guidelines from the American Diabetes Association (ADA),

European Association for the Study of Diabetes (EASD),

Canadian Diabetes Association (CDA) and UK National

Institute for Health and Clinical Excellence (NICE).20,42-46

Since diet is a culture-specific behavior, there is a need to

take into consideration the trans-cultural attributes in guiding

nutritional recommendations in clinical practice.42,47,48 Table

2 lists the nutritional recommendations from five Asian

countries/cities.42,47,48 Although there are some differences in

the nutritional recommendations between the East and the

West, as well as between different countries and cities, there

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is a general consensus regarding the importance of weight

loss in overweight and obese individuals as well as adequate

fiber intake. In fact, many of the dietary guidelines for people

with diabetes are similar to those for the general population.

Professional diabetes associations

recognize the importance of MNT

and provide nutritional

recommendations in their diabetes

management guidelines

Dietary fat and cholesterolSaturated and trans fatty acids are the principal dietary

determinants of plasma low-density lipoprotein (LDL)

cholesterol, which is atherogenic. To reduce the risk for

CVD, all diabetes associations recommend that individuals

with diabetes should restrict dietary saturated fatty acids

to less than 10% of daily energy requirements, or in some

cases even lower (<7%) (Tables 1 and 2). Trans fatty acids

should be minimized and daily intake of dietary cholesterol

should be limited to 300 mg and in some cases even lower

(<200 mg). Although the US guideline does not have a

specific recommendation on monounsaturated fatty acids

(MUFA), both the European and Canadian guidelines

encourage dietary MUFA intake. Guidelines differ on the

recommended percentage of total fat from energy.

Glycemic index and glycemic loadThe role of the quality and quantity of dietary carbohydrates

in influencing glycemic control of diabetic patients remains

an ongoing debate. Clinical attention has been drawn to the

role of glycemic index (GI) in MNT of diabetic patients.49

In the 1980’s, Jenkins and colleagues first introduced the

concept of GI in the management of diabetes.50 The index

is used to characterize the glycemic potential of different

carbohydrate-rich foods. It is defined as the area under the

glucose response curve after consumption of a carbohydrate-

containing food compared with that due to intake of 25–50 g

carbohydrate from a control food.45,50-52 The higher the GI of a

food, the greater the area under the curve. In clinical practice,

it is important to understand that many factors can influence

the GI value of food and that GI should be considered in the

context of a healthy diet. Factors that tend to increase the

GI value of carbohydrate-rich foods include higher degree of

processing and preparation, longer cooking time and greater

ripeness or maturity of the food. On the other hand, food with

high fat, protein or fiber, especially soluble fiber, content tends

to have a lower GI value due to slower gastric emptying.

A meta-analysis of 14 randomized controlled trials,

including 356 subjects (203 with type 1 and 153 with type

2 diabetes), found that low GI diets reduced HbA1c by

0.43% compared with high GI diets.53 In this context, there

is increasing evidence, albeit not without controversies,

suggesting that post-prandial hyperglycemia might be an

independent risk factor for CVD.54-58 As such, low GI foods

may have the potential to reduce cardiovascular risk in diabetic

populations, although more evidence is needed to confirm

these benefits. Meanwhile, many diabetes associations, such

as those in Australia, Canada and Europe, encourage the use

of low GI and low glycemic load (GL) diets; however, not all

diabetes associations concur or include such recommendations

(Tables 1 and 2).

MNT for patients requiring nutritional support

There are situations where diabetic patients require special

nutritional support, which can be on either a short- or long-term

basis. These may include, but are not limited to: frail elderly

patients living in nursing homes; patients with suboptimal

nutrition during the pre- and postoperative periods; patients

with acute conditions, such as sepsis; or during the post-stroke

or -myocardial infarction rehabilitation periods. When patients

are unable to take an oral diet, tube feeding is the preferred route

of feeding. Tube feeding is associated with fewer complications

than parenteral nutrition, particularly in terms of glycemic

control, metabolic abnormalities and infection risk.59

Diabetes-specific formulamay be considered to provide

energy, as well as macro- and micronutrients, as a

component of MNT in diabeticpatients with special needs

Diabetes-specific formulas are typically formulated with

less carbohydrate, slowly digested carbohydrates, and more

fiber and fat than standard formulas, with a large proportion

of fat from MUFA. Compared to standard formulas, the

higher fat and fiber content of diabetes-specific formulas

can delay gastric emptying and intestinal absorption of

carbohydrate, resulting in a smaller post-prandial glycemic

rise. In a systematic review including 23 trials (19 randomized

controlled trials, three controlled clinical trials and one

clinical trial),60 the authors concluded that diabetes-specific

formulas given as oral supplements or tube feeds resulted in

less increase in postprandial blood glucose (1.03 mmol/L; 95%

confidence interval [CI] 0.58–1.47), peak blood glucose (1.59

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Table 1. Major nutritional recommendations in management guidelines for diabetes from North America and Europe

American Diabetes Association (ADA) (2008 and 2012)43,44

European Association for the Study of Diabetes (EASD) (2004)45

Canadian Diabetes Association (CDA) (2008)20

United Kingdom National Institute for Health and Clinical Excellence (NICE) (2008)46

Energy balance and body weight

For overweight and obese individuals: Deficit in caloric intake by 500–1,000 kcal/d; target to decrease body weight by 5–10%

For overweight individuals, caloric intake should be reduced and energy expenditure be increased

Not specified Target an initial body weight loss of 5–10% for overweight individuals

Carbohydrates (CHO) Not specified; Refer to RDA of average minimum of 130g/d

45–60% TEI 45–60% TEI Individualized

Glycemic index (GI) / Glycemic load (GL)

GI and GL provide a modest additional benefit that is observed when total CHO is considered alone

CHO-rich, low GI foods are suitable

Choose low GI foods more often

Encourage high-fibre, low GI sources of CHO

Sucrose Sucrose can be substituted for other CHO sources, but avoid excess energy intake

<10% TEI from sucrose (up to 50 g/d)

Up to 10% TEI from sucrose

Limited substitution of sucrose-containing foods for other CHO

Dietary fiber 14 g/1,000 kcal/d and foods containing whole grains (one half of grain intake)

40 g/d (or 20 g/1,000 kcal/d), about half of which should be soluble

25-50 g/d from a variety of sources, including soluble and cereal fibers

Encourage high fiber intake

Protein 15–20% TEI for normal renal function;0.8–1.0 g/kg body weight/d in earlier stage of CKD; 0.8 g/kg/d in later stage of CKD

10–20% TEI for normal renal function;0.8 g/kg body weight/d if nephropathy is established

15–20% TEI Not discussed

Fat Not specified <35% TEI (<30% if overweight)

≤35% TEI Not discussed

Saturated fat <7% TEI <10% TEI (saturated fat and trans fat)

≤7% TEI Not discussed

Trans fat Should be minimized <8% TEI if LDL-C ↑ Should be minimized Not discussed

Cholesterol <200 mg/d <300 mg/d and be further reduced if LDL-C ↑

<200 mg/d Not discussed

Monounsaturated fatty acids (MUFA)

Not specified Encourage MUFA which may provide 10–20% TEI

MUFA instead of saturated fat more often

Not discussed

Polyunsaturated fatty acids (PUFA)

Not specified;≥2 servings of fish intake per week to provide n-3 PUFA

≤10% TEI2–3 servings of oily fish weekly and plant sources of n-3 PUFA

<10% TEI (food rich in n-3 and plant oils)

Not discussed

Sodium / Salt Reduced sodium intake (eg, 2,300 mg/d) in normotensive and hypertensive individuals

<6 g salt/d and further restriction for those with elevated blood pressure

Not discussed Not discussed

Vitamin and mineral supplementation

No clear evidence of benefit in those who do not have underlying deficiencies;A daily multivitamin supplement may be appropriate, especially for older adults with reduced energy intake

Not discussed Routine supplementation is not necessary, except for vitamin D in persons aged >50 years and folic acid in women planning pregnancy

Not discussed

Alcohol Limit to ≤1 drink/d for women and ≤2 drinks/d for men

Moderate use of alcohol (up to 10 g/d for women and 20 g/d for men)

Limit to 1–2 drinks /d (≤14 standard drinks/week for men and ≤9/week for women)

Individualized

CKD, chronic kidney disease; CHO, carbohydrate; GI, glycemic index; GL, glycemic load; LDL-C, low density lipoprotein cholesterol; MUFA; monounsaturated fatty acids; PUFA, polyunsaturated fatty acids; RDA: recom-mended daily allowance; TEI, total energy intake

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Table 2. Major nutritional recommendations in diabetes management guidelines from five Asian cities or countries

Taiwan42,47 PR China42,47 Hong Kong SAR42,47 India42,47 Malaysia42,47,48

Energy balance and body weight

Weight loss for overweight and obese individuals

Weight loss for overweight and obese individuals

Weight loss for overweight and obese individuals (5–7%)

Weight loss for overweight and obese individuals (slow reduction of 7–10% over 1 year)

Weight loss for overweight and obese individuals (5–10% initial body weight over 6 months)

Carbohydrates (CHO) Amount not specified; recommend to distribute amongst three main meals per day

<55–65% TEI and not <130 g/d

45–65% TEI 60–70% TEI 50–60% TEI

Glycemic index (GI) / Glycemic load (GL)

Not discussed Not discussed Not discussed Not discussed Choice of low GI foods in place of conventional or high GI foods has a small effect on medium term glycemic control. GI must be used to complement established dietary concerns

Sucrose Not discussed Not discussed Not discussed Not discussed Limit to 10% TEI

Dietary fiber 15 g/1,000 kcal Not discussed Not discussed Not discussed 20–30 g/d

Protein 15–20% TEI <20% TEI 15–20% TEI 12–18% TEI 15% TEI or 0.8–1.0 g/kg/day

Fat Not discussed <30% TEI <30% TEI 20–25% TEI 25–30% TEI

Saturated fat <7% TEI Not discussed <10% TEI <7% TEI <7–10% TEI

Trans fat Not discussed Not discussed Not discussed Not discussed Minimize

Cholesterol <200 mg/d <300 mg/d <300 mg/d;<200 mg/d if LDL >100 mg/dL (or 2.6 mmol/L)

<200 mg/d 300 mg/d

Monounsaturated fatty acids (MUFA)

Not discussed Not discussed Not discussed Not discussed Maximize

Polyunsaturated fatty acids (PUFA)

Not discussed Not discussed Not discussed Not discussed 4–7% TEI

Sodium / Salt <2,400 mg/d Not discussed Not discussed Not discussed <2,400 mg/d

Vitamin and mineral supplementation

Not discussed Not discussed Not discussed Not discussed Supplement is indicated with confirmed deficiency

Alcohol Not discussed Not discussed Not discussed Not discussed Limit to ≤1drink/d for women and ≤2 drinks/d for men

CHO, carbohydrate; GI, glycemic index; GL, glycemic load; LDL-C, low density lipoprotein cholesterol; MUFA; monounsaturated fatty acids; PUFA, polyunsaturated fatty acids; TEI, total energy intake

mmol/L; 0.86–2.32) and glucose area under curve (7.96 mmol/

l*l-1*min-1; 2.25–13.66) compared with standard formulas.

Given the epidemiological data that has identified an association

between postprandial hyperglycemia and cardiovascular

morbidity and mortality in diabetes and pre-diabetes,54-58 these

favorable glycemic effects of diabetes-specific formulas may be

translated to long-term benefits on cardiovascular outcomes.

Pending definitive evidence, diabetes-specific formulas

may be considered to provide energy as well as macro- and

micronutrients as a component of MNT in diabetic patients

with special needs.42

MNT during pregnancy

In women with gestational diabetes mellitus (GDM), several

small studies have suggested that low GI diets might safely

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decrease maternal body weight, reduce the need for insulin

and lower the risk of macrosomia.61-63 A recently published

randomized controlled trial including 800 women, with history

of previously delivering an infant >4 kg and without diabetes

in their second pregnancy, were randomized to receive no

dietary intervention or a low GI diet from early pregnancy.64

Although there was no significant difference between the two

groups, there was a trend for less gestational weight gain and

lower rate of glucose intolerance in the intervention compared

with the control arm.64

Pregnancy in obese women with GDM requires special

nutritional consideration. While hypocaloric diets in these

women can result in ketonemia and ketonuria, moderate caloric

restriction (eg, 30% reduction of estimated energy needs) may

improve glycemic control without ketonemia. However, there

are limited data on the effects of caloric restriction on fetal

outcomes and there are only few data from randomized clinical

trials regarding dietary intervention in pregnant women with

GDM. In a clinical trial including 1,000 women with GDM

(490 randomized to the intervention group and 510 to routine

care), intervention (dietary advice, blood glucose monitoring

and insulin therapy, if needed) significantly reduced serious

perinatal complications (1% versus 4%; relative risk 0.33; 95%

CI 0.14-0.75: P = 0.01).65

MNT – Controversies and challenges

Despite the advocacy for use of a low GI diet by some diabetes

associations, its role in the management of obesity and

prevention of diabetes remains inconclusive.66 Modern food

processing technology produces many food products with

refined carbohydrates and high GI, which may cause accelerated

and transient surges in blood glucose and insulin, reduced

satiety and excessive caloric intake. These post-prandial events

may cause neurohormonal dysregulation (eg, hyperinsulinemia

and activation of sympathetic nervous system) and endothelial

dysfunction (hyperglycemia and oxidative stress).66 On the

other hand, whether low GI diets and increased intake of

whole grains and dietary fiber can reduce risk of diabetes67-72

remains to be proven.73 Similarly, the beneficial effect of low

GI foods on plasma lipid levels remains controversial.45 In

a preliminary interim analysis of an ongoing randomized

controlled trial of 100 obese school children aged 15–18 years

in Hong Kong (ClinicalTrials.gov Ref. No.: NCT 01278563),

subjects assigned to a low GI diet had greater weight reduction

after 6 months, but similar glycemic, lipid and blood pressure

profiles, to those taking traditional Chinese diets (Kong A, et al.;

unpublished data).

