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Healthcare systems and patients today are challenged by high and ever-escalating costs for care. With increasing costs and declining affordability, public and private healthcare payers are all seeking value in care. As the evidence regarding health benefits of nutrition products and interventional nutrition care is increasing, cost-effectiveness of these interventions needs consideration. Health economics and outcomes research (HEOR) examines the value of healthcare treatments, including nutrition interventions. This review summarizes how HEOR tools are used to measure health impact, that is, the burden of illness, the effect of interventions on the illness, and the value of the nutrition intervention in terms of health and cost outcomes. How studies are designed to compile data for economic analyses is briefly discussed. Then, studies that use HEOR methods to measure efficacy, cost-effectiveness, and cost savings from nutrition care across the healthcare spectrum-from hospitals to nursing homes and rehabilitation centers, to care for community-living individuals, with an emphasis on individuals who are older or experiencing chronic health issues-are reviewed. Overall, findings from HEOR studies over the past decade build considerable evidence to show that nutrition care improves the health of at-risk or malnourished patients effectively and at a reasonable cost. As such, the evidence suggests that nutrition care brings value to healthcare across multiple settings and populations., (© 2024 The Author(s). Nutrition in Clinical Practice published by Wiley Periodicals LLC on behalf of American Society for Parenteral and Enteral Nutrition.)

This review examines our current understanding of consensus definitions for frailty, sarcopenia, and cachexia and their perceived overlap with malnutrition. Patients with these syndromes will often meet the criteria for malnutrition. It is common for these overlap syndromes to be misapplied by practitioners, and confusion has been further exacerbated by the lack of a common malnutrition language. To address the latter concern, we recommend using either the standalone Global Leadership Initiative in Malnutrition (GLIM) framework or the GLIM consensus criteria integrated with other accepted approaches as dictated by preference and available resources. Established care standards should guide the recognition and treatment of malnutrition to promote optimal clinical outcomes and quality of life. The effectiveness of nutrition interventions may be reduced in settings of severe acute inflammation and in end-stage disease that is associated with cachexia. However, such interventions may still assist patients to tolerate treatments that target the underlying etiology for an overlap syndrome, and they may help to improve select clinical outcomes and quality of life. Recent, large, well-designed randomized controlled trials have demonstrated the compelling positive clinical effects of medical nutrition therapy. The application of concurrent malnutrition risk screening and assessment is therefore a high priority. The necessity to deliver specific interventions that target the underlying mechanisms of these overlap syndromes and also diagnose and address malnutrition is paramount. It must be highlighted that securing beneficial outcomes for frailty, sarcopenia, and cachexia will also require nonnutrition interventions, like comprehensive care plans, pharmacologic agents, and prescribed exercise., (© 2024 American Society for Parenteral and Enteral Nutrition.)

The presence and impact of malnutrition in adult hospitalized patients has been well documented by a significant body of literature. However, current malnutrition care practices often vary widely and frequently lack standardization. The Global Malnutrition Composite Score (GMCS), the first nutrition-related electronic clinical quality measure, is intended to evaluate the quality of malnutrition care provided to inpatient adults. This measure aims to aid in standardizing malnutrition care through performance measurement. The four components of the measure (nutrition screening, nutrition assessment, malnutrition diagnosis, and nutrition care plans) follow the well-established Nutrition Care Process and encourage the use of standardized terminology. Facilities with high-performance scores on the GMCS are likely to experience improved outcomes associated with high-quality malnutrition care., (© 2024 American Society for Parenteral and Enteral Nutrition.)

Background: Stroke patients often face disabilities that significantly interfere with their daily lives. Poor nutritional status is a common issue amongst these patients, and malnutrition can severely impact their functional recovery post-stroke. Therefore, nutritional therapy is crucial in managing stroke outcomes. However, its effects on disability, activities of daily living (ADL), and other critical outcomes have not been fully explored., Objectives: To evaluate the effects of nutritional therapy on reducing disability and improving ADL in patients after stroke., Search Methods: We searched the trial registers of the Cochrane Stroke Group, CENTRAL, MEDLINE (from 1946), Embase (from 1974), CINAHL (from 1982), and AMED (from 1985) to 19 February 2024. We also searched trials and research registries (ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform) and reference lists of articles., Selection Criteria: We included randomised controlled trials (RCTs) that compared nutritional therapy with placebo, usual care, or one type of nutritional therapy in people after stroke. Nutritional therapy was defined as the administration of supplemental nutrients, including energy, protein, amino acids, fatty acids, vitamins, and minerals, through oral, enteral, or parenteral methods. As a comparator, one type of nutritional therapy refers to all forms of nutritional therapies, excluding the specific nutritional therapy defined for use in the intervention group., Data Collection and Analysis: We used Cochrane's Screen4Me workflow to assess the initial search results. Two review authors independently screened references that met the inclusion criteria, extracted data, and assessed the risk of bias and the certainty of the evidence using the GRADE approach. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous data and the odds ratio (OR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I 2 statistic. The primary outcomes were disability and ADL. We also assessed gait, nutritional status, all-cause mortality, quality of life, hand and leg muscle strength, cognitive function, physical performance, stroke recurrence, swallowing function, neurological impairment, and the development of complications (adverse events) as secondary outcomes., Main Results: We identified 52 eligible RCTs involving 11,926 participants. Thirty-six studies were conducted in the acute phase, 10 in the subacute phase, three in the acute and subacute phases, and three in the chronic phase. Twenty-three studies included patients with ischaemic stroke, three included patients with haemorrhagic stroke, three included patients with subarachnoid haemorrhage (SAH), and 23 included patients with ischaemic or haemorrhagic stroke including SAH. There were 25 types of nutritional supplements used as an intervention. The number of studies that assessed disability and ADL as outcomes were nine and 17, respectively. For the intervention using oral energy and protein supplements, which was a primary intervention in this review, six studies were included. The results for the seven outcomes focused on (disability, ADL, body weight change, all-cause mortality, gait speed, quality of life, and incidence of complications (adverse events)) were as follows: There was no evidence of a difference in reducing disability when 'good status' was defined as an mRS score of 0 to 2 (for 'good status': OR 0.97, 95% CI 0.86 to 1.10; 1 RCT, 4023 participants; low-certainty evidence). Oral energy and protein supplements may improve ADL as indicated by an increase in the FIM motor score, but the evidence is very uncertain (MD 8.74, 95% CI 5.93 to 11.54; 2 RCTs, 165 participants; very low-certainty evidence). Oral energy and protein supplements may increase body weight, but the evidence is very uncertain (MD 0.90, 95% CI 0.23 to 1.58; 3 RCTs, 205 participants; very low-certainty evidence). There was no evidence of a difference in reducing all-cause mortality (OR 0.57, 95% CI 0.14 to 2.28; 2 RCTs, 4065 participants; low-certainty evidence). For gait speed and quality of life, no study was identified. With regard to incidence of complications (adverse events), there was no evidence of a difference in the incidence of infections, including pneumonia, urinary tract infections, and septicaemia (OR 0.68, 95% CI 0.20 to 2.30; 1 RCT, 42 participants; very low-certainty evidence). The intervention was associated with an increased incidence of diarrhoea compared to usual care (OR 4.29, 95% CI 1.98 to 9.28; 1 RCT, 4023 participants; low-certainty evidence) and the occurrence of hyperglycaemia or hypoglycaemia (OR 15.6, 95% CI 4.84 to 50.23; 1 RCT, 4023 participants; low-certainty evidence)., Authors' Conclusions: We are uncertain about the effect of nutritional therapy, including oral energy and protein supplements and other supplements identified in this review, on reducing disability and improving ADL in people after stroke. Various nutritional interventions were assessed for the outcomes in the included studies, and almost all studies had small sample sizes. This led to challenges in conducting meta-analyses and reduced the precision of the evidence. Moreover, most of the studies had issues with the risk of bias, especially in terms of the absence of blinding and unclear information. Regarding adverse events, the intervention with oral energy and protein supplements was associated with a higher number of adverse events, such as diarrhoea, hyperglycaemia, and hypoglycaemia, compared to usual care. However, the quality of the evidence was low. Given the low certainty of most of the evidence in our review, further research is needed. Future research should focus on targeted nutritional interventions to reduce disability and improve ADL based on a theoretical rationale in people after stroke and there is a need for improved methodology and reporting., (Copyright © 2024 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

In healthcare, weight is often equated to and used as a marker for health. In examining nutrition and health status, there are many more effective markers independent of weight. In this article, we review practical and emerging clinical applications of technologies and tools used to collect non-weight-related data in nutrition assessment, monitoring, and evaluation in the outpatient setting. The aim is to provide clinicians with new ideas about various types of data to evaluate and track in nutrition care., (© 2024 American Society for Parenteral and Enteral Nutrition.)

