Daily Nutritional Requirements Research Articles

Feeding intravenously saves the patient but starves the gut: consequences for the intestinal barrier

During the late 1960s, the medical breakthrough of providing a patient's complete daily nutritional requirement via intravenous catheter was successfully developed (Dudrick, 2009). When coupled with a growing understanding of the role of optimal nutrition in the recovery of patients unable to consume food, total parenteral nutrition (TPN) has saved numerous lives. However, as with any advanced medical therapy, TPN comes with a number of important complications, many of which are life-threatening. One specific consequence of TPN is gut mucosal atrophy, in which the intestinal mucosa is reduced in thickness because of the importance of luminal nutrients on mucosal growth. Furthermore, there is an associated breakdown in intestinal barrier function, which is critical because the mucosal barrier is the most important line of defence against microorganisms within the intestinal lumen. Bacterial translocation can in turn trigger sepsis, an important cause of mortality in gravely ill patients. However, the mechanisms of intestinal barrier breakdown in patients on TPN are poorly understood. The intestinal mucosal barrier is composed of a single layer of columnar epithelial cells attached side-by-side by a series of interepithelial junctions, including the apical-most tight junctions. Over the last 10–15 years, tight junctions have been the subject of intensive study because although they are ‘tight’ they are also the weakest link in the barrier. Tight junctions are composed of interdigitating extracytoplasmic loops of junctional proteins, including occludin, claudins and junction adhesion molecules. Loss of barrier function at the level of the tight junctions is thought to be a pivotal event in the pathophysiology of a number of important disease syndromes, including infectious diarrhoeal disease, ischaemia/reperfusion injury and inflammatory bowel disease (Hering et al. 2012). However, the mechanisms whereby intestinal barrier function is pathologically altered in intestinal disease are not well defined. In this issue of The Journal of Physiology, Feng & Teitelbaum (2013) have built on their previous findings of barrier disruption in experimental animals on TPN by showing that a complex interplay of tumour necrosis factor (TNFα) and its two receptors (TNFR1 and TNFR2) is responsible for the breakdown of intestinal epithelial tight junctions. Experiments using mutant mice in which TNFR1, TNFR2, or both receptors were knocked out revealed that the absence of either TNF receptor partially prevented the effects of TPN on tight junctions. Additionally, genetic deletion of both TNF receptors prevented any notable effect of TPN on intestinal barrier function. This is interesting not only to researchers studying the mechanisms of TPN-induced barrier disruption, but also to others who have focused on mechanisms whereby cytokines such as TNFα disrupt epithelial barrier function. The TPN model is particularly interesting because it involves selective loss of tight junction integrity independent of inflammatory cell infiltration. In this way, TPN models may allow more precise studies assessing the effect of select factors on tight junction integrity in vivo which are complicated in many models by inflammation. From cell studies, it is well known that cytokines, including TFNα, interferon-γ and interleukin-1-β, can disrupt epithelial barrier function. For example, initial studies assessing the role of cytokines in cell culture models revealed that TNFα dose-dependently reduced epithelial barrier function associated with morphological disruption of tight junctions using electron microscopy (Schmitz et al. 1999). With advancing technology, studies of specific tight junction proteins have shown that TNFα induces endocytosis of occludin as a consequence of activation of the cytoskeletal-associated enzyme myosin light chain kinase (MLCK). Interestingly, Feng et al. noted increased phosphorylation of myosin light chain by MLCK in their TPN mouse model. MLCK has a physiological role in ‘opening’ tight junctions in response to sodium-coupled glucose intestinal epithelial transport, but has more recently been closely linked to pathological states involving disruption of tight junctions. TNFα has also been shown to have alternate mechanisms of barrier disruption. For example, recent studies have shown that TNFα disrupts the highly controlled process of cell shedding of the most superficial surface epithelium resulting in excessive cell loss that can be seen in patients with inflammatory bowel disease (Watson et al. 2012). Such cell loss is also associated with perturbation of tight junctions, allowing cell detachment. Which of the actions of TNFα is critical to loss of barrier function in TPN-treated mice is not entirely clear, although the tight junctions and MLCK are certainly involved. As far as the translational relevance of TNFα in disruption of the gut barrier is concerned, Feng & Teitelbaum (2013) have additionally shown that the TNFα inhibitor etanercept prevents loss of barrier function in TPN-infused mice. Etanercept is a TNFR fusion protein that was originally studied for the treatment of shock (Fisher et al. 1996) and has been marketed for the treatment of select autoimmune diseases. Considering the fact that placement of a patient on TPN is elective, there may be the opportunity to intervene prior to onset of intestinal barrier disruption.