Apart from carbohydrate, there are ongoing deliberations

on the effects of the quantity and quality of dietary fat on

primary, secondary and tertiary management of diabetes.

The optimal ratio of carbohydrate-to-fat in the prevention of

diabetes is not known.74 Despite quite a number of functional

foods and supplements, such as fiber-enriched products and

margarines containing plant sterols, that are being actively

promoted or marketed, many of the claims in preserving health

and preventing or controlling disease are not supported by

sufficient clinical evidence.45

From a practical perspective, the challenges encountered

by diabetic patients in understanding the variety of food choices

and compositions, including counting of macronutrients

especially on carbohydrates, cannot be over-emphasized. Spiegel

and colleagues recently reported results from a randomized

controlled nutrition interventional trial to improve carbohydrate

counting among adolescents with type 1 diabetes.75 Although

HbA1c decreased in both intervention and control groups

after 3 months, the change in the intervention group was not

statistically significant; thereby, further research is needed to

translate nutrition education into improved health outcomes.

Patients should be encouraged to regularly monitor

their post-prandial blood glucose levels to ascertain their food

choices, and ensure that carbohydrate counts are accurate. The

recent advances in blood glucose monitoring technology, such

as the use of a continuous glucose monitoring device (CGMS),

can assist with meal planning for patients with diabetes.

Furthermore, such technology can facilitate effective counselling

to improve glycemic control, and provide on-going feedback

on glucose levels to empower our diabetic patients. Here, more

translational studies are needed to evaluate different strategies

to educate, engage and enable patients in choosing healthy

food choices.

Conclusions

Based on a large body of evidence, most international

diabetes associations recommend MNT as an integral part

in the prevention and management strategies of diabetes

and its complications. The diabetes associations have a

general consensus regarding the importance of weight loss

in overweight and obese individuals, adequate dietary fiber

intake, and restrictions on dietary saturated fat, trans fat and

cholesterol intakes. However, there is no unified agreement

on specific distribution of protein, carbohydrates and fat from

total energy. All members of the multidisciplinary diabetes

management team should be aware of the importance and

be equipped with knowledge to help patients to implement

MNT as part of their comprehensive diabetes treatment

plan. Prescription of MNT should also be individualized,

patient-centered and take into consideration cultural and

social factors to facilitate successful patient implementation.

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17. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577-1589.

18. Pastors JG, Franz MJ, Warshaw H, Daly A, Arnold MS. How effective is medical nutrition therapy in diabetes care? J Am Diet Assoc 2003;103:827-831.

19. Pastors JG, Warshaw H, Daly A, Franz M, Kulkarni K. The evidence for the effectiveness of medical nutrition therapy in diabetes management. Diabetes Care 2002;25:608-613.

20. Canadian Diabetes Association. Canadian Diabetes Association 2008 Clinical Practice Guidelines of the Prevention and Management of Diabetes in Canada. Can J Diabetes 2008;32(Suppl 1):S40-S46.

21. Franz MJ, Monk A, Barry B, et al. Effectiveness of medical nutrition therapy provided by dietitians in the management of non-insulin-dependent diabetes mellitus: a randomized, controlled clinical trial. J Am Diet Assoc 1995;95:1009-1017.

22. Miller CK, Edwards L, Kissling G, Sanville L. Nutrition education improves metabolic outcomes among older adults with diabetes mellitus: results from a randomized controlled trial. Prev Med 2002;34:252-259.

23. Graber AL, Elasy TA, Quinn D, Wolff K, Brown A. Improving glycemic control in adults with diabetes mellitus: shared responsibility in primary care practices. South Med J 2002;95:684-690.

24. Goldhaber-Fiebert JD, Goldhaber-Fiebert SN, Tristan ML, Nathan DM. Randomized controlled community-based nutrition and exercise intervention improves glycemia and cardiovascular risk factors in type 2 diabetic patients in rural Costa Rica. Diabetes Care 2003;26:24-29.

25. Wilson C, Brown T, Acton K, Gilliland S. Effects of clinical nutrition education and educator discipline on glycemic control outcomes in the Indian health service. Diabetes Care 2003;26:2500-2504.

26. Lemon CC, Lacey K, Lohse B, et al. Outcomes monitoring of health, behavior, and quality of life after nutrition intervention in adults with type 2 diabetes. J Am Diet Assoc 2004;104:1805-1815.

27. Logminiene Z, Norkus A, Valius L. Direct and indirect diabetes costs in the world. Medicina (Kaunas) 2004;40:16-26.

28. Gaetke LM, Stuart MA, Truszczynska H. A single nutrition counseling session with a registered dietitian improves short-term clinical outcomes for rural Kentucky patients with chronic diseases. J Am Diet Assoc 2006;106:109-112.

29. Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med 1997;336:1117-1124.

30. Van Horn L, McCoin M, Kris-Etherton PM, et al. The evidence for dietary prevention and treatment of cardiovascular disease. J Am Diet Assoc 2008;108:287-331.

31. Wing RR. Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: four-year results of the Look AHEAD trial. Arch Intern Med 2010;170:1566-1575.

32. Kong AP, Chan NN, Chan JC. The role of adipocytokines and neurohormonal dysregulation in metabolic syndrome. Cur Diabetes Rev 2006;2:397-407.

33. Henry RR, Gumbiner B, Ditzler T, et al. Intensive conventional insulin therapy for type II diabetes. Metabolic effects during a 6-mo outpatient trial. Diabetes Care 1993;16:21-31.

34. Turner RC, Cull CA, Frighi V, Holman RR. Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: progressive requirement for multiple therapies (UKPDS 49). UK Prospective Diabetes Study (UKPDS) Group. JAMA 1999;281:2005-2012.

35. Unick JL, Beavers D, Jakicic JM, et al. Effectiveness of lifestyle interventions for individuals with severe obesity and type 2 diabetes: results from the Look AHEAD trial. Diabetes Care 2011;34:2152-2157.

36. National Institutes of Health. NIH News; October 2012. Available at: www.nih.gov/news/health/oct2012/niddk-19.htm. Accessed: 19 November 2012.

37. Dullaart RP, Beusekamp BJ, Meijer S, van Doormaal JJ, Sluiter WJ. Long-term effects of protein-restricted diet on albuminuria and renal function in IDDM patients without clinical nephropathy and hypertension. Diabetes Care 1993;16:483-492.

38. Pomerleau J, Verdy M, Garrel DR, Nadeau MH. Effect of protein intake on glycaemic control and renal

function in type 2 (non-insulin-dependent) diabetes mellitus. Diabetologia 1993;36:829-834.39. Narita T, Koshimura J, Meguro H, et al. Determination of optimal protein contents for a protein

restriction diet in type 2 diabetic patients with microalbuminuria. Tohoku J Exp Med 2001;193:45-55.40. Pijls LT, de Vries H, van Eijk JT, Donker AJ. Protein restriction, glomerular filtration rate and albuminuria

in patients with type 2 diabetes mellitus: a randomized trial. Eur J Clin Nutr 2002;56:1200-1207.41. Hansen HP, Tauber-Lassen E, Jensen BR, Parving HH. Effect of dietary protein restriction on prognosis

in patients with diabetic nephropathy. Kidney Int 2002;62:220-228.42. Mechanick JI, Marchetti AE, Apovian C, et al. Diabetes-specific nutrition algorithm: a transcultural

program to optimize diabetes and prediabetes care. Curr Diab Rep 2012;12:180-194.43. American Diabetes Association. Nutrition Recommendations and Interventions for Diabetes. Diabetes

Care 2008;27(Suppl 1):S61-S78.44. American Diabetes Association. Standards of Medical Care in Diabetes – 2012. Diabetes Care

2012;35(Suppl 1):S11-S63.45. Diabetes and Nutrition Study Group (DNSG) of the European Association for the Study of Diabetes

(EASD). Evidence-based nutritional approaches to the treatment and prevention of diabetes mellitus. Nutr Metab Cardiovasc Dis 2004;14:373-394.

46. National Collaborating Centre for Chronic Conditions (United Kingdom). Type 2 Diabetes: National Clinical Guidelines for Management in Primary and Secondary Care (Update). London: Royal College of Physicians: 2008.

47. Su HY, Tsang MW, Huang SY, et al. Transculturalization of a diabetes-specific nutrition algorithm: Asian application. Curr Diab Rep 2012;12:213-219.

48. Malaysian Dietitians’ Association and Malaysia Ministry of Health. Medical Nutrition Therapy Guide-lines for Type 2 Diabetes. 2005.

49. Brand-Miller J, McMillan-Price J, Steinbeck K, Caterson I. Carbohydrates--the good, the bad and the whole grain. Asia Pac J Clin Nutr 2008;17(Suppl 1):16-19.

50. Jenkins DJ, Wolever TM, Taylor RH, et al. Glycemic index of foods: a physiological basis for carbohy-drate exchange. Am J Clin Nutr 1981;34:362-366.

51. Jenkins DJ, Wolever TM, Jenkins AL, et al. The glycaemic response to carbohydrate foods. Lancet 1984;2:388-391.

52. Hofman Z, De Van Drunen J, Kuipers H. The glycemic index of standard and diabetes-specific enteral formulas. Asia Pac J Clin Nutr 2006;15:412-417.

53. Brand-Miller J, Hayne S, Petocz P, Colagiuri S. Low-glycemic index diets in the management of diabetes: a meta-analysis of randomized controlled trials. Diabetes Care 2003;26:2261-2267.

54. Chiasson JL, Josse RG, Gomis R, et al. Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomised trial. Lancet 2002;359:2072-2077.

55. Chiasson JL, Josse RG, Gomis R, et al. Acarbose treatment and the risk of cardiovascular disease and hypertension in patients with impaired glucose tolerance: the STOP-NIDDM trial. JAMA 2003;290:486-494.

56. Fonseca V. Clinical significance of targeting postprandial and fasting hyperglycemia in managing type 2 diabetes mellitus. Curr Med Res Opin 2003;19:635-641.

57. Heine RJ, Balkau B, Ceriello A, et al. What does postprandial hyperglycaemia mean? Diabet Med 2004;21:208-213.

58. Ceriello A, Davidson J, Hanefeld M, et al. Postprandial hyperglycaemia and cardiovascular complica-tions of diabetes: an update. Nutr Metab Cardiovasc Dis 2006;16:453-456.

59. Garvey, LNT. Nutritional and Medical Management of Diabetes Mellitus in Hospitalized Patients: in The A.S.P.E.N. Adult Nutrition Support Core Curriculum. C.M. Mueller, Editor. 2012, A.S.P.E.N.: Silver Spring: 580-602.

60. Elia M, Ceriello A, Laube H, et al. Enteral nutritional support and use of diabetes-specific formulas for patients with diabetes: a systematic review and meta-analysis. Diabetes Care 2005;28:2267-2279.

61. Clapp JF, 3rd. Maternal carbohydrate intake and pregnancy outcome. Proc Nutr Soc 2002;61:45-50.62. Moses RG, Luebcke M, Davis WS, et al. Effect of a low-glycemic-index diet during pregnancy on

obstetric outcomes. Am J Clin Nutr 2006;84:807-812.63. Moses RG, Barker M, Winter M, Petocz P, Brand-Miller JC. Can a low-glycemic index diet reduce the

need for insulin in gestational diabetes mellitus? A randomized trial. Diabetes Care 2009;32:996-1000.

64. Walsh JM, McGowan CA, Mahony R, Foley ME, McAuliffe FM. Low glycaemic index diet in pregnancy to prevent macrosomia (ROLO study): randomised control trial. BMJ 2012;345:e5605.

65. Crowther CA, Hiller JE, Moss JR, et al. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005;352:2477-2486.

66. Kong AP, Chan RS, Nelson EA, Chan JC. Role of low-glycemic index diet in management of childhood obesity. Obes Rev 2011;12:492-498.

67. Meyer KA, Kushi LH, Jacobs DR Jr, et al. Carbohydrates, dietary fiber, and incident type 2 diabetes in older women. Am J Clin Nutr 2000;71:921-930.

68. Schulze MB, Liu S, Rimm EB, et al. Glycemic index, glycemic load, and dietary fiber intake and incidence of type 2 diabetes in younger and middle-aged women. Am J Clin Nutr 2004;80:348-356.

69. Stevens J, Ahn K, Juhaeri, et al. Dietary fiber intake and glycemic index and incidence of diabetes in African-American and white adults: the ARIC study. Diabetes Care 2002;25:1715-1721.

70. Villegas R, Liu S, Gao YT, et al. Prospective study of dietary carbohydrates, glycemic index, glycemic load, and incidence of type 2 diabetes mellitus in middle-aged Chinese women. Arch Intern Med 2007;167:2310-2316.

71. Krishnan S, Rosenberg L, Singer M, et al. Glycemic index, glycemic load, and cereal fiber intake and risk of type 2 diabetes in US black women. Arch Intern Med 2007;167:2304-2309.

72. Barclay AW, Petocz P, McMillan-Price J, et al. Glycemic index, glycemic load, and chronic disease risk--a meta-analysis of observational studies. Am J Clin Nutr 2008;87:627-637.

73. Liese AD, Schulz M, Fang F, et al. Dietary glycemic index and glycemic load, carbohydrate and fiber intake, and measures of insulin sensitivity, secretion, and adiposity in the Insulin Resistance Athero-sclerosis Study. Diabetes Care 2005;28:2832-2838.