Patients with hematological malignancies (HMs) are more frequently admitted now than in the past to the intensive care unit (ICU) due to more aggressive approaches in primary therapy of HMs and the need for critical care support. Pathophysiological alterations derived from HMs and the different hematological therapies, such as chemotherapy, negatively affect gastrointestinal (GI) function, metabolism, and nutrition status. Further, malnutrition strongly influences outcomes and tolerance of the different hematological therapies. In consequence, these critically ill patients frequently present with malnutrition and pathophysiological alterations that create challenges for the delivery of medical nutrition therapy (MNT) in the ICU. Frequent screening, gauging tolerance, and monitoring nutrition status are mandatory to provide individualized MNT and achieve nutrition objectives. The present review discusses how HM impact GI function and nutrition status, the importance of MNT in patients with HM, and specific considerations for guidance in providing adequate MNT to these patients when admitted to the ICU., (© 2024 The Authors. Nutrition in Clinical Practice published by Wiley Periodicals LLC on behalf of American Society for Parenteral and Enteral Nutrition.)

The rapid surge in artificial intelligence (AI) has dominated technological innovation in today's society. As experts begin to understand the potential, a spectrum of opportunities could yield a remarkable revolution. The upsurge in healthcare could transform clinical interventions and outcomes, but it risks dehumanization and increased unethical practices. The field of clinical nutrition and dietetics is no exception. This article finds a multitude of developments underway, which include the use of AI for malnutrition screening; predicting clinical outcomes, such as disease onset, and clinical risks, such as drug interactions; aiding interventions, such as estimating nutrient intake; applying precision nutrition, such as measuring postprandial glycemic response; and supporting workflow through chatbots trained on natural language models. Although the opportunity and scalability of AI is incalculably attractive, especially in the face of poor healthcare resources, the threat cannot be ignored. The risk of malpractice and lack of accountability are some of the main concerns. As such, the healthcare professional's responsibility remains paramount. The data used to train AI models could be biased, which could risk the quality of care to vulnerable or minority patient groups. Standardized AI-development protocols, benchmarked to care recommendations, with rigorous large-scale validation are required to maximize application among different settings. AI could overturn the healthcare landscape, and this article skims the surface of its potential in clinical nutrition and dietetics., (© 2024 American Society for Parenteral and Enteral Nutrition.)

Iatrogenic malnutrition and underfeeding are ubiquitous in intensive care units (ICUs) worldwide for prolonged periods after ICU admission. A major driver leading to the lack of emphasis on timely ICU nutrition delivery is lack of objective data to guide nutrition care. If we are to ultimately overcome current fundamental challenges to effective ICU nutrition delivery, we must all adopt routine objective, longitudinal measurement of energy targets via indirect calorimetry (IC). Key evidence supporting the routine use of IC in the ICU includes (1) universal societal ICU nutrition guidelines recommending IC to determine energy requirements; (2) data showing predictive equations or body weight calculations that are consistently inaccurate and correlate poorly with measured energy expenditure, ultimately leading to routine overfeeding and underfeeding, which are both associated with poor ICU outcomes; (3) recent development and worldwide availability of a new validated, accurate, easy-to-use IC device; and (4) recent data in ICU patients with coronavirus disease 2019 (COVID-19) showing progressive hypermetabolism throughout ICU stay, emphasizing the inaccuracy of predictive equations and marked day-to-day variability in nutrition needs. Thus, given the availability of a new validated IC device, these findings emphasize that routine longitudinal IC measures should be considered the new standard of care for ICU and post-ICU nutrition delivery. As we would not deliver vasopressors without accurate blood pressure measurements, the ICU community is only likely to embrace an increased focus on the importance of early nutrition delivery when we can consistently provide objective IC measures to ensure personalized nutrition care delivers the right nutrition dose, in the right patient, at the right time to optimize clinical outcomes., (© 2021 American Society for Parenteral and Enteral Nutrition.)

Acute respiratory distress syndrome (ARDS) is a complex disease characterized by inflammation, resulting in diffuse alveolar damage, proliferation, and fibrosis, and carries a high mortality rate. Recently, the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has overwhelmed healthcare systems worldwide, as many patients have required hospitalization for the management of respiratory failure similar in nature to ARDS. In addition to lung-protective ventilation strategies aimed to maintain an oxygen saturation >90%, a ratio of partial pressure of oxygen to fraction of inspired oxygen >200, a pH of 7.25-7.40, and a plateau pressure <35 cm H 2 O, prone positioning has emerged as an effective treatment strategy for severe ARDS by improving oxygenation and secretion clearance. Although early nutrition assessment and intervention are recommended for acutely and critically ill patients, rotational therapy may present challenges in providing this care. Here, we will describe the pathophysiology of ARDS and the rationale for use of prone positioning and review the considerations and challenges of providing nutrition therapy for patients in the prone position., (© 2020 American Society for Parenteral and Enteral Nutrition.)

Diseases of the pancreas vary by type, etiology, pathophysiology, and outcomes. One of the principle therapeutic considerations in all types of pancreatic diseases is nutrition. This review will consider acute pancreatitis (AP). Choice of patient, type and composition of nutrition, and timing of initiation will be discussed as components for achieving the maximum benefits of nutrition therapy in AP. The paradigm of nutrition therapy in AP has shifted to early enteral and/or oral nutrition based on disease severity to help mitigate the underlying inflammatory cascade of events leading to AP, beginning with anatomic and functional intestinal changes. Additionally, newer research investigating the inflammatory changes that instigate, maintain, and propagate AP will be discussed in terms of the nutrition effects on systemic inflammation. Nutrition therapy can mitigate the inflammatory changes in the intestinal tract and help with intestinal motility, bacterial overgrowth and translocation. It can help maintain intestinal bacterial composition and abundance similar to predisease levels. This review will also discuss the changes in the intestinal microbiome and effects of probiotics in AP., (© 2020 American Society for Parenteral and Enteral Nutrition.)

Postural tachycardia syndrome (POTS) is a syndrome characterized by elevated heart rate without hypotension and most commonly occurs in young females (generally <35 years of age). The prevalence of POTS is on the rise, but the etiology is still under investigation, and there appear to be multiple potential physiologic causes. The majority of these patients experience a multitude of gastrointestinal (GI) and systemic symptoms and conditions that may contribute to functional debility and poor quality of life. Although symptoms generally improve with age, they can still lead to significant issues meeting nutrition and hydration needs. This paper summarizes the understood potential pathophysiology of POTS, associated GI and nutrition issues, general treatment of POTS, and strategies to assess and meet the unique nutrition and hydration needs of these patients., (© 2020 American Society for Parenteral and Enteral Nutrition.)

Growth and nutrition in preterm infants have long-term implications for neurodevelopmental and cardiometabolic outcomes. Many infants are discharged from the neonatal intensive care unit (NICU) with growth restriction, but often without a specialized team to monitor postdischarge growth. At our institution, we addressed our ongoing concerns for the health and growth of these infants post-discharge by creating a Nutrition NICU Graduate Clinic. This clinic serves infants discharged from our NICU who were born with very low birth weight, had difficulty growing or feeding while inpatient, had a gastrostomy tube placed during hospitalization, or were deemed high risk for other reasons by our neonatal team, with the first clinic visit within 5 weeks of discharge. Data from our first 227 patients at time of discharge, first clinic visit, and any available second clinic visits are described. Anthropometrics show a high rate of extrauterine growth restriction at time of discharge with continued growth restriction at follow-up. Feeding regimens prescribed at discharge and variations from the prescribed regimen at time of follow-up are described. At time of first clinic visit, most patients (92.2%) required a medical or dietary intervention by our team. Our findings illustrate the need for early and specialized nutrition follow-up in this patient population to improve growth trajectory post-discharge., (© 2020 American Society for Parenteral and Enteral Nutrition.)

Background: After lower gastrointestinal surgery, few patients start eating within timeframes outlined by evidence-based guidelines or meet their nutrition requirements in hospital. The present study explored hospital staffs' perceptions of factors influencing timely and adequate feeding after colorectal surgery to inform future interventions for improving postoperative nutrition practices and intakes., Methods: This qualitative exploratory study was conducted at an Australian hospital where Enhanced Recovery After Surgery guidelines had not been formally implemented. One-on-one semistructured interviews were conducted with hospital staff who provided care to patients undergoing colorectal surgery. Interviews lasted from 21 to 47 minutes and were audio recorded and transcribed verbatim. Data were analyzed using inductive thematic analysis. Emergent themes and subthemes were discussed by all investigators to ensure consensus of interpretation., Results: Eighteen staff participated in interviews, including 9 doctors, 5 nurses, 2 dietitians, and 2 foodservice staff. Staffs' responses formed 3 themes: (1) variability in perceived acceptability of postoperative feeding; (2) improving dynamics and communication within the treating team; and (3) optimizing dietary intakes with available resources., Conclusion: Staff and organizational factors need to be considered when attempting to improve postoperative nutrition among patients who undergo colorectal surgery. Introducing a feeding protocol, enhancing intraprofessional and interdisciplinary communication, and ensuring the availability of appropriate, nutrient-dense foods are pivotal to improve nutrition practices and intakes., (© 2019 American Society for Parenteral and Enteral Nutrition.)

