Nutrition in Clinical Practice最新文献

Suboptimal nutrition provision has been observed during and after the intensive care unit (ICU) stay. Reasons for suboptimal nutrition provision are due to various barriers to intake found across hospitalization and after discharge home. The aim of this narrative review is to provide an overview of the nutrition challenges faced by patients after ICU discharge and in the home, as well as provide suggestions to promote recovery for survivors. Key areas to consider include the role of the patient, caregiver and clinician education, nutrition impact symptoms, the role of communication, and the use of multimodal interventions. Nutrition interventions may be of greatest benefit with longer-term optimization, identifying strategies to overcome barriers and the importance of transition periods as well as a clear follow-up plan.

Background: Pancreatic enzyme insufficiency (PEI) contributes to symptom burden and malnutrition in advanced pancreatic cancer (aPC). We aimed to evaluate the impact of pancreatic enzyme replacement therapy (PERT) on symptom burden and weight during chemotherapy.

Methods: Patients with aPC who were referred to a dietitian for suspected PEI at the Cross Cancer Institute (Edmonton, Canada) were enrolled. Baseline (BL) PEI symptoms were evaluated prior to PERT initiation; dose was optimized by 1 month. PEI symptom severity was assessed with the Pancreatic Enzyme Insufficiency Questionnaire (PEI-Q) at BL, reassessed after 1 and 3 months, and compared between BL and first reassessment. Mean weight change from BL to 1 month (percentage per 30 days) was compared with change from 1 to 3 months. Continuous and categorical variables were compared using paired samples t tests and McNemar test, respectively.

Results: Of 29 patients enrolled, 23 initiated PERT and completed ≥1 symptom reassessment. Median reported PERT dose at reassessment was 200,000 USP lipase units/day (IQR 97,200, 300,000). Improvements in mean severity scores for stomach pain (P = 0.001) bloating (P = 0.049) and stomach noises (P = 0.032) were reported at reassessment, with a trend toward improved appetite (P = 0.053). Prevalence of moderate/severe PEI decreased (11/23 vs 4/23, P = 0.020). Weight loss slowed after 1 month (-4.3 ± 4.8%/30 days [BL to 1 month] vs -0.2 ± 3.9%/30 days, P = 0.033).

Conclusion: Patients receiving dietitian-directed PERT showed improved abdominal symptoms and attenuated weight loss after dose optimization, addressing a patient priority for those with aPC.

Background: Low-carbohydrate diets (LCDs) are widely adopted for metabolic management, but their long-term cardiometabolic effects in diverse populations remain unclear. We aimed to evaluate the association between self-selected moderate LCD adherence and cardiometabolic parameters in individuals with and without diabetes.

Methods: This prospective cohort study included 9658 participants from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil; baseline: 2008-2010; follow-up: 2017-2019). LCD adherence (carbohydrate <45% of total energy) was assessed through validated food frequency questionnaires. Quantile regression models, adjusted for sociodemographic, lifestyle, and clinical factors, were used to analyze changes in body mass index (BMI), blood pressure, insulin, and homeostatic model assessment for insulin resistance (HOMA-IR) and beta cell function (HOMA-B).

Results: Among individuals without diabetes, those who followed an LCD only at the follow-up showed decreased insulin levels (β = -0.33 [95% CI, -0.6 to -0.1] μIU/ml), HOMA-IR (-0.11 [-0.2 to -0.1] μIU/ml), and HOMA-B (-4.95 [-7.2 to -2.1] μIU/ml) alongside modest BMI increases (0.16 [0.1-0.3]). Consistent LCD adherents (at both time points) showed a decrease in HOMA-B (-3.21 [-6.4 to -0.1] μIU/ml) and an increase in BMI (0.29 [0.2-0.4]). In individuals with diabetes, LCD adherence led to reduced HOMA-IR (-1.25 [-2.2 to -0.3] μIU/ml) and insulin levels (-3.61 [-6.0 to -1.2] μIU/ml).

Conclusion: Moderate LCD adherence improved insulin sensitivity and reduced pancreatic demand in individuals without diabetes. Despite slight BMI increases, LCD may be a feasible dietary strategy for metabolic risk management in middle-aged and older adults. Personalized nutrition approaches are recommended to optimize outcomes.

Background: Obesity increases the risks and complexity of laparoscopic surgeries. Preoperative very low-calorie diets (VLCDs) can demonstrate significant preoperative weight loss. However, the optimal VLCD duration remains unclear. Excessive loss of muscle mass associated with VLCDs may elevate surgical and postoperative risks. This study aimed to assess the impact of a dietitian-led preoperative VLCD intervention on changes in weight, muscle, and fat mass and to examine their relationships with intervention duration and surgical time.

Methods: A retrospective chart review of patients attending a dietitian-led VLCD outpatient clinic for 1-8 weeks. Primary outcomes were changes in weight, muscle and fat mass, and their relationships with VLCD duration. Associations between preoperative fat mass and operative time for cholecystectomies and hernia repairs were explored using a general linear model.

