Nutrition in Clinical Practice recent issues

Editor's Note

Mon, 19 Oct 2009 11:35:04 PDT

Evidence-Based Nutrition Support: Is a Recession a Good Thing?

Seres, D. S. — Mon, 19 Oct 2009 11:35:04 PDT

Issues in Complementary and Alternative Nutrition Treatments

Mullin, G. E. — Mon, 19 Oct 2009 11:35:04 PDT

An Overview of CAM: Components and Clinical Uses

Kiefer, D., Pitluk, J., Klunk, K. — Mon, 19 Oct 2009 11:35:04 PDT

Complementary and alternative medicine (CAM), more recently known as integrative health or integrative medicine, is a diverse field comprising numerous treatments and practitioners of various levels of training. This review defines several of the main CAM modalities and reviews some of the research relevant to their clinical application. The goal is to provide healthcare providers with a basic understanding of CAM to start the incorporation of proven treatments into their clinical practice as well as guide them to working with CAM providers; ultimately, such knowledge is a fundamental part of a collaborative approach to optimal patient health and wellness.

The Metabolic Syndrome: Definition, Global Impact, and Pathophysiology

Potenza, M. V., Mechanick, J. I. — Mon, 19 Oct 2009 11:35:04 PDT

The metabolic syndrome (MS) is a cluster of metabolic derangements that are associated with primary disturbances in adipose tissue. Abnormal visceral fat accumulates from physical inactivity and excess calories in genetically susceptible individuals. This increased adipocyte mass acts as an endocrine organ and communicates with other organ systems via increases in inflammatory cytokines. The resulting disorders define MS as increased waist circumference, decreased serum high-density lipoprotein, and increased serum triglyceride levels, hypertension, and insulin resistance. MS accounts for the majority of cardiovascular disease risk in the U.S. population. Dietary interventions, such as the Mediterranean diet, have been shown to improve these metabolic derangements. Many substances found in these diets are being investigated as specific therapies for MS, and when scientific substantiation is lacking, they may be considered as part of complementary and alternative medicine (CAM). However, as scientific evidence accumulates, these CAM treatments may become part of conventional medicine. This review will scrutinize the emerging evidence behind many, though not all, CAM treatments currently thought to target the various derangements found in MS.

Pediatric Asthma: An Integrative Approach to Care

Mark, J. D. — Mon, 19 Oct 2009 11:35:04 PDT

Asthma in children and young adults is a complex disease with many different phenotypic expressions. Diagnosis is often made based on history and lung function including measuring airway reversibility. However, in children younger than 6 years of age, the diagnosis is more difficult because many children wheeze in the first 4-6 years of life, especially with viral infections. For those children, asthma treatment is often started empirically. Those who go on to develop chronic asthma most likely have a genetic predisposition and exposure to various environmental factors resulting in chronic inflammation of the lower respiratory tract. There are established national guidelines for diagnosing and treating asthma in children and adults. For persistent asthma, it is recommended that medications be taken on a regular basis after identifying and avoiding environmental triggers. Because many factors play a role in developing asthma in children, many nonmedical approaches to asthma and asthma-like conditions have been promoted even when the diagnosis is at times uncertain. The nonmedical approaches and therapies are often referred to as complementary and alternative medicine (CAM). This review will discuss the conventional therapies recommended for children with asthma in addition to CAM therapies, some of which have supporting scientific evidence. Integrating conventional and CAM therapies can prove to be an effective way to treat pediatric asthma, a common and chronic childhood lung disorder. A case is provided to illustrate how such an integrative approach was used in the successful treatment of a child with moderate persistent asthma.

Complementary and Alternative Medications for Women's Health Issues

Lloyd, K. B., Hornsby, L. B. — Mon, 19 Oct 2009 11:35:04 PDT

Women often seek alternative treatment options such as herbs, dietary supplements, and vitamins and minerals to treat women’s health issues across the lifespan. Women may use complementary and alternative supplements for dysmenorrhea, premenstrual syndrome, infertility, nausea and vomiting during pregnancy, and symptoms of menopause. In general, there is a deficit of well-designed, randomized, controlled trials to evaluate the efficacy and safety of complementary and alternative medicine for these indications, which makes it difficult to provide evidence-based recommendations. This review outlines the evidence for efficacy and safety that is currently available for dietary supplement use by women to manage health conditions specific to the female patient.

CAM and Respiratory Disease

Sorkness, R. L. — Mon, 19 Oct 2009 11:35:04 PDT

Complementary and alternative medicine is used commonly for respiratory diseases. This review summarizes data that identify potential links between dietary intake and asthma, and results of interventional trials of herbal substances for the treatment of asthma, chronic obstructive pulmonary disease, and acute bronchitis.

Formulation, Stability, and Administration of Parenteral Nutrition With New Lipid Emulsions

Hardy, G., Puzovic, M. — Mon, 19 Oct 2009 11:35:05 PDT

Intravenous lipid emulsions (IVLE) are an important source of energy and essential fatty acids and their incorporation into pediatric and adult parenteral nutrition (PN) regimens has revolutionized nutrition therapy. However, their clinical use has not been without risk, and will continue to remain so because of the intravenous route of administration. Pharmaceutical and microbiological concerns are centered around the methods of compounding all-in-one (AIO) admixtures, but these can be largely minimized with today’s technologies and advanced understanding of aseptic principles. Modern lipid products, based on olive, coconut, and/or fish oils, have demonstrable formulation and clinical benefits over traditional soybean and safflower IVLE and, when combined in the new multi-chamber bags, can also offer improvements in stability and safety. This review outlines the rationale for different lipid formulations in PN admixtures, reviews the factors influencing stability and efficacy of lipid-based AIO regimens and evaluates some technologies for minimizing peroxidation and maximizing stability of AIO admixtures.

Hyperglycemic Events in Non-Intensive Care Unit Patients Receiving Parenteral Nutrition

Pleva, M., Mirtallo, J. M., Steinberg, S. M. — Mon, 19 Oct 2009 11:35:05 PDT

Background:

Evidence supports the benefits of tight glycemic control in many patient populations. There is no consensus on appropriate targets for blood glucose (BG) values in patients receiving parenteral nutrition (PN). Characterization of the frequency of BG abnormalities is necessary to identify effective strategies to improve glycemic control in this patient population.

