Nutrition Practice Guidelines Research Articles

Nutrition and Physical Activity Clinical Practice Guidelines for Older Adults Living with Frailty

BackgroundWe developed clinical practice guidelines to provide health care providers with evidence-based recommendations for decisions related to the effective management of frailty and pre-frailty using nutrition and physical activity interventions.MethodsWe based the recommendations on two systematic reviews with meta-analyses. Nutrition, physical activity, and combined nutrition and physical activity interventions for adults ≥65y were considered if study populations were identified as frail using a frailty tool or assessment. Risk of bias and certainty of evidence were evaluated. We included physical outcomes, mobility, frailty, cognitive function, activities of daily living, falls, quality of life, diet quality, energy/fatigue levels, health services use, and caregiver outcomes.ResultsOverall, mobility improvements were moderate with nutritional strategies that optimize dietary intake, various types of physical activity interventions, and interventions that combine nutrition and physical activity. Physical outcomes, such as body mass and muscle strength, improved moderately with nutritional strategies and interventions that combined nutrition with physical activity. Frailty status improved with multi-component physical activity interventions. Strong recommendations include optimizing dietary intake, performing physical activity, and adopting interventions that combine nutrition and physical activity. We strongly recommend various types of physical activity including muscle strengthening activities, mobilization or rehabilitation exercises, and multi-component physical activity interventions.InterpretationTailored nutrition and physical activity interventions based on individual goals and health status are associated with improved clinical and physical outcomes. While the recommendations facilitate shared decision-making, we identified sparse application of validated frailty assessments and lack of standardized research outcomes as critical gaps in knowledge.

Impact of Diabetes Prevention Guideline Adoption on Health Outcomes: A Pragmatic Implementation Trial

Limited research exists to evaluate nutrition guideline impact on clinical practice and patient health outcomes. In this study we investigate (1) the impact of guideline training on the implementation of the diabetes prevention Evidence-Based Nutrition Practice Guideline (EBNPG), and (2) the relationship between EBNPG congruence and resulting health outcomes in patients with prediabetes. We conducted an implementation study in which registered dietitian nutritionists (RDNs) provided nutrition care with 3-month follow-up to 102 pre-diabetes patients before and after a professional training on the implementation of the Diabetes Prevention EBNPG. Using the RDNs' Nutrition Care Process (NCP) documentation, we measured percent guideline congruence and health outcomes (body weight, waist circumference, fasting glucose, glycosylated hemoglobin), and modeled health outcomes. Guideline congruence improved after training by 4.3% (P < 0.05). However, no significant associations were observed between guideline training, or guideline congruence and health outcomes. Our model showed a reduction in waist circumference (2.1 ± 0.92 cm; P= 0.023), and body weight (-1.78 ± 0.55 kg; P= 0.001) throughout the course of the study. Training of nutrition professionals improved congruence to EBNPG for Diabetes Prevention. Nevertheless, improved guideline congruence did not impact related health outcomes. Standard care including nutrition intervention resulted in body weight and waist circumference reductions. Future research needs to further address the impact of evidence-based guidelines on outcomes in all areas of practice.

Executive Summary of the 2020 Academy of Nutrition and Dietetics and National Kidney Foundation Clinical Practice Guideline for Nutrition in CKD

The 2020 update to KDOQI Clinical Practice Guidelines for Nutrition in chronic kidney disease (CKD) is a result of the collaboration between the National Kidney Foundation (NKF) and the Academy of Nutrition and Dietetics (Academy). The target population for this guideline is adults with stages 1 through 5 CKD who are not receiving dialysis, end-stage kidney disease including those on dialysis, and individuals with functional kidney transplant. The updated guideline includes 83 recommendations on important nutrition topics in CKD, including nutrition screening and assessment; medical nutrition therapy; dietary protein and energy intake; micronutrients; electrolytes; nutritional supplementation; and dietary patterns. Both Academy and Grading of Recommendations Assessment, Development and Evaluation (GRADE) approaches were used to assess quality of evidence and rate the recommendation statements. Guideline recommendations were the result of a comprehensive systematic review, clinical expertise, and considerations for individualized care.