Background: The aim of this study was to systematically review effects of nutrition interventions on outcomes in patients with chronic gastrointestinal (GI) motility disorders. There is currently a lack of evidence-based guidelines for nutrition management in this group, likely a result of the rarity of the conditions., Methods: A systematic review of all study types to evaluate current evidence-based nutrition interventions was performed using Medline, Embase, and CINAHL databases. Two independent reviewers participated in the process of this systematic review. A total of 15 studies and a total of 524 subjects were included., Results: Best treatment of this population group was found to include a stepwise process, progressing from oral nutrition to jejunal nutrition and lastly to parenteral nutrition. Small particle, low-fat diets were significantly better tolerated than the converse, with jejunal nutrition prior to consuming oral food significantly improving oral intake and motility. In more progressive cases, percutaneous endoscopic gastrostomy with jejunal extension nutrition had lower reported symptoms than other enteral routes. Exclusive long-term parenteral nutrition is a feasible option for advanced cases, with a 68% survival rate at 15 years duration, though oral intake with parenteral nutrition is associated with higher survival rates., Conclusion: Treatment of patients with GI motility disorders should first trial oral nutrition. For patients who progress to jejunal or parenteral feeds, the primary aim should be to maintain or reinstate oral intake to reduce morbidity and mortality risk. Higher-quality studies are still required in this area, particularly in the areas of chronic intestinal pseudo-obstruction and systemic sclerosis., (© 2019 American Society for Parenteral and Enteral Nutrition.)

Patients with chronic liver disease have a very high lifetime risk of malnourishment. It has been increasingly identified in literature that the severity of liver disease affects severity of malnutrition and vice versa. The objective of this review article is to recognize the severity of complications associated with malnutrition in patients with cirrhosis and ways to overcome these obstacles., (© 2020 American Society for Parenteral and Enteral Nutrition.)

This article presents 7 nutrition steps that, if not followed by the clinical staff, may be metaphorically considered as "7 deadly sins" of nutrition therapy. In this review, we suggest approaches that must be avoided or accomplished to increase compliance with the "Ten Commandments" of good nutrition practice in the intensive care setting. Multiple aggressive and simultaneous sets of therapies are implemented in the intensive care setting, which include nutrition and metabolic support as important components in these therapies. "Sins" should be remembered as a mnemonic device for nutrition standard care in the intensive care unit; this incorporates nutrition adequacy and protocol adherence., (© 2019 American Society for Parenteral and Enteral Nutrition.)

Gastrointestinal (GI) motility disorders are associated with suboptimal nutrition in children, mainly because of malabsorption and symptoms limiting dietary intake. Apart from medical therapy, nutrition support has a crucial role in maintaining growth and improving clinical outcomes in children. Based on recent data and guidelines, this review provides an overview of nutrition assessment and specific interventions for common pediatric GI disorders including gastroesophageal reflux disease, esophageal motility disorders, gastroparesis, chronic intestinal pseudo-obstruction, and constipation. Several approaches including diet modification, enteral nutrition (gastric vs post-pyloric, temporary vs permanent access, bolus vs continuous), and parenteral nutrition need to be tailored based on patient's nutrition and clinical assessment., (© 2019 American Society for Parenteral and Enteral Nutrition.)

The accurate diagnosis and subsequent treatment of malnutrition is an essential component of nutrition care because of the known negative impacts of malnutrition on patient outcomes. The detection of malnutrition is influenced by disease-specific characteristics, practice settings, and the availability of resources. This article explores how malnutrition diagnosis through the application of the Global Leadership Initiative on Malnutrition global consensus on malnutrition diagnostic criteria is impacted by the unique characteristics of the heart failure, oncology, and trauma populations., (© 2019 American Society for Parenteral and Enteral Nutrition.)

Malnutrition is prevalent in patients with hepatic failure and remains an independent risk factor for morbidity and mortality in these patients. Factors that contribute to malnutrition in this patient population include altered metabolic rate, fat malabsorption, and impaired gastric emptying, all in the setting of an acute and potentially prolonged hospitalization. Acute liver failure (ALF), different from cirrhosis or chronic liver disease, is an uncommon but dramatic clinical syndrome that demonstrates severe and rapid decline in hepatic metabolic function. ALF has a significant risk of mortality. There are >10 cases per million persons per year in developed countries, but ALF presents with unique challenges in clinical management related to heterogeneity in severity and etiology. Patients with ALF by definition should not have a prior history of liver disease, and liver disease is subsequently defined by the onset of liver injury, the presence of hepatic encephalopathy (HE), and coagulopathy as defined by an international normalized ratio > 1.5. HE usually develops within 1-4 weeks of the onset of liver injury but may occur within 26 weeks of the initial presentation. Rates of survival from ALF have improved over recent years, but the rarity and severity of presentation have resulted in traditionally limited evidence to guide basic supportive care. Over time, advances in critical care management and the use of emergency liver transplantation have improved. In this article, we will review current nutrition considerations for patients with ALF., (© 2019 American Society for Parenteral and Enteral Nutrition.)

Provision of nutrition care is vital to the health and well-being of any patient who enters the health care system, whether in the ambulatory, inpatient, or long-term care setting. Interdisciplinary professionals-nurses, physicians, advanced practice providers, pharmacists, and dietitians-identify and treat nutrition problems or clinical conditions in each of these health care settings. The documentation of nutrition care in a structured format from screening and assessment to discharge allows communication of the nutrition treatment plans. The goal of this document is to provide recommendations to clinicians for working with an organization's Information Systems department to create tools for documentation of nutrition care in the electronic health record. These recommendations can also serve as guidance for health care organizations choosing and implementing health care software., (© 2019 the Academy of Nutrition and Dietetics, American Society for Parenteral and Enteral Nutrition, and Association of Clinical Documentation Improvement Specialists.)

Background: Nutrition can play a significant role in the management of liver cirrhosis and its complications. However, adherence to the clinical practice guidelines (CPGs) is essential for the practice of evidence-based medicine and is considered as a health-quality indicator., Methods: A systematic search was conducted in scientific databases, and retrieved CPGs fulfilling the inclusion criteria were independently reviewed and appraised from 3 experienced researchers, based on the Appraisal of Guidelines for Research and Evaluation II instrument., Results: A total of 13 relevant CPGs were retrieved, published by 7 associations/societies, focusing on the nutrition management (enteral nutrition and/or parenteral nutrition) on cirrhosis, decompensated cirrhosis, liver transplantation, and cirrhosis-related complications. Most CPGs scored low in the stakeholder, rigor of development, and applicability domains. Half of the CPGs recognized the need for counseling patients with cirrhosis on nutrition-related issues. Small meals spread throughout the day, including a late-night snack, were suggested, with protein intake ranging between 1.2 and 1.5 g/kg of body weight. In ascites, Na restriction recommendation appeared unanimous., Conclusions: Several shortcomings and bias were recognized in cirrhosis-related medical nutrition therapy CPGs, indicating the need of improving CPG methodology., (© 2019 American Society for Parenteral and Enteral Nutrition.)

The diagnosis of exocrine pancreatic insufficiency (EPI) can be difficult, as symptoms may be nonspecific. A delayed diagnosis of EPI can negatively impact health through poor weight gain, impaired growth, and malabsorption of nutrients. Because of active growth and development, children are more vulnerable to the consequences of untreated EPI. Pancreatic enzyme replacement therapy is the cornerstone of management and offers both symptomatic relief and improvement in clinical outcomes. Additionally, a high-energy diet with unrestricted fat and supplementation with fat-soluble vitamins is often required to optimize growth and prevent nutrition deficiencies. Cystic fibrosis (CF) is the most common condition in children that causes EPI, and improvement in nutrition management is associated with improved pulmonary function and increased survival. Currently, the management of other conditions leading to EPI in children is not well studied, and inferences from the CF literature are often necessary in caring for these patients., (© 2019 American Society for Parenteral and Enteral Nutrition.)

