Search

BACKGROUND Preoperative malnutrition adversely impacts perioperative outcomes among patients with gastrointestinal (GI) cancer. The attributable risk (AR) that nutrition status contributes towards negative outcomes is poorly understood. METHODS Adults undergoing GI cancer surgeries were identified within the American College of Surgeons National Surgical Quality Improvement Program database (2005-2017). Emergency surgeries, outpatients, and cases with an American Society of Anesthesiologists status above III were excluded. Adjusted multivariable models were constructed to determine the associations between markers of nutrition status (body mass index, >10% weight loss in last 6 months, functional status, and serum albumin level) and adverse perioperative outcomes (presence and number of complications, death, 30-day readmission, and length of stay). Predictive accuracy statistics and population AR (PAR) were determined. RESULTS The final sample included 78,662 cases. Patients with >10% weight loss 6 months preceding surgery (compared with those who did not), had a significantly increased risk of complications (Relative Risk = 1.28; 95% CI, 1.20-1.37) and odds of death (odds ratio [OR] = 1.37; 95% CI, 1.18-1.59). A totally dependent functional status (compared with independent status) was associated with a 3.3-times higher odds of death (OR = 3.30; 95% CI, 1.53-7.15). Multivariable models were not predictive of adverse outcomes; PAR from the markers ranged 1%-2%. CONCLUSION Ten percent weight loss in preceding 6 months was associated with increased risk of adverse perioperative outcomes among adults undergoing GI cancer surgery. The contribution of nutrition status markers to surgical outcomes as assessed by PAR was small (1%-2%), a finding not previously reported. Future intervention studies should include validated nutrition risk markers, control for effects of perioperative variables, and evaluate PAR within the immediate/long-term postoperative periods.

Background Cystic fibrosis (CF) is a life-shortening genetic disease, yet life expectancy has recently increased, shifting the focus to disease management and health-related quality of life (HRQoL). Identification of clinical factors, such as weight status and CF-related diabetes (CFRD), that are associated with HRQoL can inform clinicians about the patient's health perception. The goal of this systematic review was two prong: identify the association of pediatric weight status and HRQoL and determine how CFRD status impacts HRQoL. Methods A systematic review of published research was conducted following the methodology in the Cochrane Handbook on Systematic Reviews for Interventional Studies. Results were reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses. Risk of bias was assessed using the National Heart Lung & Blood Institute tool. A meta-analysis was not performed due to variability of the inclusion/exclusion criteria, differences in outcome reporting, and insufficient primary outcome data to pool. Results Nine studies met inclusion criteria (n = 6 explored weight status and n = 3 studied CFRD), for a total of 1585 subjects (CFRD cases = 87). Pediatric weight status was positively associated with HRQoL, most commonly the Body Image and Eating Disturbance domains. CFRD was negatively associated with HRQoL, specifically the Treatment Burden and Weight domains. Conclusions Based on the limited data available, improved pediatric weight status appears to increase HRQoL while a CFRD diagnosis appears to decrease HRQoL. More research is needed to fully understand the role of these clinical factors on HRQoL, especially with life expectancy increasing among those with CF.

Dietary sodium intake can increase risk of hypertension, a leading cause of kidney failure in individuals with chronic kidney disease. The objective of this systematic review was to examine the effect of sodium-specific medical nutrition therapy provided by a registered dietitian nutritionist or international equivalent on blood pressure and urinary sodium excretion in individuals with chronic kidney disease, stages 2 through 5, receiving maintenance dialysis and posttransplant. Medline, the Cumulative Index to Nursing and Allied Health Literature, Cochrane Cochrane Central Register of Controlled Trials, and other databases were searched to identify eligible controlled trials published in the English language from January 2000 until June 2020 that addressed the research question. Risk of bias was assessed using the RoB 2.0 tool and quality of evidence was examined by outcome using the Grading of Recommendations Assessment, Development, and Evaluation method. Of the 5,642 articles identified, eight studies were included in the final analyses. Six studies targeted clients who were not dialyzed, including one with clients who were posttransplantation, and two studies with clients receiving maintenance hemodialysis. Sodium-specific medical nutrition therapy from a registered dietitian nutritionist significantly reduced clinic systolic blood pressure (mean difference –6.7, 95% CI –11.0 to –2.4 mm Hg; I2 = 51%) and diastolic blood pressure (mean difference –4.8, 95% CI, –7.1 to –2.4 mm Hg; I2 = 23%) as well as urinary sodium excretion (mean difference –67.6, 95% CI –91.6 to –43.6 mmol/day; I2 = 84.1%). Efficacy was limited to individuals who were not dialyzed, including posttransplantation, but the intervention did not significantly improve blood pressure in individuals receiving maintenance hemodialysis. Adults with chronic kidney disease should begin to work with registered dietitian nutritionist early in the course of disease to receive individualized, effective counseling to improve risk factors and, ultimately, health outcomes.

