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Substantial international differences in the prevalence of cancer disease suppose that nutrition may be an important factor in the development of cancer. Many experts believe, that nutritional factors may contribute up to 35 % to the development of malignant tumors. Many patients have lost substantial body weight already at the time of the diagnosis of the disease as consequence of undernutrition and malnutrition, respectively. During the course of the disease the nutritional status often is deteriorating further. Caused by both the cancer disease itself and the treatment, loss of appetite, changes in taste, nausea and vomiting may additionally contribute to undernutrition. Undernutrition is a relevant factor for the outcome of the disease and for the tolerance of the treatment as well. Therefore, supporting the heavily impaired patients in nutritional intake is of paramount importance and an urgent task for physicians and nurses. In view of physiology, pathophysiology, genetics and molecular biology, metabolic processes in cancer are highly complex regulated and there is increasing evidence that a diet rich in fat and protein is favourable. This, however, implies a paradigma shift away from the "healthy" balanced diet rich in fruit, vegetable and complex carbohydrates. So far, the evidence based data of this new concept is, however, a controversial issue.Deutliche internationale Unterschiede in der Häufigkeit von Krebs haben zu der Vermutung geführt, dass die Ernährung ein wichtiger Risikofaktor für die Entstehung von Krebs sein könnte. Experten sind der Meinung, dass die Ernährung in 30–35 % mitverantwortlich für die Entstehung von bösartigen Tumoren ist. Bereits vor Tumordiagnose haben viele Patienten Gewicht verloren als Folge einer Unter- oder Mangelernährung. Häufig verschlechtert sich der Ernährungszustand während der Erkrankung weiter. Als Folge der Tumorerkrankung sowie therapiebedingt führen Appetitlosigkeit, Geschmacksveränderungen, Übelkeit, Erbrechen zusätzlich zu Mangel- und Unterernährung. Die Mangelernährung hat einen erheblichen Einfluss auf die Prognose der Erkrankung und auch auf die Verträglichkeit der Therapie. Deshalb ist die Unterstützung der stark beeinträchtigten Patienten bei der Nahrungsaufnahme eine wichtige und vordringliche ärztliche und pflegerische Tätigkeit. Die physiologischen, pathophysiologischen, genetischen und molekularbiologischen Stoffwechselprozesse bei Krebs sind hochkomplex reguliert, deuten in ihrer Gesamtheit darauf hin, dass eine fett- und eiweißbasierte Ernährung favorisiert werden sollte, was einem Paradigmenwechsel zur sog. gesunden, ausgewogenen Ernährung mit viel Früchten, Gemüse und komplexen Kohlenhydraten entspricht. Die evidenzbasierte Datenlage wird aber durchaus kontrovers diskutiert.

Polymorbidity and old age are rather the rule than the exception in hospitalised patients. Malnutrition is common in such patients and should be identified by appropriate screening and assessment measures in order to devise a nutrition plan and act accordingly. Unlike in the UK or The Netherlands, malnutrition screening and nutrition teams are not mandatory for German hospitals. Malnutrition and, in particular, sarcopenia are indicators of a nutrition associated risk or increased morbidity and mortality. Malnutrition can affect patients of any medical discipline and, therefore, is managed most efficiently by the interdisciplinary and multiprofessional nutrition team. By this approach goal directed nutrition therapy can improve morbidity and mortality of hospitalised patients.

Today, food addiction has become an increasing area of research. Multiple studies aim to characterize individuals in terms of food addiction based on the assumption, that hyperpalatable foods rich of salt, sugar and fat may induce a cluster of behavioral changes that may resemble a substance use disorder, despite the fact that to date there is no evidence, that nutritional factors lead to an addictive eating-like behavior in humans. In this review article, we aim to introduce the basic experiments, that build the framework upon which food addiction is being investigated and to critically discuss the concept of food addiction.