Assessing Foods Offered to Children at Child-Care Centers Using the Healthy Eating Index-2005

The Healthy Eating Index-2005 (HEI-2005) has been applied primarily to assess the quality of individual-level diets but has recently been applied to environmental-level data as well. Currently, no studies have applied the HEI-2005 to foods offered in child-care settings. This cross-sectional study used the HEI-2005 to assess the quality of foods and beverages offered to preschool children (3 to 5 years old) in child-care centers. Two days of dietary observations were conducted and 120 children (six children per center) were observed at 20 child-care centers in North Carolina between July 2005 and January 2006. Data were analyzed between July 2011 and January 2012 using t tests. Mean total HEI-2005 score (59.12) was significantly (P<0.01) lower than the optimal score of 100, indicating the need to improve the quality of foods offered to children. All centers met the maximum score for milk. A majority also met the maximum scores for total fruit (17 of 20 centers), whole fruit (15 of 20 centers), and sodium (19 of 20 centers). Mean scores for total vegetable (mean=2.26±1.09), dark green/orange vegetables and legumes (mean=0.20±0.43), total grain (mean=1.09±1.25), whole grain (mean=1.29±1.65), oils (mean=0.44±0.25), and meat/beans (mean=0.44±0.25) were significantly lower than the maximum scores recommended (P<0.01). Mean scores for saturated fat (mean=3.32±3.41; P<0.01) and calories from solid fats and added sugars (mean=14.76±4.08; P<0.01) suggest the need to decrease the provision of foods high in these components. These findings indicate the need to improve the quality of foods offered to children at the centers to ensure that the foods provided contribute to children's daily nutrition requirements.

Low Dose β Carotene Supplementation Diminishes Oxidative Stress in Type 2 Diabetics and Healthy Individuals

Type 2 diabetes is a chronic, multifactorial disease, and oxidative stress one of the pathophysiological mechanisms associated with its appearance and development. The objective was to determine the effect of supplementation with β-carotene to type 2 diabetics and healthy individuals, on iron metabolism, oxidative balance, and antioxidant plasma capacity, using doses similar to the daily nutritional requirement. A total of 117 randomly selected non-smoker volunteers participated in the study. Type 2 diabetics (34) and healthy individuals (24), received 6 mg β-carotene for 45 d, and were compared to similar non-supplemented diabetic (33) and control (26) groups. Blood samples were taken at the beginning, end and 30 days after finishing supplementation, to determine hemoglobin, hematocrit unsaturated iron binding capacity, total iron binding capacity, transferrin saturation, ferritin, glycemia, glycosilated hemoglobin, cholesterol, triglycerides, HDL, LDL, oxidized LDL, copper, zinc, TBARS, FRAP, nitrites, GPx, SOD, folates, retinol and β-carotene. In supplemented diabetics, there was a significant diminution in copper concentrations (24.8%), and TBARS (9.5%), associated with a non significant increase in FRAP. Also, hemoglobin decreased and oxidized LDL augmented in supplemented diabetics. All the changes were still present one month after finishing the supplementation. In conclusion, supplementation with β-carotene had a positive effect on the oxidative balance of both, type 2 diabetics and healthy individuals, which makes the inclusion of β-carotene rich foods, part of the prevention and/or treatment strategies in type 2 diabetes.