Methods:

Data were retrospectively collected over a 2-month period from 50 non–intensive care unit (ICU) patients who received PN. Frequencies of abnormal BG (defined as BG outside the range of 2 criteria: 80-200 mg/dL and 100-150 mg/dL) were determined. An event of hyperglycemia was defined as the 48-hour period following a BG value outside of 80-200 mg/dL. Each event was evaluated for resolution within 48 hours of the triggering BG value.

Results:

Hyperglycemia (at least 1 BG value >200 mg/dL) occurred in 22 patients (44%). Of the 1738 BG values measured, 8.7% were >200 mg/dL, resulting in 1.4 events of hyperglycemia per patient. The average blood glucose value for the population was 140 mg/dL. The frequency of hyperglycemia and hypoglycemia increased substantially, with only 1 patient having a PN course with normoglycemia using the 100-150 mg/dL criterion.

Conclusion:

The frequency of hyperglycemia in non-ICU PN patients is high according to either evaluation criterion. A method is described for using events to characterize hyperglycemia, which may be more useful than traditional methods in clinical decision making and identification of need for process improvements. These data suggest the need to develop better methods for BG control in non-ICU PN patients.

Enteral Nutrition in Nursing Home Residents: A 5-Year (2001-2005) Epidemiological Analysis

Mon, 19 Oct 2009 11:35:05 PDT

Background.

Despite controversy and increasing use of enteral nutrition (EN) among elderly people, descriptive population-based data are scarce. The aim of this study was to evaluate the epidemiological data of nursing home residents (NHRs) who received EN in a northeast area of Italy.

Methods.

All NHRs referred to our Nutrition Service for EN between 2001 and 2005 were enrolled. Data collected at EN initiation included age, gender, underlying disease, Karnofsky index, type of enteral access device, presence of pressure ulcers, weight, body mass index, and daily enteral intake. The outcomes considered were patient survival and duration of therapy.

Results.

The 482 NHRs (130 males; 352 females) received EN. The mean incidence (cases/million population/year) and prevalence (cases/million population) were 223.4 and 279.4, respectively. An average of 6.6% of all NHRs were tube fed. EN was prescribed for the following conditions: 27.7% cerebrovascular accident, 54.6% neurodegenerative disease, 2.7% head and neck cancer, 1.2% abdominal cancer, 1.3% head trauma, 4.8% congenital disease, 7.7% other. Almost all patients had a Karnofsky index ≤50; 42.3% of patients had pressure ulcers. The median duration of EN was 296 days and the median overall survival was 411 days.

Conclusions.

NHRs receiving EN were mainly afflicted with neurodegenerative and cerebrovascular diseases, functional impairments, and a high incidence of pressure sores. The mortality rate was low compared with others reported in literature. The low EN use among NHRs in our study may suggest a limited use in advanced dementia and at end-stage of life.

Vitamin D: A D-Lightful Health Supplement

Mullin, G. E., Turnbull, L., Kines, K., Mullin, G. E. — Mon, 19 Oct 2009 11:35:05 PDT

Article Commentary: Higher Dose of Docosahexaenoic Acid in the Neonatal Period Improves Visual Acuity of Preterm Infants: Results of a Randomized Controlled Trial

Slicker, J. — Mon, 19 Oct 2009 11:35:05 PDT

Article Commentary: Efficacy of Glutamine-Supplemented Parenteral Nutrition on Short-Term Survival Following Allo-SCT: A Randomized Study

Phillips, S. K. — Mon, 19 Oct 2009 11:35:05 PDT

Book Review: Integrating Therapeutic and Complementary Nutrition

Ireton-Jones, C. — Mon, 19 Oct 2009 11:35:05 PDT

Book Review: Nutrition and Gastrointestinal Disease

Ireton-Jones, C. — Mon, 19 Oct 2009 11:35:05 PDT

A Commentary on the Construction of Weight Velocity Charts

Zemel, B. S. — Mon, 19 Oct 2009 11:35:05 PDT

Erratum

Mon, 19 Oct 2009 11:35:05 PDT

Erratum

Mon, 19 Oct 2009 11:35:05 PDT

What Does it Mean to "Own Feeding Tubes"?

McClave, S. A. — Wed, 15 Jul 2009 13:51:45 PDT

Change Is in the Wind

Van Way, C. W. — Wed, 15 Jul 2009 13:51:46 PDT

Innovation, Persistence, and Proficiency in Parenteral Nutrition

Dudrick, S. J. — Wed, 15 Jul 2009 13:51:46 PDT

Compounding Parenteral Nutrition: Reducing the Risks

Curtis, C., Sacks, G. S. — Wed, 15 Jul 2009 13:51:46 PDT

Compounding parenteral nutrition, either manually or with an automated compounding device, requires aseptic conditions and trained personnel. The revised version of United States Pharmacopeia Chapter <797> is a comprehensive document that describes standards and procedures to minimize the risk of contamination of compounded parenteral products. The chapter includes evidence-based instructions for pharmacy design, washing, garbing, cleaning, quality assurance, and personnel training and evaluation designed to improve compounding practices in all pharmacies that compound parenteral products. Because parenteral nutrition is a compounded product mixed from multiple additives, it is important to maintain these standards, especially when using an automated compounding device. This article is an overview of United States Pharmacopeia Chapter <797>, with special emphasis on parenteral nutrition.

A Nutrition Support Service Web Application to Manage Patients Receiving Parenteral Nutrition

Mirtallo, J. M., Hawksworth, K., Payne, B. — Wed, 15 Jul 2009 13:51:46 PDT

Parenteral nutrition (PN) is a complex therapy that requires expertise and experience to avoid errors in prescribing and management. Because of care coordination issues, one medical center has developed and implemented a Web-based application to manage PN patients. PN orders have already been programmed into the physician order entry system, but the nutrition support service (NSS) consult and daily PN management have been performed using paper forms. The Web system is developed for ease of use by clinicians and accessibility at any computer within the medical center. The database consists of 12 tables interrelated by the patient medical record number, admission number, or location. The NSS consult is the main table used to navigate to the other tables. Update of the laboratory and PN formula table must be done through the consult table. The system is compliant with the Health Insurance Portability and Accountability Act guidelines, and has been developed so that the forms that are required to be placed in the patient's permanent record can be printed. Demographic information and laboratory data are automatically populated via a link to the medical center's medication management system. At present, there are 1393 patients in the database and 21,000 pages are viewed each month during daily PN management by clinicians. Data can be easily retrieved for management reports. Data elements can be exported directly from the database to worksheets. This function has been used for projects designed to improve the efficiency of this PN system.