On comparing surgical and conservative approaches in therapy for obesity it is accepted that there is a more rapid decline in body weight after surgery than by conservative measures. In contrast to widespread convictions, it has been shown that even in extreme obesity (BMI60 kg/m²) both a meaningful and a long-lasting reduction of body weight is possible by conservative approach. There is an increasing body of evidence that bariatric surgery, especially malabsorptive and combined forms, causes endocrine disturbances and both vitamin and micronutrient deficiencies. Furthermore, alterations in drug pharmacokinetics are possible. Even bariatric surgeons have stated that surgery neither removes the chronic disease obesity nor is its final therapy.

Orthorectic eating behaviour is characterised by a fixation on a healthy diet and rigidity regarding self-imposed nutrition standards. Besides malnutrition, subjective distress and social isolation might be consequences of clinical relevance. So far there are few reliable data about nosology and prevalence rates, so that it is not yet possible to evaluate the clinical significance of orthorectic eating behaviour. This article discusses nosological classifications of orthorexia and presents prevalence rates of extremely healthy eating behaviour in general population as well as in several specific subgroups. To summarise, orthorectic eating behaviour seems to be most likely an eating disorder with healthy dieting as an overvalued idea. Data on prevelance of orthorectic eating behaviour, assessed with the recently developed Düsseldorfer Orthorexie Skala, suggest a rate of 1 to 2% in general population.

The relative contribution of nutrition-related chronic diseases to the total disease burden of the society and the healthcare costs have risen continuously over the last decades. This challenge requires to explore and use the potential of dietary prevention of diseases such as obesity, type 2 diabetes, dyslipidaemia, cardiovascular disease and cancer. This evidence-based guideline systematically assessed the potential role of carbohydrates in the primary prevention of these diseases. The major findings were: a high consumption of sugar-sweetened beverages increases the risk of obesity and type 2 diabetes (strength of evidence: probable), whereas a high dietary fibre intake, mainly from whole-grain products, reduces the risk of obesity, type 2 diabetes, dyslipidaemia, hypertension, coronary heart disease and colorectal cancer (strength of evidence: probable and convincing, respectively). The practical consequences for current dietary recommendations are presented.

Severe trauma triggers endocrine and inflammatory responses, leading to hyperglycaemia, insulin resistance and protein catabolism. Pharmacological and nutritional interventions cannot counteract these metabolic disturbances. However, adequate supply of energy and proteins may reduce excessive catabolism.Available guidelines recommend early use of enteral nutrition with energetic supply of about 25 kcal/kg and additional protein supply of 1.5 g/kg/day. These aims will be missed frequently by solely providing enteral nutrition in severely injured patients. Early supplemental parenteral nutrition should be used in these cases. Concomitantly, gastric paresis and paralytic ileus hampering enteral nutrition should be treated by propulsive and prokinetic drugs and by use of duodenal or jejunal site of application in selected cases.Euphoric hopes linked with intensified insulin therapy (IIT), targeting blood glucose levels110 mg/dl in intensive care patients, had to be widely abandoned in recent years. The goal for blood glucose levels should be set at 180 mg/dl as the upper limit according to current knowledge, which promises to optimize the balance between efficacy and safety.

Immunonutrition may be superior to standard clinical nutrition in specific clinical situations. After severe trauma, an enteral immuno-enhancing diet, enriched with arginine, omega-3 fatty acids, and nucleotides, decreases infectious complications. During acute respiratory distress syndrome, a continuous enteral diet with high-dose omega-3 fatty acids, gamma-linolenic acid, and antioxidants improved clinical outcome. Glutamine should be administered enterally or parenterally whenever total parenteral nutrition is indicated.

Tumours of the upper aerodigestive tract cause malnutrition in the majority of ENT cancer patients. This situation is complicated by multimodal treatment regimens (including surgery and/or irradiation). The resulting malnutrition is a disease entity in its own right and requires special treatment concepts. Effective screening tools (NRS 2002) need to be introduced and data such as body mass index and bioimpedance analysis need to be gathered. The nutrition plan for individual ENT patients differs according to the grade of malnutrition and dysphagia. Oral nutrition should always form the basis of any nutrition programme, such that logopedic therapy is required in all cases of dysphagia. Artifical, oral high-energy nutrition is a pharmacological procedure as well as enteral feeding via PEG or PEJ. Partial or total parenteral nutrition (central venous access) should be restricted to crisis interventions or fast-track regimens.