English

&nbsp; Attaining the daily required nutritional recommendations is a major challenge in Ghana where the average person earns about $1.89 per day. A linear programming diet model is used to determine the cheapest basket of food items that satisfy the recommended daily nutritional requirements of the average Ghanaian. Initial findings show that an average Ghanaian requires $0.36 per day to meet his daily nutritional needs. This would be met with a food basket made up of sorghum, yam, cassava, coconut and milk. With this food basket and the estimated food expenditure, the average person in Ghana would save about 40% of his/her daily food expenditure. Sensitivity analyses are also performed to test the robustness of the findings. &nbsp; Key words: Developing countries, nutrition, minimum costs, linear programming.

Alimentação escolar nas comunidades quilombolas: desafios e potencialidades

The Brazilian School Nutrition Program (PNAE) is a Food and Nutritional Security (SAN) strategy for public school students. This article seeks to discuss the challenges and opportunities of school nutrition in 'quilombola'* communities and report on the experience of the Cooperation Center for Student Food and Nutrition of the Federal University of Goiás and the Midwest Region (CECANE UFG/ Centro-Oeste). It includes a report on the experience with the systematization on PNAE, SAN and other policies. Continued access and adequate social policies are a challenge for the 'quilombola'* communities. Some economic, structural and social barriers have been identified in PNAE. In this context, Law 11.947/2009 encourages local development, with the acquisition of food from the region, and it establishes differentiated values per capita, which are translated into menus including products inherent to Afro-Brazilian culture that provide at least 30% of daily nutritional requirements. In the nutrition, health and quality of life project of 'quilombola'* schoolchildren, the CECANE UFG/Midwest carry out food and nutritional security actions. The area of school nutrition has proven responsive to local needs and supports the development and promotion of quality of life.

Determinação de vitamina E na castanha de caju e sua relação com a recomendação nutricional em humanos

Alpha-tocopherol is the most biologically active form of vitamin E. Its main function is related to the antioxidant activity, which protects the cell membranes from damage caused by free radicals. Given to the importance of adequate intake of this vitamin and the scarcity of Brazilian data on their contents in foods, this study aimed at determining the alpha-tocopherol concentration in cashew nuts, and these findings were compared with the vitamin E nutritional requirement. In this context, four brands of roasted cashew nuts purchased in supermarkets in Natal/RN were analyzed. The alpha-tocopherol was extracted from samples by lipid extraction, and its determination was performed by HPLC. The alpha-tocopherol values in the analyzed nuts were expressed as mean and standard deviation. The average concentration of alpha-tocopherol in 100 g of roasted cashew nuts was 0.96 ± 0.12 mg. The amount of this vitamin contained in the medium portion of cashew-nuts consumed by the interviewed population was equivalent to 3.6 % of the daily nutritional requirement for vitamin E. The analyzed toasted nuts cannot be considered as good sources of alpha-tocopherol, as they did not reach the percentage of 10 to 20 % of the daily nutritional requirement.

Effects and Side Effects Associated with the Non-Nutritional Use of Tryptophan by Humans1–3

The daily nutritional requirement for ʟ-tryptophan (Trp) is modest (5 mg/kg). However, many adults choose to consume much more, up to 4–5 g/d (60–70 mg/kg), typically to improve mood or sleep. Ingesting ʟ-Trp raises brain tryptophan levels and stimulates its conversion to serotonin in neurons, which is thought to mediate its actions. Are there side effects from Trp supplementation? Some consider drowsiness a side effect, but not those who use it to improve sleep. Though the literature is thin, occasional side effects, seen mainly at higher doses (70–200 mg/kg), include tremor, nausea, and dizziness, and may occur when Trp is taken alone or with a drug that enhances serotonin function (e.g., antidepressants). In rare cases, the “serotonin syndrome” occurs, the result of too much serotonin stimulation when Trp is combined with serotonin drugs. Symptoms include delirium, myoclonus, hyperthermia, and coma. In 1989 a new syndrome appeared, dubbed eosinophilia myalgia syndrome (EMS), and was quickly linked to supplemental Trp use. Key symptoms included debilitating myalgia (muscle pain) and a high peripheral eosinophil count. The cause was shown not to be Trp but a contaminant in certain production batches. This is not surprising, because side effects long associated with Trp use were not those associated with the EMS. Over 5 decades, Trp has been taken as a supplement and as an adjunct to medications with occasional modest, short-lived side effects. Still, the database is small and largely anecdotal. A thorough, dose-related assessment of side effects remains to be conducted.

