Nestle Nutrition workshop series. Clinical & performance programme最新文献

Despite extensive information on the adverse physical and psychological consequences of malnutrition, there is little information on its economic consequences. International studies suggest that disease-related malnutrition increases hospital costs by 30-70%. In the United Kingdom the Malnutrition Universal Screening Tool (MUST) was used as the basis for identifying the prevalence of malnutrition in various care settings. Malnutrition increased both the frequency of admissions and length of stay in hospitals, as well as the frequency of visits to a general practitioner and hospital outpatient visits, and residency in care homes. After assigning nationally representative costs to the utilization of these services, the public expenditure on disease-related malnutrition in the UK in 2003 was estimated to be more than GBP 7.3 billion. The large cost of disease-related malnutrition means that small fractional cost savings from intervention can result in substantial absolute cost savings. A summary of nutritional intervention studies with cost analyses (including meta-analyses) and cost-effectiveness analyses are presented, and some of the clinical and ethical implications discussed.

In 2005, the European Nutrition for Health Alliance (ENHA, the Alliance) was established to raise awareness of the relevance and urgency of malnutrition and ensure that this important issue is included in policy discussions and appropriate action is taken by policymakers and stakeholders at EU and member state levels. Malnutrition remains under-recognized, under-detected and under-managed across Europe, 4 years after the publication of the Call to Action resolution issued by the Council of Europe in 2003, on food and nutritional care in hospitals. The goal of the ENHA is to implement policy changes in nutrition and health at government and healthcare organizational levels. The value of specific evidence-based medical interventions must be demonstrated.

A review of the publications on hospital malnutrition in Europe over the last 5 years shows that the incidence and prevalence of malnutrition are still very high: 21 and 37%, respectively. The process of structured nutrition support is still far from being generally implemented, as based on the few studies available. As a result, malnutrition diagnosed on admission to hospital is still associated with adverse clinical outcome (increased length of stay and higher rates of complications).

This review focuses on the efficacy and safety of Chinese medicine in the treatment of type-2 diabetes. Included were 84 controlled clinical studies of type-2 diabetes treated with Chinese medicine for at least 1 month. Reported outcomes were: symptom relief; improvement in glycemia, insulin resistance and secondary failure, and adverse events. Symptom relief was achieved in most (>80%) of the patients receiving Chinese medicine. Compared with orthodox drugs, Chinese medicine had a 1.2-fold (95% CI 1.2-1.3) increase in symptom relief. The relative risk of achieving a fasting blood glucose of <7.3 mmol/l or a postprandial blood glucose of <8.2 mmol/l was: 3.0 (95% CI 1.4-6.5) for Chinese medicine plus diet versus diet; 2.0 (95% CI 1.4-3.0) for Chinese medicine versus placebo; 1.8 (95% CI 1.4-2.3) for combined Chinese medicine and orthodox drugs versus Yuquan Wan (a classic Chinese herbal formula for diabetes), 1.5 (95% CI 1.4-1.7) for combined Chinese medicine and orthodox drugs vs. orthodox drugs, and 1.3 (95% CI 1.2-1.5) for Chinese medicine versus orthodox drugs. A fasting blood glucose of <8.2 mmol/l plus symptom relief was observed in 71-100% of the patients with secondary failure to oral anti-diabetic drugs. Serious adverse events including hypoglycemic coma and death were caused by adulteration with orthodox drugs, erroneous substitution, self-meditation, overdoses, and improper preparation. Chinese herbal medicine should be used cautiously with doctors' prescription and follow-up. Long-term clinical studies may disclose the effectiveness of Chinese medicine in reducing the mortality and morbidity of diabetic complications.

Obesity and type-2 diabetes can be considered diseases of physical inactivity. Physically activity protects against type-2 diabetes through its positive effects on weight management and on the metabolic pathways involved in glycemic control that are not weight-dependent. Increasing physical activity is one of the most effective strategies both for preventing type-2 diabetes and for managing it once it is present. However, we still face an enormous challenge in getting people to achieve sustainable increases in physical activity. A promising strategy is to get people walking more, starting small and increasing gradually over time.

There is a large bulk of evidence that using low glycemic index (GI) foods has a very significant impact on the amelioration of metabolic disturbances observed in diabetic and/or hyperlipidemic patients and in subjects affected by the metabolic syndrome. Studies bringing convincing evidence against this concept are very rare if any. Improvement is observed not only in postprandial blood glucose and insulin variations but also in circulating plasma lipid levels and the morphology and function of adipocytes. Using the concept of low GI foods in diet counseling of diabetic patients is not exclusive of other measures to improve postprandial and overall blood glucose control. On the contrary, the use of low GI foods should be considered as one of other means and tools available to improve diabetes control (such as other dietary modifications, use of specific and nonspecific drug therapy altering postprandial blood glucose). Among these therapies, the most promising ones are alpha-glucosidase inhibitors, glynides, rapid insulin analogues and in the near future the GLP1 analogue. Again, all these classes of drugs could be associated with one another in order to obtain a postprandial delta excursion target of not below 20 and not above 40-50 mg/dl blood glucose.