Objective To determine the effectiveness of liquid human milk fortifiers (HMFs) derived from exclusive HM or hydrolyzed protein on growth, necrotizing enterocolitis (NEC), or late-onset sepsis in North American very low-birth-weight (VLBW) infants compared with powder HMFs (control). Methods Prospective trials published between 2009 and 2020 were systematically reviewed, and meta-analysis was conducted by using a random-effects model. Results Five studies were identified for up to 591 participants across 39 centers. Study treatments included whey or casein hydrolysate HMF and exclusive HM HMF. Infants fed whey or casein hydrolysate HMF had growth differences compared with the control. No differences were found across treatments in regard to NEC or sepsis. Conclusion Very low-quality evidence suggests greater linear growth in VLBW infants fed whey hydrolysate liquid HMF, as well as greater weight gain in those fed casein hydrolysate HMF, compared with the control. Additional prospective, multicenter randomized controlled trials are needed to confirm these estimates because of sparsity of evidence. There is insufficient evidence to support HMF decisions regarding NEC or late-onset sepsis prophylaxis.

OBJECTIVE Associations between changes in physical activity (PA) and cardiometabolic risk factors among women with overweight/obesity enrolled in a university-based worksite wellness program (WWP) were examined. METHODS Data from 173 women who completed a 26-week WWP were analyzed retrospectively. Participants completed diet and PA assessments and received client-centered diet/lifestyle counseling at baseline, and 12 and 26 weeks thereafter. Anthropometrics, blood pressure, and total cholesterol were measured; PA was self-reported using the International Physical Activity Questionnaire-short form at each visit. RESULTS Significant improvements in anthropometrics (P

BACKGROUND Underfeeding with enteral nutrition (EN) is prevalent in intensive care units (ICUs) and associated with negative outcomes. This study evaluated the impact of volume-based EN (VBEN) vs rate-based EN (RBEN) on delivery of prescribed energy and protein, and glycemic control (GC). METHODS This retrospective study included adult patients who require mechanical ventilation within 48 hours of ICU admission and with an RBEN (n = 85) or VBEN (n = 86) order for ≥3 consecutive days during the first 12 ICU days. RESULTS Patients receiving VBEN, vs RBEN, received more prescribed energy (RBEN, 67.6%; VBEN, 79.6%; P

International audience; The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for nutrition in kidney diseases since 1999. Since the publication of the first KDOQI nutrition guideline, there has been a great accumulation of new evidence regarding the management of nutritional aspects of kidney disease and sophistication in the guidelines process. The 2020 update to the KDOQI Clinical Practice Guideline for Nutrition in CKD was developed as a joint effort with the Academy of Nutrition and Dietetics (Academy). It provides comprehensive up-to-date information on the understanding and care of patients with chronic kidney disease (CKD), especially in terms of their metabolic and nutritional milieu for the practicing clinician and allied health care workers. The guideline was expanded to include not only patients with end-stage kidney disease or advanced CKD, but also patients with stages 1-5 CKD who are not receiving dialysis and patients with a functional kidney transplant. The updated guideline statements focus on 6 primary areas: nutritional assessment, medical nutrition therapy (MNT), dietary protein and energy intake, nutritional supplementation, micronutrients, and electrolytes. The guidelines primarily cover dietary management rather than all possible nutritional interventions. The evidence data and guideline statements were evaluated using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

