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The 2019 ESPEN Arvid Wretlind lecture perioperative nutritional and metabolic care: Patient-tailored or organ-specific approach?
Gianotti, L, Sandini, M
Clinical nutrition (Edinburgh, Scotland). 2020;(8):2347-2357
Abstract
BACKGROUND & AIM: The perioperative severe changes in the nutritional and metabolic homeostasis are, by some means, proportional to the extent of tissue injury and magnitude of operative trauma. An adequate qualitative and quantitative replacement of nutritional substrates are of utmost importance to facilitate proper tissue healing and recovery and maintenance of organ function after surgery. METHODS The present manuscript has been planned to put the most recent research of the Milano-Bicocca University surgical working group in the context of a more personalized nutritional therapy and metabolic care for surgical patients. Particular prominence has been given to major pancreatic resections because these surgeries are among the most complex and challenging operations for the degree of parenchyma resection and tissue dissection, the consequent overall injury, and the fairly high rate of major complications resulting in a catabolic response. RESULTS Anthropometric parameters and particularly sarcopenia, visceral obesity - and their relative proportion -, are strongly associated with poor outcome after pancreatic surgery. Adequate perioperative nutritional therapy is of utmost importance in affecting morbidity. Long-term nutritional and metabolic sequelae, caused by exocrine pancreatic insufficiency, need to be promptly recognized and treated with an adequate enzyme supplementation. CONCLUSIONS There is strong evidence sustaining the necessity of proper perioperative metabolic and nutritional care into the management of patients undergoing major pancreatic surgery.
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Nutrition in Cancer Therapy in the Elderly-An Epigenetic Connection?
Blasiak, J, Chojnacki, J, Pawlowska, E, Szczepanska, J, Chojnacki, C
Nutrients. 2020;(11)
Abstract
The continuous increase in life expectancy results in a steady increase of cancer risk, which consequently increases the population of older adults with cancer. Older adults have their age-related nutritional needs and often suffer from comorbidities that may affect cancer therapy. They frequently are malnourished and present advanced-stage cancer. Therefore, this group of patients requires a special multidisciplinary approach to optimize their therapy and increase quality of life impaired by aging, cancer, and the side effects of therapy. Evaluation strategies, taking advantage of comprehensive geriatric assessment tools, including the comprehensive geriatric assessment (CGA), can help individualize treatment. As epigenetics, an emerging element of the regulation of gene expression, is involved in both aging and cancer and the epigenetic profile can be modulated by the diet, it seems to be a candidate to assist with planning a nutritional intervention in elderly populations with cancer. In this review, we present problems associated with the diet and nutrition in the elderly undergoing active cancer therapy and provide some information on epigenetic aspects of aging and cancer transformation. Nutritional interventions modulating the epigenetic profile, including caloric restriction and basal diet with modifications (elimination diet, supplementary diet) are discussed as the ways to improve the efficacy of cancer therapy and maintain the quality of life of older adults with cancer.
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Acute Hepatic Failure and Nutrition.
Kappus, MR
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2020;(1):30-35
Abstract
Malnutrition is prevalent in patients with hepatic failure and remains an independent risk factor for morbidity and mortality in these patients. Factors that contribute to malnutrition in this patient population include altered metabolic rate, fat malabsorption, and impaired gastric emptying, all in the setting of an acute and potentially prolonged hospitalization. Acute liver failure (ALF), different from cirrhosis or chronic liver disease, is an uncommon but dramatic clinical syndrome that demonstrates severe and rapid decline in hepatic metabolic function. ALF has a significant risk of mortality. There are >10 cases per million persons per year in developed countries, but ALF presents with unique challenges in clinical management related to heterogeneity in severity and etiology. Patients with ALF by definition should not have a prior history of liver disease, and liver disease is subsequently defined by the onset of liver injury, the presence of hepatic encephalopathy (HE), and coagulopathy as defined by an international normalized ratio > 1.5. HE usually develops within 1-4 weeks of the onset of liver injury but may occur within 26 weeks of the initial presentation. Rates of survival from ALF have improved over recent years, but the rarity and severity of presentation have resulted in traditionally limited evidence to guide basic supportive care. Over time, advances in critical care management and the use of emergency liver transplantation have improved. In this article, we will review current nutrition considerations for patients with ALF.
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A Review of Nutrition Support Guidelines for Individuals with or Recovering from COVID-19 in the Community.