The metabolic syndrome is a common metabolic disorder that results from the increasing prevalence of obesity. It also refers to a clustering of specific cardiovascular disease risk factors whose underlying pathophysiology is thought to be related to insulin resistance with an excessive flux of fatty acids implicated. Opinions have varied as to whether the metabolic syndrome should be defined to indicate mainly insulin resistance, the metabolic consequences of obesity, risk of cardiovascular disease, or simply a collection of statistically related factors. Based on these different viewpoints 4 definition sets of the metabolic syndrome are formulated. The pros and cons of each of them are extensively discussed. A major role in the etiology of the metabolic syndrome is ascribed to the occurrence of insulin resistance. Data are provided that insulin resistance can worsen the expression of this syndrome, but cannot have a primary role. Therefore, insulin resistance is not the main player of the metabolic syndrome, but central obesity is. Free fatty acid induced insulin resistance is found and induced by central obesity. The metabolic syndrome is a cluster of abnormalities in which each of them deserves its own (maximal) treatment to diminish the risk for cardiovascular disease.

The glycemic index concept owes much to the dietary fiber hypothesis that fiber would reduce the rate of nutrient absorption and increase the value of carbohydrate foods in the maintenance of health and treatment of disease. However, properties and components of food other than its fiber content contribute to the glycemic and endocrine responses postprandially. The aim of the glycemic index classification of foods was therefore to assist in the physiological classification of carbohydrate foods which, it was hoped, would be of relevance in the prevention and treatment of chronic diseases such as diabetes. Over the past two decades low glycemic index diets have been reported to improve glycemic control in diabetic subjects, to reduce serum lipids in hyperlipidemic subjects and possibly to aid in weight control. In large cohort studies, low glycemic index or glycemic load diets (glycemic index multiplied by total carbohydrate) have also been associated with higher levels of high-density lipoprotein cholesterol, reduced C-reactive protein concentrations and with a decreased risk of developing diabetes and cardiovascular disease. More recently, some case-control and cohort studies have also found positive associations between the dietary glycemic index and the risk of colon, breast and other cancers. While the glycemic index concept continues to be debated and there remain inconsistencies in the data, sufficient positive findings have emerged to suggest that the glycemic index is an aspect of diet of potential importance in the treatment and prevention of chronic diseases.

Concentrations of glucose and lipids in the blood have important health implications and are influenced by dietary intake. Dietary intake and energy expenditure regulate body weight, which is also an important determinant of health. Thus it would be important to determine the optimal diet for affecting blood glucose and lipids and body weight. Many professional health organizations in different countries have made dietary recommendations that include caloric restriction when needed to prevent or reverse overweight or obesity, limitation of saturated and trans fat, and emphasis on fruits and vegetables. These professional groups have not recommended extremely low carbohydrate or extremely low fat diets, despite much popular interest and recent research in these approaches. In several clinical trials, diet and exercise interventions prevented or delayed the development of type-2 diabetes. These trials showed the value of diet interventions, but did not attempt to determine which dietary approach was optimal. Clinical trials attempting to determine the optimal diet suffer from small sample sizes, short follow-up, and poor follow-up of participants. Therefore, the optimal balance between the total fat and carbohydrate contents and the optimal types of fats and carbohydrates remain unknown.

The nutrition recommendations of 6 major scientific organizations (the American Diabetes Association, the Diabetes and Nutrition Study Group of the European Association for the Study of Diabetes, the Canadian Diabetes Association, the Joslin Diabetes Center and Joslin Clinic, the American Association of Clinical Endocrinologists and Diabetes UK) are reviewed. They all agree that weight loss (with reduction in energy intake and increase in physical activity) is an important therapeutic strategy in all overweight/obese individuals who have or are at risk of type-2 diabetes. Very low carbohydrate diets are not considered appropriate. The recommended proportion varies slightly (from 40 to 65%). The concept of the glycemic index is stressed as important in nearly all guidelines. Fiber intake is advised, up to 50 g/day, if tolerated. Protein intake (for normal kidney function) is advised to range from 10 to 20% of total energy. A low fat diet (<30-35%) is recommended by all. Saturated fat and trans-fatty acids should be restricted to <10% and dietary cholesterol to <300 mg/day. Monounsaturated fatty acids are generally considered beneficial and should replace saturated fat or carbohydrates in low-fat diets. Polyunsaturated fatty acids (PUFAs) should comprise about 10%, with the n-3 PUFAs being more beneficial, especially for high triglyceride levels. Alcohol intake has cardioprotective effects when used in moderation. Routine supplementation of the diet with antioxidants and vitamins is not necessary.