Despite advances in medicine and technology, clinical outcomes among patients diagnosed with chronic kidney disease (CKD) have remained suboptimal. Historically, much of the focus in kidney disease had been on the burgeoning end-stage kidney disease (ESKD) population and the respective renal replacement therapies (RRTs) necessary for life maintenance, i.e., hemodialysis (HD), peritoneal dialysis (PD), and kidney transplantation. For the first time in decades, the incidence of individuals advancing to ESKD has slowed and may be related to the greater emphasis on early screening for CKD in primary care settings, leading to more timely and appropriate intervention(s) [1]. Capturing the patient once at stage 5 CKD may be too late to make meaningful changes in the factors associated with poorer outcomes.

People with chronic kidney disease (CKD) are at increased risk of hyperkalemia, an electrolyte abnormality that can cause serious, sometimes fatal, cardiac arrhythmias. Muscle contraction causes potassium to be released from cells, increasing serum potassium concentrations. However, these effects are transient, and the long-term impact of exercise training on hyperkalemia risk in CKD patients is largely unknown. In this review, we examine the effects of exercise on factors affecting potassium balance in people with CKD, highlighting the potential benefits of regular exercise on hyperkalemia risk in this population. Although regular exercise is already recommended for people with CKD, research examining this hypothesis may lead to novel therapeutic treatments for this life-threatening condition.

To determine the influence of admission anthropometry on clinical outcomes in mechanically ventilated children in the PICU.Data from two multicenter cohort studies were compiled to examine the unique contribution of nutritional status, defined by body mass index z score, to 60-day mortality, hospital-acquired infections, length of hospital stay, and ventilator-free days, using multivariate analysis.Ninety PICUs from 16 countries with eight or more beds.Children aged 1 month to 18 years, admitted to each participating PICU and requiring mechanical ventilation for more than 48 hours.Data from 1,622 eligible patients, 54.8% men and mean (SD) age 4.5 years (5.1), were analyzed. Subjects were classified as underweight (17.9%), normal weight (54.2%), overweight (14.5%), and obese (13.4%) based on body mass index z score at admission. After adjusting for severity of illness and site, the odds of 60-day mortality were higher in underweight (odds ratio, 1.53; p0.001) children. The odds of hospital-acquired infections were higher in underweight (odds ratio, 1.88; p = 0.008) and obese (odds ratio, 1.64; p0.001) children. Hazard ratios for hospital discharge were lower among underweight (hazard ratio, 0.71; p0.001) and obese (hazard ratio, 0.82; p = 0.04) children. Underweight was associated with 1.3 (p = 0.001) and 1.6 (p0.001) fewer ventilator-free days than normal weight and overweight, respectively.Malnutrition is prevalent in mechanically ventilated children on admission to PICUs worldwide. Classification as underweight or obese was associated with higher risk of hospital-acquired infections and lower likelihood of hospital discharge. Underweight children had a higher risk of mortality and fewer ventilator-free days.

Nutritional therapy is an integral component in the prevention and treatment of kidney stones. This chapter summarizes recent research conducted from 2012 to 2017 on the dietary factors associated with the risk of kidney stones and the factors used to prevent recurrent stone formation in adults. PubMed/Scopus was searched that identified 971 articles; 23 articles (18 original research and 5 reviews and consensus statements) qualified for this paper. Dietary measures identified were fluid, dietary and supplemental calcium, vitamin D and vitamin C, sodium, oxalate, zinc, caffeine, protein, energy, fiber, fruit and vegetable intakes, and acid load. This review has shown that key dietary factors that appear to have the greatest influence on the formation and management of kidney stones are intake of fluids and overall diet composition.