74. Grundy SM. The optimal ratio of fat-to-carbohydrate in the diet. Annu Rev Nutr 1999;19:325-341.75. Spiegel G, et al. Randomized nutrition education intervention to improve carbohydrates counting

in adolescents with type 1 diabetes study: Is more intensive education needed? J Acad Nutr Diet 2012;112:1736-1746.

References

Acknowledgements: The data of some of the studies described in this manuscript were supported by the Research Grant Committee (CUHK 467410), Li Ka Shing Institute of Health Science and Hong Kong Institute of Diabetes and Obesity, under the auspices of The Chinese University of Hong Kong.

Health eco

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As of 2012, an estimated 371 million individuals worldwide had diabetes (8.3% of the total adult population), of which 187 million people were undiagnosed.1 Moreover, an additional 280 million people had impaired glucose tolerance (6.4%).2 The prevalence of diabetes is expected to reach 552 million by 2030, with major increases forecast in the Middle East and Africa (83–90% increase, with 81% undiagnosed today) and South-east Asia (69% increase).1,3 Diabetes is associated with multiple morbidities (Figure 1), which place a significant burden on healthcare resources worldwide.

Figure 1. Global burden of diabetes and its multiple comorbidities

In the United States (US), the total medical expenditure related to diabetes increased from USD 1.7 billion in 1969 to USD 44.4 billion in 1997.14 Total costs of diagnosed diabetes in the US in 2007 were estimated at USD 174 billion; direct medical costs represented USD 116 billion and indirect costs USD 58 billion (ie, disability, work loss, premature mortality).6 After adjusting for population, age and sex differences, average medical expenditure among people with diagnosed diabetes was 2.3 times greater than in those without diabetes.6

Expressed as a percentage of gross domestic product (GDP), India currently bears the heaviest cost burden for diabetes, accounting for approximately 2.1% of GDP (Figure 2). Among developed countries, the US faces the biggest burden, with an estimated cost equivalent to 1.2% of GDP in 2007. The United Kingdom faces costs of 0.4% of GDP, while Denmark incurs costs equivalent to 0.6% of GDP. Lost productivity costs alone for China are equivalent to 0.6% of GDP (USD 20.5 billion). While this data for China may not seem large on face value across the general population, it represents over 20% of GDP per capita.1

In most countries, 5% to 18% of healthcare expenditure is on diabetes. In 2012, an estimated USD 471 billion was spent on diabetes worldwide, mainly for treating complications.1

One study from the Diabetes Prevention Program (DPP) concluded that Intensive Lifestyle Change (ILC – Diet

plus moderate exercise) reduced the risk of developing type 2 diabetes by 58% versus control.16 Based on these clinical results, Palmer et al. showed an incremental cost-effectiveness ratio (ICER) of €6,381 (USD 8,166)/life-year gained for ILC versus control (2002 costs).17 The DPP group also found that ILC was more cost-effective than control. Furthermore, from both a health system and societal perspective, ILC is more cost-effective than metformin in terms of cost/quality-adjusted life year (QALY) and cost/case prevented (Table).18

Table. Cost-effectiveness analysis of Intensive Lifestyle Change versus metformin in diabetes18

DPP group results

Health system perspective Societal perspective

Costs [USD] Per prevented/delayed diabetes case

Per QALY Per prevented/delayed diabetes case

Per QALY

Lifestyle inter-vention (ILC)

15,700 31,500 24,400 51,600

Metformin 1,300 99,600 34,500 99,200

Adapted from Diabetes Prevention Program (DPP).18 QALY: quality-adjusted life year

Similar results were found in a study conducted in Finland by Eriksson et al.19 The combination of diet and exercise was most effective in reversing the insulin resistance syndrome compared with each of these components separately.

Diabetes is running at record levels worldwide and half of the people estimated to have the disease are as of yet undiagnosed. Diabetes can lead to serious and costly complications, with a significant worldwide economic burden. Dietary intervention should be considered as part of the solution as it is a worthwhile investment as part of a diabetes prevention and management program.

Health economic perspectiveWorldwide burden of diabetes and its multiple morbiditiesClaire Takizawa PharmD, MSc Nestlé Health Science Switzerland

Alice Pik-Shan Kong FRCP Department of Medicine and Therapeutics The Chinese University of Hong Kong Hong Kong SAR

References1. International Diabetes Federation. IDF Diabetes Atlas. 5th Edition. 2012 Update. Accessed: 19 November 2012. 2. International Diabetes Federation. IDF Global Burden. Available at: http://www.idf.org/diabetesatlas/5e/the-global-burden. Accessed: 26 November 2012. 3. International Diabetes Federation. IDF Diabetes Atlas. Regional overviews. Available at: http://www.idf.org/diabetesatlas/5e/regional-overviews. Accessed: 26 November 2012. 4. Roglic G, Unwin N. Diabetes Res Clin Pract 2010;87:15-19. 5. International Diabetes Feder-ation. Factsheet: Diabetes and Cardiovascular disease. Available at: http://www.idf.org/fact-sheets/diabetes-cvd. Accessed: 26 November 2012. 6. Center for Disease Control and Prevention. National Diabetes Fact Sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed: 19 November 2012. 7. Haffner SM, et al. N Engl J Med 1998;339:229-334. 8. Kannel WB, et al. Am Heart J 1990;120:672-676. 9. Fong DS, et al. Diabetes Care 2004;27(Suppl 1):S84-S87. 10. Ritz E, et al. Am J Kidney Dis 1999;34:795-808. 11. Boulton AJ, et al. Diabetes Care 2004;27:1458-1486. 12. Kong AP, Chan JC. Curr Diab Rep 2012;12:325-328. 13. The Emerging Risk Factors Collaboration. N Engl J Med 2011;364:829-841. 14. Logeminiene Z, et al. Medicina (Kaunas) 2004;40:16-26. 15. Silent epidemic – An economic study of diabetes in developed and developing countries. The Economist 2011. Available at: http://www.eiu.com/site_info.asp?info_name=eiu_NovoNordisk_The_silent_epidemic. Accessed: 19 November 2012 16. The Diabetes Prevention Program Research Group. N Engl J Med 2002;346:393-403. 17. Palmer AJ, et al. Clin Ther 2004;26:304-321. 18. Diabetes Prevention Program Research Group. Diabetes Care 2003;26:2518-2523. 19. Eriksson J, et al. Diabetologia 1999;42:793-801.

DenmarkTotal cost as %

of GDP 0.6

IndiaTotal cost as %

of GDP 2.1

UKTotal cost as %

of GDP 0.4

USTotal cost as %

of GDP 1.2

Mortality- 4.6 million adults in 20124

- 6-8% all-cause mortality (all ages)4

Cancer- important comorbidity and cause of death12

- premature death from cancer and infectious diseases13

Cardiovascular comorbidities- CVD: a leading cause of death, up to 50% or more in some populations5

- CHD: 2- to 4-times increased risk6,7

- stroke: 2-times increased risk6,8

Retinopathy- most frequent cause of new cases of blindness in adults (20–74 years)6,9

Neuropathy- up to 50% of diabetes patients6,11

Renal disease- leading cause of kidney failure6,10

- 40% of patients on dialysis are diabetics6,10

Diabetes371 million

individuals globally1

Healthcare costs 0.2

Productivity loss 0.4







CHD, coronary heart disease; CVD, cardiovascular disease

GDP, gross domestic product

Figure 2. Productivity and healthcare as percentage of GDP15

DenmarkTotal cost as %

of GDP 0.6

IndiaTotal cost as %

of GDP 2.1

UKTotal cost as %

of GDP 0.4

USTotal cost as %

of GDP 1.2

Mortality- 4.6 million adults in 20124

- 6-8% all-cause mortality (all ages)4

Cancer- important comorbidity and cause of death12

- premature death from cancer and infectious diseases13

Cardiovascular comorbidities- CVD: a leading cause of death, up to 50% or more in some populations5

- CHD: 2- to 4-times increased risk6,7

- stroke: 2-times increased risk6,8

Retinopathy- most frequent cause of new cases of blindness in adults (20–74 years)6,9

Neuropathy- up to 50% of diabetes patients6,11

Renal disease- leading cause of kidney failure6,10

- 40% of patients on dialysis are diabetics6,10

Diabetes371 million

individuals globally1









CHD, coronary heart disease; CVD, cardiovascular disease

GDP, gross domestic product

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CLINICAL NUTRITION ABSTRACTS

The abstracts included in this section were selected from a search on clinical nutrition and related topics of the PubMed database of the United States National Library of Medicine. PubMed may be accessed via the National Library of Medicine Web site at www.nlm.nih.gov.

CANCER

Perioperative nutrition support in cancer patientsNutr Clin Pract 2012 Oct;27(5):586-592. Huhmann MB, August DA. Department of Nutritional Science, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.

Malnutrition and weight loss negatively affect outcomes in surgical cancer patients. Decades of research have sought to identify the most appropriate use of nutrition support in these patients. National and international guidelines help to direct clinicians’ use of nutrition support in surgical patients, but a number of specific issues concerning the use of nutrition support continue to evolve. This review focuses on five key issues related to perioperative nutrition support in cancer patients: (1) Which perioperative cancer patients should receive nutrition support?; (2) How can the nutrition status and requirements of these patients be optimally assessed?; (3) What is the optimal route of administration (parenteral nutrition vs enteral nutrition) and composition of nutrition support in this setting?; (4) When should feedings be initiated?; (5) What is the role of glycemic control in these patients?

CRITICAL CARE

Intra-abdominal pressure as a prognostic factor for tolerance of enteral nutrition in critical patientsJPEN J Parenter Enteral Nutr 2012 Oct 15. [Epub ahead of print] Bejarano N, Navarro S, Rebasa P, García-Esquirol O, Hermoso J. Department of Surgery, Intensive Care Unit, Hospital Universitario, Barcelona, Spain.

BACKGROUND: The purpose of this study is to establish a relationship between tolerance of enteral nutrition (EN) and intra-abdominal pressure (IAP) in critical patients, establish an objective measure for monitoring tolerance, and determine a threshold value for IAP. MATERIALS AND METHODS: Prospective and observational study at the critical care unit. Seventy-two patients were recruited with an expected stay of more than 72 hours and scheduled to receive EN. We recorded IAP and clinical and laboratory variables to describe predictive ones for tolerance of EN at the start of nutrition. RESULTS: The largest group was polytrauma patients (41.7%). Of the patients, 40.3% had undergone surgery prior to inclusion in the study. Most patients (87.5%) were fed via nasogastric tube. Physiological POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity) on admission was 26.4 ± 7.6, and surgical POSSUM was 22.4 ± 8.0. The mean Acute Physiology and Chronic Health Evaluation II

(APACHE II) score was 13.6 ± 6.0. Mortality was 31.9%. In all, 70.8% tolerated EN. The univariate analysis revealed a statistically significant relation between tolerance of EN and surgical POSSUM, APACHE II, and baseline IAP. The multi-variate analysis showed a relationship between APACHE II score, baseline IAP, and the tolerance of EN. So, on the basis of these two variables, logistic regression analysis can predict whether a patient will tolerate the diet with an overall precision of 80.3%. CONCLUSIONS: In critically ill patients, there is a relation between IAP values and the tolerance of EN. The baseline IAP with the APACHE II score can predict the tolerance of EN.

The effects of probiotics in early enteral nutrition on the outcomes of trauma: A meta-analysis of randomized controlled trialsJPEN J Parenter Enteral Nutr 2012 Oct 12. [Epub ahead of print] Gu WJ, Deng T, Gong YZ, Jing R, Liu JC. Department of Anaesthesiology, The First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi, People’s Republic of China.

BACKGROUND: The role of probiotics in trauma patients remains unclear. We undertook a meta-analysis of published randomized controlled trials (RCTs) to assess the effects of probiotics on the clinical outcomes of trauma patients. METHODS: A systematic electronic literature search was conducted to identify RCTs comparing the use of probiotics with a control in trauma patients. Results were expressed as risk ratios (RRs) or standardized mean differences (SMDs) with accompanying 95% confidence intervals (CIs). The primary outcome measurement was the incidence of nosocomial infections. Secondary outcome measurements included the incidence of ventilator-associated pneumonia (VAP), length of intensive care unit (ICU) stay, and mortality. The meta-analysis was performed with the fixed-effect or random-effect model according to the hetero-geneity. RESULTS: Five studies involving 281 patients met our inclusion criteria. The use of probiotics was associated with a reduction in the incidence of nosocomial infections (five trials; RR, 0.65; 95% CI, 0.45–0.94, P = 0.02), VAP (three trials; RR, 0.59; 95% CI, 0.42–0.81, P = 0.001), and length of ICU stay (two trials; SMD, -0.71; 95% CI, -1.09–0.34, P < 0.001) but no reduction in mortality (four trials; RR, 0.63; 95% CI, 0.32–1.26, P = 0.19). CONCLUSIONS: The use of probiotics is associated with a reduction in the incidence of nosocomial infections, VAP, and length of ICU stay but is not associated with an overall mortality advantage. However, the results should be interpreted cautiously due to the heterogeneity among study designs. Further large-scale, well-designed RCTs are needed.

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Permissive underfeeding versus target enteral feeding in adult critically ill patients (PermiT trial): A study protocol of a multicenter randomized controlled trialTrials 2012 Oct 12;13(1):191. Arabi YM, Haddad SH, Aldawood AS, Al-Dorzi HM, Tamim HM, Sakkijha M, Jones G, McIntyre L, Mehta S, Solaiman O, Sadat M, Afesh L, Sami B. King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.

