Nutrition in Clinical Practice最新文献

Background: Enteral nutrition (EN) is the preferred method of nutrition support for critically ill patients, but its continuation during nonclinically important nonvariceal upper gastrointestinal bleeding (NVUGIB) remains controversial.

Methods: This retrospective cohort study was conducted in patients in an intensive care unit (ICU) who developed nonclinically important NVUGIB while receiving EN. Patients were categorized into two groups: continued EN group and suspended EN group after the bleeding episode. The primary outcome was progression to clinically important GIB. Secondary outcomes included mortality and being mechanical ventilation free at 28 days. Propensity score matching (PSM) was performed to account for potential confounding variables.

Results: Among 590 eligible patients, 400 (67.8%) continued EN and 190 (32.2%) had EN suspended. Progression to clinically important GIB was similar between groups (6.0% vs 6.3%, P = 0.88), a finding confirmed after PSM (7.3% vs 7.3%, P > 0.99). Patients continuing EN had more ventilation-free days (9 vs 6 days, P < 0.001; matched: 10 vs 6 days, P = 0.005). Unmatched analysis showed higher in-hospital mortality in the suspension group (45.5% vs 54.7%, P = 0.036), but this was nonsignificant post-PSM (53.3% vs 46.7%, P = 0.12). Continuation of EN was not found to be significantly associated with clinically important GIB (odds ratio = 1.913, P = 0.30).

Conclusion: Continuing EN in critically ill patients with nonclinically important NVUGIB appears to be safe and may be associated with a reduced duration of mechanical ventilation. These findings suggest that EN can be safely continued in patients with nonclinically important NVUGIB, potentially offering benefits in terms of respiratory outcomes and nutrition support.

Human milk is the optimal source of nutrition for infants; when mother's own milk (MOM) is unavailable, pasteurized donor human milk (DHM) is the preferred feeding alternative. DHM does not confer the same benefits as MOM, but as a human milk substrate, it remains distinctly unique from infant formulas. Although the evidence for DHM use is strong for high-risk preterm infants, especially very low birth weight infants, DHM's superiority over infant formula in improving clinical outcomes is less clear for other infant populations. Regardless, for some institutions, DHM use has been inconsistently extended to infants with congenital heart disease, gastrointestinal anomalies, neonatal opioid withdrawal syndrome, and other term or moderate and late preterm infants. Here, we describe the potential benefits and limitations to the expanded use of DHM as well as controversies related to access to DHM, including regulatory, financial, logistical, and distribution barriers.

Background: In individuals with cystic fibrosis (CF), lean mass and muscle strength are important predictors of clinical outcomes. This study evaluated associations among body composition, handgrip strength, muscle quality, physical activity, and health-related quality of life in CF.

Methods: This observational, cross-sectional study included 27 adults with CF and 24 age-matched healthy controls. Body composition was assessed using dual-energy x-ray absorptiometry, physical activity by self-reported questionnaire, strength by handgrip dynamometry, and quality of life by the CF Quality of Life-Revised (CFQ-R) questionnaire. Muscle quality was defined as handgrip strength divided by appendicular lean mass. Analyses included t- tests and Pearson or Spearman correlations.

Results: Demographics, body composition, handgrip strength, and muscle quality were similar between those with CF and controls. Among those with CF, muscle quality was positively associated with total physical activity score (r = 0.49, P = 0.009). Handgrip strength was positively associated with lean mass (r = 0.86, P < 0.001) and bone mineral density (r = 0.64, P < 0.001). Regarding CFQ-R, lean mass was positively associated with body image and emotion (r = 0.41, P = 0.03), and body fat was associated with lower physical functioning (r = -0.63, P = 0.004), greater treatment burdens (r = -0.49, P = 0.01), and worse digestive health (r = -0.45, P = 0.02).

Conclusion: As the CF population ages, these data support continued efforts to promote physical activity and improve body composition for enhanced quality of life while also highlighting the value of integrating accessible measures of muscle function and quality into routine clinical care.

Background: This study examined the overlap of sarcopenic obesity and malnutrition using the 2025 Global Leadership Initiative on Malnutrition (GLIM) criteria and their impact on geriatric outcomes.

Methods: In this cross-sectional study, 264 geriatric outpatients (body mass index [BMI] ≥ 25 kg/m²) were assessed. Sarcopenia and sarcopenic obesity were diagnosed using the European Working Group on Sarcopenia in Older People 2 and the European Society for Clinical Nutrition and Metabolism (ESPEN) and The European Association for the Study of Obesity (EASO) consensus definitions. Malnutrition was diagnosed using the GLIM criteria, applied regardless of their Mini Nutritional Assessment Short Form (MNA-SF) results to detect overlooked cases. Outcomes included frailty, disability, incontinence, and falls.