Results: One hundred fifty-seven participants (97 female; mean body mass index, 39.2) achieved significant weight reduction (6.4 kg, P < 0.001). Muscle mass accounted for 28.5% of mean weight loss and fat mass for 68%, with an increased muscle to fat ratio (P < 0.001). VLCDs of >4 weeks showed greater median muscle mass loss (26.9% vs 8.8%). Operative time decreased by an estimated 0.61 min for every kilogram reduction in preoperative fat mass, after adjusting for surgical type (P < 0.001, adjusted R² = 0.262).

Conclusions: A dietitian-led preoperative VLCD intervention for 5-8 weeks can achieve clinically significant weight loss, primarily from fat mass. Exploratory analysis suggested lower preoperative fat mass may contribute to shorter surgical time, but further research is needed to control for other factors, such as complexity and surgeon experience.

Background: The triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio is a well-known marker of cardiometabolic risk and insulin resistance and has been linked to metabolic diseases and sarcopenia in older adults, yet its association with frailty remains underexplored. Given the association of frailty with these conditions, our study aims to explore the previously unexamined link between TG/HDL-C and frailty.

Methods: This cross-sectional study analyzed 520 patients aged ≥65 years who underwent comprehensive geriatric assessments. Frailty was defined using the Fried Frailty Phenotype. Associations between TG/HDL-C and frailty were evaluated using multivariate logistic regression with adjustments for confounding variables.

Results: The mean age of the participants was 75.2 ± 6.4, with 62.1% (n = 323) being women and 20.2% (n = 105) classified as frail. Frail patients exhibited a higher TG/HDL-C ratio than the nonfrail group (P = 0.001). When the relationship between fat measurements and frailty was analyzed separately for men and women, the TG/HDL-C ratio was significantly higher in the frail group for both male and female patients (P < 0.05). Multivariate logistic regression analysis revealed that the TG/HDL-C ratio was significantly and independently associated with frailty even after adjusting for potential confounding factors (β = 1.30, 95% CI = 1.11-1.51, P = 0.001). The optimal TG/HDL-C cutoff for frailty was >2.82 (area under the curve = 0.608; negative predictive value = 89.7%).

Conclusion: TG/HDL-C is significantly associated with frailty in older adults. Further research is needed to explore causal relationships and clinical implications.

Background: Body composition and energy metabolism assessments are central to nutrition care but remain underused. This study evaluated dietitians' access, use, education, and beliefs toward these assessments, and the impact of an educational session.

Methods: Dietitians (≥1 year experience) within Alberta Health Services completed online surveys on their access, use, education, confidence, and clinical protocol awareness regarding body composition and energy metabolism assessments. Participants attended a 4-h virtual educational session on these topics, with presession and postsession knowledge recall compared using Wilcoxon signed rank test.

Results: We surveyed 36 participants (97% women), primarily from inpatient care (36%) or oncology (31%). Most (86%) never used body composition methods, despite access to computerized tomography (CT; 31%), ultrasound (US; 25%), bioelectrical impedance analysis (BIA; 6%), and dual-energy x-ray absorptiometry (DXA; 3%). Although 67% received body composition education (47% BIA, 31% DXA, 22% CT, 8% US), 64% lacked confidence. Protocol awareness was 67% for malnutrition and 8% for sarcopenia. Most never (58%) or occasionally (19%) used energy metabolism methods; Q-NRG (COSMED; 28%) and standard metabolic carts (19%) were the most available devices. Although 67% received energy metabolism education (53% metabolic cart, 31% Q-NRG), 50% were not confident in using these methods. After the educational session, body composition knowledge recall improved (median, +20% [IQR, 10-30]; P < 0.001), whereas energy metabolism scores were unchanged (P = 0.530).

Conclusion: Despite prior education, dietitians used body composition and energy metabolism assessments inconsistently because of limited access, insufficient applied knowledge, lack of protocols, and low confidence. These results underscore the need to strengthen curriculum and professional development to support adoption.

Background: The aim of this study was to explore whether skeletal bone age (biological maturation marker) and sex moderate the association between the phase angle with muscular strength and aerobic fitness in children and adolescents with diagnosed with HIV.

Methods: The sample consisted of 62 children and adolescents (aged 8-15 years) diagnosed with HIV. The phase angle was determined using bioelectrical impedance analysis. Muscular strength was assessed by handgrip strength, and aerobic fitness was assessed by an incremental test on a cycle ergometer. Skeletal bone age and sex were determined through hand and wrist x-rays (Greulich-Pyle method) and a questionnaire, respectively. Both simple and multiple linear regression models were performed, and moderation models with P ≥ 0.05 were constructed.

Results: Among male children and adolescents with both normal and early skeletal bone age, muscular strength directly impacted phase angle values (b = 0.0197, P = 0.0001; b = 0.0286, P < 0.0001, respectively). However, for female children and adolescents, regardless of skeletal bone age, muscular strength did not influence the phase angle. In male children and adolescents with both normal and early skeletal bone age, aerobic fitness directly influenced the phase angle (b = 0.0007, P = 0.0001; b = 0.011, P = 0.0001, respectively). Similarly, in female children and adolescents with early skeletal bone age, aerobic fitness directly impacted the phase angle (b = 0.0006, P = 0.0282).