BACKGROUND: Nutritional support is an essential part of the management of critically ill patients. However, optimal caloric intake has not been systematically evaluated. We aim to compare two strategies of enteral feeding: permissive underfeeding versus target feeding. METHOD/DESIGN: This is an international multicenter randomized controlled trial in critically ill medical-surgical adult patients. Using a centralized allocation, 862 patients will be randomized to permissive underfeeding or target feeding. Patients in the permissive group receive 50% (acceptable range is 40% to 60%) of the calculated caloric requirement, while those in the targeted group receive 100% (acceptable range 70% to 100%) of the calculated caloric requirement. The primary outcome is 90-day all-cause mortality. Secondary outcomes include ICU and hospital mortality, 28-day, and 180-day mortality as well as health care-associated infections, organ failure, and length of stay in the ICU and hospital. The trial has 80% power to detect an 8% absolute reduction in 90-day mortality assuming a baseline risk of death of 25% at an alpha level of 0.05. DISCUSSION: Patient recruitment started in November 2009 and is currently active in five centers. The Data Monitoring Committee advised continuation of the trial after the first interim analysis. The study is expected to finish by November 2013.

Combined enteral feeding and total parenteral nutritional support improves outcome in surgical intensive care unit patientsJ Chin Med Assoc 2012 Sep;75(9):459-463. Hsu MH, Yu YE, Tsai YM, Lee HC, Huang YC, Hsu HS. Institute of Emergency and Critical Care Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC.

BACKGROUND: For intensive care unit (ICU) patients with gastrointestinal dysfunction and in need of total parenteral nutrition (TPN) support, the benefit of additional enteral feeding is not clear. This study aimed to investigate whether combined TPN with enteral feeding is associated with better outcomes in surgical intensive care unit (SICU) patients. METHODS: Clinical data of 88 patients in SICU were retro-spectively collected. Variables used for analysis included route and percentage of nutritional support, total caloric intake, age, gender, body weight, body mass index, admission diagnosis, surgical procedure, Acute Physiology and Chronic Health Evaluation (APACHE) II score, comorbidities, length of hospital stay, postoperative complications, blood glucose values and hospital mortality. RESULTS: Wound dehiscence and central catheter infection were observed more frequently in the group of patients receiving TPN calories less than 90% of total calorie intake (P = 0.004 and 0.043, respec-tively). APACHE II scores were higher in nonsurvivors than in survivors (P = 0.001). More nonsurvivors received TPN

calories exceeding 90% of total calorie intake and were in need of dialysis during ICU admission (P = 0.005 and 0.013, respec-tively). Multivariate analysis revealed that the percentage of TPN calories over total calories and APACHE II scores were independent predictors of ICU mortality in patients receiving supplementary TPN after surgery. CONCLUSION: In SICU patients receiving TPN, patients who could be fed enterally more than 10% of total calories had better clinical outcomes than patients receiving less than 10% of total calorie intake from enteral feeding. Enteral feeding should be given whenever possible in severely ill patients.

Barriers to feeding critically ill patients: A multicenter survey of critical care nursesJ Crit Care 2012 Dec;27(6):727-734. Cahill NE, Murch L, Cook D, Heyland DK; On behalf of the Canadian Critical Care Trials Group. Department of Community Health and Epidemiology, Queen’s University, Kingston, Ontario, Canada; Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada.

PURPOSE: The aims of this study were to describe the barriers to enterally feeding critically ill patients from a nursing perspective and to examine whether these barriers differ across centers. MATERIALS AND METHODS: A cross-sectional survey was conducted in five hospitals in North America. A 45-item questionnaire was administered to critical care nurses to evaluate the barriers to enterally feeding patients. RESULTS: A total of 138 of 340 critical care nurses completed the questionnaire (response rate of 41%). The five most important barriers to nurses were as follows: (1) other aspects of patient care taking priority over nutrition; (2) not enough feeding pumps available; (3) enteral formula not available on the unit; (4) difficulties in obtaining small bowel access in patients not tolerating enteral nutrition; and (5) no or not enough dietitian coverage during weekends and holidays. For 18 (81%) of 22 potential barriers, the rated magnitude of importance was similar across the five intensive care units. CONCLUSION: Nurses in our multicenter survey identified important barriers to providing adequate enteral nutrition to their critically ill patients. The importance of these barriers does not appear to differ significantly across different clinical settings. Future research is required to evaluate if tailoring interventions to overcome these identified barriers is an effective strategy of improving nutrition practice.

Association of low serum 25-hydroxyvitamin D levels and acute kidney injury in the critically illCrit Care Med 2012 Dec;40(12):3170-3179. Braun AB, Litonjua AA, Moromizato T, Gibbons FK, Giovannucci E, Christopher KB. Renal Division, Brigham and Women’s Hospital (ABB); Channing Laboratory and Pulmonary and Critical Care Division (AAL); The Nathan E. Hellman Memorial Laboratory, Renal Division (TM, KBC), Brigham and Women’s Hospital, Boston, Massachusetts, USA; Pulmonary Division, Massachusetts General Hospital (FKG), Boston, Massachusetts, USA; Departments of Nutrition and Epidemiology (EG), Harvard School of Public Health, Boston, Massachusetts, USA.

OBJECTIVE: Given the importance of inflammation in acute kidney injury and the relationship between vitamin D and inflammation, we sought to elucidate the effect of vitamin D on acute kidney injury. We hypothesized that deficiency

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in 25-hydroxyvitamin D prior to hospital admission would be associated with acute kidney injury in the critically ill. DESIGN: Two-center observational study of patients treated in medical and surgical intensive care units. SETTING: Two hundred nine medical and surgical intensive care beds in two teaching hospitals in Boston, Massachusetts. PATIENTS: Two thousand seventy-five patients, aged ≥18 yrs, in whom serum 25-hydroxyvitamin D was measured prior to hospitalization between 1998 and 2009. INTERVEN-TIONS: None. MEASUREMENTS AND MAIN RESULTS: The exposure of interest was preadmission serum 25-hydroxyvitamin D and categorized a priori as deficiency (25-hydroxyvitamin D ≤15 ng/mL), insuffi-ciency (25-hydroxyvitamin D15–30 ng/mL), or sufficiency (25-hydroxyvitamin D ≥30 ng/mL). The primary outcome was acute kidney injury defined as meeting Risk, Injury, Failure, Loss, and End-stage kidney disease (RIFLE) Injury or Failure criteria. Logistic regression examined the RIFLE criteria outcome. Adjusted odds ratios were estimated by multivariate logistic regression models. Preadmission 25-hydroxyvitamin D deficiency is predictive of acute kidney injury. Patients with 25-hydroxyvitamin D deficiency have an odds ratio for acute kidney injury of 1.73 (95% confidence interval [CI] 1.30–2.30; P < 0.0001) relative to patients with 25-hydroxyvi-tamin D sufficiency. 25-Hydroxyvitamin D deficiency remains a significant predictor of acute kidney injury following multivariable adjustment (adjusted odds ratio 1.50; 95% CI 1.42–2.24; P < 0.0001). Patients with 25-hydroxyvitamin D insufficiency have an odds ratio for acute kidney injury of 1.49 (95% CI 1.15–1.94; P = 0.003) and an adjusted odds ratio of 1.23 (95% CI 1.12–1.72; P = 0.003) relative to patients with 25-hydroxyvitamin D sufficiency. In addition, preadmission 25-hydroxyvitamin D deficiency is predictive of mortality. Patients with 25-hydroxyvitamin D insufficiency have an odds ratio for 30-day mortality of 1.60 (95% CI 1.18–2.17; P = 0.003) and an adjusted odds ratio of 1.61 (95% CI 1.06–1.57; P = 0.004) relative to patients with 25-hydroxyvitamin D sufficiency. CONCLUSION: Deficiency of 25-hydroxyvi-tamin D prior to hospital admission is a significant predictor of acute kidney injury and mortality in a critically ill patient population.

Predicting energy expenditure in sepsis: Harris-Benedict and Schofield equations versus the Weir derivationCrit Care Resusc 2012 Sep;14(3):202-210. Subramaniam A, McPhee M, Nagappan R. Intensive Care Unit, Box Hill Hospital, Melbourne, Victoria, Australia.

BACKGROUND: Given the difficulties of using indirect calorimetry in many intensive care units, clinicians routinely employ predictive equations (the Harris-Benedict equation [HBE] and Schofield equation are commonly used) to estimate energy expenditure in critically ill patients. Some extrapolate CO2 production (V CO2) and O2 consumption (V O2) by the Weir derivation to estimate energy expenditure. These derivative methods have not been compared with predictive equations. OBJECTIVE: To compare prediction of energy expenditure by the HBE and Schofield equation with energy

expenditure as estimated by the Weir derivation in a cohort of critically ill patients. METHODS: Between June 2009 and May 2010, we conducted a prospective single-center study of 60 mechanically ventilated patients with sepsis of varying severity in the ICU of a metropolitan hospital. Three groups of patients were compared: those with systemic inflammatory response syndrome (SIRS), severe sepsis and septic shock. The HBE and Schofield equation are age-based, weight-deter-mined, sex-specific derivations that may incorporate stress and/or activity factors. Total energy expenditure (TEE) values calculated from these equations (TEE(HBE) and TEE(SCH), respectively) were compared with the measured energy expen-diture (MEE) calculated by the Weir derivation. We derived V CO2 from end-tidal CO2 and deduced V O2 assuming a respi-ratory quotient of 0.8381. RESULTS: Mean (± SD) APACHE II score for the 60 patients was 25.7 ± 8.4. All patients received nutrition (51 enteral, eight parenteral and one combined) in addition to standard management for sepsis and multiorgan supportive therapy. Overall, 45 patients required inotropes and four received continuous renal replacement therapy. TEE derived from both predictive equations correlated well with MEE derived from the Weir equation (mean TEE(HBE), 7810.7 ± 1669.2 kJ/day; mean TEE(SCH), 8029.1 ± 1418.6 kJ/day; mean MEE, 7660.8 ± 2092.2 kJ/day), being within 8% of each other. Better correlations between TEE and MEE were observed in patients with APACHE II scores <25 (vs those with scores ≥25) and patients with SIRS or severe sepsis (vs those with septic shock). CONCLUSION: In a cohort of patients with sepsis, TEE values calculated by the HBE and Schofield equation matched reasonably well with MEE values derived from the Weir equation. Correlation was better in patients with less severe sepsis (SIRS and severe sepsis and APACHE II score <25). Our results suggest that predictive equations have sufficient validity for ongoing regular use in clinical practice.

Nourishing the dysfunctional gut and whey proteinCurr Opin Clin Nutr Metab Care 2012 Sep;15(5):480-484. Abrahão V. ETERNU Multidisciplinary Nutritional Team/Rio de Janeiro – Casa de Saúde São José, Hospital Badim, Hospital Pasteur, Hospital Israelita Albert Sabin, Hospital Cardiotrauma, Casa de Saúde Santa Lúcia, Brazil.

PURPOSE OF REVIEW: This review discusses the mecha-nisms of the dysfunctional gut during the critical illness and the possibility that an immunonutrient such as whey protein can play a role in better tolerance of enteral nutrition, also decreasing inflammation and increasing anti-inflammatory defenses. RECENT FINDINGS: Impaired gastric motor function and associated feed intolerance are common issues in critically ill patients. Some studies have been published with enteral nutrition enriched with whey protein as a dietary protein supplement that provides antimicrobial activity, immune modulation, improving muscle strength and body composition, and preventing cardiovascular disease and osteoporosis. SUMMARY: Early enteral feeding will enhance patient recovery and the use of enteral diets enriched with whey protein may play a role in these patients.

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A multicenter, randomized controlled trial comparing early nasojejunal with nasogastric nutrition in critical illnessCrit Care Med 2012 Aug;40(8):2342-2348. Davies AR, Morrison SS, Bailey MJ, Bellomo R, Cooper DJ, Doig GS, Finfer SR, Heyland DK; ENTERIC Study Investigators; ANZICS Clinical Trials Group. Intensive Care Unit, Alfred Hospital, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.

OBJECTIVE: Current guidelines recommend enteral nutrition in critically ill adults; however, poor gastric motility often prevents nutritional targets being met. We hypothesized that early nasojejunal nutrition would improve the delivery of enteral nutrition. DESIGN: Prospective, randomized, controlled trial. SETTING: Seventeen multidisciplinary, closed, medical/surgical, intensive care units in Australia. PATIENTS: One hundred and eighty-one mechanically ventilated adults who had elevated gastric residual volumes within 72 hrs of intensive care unit admission. INTERVENTIONS: Patients were randomly assigned to receive early nasojejunal nutrition delivered via a spontaneously migrating frictional nasoje-junal tube, or to continued nasogastric nutrition. MEASURE-MENTS AND MAIN RESULTS: The primary outcome was the proportion of the standardized estimated energy requirement that was delivered as enteral nutrition. Secondary outcomes included incidence of ventilator-associated pneumonia, gastro-intestinal hemorrhage, and in-hospital mortality rate. There were 92 patients assigned to early nasojejunal nutrition and 89 to continued nasogastric nutrition. Baseline character-istics were similar. Nasojejunal tube placement into the small bowel was confirmed in 79 (87%) early nasojejunal nutrition patients after a median of 15 (interquartile range 7–32) hrs. The proportion of targeted energy delivered from enteral nutrition was 72% for the early nasojejunal nutrition and 71% for the nasogastric nutrition group (mean difference 1%, 95% confidence interval -3% to 5%, P = 0.66). Rates of ventilator-associated pneumonia (20% vs 21%, P = 0.94), vomiting, witnessed aspiration, diarrhea, and mortality were similar. Minor, but not major, gastrointestinal hemorrhage was more common in the early nasojejunal nutrition group (12 [13%] vs 3 [3%], P = 0.02). CONCLUSIONS: In mechanically venti-lated patients with mildly elevated gastric residual volumes and already receiving nasogastric nutrition, early nasojejunal nutrition did not increase energy delivery and did not appear to reduce the frequency of pneumonia. The rate of minor gastro-intestinal hemorrhage was increased. Routine placement of a nasojejunal tube in such patients is not recommended.