Objective To determine the relationship between physical activity (PA) and health-related quality of life among university employees who enrolled in a worksite wellness program (WWP). Methods The study was an interim analysis of data collected in a WWP. The sample consisted of 64 participants who completed 12- and 26-week follow-up appointments. Results Self-reported anxiety days significantly decreased from baseline to week 12. There were positive trends in self-rated health, vitality days, and summative unhealthy days from baseline to week 26. Among those with a self-reported history of hypertension (HTN), there was an inverse correlation between PA and summative physically and mentally unhealthy days at week 12. Conclusions Among participants in this WWP with HTN, as PA increased there was a significant decrease in summative physically and mentally unhealthy days at week 12.

Background Prior studies have provided evidence that lifestyle change prevents or delays the occurrence of type 2 diabetes mellitus. The challenge is to translate research evidence for type 2 diabetes mellitus prevention into health care settings. Objective We investigated the effect of medical nutrition therapy (MNT) compared with usual care on fasting plasma glucose values, glycated hemoglobin (HbA1c), serum lipid levels, and Diabetes Risk Score, from baseline to the end of a 12-week intervention in overweight or obese adults with prediabetes. Design Prospective, randomized, parallel group study of 76 adults with impaired fasting plasma glucose or an HbA1c of 5.7% to 6.4%, recruited between April 2010 and May 2011 who completed a 12-week intervention period. Main outcome measures The primary outcome measure was fasting plasma glucose. Secondary outcome measures were HbA1c, serum lipid levels, and Diabetes Risk Score. Statistical analyses A factorial repeated measures analysis of variance was used to make comparisons between the two groups (the MNT and usual care groups) and two measures of time (baseline and 12 weeks postintervention). Data analysis was performed using the Statistical Package for the Social Sciences (release 19.0, 2010, SPSS Inc). Results There was a significant interaction for group assignment and HbA1c ( P =0.01), with the MNT group experiencing significantly lower HbA1c levels than the usual care group (5.79% vs 6.01%) after the 12-week intervention. There was a significant interaction for group assignment and Diabetes Risk Score ( P =0.001). Diabetes Risk Score for the MNT group decreased from 17.54±3.69 to 15.31±3.79 compared with the usual care group score, which went from 17.23±4.69 to 16.83±4.73. Regardless of group assignment, both groups experienced a reduction in total cholesterol ( P =0.01) and low-density lipoprotein cholesterol ( P =0.04) level. Conclusions The results demonstrate that individualized MNT is effective in decreasing HbA1c level in patients diagnosed with prediabetes.

OBJECTIVES: To assess the associations between smell function and adiposity and cardiometabolic measures in a nationally representative sample of US adults. METHODS: In the 2013–2014 NHANES, 3527 adults ≥40 years, completed the NHANES Taste and Smell Exam. Smell function was assessed with an 8-item odor identification test. Participants smelled and identified each odorant by selecting one of four descriptors. Smell impairment was defined as incorrect identification of ≥3 (of 8) odors. Survey-weighted linear regression models estimated cross-sectional associations of smell function with adiposity (body mass index (BMI), waist circumference (WC)) and cardiometabolic measures (total cholesterol, high density lipoprotein (HDL), low density lipoprotein (LDL), triglycerides, fasting plasma glucose (FPG), and systolic (SBP) and diastolic blood pressure (DBP)). Models were adjusted for age, race, education, physical activity, self-reported health status, smoking history, and income-poverty ratio, and stratified by sex and age group (40–64 years vs. ≥65 years). RESULTS: In US adults ≥40 years, smell function was significantly associated with several adiposity and cardiometabolic measures in adjusted models, with significant interactions by sex and age. Compared to normal smell, smell impairment was significantly associated with higher BMI [β = 3.0; 95% CI: 0.6, 5.4)] and WC [β = 5.0; 95% CI: 0.3, 9.8] among women