Commercial Premixed Parenteral Nutrition: Is It Right for Your Institution?

Miller, S. J. — Wed, 15 Jul 2009 13:51:46 PDT

Two-compartment premixed parenteral nutrition (PN) products are heavily promoted in the United States. These products may present safety advantages over PN solutions mixed by a local pharmacy, although clinical data to support this assertion are scarce. Multicompartment products can be labor-saving for pharmacy and therefore may be cost-effective for some institutions. Before adopting such products for use, an institution must determine that standardized PN solutions are acceptable for many or most of their patients compared with customized PN compounded specifically for individual patients. A larger selection of premixed products is available in Europe and some other parts of the world compared with the United States. Availability of a broader selection of products in the United States, including 3-compartment bags and a wider range of macronutrient concentrations and volumes, may make the use of such products more desirable in the future.

Intradialytic Parenteral Nutrition and Intraperitoneal Nutrition

Fuhrman, M. P. — Wed, 15 Jul 2009 13:51:46 PDT

Intradialytic parenteral nutrition and intraperitoneal nutrition are methods to provide supplemental nutrition support to patients with chronic kidney disease (also referred to as end-stage renal disease) while they are receiving dialytic therapy. There has been considerable controversy over indications and benefits of intradialytic parenteral nutrition and intraperitoneal nutrition. A major stumbling block had been problematic reimbursement for the therapy under Medicare. Medicare Part D has alleviated some of the reimbursement obstacles and has increased interest in reexamining the benefits and burdens of supplemental nutrition support therapies for patients receiving dialysis.

Pediatric Parenteral Nutrition: Putting the Microscope on Macronutrients and Micronutrients

Slicker, J., Vermilyea, S. — Wed, 15 Jul 2009 13:51:46 PDT

Parenteral nutrition can be a life-saving therapy, but its benefits need to be balanced with a unique set of risks and complications. Methods of practice vary because there is a dearth of research in the area of pediatric parenteral nutrition. This article reviews the available literature on parenteral nutrition in children and provides suggestions on prevention and management of parenteral nutrition–associated liver disease. Some of the issues discussed in this article include glucose infusion rates, cycling of parenteral nutrition, copper and manganese toxicity, and the provision of glutamine, selenium, and carnitine.

Fish Oil Lipid Emulsions and Immune Response: What Clinicians Need to Know

Waitzberg, D. L., Torrinhas, R. S. — Wed, 15 Jul 2009 13:51:46 PDT

Current evidence indicates that -3 polyunsaturated fatty acids (PUFAs), particularly eicosapentaenoic acid and docosahexaenoic acid found in fish oil, can prevent the development of inflammatory diseases by affecting different steps of the immune response. The capacity of -3 PUFAs to modulate synthesis of eicosanoids, activity of nuclear receptor and nuclear transcription factors, and production of resolvins may also mitigate inflammatory processes already present. Parenteral infusion of -3 PUFAs is advantageous, particularly in severely ill patients, because the fatty acids are rapidly incorporated by cells. In addition, when fatty acids are given parenterally, there are no losses from digestion and absorption as there are with enteral infusion. Recently, lipid emulsions enriched with -3 fish oil have been introduced as a component of parenteral nutrition. Currently, there is one lipid emulsion that contains only fish oil; it is infused together with conventionally used lipid emulsions. Other commercially available lipid emulsions contain fish oil in a fat mixture; one contains 10% fish oil and another 15% fish oil. Relevant experimental and clinical data from studies evaluating fish oil lipid emulsions are discussed in the present review. Administration of fish oil lipid emulsion, when compared with soybean oil lipid emulsion (rich in -6 PUFA), decreases the length of hospital and intensive care unit stay in surgical patients.

Development and Implementation of an Audit Tool for Quality Control of Parenteral Nutrition

Garcia-Rodicio, S., Abajo, C., Godoy, M., Catala, M. A. — Wed, 15 Jul 2009 13:51:46 PDT

Background: The aim of this article is to describe the development of a quality control methodology applied to patients receiving parenteral nutrition (PN) and to present the results obtained over the past 10 years. Development of the audit tool: In 1995, a total of 13 PN quality criteria and their standards were defined based on literature and past experiences. They were applied during 5 different 6-month audits carried out in subsequent years. According to the results of each audit, the criteria with lower validity were eliminated, while others were optimized and new criteria were introduced to complete the monitoring of other areas not previously examined. Currently, the quality control process includes 22 quality criteria and their standards that examine the following 4 different areas: (1) indication and duration of PN; (2) nutrition assessment, adequacy of the nutrition support, and monitoring; (3) metabolic and infectious complications; and (4) global efficacy of the nutrition support regimen. The authors describe the current definition of each criterion and present the results obtained in the 5 audits performed. In the past year, 9 of the 22 criteria reached the predefined standards. The areas detected for further improvements were: indication for PN, nutrition assessment, and management of catheter infections. Conclusions: The definition of quality criteria and their standards is an efficient method of providing a qualitative and quantitative analysis of the clinical care of patients receiving PN. It detects areas for improvement and assists in developing a methodology to work efficiently.