Fundamental Approaches to the Study of Zebrafi sh Nutrition

The value of the zebrafish model has been well established. However, culture variability within and among laboratories remains a concern, particularly as it relates to nutrition. Investigators using rodent models addressed this concern several decades ago and have developed strict nutritional regimes to which their models adhere. These investigators decreased the variability associated with nutrition in most studies by developing standardized reference and open formulation diets. Zebrafish investigators have not embraced this approach. In this article, we address the problems associated with the lack of nutritional information and standardization in the zebrafish research community. Based on the knowledge gained from studies of other animals, including traditional research models, other fish species, domesticated and companion animals, and humans, we have proposed an approach that seeks to standardize nutrition research in zebrafish. We have identified a number of factors for consideration in zebrafish nutrition studies and have suggested a number of proposed outcomes. The long term-goal of nutrition research will be to identify the daily nutritional requirements of the zebrafish and to develop appropriate standardized reference and open formulation diets.

Evaluating the quality of foods and beverages offered to preschool children at childcare centers using the Healthy Eating Index‐2005 (HEI‐2005)

Nutrition standards for evaluating foods offered in childcare settings have included the Dietary Reference Intakes, the Child and Adult Care Food Program's guidelines, and the American Dietetic Association's benchmarks. To date, no studies have applied the HEI‐2005 to foods offered in childcare settings. The current study evaluated the diet quality of foods offered to preschool children in 20 North Carolina childcare centers using the HEI‐2005. Four days of dietary observations were conducted and 3 children were observed daily at each center (240 observations). The total HEI‐2005 score for the centers ranged from 60.73 to 79.96 out of a possible 100 points. All centers met the recommendation for saturated fat, and the majority met recommendations for total fruit, whole fruit, total grains, and milk. None met the recommendations for total vegetables, dark green/orange vegetables and legumes, whole grains, oils, and meat/beans, while half exceeded recommendations for sodium and calories from solid fats and added sugars. Findings show that childcare centers need to improve the overall quality of foods offered to children to ensure that foods provided contribute to children's daily nutrition requirements.

The effect of maternal undernutrition on muscle development in the ovine fetus*

The effect of maternal undernutrition on muscle development of near-term ovine fetuses was studied in 2 experiments. In each experiment, Welsh mountain ewes were randomly assigned to either control (C) or nutrient-restricted (R) groups. In the first experiment, mild maternal undernutrition (85% of daily nutritional requirement (DNR)), and in the second experiment, severe maternal undernutrition (50% of DNR), were imposed between 0 and 70 days of gestation (dg). Controls for both groups were maintained on 100% of their DNR throughout the experiment. In each experiment, ewes were killed at 126 ± 1 dg by an intravenous injection of pentobarbitone. The semitendinosus muscle was dissected, and sections were stained for alkali-stable ATPase. The total number of primary and secondary fibers and the total number of fibers were estimated. In both experiments, there was a significant decrease in primary, secondary, and total fiber numbers (P < 0.05 for each). We speculate that the decrease in primary fiber number in both experiments is due to some of the large, central, and alkali-ATPase-negative (slow) fibers at near-term being secondary fibers. Therefore, the real primary fibers may not be affected.