Objective The purpose of this study was to determine whether a subjective global assessment (SGA) score was predictive of health-related quality of life (HRQoL) in stage 5 chronic kidney disease patients on maintenance hemodialysis (MHD). Design and Setting This was a cross-sectional secondary data analysis of MHD patients receiving therapy 3 times a week at dialysis centers located in the United States, Canada, and New Zealand. Nutritional status was assessed using the 7-point SGA. HRQoL was determined using the Medical Outcomes Study 36-item Short Form (SF-36). Results The study sample consisted of 94 men (n = 47, 50%) and women (n = 47, 50%), with a mean age of 64.9 ± 12.9 years. The mean SGA score at the end point of the study (6 months) was 5.8 ± 1.1. Participants had a mean HRQoL physical health score of 36.5 ± 9.3 at 6 months, indicating a worse physical health state. The HRQoL mental health summary score was within the normal range (50.5 ± 11.1). After controlling for confounders in the hierarchical regression models, the SGA score significantly predicted HRQoL physical health ( R 2 change=0.124; P = .012). No association was found between the SGA score and HRQoL mental health ( P = .925). Conclusions The SGA score is a significant predictor of HRQoL physical health. Given that nutritional status impacts HRQoL and that decreased HRQoL in patients on MHD is associated with mortality, complications, and reduced compliance with treatment, using the SGA to measure nutritional status can be a tool to help identify dialysis patients with a lower HRQoL in terms of physical health.

Background Hypermetabolism is theorized in patients diagnosed with chronic kidney disease who are receiving maintenance hemodialysis (MHD). We aimed to distinguish key disease-specific determinants of resting energy expenditure to create a predictive energy equation that more precisely establishes energy needs with the intent of preventing protein-energy wasting. Materials and methods For this 3-year multisite cross-sectional study (N = 116), eligible participants were diagnosed with chronic kidney disease and were receiving MHD for at least 3 months. Predictors for the model included weight, sex, age, C-reactive protein (CRP), glycosylated hemoglobin, and serum creatinine. The outcome variable was measured resting energy expenditure (mREE). Regression modeling was used to generate predictive formulas and Bland-Altman analyses to evaluate accuracy. Results The majority were male (60.3%), black (81.0%), and non-Hispanic (76.7%), and 23% were ≥65 years old. After screening for multicollinearity, the best predictive model of mREE (R2 = 0.67) included weight, age, sex, and CRP. Two alternative models with acceptable predictability (R2 = 0.66) were derived with glycosylated hemoglobin or serum creatinine. Based on Bland-Altman analyses, the maintenance hemodialysis equation that included CRP had the best precision, with the highest proportion of participants' predicted energy expenditure classified as accurate (61.2%) and with the lowest number of individuals with underestimation or overestimation. Conclusions This study confirms disease-specific factors as key determinants of mREE in patients on MHD and provides a preliminary predictive energy equation. Further prospective research is necessary to test the reliability and validity of this equation across diverse populations of patients who are receiving MHD.

The study investigated whether the type of bone disease management (aggressive versus conventional) had an impact on clinical outcomes, namely bone health measures (e.g., biointact parathyroid hormone [BiPTH], serum corrected calcium [cCa] level, serum phosphorus [phos] level, and corrected calcium-phosphorus product [cCaPO(4)]).Retrospective chart review of 173 closed medical records of maintenance hemodialysis patients on thrice-weekly therapy from January 1, 2005, through December 31, 2005. Two Conventional Management (i.e., control group) and three Aggressive Management (i.e., treatment group) dialysis facilities were enrolled.There was a significant interaction for group assignment and BiPTH levels (F = 4.12, P = .01), with the Aggressive Group trending toward lower BiPTH levels than the Conventional Group. The Conventional Group experienced a significantly lower mean annualized serum cCa level (F = 8.85, P = .003), and used non-calcium-based binders significantly more (P.0005) than the Aggressive Group. In terms of serum phos level, the Aggressive Group had a significantly lower (F = 2.73, P = .05) value than the Conventional Group. No significant differences were reported for cCaPO(4) product (F = 1.87, P = .17). The percentage of the total sample that achieved target range for all bone health measures included 29.8% (n = 50).The study demonstrated that aggressive bone disease management appears to be as effective as traditional interventions in the treatment of mineral and bone metabolism disorders in chronic kidney disease.