Fish Oil Supplementation Lowers C-Reactive Protein Levels Independent of Triglyceride Reduction in Patients With End-Stage Renal Disease

Bowden, R. G., Wilson, R. L., Deike, E., Gentile, M. — Wed, 15 Jul 2009 13:51:46 PDT

Background: Inflammation has been identified as a marker for cardiovascular disease. The purpose of this study is to examine the effects of fish oil fatty acid supplementation on C-reactive protein (CRP) levels. Methods: The study uses a double-blind, permuted-randomized, and placebo-controlled experimental protocol. Patients are randomly placed into a fish oil group or a control group. Thirty-three patients in the experimental and control groups ingest 2 soft-gel pills (1 g each) of fish oil supplements containing eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) or placebo at each meal. Patients follow the supplementation protocol for 6 months. Analysis of variance (ANOVA) is used to measure pretest and posttest differences in the variable of interest. A Kolmogorov-Smirnov test for normality is used to test whether CRP levels are normally distributed. Results:The Kolmogorov-Smirnov test for CRP finds a P value of .273 (KS = .997), revealing that the distribution is normal. ANOVA reveals no statistically significant difference between groups at baseline for CRP (F = 4.118, P = .053). ANOVA reveals a significant main effect (F = 4.29, P = .048) for CRP, with the EPA/DHA group having a significant change in values from pretest (16 mg/dL, standard deviation [SD] = 13.80) to posttest (10.22 mg/dL, SD = 7.87). The placebo group's CRP levels do not change significantly from pretest (13.37, standard deviation [SD] = 7.94) to posttest (13.67, SD = 7.07). An observed power calculation using Cohen's D with a computed of .05 is .588. Conclusions: The study demonstrates that consuming 960 mg/d of EPA and 600 mg/d of DHA can lower CRP.

A Reduced Abbreviated Indirect Calorimetry Protocol Is Clinically Acceptable for Use in Spontaneously Breathing Patients With Traumatic Brain Injury

McEvoy, C., Cooke, S. R., Young, I. S. — Wed, 15 Jul 2009 13:51:46 PDT

A steady state should be established when using indirect calorimetry to assess resting energy expenditure, reduce error, and improve the validity of the measurement. Steady-state criteria are often rigorous and difficult to achieve in hospitalized patients, particularly in patients recovering from traumatic brain injury. This study aimed to assess whether reducing the timeframe for steady-state conditions to 2, 3, or 4 minutes when using indirect calorimetry was significantly different from the widely accepted 5-minute steady-state protocol in patients recovering from traumatic brain injury. Indirect calorimetry using an open-circuit calorimeter was used to measure resting energy expenditure in 20 spontaneously breathing patients with traumatic brain injury. Each patient underwent repeated measurements once per day at various stages of his or her recovery. Bland-Altman methods comparison was used for statistical analysis. In total, 124 measurements were recorded, of which 59% met 5-minute, 70% met 4-minute, 76% met 3-minute, and 84% met 2-minute steady-state conditions. Mean within-patient coefficient of variation was 13% (range, 0%-35%). Agreement at the ±10% level using Bland-Altman plots was 100% for a 4-minute steady-state protocol, 96% for a 3-minute protocol, and 90% using a 2-minute protocol. A 4-minute or 3-minute abbreviated steady-state indirect calorimetry protocol is clinically acceptable to measure resting energy expenditure in spontaneously breathing patients with a traumatic brain injury.

Nutrition Support in Surgical Oncology

Huhmann, M. B., August, D. A. — Wed, 15 Jul 2009 13:51:46 PDT

This review article, the second in a series of articles to examine the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients, evaluates the evidence related to the use of nutrition support in surgical oncology patients. Cancer patients develop complex nutrition issues. Nutrition support may be indicated in malnourished cancer patients undergoing surgery, depending on individual patient characteristics. As with the first article in this series, this article provides background concerning nutrition issues in cancer patients, as well as discusses the role of nutrition support in the care of surgical cancer patients. The goal of this review is to enrich the discussion contained in the clinical guidelines as they relate to recommendations made for surgical patients, cite the primary literature more completely, and suggest updates to the guideline statements in light of subsequently published studies.

The Evolving Rationale for Early Enteral Nutrition Based on Paradigms of Multiple Organ Failure: A Personal Journey

Moore, F. A., Moore, E. E. — Fri, 29 May 2009 10:31:46 PDT

The Physiologic Response and Associated Clinical Benefits From Provision of Early Enteral Nutrition

McClave, S. A., Heyland, D. K. — Fri, 29 May 2009 10:31:46 PDT

Provision of enteral nutrition (EN) to critically ill patients early upon admission to the intensive care unit exerts a beneficial physiologic effect that downregulates systemic immune responses, reduces oxidative stress, and improves patient outcome. Adding specific pharmaconutrient agents to EN in certain patient populations has a synergistic effect, magnifying the degree of this favorable physiologic response. In contrast, failure to provide enteral nutrients creates a physiologic profile that exacerbates oxidative stress and increases the systemic inflammatory response syndrome. Unfortunately, parenteral nutrition (PN) in the form and manner currently provided in North America does not appear to mimic the same physiologic response seen with EN. In the future, use of alternative fuel sources, steps to promote better tolerance of EN, and innovative strategies for delivery of both EN and PN may serve to further enhance the physiologic effect of nutrition therapy and to achieve even greater improvement in patient outcome.

Enteral Nutrition: A Hard Look at Some Soft Evidence

Koretz, R. L. — Fri, 29 May 2009 10:31:46 PDT

Those who read the medical literature should understand the principles of evidence-based medicine. Even randomized trials can contain design or interpretative flaws that allow bias to produce, or exaggerate the size of, beneficial effects. Such problems beset the literature of enteral nutrition (EN). Investigators who have compared EN with parenteral nutrition (PN) have alleged that EN produces fewer adverse events, but such studies do not assess the absolute value of either therapy, and data exist suggesting that PN causes net harm. Trials comparing EN with no nutrition therapy have not yielded convincing evidence of efficacy because the study designs have failed to use methods to prevent bias from interfering with the observations. This same problem exists with trials that have assessed volitional feeding programs (eg, oral supplements). Thus, although systematic reviews have alleged that EN benefits patients undergoing surgery, patients in the critical care unit, patients with liver disease, and patients with pancreatitis, the presence of bias limits any positive conclusions. As a manifestation of this issue, when the various trials are separated into studies with high and low risks of bias, those with low risks have not shown any benefit. EN has been accepted and implemented despite the lack of convincing scientific support of efficacy.