Cawood, AL, Walters, ER, Smith, TR, Sipaul, RH, Stratton, RJ
Nutrients. 2020;(11)
Abstract
COVID-19 negatively impacts nutritional status and as such identification of nutritional risk and consideration of the need for nutrition support should be fundamental in this patient group. In recent months, clinical nutrition professional organisations across the world have published nutrition support recommendations for health care professionals. This review summarises key themes of those publications linked to nutrition support of adults with or recovering from COVID-19 outside of hospital. Using our search criteria, 15 publications were identified from electronic databases and websites of clinical nutrition professional organisations, worldwide up to 19th June 2020. The key themes across these publications included the importance in the community setting of: (i) screening for malnutrition, which can be achieved by remote consultation; (ii) care plans with appropriate nutrition support, which may include food based strategies, oral nutritional supplements and referral to a dietitian; (iii) continuity of nutritional care between settings including rapid communication at discharge of malnutrition risk and requirements for ongoing nutrition support. These themes, and indeed the importance of nutritional care, are fundamental and should be integrated into pathways for the rehabilitation of patients recovering from COVID-19.
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Effect of a double nutritional intervention on the nutritional status, functional capacity, and quality of life of patients with chronic heart failure: 12-month results from a randomized clinical trial.
Guerra-Sánchez, L, Fresno-Flores, M, Martínez-Rincón, C
Nutricion hospitalaria. 2020;(3):422-431
Abstract
Introduction: malnutrition is commonly associated with, and worsens the prognosis of heart failure. The management of chronic heart failure and its complications based only on the application of pharmacologic guidelines is incomplete. The benefits of interventions to improve nutritional status may be limited by the multifactorial nature of malnutrition. The objective of the present study was to determine whether nutritional advice and nutritional supplementation can improve the nutritional status of patients with chronic heart failure. Methods: we performed a randomized clinical trial on an intention-to-treat basis with blinded observers. We divided a sample of 76 patients into 2 groups: one that received structured advice combined with nutritional supplements for 12 weeks (test group), and one that received treatment as usual (control group). The outcome measure was nutritional status as evaluated using the Subjective Global Assessment and the Mini Nutritional Assessment tools. After 12 weeks of treatment the test group received a leaflet that served as a reminder. No further interventions were applied in either group. Patients were followed for 1 year. Results: at 3 months of follow-up nutritional status improved 4-fold in the test group, whereas no change was observed in the control group. At 9 months nutritional status in the intervention group had improved 2-fold with respect to the baseline visit, whereas no differences were recorded in the control group. Differences in mortality and length of stay at 1 year did not reach statistical significance.
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Nutritional Status in Peritoneal Dialysis: Nutritional Guidelines, Adequacy and the Management of Malnutrition.
Kiebalo, T, Holotka, J, Habura, I, Pawlaczyk, K
Nutrients. 2020;(6)
Abstract
The positive impact of nutritional status on the health and treatment adequacy of peritoneal dialyzed patients has been well established. Protein intake is an important factor used to stratify malnutrition, with inadequate intake leading to protein-energy wasting during the course of therapy. In this review, we discuss the recommendations made by nephrological societies regarding nutrition in this population of dialysis patients. Special attention is given to the intake of protein, and recommendations on the intake of micronutrients are also discussed. Furthermore, factors that may impair nutritional intake and balance are discussed, with mention of the innovative strategies utilized to combat them. In light of inconsistent recommendations that vary between each respective society, as well as a general lack of concise information, it is our intention to call for further research regarding nutritional recommendations in peritoneal dialysis (PD), as well as to advocate for clear and accessible information for patients.
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The significant role of carnitine and fatty acids during pregnancy, lactation and perinatal period. Nutritional support in specific groups of pregnant women.
Manta-Vogli, PD, Schulpis, KH, Dotsikas, Y, Loukas, YL
Clinical nutrition (Edinburgh, Scotland). 2020;(8):2337-2346
Abstract
BACKGROUND & AIMS Pregnancy is characterized by a complexity of metabolic processes that may impact fetal health and development. Women's nutrition during pregnancy and lactation is considered important for both mother and infant. This review aims to investigate the significant role of fatty acids and carnitine during pregnancy and lactation in specific groups of pregnant and lactating women. METHODS The literature was reviewed using relevant data bases (e.g. Pubmed, Scopus, Science Direct) and relevant articles were selected to provide information and data for the text and associated Tables. RESULTS Dynamic features especially of plasma carnitine profile during pregnancy and lactation, indicate an extraordinarily active participation of carnitine in the intermediary metabolism both in pregnant woman and in neonate and may also have implications for health and disease later in life. Maternal diets rich in trans and saturated fatty acids can lead to impairments in the metabolism and development of the offspring, whereas the consumption of long chain-polyunsaturated fatty acids during pregnancy plays a beneficial physiologic and metabolic role in the health of offspring. CONCLUSIONS Pregnant women who are underweight, overweight or obese, with gestational diabetes mellitus or diabetes mellitus and those who choose vegan/vegetarian diets or are coming from socially disadvantaged areas, should be nutritionally supported to achieve a higher quality diet during pregnancy and/or lactation.
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Weight Loss after 12 Weeks of Exercise and/or Nutritional Guidance Is Not Obligatory for Induced Changes in Local Fat/Lean Mass Indexes in Adults with Excess of Adiposity.