Nutritional disorders and a reduced performance are common reasons to send in feedstuffs for quality control. The following review illustrates the main nutritional-related problems on pig farms and presents possible causal relationships between feed/feeding and health disorders.The analysis results of feedstuff and drinking water samples that were sent to the institute for animal nutrition between 2000 and 2009 were evaluated retrospectively.Certain trends were revealed. Whereas previously fertility disorders gave rise to analysis of food samples, in recent years the grinding intensity of mixed feeds (potential relationship to gastric ulcers) has become of more interest. Mixed feed in meal form (n=143) showed a usual particle size structure, whereas pelleted and crumbled diets exhibited undesirable, higher proportions of fine particles. A contamination with pests was only found in a few feed samples (0.9% of analysed feedstuffs in 2007). With only a few exceptions the feedstuffs were of a satisfactory hygienic quality. With respect to the chemical composition of the mixed feeds, differences between analysed and labelled levels were detected in terms of crude fibre (63.0% of 138 analysed feed samples). More than 50% of the feedstuffs (n=64) showed aberrations in the botanical composition. Samples of drinking water were checked to an increasing extent (n=120 in 2009) probably due to the fact that drinking water is defined by law as a feedstuff and evaluation criteria exist. Elevated levels of iron and aerobe bacteria (in 50% and 30.8% of samples, respectively) were among the most common findings.The spectrum of analyses has been expanded in recent years. In many cases a relationship could be found between clinical symptoms and alterations within the feed or the drinking water.

A close cooperation between medical teams is necessary when calculating the fluid intake of parenterally fed patients. Fluids supplied parenterally, orally and enterally, other infusions, and additional fluid losses (e.g. diarrhea) must be considered. Targeted diagnostic monitoring (volume status) is required in patients with disturbed water or electrolyte balance. Fluid requirements of adults with normal hydration status is approximately 30–40 ml/kg body weight/d, but fluid needs usually increase during fever. Serum electrolyte concentrations should be determined prior to PN, and patients with normal fluid and electrolyte balance should receive intakes follwing standard recommendations with PN. Additional requirements should usually be administered via separate infusion pumps. Concentrated potassium (1 mval/ml) or 20% NaCl solutions should be infused via a central venous catheter. Electrolyte intake should be adjusted according to the results of regular laboratory analyses. Individual determination of electrolyte intake is required when electrolyte balance is initially altered (e.g. due to chronic diarrhea, recurring vomiting, renal insufficiency etc.). Vitamins and trace elements should be generally substituted in PN, unless there are contraindications. The supplementation of vitamins and trace elements is obligatory after a PN of >1 week. A standard dosage of vitamins and trace elements based on current dietary reference intakes for oral feeding is generally recommended unless certain clinical situations require other intakes., GMS German Medical Science; 7:Doc21; ISSN 1612-3174

Catheter type, access technique, and the catheter position should be selected considering to the anticipated duration of PN aiming at the lowest complication risks (infectious and non-infectious). Long-term (>7–10 days) parenteral nutrition (PN) requires central venous access whereas for PN 3 weeks subcutaneous tunnelled catheters or port systems are appropriate. CVC (central venous catheter) should be flushed with isotonic NaCl solution before and after PN application and during CVC occlusions. Strict indications are required for central venous access placement and the catheter should be removed as soon as possible if not required any more. Blood samples should not to be taken from the CVC. If catheter infection is suspected, peripheral blood-culture samples and culture samples from each catheter lumen should be taken simultaneously. Removal of the CVC should be carried out immediately if there are pronounced signs of local infection at the insertion site and/or clinical suspicion of catheter-induced sepsis. In case PN is indicated for a short period (max. 7–10 days), a peripheral venous access can be used if no hyperosmolar solutions (>800 mosm/L) or solutions with a high titration acidity or alkalinity are used. A peripheral venous catheter (PVC) can remain in situ for as long as it is clinically required unless there are signs of inflammation at the insertion site., GMS German Medical Science; 7:Doc19; ISSN 1612-3174