Fries or a fruit bag? Investigating the nutritional composition of fast food children’s meals

The impact of children’s fast food meals on their daily nutritional requirements has not been assessed in Australia. Analysis of the nutritional composition of children’s meals from six fast food chains was conducted. The energy, saturated fat, sugar and sodium content of all children’s meals from the chains were assessed against the fast food industry-defined nutrient criteria for healthy meals and children’s recommended daily nutritional requirements, as defined by the Nutrient Reference Values and the Dietary Guidelines for Children and Adolescents in Australia. Overall children’s fast food meals are high in saturated fat, sugar and sodium. Only 16% and 22% of meals met the industry’s nutrient criteria for children aged 4–8 and 9–13 years, respectively. Seventy-two percent of fast food meals exceeded 30% of the daily energy recommendations for 4 year old children, and 90% of meals exceeded 30% of the upper limit for sodium for children aged 4–8. Some meals also exceeded the upper limit for sodium and daily saturated fat recommendations for children aged 4–8 years. Reformulation of children’s meals to improve their nutritional composition and revision of the industry’s nutrient criteria to align with children’s dietary requirements are urgently needed.

Evaluation of an intensive desensitisation, oral tolerance therapy and hunger provocation program for children who have had prolonged periods of tube feeds

Some children with feeding difficulties may require nasogastric tube feeding or insertion of a percutaneous endoscopic gastrostomy (PEG) from a young age. A small cohort of these children can develop severe oral aversions that can delay the re-introduction of oral feeding. Multidisciplinary approaches that provide an intensive approach are deemed the most effective method of intervention to reduce nasogastric and PEG dependency. Two children and their parents received an intensive approach to reduce PEG feeds (Child A and Child B), while one child and her parents elected to receive a traditional feeding clinic approach (Child C). The mean age of the participants was 4 years 4 months. Child A initially took 2090 kJ (44% daily nutritional requirement) via her PEG before the intensive program, and Child B took 100% daily nutritional requirement via his PEG. Three months post the intervention, Child A took 100% of her nutritional requirements orally and Child B had reduced PEG requirement significantly to 38% of daily nutritional requirement. Child C showed no changes in PEG versus oral intake. Children who received the intervention were able to remain focused on mealtimes for longer, with fewer instances of leaving the table. Parents altered their language styles post coaching on the intensive intervention using fewer reprimands. No changes with these behaviours were noted with Child C. Although this was a small pilot study, there are some strategies used within an intensive multidisciplinary context that can enable children to reduce their reliance on PEG feeds significantly.

The role of banned substance residue analysis in the control of dietary supplement contamination

The potential for contaminated dietary supplements to result in a failed doping test remains a concern for athletes, trainers, and sporting authorities despite improvements to regulatory guidelines. Previous surveys of readily available supplements confirm that many are contaminated with steroids and stimulants prohibited for use in elite sport. Suggested responses to this issue include the complete avoidance of all supplements. Many athletes, however, use nutritional supplements to achieve effective training and also to ensure that daily nutritional requirements are met (e.g. recommended levels of vitamins and minerals). This ensures that the use of supplements is and will remain the norm for a range of sports. As a result, an alternative approach of rigorous testing of materials destined for use by elite athletes has been introduced in several countries. While the testing of final product for banned substances may help mitigate the problem, it will not help to remove the underlying issue of contamination. In this article we describe an alternative approach that uses appropriate quality assurance procedures backed up by testing to remove sources of contamination. The decrease in the incidence of contamination amongst supplement companies adopting such a system is explained, and contrasted with the relatively high incidences of contamination found in products that are not part of a quality system. These findings are of key importance to both supplement manufacturers and those involved in advising athletes about supplement use.