Nutrition and maternal health: a mapping of Australian dietetic services

BackgroundStrong associations between diet and maternal and child outcomes emphasise the importance of evidence-based care for women across preconception, antenatal and postnatal periods. A 2008 survey of Australian maternal health dietetic services documented critically low resourcing with considerable variation in staffing levels and models of care. This study repeated the survey to examine resourcing in Australian maternal health services.MethodsA cross-sectional online survey was emailed to publicly-funded Australian maternal health dietetic services in May 2018. Quantitative and qualitative variables collected across preconception to postnatal services (including diabetes) included; births per year (BPY), number of beds, staffing (full time equivalents; FTE), referral processes, and models of care. Results were collated in > 5000; 3500 and 5000; and < 3500 BPY.ResultsForty-three eligible surveys were received from seven states/territories. Dietetic staffing levels ranged from 0 to 4.0 FTE (> 5000 BPY), 0–2.8 FTE (3500–5000 BPY), and 0–2.0 FTE (< 3500 BPY). The offering of preconception, antenatal and postnatal services varied significantly between hospitals (format, staffing, referral processes, delivery models). Few sites reported service effectiveness monitoring and only one delivered gestational diabetes mellitus care according to nutrition practice guidelines. Low staffing levels and extensive service gaps, including lack of processes to deliver and evaluate services, were evident with major concerns expressed about the lack of capacity to provide evidence-based care.ConclusionsTen years after the initial survey and recommendations there remains an identified role for dietitians to advocate for better staffing and for development, implementation, and evaluation of service models to influence maternal nutrition.

Methodological quality of clinical practice guidelines for nutrition and weight gain during pregnancy: a systematic review.

Ensuring a healthy pregnancy and achieving optimal gestational weight gain (GWG) are important for maternal and child health. Nevertheless, the nutritional advice provided during pregnancy is often conflicting, suggesting limited adherence to clinical practice guidelines (CPGs). The aim of this review was to identify all CPGs on maternal nutrition and GWG and to critically appraise their methodological quality. The MEDLINE/PubMed, Cochrane, Guidelines International Network, and BMJ Best Practice databases, along with gray literature, were searched from inception until February 2019 for CPGs and consensus, position, and practice papers. Clinical practice guidelines published in English and containing advice on maternal nutrition or GWG were eligible. Two authors independently extracted data on items pertaining to maternal nutrition or GWG, and CPGs were appraised using the AGREEII instrument. Twenty-two CPGs were included. All scored adequately in the "scope" domain, but most were considered inadequate with regard to stakeholder involvement, rigor of development, applicability, and editorial independence. Many CPGs lacked patient or dietician involvement, and more than half did not disclose funding sources or conflicts of interest. Guidance on GWG was based mostly on Institute of Medicine thresholds, while nutrition recommendations appeared scattered and heterogeneous. Despite the importance of maternal nutrition and the plethora of advising bodies publishing relevant guidance, there is room for substantial improvement in terms of development standards and content of nutritional recommendations. PROSPERO registration number CRD42019120898.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists.

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists. Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Clinical practice guideline on pregnancy and renal disease

Background Chronic kidney disease (CKD) is estimated to affect 3% of pregnant women in high-income countries, (Piccoli et al., 2018, #13860) which equates to between 15,000–20,000 pregnancies per year in England. The prevalence of CKD in pregnancy is predicted to rise in the future due to increasing maternal age and obesity. Although CKD is not a barrier to reproduction in most women, the risk of adverse pregnancy outcomes is increased in women with CKD including pre-eclampsia, fetal growth restriction, preterm delivery and accelerated loss of maternal renal function. CKD impacts on communication, decision-making, and the surveillance and management of women before, during, and after pregnancy. Existing guidance on the management of CKD in pregnancy includes the UK Consensus Group on Pregnancy in Renal Disease (ISBN 978–1,107,124,073) and expert review. Neither Kidney Disease Outcomes Quality Initiative (KDOQI) or National Institute of Health and Care Excellence (NICE) have produced specific guidance on the management of renal disease in pregnancy. Published guidance containing information relevant to the care of women with CKD in pregnancy includes: KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD-MBD). UK Renal Association Commentary available at: BMC Nephrology 2018; 19: 240. KDOQI Clinical Practice Guideline for Haemodialysis, 2015. KDIGO Clinical Practice Guideline for the Evaluation and Management of CKD, 2012 KDIGO Clinical Practice Guideline for Glomerulonephritis, 2012 KDIGO Guideline for the Care of Kidney Transplant Recipients, 2009. KDIGO Clinical Practice Guidelines for Nutrition in Chronic Renal Failure, 2008. NICE: Intrapartum Care for Women with Existing Medical Conditions or Obstetric Complications and their Babies [NG121], 2019. NICE: Urinary Tract Infection (Lower) Antimicrobial Prescribing [NG109], 2018 NICE: Urinary Tract Infection (Recurrent) Antimicrobial Prescribing [NG112], 2018. NICE: Antenatal Care for Uncomplicated Pregnancies [CG62], 2008, updated 2017. NICE: Vitamin D supplement use in specific population groups [PH56], 2017 NICE: Diabetes in Pregnancy: Management from Pre-conception to the Post-partum Period [NG3], 2015. NICE: Antenatal and postnatal mental health: clinical management and service guidance [CG192], 2014, updated 2018. NICE: Fertility: Assessment and Treatment for People with Fertility Problems, 2013. NICE: Weight management before, during and after pregnancy [PH27], 2010 [additional data from 2017 surveillance available at: https://www.nice.org.uk/guidance/ph11/evidence/appendix-a-summary-of-evidence-from-surveillance-pdf-4671107966] NICE: Hypertension in Pregnancy: Diagnosis and Management [CG107], 2011 (update awaited 2019). UK Renal Association Clinical Practice Guidelines: Undernutrition in Chronic Kidney Disease, June 2019 RCOG: Thrombosis and Embolism During Pregnancy and the Puerperium, Reducing the Risk [Green-Top Guideline 37a], 2015. MBBRACE Confidential Enquiry into Maternal Deaths and Morbidity: lessons learned to inform maternity care (triennial reports) www.european-renal-best-practice.org/content/erbp-documents