This study investigated the prevalence of vitamin D deficiency, its association with nutrition-related parameters, and the effects of ergocalciferol supplementation in stage 5 chronic kidney disease (CKD). Measures of interest included serum albumin, glycosylated hemoglobin (HgA1c), hemoglobin, phosphorus, corrected calcium, parathyroid hormone (iPTH), equilibrated normalized protein catabolic rate (enPCR), and quality-of life-survey physical component score (SF-36 PCS).This retrospective study was conducted at five dialysis centers in western Massachusetts. Patient records were examined for a 6-month period in 2006, after initiation of a protocol to assess serum 25(OH)D and implement treatment with ergocalciferol if the level of serum 25(OH)D were40 ng/mL.Over 90% (i.e., 92.4%) of patients had vitamin D levels of less than 40 ng/mL; 80% had vitamin D levels at 31 ng/mL or less. Ergocalciferol supplementation (50,000 IU/week x 24) was associated with significant improvements in serum 25(OH)D from baseline (18.4 +/- 9.0 ng/mL; mean +/- SD) to 6 months (42.0 +/- 24.7 ng/mL) (P.0005). The level of glycosylated hemoglobin decreased from 6.9% +/- 1.9% at baseline to 6.4% +/- 1.5% at 6 months (P.0005), while hemoglobin improved from 12.1 +/- 1.6 g/dL to 12.3 +/- 1.4 g/dL (P.0005). Corrected calcium decreased from 8.7 +/- 0.8 mg/dL to 8.5 +/- 0.9 mg/dL at 6 months (P = .002). Phosphorus and iPTH exhibited a downward trend, though not significantly. Albumin remained stable, while enPCR increased (0.91 +/- 0.23 at baseline, vs. 0.98 +/- 0.32 at 6 months) (P = .01). The SF-36 PCS scores did not differ significantly from baseline (35.4 +/- 11.8) at 6 months (35.0 +/- 11.1).Vitamin D [25(OH)D] deficiency appears to be widely prevalent in stage 5 CKD. Repletion with ergocalciferol may assist in improving glycemic control in the management of diabetes. Additional research is needed to confirm these results and determine the optimal levels of serum 25(OH)D.

Background. Physical activity (PA) can facilitate weight loss, help avoid weight regain, and improve body composition. This study examined the relationships between PA level and changes in anthropometric measures among university employees in a worksite wellness program. Methods. A registered dietitian provided individualized assessments at baseline followed by a 12-week education intervention with follow-up at 12 and 26 weeks. The International Physical Activity Questionnaire–Short Form was used to calculate PA ≤150 or ≥150 min/wk, median min/wk, and metabolic equivalent of task (MET) min/wk at each time point. Repeated-measures general linear model and nonparametric tests were used to assess significant differences over time. Results. Of the 64 participants, 89% were women and 50% were non-Hispanic white. At 12 and 26 weeks, participants experienced significant decreases in weight (P = .001). Among women, waist circumference and abdominal obesity decreased significantly (P < .01). PA ≥150 min/wk (n = 21) was associated with continued weight loss (P = .03) and decreases in body fat percentage (P = .02) between 12 and 26 weeks whereas PA ≤150 min/wk was associated with weight and body fat percentage regain during the same time period. Conclusion. Among women in a worksite wellness program, higher levels of PA were associated with avoiding weight and body fat regain following successful loss.

Summary Purpose: Research has identified significant challenges that patients experience following treatment for head and neck cancer (HNC). These include the physical and emotional impacts of the diagnosis and treatment, which compound weight loss and negatively impact eating ability. There is limited research about the lived experience and the changed meaning of food, eating and the eating experience after treatment for patients with HNC. The purpose of this review was to explore available research pertinent to the lived experiences of patients in regards to the changed meaning of food, eating and the eating experience after treatment for HNC. Principal results: The review identified a limited number of studies that focused on the eating experience and/or the changed meaning of food after a HNC diagnosis. However, the findings do highlight that there are physical, psychological/emotional and social losses associated with the changed meaning of food and eating within the HNC population. Conclusions: The eating experience is impacted after treatment for HNC. Physical, emotional and social losses in regards to the eating experience have been identified. Acknowledging the significance of eating challenges and the changed meaning of food is necessary to ensure patients receive the appropriate management and support to best manage these challenges in a timely manner.