All-in-one admixtures (AIO-admixtures) provide safe, effective and low-risk PN (parenteral nutrition) for practically all indications and applications. Water, energy (carbohydrates and lipids), amino acids, vitamins and trace elements are infused together with PN either as industrially-manufactured AIO admixtures provided as two- or three-chamber bags (shelf life usually more than 12 months) completed with electrolytes and micronutrients where appropriate or as individually compounded ready-to-use AIO admixtures (compounding, usually prepared by a pharmacy on either a daily or weekly basis and stored at 2–8°C). Physico-chemical and microbial stability of an AIO admixture is essential for the safety and effectiveness of patient-specific PN, and its assurance requires specialist pharmaceutical knowledge. The stability should be documented for an application period of 24 (–48) hours. It is advisable to offer a limited selection of different PN regimes in each hospital. For reasons of drug and medication safety, PN admixtures prepared for individual patients must be correctly labelled and specifications for storage conditions must also be followed during transport. Monitoring is required where applicable. Micronutrients are usually administered separately to AIO admixtures. In case compatibility and stability have been well documented trace elements and/or combination preparations including water-soluble or water-soluble/fat soluble vitamin supplements can be added to PN admixtures under strict aseptic conditions. AIO admixtures are usually not used as vehicles for drugs (incompatibilities)., GMS German Medical Science; 7:Doc18; ISSN 1612-3174

Compared to enteral or hypocaloric oral nutrition, the use of PN (parenteral nutrition) is not associated with increased mortality, overall frequency of complications, or longer length of hospital stay (LOS). The risk of PN complications (e.g. refeeding-syndrome, hyperglycaemia, bone demineralisation, catheter infections) can be minimised by carefully monitoring patients and the use of nutrition support teams particularly during long-term PN. Occuring complications are e.g. the refeeding-syndrome in patients suffering from severe malnutrition with the initiation of refeeding or metabolic, hypertriglyceridemia, hyperglycaemia, osteomalacia and osteoporosis, and hepatic complications including fatty liver, non-alcoholic fatty liver disease, cholestasis, cholecystitis, and cholelithiasis. Efficient monitoring in all types of PN can result in reduced PN-associated complications and reduced costs. Water and electrolyte balance, blood sugar, and cardiovascular function should regularly be monitored during PN. Regular checks of serum electrolytes and triglycerides as well as additional monitoring measures are necessary in patients with altered renal function, electrolyte-free substrate intake, lipid infusions, and in intensive care patients. The metabolic monitoring of patients under long-term PN should be carried out according to standardised procedures. Monitoring metabolic determinants of bone metabolism is particularly important in patients receiving long-term PN. Markers of intermediary, electrolyte and trace element metabolism require regular checks., GMS German Medical Science; 7:Doc17; ISSN 1612-3174

The aim of this study is based on the analysis of diachronically social and sexual specific considerations on the life situation of the early medieval population of Schleitheim, Kanton Schaffhausen, Switzerland. Cribra orbitalia and the linear enamel hypoplasia of the teeth are considered as stressors. This study is based on the life expectancy of the 20 years old, as the life expectancy gives information on the health condition of a social group or an entire population. The considered indicators show the same tendencies in three of the four social groups (women social group A and group B/C, men of the social group A). The female and male population of the social group A show a steady decrease in the indicator from the 5th century to come to its lowest level in the 7th century. The same parameters indicate a continuous increase in stress for the female population of the group B/C. Only one of the three indicators, the Cribra orbitalia, shows a positive tendency in the male population of the social group B/C from the 6th century to the following period, while hypoplasia and the life expectancy on the other hand indicate a negative tendency. The results show equal tendencies in the three independent indicators concerning three of the four social groups. This proves the high reliability of the indicators. These results are astonishing in two ways. First of all, the tendencies show that the originally better life situation of women of the higher ranking social group decreases in the following periods, whereas the women of the lower social group show an inverse development. This female population of low life situation in the 5th century shows an increase in life qualities in the following periods. Remarkable, too, is the fact, that the female population of both social groups shows a lower level of stress than the corresponding male population. This fact is astonishing, as we would expect inverse results in a patriarchal society. This may point to a well known fact: Women show a higher vitality than the male population.