The pathophysiologic process of severe acute pancreatitis involves a vicious cycle of inflammation and increasing oxidative stress. Secretory defects trap activated pancreatic enzymes within the gland leading to autodigestion while circulatory abnormalities add the insult of ischemia/reperfusion injury. What may have the greatest impact in amplifying the systemic inflammatory response, though, is intestinal failure with breakdown of gut barrier defenses, subversion of submucosal immune responses, and emergence of a virulent pathobiome. Understanding the intricacies of these changes has broad-reaching implications for nutrition therapy, which should no longer be limited to the provision of early enteral feeding alone. Emerging strategies should attempt to maintain commensalism, bind potential pathogens, refaunate the microbiome, actively turn off inflammation, reset cross-talk signaling with epithelial receptors, and deliver nutrients further down the gastrointestinal tract to the level of greatest microbial burden. Innovative nutrition therapy for the patient with severe acute pancreatitis should be designed to address and include all of these strategies in order to shift the course of clinical outcome toward a pattern of recovery and homeostasis., (© 2019 American Society for Parenteral and Enteral Nutrition.)

Background: Close adherence to the Enhanced Recovery After Surgery (ERAS) program is associated with improved outcomes. A nutrition-focused qualitative analysis of patient experience and of ERAS implementation across our province was conducted to better understand the barriers to successful adoption of ERAS nutrition elements., Methods: Enrolled colorectal patients (n = 27) were asked to describe their surgical experience. Narrative interviews (n = 20) and focus groups (n = 7) were transcribed verbatim and analyzed inductively for food and nutrition themes. Qualitative data sources (n = 198 documents) collected throughout our implementation of ERAS were categorized as institutional barriers that impeded the successful adoption of ERAS nutrition practices., Results: We identified patient barriers related to 3 main themes. The first theme, Mistaken nutrition facts & beliefs, describes how information provision was a key barrier to the successful adoption of nutrition elements. Patients held misconceptions and providers tended to provide them with contradictory nutrition messages, ultimately impeding adequate food intake and adherence to ERAS elements. The second theme, White bread is good for the soul?, represents a mismatch between prescribed medical diets and patient priorities. The third theme, Food is medicine, details patient beliefs that food is healing; the perception that nutritious food and dietary support was lacking produced dissatisfaction among patients. Overall, the most important institutional barrier limiting successful adoption of nutrition practices was the lack of education for patients and providers., Conclusion: Applying a patient-centered model of care that focuses on personalizing the ERAS nutrition elements might be a useful strategy to improve patient satisfaction, encourage food intake, correct previously held beliefs, and promote care adherence., (© 2018 American Society for Parenteral and Enteral Nutrition.)

Background: Nutritional interventions to prevent stunting of infants and young children are most often applied in rural areas in low- and middle-income countries (LMIC). Few interventions are focused on urban slums. The literature needs a systematic assessment, as infants and children living in slums are at high risk of stunting. Urban slums are complex environments in terms of biological, social, and political variables and the outcomes of nutritional interventions need to be assessed in relation to these variables. For the purposes of this review, we followed the UN-Habitat 2004 definitions for low-income informal settlements or slums as lacking one or more indicators of basic services or infrastructure., Objectives: To assess the impact of nutritional interventions to reduce stunting in infants and children under five years old in urban slums from LMIC and the effect of nutritional interventions on other nutritional (wasting and underweight) and non-nutritional outcomes (socioeconomic, health and developmental) in addition to stunting., Search Methods: The review used a sensitive search strategy of electronic databases, bibliographies of articles, conference proceedings, websites, grey literature, and contact with experts and authors published from 1990. We searched 32 databases, in English and non-English languages (MEDLINE, CENTRAL, Web of Science, Ovid MEDLINE, etc). We performed the initial literature search from November 2015 to January 2016, and conducted top up searches in March 2017 and in August 2018., Selection Criteria: Research designs included randomised (including cluster-randomised) trials, quasi-randomised trials, non-randomised controlled trials, controlled before-and-after studies, pre- and postintervention, interrupted time series (ITS), and historically controlled studies among infants and children from LMIC, from birth to 59 months, living in urban slums. The interventions included were nutrition-specific or maternal education. The primary outcomes were length or height expressed in cm or length-for-age (LFA)/height-for-age (HFA) z-scores, and birth weight in grams or presence/absence of low birth weight (LBW)., Data Collection and Analysis: We screened and then retrieved titles and abstracts as full text if potentially eligible for inclusion. Working independently, one review author screened all titles and abstracts and extracted data on the selected population, intervention, comparison, and outcome parameters and two other authors assessed half each. We calculated mean selection difference (MD) and 95% confidence intervals (CI). We performed intervention-level meta-analyses to estimate pooled measures of effect, or narrative synthesis when meta-analyses were not possible. We used P less than 0.05 to assess statistical significance and intervention outcomes were also considered for their biological/health importance. Where effect sizes were small and statistically insignificant, we concluded there was 'unclear effect'., Main Results: The systematic review included 15 studies, of which 14 were randomised controlled trials (RCTs). The interventions took place in recognised slums or poor urban or periurban areas. The study locations were mainly Bangladesh, India, and Peru. The participants included 9261 infants and children and 3664 pregnant women. There were no dietary intervention studies. All the studies identified were nutrient supplementation and educational interventions. The interventions included zinc supplementation in pregnant women (three studies), micronutrient or macronutrient supplementation in children (eight studies), nutrition education for pregnant women (two studies), and nutrition systems strengthening targeting children (two studies) intervention. Six interventions were adapted to the urban context and seven targeted household, community, or 'service delivery' via systems strengthening. The primary review outcomes were available from seven studies for LFA/HFA, four for LBW, and nine for length.The studies had overall high risk of bias for 11 studies and only four RCTs had moderate risk of bias. Overall, the evidence was complex to report, with a wide range of outcome measures reported. Consequently, only eight study findings were reported in meta-analyses and seven in a narrative form. The certainty of evidence was very low to moderate overall. None of the studies reported differential impacts of interventions relevant to equity issues.Zinc supplementation of pregnant women on LBW or length (versus supplementation without zinc or placebo) (three RCTs)There was no evidence of an effect on LBW (MD -36.13 g, 95% CI -83.61 to 11.35), with moderate-certainty evidence, or no evidence of an effect or unclear effect on length with low- to moderate-certainty evidence.Micronutrient or macronutrient supplementation in children (versus no intervention or placebo) (eight RCTs)There was no evidence of an effect or unclear effect of nutrient supplementation of children on HFA for studies in the meta-analysis with low-certainty evidence (MD -0.02, 95% CI -0.06 to 0.02), and inconclusive effect on length for studies reported in a narrative form with very low- to moderate-certainty evidence.Nutrition education for pregnant women (versus standard care or no intervention) (two RCTs)There was a positive impact on LBW of education interventions in pregnant women, with low-certainty evidence (MD 478.44g, 95% CI 423.55 to 533.32).Nutrition systems strengthening interventions targeting children (compared with no intervention, standard care) (one RCT and one controlled before-and-after study)There were inconclusive results on HFA, with very low- to low-certainty evidence, and a positive influence on length at 18 months, with low-certainty evidence., Authors' Conclusions: All the nutritional interventions reviewed had the potential to decrease stunting, based on evidence from outside of slum contexts; however, there was no evidence of an effect of the interventions included in this review (very low- to moderate-certainty evidence). Challenges linked to urban slum programming (high mobility, lack of social services, and high loss of follow-up) should be taken into account when nutrition-specific interventions are proposed to address LBW and stunting in such environments. More evidence is needed of the effects of multi-sectorial interventions, combining nutrition-specific and sensitive methods and programmes, as well as the effects of 'up-stream' practices and policies of governmental, non-governmental organisations, and the business sector on nutrition-related outcomes such as stunting.

Background: Assessing and monitoring food intake and body weight of all hospital patients is considered part of "best practice" nutrition care. This study presents case examples describing the impact of behavior change strategies on embedding these 2 monitoring processes in hospitals., Methods: Four hospital medical units that participated in the More-2-Eat implementation study to improve nutrition care focused on improving food intake and/or weight monitoring practices. The percentage of admitted patients who received these care practices were tracked through chart audits over 18 months. Implementation progress and behavior change strategies were documented through interviews, focus groups, scorecards, and monthly telephone calls. Case examples are explored using mixed methods., Results: Of the 4 units, 3 implemented food intake monitoring. One provided food service workers the opportunity to record food intake, with low intake discussed by an interdisciplinary team during bedside rounds (increased from 0% to 97%). Another went from 0% to 61% of patients monitored by introducing a new form ("environmental restructuring") reminding staff to ask patients about low intake. A third unit increased motivation to improve documentation of low intake and improved from 3% to 95%. Two units focused on regularity of body weight measurement. One unit encouraged a team approach and introduced 2 weigh days/week (improved from 14% to 63%), while another increased opportunity by having all patients weighed on Saturdays (improved from 11% to 49%)., Conclusion: Difficult-to-change nutrition care practices can be implemented using diverse and ongoing behavior change strategies, staff input, a champion, and an interdisciplinary team., (© 2018 American Society for Parenteral and Enteral Nutrition.)