Enteral Feeding Misconnections: An Update

Guenter, P., Hicks, R. W., Simmons, D. — Fri, 29 May 2009 10:31:46 PDT

Enteral misconnections are defined as inadvertent connections between enteral feeding systems and nonenteral systems such as intravascular lines, peritoneal dialysis catheters, tracheostomy tube cuffs, medical gas tubing, and so on. Sentinel event data and causative factors are outlined along with potential solutions to prevent such medical errors. The solutions can be grouped into 3 areas: (1) education, awareness, and human factors; (2) purchasing strategies; and (3) design changes. Updates on safety innovations and programs are presented.

Implementation of the Enteral Nutrition Practice Recommendations

Brantley, S. L. — Fri, 29 May 2009 10:31:46 PDT

In developing the evidence-based Enteral Nutrition Practice Recommendations, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) formed a task force to address the many aspects of safety in the delivery and provision of enteral nutrition support. This recently published document provides healthcare professionals with recommendations that are derived from evidence-based practice. The development and use of clinical practice guidelines (CPGs) is a recent, significant contribution for the dissemination of evidence-based medicine. This involves the review of scientific literature along with clinical skill and knowledge to generate specific recommendations assisting healthcare providers and patients with decisions regarding appropriate healthcare. A primary opportunity to improve patient outcomes will come from the effective delivery of existing therapies rather than from the new development of treatment modalities. Compliance with CPGs is challenging because it depends on a variety of factors. Both general and specific strategies have been devised with the expansion of the new discipline of implementation science. The high degree of evidence now available in medicine gives clinicians more opportunity to improve patient outcomes and quality of care. It remains for clinicians to evaluate their institutional mission and goals, and to investigate those CPGs appropriate to improve patient care in that setting.

Enteral Nutrition Formulas: Which Formula Is Right for Your Adult Patient?

Chen, Y., Peterson, S. J. — Fri, 29 May 2009 10:31:46 PDT

In the last few decades, there has been tremendous advancement in the area of enteral nutrition formulas. Enteral nutrition makes it possible to provide important substrates for those who cannot or will not meet daily requirements via oral intake but who have an intact digestive system. Numerous enteral nutrition formulas are currently available, with a large portion of them targeting specific disease conditions, thus making it a daunting task at times for a clinician to sort through all the possibilities and decide on the most appropriate formula. This review provides a close examination of various enteral formula categories and presents proposed mechanisms of specialized ingredients, followed by a thorough evidence-based analysis of existing literature before making recommendations for the various enteral formula categories.

Overview of Infant and Pediatric Formulas

Joeckel, R. J., Phillips, S. K. — Fri, 29 May 2009 10:31:46 PDT

Because every child has individual needs, there are a variety of infant and pediatric formulas from which to choose. Not only are there several categories of formulas including milk protein-based, soy protein-based, hydrolyzed protein, and amino acid-based, but there are differences between products within each category. Research is being done in the area of formula design for the prevention or treatment of disease. In this article, the authors review types of formulas and their indications for use for infants and children, and review current literature on formula trends.

Enteral Nutrition Support of the Preterm Infant in the Neonatal Intensive Care Unit

Groh-Wargo, S., Sapsford, A. — Fri, 29 May 2009 10:31:46 PDT

The delivery of a preterm baby is a nutrition emergency. Growth and the accumulation of nutrient reserves are higher during the third trimester of pregnancy than at any other time during the life cycle. Enteral nutrition is the preferred mode of support and human milk the preferred source of enteral nutrition. Human milk is highly digestible and contains many anti-infective components, which confer a lower risk of infection. The mother of a preterm infant requires education, equipment, and encouragement to successfully initiate and sustain lactation. Human milk requires nutrient fortification to meet the protein and mineral needs of the rapidly growing preterm infant. Commercial human milk fortifiers are available. If human milk is unavailable or the volume is insufficient, preterm formulas are available. Preterm formulas have different sources of macronutrients and greater density of all nutrients than formulas intended for term newborns. Preterm infants benefit from early enteral feedings with slow but steady increases in feedings to achieve full support. Infants born at <35 weeks gestational age are supported with tube feedings. A transition to feedings at the breast or to bottle feedings is gradually made as the baby matures. Nutrient recommendations specific to the preterm infant are available. Special products and feeding strategies exist to respond to common medical conditions that can complicate nutrition management. Optimal nutrition care of the preterm infant offers the opportunity to improve outcomes for children.

Approach to Enteral Feeding in the PICU

Mehta, N. M. — Fri, 29 May 2009 10:31:46 PDT

The pediatric intensive care unit (PICU) environment poses unique challenges to achieving enteral nutrition (EN) goals for the critically ill child. Nutrition support in the PICU is often in conflict with the complexity of care provided to acutely ill children. A significant proportion of eligible patients do not receive optimal enteral nutrition for avoidable reasons. Early institution of EN is recommended and the gastric route is preferred because of ease of administration and reduced costs compared with the transpyloric route. In patients with poor gastric emptying or in cases where a trial of gastric feeding has failed, transpyloric or postpyloric feeding may be used to decrease the risk of aspiration and to improve enteral feed tolerance. However, there is no evidence of benefit for routine use of small bowel feeding in all patients admitted to the PICU. The placement of blind nasoenteric feeding tubes can be technically challenging, is not without complications, and requires local expertise and experience for successful placement and maintenance. A protocolized approach to selecting the optimal route and advancing enteral feedings may optimize EN delivery. Institutional practice guidelines based on consensus, available evidence, and national guidelines may decrease time to reaching caloric goal, improve protein balance, and potentially affect clinical outcomes. The rationale and challenges to the delivery and maintenance of optimal EN, and strategies to achieve optimal EN during critical illness, are discussed.

