Research and Advocacy in Nutrition Therapy: Our Specialty Needs You

Abstract

swered in clinical nutrition. The old nutrition support specialty was plagued by a preponderance of small, singlecenter, and/or underpowered studies. We have attempted to use these often very small trials to create our clinical guidelines. I believe that we as a new nutrition therapy specialty must now approach our clinical trials as cardiology or oncology would approach their new drug trials: with well-designed, appropriately powered, multicenter trials. We are currently close to developing the critical mass to bring to bear a powerful multinational nutrition network of researchers that will be capable of performing these key multicenter trials. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and the Journal of Parenteral and Enteral Nutrition (JPEN) can and should be catalysts and leaders in this field. Some examples of the key areas that must be acutely addressed include a clearer understanding of the risks and benefits of parenteral nutrition (PN). It is clearly possible that the risks of PN may now be reduced with the advent of glucose control, new lipid emulsions, and an understanding of the risks of overfeeding. New trials examining the safety and efficacy of parenteral nutrients must be undertaken. A major controversy growing in this field is the use of W-6–based lipids in critical illness. Some data suggest that, in the sickest critical care patient, withholding these lipids for an unclear period of time may be beneficial. But a more definitive trial is clearly required. Speaking of glucose control, how to safely use glucose control in critically ill patients has now become unclear. Current data leave us quite conflicted with regard to the safety and benefit of tight glucose control in the critically ill patient. The new Glucontrol trial by Dr Preiser and colleagues in Europe has demonstrated a significant mortality risk of hypoglycemia in patients receiving tight glucose control. Of the patients in the tight glucose control arm, 41% had a glucose level <60 mg/dL during their intensive care unit (ICU) stay. These patients had a 2-fold increase in risk of death. This trial also did not show any overall mortality benefit from tight glucose control (J. C. Preiser, personal communication, 2007). This is, of course, in contrast to Dr van den Berghe’s findings on the benefits He who refuses to embrace a unique opportunity loses the prize as surely as if he had failed.