Background: The Patient- And Nutrition-Derived Outcome Risk Assessment (PANDORA) was recently validated for predicting mortality in hospitalized patients; however, its utility in the intensive care unit (ICU) remains unknown., Methods: We investigated whether PANDORA is associated with 30, 90, and 180 day mortality in critically ill surgical patients by performing logistic regressions, controlling for age, sex, race, body mass index, macronutrient deficit, and length of stay. The area under the receiver operating characteristic curves (AUC) of PANDORA vs Acute Physiology and Chronic Health Evaluation (APACHE) II scores for mortality at each time point were also compared., Results: 312 patients comprised the analytic cohort. PANDORA was associated with mortality at 30 (OR 1.08; 95% CI 1.04-1.13; P < .001), 90 (OR 1.09; 95% CI 1.03-1.12; P < .001), and 180 days (OR 1.10; 95% CI 1.06-1.15; P < .001). PANDORA and APACHE II were comparable for mortality prediction at 30 (AUC: 0.69, 95% CI 0.62-0.76 vs 0.74, 95% CI 0.67-0.81; P = .29), 90 (AUC: 0.71, 95% CI 0.63-0.77 vs 0.74, 95% CI 0.67-0.80; P = .52), and 180 days (AUC: 0.73, 95% CI 0.67-0.79 vs 0.75, 95% CI 0.69-0.81; P = .66)., Conclusion: In surgical ICU patients, PANDORA was associated with mortality and was comparable with APACHE II for mortality prediction at 30, 90, and 180 days after initiation of care. Prospective studies are needed to assess whether nutrition support, stratified by PANDORA scores, can improve outcomes in surgical ICU patients., (© 2018 American Society for Parenteral and Enteral Nutrition.)

Background: Identification of intensive care unit (ICU) patients who require nutrition intervention is crucial to initiating nutrition therapy. This prospective quality improvement study evaluated the Nutritional Risk Screening (NRS) 2002, Malnutrition Universal Screening Tool (MUST), and Nutrition Risk in Critically Ill (NUTRIC) score in comparison with the Veterans Administration Nutrition Status Classification (VANSC) tool to determine which best identified the need for nutrition intervention., Methods: A convenience sample of 150 ICU patients was evaluated using the VANSC, NRS 2002, MUST, and the NUTRIC score. The resultant score, need for nutrition intervention, and presence of malnutrition were recorded for patients. Interventions were defined as need for enteral or parenteral nutrition, nutritional supplements, or diet change. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), Matthews Correlation Coefficient (MCC), F1 score, and accuracy to predict need for nutrition intervention were calculated for each screening tool., Results: Of the 150 patients, 49 (33%) required 1 or more nutrition interventions. The NRS 2002 (0.878) and VANSC (0.816) had the highest sensitivity. The NUTRIC (0.921) and VANSC (0.911) had the highest specificity. The VANSC (0.816) and MUST (0.687) had the highest PPV. The VANSC (0.911) and NRS 2002 (0.872) had the highest NPV. The VANSC (0.727) and MUST (0.528) had the highest MCC. The VANSC (0.816) and MUST (0.680) had the highest F1 score., Conclusions: Trialing several tools to identify their efficacy and reliability individual setting may help determine the most appropriate tool to utilize for your patient population and specific goals., (© 2019 American Society for Parenteral and Enteral Nutrition.)

Background: Evidence-based guidelines (EBG) recommend recommencing oral feeding (liquids and solids) ≤24 hours after surgery. The aims of this study were to determine time to first diet (any) and solid-diet prescriptions, delivery, and intakes among adult, non-critically ill, postoperative patients., Methods: This prospective cross-sectional study included 100 postsurgical patients. Demographic and perioperative dietary-related data were collected from patients' medical records or via direct observation. Dietary intakes were observed for the duration patients were enrolled in the study (from end of surgery to discharge). The amount of energy (kcal) and protein (g) consumed per patient per day was analyzed and considered adequate if it met ≥75% of a patient's estimated requirements., Results: 89 and 52 patients consumed their first intake and first solid intake ≤24 hours after surgery, respectively. For their first intake, 53% of patients had clear or free liquids. Median times to first diet prescription (range: 1.3-5.7 hours), delivery (range: 2.1-12.5 hours), and intake (range: 2.2-13.9 hours) were ≤24 hours after surgery for all patient groups. Time to first solid-diet prescription (range: 1.3-77.8 hours), delivery (range: 2.1-78.0 hours) and intake (range: 2.2-78.2 hours) varied considerably. Urologic and gastrointestinal patients experienced the greatest delays to first solid-diet prescription and first solid intake. Only 26 patients met both their energy and protein requirements for ≥1 day during their stay., Conclusion: While practice appears consistent with EBG recommendations for commencing nutrition (any type) after surgery, the reintroduction of adequate diet requires improvement., (© 2018 American Society for Parenteral and Enteral Nutrition.)

Background: Severe burns are associated with a plethora of profound metabolic, immunologic, and physiologic responses, demanding prompt and adequate management. The objective of the present study was to review, compare, and critically appraise medical nutrition therapy guidelines for adult patients with severe burns, and produce salient points for the future update of relevant guidelines., Methods: A total of 8 clinical practice guidelines developed by the American Burn Association (ABA), the European Burn Association (EBA), the European Society for Parenteral and Enteral Nutrition (ESPEN), the Midlands National Health Service, the Society for Critical Care Medicine (SCCM)/American Society for Parenteral and Enteral Nutrition (ASPEN), the Spanish Society of Intensive Care Medicine and Coronary Units and Spanish Society of Parenteral and Enteral Nutrition, the Indian Association for Parenteral and Enteral Nutrition (IAPEN), and the International Society for Burn Injury regarding medical nutrition therapy in burn patients was independently reviewed by a team of 4 multidisciplinary researchers using the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument., Results: From the appraised guidelines, the SCCM/ASPEN guidelines received the greatest scoring in the majority of AGREE domains compared with ABA, EBA, and IAPEN, which obtained the lowest scores. On the other hand, the ESPEN guidelines provided the majority of information concerning nutrition support and medical nutrition therapy., Conclusion: Our study identified gaps in most nutrition guidelines and emphasized methodologic issues that could improve the quality of future guidelines concerning nutrition support among adult severe burn patients., (© 2018 American Society for Parenteral and Enteral Nutrition.)

Background: We assessed the impact of a standardized nutrition initiative for very low-birth-weight (VLBW) infants on their nutrition and clinical outcomes., Methods: This was a prospective analysis of VLBW infants born before and after the initiation of a nutrition protocol. This protocol included trophic feeds, feeding advancement, fortification guidelines, parameters on the concentration of parenteral nutrition (PN), and the discontinuation of PN and central lines. Gastric residual monitoring was discontinued. Statistical analyses were performed with Fisher's exact and Student's t-tests. Primary outcome measures were days receiving PN, days made nil per os (NPO) after feeding initiation, necrotizing enterocolitis, and growth parameters. Secondary outcome measures were central-line days, sepsis, blood transfusions, cholestasis, osteopenia, chronic lung disease, and retinopathy of prematurity., Results: 136 VLBW infants were analyzed, including 77 in the preprotocol group and 59 in the postprotocol group. Infants postprotocol were found to have reduced PN days (26.1 versus [vs] 18.4, P < .01), fewer days made NPO after feeding initiation (7.2 vs 4.0, P = .02), NEC (7.8% vs 0%, P = 0.038), central-line days (26.5 vs 18.6, P < .01), cholestasis (16% vs 3%, P = .02), and blood transfusions (5.3 vs 3.1, P = .028). Growth, defined by change in z-score from birth to discharge, improved for weight (-1.3 vs -0.8, P < .01), length (-1.5 vs -1.0, P = .033), and head (-1.1 vs -0.6, P = .024)., Conclusion: Initiation of a standardized nutrition initiative for VLBW infants significantly improved growth, reduced PN use, and improved patient outcomes., (© 2018 American Society for Parenteral and Enteral Nutrition.)