Maintaining quality of care 24/7 in a nontrauma surgical intensive care unitJ Trauma Acute Care Surg 2012 Jul;73(1):202-208. McMillen MA, Boucher N, Keith D, Gould DS, Gave A, Hoffman D. Department of Surgery, Beth Israel Medical Center, New York, USA.

BACKGROUND: Most surgical critical care literature reflects practices at trauma centers and tertiary hospitals. Surgical critical care needs and practices may be quite different at nontrauma center teaching hospitals. As acute care surgery develops as a component of surgical critical care and trauma, the opportunities and challenges of the nontrauma centers

should be considered. METHODS: In 2001, a new surgical critical care service was created for an 800-bed urban teaching hospital with a 12-bed surgical intensive care unit (SICU). Consults, daily rounds, daily notes, and adherence to best practices were standardized over the next 9 years for a team of postgraduate year-1 and -2 surgical residents, physician assistants and surgical intensivists. The Fundamentals of Critical Care Support course was given as basic introduction, and published guidelines for ventilators, hemodynamics, cardiac, infections, and nutrition management were implemented. A “beyond FCCS” curriculum was repeated every resident rotation. A 12-bed stepdown unit was developed for the more stable patients, mostly run by SICU physician assistants with SICU attending coverage. The first 5 years, night coverage was by the daytime intensivist from home. The last 4 years, night coverage was in-unit surgical intensivists or cardiac surgeons. RESULTS: Data for 13,020 patients drawn from 152,154 operations over 9 years is reported. Surgery grew 89% to 24,000 cases/year in 2010. Half the patients were general, gastrointestinal oncology, or vascular surgery. Ninety-two percent were perioperative. The 8% nonoperative patients were mostly gastrointestinal bleeding, abdominal pain, or pancreatitis. In the first year, annual SICU mortality decreased from an average of 4.5% the 5 previous years to 1.96% (2002) and remained 1.75% (2003), 2.1% (2004), 1.9% (2005), 1.5% (2006), 1.5% (2007), 2.2% (2008), 2.4% (2009), and 2.1% (2010). CONCLUSION: Annual mortality immediately improved at a busy nontrauma hospital with rapid, structured consultation by the SICU team, comprehensive daily rounds guided by critical care best practices, and daytime in-unit surgical intensivists. Low mortality was maintained over 9 years as surgery volume nearly doubled but did not improve further with 24/7 in-unit coverage by surgical intensivists and cardiac surgeons. The process of care in an SICU may be more important than 24 hour a day, 7 days a week intensivists.

DYSPHAGIA

Nutrition assessment and intervention in the patient with dysphagia: Challenges for quality improvementNestlé Nutr Inst Workshop Ser 2012;72:77-83. Ochoa JB. Nestlé HealthCare Nutrition, Nestlé Health Science, Florham Park, New Jersey, USA.

Dysphagia, a symptom characterized by difficulty swallowing, is an independent predictor of poor outcome, worsening morbidity, increasing the risk for hospital readmissions, health care costs and mortality. Dysphagia is a result of a number of illnesses including neurological diseases, after surgery for head and neck pathology, observed in the intensive care unit after prolonged endotracheal intubation among others, and is particularly frequent in the elderly. Dysphagia increases the incidence of malnutrition, which in turn delays patient recovery. Treatment of dysphagia can be successful, but requires the use of multidisciplinary teams. A focus on

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the management of malnutrition including prevention and treatment is essential. Perhaps the biggest challenge is the lack of awareness of the presence of dysphagia and malnutrition, so that only a minority of patients are identified and successfully treated. We propose that better identification and treatment of dysphagia could occur with the systematic implementation of clinical practice improvement processes with a consequent decrease in morbidity, mortality and cost.

DIABETES

Perioperative glycaemic control for diabetic patients undergoing surgeryCochrane Database Syst Rev 2012 Sep 12;9:CD007315. Buchleitner AM, Martínez-Alonso M, Hernández M, Solà I, Mauricio D. Department of Endocrinology and Nutrition, Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida (IRBLLEIDA), Lleida, Spain.

BACKGROUND: Patients with diabetes mellitus are at increased risk of postoperative complications. Data from randomized clinical trials and meta-analyses point to a potential benefit of intensive glycemic control, targeting near-normal blood glucose, in patients with hyperglycemia (with and without diabetes mellitus) being submitted to surgical procedures. However, there is limited evidence concerning this question in patients with diabetes mellitus undergoing surgery. OBJECTIVES: To assess the effects of perioperative glycemic control for diabetic patients undergoing surgery. SEARCH METHODS: Trials were obtained from searches of The Cochrane Library, MEDLINE, EMBASE, LILACS, CINAHL and ISIS (all up to February 2012). SELECTION CRITERIA: We included randomized controlled clinical trials that prespecified different targets of perioperative glycemic control (intensive versus conventional or standard care). DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed risk of bias. We summarized studies using meta-analysis or descriptive methods. MAIN RESULTS: Twelve trials randomized 694 diabetic participants to intensive control and 709 diabetic participants to conven-tional glycemic control. The duration of the intervention ranged from just the duration of the surgical procedure up to 90 days. The number of participants ranged from 13 to 421, and the mean age was 64 years. Comparison of intensive with conventional glycemic control demonstrated the following results for our predefined primary outcomes: analysis restricted to studies with low or unclear detection or attrition bias for infectious complications showed a risk ratio (RR) of 0.46 (95% confidence interval (CI) 0.18 to 1.18), P = 0.11, 627 participants, eight trials, moderate quality of the evidence (grading of recommendations assessment, development and evaluation – [GRADE]). Evaluation of death from any cause revealed an RR of 1.19 (95% CI 0.89 to 1.59), P = 0.24, 1,365 participants, 11 trials, high quality of the evidence (GRADE).On the basis of a posthoc analysis, there is the hypothesis that intensive glycemic control may increase the risk of hypogly-cemic episodes if longer-term outcome measures are analyzed (RR 6.92, 95% CI 2.04 to 23.41), P = 0.002, 724 patients, three trials, low quality of the evidence (GRADE). Analysis

of our predefined secondary outcomes revealed the following findings: cardiovascular events had an RR of 1.03 (95% CI 0.21 to 5.13), P = 0.97, 682 participants, six trials, moderate quality of the evidence (GRADE) when comparing the two treatment modalities; and renal failure also did not show significant differences between intensive and regular glucose control (RR 0.61, 95% CI 0.34 to 1.08), P = 0.09, 434 partici-pants, two trials, moderate quality of the evidence (GRADE). We did not meta-analyse length of hospital stay and intensive care unit (ICU) stay due to substantial unexplained heteroge-neity. Mean differences between intensive and regular glucose control groups ranged from -1.7 days to 2.1 days for ICU stay and between -8 days to 3.7 days for hospital stay (moderate quality of the evidence [GRADE]). One trial assessed health-related quality of life in 12/37 (32.4%) of participants in the intervention group and 13/44 (29.5%) of participants in the control group, and did not show an important difference (low quality of the evidence [GRADE]) in the measured physical health composite score of the short-form 12-item health survey (SF-12). None of the trials examined the effects of the interventions in terms of costs. AUTHORS’ CONCLU-SIONS: The included trials did not demonstrate significant differences for most of the outcomes when targeting intensive perioperative glycemic control compared with conventional glycemic control in patients with diabetes mellitus. However, posthoc analysis indicated that intensive glycemic control was associated with an increased number of patients experi-encing hypoglycemic episodes. Intensive glycemic control protocols with near-normal blood glucose targets for patients with diabetes mellitus undergoing surgical procedures are currently not supported by an adequate scientific basis. We suggest that insulin treatment regimens, patient- and health-system relevant outcomes, and time points for outcome measures should be defined in a thorough and uniform way in future studies.

Nutritional therapy for the management of diabetic gastroparesis: Clinical reviewDiabetes Metab Syndr Obes 2012;5:329-335. Sadiya A. Lifestyle Clinic, Rashid Centre for Diabetes and Research, Ministry of Health, Ajman, United Arab Emirates.

Diabetic gastroparesis (DGP), or slow emptying of the stomach, is a well-established complication of diabetes mellitus and is typically considered to occur in individuals with long-standing type 1 and type 2 diabetes mellitus. Clinical consequences of DGP include induction of gastrointestinal (GI) symptoms (early satiety, abdominal distension, reflux, stomach spasm, postprandial nausea, vomiting), alteration in drug absorption, and destabilization of glycemic control (due to mismatched postprandial glycemic and insulin peaks). Effective nutritional management not only helps in alleviating the symptoms, but also in facilitating better glycemic control. Although there have been no evidence-based guidelines pertaining to the nutrition care process of the DGP, the current dietary recom-mendations are based on expert opinions or observational studies. The dietary management of gastroparesis needs to be tailored according to the severity of malnutrition and kind

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of upper GI symptom by changing the volume, consistency, frequency, fiber, fat, and carbohydrates in the meal. Small frequent meals, using more liquid calories, reducing high fat or high fiber, consuming bezoar forming foods, and adjusting meal carbohydrates based on medications or insulin helps in improving the upper GI symptoms and glycemic control. Enteral nutrition can be an option for patients who fail to stabilize their weight loss, or for those who cannot gain weight with oral feedings, while total parenteral nutrition is rarely necessary for the patient with gastroparesis.

GERIATRICS

Sarcopenia in older adultsCurr Opin Rheumatol 2012 Nov;24(6):623-627. Walston JD. Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

PURPOSE OF REVIEW: Sarcopenia, or the decline of skeletal muscle tissue with age, is one of the most important causes of functional decline and loss of independence in older adults. The purpose of this article is to review the current definitions of sarcopenia, its potential causes and clinical consequences, and the potential for intervention. RECENT FINDINGS: Although no consensus diagnosis has been reached, sarcopenia is increasingly defined by both loss of muscle mass and loss of muscle function or strength. Its cause is widely regarded as multifactorial, with neuro-logical decline, hormonal changes, inflammatory pathway activation, declines in activity, chronic illness, fatty infil-tration, and poor nutrition, all shown to be contributing factors. Recent molecular findings related to apoptosis, mitochondrial decline, and the angiotensin system in skeletal muscle have highlighted biological mechanisms that may be contributory. Interventions in general continue to target nutrition and exercise. SUMMARY: Efforts to develop a consensus definition are ongoing and will greatly facilitate the development and testing of novel interventions for sarco-penia. Although pharmaceutical agents targeting multiple biological pathways are being developed, adequate nutrition and targeted exercise remain the gold standard for therapy.

IMMUNONUTRITION

Perioperative immunonutrition and gut functionCurr Opin Clin Nutr Metab Care 2012 Sep;15(5):485-488. Braga M. Professor of Surgery, San Raffaele University, Milan, Italy.

PURPOSE OF REVIEW: In the last year, several meta-analyses focused on the potential clinical benefits of periop-erative immunonutrition in surgical patients. Purpose of this review is to summarize their results and to draw recommen-dations about the current indication of immunonutrition in surgery. RECENT FINDINGS: Standard enteral prepara-tions have been modified by adding specific nutrients, such as arginine, omega-3 fatty acids and others, which have been

shown to upregulate immune response, to control inflam-matory response, and to improve gut function after surgery. The majority of the randomized trials found that periop-erative immunonutrition improved short-term outcome in patients, who underwent elective major gastrointestinal (GI) surgery. Four meta-analyses including a large number of randomized clinical trials reported that perioperative immunonutrition is associated with a substantial reduction in both infection rate and length of hospital stay. These results have been found in both upper and lower GI patients, regardless of their baseline nutritional status. Promising results have been found also in head and neck surgery. SUMMARY: In the light of these findings the use of periop-erative immunonutrition should be implemented in patients undergoing elective major GI surgery. This should result in a considerable reduction in both postoperative morbidity and costs for healthcare systems. Larger trials are required before recommending immunonutrition as a routine practice in head and neck surgery.

Immunonutrition for patients undergoing elective surgery for gastrointestinal cancer: Impact on hospital costsWorld J Surg Oncol 2012 Jul 6;10(1):136. Mauskopf JA, Candrilli SD, Chevrou-Séverac H, Ochoa JB. RTI Health Solutions, Durham, North Carolina, USA; Nestlé Health Sciences, Vevey, Switzerland; Nestlé Healthcare Nutrition and University of Pittsburgh, Pittsburgh, USA.

BACKGROUND: Oral or enteral dietary supplementation with arginine, omega-3 fatty acids and nucleotides (known as immunonutrition) significantly improve outcomes in patients undergoing elective surgery. The objective of the study was to determine the impact on hospital costs of immunonutrition formulas used in patients undergoing elective surgery for gastrointestinal cancer. METHODS: US hospital costs of stay with and without surgical infec-tious complications, and average cost per day in the hospital for patients undergoing elective surgery for gastrointestinal cancer were estimated using data from the Healthcare Cost and Utilization Project’s 2008 Nationwide Inpatient Sample. These costs were then used to estimate the impact of periop-erative immunonutrition on hospital costs using estimates of reduction in infectious complications or length of stay from a meta-analysis of clinical trials in patients undergoing elective surgery for gastrointestinal cancer. Sensitivity of the results to changes in baseline complication rates or length of stay was tested. RESULTS: From the meta-analysis estimates, use of immunonutrition resulted in savings per patient of $3,300 with costs based on reduction in infectious complication rates or $6,000 with costs based on length of hospital stay. Cost savings per patient were present for baseline compli-cation rates above 3.5% or when baseline length of stay and infectious complication rates were reduced to reflect recent US data for those with upper and lower GI elective cancer surgery (range, $1,200 to $6,300). CONCLU-SIONS: Use of immunonutrition for patients undergoing elective surgery for gastrointestinal cancer is an effective and cost-saving intervention.