The purpose of this study was to examine current professional practices of registered dietitians (RDs) in the Diabetes Care and Education dietetic practice group (DPG), analyzed by levels of practice: entry-level, specialty-practice, or advanced-level. The results of the Diabetes Care and Education DPG 2002–2003 membership survey were used for this study. The study was limited to RD members of the Diabetes Care and Education DPG who completed the membership survey in its entirety. Frequency distributions, χ 2 , Fisher exact test, and cluster analysis were performed with a prior alpha set at .10. Sixty-one (5.0%) RDs were functioning as an entry-level practitioner, 851 (69.1%) were functioning as a specialty-practice practitioner, and 320 (25.1%) as an advanced-level practitioner. Significantly more advanced-level practitioners were performing more tasks compared with entry-level practitioners. Entry-level RDs performed a mean of 2.4 functions, specialty-practice practitioners performed 7.7, and advanced-level practitioners performed 11.6 functions. The results of this survey further delineated that RDs function at various levels of practice and that credentials for RDs increased as level of practice advanced.

Compelling evidence indicates that the incidence of chronic kidney disease (CKD) is increasing because of an aging population and a higher prevalence of cardiovascular disease, diabetes, and hypertension. Nutrition management of patients with CKD requires early disease recognition, appropriate interpretation of the markers and stages of CKD, and collaboration with other health care practitioners. Better management of CKD can slow its progression, prevent metabolic complications, and reduce cardiovascular related outcomes. Caring for patients with CKD necessitates specialized knowledge and skills to meet the challenges associated with this growing epidemic. The Academy of Nutrition and Dietetics Renal Dietitians Practice Group and the National Kidney Foundation Council on Renal Nutrition, with guidance from the Academy of Nutrition and Dietetics Quality Management Committee, have updated the 2009 Standards of Practice in Nutrition Care and Standards of Professional Performance as a tool for registered dietitian nutritionists working in nephrology nutrition to assess their current skill levels and to identify areas for additional professional development in this practice area. The Standards of Practice apply to the care of patients/clients with kidney disease. The Standards of Professional Performance consist of six domains of professionalism, including: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Within each standard, specific indicators provide measurable action statements that illustrate how nephrology nutrition principles can be applied to practice. The indicators describe three skill levels (ie, competent, proficient, and expert) for registered dietitian nutritionists working in nephrology nutrition.

Part I Foundations for Clinical Practice and Overview Chapter 1 Kidney Function in Health and Disease Alluru S. Reddi, MD, and Kishore Kuppasani, MS Chapter 2 Historical Perspective of Nutrition in Kidney Disease Mary Kay Hensley, MS, RD, CSR Chapter 3 The Changing Demographics of Chronic Kidney Disease in the US and Worldwide Garabed Eknoyan, MD Chapter 4 Nutrition Assessment in Kidney Disease Wm. Cameron Chumlea, PhD, David B. Cockram, PhD, RD, Johanna T. Dwyer DSc, RD, Haewook Han, PhD, RD, and Mary Pat Kelly, MS, RD, GNP Part II Chronic Kidney Disease During Stages 1-4 in Adults Section 1: Prevention Chapter 5 Hypertension Kristie J. Lancaster, PhD, RD Chapter 6 Diabetes Mellitus Joni J. Pagenkemper, MA, MS, RD, LMNT Chapter 7 Dyslipidemias Judith A. Beto PhD RD and Vinod K. Bansal MD Section 2: Treatment Chapter 8 Nutrition and Pharmacologic Approaches Kathy Harvey, MS, RD, CSR Part III Chronic Disease (Stage 5) in Adults Section 1: Treatment Chapter 9 Dialysis Karen Wiesen, MS, RD, LD and Graeme Mindel, MD Chapter 10 Transplantation Pamela S. Kent MS, RD, CSR, LD Section 2 : Management Chapter 11 Protein-Energy Malnutrition Kamyar Kalantar-Zadeh, MD, MPH, PhD Chapter 12: Nutrition Support Marcia Kalista-Richards MPH, RD, CNSD, LDN and Robert N. Pursell, MD Chapter 13: Anemia Management Arthur Tsai, MD and Jeffrey S. Berns, MD Chapter 14: Bone and Mineral Metabolism and Disease Linda McCann, RD, CSR, LD Chapter 15: Chronic Diseases: Diabetes, Cardiovascular Disease, and Human Immunodeficiency Virus Infection Sharon R. Schatz, MS, RD, CSR, CDE Part IV Nutrition in Chronic Disease in Special Needs Populations Section 1: Over the Lifespan Chapter 16: Pregnancy Jean Stover, RD, LDN Chapter 17: Infancy, Childhood, and Adolescence Donna Secker, PhD, MSc, RD Chapter 18: The Aging Adult Julie Barboza MSN, RD, APRN-BC Section 2: Management of Other Disorders Chapter 19: Acute Kidney Failure Wilfred Druml, MD Chapter 20: Nephrotic Syndrome Jane Y. Yeun, MD, FACP and George A. Kaysen, MD, PhD, FASN Chapter 21: Kidney Stones Orfeas Liangos, MD and Bertrand L. Jaber, MD Part IV: Additional Nutritional Considerations in Kidney Disease Chapter 22: Dietary Supplements Diane Rigassio Radler, PhD, RD Chapter 23: Issues Affecting Dietary Adherence Jerrilynn D. Burrowes, PhD, RD, CDN Chapter 24: Outcomes Research Laura D. Byham-Gray, PhD, RD Chapter 25: Suggested Resources for the Practitioner Patricia DiBenedetto Barb'a, MS, RD, Jerrilynn D. Burrowes, PhD, RD, CDN and Laura D. Byham-Gray, PhD, RD.