Background: Adequate nutrition therapy in critically ill patients poses a challenge because of the variable energy and substrate needs. The objective was to investigate whether nutrition therapy involving indirect calorimetry (IC), instead of equations for assessment of energy needs, could improve the nutrition status of critically ill patients., Methods: Forty mechanically ventilated patients were randomized into a group in which energy needs were controlled by calorimetry (IC group) and a group treated with a formula-based approach reflecting standard care (SC group). The primary outcome was change in the phase angle (PhA), a bioelectrical impedance parameter related to nutrition status and prognosis., Results: The mean IC-based energy requirement was lower than the formula-based estimate (21.1 ± 6.4 versus [vs] 25 kcal/kg/d, P < .01). The IC group reached 98% ± 8% of the energy goal, whereas the SC group reached only 79% ± 29% (P < 0.05), although mean intake was similar in both groups. The protein intake goal was better met in the IC group (91% ± 24%) than the SC group (73% ± 33%). The PhA of the IC group did not change during treatment, whereas that of the SC group tended to decrease by 0.36° ± 0.86° (P = .077). A shorter length of stay in intensive care was observed in the IC than in the SC group (13 ± 8 vs 24 ± 20 days, P < .05)., Conclusion: Intensified individual nutrition therapy involving IC appears to be useful for improving nutrition status in critically ill patients., (© 2018 American Society for Parenteral and Enteral Nutrition.)

Background: Enhanced recovery after surgery (ERAS) programs are multimodal evidenced-based care pathways for optimal recovery. Central to ERAS is integration of perioperative nutrition care into the overall management of the patient. This study describes changes to perioperative nutrition care after implementation of an ERAS program, and identifies factors that affect compliance to ERAS care elements and short-term postoperative outcomes., Methods: Data were prospectively collected from patients undergoing elective colorectal surgery at 6 hospitals in Alberta, Canada, from 2013-2017. Compliance to nutrition care elements (nutrition risk screening, preoperative carbohydrate loading, early postoperative oral feeding, and mobilization) was recorded before ERAS implementation (pre-ERAS group, n = 487) and with ERAS implementation (ERAS group, n = 3536). Logistic regression identified factors that affect compliance to care elements, length of hospital stay (LOS), and postoperative complications., Results: A total of 4023 patients were included. The rate of nutrition risk screening improved from 9% (pre-ERAS group) to 74% (ERAS group); 12% were at nutrition risk. Compliance increased for preoperative carbohydrate loading (4%-61%), early postoperative oral feeding (P < .001), and mobilization (P < .001). In multivariable logistic regression, nutrition risk independently predicted low overall compliance (<70%) to ERAS care elements (odds ratio [OR] 2.77; 95% CI, 2.11-3.64; P < .001) and a trend for LOS >5 days (OR 1.40; 95% CI, 1.00-1.96; P = .052). Low compliance to ERAS (<70%) predicted postoperative complications (OR 2.69; 95% CI, 2.23-3.24; P < .001)., Conclusion: ERAS implementation positively impacted the adoption of standardized perioperative nutrition care practices. Nutrition risk screening identified patients less able to comply with postoperative nutrition care elements and who had longer LOS., (© 2018 American Society for Parenteral and Enteral Nutrition.)

Background: Little is currently known about nutrition intake and energy requirements in the post-intensive care unit (ICU) hospitalization period in critically ill patients. We aimed to describe energy and protein intake, and determine the feasibility of measuring energy expenditure during the post-ICU hospitalization period in critically ill adults., Methods: This is a nested cohort study within a randomized controlled trial in critically ill patients. After discharge from ICU, energy and protein intake was quantified periodically and indirect calorimetry attempted. Data are presented as n (%), mean (SD), and median (interquartile range [IQR])., Results: Thirty-two patients were studied in the post-ICU hospitalization period, and 12 had indirect calorimetry. Mean age and BMI was 56 (18) years and 30 (8) kg/m 2 , respectively, 75% were male, and the median estimated energy and protein requirement were 2000 [1650-2550] kcal and 112 [84-129] g, respectively. Oral nutrition either alone (n = 124 days, 55%) or in combination with enteral nutrition (n = 96 days, 42%) was the predominant mode. Over 227 total days in the post-ICU hospitalization period, a median [IQR] of 1238 [869-1813] kcal and 60 [35-89.5] g of protein was received from nutrition therapy. In the 12 patients who had indirect calorimetry, the median measured daily energy requirement was 1982 [1843-2345] kcal and daily energy deficit was -95 [-1050 to 347] kcal compared with the measured energy requirement., Conclusions: Energy and protein intake in the post-ICU hospitalization period was less than estimated and measured energy requirements. Oral nutrition provided alone was the most common mode of nutrition therapy., (© 2018 American Society for Parenteral and Enteral Nutrition.)

The use of extracorporeal membrane oxygenation (ECMO) for both severe respiratory and cardiac failure is increasing. Because these patients are some of the sickest in the intensive care unit, a multidisciplinary approach to their treatment, including appropriate nutrition therapy, is warranted. Currently, limited data exist on the optimal timing, type, and amount of nutrition to be provided. This review focuses on describing the current nutrition practices in patients receiving ECMO, details research that is currently being undertaken, and lists important research questions that require exploration in this field. Observational data suggest that early enteral nutrition is safe and that although nutrition targets can be met, underfeeding is still common. Until further research is available, these patients should be fed according to guidelines for the general critically unwell population., (© 2018 American Society for Parenteral and Enteral Nutrition.)

Decisions surrounding the timing and dosing of nutrition support are made for thousands of ICU patients daily and yet remain a topic of controversy. Nutrition support designed to replenish resting energy expenditure (REE) early in critical illness has led to worse clinical outcomes in at least three recent prospective randomized clinical trials. Producing sufficient energy from nutrient substrates requires use of the mitochondrial electron transport chain (ETC). This process is functionally linked to the creation of a tightly regulated series of chemical messengers known as reactive oxygen species (ROS). In health, ROS are kept at low levels by a system of mitochondrial/cellular enzymes and antioxidants, allowing ROS to act as a signal for the redox health of the cell. In inflammatory conditions, however, this system is altered, leading to changes in the physiologic function of the ETC such that its usage produces greater ROS per unit of substrate. This increased ROS is capable of deactivating antioxidant systems, as well as activating further ROS-producing pathways and stimulating localized inflammatory activity. We propose that exacerbation of this process at this time by the forced influx of exogenously acquired nutrient substrates leads to mitochondrial damage, amplified ROS production, increased inflammation, decreased ATP-productive capacity, and, eventually, the death of the cell by either apoptosis or necrosis. Knowledge of this process is vital to determining the safe dosing and timing of nutrition support in the ICU. It is possible that the physiologic cost of meeting the REE under these conditions of mitochondrial stress may simply be too high. This paper details the proposed process by which inappropriately timed feeding in critically ill patients may damage the very mitochondria required for its utilization., (© 2017 American Society for Parenteral and Enteral Nutrition.)

Background: Staff play key roles in the prevention, detection, and treatment of hospital malnutrition. Understanding staff knowledge, attitudes, and practices (KAP) is important for developing and evaluating change management strategies., Methods: The More-2-Eat project improved nutrition care in 5 Canadian hospitals by implementing the Integrated Nutrition Pathway for Acute Care (INPAC). To understand staff views before (T1) and after 1 year of implementation (T2), a reliable KAP questionnaire, based on INPAC, was administered. T2 included questions about involvement in implementation. The mean difference between T2 and T1 responses was calculated, and t tests were used for comparisons., Results: The questionnaire was completed at T1 (n = 189) and T2 (n = 147) (unpaired); 57 staff completed both questionnaires (paired). A significant increase in total score was seen in unpaired results at T2 (from 93.6/128 [range, 51-124] to 99.5/128 [range, 54-119]; t = 5.97, P < .0001), with an increase in knowledge/attitudes (KA) (t = 2.4, P = .016) and practice (t = 3.57, P < .0001) components. There were no statistically significant changes in paired responses. Seventy percent (n = 102/147) noticed positive changes in practices, 12% (n = 18) noticed positive/negative changes, 1% (n = 1) noticed negative change, and 17% (n = 25) noticed no change. Fifty-nine percent (n = 86) felt involved in the change, and these staff had higher KA and KAP scores than those who did not feel involved., Conclusion: Staff involvement is important in the implementation process for improving nutrition care., (© 2017 American Society for Parenteral and Enteral Nutrition.)

Over the past few years, numerous studies have called into question the optimal dose, timing, composition, and advancement rate of nutrition during the early acute phase of critical illness. These studies suggest permissive underfeeding with slow advancement may be more beneficial than aggressive full feeding. These counterintuitive results were possibly explained by enhanced autophagy, less hyperglycemia, or prevention of refeeding syndrome. This review underscores the controversies surrounding permissive underfeeding, aims to answer whether permissive underfeeding is appropriate for all critically ill patients, describes the impact of optimal protein delivery on critical care outcomes, discusses nutrition risk, and cogitates on the impact of nutrition on critical care outcomes., (© 2017 American Society for Parenteral and Enteral Nutrition.)