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MEDICAL NUTRITION THERAPY

Enteral nutrition in the chronic obstructive pulmonary disease (COPD) patientJ Pharm Pract 2012 Dec;25(6):583-585. Debellis HF, Fetterman JW Jr. South University School of Pharmacy, Savannah, Georgia, USA.

Chronic obstructive pulmonary disease (COPD) is a progressive, chronic disease, in which malnutrition can have an undesirable effect. Therefore, the patient’s nutritional status is critical for optimizing outcomes in COPD. The initial nutrition assessment is focused on identifying calorically compromised COPD patients in order to provide them with appropriate nutrition. Nutritional intervention consists of oral supplementation and enteral nutrition to prevent weight loss and muscle mass depletion. Evaluation of nutritional status should include past medical history (medications, lung function, and exercise tolerance) and dietary history (patient’s dietary habits, food choices, meal patterns, food allergy infor-mation, and malabsorption issues), in addition to physio-logical stress, visceral proteins, weight, fat-free mass, and body mass index. The current medical literature conflicts regarding the appropriate type of formulation to select for nutritional intervention, especially regarding the amount of calories from fat to provide COPD patients. This review article focuses on the enteral product formulations currently available, and how they are most appropriately utilized in patients with COPD.

Feeding tube placement: Errors and complicationsNutr Clin Pract 2012 Dec;27(6):738-748. Stayner JL, Bhatnagar A, McGinn AN, Fang JC. Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA.

Feeding tube placement for enteral nutrition (EN) support is widely used in both critically ill and stable chronically ill patients who are unable to meet their nutrition needs orally. Nasal or oral feeding tubes can be performed blindly at the bedside or with fluoroscopic or endoscopic guidance into the stomach or small bowel. Percutaneous feeding tubes are used when EN support is required for longer periods (>4–6 weeks) and are most commonly placed endoscopically or radiographically. Although generally safe and effective, there is a wide spectrum of known complications associated with feeding tube placement. Errors made at the time of feeding tube placement can result in a number of these procedural and postprocedural complications. In many cases, a single error at the time of placement can result in numerous complications. A thorough knowledge of these errors and avoiding them in practice will decrease iatrogenic complications in a vulnerable population. In addition, early recognition and management of complications will further minimize morbidity and even mortality in enteral feeding tube placement. This article reviews the common errors leading to complications of enteral feeding tube placement and their prevention and management.

Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced recovery after surgery (ERAS®) society recommendationsWorld J Surg 2012 Oct 6. [Epub ahead of print]

Nygren J, Thacker J, Carli F, Fearon KC, Norderval S, Lobo DN, Ljungqvist O, Soop M, Ramirez J. Department of Surgery, Ersta Hospital, Karolinska Institutet, Stockholm, Sweden.

BACKGROUND: This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery, and to provide graded recommendations for items for an evidenced-based enhanced recovery protocol. METHODS: Studies were selected with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group. RESULTS: For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (evidence grade: high or moderate). CONCLUSIONS: Based on the evidence available for each item of the multi-modal perioperative care pathway, the Enhanced Recovery After Surgery (ERAS) Society, European Society for Clinical Nutrition and Metabolism (ESPEN) and International Associ-ation for Surgical Metabolism and Nutrition (IASMEN) present a comprehensive evidence-based consensus review of perioperative care for rectal surgery.

Guidelines for perioperative care in elective colonic surgery: Enhanced recovery after surgery (ERAS®) society recommendationsWorld J Surg 2012 Oct 6. [Epub ahead of print] Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, Macfie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O. Department of Surgery, Ersta Hospital, Stockholm, Sweden.

BACKGROUND: This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide graded recommendations for items for an evidenced-based enhanced perioperative protocol. METHODS: Studies were selected with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group. RESULTS: For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (quality of evidence and recommendations according to the GRADE system). CONCLUSIONS: Based on the evidence available for each item of the multimodal perioperative care pathway, the Enhanced Recovery After Surgery (ERAS) Society, International Association for Surgical Metabolism and Nutrition (IASMEN) and European Society for Clinical Nutrition and Metabolism (ESPEN) present a comprehensive evidence-based consensus review of perioperative care for colonic surgery.

A.S.P.E.N. Clinical Guidelines: Nutrition support of adult patients with hyperglycemiaJPEN J Parenter Enteral Nutr 2012 Jun 29. [Epub ahead of print] McMahon MM, Nystrom E, Braunschweig C, Miles J, Compher C; American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. Mayo Clinic, Rochester, Minnesota, USA.

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BACKGROUND: Hyperglycemia is a frequent occurrence in adult hospitalized patients who receive nutrition support. Both hyperglycemia and hypoglycemia (resulting from attempts to correct hyperglycemia) are associated with adverse outcomes in diabetic as well as nondiabetic patients. This American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Clinical Guideline summarizes the most current evidence and provides guidelines for the desired blood glucose goal range in hospitalized patients receiving nutrition support, the definition of hypoglycemia, and the rationale for use of diabetes-specific enteral formulas in hospitalized patients. METHOD: A systematic review of the best available evidence to answer a series of questions regarding glucose control in adults receiving parenteral or enteral nutrition was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process was used to develop the clinical guideline recommendations prior to external and internal review and approval by the A.S.P.E.N. Board of Directors. RESULTS/ CONCLUSIONS: 1. What is the desired blood glucose goal range in adult hospitalized patients receiving nutrition support? We recommend a target blood glucose goal range of 140–180 mg/dL (7.8–10 mmol/L). (Strong) 2. How is hypoglycemia defined in adult hospitalized patients receiving nutrition support? We recommend that hypogly-cemia be defined as a blood glucose concentration of <70 mg/dL (<3.9 mmol/L). (Strong) 3. Should diabetes-specific enteral formulas be used for adult hospitalized patients with hyperglycemia? We cannot make a recommendation at this time. (Further research needed).

PEDIATRICS

Nutrition support in critically ill children: Underdelivery of energy and protein compared with current recommendationsJ Acad Nutr Diet 2012 Dec;112(12):1987-1992. Kyle UG, Jaimon N, Coss-Bu JA. Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children’s Hospital, Houston, Texas, USA.

Critically ill children are at high risk for developing nutritional deficiencies, and hospital undernutrition is known to be a risk factor for morbidity and mortality in children. This study’s aims were to examine current nutrition practices and the adequacy of nutrition support in the pediatric intensive care unit (PICU). This retrospective chart review included 240 PICU patients admitted to PICU for longer than 48 hours and documented all intravenous (IV), parenteral, and enteral energy and protein for the first 8 days. Basal metabolic rate and protein requirements were estimated by Schofield equation and the American Society for Parenteral and Enteral Nutrition Clinical Guidelines, respec-tively. Moderate/severe acute malnutrition was defined as weight for age greater than -2 z scores, and moderate/severe chronic malnutrition (growth stunting) was defined as height for age greater than -2 z scores, using 2000 Centers for Disease Control and Prevention growth charts. During the first 8 days of PICU stay, the actual energy intake for all patient-days was an average of 75.7% ± 56.7% of basal metabolic rate and was significantly

lower than basal metabolic rate (P < 0.001); the actual protein intake for all patient-days met an average of 40.4% ± 44.2% of protein requirements and was significantly lower than the American Society for Parenteral and Enteral Nutrition guide-lines (P < 0.001). Delivery of energy and protein were inade-quate on 60% and 85% of patient-days, respectively. Only 75% of estimated energy and 40% of protein requirements were met in the first 8 days of PICU stay. These data demonstrate a high prevalence of critically ill children who are not meeting their recommended levels of protein and energy. In order to avoid undernutrition of these children, providers must conduct ongoing assessment of protein and energy intake compared with protein and energy requirements.

Effect of exclusive enteral nutrition on gut microflora function in children with Crohn’s diseaseScand J Gastroenterol 2012 Dec;47(12):1454-1459. Tjellström B, Högberg L, Stenhammar L, Magnusson KE, Midtvedt T, Norin E, Sundqvist T. Department of Microbiology, Karolinska Institute, Tumor and Cell Biology, Stockholm, Sweden.

OBJECTIVE: Exclusive enteral nutrition (EEN) is a first-line treatment in children with active Crohn’s disease (CD) but is seldom used in adults with active disease. The mode of action of EEN in suppressing mucosal inflammation is not fully understood, but modulation of intestinal microflora activity is one possible explanation. The aim of this study was to investigate the effect of 6-week EEN in children with active CD, with special reference to intestinal microflora function. MATERIALS AND METHODS: Fecal samples from 18 children (11 boys, 7 girls; median age 13.5 years) with active CD (13 children with small bowel/colonic and 5 with perianal disease) were analyzed for short chain fatty acid (SCFA) pattern as marker of gut microflora function. The children were studied before and after EEN treatment. Results from 12 healthy teenagers were used for comparison. RESULTS: Eleven (79%) of the children with small bowel/colonic CD responded clinically positively to EEN treatment showing decreased levels of pro-inflammatory acetic acid as well as increased concen-trations of anti-inflammatory butyric acids and also of valeric acids, similar to the levels in healthy age-matched children. In children with active perianal CD, however, EEN had no positive effect on clinical status or inflammatory parameters. CONCLU-SIONS: The authors present new data supporting the hypothesis that the well-documented anti-inflammatory effect of EEN in children with active small bowel/colonic CD is brought about by modulation of gut microflora activity, resulting in an anti-inflam-matory SCFA pattern. By contrast, none of the children with perianal disease showed clinical or biochemical improvement after EEN treatment.

Nutritional practices and their relationship to clinical outcomes in critically ill children – An international multicenter cohort studyCrit Care Med 2012 Jul;40(7):2204-2211. Mehta NM, Bechard LJ, Cahill N, Wang M, Day A, Duggan CP, Heyland DK. Division of Critical Care Medicine, Department of Anesthesiology, Pain and Perioperative Medicine at Children’s Hospital Boston, Boston, Massachusetts, USA.

OBJECTIVES: To examine factors influencing the adequacy of energy and protein intake in the pediatric intensive care unit and

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to describe their relationship to clinical outcomes in mechani-cally ventilated children. DESIGN, SETTING, PATIENTS: We conducted an international prospective cohort study of consec-utive children (ages 1 month to 18 yrs) requiring mechanical ventilation longer than 48 hrs in the pediatric intensive care unit. Nutritional practices were recorded during the pediatric intensive care unit stay for a maximum of 10 days, and patients were followed up for 60 days or until hospital discharge. Multivariate analysis, accounting for pediatric intensive care unit clustering and important confounding variables, was used to examine the impact of nutritional variables and pediatric intensive care unit characteristics on 60-day mortality and the prevalence of acquired infections. MAIN RESULTS: 31 pediatric intensive care units in academic hospitals in eight countries participated in this study. Five hundred patients with mean (SD) age 4.5 (5.1) yrs were enrolled and included in the analysis. Mortality at 60 days was 8.4%, and 107 of 500 (22%) patients acquired at least one infection during their pediatric intensive care unit stay. Over 30% of patients had severe malnutrition on admission, with body mass index z-score > 2 (13.2%) or < -2 (17.1%) on admission. Mean prescribed goals for daily energy and protein intake were 64 kcals/kg and 1.7 g/kg respectively. Enteral nutrition was used in 67% of the patients and was initiated within 48 hrs of admission in the majority of patients. Enteral nutrition was subsequently interrupted on average for at least 2 days in 357 of 500 (71%) patients. Mean (SD) percentage daily nutritional intake (enteral nutrition) compared to prescribed goals was 38% for energy and 43% (44) for protein. A higher percentage of goal energy intake via enteral nutrition route was significantly associated with lower 60-day mortality (Odds ratio for increasing energy intake from 33.3% to 66.6% is 0.27 [0.11, 0.67], P = 0.002). Mortality was higher in patients who received parenteral nutrition (odds ratio 2.61 [1.3, 5.3], P = 0.008). Patients admitted to units that utilized a feeding protocol had a lower prevalence of acquired infections (odds ratio 0.18 [0.05, 0.64], P = 0.008), and this association was independent of the amount of energy or protein intake. CONCLUSIONS: Nutrition delivery is generally inadequate in mechanically ventilated children across the world. Intake of a higher percentage of prescribed dietary energy goal via enteral route was associated with improved 60-day survival; conversely, parenteral nutrition use was associated with higher mortality. Pediatric intensive care units that utilized protocols for the initiation and advancement of enteral nutrient intake had a lower prevalence of acquired infections. Optimizing nutrition therapy is a potential avenue for improving clinical outcomes in critically ill children.

Subjective global nutritional assessment in critically ill childrenJPEN J Parenter Enteral Nutr 2012 Jun 22. [Epub ahead of print] Vermilyea S, Slicker J, El-Chammas K, Sultan M, Dasgupta M, Hoffmann RG, Wakeham M, Goday PS. Children’s Hospital of Wisconsin, Milwaukee, Wisconsin, USA.