Conclusion: Skeletal bone age and sex moderated the relationship between phase angle and both muscular strength and aerobic fitness, especially in children and adolescents with normal and early skeletal bone age, and predominantly in boys.

Background: Although calf circumference (CC) may be used to distinguish body composition, methods applying adjustment coefficients based on body mass index (BMI) and edema have been reported. This study evaluated whether malnutrition assessed using BMI- and edema-adjusted CC predicts mortality in hospitalized adult patients compared with unadjusted CC across cutoff values.

Methods: This retrospective cohort study used the medical records of patients aged ≥18 years hospitalized between December 2017 and March 2022 and at risk for nutrition disorders through nutrition screening. Low muscle mass was defined using CC cutoff values of 34-30 cm for men and 33-29 cm for women.

Results: The data of 11,606 patients were analyzed. The mean age was 71.2 ± 16.3 years, and 5949 patients (51.3%) were women. No significant difference was observed compared with the unadjusted state, regardless of sex, cutoff value, or adjustment method (male: unadjusted hazard ratio [HR]: 2.13 to 2.30 vs adjusted HR: 2.11 to 2.36; memale: unadjusted HR 1.75: to 2.59 vs adjusted HR: 1.75 to 3.00). Furthermore, even when edema was adjusted, no significant difference was observed in the HR for mortality compared with the unadjusted state, regardless of sex, cutoff value, or adjustment method (male: unadjusted HR: 2.13 to 2.30 vs adjusted HR: 2.23 to 2.52; female: unadjusted HR: 1.75 to 2.59 vs adjusted HR: 2.02 to 3.57).

Conclusion: When assessing low muscle mass using lower CC, we found that adjusting for BMI and edema did not result in a significant mortality difference compared with unadjusted actual measurements.

Background: The prognostic value of nutrition status assessed by the Patient-Generated Subjective Global Assessment (PG-SGA) in postoperative patients with recurrent or metastatic (R/M) cancer remains unclear. This study assessed whether combining PG-SGA-defined malnutrition with systemic inflammation indices improves mortality prediction accuracy.

Methods: Nutrition status was evaluated via PG-SGA, with systemic inflammation assessed by systemic immune-related inflammation index (SII), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and monocyte to lymphocyte ratio (MLR). Kaplan-Meier and Cox regression analyses examined associations （individual/combined) of PG-SGA-defined malnutrition and systemic inflammation with all-cause mortality. Receiver operating characteristic curves and concordance index (C index) evaluated accuracy.

Results: Among 537 postoperative patients with R/M cancer, multivariable Cox regression analysis showed malnutrition significantly increased mortality risk (malnourished: hazard ratio [HR] = 1.82 [95% CI, 1.23-2.72; P < 0.001]; severely malnourished: HR = 2.46 [95% CI, 1.67-3.62; P < 0.001]). In joint analysis, severely malnourished patients with high systemic inflammation burden had the highest overall mortality risks. The C index was 0.626 for PG-SGA-SII, 0.630 for PG-SGA-NLR, 0.618 for PG-SGA-PLR, and 0.630 for PG-SGA-MLR. Subgroup analyses revealed amplified composite risks in women, older adults, and those with chemotherapy history.

Conclusion: This study highlights the synergistic prognostic impact of PG-SGA-assessed malnutrition and systemic inflammation in postoperative R/M cancer, identifying a high-risk subgroup requiring prioritized nutrition and immunomodulatory interventions. Prospective multi-center validition is warranted.

Background: Several publications demonstrate the impact of home parenteral nutrition (HPN) in reducing healthcare costs. The question is are HPN practices in Latin America also cost saving when compared with hospital PN? This study aimed to compare the direct healthcare and nonhealthcare costs of HPN with hospital PN through a prospective, analytical, and longitudinal, multicenter noninterventional study.

Materials and methods: Adult patients receiving PN were included during the last week of hospital PN (week -1 before discharge), through the first week of HPN (week +1), and up to the first month of HPN (month +1). Clinical, nutrition, and cost variables were recorded. The total direct cost from hospital PN week -1 was compared with HPN week +1. Additionally, HPN month +1 was compared with an estimate of the total costs of hospital PN month -1.

Results: Forty-four patients were included for analysis. Comparing HPN week +1 vs hospital PN week -1. HPN was associated with lower total direct healthcare costs (mean difference -$1498.1, 95% CI -1203.2 to -1789.9). Lastly, the total direct cost (healthcare and nonhealthcare) was lower in the HPN setting vs the hospital setting for 1 week (mean difference $ -1452.0, 95% CI -1756.28 to -1148.4). The cost reduction of HPN for 1 week was 32% (20.3%-42.8%) and for 1 month was 36% (27.5%-48.5%).

Conclusion: HPN is cost saving compared with hospital PN, with most of the cost reduction related to direct healthcare costs.