Recent literature has created considerable confusion about the optimal amount of protein/amino acids that should be provided to the critically ill patient. In fact, the evidentiary basis that directly tries to answer this question is relatively small. As a clinical nutrition research community, there is an urgent need to develop the optimal methods to assess the impact of exogenous protein/amino acid administration in the intensive care unit setting. That assessment can be conducted at various levels: (1) impact on stress response pathways, (2) impact on muscle synthesis and protein balance, (3) impact on muscle mass and function, and (4) impact on the patient's recovery. The objective of this research workshop was to review current literature relating to protein/amino acid administration for the critically ill patient and clinical outcomes and to discuss the key measurement and methodological features of future studies that should be done to inform the optimal protein/amino acid dose provided to critically ill patients.

The quantity of formalized nutrition education is shrinking in curricula of health professions, such as physicians, nurses, dietitians, and pharmacists. The current nutrition education being taught in U.S. schools of healthcare professionals does not appropriately prepare students for identification of patients at nutrition risk or management of undernourished hospitalized patients with specialized nutrition therapies. In U.S. schools of pharmacy, parenteral nutrition is considered a highly specialized and advanced practice so little time is devoted to this area and more attention is focused on chronic disease state management (ie, hypertension, diabetes mellitus, and congestive heart failure). Nutrition support fellowships for physicians and nutrition support residency programs for pharmacists have dwindled in number over the years so that only a handful of these healthcare professionals are produced each year from the remaining formalized programs. Physicians, nurses, pharmacists, and dietitians can positively affect patient care, but each profession must first determine how best to integrate basic and applied nutrition concepts into their professional curricula and training programs. There must also be consensus among the healthcare professions as to the depth of nutrition education and the stage of training at which these integrations should occur. Only by having these crucial conversations among all disciplines will we be able to develop new strategies to expand nutrition education in the training of future medical practitioners.

Severe nutrition complications after bariatric surgery remain poorly described. The aim of this case series was to identify specific factors associated with nutrition complications after bariatric surgery and to characterize their nutrition disorders. We retrospectively reviewed all people referred to the clinical nutrition intensive care unit of our university hospital after bariatric surgery from January 2013 to June 2015. Twelve persons who required artificial nutrition supplies (ie, enteral nutrition or parenteral nutrition) were identified. Seven persons underwent a "one-anastomosis gastric bypass" (OAGB) or "mini gastric bypass," 2 underwent a Roux-en-Y gastric bypass, 2 had a sleeve gastrectomy, and 1 had an adjustable gastric band. This case series suggests that OAGB could overexpose subjects to severe nutrition complications requiring intensive nutrition care and therefore cannot be considered a "mini" bariatric surgery. Even if OAGB is often considered a simplified surgical technique, it obviously requires as the other standard bariatric procedures a close follow-up by experimented teams aware of its specific complications.

Background: Childhood cancer survivors are at a higher risk of developing health conditions such as osteoporosis, and cardiovascular disease than their peers. Health-promoting behaviour, such as consuming a healthy diet, could lessen the impact of these chronic issues, yet the prevalence rate of health-protecting behaviour amongst survivors of childhood cancer is similar to that of the general population. Targeted nutritional interventions may prevent or reduce the incidence of these chronic diseases., Objectives: The primary aim of this review was to assess the efficacy of a range of nutritional interventions designed to improve the nutritional intake of childhood cancer survivors, as compared to a control group of childhood cancer survivors who did not receive the intervention. Secondary objectives were to assess metabolic and cardiovascular risk factors, measures of weight and body fat distribution, behavioural change, changes in knowledge regarding disease risk and nutritional intake, participants' views of the intervention, measures of health status and quality of life, measures of harm associated with the process or outcomes of the intervention, and cost-effectiveness of the intervention, Search Methods: We searched the electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL; 2013, Issue 3), MEDLINE/PubMed (from 1945 to April 2013), and Embase/Ovid (from 1980 to April 2013). We ran the search again in August 2015; we have not yet fully assessed these results, but we have identified one ongoing trial. We conducted additional searching of ongoing trial registers - the International Standard Randomised Controlled Trial Number register and the National Institutes of Health register (both screened in the first half of 2013) - reference lists of relevant articles and reviews, and conference proceedings of the International Society for Paediatric Oncology and the International Conference on Long-Term Complications of Treatment of Children and Adolescents for Cancer (both 2008 to 2012)., Selection Criteria: We included all randomised controlled trials (RCTs) that compared the effects of a nutritional intervention with a control group which did not receive the intervention in this review. Participants were childhood cancer survivors of any age, diagnosed with any type of cancer when less than 18 years of age. Participating childhood cancer survivors had completed their treatment with curative intent prior to the intervention., Data Collection and Analysis: Two review authors independently selected and extracted data from each identified study, using a standardised form. We assessed the validity of each identified study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We used the GRADE criteria to assess the quality of each trial., Main Results: Three RCTs were eligible for review. A total of 616 participants were included in the analysis. One study included participants who had been treated for acute lymphoblastic leukaemia (ALL) (275 participants). Two studies included participants who had all forms of paediatric malignancies (266 and 75 participants). All participants were less than 21 years of age at study entry. The follow-up ranged from one month to 36 months from the initial assessment. All intended outcomes were not evaluated by each included study. All studies looked at different interventions, and so we were unable to pool results. We could not rule out the presence of bias in any of the studies.There was no clear evidence of a difference in calcium intake at one month between those who received the single, half-day, group-based education that focused on bone health, and those who received standard care (mean difference (MD) 111.60, 95% confidence interval (CI) -258.97 to 482.17; P = 0.56, low quality evidence). A regression analysis, adjusting for baseline calcium intake and changes in knowledge and self-efficacy, showed a significantly greater calcium intake for the intervention as compared with the control group at the one-month follow-up (beta coefficient 4.92, 95% CI 0.33 to 9.52; P = 0.04). There was statistically significant higher, self-reported milk consumption (MD 0.43, 95% CI 0.07 to 0.79; P = 0.02, low quality evidence), number of days on calcium supplementation (MD 11.42, 95% CI 7.11 to 15.73; P < 0.00001, low quality evidence), and use of any calcium supplementation (risk ratio (RR) 3.35, 95% CI 1.86 to 6.04; P < 0.0001, low quality evidence), with those who received this single, face-to-face, group-based, health behaviour session.There was no clear evidence of a difference in bone density Z-scores measured with a dual-energy X-ray absorptiometry (DEXA) scan at 36 months follow-up (MD -0.05, 95% CI -0.26 to 0.16; P = 0.64, moderate quality evidence) between those who received calcium and vitamin D supplementation combined with nutrition education and those who received nutrition education alone. There was also no clear evidence of a difference in bone mineral density between the intervention and the control group at the 12-month (median difference -0.17, P = 0.99) and 24-month follow-up (median difference -0.04, P = 0.54).A single multi-component health behaviour change intervention, focusing on general healthy eating principles, with two telephone follow-ups brought about a 0.17 lower score on the four-point Likert scale of self-reported junk food intake compared with the control group (MD -0.17, 95% CI -0.33 to -0.01; P = 0.04, low quality evidence); this result was statistically significant. There was no clear evidence of a difference between the groups in the self-reported use of nutrition as a health protective behaviour (MD -0.05, 95% CI -0.24 to 0.14; P = 0.60, low quality evidence)., Authors' Conclusions: Due to a paucity of studies, and the heterogeneity of the studies included in this review, we are unable to draw conclusions regarding the effectiveness of nutritional interventions for use with childhood cancer survivors. Although there is low quality evidence for the improvement in health behaviours using health behaviour change interventions, there remains no evidence as to whether this translates into an improvement in dietary intake. There was also no evidence that the studies reduced the risk of cardiovascular and metabolic disorders in childhood cancer survivors, although no evidence of effect is not the same as evidence of no effect. This review highlights the need for further well designed trials to be implemented in this population.