The actual dietary protein intake of adults without and with different stages of chronic kidney disease is not known. To evaluate this we performed cross-sectional analyses of 16,872 adults (20 years of age and older) participating in the National Health and Nutrition Examination Survey 2001-2008 who completed a dietary interview by stage of kidney disease. Dietary protein intake was assessed from 24-h recall systematically collected using the Automated Multiple Pass Method. Complex survey analyses were used to derive population estimates of dietary protein intake at each stage of chronic kidney disease. Using dietary protein intake of adults without chronic kidney disease as the comparator, and after adjusting for age, the mean dietary protein intake was 1.30 g/kg ideal body weight/day (g/kgIBW/d) and was not different from stage 1 or stage 2 (1.28 and 1.25 g/kgIBW/d, respectively), but was significantly different in stage 3 and stage 4 (1.22 and 1.13 g/kgIBW/d, respectively). These mean values appear to be above the Institute of Medicine requirements for healthy adults and the NKF-KDOQI guidelines for stages 3 and 4 chronic kidney disease. Thus, the mean dietary protein intake is higher than current guidelines, even after adjusting for age.

Information is one of the most important resources for the practitioner. This chapter provides many of the most up-to-date resources in print and on the internet for the practitioner involved in the care of patients with kidney disease. This subject matter is constantly changing and being updated. The resources listed are of interest to professionals, clients and other interested individuals. The topics covered include information on kidney disease, diabetes, hypertension, and other related areas of these general topics. However, the sites and information listed do not constitute an endorsement by the authors or editors.

Clinical standards for practice in renal nutrition can vary dramatically from region to region, state to state, and clinic to clinic, and are greatly affected by the policies of several governing bodies. This review explores the factors that influence practice patterns among renal dietitians and examines the current American Dietetic Association's Scope of Dietetics Practice Framework for its applicability to kidney disease. Lastly, this article discusses current strategies for establishing a scope of practice in renal nutrition and evaluates licensure and credentialing issues that impact standards for practice across the various regions of the United States.

Evidence based guidelines for medical nutrition therapy (MNT) in chronic kidney disease (CKD) recommend a range of caloric levels, dependent on age and level of kidney function. Recent literature has explored whether current research findings still support these earlier conclusions, and if new energy determinations for CKD are warranted. This review will take a brief look at the history of the controversy, examine the research evidence at the time of practice guideline development, investigate emerging research, and discuss implications for additional scientific inquiry.