Ramírez-Vélez, R, Izquierdo, M, Castro-Astudillo, K, Medrano-Mena, C, Monroy-Díaz, AL, Castellanos-Vega, RDP, Triana-Reina, HR, Correa-Rodríguez, M
Nutrients. 2020;(8)
Abstract
The objectives of this secondary analysis are (1) to investigate the differential effects of exercise training modalities-high-intensity interval training (HIIT), resistance training (RT), combined training (CT = HIIT + RT), and/or nutritional guidance (NG) alone-on local fat/lean mass indexes in adults with excess of adiposity; (2) to identify the individual patterns of response based on either a clinical criterion of weight loss (≥5%) and/or technical error (TE) of measurement of local fat/lean mass indexes; and (3) to assess the individual change for body composition parameters assigned either to HIIT, RT, CT, and/or NG groups utilizing a TE. A 12-week trial was conducted in 55 participants randomized to one of the four interventions. The primary outcome was clinical change in body weight (i.e., weight loss of ≥5%). Secondary outcomes included change in ratio of android and gynoid fat mass, as well as local fat and lean mass indexes (arms, trunk, and legs), before and after intervention. The main findings from the current analysis revealed that (i) after 12 weeks of follow-up, significant decreases in several body composition indexes were found including body weight, arm, trunk, and legs fat mass, and android and gynecoid fat mass were observed in HIIT, RT, and CT groups (p < 0.05); (ii) a significant proportion of individuals showed a positive response following 12 weeks of training, led by the HIIT group with 44% and followed by RT with 39% in 9 indexes; (iii) the HIIT group showed lowest rates of adverse responders with (6%); and (iv) the individual patterns of response utilizing clinically meaningful weight loss were not necessarily associated with the corresponding individual training-induced changes in body composition indexes in adults with excess of adiposity. Overall, the study suggests that HIIT has an important ability to reduce the prevalence of non-response to improve body composition indexes.
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Metabolic aspects of muscle wasting during critical illness.
van Gassel, RJJ, Baggerman, MR, van de Poll, MCG
Current opinion in clinical nutrition and metabolic care. 2020;(2):96-101
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Abstract
PURPOSE OF REVIEW Skeletal muscle wasting during critical illness is the result of disturbed metabolism. No proven effective interventions targeting skeletal muscle mass and function during critical illness currently exist. This review summarizes recent advances regarding the complexity of metabolic factors involved and the challenge of establishing the clinical effects of metabolic interventions targeting the muscle. RECENT FINDINGS Although the catabolic state is limited to the acute phase of critical illness, its subsequent impact on muscle mass and function persists long after ICU discharge. Immobilization, inflammation and disturbed muscle energy and nutrient metabolism are key drivers of muscle protein loss. Current research focuses on the effects of enhanced protein provision, specific substrate delivery and physical exercise. Whilst some interventions have been successful at improving muscle mass, these effects do not always carry over into muscle function or strength. SUMMARY Increased understanding of metabolic derangements during critical illness provides new potential targets for treatment. The potential of dietary protein to attenuate the muscle protein catabolic state has yet to be established in clinical trials. Basic research should focus on ways to further improve the anabolic potential of nutrition by unravelling mechanisms that regulate anabolic and catabolic pathways and energy metabolism.
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Nutrition Management in Patients With Chronic Gastrointestinal Motility Disorders: A Systematic Literature Review.
Lehmann, S, Ferrie, S, Carey, S
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2020;(2):219-230
Abstract
BACKGROUND The aim of this study was to systematically review effects of nutrition interventions on outcomes in patients with chronic gastrointestinal (GI) motility disorders. There is currently a lack of evidence-based guidelines for nutrition management in this group, likely a result of the rarity of the conditions. METHODS A systematic review of all study types to evaluate current evidence-based nutrition interventions was performed using Medline, Embase, and CINAHL databases. Two independent reviewers participated in the process of this systematic review. A total of 15 studies and a total of 524 subjects were included. RESULTS Best treatment of this population group was found to include a stepwise process, progressing from oral nutrition to jejunal nutrition and lastly to parenteral nutrition. Small particle, low-fat diets were significantly better tolerated than the converse, with jejunal nutrition prior to consuming oral food significantly improving oral intake and motility. In more progressive cases, percutaneous endoscopic gastrostomy with jejunal extension nutrition had lower reported symptoms than other enteral routes. Exclusive long-term parenteral nutrition is a feasible option for advanced cases, with a 68% survival rate at 15 years duration, though oral intake with parenteral nutrition is associated with higher survival rates. CONCLUSION Treatment of patients with GI motility disorders should first trial oral nutrition. For patients who progress to jejunal or parenteral feeds, the primary aim should be to maintain or reinstate oral intake to reduce morbidity and mortality risk. Higher-quality studies are still required in this area, particularly in the areas of chronic intestinal pseudo-obstruction and systemic sclerosis.