Background: Shared decision making (SDM) holds great potential for improving the therapeutic efficiency and quality of nutritional treatment of dyslipidaemia by promoting patient involvement in decision making. Adoption of specific behaviours fostering SDM during consultations has yet to be studied in routine dietetic practice., Objective: Using a cross-sectional study design, we aimed to explore both dieticians' and patients' adoption of SDM behaviours in dietetic consultations regarding the nutritional treatment of dyslipidaemia., Methods: Twenty-six dieticians working in local health clinics in the Quebec City metropolitan area were each asked to identify one dyslipidaemic patient they would see in an upcoming consultation. Based on the Theory of Planned Behaviour (TPB), questionnaires were designed to study two targeted SDM behaviours: 'to discuss nutritional treatment options for dyslipidaemia' and 'to discuss patients' values and preferences about nutritional treatment options for dyslipidaemia'. These questionnaires were administered to the dietician-patient dyad individually before the consultation. Associations between TPB constructs (attitude, subjective norm and perceived behavioural control) towards behavioural intentions were analysed using Spearman's partial correlations., Results: Thirteen unique patient-dietician dyads completed the study. Perceived behavioural control was the only TPB construct significantly associated with both dieticians' and patients' intentions to adopt the targeted SDM behaviours (P < 0.05)., Conclusions: As perceived behavioural control seems to determine dieticians' and patients' adoption of SDM behaviours, interventions addressing barriers and reinforcing enablers of these behaviours are indicated. This exploratory study highlights issues that could be addressed in future research endeavours to expand the knowledge base relating to SDM adoption in dietetic practice., (© 2014 John Wiley & Sons Ltd.)

Bariatric surgery is considered one of the most effective methods of achieving long-term weight loss when all other medical treatments have failed. The number of bariatric procedures increases each year. Nevertheless, bariatric procedures are associated with a number of complications that require careful multidisciplinary management. Nutrition supervision is of substantial value, as malnutrition, vitamin, and micro- and macronutrient deficiencies may lead to deleterious consequences. In this review, we provide essential information on nutrition management, both before and after bariatric surgical procedures., (© 2014 American Society for Parenteral and Enteral Nutrition.)

Selenium is a component of selenoproteins with antioxidant, anti-inflammatory, and immunomodulatory properties. Systemic inflammatory response syndrome (SIRS), multiorgan dysfunction (MOD), and multiorgan failure (MOF) are associated with an early reduction in plasma selenium and glutathione peroxidase activity (GPx), and both parameters correlate inversely with the severity of illness and outcomes. Several randomized clinical trials (RCTs) evaluated selenium therapy as monotherapy or in antioxidant cocktails in intensive care unit (ICU) patient populations, and more recently several meta-analyses suggested benefits with selenium therapy in the most seriously ill patients. However, the largest RCT on pharmaconutrition with glutamine and antioxidants, the REducing Deaths due to Oxidative Stress (REDOXS) Study, was unable to find any improvement in clinical outcomes with antioxidants provided by the enteral and parenteral route and suggested harm in patients with renal dysfunction. Subsequently, the MetaPlus study demonstrated increased mortality in medical patients when provided extra glutamine and selenium enterally. The treatment effect of selenium may be dependent on the dose, the route of administration, and whether administered with other nutrients and the patient population studied. Currently, there are few small studies evaluating the pharmacokinetic profile of intravenous (IV) selenium in SIRS, and therefore more data are necessary, particularly in patients with MOD, including those with renal dysfunction. According to current knowledge, high-dose pentahydrate sodium selenite could be given as an IV bolus injection (1000-2000 µg), which causes transient pro-oxidant, cytotoxic, and anti-inflammatory effects, and then followed by a continuous infusion of 1000-1600 µg/d for up to 10-14 days. Nonetheless, the optimum dose and efficacy still remain controversial and need to be definitively established., (© 2014 American Society for Parenteral and Enteral Nutrition.)

Background: With burn injuries involving a large total body surface area (TBSA), the body can enter a state of breakdown, resulting in a condition similar to that seen with severe lack of proper nutrition. In addition, destruction of the effective skin barrier leads to loss of normal body temperature regulation and increased risk of infection and fluid loss. Nutritional support is common in the management of severe burn injury, and the approach of altering immune system activity with specific nutrients is termed immunonutrition. Three potential targets have been identified for immunonutrition: mucosal barrier function, cellular defence and local or systemic inflammation. The nutrients most often used for immunonutrition are glutamine, arginine, branched-chain amino acids (BCAAs), omega-3 (n-3) fatty acids and nucleotides., Objectives: To assess the effects of a diet with added immunonutrients (glutamine, arginine, BCAAs, n-3 fatty acids (fish oil), combined immunonutrients or precursors to known immunonutrients) versus an isonitrogenous diet (a diet wherein the overall protein content is held constant, but individual constituents may be changed) on clinical outcomes in patients with severe burn injury., Search Methods: The search was run on 12 August 2012. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library, MEDLINE (OvidSP), Embase (OvidSP), ISI WOS SCI-EXPANDED & CPCI-S and four other databases. We handsearched relevant journals and conference proceedings, screened reference lists and contacted pharmaceutical companies. We updated this search in October 2014, but the results of this updated search have not yet been incorporated., Selection Criteria: Randomised controlled trials comparing the addition of immunonutrients to a standard nutritional regimen versus an isonitrogenated diet or another immunonutrient agent., Data Collection and Analysis: Two review authors were responsible for handsearching, reviewing electronic search results and identifying potentially eligible studies. Three review authors retrieved and reviewed independently full reports of these studies for inclusion. They resolved differences by discussion. Two review authors independently extracted and entered data from the included studies. A third review author checked these data. Two review authors independently assessed the risk of bias of each included study and resolved disagreements through discussion or consultation with the third and fourth review authors. Outcome measures of interest were mortality, hospital length of stay, rate of burn wound infection and rate of non-wound infection (bacteraemia, pneumonia and urinary tract infection)., Main Results: We identified 16 trials involving 678 people that met the inclusion criteria. A total of 16 trials contributed data to the analysis. Of note, most studies failed to report on randomisation methods and intention-to-treat principles; therefore study results should be interpreted with caution. Glutamine was the most common immunonutrient and was given in seven of the 16 included studies. Use of glutamine compared with an isonitrogenous control led to a reduction in length of hospital stay (mean stay -5.65 days, 95% confidence interval (CI) -8.09 to -3.22) and reduced mortality (pooled risk ratio (RR) 0.25, 95% CI 0.08 to 0.78). However, because of the small sample size, it is likely that these results reflect a false-positive effect. No study findings suggest that glutamine has an effect on burn wound infection or on non-wound infection. All other agents investigated showed no evidence of an effect on mortality, length of stay or burn wound infection or non-wound infection rates., Authors' Conclusions: Although we found evidence of an effect of glutamine on mortality reduction, this finding should be taken with care. The number of study participants analysed in this systematic review was not sufficient to permit conclusions that recommend or refute the use of glutamine. Glutamine may be effective in reducing mortality, but larger studies are needed to determine the overall effects of glutamine and other immunonutrition agents.

The estimation of caloric needs of critically ill patients is usually based on energy expenditure (EE), while current recommendations for caloric intake most often rely on a fixed amount of calories. In fact, during the early phase of critical illness, caloric needs are probably lower than EE, as a substantial proportion of EE is covered by the non-inhibitable endogenous glucose production. Hence, the risk of overfeeding is higher during the early phase than the late phase, while the risk of underfeeding is higher during the late phase of critical illness. Therefore, an accurate measurement of EE can be helpful to prevent early overfeeding and late underfeeding. Available techniques to assess EE include predictive equations, calorimetry, and doubly labeled water, the reference method. The available predictive equations are often inaccurate, while indirect calorimetry is difficult to perform for several reasons, including a shortage of reliable devices and technical limitations. In this review, the authors intend to discuss the different techniques and the influence of the method used on the interpretation of the results of clinical studies.

Background: Cystic fibrosis (CF) affects approximately 30,000 people in the United States and is characterized by pulmonary disease and poor nutrition. Optimal nutrition is associated with better pulmonary function, and aggressive nutrition interventions have played a major role in increased survival. Even though the CF Foundation (CFF) has published treatment guidelines for certain areas of nutrition care, there may still be variability in other areas. Thus, the purpose of this study was to survey current practices among CF dietitians., Materials and Methods: A 25-item web-based survey was developed and sent to nutrition professionals via the CFF nutrition listserv. Responses were anonymous. Areas of practice surveyed included nutrition care for infants, pancreatic enzyme replacement, vitamins and bone health, and miscellaneous practices. Descriptive statistics were used to report the results., Results: Among the 76 respondents (21% response rate), there was general agreement regarding nutrition practices for infants and pancreatic enzyme replacement. Responses varied regarding enzyme administration with gastrostomy tube feeds and in practices related to bone health. Of miscellaneous practices, there was agreement regarding zinc supplementation and appetite stimulants. However, opinions varied regarding concern for coronary artery disease with the CF high-fat diet. Practices related to use of acid blockers also varied., Conclusion: The results of this survey demonstrate good agreement among nutrition professionals in some areas and variability in others for the nutrition management of patients with CF. Areas of variability point to the need for further research and continued additions to the guidelines and consensus statements.