Patterns of daily activity of Meyer's Parrot (Poicephalus meyeri) in the Okavango Delta, Botswana

Most parrots from Africa, Australasia and the Neotropics have bimodal patterns of daily activity owing to physiological restrictions (e.g. crop-size) and climatic constraints (e.g. seasonal fluctuations in temperature and rainfall). We monitored the daily patterns of flight, feeding and non-feeding activities of Meyer's Parrots (Poicephalus meyeri) over 24 months at two study sites for correlation with climatic conditions, availability of food, and mean rates of protein and energy acquisition from these food resources. Feeding activity between 0830 and 1100 hours was likely to be obligate, whereas feeding between 1600 and 1830 hours was seasonally needed to achieve daily protein requirements. This weak bimodality was supported by daily nutritional requirements and midday digestive restrictions (e.g. fixed crop-size). Feeding activity patterns of Meyer's Parrots at population level were significantly influenced by high and low temperatures throughout the year. A bimodal pattern of daily flight-activity was, however, a function of communal roosting and dispersal for foraging as central-place foragers. The patterns of daily activity of other parrots that rely on seeds may also be constrained by similar physiological, behavioural and climatic factors. Counting Meyer's Parrots in the late morning, between 0830 and 1100 hours, would yield the highest minimum population estimate for a given area.

Design and construction of a yam pounding machine

Yam is a daily nutritional food requirement for man and in order to facilitate the processing of yam for consumption, a yam pounding machine has been developed using mainly some locally sourced materials. The machine consists of a shaft, pulleys, belt, bearings, electric motor, yam beaters, bowl and the frame. The machine was developed to enhance the hygienic processing of yam for both domestic and commercial consumption, while eliminating the tedious and laborious indigenous process of preparing pounded yam.Keywords: Yam, pounding machine, hygienic processing, yam beaters

Feed additives for swine: Fact sheets – flavors and mold inhibitors, mycotoxin binders, and antioxidants (2010)

Under the conditions of modern swine production, pigs need to be fed a balanced diet that meets their daily nutritional requirement for maintenance, growth, and reproduction. However, nutrient intake is largely determined by voluntary feed intake, which is greatly influenced by the chemical senses of olfaction and taste. Thus, it is essential to make sure that diets being offered to pigs are highly palatable to ensure high feed intake. This is especially important during times when pigs have decreased appetite, such as the first few days post weaning. Therefore, it is believed that enhancement of taste or smell through the use of flavors may help to improve the palatability of diets and, consequently, feed intake.; Journal of Swine Health and Production; 18; Swine Day, 2010, Kansas State University, Manhattan, KS, November 18, 2010

Role of enteral nutrition in adult short bowel syndrome undergoing intestinal rehabilitation: the long-term outcome.

The objective of this study is to evaluate the long-term clinical significance of enteral nutrition (EN) in weaning adult short bowel patients off parenteral nutrition (PN) undergoing intestinal rehabilitation therapy (IRT). Sixty-one adult patients with small bowel length 47.95+/-19.37 cm were retrospectively analyzed. After a 3-week IRT program, including recombinant human growth hormone (rhGH, 0.05 mg/kg/d), glutamine (30 g/d), and combined EN and PN support, patients were maintained on EN or plus a high-carbohydrate, low fat (HCLF) diet. Continuous tube feeding was used when EN was started. Patients were followed up for 50.34+/-24.38 months and had an overall survival rate 95.08% (58/61). On last evaluation, 85.24% (52/61) of the patients were free of PN. For 77.42% patients (24/31) with small bowel length<35 cm in jejunoileocolic anastomosis (type III) and <60 cm in jejunocolic anastomosis (type II), weaning off PN was achieved. EN comprised of 52.56+/-13.47% of patients' daily calorie requirements on follow-up. Five patients were maintained on home PN (HPN) plus EN. Nutritional and anthropometric parameters, urine 5-hr D-xylose excretion and serum citrulline levels all increased significantly after IRT and on follow-up compared with baseline. In conclusion, with proper EN management during and after IRT, a significant number of SBS patients could be weaned from PN, especially for those who were considered as permanent intestinal failure; continuous tube feeding is recommended for enteral access, and long-term EN support could meet the daily nutritional requirement in majority of SBS patients.