Systematic Review of Postdischarge Oral Nutritional Supplementation in Patients Undergoing GI Surgery

Lidder, P. G, Lewis, S., Duxbury, M., Thomas, S. — Fri, 29 May 2009 10:31:46 PDT

Objective: To determine whether nutritional supplementation following hospital discharge in patients who undergo gastrointestinal (GI) surgery is benefical in specific outcome measures. Methods: A systematic review was conducted of randomized controlled trials comparing nutritional supplements vs a "standard care" regimen given to patients following discharge from hospital after GI surgery. Outcome measures were weight change, quality of life, clinical complications, fatigue, and hand grip strength. Results: Four studies were identified. Postdischarge oral nutritional supplements were found to be safe and increased energy intake, protein intake, and weight in patients after discharge from hospital. The greatest gains in weight were seen in malnourished patients. Little evidence was found that nutritional supplements reduce morbidity or improve quality of life, fatigue, or hand-grip strength. Only one study was methodologically adequate, and none were powered to detect differences in clinical complications. Conclusions: In patients who undergo GI surgery and receive nutritional supplements after discharge from hospital, little evidence of clinical benefit was found, principally through lack of robust data. All the studies were under-powered or not specifically designed to show benefit during this period. It is recommended that nutritional supplements be offered to malnourished patients or those at high risk of poor dietary intake at discharge from hospital.

Senescent Swallowing: Impact, Strategies, and Interventions

Ney, D. M., Weiss, J. M., Kind, A. J. H., Robbins, J. — Fri, 29 May 2009 10:31:46 PDT

The risk for disordered oropharyngeal swallowing (dysphagia) increases with age. Loss of swallowing function can have devastating health implications, including dehydration, malnutrition, pneumonia, and reduced quality of life. Age-related changes increase risk for dysphagia. First, natural, healthy aging takes its toll on head and neck anatomy and physiologic and neural mechanisms underpinning swallowing function. This progression of change contributes to alterations in the swallowing in healthy older adults and is termed presbyphagia, naturally diminishing functional reserve. Second, disease prevalence increases with age, and dysphagia is a comorbidity of many age-related diseases and/or their treatments. Sensory changes, medication, sarcopenia, and age-related diseases are discussed herein. Recent findings that health complications are associated with dysphagia are presented. Nutrient requirements, fluid intake, and nutrition assessment for older adults are reviewed relative to dysphagia. Dysphagia screening and the pros and cons of tube feeding as a solution are discussed. Optimal intervention strategies for elders with dysphagia ranging from compensatory interventions to more rigorous exercise approaches are presented. Compelling evidence of improved functional swallowing and eating outcomes resulting from active rehabilitation focusing on increasing strength of head and neck musculature is provided. In summary, although oropharyngeal dysphagia may be life threatening, so are some of the traditional alternatives, particularly for frail, elderly patients. Although the state of the evidence calls for more research, this review indicates that the behavioral, dietary, and environmental modifications emerging in this past decade are compassionate, promising, and, in many cases, preferred alternatives to the always present option of tube feeding.

Reduced Incidence of Aspiration With Spoon-Thick Consistency in Stroke Patients

Diniz, P. B., Vanin, G., Xavier, R., Parente, M. A. — Fri, 29 May 2009 10:31:46 PDT

Background: Dysphagia and aspiration occur frequently in stroke patients. The aim of the present study was to evaluate 2 consistencies (liquid and spoon-thick/pudding-like) regarding the risk of aspiration and to determine the usefulness of a bedside speech therapy assessment to predict risk of aspiration. Methods: This randomized, crossover clinical trial was carried out April to August 2001 at a university hospital. Sixty-one inpatients diagnosed with acute phase or prior stroke received liquid and spoon-thick (pudding-like) feeds during nasoendoscopy and bedside clinical assessment. Results: Aspiration occured in only 3 patients with the spoon-thick consistency vs 21 with the liquid consistency (relative risk = 0.13; 95% confidence interval = 0.04-0.39; P < .001). The bedside assessment had a sensitivity of 81% and a specificity of 70.8% to detect risk of aspiration. Conclusions: The use of a spoon-thick consistency reduced the risk of aspiration compared with the liquid consistency. Clinical assessment was useful to predict aspiration, although the probability of dysphagia in the presence of a negative clinical assessment (29%) is a reason for concern.

Comment On: Nutritional Deficiencies After Roux-en-Y Gastric Bypass for Morbid Obesity Often Cannot be Prevented by Standard Multivitamin Supplementation

Trumpy, M. S. — Fri, 29 May 2009 10:31:46 PDT

Background: Despite the increasing use of Rouxen-Y gastric bypass (RYGBP) in the treatment of morbid obesity, data about postoperative nutritional deficiencies and their treatment remain scarce. Objective: The aim of this study was to evaluate the efficacy of a standard multivitamin preparation in the prevention and treatment of nutritional deficiencies in obese patients after RYGBP. Design: This was a retrospective study of a 2-year follow-up of obese patients after RYGBP surgery. Between the first and the sixth postoperative months, a standardized multivitamin preparation was prescribed for all patients. Specific requirements for additional substitutive treatments were systematically assessed by a biologic workup at 3, 6, 9, 12, 18, and 24 months. Results: A total of 137 morbidly obese patients (110 women and 27 men) were included. The mean (±SD) age at the time of surgery was 39.9 ± 10.0 years, and the body mass index (in kg/m²) was 46.7 ± 6.5. Three months after RYGBP, 34% of these patients required at least one specific supplement in addition to the multivitamin preparation. At 6 and 24 months, this proportion increased to 59% and 98%, respectively. Two years after RYGBP, a mean amount of 2.9 ± 1.4 specific supplements had been prescribed for each patient, including vitamin B-12, iron, calcium + vitamin D, and folic acid. At that time, the mean monthly cost of the substitutive treatment was $34.83. Conclusion: Nutritional deficiencies are very common after RYGBP and occur despite supplementation with the standard multivitamin preparation. Therefore, careful postoperative follow-up is indicated to detect and treat those deficiencies. (Am J Clin Nutr. 2008;87:1128-33.)

Gasteyger C, Suter M, Gaillard RC, and Giusti V.

Hasse, J. M. — Wed, 25 Mar 2009 16:12:03 PDT

Issues in Geriatric Nutrition

Chernoff, R. — Wed, 25 Mar 2009 16:12:03 PDT

Micronutrients and Older Adults

Marian, M., Sacks, G. — Wed, 25 Mar 2009 16:12:03 PDT

The aging population worldwide is increasing. Although many older adults are living longer, healthier lives, aging is also associated with a variety of physiologic and psychological changes that influence nutrition status and the need for medical care. Many factors increase the risk for poor nutrient intake among older adults. Suboptimal micronutrient intake for particular vitamins and minerals is reported to be common.