BACKGROUND: Underweight children admitted to the pediatric intensive care unit (PICU) have a higher risk of mortality than normal-weight children. The authors

hypothesized that subjective global nutrition assessment (SGNA) could identify malnutrition in the PICU and predict nutrition-associated morbidities. METHODS: The authors prospectively evaluated the nutrition status of 150 children (aged 31 days to 5 years) admitted to the PICU with the use of SGNA and commonly used objective anthropometric and laboratory measurements. Each child was administered the SGNA by a dietitian while anthropometric measurements were performed by an independent assessor. To test inter-rater reproducibility, 76 children had SGNA performed by another dietitian. Occurrence of nutrition-associated complications was documented for 30 days after admission. RESULTS: SGNA ratings of well nourished, moderately malnourished, or severely malnourished demonstrated moderate to strong correlation with several standard anthro-pometric measurements (P < 0.05). The laboratory markers did not demonstrate any correlation with SGNA. Interrater agreement showed moderate reliability (κ = 0.671). Length of stay, pediatric logistic organ dysfunction, and Pediatric Risk of Mortality III were not significantly different across the groups and did not correlate with SGNA.

Malnutrition may worsen the prognosis of critically ill children with hyperglycemia and hypoglycemiaJPEN J Parenter Enteral Nutr 2012 Aug 28. [Epub ahead of print] Leite HP, de Lima LF, de Oliveira Iglesias SB, Pacheco JC, de Carvalho WB. Federal University of São Paulo, São Paulo, Brazil.

OBJECTIVES: To determine whether hyperglycemia and hypoglycemia are associated with higher mortality, longer length of intensive care unit (ICU) stay, and fewer venti-lator-free days in critically ill children while taking into account the clinical severity and nutrition status. Patients and METHODS: A prospective observational cohort study was conducted on 221 children admitted to the ICU. Blood glucose levels were analyzed in the first 72 hours. Potential exposure variables for adverse prognosis included hypergly-cemia (blood glucose >150 mg/dL), hypoglycemia (blood glucose ≤60 mg/dL), age <1 year, sex, nutrition status, the revised Pediatric Index of Mortality (PIM 2), and the Pediatric Logistic Organ Dysfunction (PELOD). RESULTS: Of the patients, 47.1% were malnourished. Controlling for nutrition status, both hyperglycemia and hypoglycemia increased the risk of mortality in the malnourished patients compared with the well-nourished ones. Adjusting for clinical severity, the odds ratio of mortality was higher in malnourished patients with hyperglycemia (odds ratio [OR], 3.98; 95% confidence interval [CI], 1.14–13.94; P = 0.03), whereas no significant associations were detected in the well-nourished patients. After controlling for nutrition status, hypoglycemia was associated with longer length of ICU stay (OR, 6.5; 95% CI, 1.30–32.57; P < 0.01) and fewer ventilator-free days (OR, 4.11; 95% CI, 1.26–13.40; P < 0.01) only in the malnour-ished group of patients. CONCLUSIONS: Compared with the well nourished, malnourished patients with hyperglycemia are at a greater risk of mortality, independent of clinical severity. Hypoglycemia was shown to be associated with mortality, longer length of ICU stay, and fewer ventilator-free days only in malnourished patients.

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Highlights of the

34th ESPEN Congress8–11 September 2012 • Barcelona, Spain

Sarcopenia plays an important etiologic role in the frailty process

of older people. It is a key player in the early, non-manifest phase

of frailty and explains many aspects of frailty itself.

Diagnosis of sarcopenia requires the documentation of

low muscle mass plus either low muscle strength or low physical

performance.1 Such criteria are included in the European

Working Group on Sarcopenia in Older People algorithm for

case finding/screening for sarcopenia.1

Sarcopenia is a common condition with adverse

consequences. In a study conducted in Italy, 32.8% of residents

in nursing homes were affected by sarcopenia; the prevalence

was higher in men than in women (68% vs 21%, respectively).2

The most important risk factors identified were low body mass

index (BMI) and inactivity. Residents with a BMI of 21 kg/m2

or greater and those who participated in physical activity for

leisure (1 hour or more per day) were less likely to be affected.1

The mortality rate in residents with sarcopenia was higher than

for those without sarcopenia (adjusted hazard ratio [HR] 2.34;

95% confidence interval [CI] 1.04–5.24).3 Community-dwelling

older people affected by sarcopenia are more than three times as

likely to fall than those without sarcopenia (adjusted HR 3.23;

95% CI 1.25–8.29).4

Anorexia is one of the most important risk factors

for the onset of sarcopenia and has been shown to have a

negative impact on function in older people.5,6 Anorexia of

aging, especially in the early stage, may be correlated with

a high risk of qualitative low intake of single nutrients,

in particular, protein and certain vitamins. It could be

hypothesized that this selective malnutrition – for example,

in terms of single macro- or micronutrients – is directly

correlated with sarcopenia.

The role of nutrition in optimizing strength and functionF Landi (Italy)

The relationship between nutrition and aging is not clear.

The observation in animals that calorie restriction is

associated with a healthier, longer life does not hold true for

humans.1,2 The relationship between BMI and mortality is

also complex. The BMI that confers lowest risk of mortality

in adults (median age at baseline 58 years) is 22.5 kg/m2 in

women and 23 kg/m2 in men.3 Recent studies show that this

is not the case for older people; BMI in the normal to obese

range is associated with lowest mortality in older people.4-6

Functional decline and nutritional status in the older adultP Soler (Spain)

The amount of protein available in the diet plays a

key role in an individual’s ability to develop muscle mass

and strength. Options to optimize post-prandial anabolic

action of dietary proteins include an increase in protein

intake, an increase in amino acid availability and the use of

specific substrates.7 High quality protein – such as whey with

high leucine content and essential amino acids – stimulates

protein synthesis at the muscle level by activation of the

mammalian target of rapamycin (mTOR) system.8 Protein

in combination with resistance exercise has been shown to

increase protein synthesis.9 The key role of vitamin D in

muscle function, physical performance and falls prevention

is well established, and there is biological plausibility for its

role in muscle function due to its anabolic, metabolic and

anti-inflammatory effects.10

Professor Landi concluded that the adverse

consequences of sarcopenia warrant identification through

screening, and that management with adequate protein

(≥ 1 g/kg/day), energy and vitamin D intake in combination

with adequate physical activity may help prevent sarcopenia.

References1. Cruz-Jentoft AJ, et al. Age Ageing 2010;39:412-423.2. Landi F, et al. J Gerontol A Biol Sci Med Sci 2012;67:48-55.3. Landi F, et al. J Am Med Dir Assoc 2012;13:121-126.4. Landi F, et al. Clin Nutr 2012;31:652-658.5. Landi F, et al. J Am Med Dir Assoc 2010;11:268-274.6. Landi F, et al. Eur J Nutr 2012;(Epub ahead of print 25 August 2012).7. Paddon-Jones D, et al. Am J Clin Nutr 2008;87:1562S-1566S.8. Casperson SL, et al. Clin Nutr 2012;31:512-519.9. Biolo G,et al. Am J Physiol 1997;273(1 Pt 1):E122-E129.10. Landi F. Aging Clin Exp Res 2012;In press.

Nestlé Nutrition Institute Satellite SymposiumSynergy in motion: Combining nutrition and exercise for optimal physical function

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The benefits of physical activity are well established. A

review of longitudinal studies looking at the relationship

between physical activity levels at different referent points

and mobility disability outcomes showed that the odds ratio

for mobility disability outcomes decreases with increasing

physical activity levels.1 The same was true in a review that

combined ADL, instrumental activities of daily living (IADL)

and global outcomes; being physically active was shown to

be protective for older adults.1 Yet, despite this, participation

• Bio-electrical impedence (BIA) is a practical replacement

for dual-energy x-ray absorptiometry (DEXA) for

assessment of low appendicular skeletal muscle mass with

good sensitivity and specificity.1

• A six-item self-administered malnutrition screening tool

(Self-MNA) has been shown to have excellent sensitivity

and specificity in detecting subjects at risk of malnu-

trition when compared to the MNA-SF administered by a

healthcare professional.2

• Cardiac mass is shown to be correlated to lean body mass

(LBM) in wasted patients with cancer and renal failure. As

a result echocardiography could offer a less invasive and

Physical activity programs for the older adult: Success factorsM Nelson (United States)

Related topics: Body composition and risksUG Kyle (United States)K Kaspar (Switzerland)A Molfino (Italy)

This has recently been confirmed in the ‘Survey in Europe on

Nutrition and the Elderly, a Concerted Action’ (SENECA)

study where a BMI of 27.1 kg/m2 was found to confer the

lowest risk of mortality in older people.7

Nutrition in older adults is complex and multifactorial,

affected by physiological, functional, cognitive, psychological

and social factors. Nutrition is one of the main contributors

to healthy and active aging. Good nutrition plays a major role

in the maintenance of function and mental health, reducing

the risk of illness and disability, while poor nutrition may

contribute to the development of chronic diseases, disability,

dependence and death. Professor Soler suggested that it is not

longevity but quality of life that is most important; function

may be more important than survival. Function, rather than

disease burden or comorbidity, is the main health index in

this population group.

Professor Soler presented results from the ongoing

Frailty and Dependency in Albacete (FRADEA) longitudinal

cohort study (unpublished data). He showed that a BMI of

25–30 kg/m2 in older adults is associated with lower prevalent

disability, followed by a BMI of 30–35 kg/m2. Frailty and

disability are strong predictors of incident disability in basic

activities of daily living (BADL). Nutritional risk is a better

predictor of incident disability in BADL than BMI, especially

when associated with frailty (HR 2.5 [Mini Nutritional

Assessment®(MNA®) <12 + Frailty]). Anorexia, weight loss

and mobility impairment are the strongest MNA® items

associated with loss of BADL. Professor Soler suggested

that nutritional risk (using MNA®), anorexia and weight

loss could be added to the range of indicators predictive

of activities of daily living (ADL) disability identified in a

recent review.8

He concluded that that the identification of older

adults at nutritional risk must be a priority.

References1. Colman RJ, et al. Science 2009;325:201-204.2. Kalm LM and Semba RD. J Nutr 2005;135:1347-1352.3. Berrington de GA, et al. N Engl J Med 2010;363:2211-2219.4. Stessman J, et al. J Am Geriatr Soc 2009;57:2232-2238.5. Kvamme JM, et al. J Epidemiol Community Health 2012;66:611-617.6. Grabowski DC, et al. J Am Geriatr Soc 2001;49:968-979.7. de Hollander EL, et al. J Nutr Health Aging 2012;16:100-106.8. Vermeulen J, et al. BMC Geriatr 2011;11:33.

rates in physical activity are low. Physical activity declines with

increasing age from childhood to older age, and fails to reach

levels recommended in government guidelines.2 The challenge

remains to understand how to develop systems, values and

cultures that encourage more people to be active.

The Physical Activity Guidelines for Americans

published in 2008 recommend that older people follow the

same guidance given for the adult population in general or, if

not possible, to be as physically active as permitted by abilities

and conditions.1 Professor Nelson stressed that there is no

need for medical clearance before exercising; in fact, being

sedentary and not exercising is more high-risk. To improve

overall health in older adults, an exercise program should

incorporate both aerobic exercise and strength training,

with balance training of importance for older people at risk

of falls.1

Professor Nelson gave an overview of two programmes:

the StrongWomen Initiative (www.strongwomen.com) a

United States evidence-based community exercise and nutrition

program targeted to women from midlife and older, which

has been shown to improve physical fitness3; and Vitality,

Independence and Vigor in Elders (VIVE), an ongoing study

investigating whether a community-based targeted exercise

and nutrition program can improve functional performance

and health in frail older people.

She concluded that to be successful, strategies to

improve physical activity need to be targeted at the individual,

community and national level, and that changes are needed to

our physical and social environment across home, community,

work place and society.

References1. Physical Activity Guidelines Advisory Committee. 2008. Wasington D.C., U.S. Department of Health

and Human Services.2. Troiano RP, et al. Med Sci Sports Exerc 2008;40:181-188.3. Seguin RA, et al. Health Educ Behav 2012;39:183-190.

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Sir David Cuthbertson studied the effects of trauma, illness

and immobility on the metabolism of surgical patients, with a

particular focus on protein metabolism. This topic is as relevant

today as it was in the 1930s, and our understanding of it continues

to deepen. During trauma, muscle releases amino acids for the

immune system to produce acute phase proteins and to aid in

repair. These amino acids are released into the bloodstream for

synthesis of proteins; however, as a result of anabolic resistance

most of the amino acids are used for oxidation. The same occurs

when patients with anabolic resistance are fed; amino acids are

used for oxidation.

What are the mechanisms of anabolic resistance? In the

post-absorptive state, protein breakdown outstrips protein

synthesis resulting in negative protein balance in the muscle.

After ingestion of a meal, stimulation of protein synthesis

and inhibition of protein breakdown leads to neutral protein

balance. Behind this process lies complex intracellular

machinery.1 Insulin is an important signal during meal intake

that acts on this machinery together with amino acids and

energy to stimulate protein synthesis, but at the same time to

inhibit protein breakdown. Stress signals, such as cytokines,

can directly stimulate protein breakdown and inhibit

protein synthesis so that the balance between both signals is

very important.

Aging has an important impact on muscle, so how does

this apply to sarcopenia? The definition of sarcopenia has been

clarified as a decrease in muscle mass with a decrease in muscle

function (strength/performance).2,3 Similarly to bone mass, the

accumulation of muscle mass peaks during adulthood and

subsequently declines during aging. However, sarcopenia is

also observed in other models beyond aging, for example in

the catabolic crisis model and in chronic organ disease, such as

chronic obstructive pulmonary disease.

During aging there is an impaired response of muscle

protein synthesis to intake of amino acids and glucose.4,5 This

lower anabolic response by muscle to meal intake may be

related to alterations in intake, absorption, availability, muscle

sensitivity or hormonal response. There is much debate about

the optimal level of protein intake, the ideal protein to energy

ratio and the most suitable composition and source of protein

The language of protein nutrition: How does food speak to our muscle?Y Boirie (France)

in the diet. The impact of disease must also be considered, for

example on absorption and utilization of amino acids. In aging

there is decreased sensitivity to leucine6 and impaired muscle

anabolic response to insulin,7 possibly due to a defect in the

regulation of the mTOR signalling pathway.