The food multimix concept: new innovative approach to meeting nutritional challenges in Sub-Saharan Africa

Food insecurity, chronic hunger, starvation and malnutrition continue to affect millions of individuals throughout the developing world, especially Sub-Saharan Africa. Various initiatives by African governments and International Agencies such as the UN, the industrial nations, the International Monetary Fund, the World Bank and the World Trade Organisation to boost economic development, have failed to provide the much-needed solution to these challenges. The impact of these economic shifts and the failures of structural adjustment programmes on the nutritional well-being and health of the most vulnerable members of poor communities cannot be over-emphasised. The use of ad hoc measures as an adjunct to community-based rural integrated projects have provided little success and will be unsustainable unless they are linked to harnessing available local resources. The present paper therefore focuses on exploring alternative ways of harnessing the scant agricultural resources by employing a scientific approach to food-related problem-solving. The food multimix (FMM) concept offers a scientific contribution alongside other attempts currently in use by the World Food Programme, WHO and FAO to meet the food insecurity challenges that confront most of the developing world in the twenty-first century. It is an innovative approach that makes better use of traditional food sources as a tool for meeting community nutritional needs. The FMM concept employs a food-based approach using traditional methods of food preparation and locally-available, cheap and affordable staples (fruits, pulses, vegetables and legumes) in the formulation of nutrient-enriched multimixes. Developed recipes can provide > or =40% of the daily nutritional requirements of vulnerable groups, including patients with HIV/AIDS and children undergoing nutrition rehabilitation. The FMM approach can also be used as a medium- to long-term adjunct to community-based rural integration projects aimed at health improvement and economic empowerment in Sub-Saharan Africa.

Randomised trial of glutamine and selenium supplemented parenteral nutrition for critically ill patients. Protocol Version 9, 19 February 2007 known as SIGNET (Scottish Intensive care Glutamine or seleNium Evaluative Trial)

BackgroundMortality rates in the Intensive Care Unit and subsequent hospital mortality rates in the UK remain high. Infections in Intensive Care are associated with a 2–3 times increased risk of death. It is thought that under conditions of severe metabolic stress glutamine becomes "conditionally essential". Selenium is an essential trace element that has antioxidant and anti-inflammatory properties. Approximately 23% of patients in Intensive Care require parenteral nutrition and glutamine and selenium are either absent or present in low amounts. Both glutamine and selenium have the potential to influence the immune system through independent biochemical pathways. Systematic reviews suggest that supplementing parenteral nutrition in critical illness with glutamine or selenium may reduce infections and mortality. Pilot data has shown that more than 50% of participants developed infections, typically resistant organisms. We are powered to show definitively whether supplementation of PN with either glutamine or selenium is effective at reducing new infections in critically ill patients.Methods/design2 × 2 factorial, pragmatic, multicentre, double-blind, randomised controlled trial. The trial has an enrolment target of 500 patients. Inclusion criteria include: expected to be in critical care for at least 48 hours, aged 16 years or over, patients who require parenteral nutrition and are expected to have at least half their daily nutritional requirements given by that route.Allocation is to one of four iso-caloric, iso-nitrogenous groups: glutamine, selenium, both glutamine & selenium or no additional glutamine or selenium. Trial supplementation is given for up to seven days on the Intensive Care Unit and subsequent wards if practicable. The primary outcomes are episodes of infection in the 14 days after starting trial nutrition and mortality. Secondary outcomes include antibiotic usage, length of hospital stay, quality of life and cost-effectiveness.DiscussionTo date more than 285 patients have been recruited to the trial from 10 sites in Scotland. Recruitment is due to finish in August 2008 with a further six months follow up. We expect to report the results of the trial in summer 2009.Trial registrationThis trial is registered with the International Standard Randomised Controlled Trial Number system. ISRCTN87144826

A New Japanese Vegetarian Food Guide Pyramid

To establish the nutritionally calculated and practical tools not only for Japanese vegetarians but also for health care professionals who provide the nutritional consultations for Japanese vegetarians to achieve their daily nutritional requirements more easily.