Home Care for the Elderly

Fuhrman, M. P. — Wed, 25 Mar 2009 16:12:03 PDT

The increasing numbers of older (>65 years) Americans will increase the demand for home health services including support services (nursing, physical therapy, occupational therapy, durable medical equipment, and respiratory therapy), infusion therapies, palliative care, and hospice. The unique characteristics and specific needs of this population must be addressed to optimize patient outcomes. The American Society for Parenteral and Enteral Nutrition has established standards for clinicians providing nutrition support in the home and provides practice guidelines for nutrition support and geriatrics. Certification in gerontological care is available for dietitians, pharmacists, physicians, and nurses. The key to optimal care for older adults is to find the confluence of expertise in nutrition support and geriatrics.

The Artificial Nutrition Debate: Still an Issue... After All These Years

Monturo, C. — Wed, 25 Mar 2009 16:12:03 PDT

Debate over withdrawal or withholding of artificial nutrition appeared a distant discussion until the furor over the Schiavo case and a Papal Allocation reignited this ethical dilemma. The purpose of this article is to provide a review of the bioethical opinion regarding artificial nutrition, as published in the Hastings Center Report from 1971 until 2007. A clinical and religious history of the evolution and use of artificial nutrition prefaces the review containing common themes and categories framed within a chronology of bioethical and legal events. Finally, an interpretative philosophical discussion is offered on the resurgence of the ethical dilemma concerning withdrawal or withholding of artificial nutrition. Through a combination of classic content analysis and grounded theory, 8 inductively derived categories emerged from a sample of 63 articles/letters with a primary focus on artificial nutrition, enteral nutrition or parenteral nutrition. These categories included illness/treatment trajectory, personhood, family, provider, cost, religion, legal, and ethics and morality. In more than 35 years, surprisingly little has changed with regard to withdrawal or withholding of artificial nutrition. As the Schiavo case revealed, despite a sense in bioethics of a firm consensus about handling the withdrawal of food and water, many are still searching for answers to this dilemma.

Tube Feeding in Patients With Dementia: Where Are We?

DeLegge, M. H. — Wed, 25 Mar 2009 16:12:03 PDT

Dementia is a common diagnosis and accounts for significant morbidity and mortality. In the United States, the practice of medicine commonly dictated that dementia patients with dysphagia should receive a feeding tube. A review of the evidence in 1999 was completed to understand the validity of the premise of an improvement in a dementia patient's survival, quality of life, malnutrition, and comorbid diseases with tube feeding. The available literature reviewed was sparse. The retrospective and prospective observational studies noted no improvement in the above-mentioned outcomes in dementia patients with the use of tube feeding. Interestingly, a recent retrospective review denoted that dementia patients had no worse survival than patients with other diseases receiving a feeding tube and tube feedings. A prospective study comparing tube feeding to hand feeding in the dementia population is sorely needed.

Anemia After Bariatric Surgery: More Than Just Iron Deficiency

von Drygalski, A., Andris, D. A. — Wed, 25 Mar 2009 16:12:03 PDT

Bariatric surgery for morbid obesity is rapidly gaining popularity. Restrictive and/or malabsorptive surgical interventions result in dramatic weight loss with significantly decreased obesity-related morbidity and mortality. Anemia, which may affect as many as two-thirds of these patients, is of concern and generally thought to be caused by iron deficiency. Although iron deficiency in this population may be frequent given pouch hypoacidity, defunctionalized small bowel, and red meat intolerance, it may not account for all anemias seen. First, there is increasing evidence that obesity creates a state of chronic inflammation. Both iron deficiency anemia and anemia of chronic inflammation present with low serum iron levels. Most studies reporting anemia after bariatric surgery lack serum ferritin determinations so that the relative contribution of inflammation to anemia cannot be assessed. Second, a significant number of anemias after bariatric surgery remain unexplained and may be attributable to less frequently seen micronutrient deficiencies such as copper, fatsoluble vitamins A and E, or an imbalance in zinc intake. Third, although deficiencies of folate and vitamin B₁₂ are infrequent, study observation periods may be too short to detect anemia attributable to vitamin B₁₂ deficiency because vitamin B₁₂ storage depletion takes many years. This review is intended to increase awareness of the mechanisms of anemia above and beyond iron deficiency in the bariatric patient and provide healthcare providers with tools for a more thoughtful approach to anemia in this patient population.

Probiotics for Preventive Health

Minocha, A. — Wed, 25 Mar 2009 16:12:03 PDT

Gut flora and probiotics have potential to affect health and disease far beyond the gut. There is increasing evidence that probiotics have beneficial effects in preventing a wide range of conditions and improving health. Randomized, double-blind studies have provided evidence of the effectiveness of probiotics for preventing various diarrheal illnesses as well as allergic disorders. Evidence for their efficacy for use in the prevention and treatment of bacterial vaginosis and urinary tract infections is also mounting. In addition, probiotics may be useful for preventing respiratory infections, dental caries, necrotizing enterocolitis, and certain aspects of inflammatory bowel disease. Data also suggest that probiotics may promote good health in day care and work settings, and may enhance growth in healthy as well as ill and malnourished children. Results from meta-analyses and systematic reviews that combine results of studies from different types of probiotics to examine the effects in any disease state should be interpreted with caution. Specific strains are effective in specific disease states. No 2 probiotics are exactly alike; we should not expect reproducible results from studies that employ different species or strains, variable formulations, and diverse dosing schedules.