Results: Sarcopenic obesity prevalence was 15.9%, and GLIM-defined malnutrition was 30.3%. More than half (58.8%) of patients with GLIM-defined malnutrition were not at risk per the MNA-SF. In patients without MNA-defined malnutrition risk, GLIM malnutrition was more frequent in patients with sarcopenic obesity than without (42.9% vs 18.7%, P = 0.002). The co-occurrence of sarcopenic obesity and GLIM-defined malnutrition showed a synergistic effect on frailty (odds ratio [OR] = 5.11) and Instrumental Activities of Daily Living disability (OR = 3.74), independent of age and comorbidity.

Conclusion: Standard tools like the MNA-SF markedly underdetect malnutrition in older adults with BMI ≥ 25 kg/m², including those with sarcopenic obesity. Because GLIM's two-step process depends on initial screening, many patients at risk may not proceed to full GLIM assessment. Our findings demonstrate that GLIM, supported by body composition analysis, more accurately identifies malnutrition and highlights the added harm of coexisting sarcopenic obesity.

Background: Heart failure (HF) affects millions of persons worldwide, with malnutrition and sarcopenia as prevalent complications. Both are characterized by low muscle mass (MM), which can be estimated using Body mass index (BMI)-adjusted calf circumference (CC). Although CC is a simple and practical surrogate for MM, it is not routinely included in standard nutrition screening tools, despite recommendations from the Global Leadership Initiative on Malnutrition. In patients with HF, low MM has been linked to elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, a marker of cardiac stress. Including CC in nutrition screening may improve detection of malnourished patients. This study aimed to assess the association between BMI-adjusted CC and NT-proBNP levels in hospitalized patients with HF.

Methods: This retrospectively conducted cross-sectional study included 202 patients with HF across different ejection fraction categories. Data on demographics, anthropometry, and biochemical markers were collected. The association between BMI-adjusted CC and NT-proBNP were analyzed using Spearman correlation and multivariate linear regression.

Results: Low BMI-adjusted CC was prevalent in 74.8% of patients, with higher NT-proBNP levels compared with those with normal CC (11,970 vs 5621 pg/ml, P < 0.001). BMI-adjusted CC was inversely associated with NT-proBNP concentrations (β = -927, 95% CI: -1543 to -311) after adjusting for confounders.

Conclusion: A high prevalence of low MM was detected in patients with HF. Low BMI-adjusted CC is associated with elevated NT-proBNP, highlighting the link between muscle depletion and cardiac stress. Incorporating BMI-adjusted CC into nutrition assessment may improve the identification of malnutrition in patients with HF and enable more targeted nutrition risk stratification and intervention strategies.

Background: Muscle mass is a strong predictor of clinical outcomes. However, its continuous monitoring is not always feasible in critically ill patients. Surrogate methods, such as bioelectrical impedance analysis (BIA), may be affected by overhydration (OH). The aim of this study was to evaluate the agreement of BIA-derived fat-free mass (FFM) adjusted for hydration status in comparison with muscle mass assessed by computed tomography (CT) in critically ill patients with pneumonia due to COVID 19.

Methods: This secondary analysis includes patients with a CT scan of the third lumbar vertebra (L3) and a BIA performed within the first 24 to 48 h of hospital admission. FFM and hydration status were estimated using BIA (FFM_BIA), and then adjusted to OH (FFM_OH). Images from the skeletal muscle area obtained from L3 were used to calculate the FFM derived from CT (FFM_CT). The concordance between FFM derived from CT and BIA was analyzed using Bland-Altman and Student t test.

Results: Seventy-four patients were included. FFM_BIA overestimated compared with CT (54.6 ± 10.3 kg vs 47.4 ± 10.9 kg) with a mean difference of 7.2 kg (limits of agreement, -5.1 to 19.5; P < 0.01). Overestimation decreased by FFM_OH, with a mean difference of 3.5 kg (limits of agreement, -9.6 to 16.8; P = 0.06).

Conclusion: FFM_OH assessed by BIA shows a better agreement with FFM_CT in comparison with FFM_BIA.

Background: Children with spinal muscular atrophy (SMA) do not follow standard anthropometric growth trajectories; disease-specific curves were published in 2021. Our aim was to apply these in SMA children comparing their growth and body composition longitudinally, relative to the World Health Organization (WHO) standard.

Methods: This was a retrospective cohort of 19 SMA pediatric patients in a long-stay hospital with monthly anthropometric measurements from admission to discharge. We calculated body mass index) and length‑for‑age z scores (BMIz and LAzs) using WHO and SMA‑specific curves. Triceps skinfold and mid-upper arm circumference z scores (TSFz and MUACz) used WHO reference.

Results: Participants had a median age of 9 (IQR, 7-14) months, followed up for 19 months (IQR, 6.5-32). At admission, BMIz was -1.31 ± 0.66 by WHO and 0.77 ± 0.50 by SMA curves (P < 0.01). According to WHO, 11 (57.9%) were malnourished, 8 (42.1%), eutrophic, and 0 overweight, but with SMA curves the comparable values were 2 (10.5%), 9 (47.4%), and 8 (42.1%), respectively. MUACz was -0.3 ± 0.7 and TSFz 2.01 ± 0.84. TSFz correlated better with BMIz based on SMA (R² = 0.46) than with WHO curves (R² = 0.27). Over time, BMIz remained stable, HAz rose slightly by both curves, MUACz showed a declining trend, and TSFz increased 0.38 annually (R² = 0.34; 95% CI, 0.11-0.63; P = 0.006).