In the presence of anabolic resistance muscle anabolic

threshold is increased, which needs to be considered in

targeting protein synthesis after meal intake. There is evidence

that omega-3 fatty acids and oleate may alter the anabolic

threshold.8,9 Lipotoxicity could be of importance, since adiposity

may be deleterious for muscle protein synthesis.10,11 Sarcopenic

obesity has been associated with adverse clinical effects, such

as poor functional status, reduced survival, and the potential

for chemotherapy toxicity in obese patients with lung and

gastrointestinal cancer.12 Vitamin D has been shown to potentiate

the effect of insulin and leucine on muscle anabolism.13 Chronic

disease, immobilization and impaired muscle blood flow may

also be modulators of muscle anabolic resistance.

To respond to this resistance, the availability of amino

acids to the muscle needs to be improved through dietary

manipulation. An increased proportion of leucine may be

required for optimal stimulation of muscle protein synthesis

in older people.14-16 Protein pulse-feeding stimulates muscle

protein synthesis and improves nitrogen retention in the

elderly.17,18 Protein digestion rate may be important; in

older people, fast proteins (meat and whey) may increase

postprandial whole body protein anabolism.19,20

Professor Boirie reminded delegates that Sir David

Cuthbertson had observed the importance of ‘the timing

of work in relation to the taking of food’. Physical exercise

could be considered as an anabolic signal.21 In summary,

the best synergistic combination to improve protein gain

involves nutrition, physical activity, hormones and possibly

pharmacological options. This lecture focused on protein

synthesis, but future research needs to focus on protein

breakdown, regeneration and apoptosis. The relationship

between the muscle and other organs, muscle metabolomics

and epigenetic regulation of muscle metabolism are amongst

a host of other possible perspectives in protein nutrition that

warrant further investigation.

References1. Glass DJ. Int J Biochem Cell Biol 2005;37:1974-1984.2. Cruz-Jentoft AJ, et al. Age Ageing 2010;39:412-423.3. Muscaritoli M, et al. Clin Nutr 2010;29:154-159.4. Mosoni L, et al. Am J Physiol 1995;268(2 Pt 1):E328-E335.5. Volpi E, et al. J Clin Endocrinol Metab 2000;85:4481-4490.6. Dardevet D, et al. J Nutr 2000;130:2630-2635.7. Guillet C, et al. FASEB J 2004;18:1586-1587.8. Smith GI, et al. Am J Clin Nutr 2011;93:402-412.9. Tardif N, et al. Clin Nutr 2011;30:799-806.10. Guillet C, et al. J Clin Endocrinol Metab 2009;94:3044-3050.11. Guillet C, et al. Curr Opin Clin Nutr Metab Care 2011;14:89-92.12. Prado CM, et al. Lancet Oncol 2008;9:629-635.13. Salles J, et al. Clin Nutr 2012;7(Suppl 1):227.14. Paddon-Jones D, et al. Am J Physiol Endocrinol Metab 2004;286:E321-E328.15. Katsanos CS, et al. Am J Physiol Endocrinol Metab 2006;291:E381-E387.16. Rieu I, et al. J Physiol 2006;575(Pt 1):305-315.17. Arnal MA, et al. Am J Clin Nutr 1999;69:1202-1208.18. Arnal MA, et al. J Nutr 2002;132:1002-1008.19. Boirie Y, et al. Proc Natl Acad Sci U S A 1997;94:14930-14935.20. Remond D, et al. Am J Clin Nutr 2007;85:1286-1292.21. Irving BA, et al. Ageing Res Rev 2012;11:374-389.

Sir David Cuthbertson Lecture

less costly tool for routine assessment and monitoring of

LBM in patients with cachexia or at risk of cachexia.3

References1. Kyle UG, et al. Clin Nutr 2012; 7(Suppl 1):1.2. Huhmann MB, et al. Clin Nutr 2012;7(Suppl 1):2.3. Molfino A, et al. Clin Nutr 2012;7(Suppl 1):3.

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The European Nutrition for Health Alliance (EHNA) is

a charity that brings together 10 key European Union

(EU) stakeholders working in health and nutrition

with the key objective to ensure that routine nutri-

tional screening and follow-up is implemented for all

individuals at risk of malnutrition across Europe. The

EHNA has made significant progress in recent years

developing strategic alliances with European patient

organizations to help promote education of patients and

physicians to improve patient care, and with the World

Health Organization to ensure that the issue of malnu-

trition in Europe is not overlooked. In addition, the

EHNA is a co-developer of the EU program Active and

Healthy Ageing, which will address the issue of under-

nutrition and is a key partner in the priority action area

‘Prevention and early diagnosis of functional decline,

both physical and cognitive, in older people’. In the

future, the EHNA will build on the success of the imple-

mentation of a pilot nutritional screening project in

Belgium in 2012, with the aim of driving and supporting

Medical and political perspectivesP Singer (Israel)O Ljungqvist (Sweden)

Medical Nutrition International Industry GrantJ Griesel (Germany)M Chourdakis (Greece)A Brotherton (United Kingdom)

Fight against malnutrition: Joint session ESPEN and Medical Nutrition International Industry

The Medical Nutrition International Industry (MNI)

mission is to bring together companies that provide

products and services to optimize patient outcome

through specialized nutritional solutions. The main

objectives of the MNI are to work in close collaboration

with the European Society for Clinical Nutrition and

Metabolism (ESPEN) to contribute to the ‘Fight Against

Malnutrition’ initiative through raising awareness for the

existence and impact of malnutrition, to help build an

environment to transition scientific evidence related to

nutritional status and patient outcome and its effect on

healthcare costs, and through supporting the development

of protocols and models for effective nutrition support.

The MNI report ‘Oral Nutritional Supplements to Tackle

Malnutrition: A summary of the Evidence Base’ and the

MNI Grant are two ways in which this is achieved.

The MNI Grant aims to support and reward

infrastructure projects that are relevant to drive national

nutrition policy and serve as a protocol to improve

the nutritional status of patients. The grant has been

awarded for 5 years, and in 2012 was awarded to the

Hellenic Society for Clinical Nutrition and Metabolism

for achievements that included educational activities,

facilitating legislative changes to ensure that malnutrition

is on the political agenda despite the challenging financial

environment, and for the introduction of mandatory

screening and nutrition support teams in all public

hospitals. Dr Michael Chourdakis presented an overview

of achievements.

On behalf of the British Association for Parenteral

and Enteral Nutrition (BAPEN), a previous MNI Grant

award-winning organization, Dr Alisa Brotherton gave

an update on the fight against malnutrition in the United

Kingdom. She outlined the national challenges, BAPEN’s

strategy and vision, the value of describing and measuring

the problem through the national Nutrition Week

surveys, and the development of recommendations for

action and practical tools. Factors that have contributed

to BAPEN’s success include lobbying government,

focusing on quality improvement, networking and

collaborating with multiple partners, and ensuring that

BAPEN is recognized as the leading multidisciplinary

charity for tackling malnutrition in the UK.

For more information visit www.medicalnutritionindustry.

com, www.grespen.org and www.bapen.org.uk.

• During aging, immobilization contributes to the devel-

opment of sarcopenia. In rats with immobilized limbs,

diets high in protein and whey induce significant muscle

mass gain during the recovery phase and in non-immobi-

lized limbs the same diet helps to attenuate muscle

mass loss.1

• Increasing protein intake (up to the Population Reference

Intake [PRI, European Food Safety Authority 2012])

improves muscle contractility and insulin sensitivity in

elite elderly athletes.2

• Intake of a protein-energy enriched formula increases

arginine appearance and nitric oxide synthesis in criti-

cally ill infants with viral bronchiolitis, compared with a

standard formula.3

References1. Magne H, et al. Clin Nutr 2012;7(Suppl 1):6.2. Baglio V, et al. Clin Nutr 2012;7(Suppl 1):7.3. de Betue CT, et al. Clin Nutr 2012;7(Suppl 1):7.

Related topics: Protein metabolismD Dardevet (France)V Baglio (Italy)C de Betue (Netherlands)

similar change across many more European countries.

For more information visit www.european-nutrition.org.

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In many countries healthcare resources are under pressure.

Efforts to understand how limited resources can be best used

to improve healthcare outcomes continue to be a key focus for

all involved in nutritional care. Understanding the impact of

nutritional factors on clinical outcome provides a springboard

to develop effective nutritional strategies focused on improving

clinical outcome.

Lack of nutritional intake due to enforced periods of

fasting is associated with poor clinical outcome. In a study

of hospitalized adult patients in Brazil (n = 1,097, in 10

hospitals) median prolonged preoperative fasting (POF)

was 14 hours (range 2–216 hours) with 84% of patients

experiencing POF of >8 hours and 54% for >12 hours,

well above the 6–8 hour fasting period normally prescribed.

POF was found to be significantly correlated with length of

hospital stay (LOS) with a POF of >12 hours associated with

an increased LOS of 2 days in patients undergoing surgery

for cancer or a major gastrointestinal procedure.1

From the NutritionDay data it has already been

established that low nutrient intake (during lunch/dinner) is

strongly associated with mortality in hospitalized patients.

A new analysis focused on how this association is affected

by age. The study found that risk of death from low intake

increases dramatically with age, and that medically-driven

periods of no intake (ie, fasting) are most detrimental in the

oldest patients.2

Malnutrition and nutritional risk is related to poor

clinical outcome. In a multicenter, prospective, cross-

sectional and longitudinal study, Wong et al. investigated

whether risk of malnutrition (assessed using the validated

Spinal Nutrition Screening Tool) was associated with adverse

clinical outcome. Adult inpatients in four spinal cord injury

The views expressed in this publication are those of the

presenters and participants, not the Nestlé Nutrition Institute.

centers in the UK were included in the study (n = 150). More

than 40% of patients were at risk of malnutrition, and

they had a significantly longer LOS than those not at risk

of malnutrition (median LOS [sd]: 129 [102.1] vs 85 days

[84.6]; P = 0.012) and greater 12-month mortality (9.2% vs

1.4%; P = 0.036).3

A study designed to investigate the relevance of

malnutrition to patient outcomes found that 37% of 13,922

patients were at risk of malnutrition (Malnutrition Universal

Screening Tool [MUST] score ≥2). Patients were stratified by

severity of background disease (using the Charlson Co-morbidity

Index [CCI]) for analysis. In the lowest CCI group complicated

hospitalization (bloodstream infection ± prolonged hospital stay

± death affecting a single patient) affected 5% of patients at low

risk versus 12% of patients at high risk for malnutrition. In the

high CCI group 25% versus 48% experienced complicated

hospitalization (low versus high risk respectively, odds ratio =

3.3).4

Cereda et al. evaluated the relationship between nutritional

risk (measured using the Geriatric Nutritional Index [GRNI])

and functional status (measured using the Barthel Index [BI])

and their association with mortality in a prospective cohort

study of older people in long-term care (n = 346). Functional

status was independently associated with age (P = 0.045), arm

muscle area (P = 0.048) and nutritional risk using GNRI (P <

0.001). Patients with high nutritional risk had a higher rate

of cardiovascular mortality (HR = 1.93; 95% CI, 1.28–2.91;

P < 0.001) demonstrating that nutritional risk is an independent

predictor of functional status and mortality in this patient

group.5

References1. Dias AL, et al. Clin Nutr 2012;7(Suppl 1):20.2. Heismayr MJ, et al. Clin Nutr 2012;7(Suppl 1):21.3. Wong S, et al. Clin Nutr 2012;7(Suppl 1):20.4. Awadie H, et al. Clin Nutr 2012;7(Suppl 1):21.5. Cereda E, et al. Clin Nutr 2012;7(Suppl 1):22.

Clinical outcomes: A summary of oral communicationsI Correia (Brazil)M Heismayr (Austria)S Wong (United Kingdom)H Awadie (Israel)E Cereda (Italy)

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January 2013

42nd Critical Care Congress19–23 January 2013 San Juan, Puerto RicoOrganizer:Society of Critical Care Medicine

Web site: www.sccm.org

February 2013

Clinical Nutrition Week 20139–12 February 2013Phoenix, Arizona, USAOrganizer:American Society for Parenteral and Enteral Nutrition

Web site: www.nutritioncare.org/cnw

28th Annual Meeting of the Japanese Society for Parenteral and Enteral Nutrition21–22 February 2013Kanazawa, JapanOrganizer:Japanese Society for Parenteral and Enteral Nutrition

Web site: www2.convention.co.jp/28jspen/top.html

March 2013

2013 Aging in America Conference12–16 March 2013Chicago, Illinois, USA Organizer:American Society on Aging

Web site: www.asaging.org/aia

2013 Dysphagia Research Society (DRS) Annual Meeting13–16 March 2013Seattle, Washington, USAOrganizer:Dysphagia Research Society

Web site: www.dysphagiaresearch.org

Long Term Care Medicine 201321–24 March 2013Washington, DC, USAOrganizer:American Medical Directors Association

Web site: www.amda.com/calendar

April 2013

28th International Conference of Alzheimer’s Disease International18–20 April 2013 Taipei, TaiwanOrganizer:Alzheimer’s Disease International and Taiwan Alzheimer’s Disease Association

Web site: www.adi2013.org

Experimental Biology 201320–24 April 2013Boston, Massachusetts, USAOrganizer:American Society for Nutrition and various societies

Web site: experimentalbiology.org/EB/pages/default.aspx?splashpage=1

Calendar 2013Conference

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