Nutrition ecology is the science that studies the impacts of human nutrition on the environment, on human health and on social systems. Environmental impacts are usually the result of intensive food production, food transport and food packaging; they include soil contamination and erosion, energy consumption, air contamination and waste disposal. Health impacts of contemporary western eating behavior concern nutrition-related diseases (diabetes, hypertension, gout, overweight etc) and their psychological and social consequences; nutrition ecology aims at a balanced diet and suitable eating behavior to reduce the risks of chronic disease. The social impacts of nutrition concern the effects of feed trade on poor working conditions and poverty, especially in developing countries. The strategies of nutrition ecology agree in many points with those of the agenda 21 and of Consumer Protection. As nutrition-related diseases are increasing further, the public health services in Germany discover nutrition as an important topic in health promotion and prevention. They will contribute remarkably to a sustainable development if they include the strategies of nutrition ecology in their projects.

Postoperative enterocutaneous fistulas are usually the result of an anastomotic leak. The likelihood of a postoperative fistula developing depends on concomitant diseases. An established gastrointestinal fistula is associated with considerable morbidity and mortality. Appreciable losses of fluid, protein and electrolytes often result in malnutrition, which has a negative impact on wound infection and the mental performance of the patient. Conservative treatment must aim to compensate these deficits as early as possible. Adequate amounts of energy (carbohydrates and fats) vitamins and trace elements must be ensured by replacement measures. In addition to appropriate drainage of the intra-abdominal focus and the use of antibiotics, treatment with octreotide (somatostatin analogues) may be considered. For conservative treatment, however, free intestinal transit distal to the fistula must be ensured. If an enterocutaneous fistula fails to heal within two or three months under conservative treatment, surgical management must be applied.

Prospektiv wurden 81 konsekutive Patienten mit fortgeschrittenem Tumorleiden und tumorassoziierter Malnutrition parenteral heimernährt und in Bezug auf die Parameter Ernährungszustand, Allgemeinzustand und Lebensqualität evaluiert. Appliziert wurden Mischbeutelinfusionen mit im Median 12,3 g/d Stickstoff, 270 g/d Kohlenhydrate und 59 g/d Fett. Die applizierte Energie lag im Median bei 7830 KJ/d, die Behandlungsdauer bei 38 Tagen. In 4158 Behandlungstagen traten 16 Komplikationen auf, davon 3 Fälle von Kathetersepsis. Der mediane Karnofsky-Index bei Behandlungsbeginn war 50%. Er verbesserte sich unter der Behandlung bei 21 Patienten, im Median um 10%. Bei Behandlungszeiten über 90 Tage verbesserte sich der Karnofsky-Index bei 50% der Behandelten. Durch die Behandlung stieg der Body Mass Index im Median um 0,3 kg/m2, bei Langzeitbehandlung um 1,1 kg/m2. Die Lebensqualität nahm unter der Behandlung bei 33 % der Patienten zu, bei 17% blieb sie konstant. Die Lebensqualität sank nach durchschnittlich 73% der gesamten Behandlungszeit unter den Ausgangswert. Die vorliegende Arbeit beweist, dass die parenterale Heimernährung bei Patienten mit tumorassoziierter Malnutrition eine sichere, gut akzeptierte und therapeutisch effektive Methode ist. Als beste Indikation für die parenterale Ernährung erwies sich die diffuse symptomatische Peritonealkarzinose bei langsam progredientem Tumorleiden.

Clinical nutrition covers a wide range of specialties of medicine. There is a need for better nutritional support in prevention of chronic diseases, investigations to assess malnutrition, dietetics including artificial nutrition and rehabilitation as well as supportive care for the severely and terminally ill patients. Clinical nutrition follows the principles of evidence-based medicine. In future the training of doctors in human nutrition has to be further improved. Since nothing works well in isolation an integration of clinical nutrition into gastroenterology is recommended.