Conclusion: SMA‑specific growth curves assess better the nutrition status in children with SMA compared with WHO standards, aligning more closely with body composition. The cohort demonstrated increased fat accretion, normal length growth, and stable BMI over time.

Background: Diagnosing malnutrition in patients with pediatric cancer is challenging because tumor masses can interfere with anthropometric measurements. STRONGkids considers cancer a general risk factor, whereas Screening Tool for Childhood Cancer (SCAN) classifies patients as at risk or not, potentially missing those who need nutrition monitoring. This study describes development and validation of a new nutrition risk screening tool for childhood cancer in Brazil.

Methods: Nutrition Risk Screening for Childhood Cancer (NUTRICCAN) underwent online expert content validation. Twelve nutritionists applied it to oncology inpatients (0-19 years old) at the Pediatric Oncology Institute at Federal University of São Paulo from June to August 2024. Nutrition risk was assessed using NUTRICCAN, STRONGkids, and SCAN. Logistic regression identified screening variables associated with malnutrition (body mass index-for-age z score < -2, mid-upper arm circumference [MUAC] <5^th percentile, calf circumference below cutoff, or met any of the criteria for malnutrition). Receiver operating characteristic analysis determined cutoff scores, and sensitivity/specificity analyses allowed comparisons among instruments.

Results: Patients not receiving intensive care were almost three times more likely to have an inadequate MUAC (odds ratio [OR], 4.505; 95% confidence interval [CI], 1.446-14.033; P = 0.009). Low socioeconomic status or caregiver education increased the risk of malnutrition (OR, 2.845; 95% CI, 1.070-7.566; P = 0.036). Dietitians' subjective assessments were associated with a fourfold increased risk of malnutrition. NUTRICCAN was 70% accurate (area under the curve, 0.701; 95% CI, 0.617-0.785), outperforming the other tools.

Conclusion: NUTRICCAN better stratifies nutritional risk, considering clinical and socioeconomic factors, and may allow for more targeted interventions, especially in resource-limited settings.

Background: Evidence-based guidelines (EBGs) in the nutrition management of advanced liver disease and enhanced recovery after surgery recommendations state that normal diet should recommence 12-24 h following liver transplantation. This study aimed to compare postoperative nutrition practices to guideline recommendations, explore clinician perceptions regarding feeding after transplant surgery, and implement and evaluate strategies to improve postoperative nutrition practices.

Methods: A pre-post multimethod implementation study was undertaken, guided by the knowledge-to-action framework. A retrospective chart audit of postoperative dietary practice and semistructured interviews with clinicians were undertaken. Implementation strategies were informed by the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change matching tool and then evaluated.

Results: An evidence-practice gap was identified, with the median day to initiation of nutrition (free-fluid or full diet) on postoperative day (POD) 2 and only 25% of patients aligning with the EBGs. Clinician interviews identified belief in the importance of nutrition, with variation in surgical practice in relation to early nutrition, competing clinical priorities, and vulnerabilities in communication contributing to delays in returning to feeding. An endorsed postoperative nutrition protocol was implemented along with a suite of theory- and stakeholder-informed intervention strategies. Following implementation, the median time to initiate nutrition reduced to POD1 and alignment with EBGs improved to 60%.

Conclusion: This study used implementation frameworks and strategies to understand, implement, and improve early feeding practices in line with EBGs after liver transplant. Ongoing sustainability of practice change as well as the impact on clinical outcomes have yet to be determined.

Parenteral nutrition (PN) is a life-sustaining therapy for patients unable to meet nutrition needs via enteral routes, but its use presents significant ethical complexity. This narrative review provides clinicians with a practical, principle-based framework to navigate the ethical dilemmas inherent in PN across diverse clinical contexts. Grounded in the four pillars of medical ethics-autonomy, beneficence, nonmaleficence, and justice-the review explores decision-making challenges in vulnerable populations, long-term PN, and end-of-life care. Clinically relevant scenarios are examined, including initiation or withdrawal of PN in terminal illness, informed consent in cognitively impaired patients, and balancing parental wishes with a child's best interests in pediatric care. The ethical tension between prolonging life and enhancing quality of life is critically appraised, particularly in oncology and palliative settings. The review also addresses disparities in PN access and resource allocation, with actionable insights for clinicians practicing in low-resource settings. Key take-home strategies include using structured ethical frameworks such as the Four-Quadrant and Shared Decision-Making models, involving ethics committees in complex cases, and prioritizing transparent, compassionate communication. Clinicians are encouraged to consider both the clinical utility and psychosocial burden of PN, and to integrate multidisciplinary perspectives into care planning. Ultimately, this review underscores the need for ethically attuned, patient-centered PN decisions that align with individual goals, values, and context. It provides structured guidance to assist nutrition support teams in translating ethical principles into clinical practice, thereby ensuring that PN is administered judiciously, safely, and in accordance with the patient's best interests.