Nutrition Support After Neonatal Cardiac Surgery

Owens, J. L., Musa, N. — Wed, 25 Mar 2009 16:12:03 PDT

Congenital heart disease is the most common birth defect in the United States, with an estimated frequency of approximately 12–14 of 1000 live births per year. Neonates with congenital heart disease often need palliative or corrective surgery requiring cardiopulmonary bypass during the first weeks of life. The neonate undergoing cardiopulmonary bypass surgery experiences a more profound metabolic response to stress than that seen in older children and adults undergoing surgery. However, compared with older children and adults, the neonate has less metabolic reserves and is extremely vulnerable to the negative metabolic impact induced by stress, which can lead to suboptimal wound healing and growth failure. There are complications associated with the metabolic derangements of neonatal surgery requiring cardiopulmonary bypass, including but not limited to acute renal failure, chylothorax, and neurological dysfunction. This article discusses the importance of nutrition and metabolic support for the neonate undergoing cardiopulmonary bypass and the immediate postoperative nutrition needs of such a patient. Also, this article uses a case study to examine the feeding methodology used at one particular institution after neonatal cardiac surgery. The purpose of the case study is to provide an illustration of the many factors and obstacles that clinicians often face in the provision and timing of nutrition support.

Chemopreventive Role of Fruits and Vegetables in Oropharyngeal Cancer

Davidson, P. G., Touger-Decker, R. — Wed, 25 Mar 2009 16:12:03 PDT

Oropharyngeal cancer is associated with lifestyle factors, including tobacco use, dietary habits, and alcohol consumption. Oropharyngeal cancers are one of the 10 most common types of cancers worldwide, and it is estimated that oropharyngeal cancers will have affected 30,990 men and women in the United States with a total of 7430 deaths in 2008. The National Cancer Institute defines chemoprevention as "the use of drugs, vitamins, or other agents to try to reduce the risk of, or delay the development or reccurrence of, cancer." Chemopreventive agents such as antioxidants are derived from dietary sources, including fruits and vegetables. This review addresses the chemopreventive role of dietary intake of fruits and vegetables in the development of oropharyngeal cancers. It focuses on the variability of the incidence of oropharyngeal cancers and possible reasons behind this phenomenon as it relates to dietary factors, specifically fruits and vegetables.

Methods for the Assessment of Gastric Emptying in Critically Ill, Enterally Fed Adults

Moreira, T. V., McQuiggan, M. — Wed, 25 Mar 2009 16:12:03 PDT

Critically ill patients may experience delayed gastric emptying. Patients receiving enteral feeding are monitored closely to detect a delay of gastric emptying, assess feeding tolerance, and prevent aspiration pneumonia. The most common practice for assessing gastric emptying is to measure the aspirated gastric residual volume; however, this is an unreliable method that lacks standardization, fails to differentiate normal digestive secretions from enteral formula, and results in unnecessary interruptions of enteral nutrition. The aim of this review is to identify an alternative method to assess gastric emptying, which should be reliable, sensitive, harmless, feasible, and inexpensive. Several techniques are discussed: scintigraphy, paracetamol absorption test, breath tests, refractometry, ultrasound, and gastric impedance monitoring. Refractometry seems to be the most appropriate tool for the regular assessment of enteral nutrition; however, standardization and validation of this method are needed before it can be routinely used to monitor critically ill patients receiving enteral nutrition.

Comparison of Tools for Nutrition Assessment and Screening for Predicting the Development of Complications in Orthopedic Surgery

Ozkalkanli, M. Y., Ozkalkanli, D. T., Katircioglu, K., Savaci, S. — Wed, 25 Mar 2009 16:12:03 PDT

Background: Malnutrition in hospitalized patients is a significant problem. The purpose of this study was to compare 2 assessment tools—the Nutritional Risk Screening 2002 (NRS 2002) and subjective global assessment (SGA)—in predicting development of complications in patients undergoing orthopedic surgery. Methods: Nutrition status was assessed by the SGA, and nutrition screening was performed using the NRS 2002 in 256 consecutively admitted patients scheduled for orthopedic surgery. Additional information recorded for all patients included age, gender, body mass index, and American Society of Anesthesiologists (ASA) physical status. Patient outcomes (postoperative complications), mortality rate, and length of hospital stay (LOS) were investigated. Results: Malnourished or nutritionally at-risk patients were significantly older than nonmalnourished or not at-risk patients according to the SGA and NRS 2002. Also, ASA physical status was correlated with malnutrition or malnutrition risk. Malnourished and at-risk patients in both the SGA and NRS 2002 groups showed longer LOS and higher morbidity and mortality rates. Sensitivity was 50% with the SGA and 69% with the NRS 2002; specificity was 77% with the SGA and 80% with the NRS 2002. Agreement between 2 methods was 0.672. The odds ratio for the association between malnutrition or risk of malnutrition and the occurrence of complications was 3.5 (1.7-7.1) for the SGA and 4.1 (2.0-8.5) for NRS 2002. Conclusions: Age and ASA physical status are risk factors for malnutrition. In patients undergoing orthopedic surgery, NRS 2002 predicted development of complications better than the SGA. Malnutrition also increased length of hospital stay.

The "Cut and Push" Method of Percutaneous Endoscopic Gastrostomy Tube Removal in Adult Patients: The Ipswich Experience

Kejariwal, D., Bromley, D., Miao, Y. — Wed, 25 Mar 2009 16:12:03 PDT

Background: The standard method of removing percutaneous endoscopic gastrostomy (PEG) tubes in the United Kingdom is by repeat gastroscopy and retrieval of the internal PEG bumper by the oral route. However, the endoscopic removal method may not always be necessary by use of the "cut and push" method. This involves cutting the tube at skin level and allowing the internal bumper to pass naturally. Methods: A local database of all patients undergoing a PEG insertion was created in February 2002. All PEG tube removals by the "cut and push" method over a 5-year period at Ipswich Hospital were reviewed. Results: Between February 2002 and December 2007, 89 Fresenius Freka 15 Fr tubes were removed by the "cut and push" method. The original indications for the PEG tubes that were removed were head and neck malignancy (55), cerebrovascular accident (24), and other miscellaneous causes (10). The mean age of the patients was 62.7 years (range 19-98 years). The average duration of the tube in-situ before removal was 6.7 months (range 1-28). No complications were recorded during the mean follow-up period of 26.8 months (range 1-66 months). Conclusion: Follow-up data provide further evidence that the "cut and push" method is a safe and cost-effective method for removing 15 Fr PEG tubes in adult patients and that an abdominal radiograph is not routinely required.

Fink, K. — Wed, 25 Mar 2009 16:12:03 PDT

Wed, 25 Mar 2009 16:12:03 PDT