Evolving the Academy Position Paper Process: Commitment to Evidence-Based Practice

The Academy of Nutrition and Dietetics (Academy) is dedicated to supporting evidence-based practice and recommends that nutrition and dietetics practitioners utilize evidence-based principles and current scientific evidence within their practice. To assist practitioners in achieving this, the Academy provided members with resources, including Evidence-Based Nutrition Practice Guidelines (EBNPGs), systematic reviews, position papers, and practice papers. These resources were designed to inform Academy members of the latest research on specific topics in the field of nutrition and to assist with implementation of evidence-based principles into daily practice. D. Handu is a senior scientist, Evidence Analysis Center Operations, Academy of Nutrition and Dietetics, Chicago, IL. L. Moloney is a nutrition researcher, Evidence Analysis Center Operations, Academy of Nutrition and Dietetics, Chicago, IL. M. R. Rozga is a nutrition researcher, Evidence Analysis Center Operations, Academy of Nutrition and Dietetics, Chicago, IL. F. Cheng is a nutrition researcher, Evidence Analysis Center Operations, Academy of Nutrition and Dietetics, Chicago, IL. D. Wickstrom is formerly research manager, Evidence Analysis Center Operations, Academy of Nutrition and Dietetics, Chicago, IL. A. Acosta is director, Evidence Analysis Center Operations, Academy of Nutrition and Dietetics, Chicago, IL.

Medical Nutrition Therapy for Patients with Non–Dialysis-Dependent Chronic Kidney Disease: Barriers and Solutions

Medical Nutrition Therapy for Patients with Non–Dialysis-Dependent Chronic Kidney Disease: Barriers and Solutions

Evaluating the impact of 2006 Australasian Clinical Practice Guidelines for nutrition in children with cystic fibrosis in Australia.

To determine the association between the implementation of the 2006 Australasian Clinical Practice Guidelines for Nutrition in Cystic Fibrosis (CF) and the nutritional status of children participating in the Australian Cystic Fibrosis Data Registry (ACFDR). This research consisted of a quantitative study using ACFDR data and a survey of clinicians and dietitians treating children with CF. Two independent cohorts of children (2-5 years and 6-11 years) were selected from ACFDR between 1998 and 2014 (N = 2304). Generalised estimating equation model was used to assess weight, height and body mass index (BMI) z-scores for each patient before and after the implementation of the nutrition guidelines. A nationwide online survey was sent to 48 clinicians to explore the enablers and barriers to implementation of the guidelines. Data analysis showed significant increase (p < 0.05) in mean weight, height and BMI z-scores ranging from 0.06 to 0.18 after implementation of the guidelines in both cohorts of children. Nineteen (39%) clinicians participated in the survey. The majority of the respondents adopted the recommendations into their practice and used the guidelines as part of their professional development. Structural barriers included a lack of adequate staff resources and clinic space for consultations, inappropriate staff classification, high staff turnover and lack of mentoring support. In children participating in the ACFDR, nutritional status improved after the implementation of the 2006 guidelines. Survey results revealed enablers and barriers to guideline implementation and will inform implementation strategies for the revised Australasian nutrition guidelines for CF, released in 2017.

Nutrition Assessment, Exposures, and Interventions for Very-Low-Birth-Weight Preterm Infants: An Evidence Analysis Center Scoping Review

Annually, 15 million infants, or approximately 1 of every 10, are born before term, 1 Centers for Disease Control and Prevention. Preterm Birth 2017. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm. Accessed September 9, 2017. Google Scholar , 2 World Health Organization. Preterm Birth. http://www.who.int/mediacentre/factsheets/fs363/en/. Accessed September 6, 2017. Google Scholar leading to short- and long-term health consequences such as infection, growth concerns, developmental impairment, and other comorbidities. 3 Institute of Medicine. 2007. Preterm Birth: Causes, Consequences, and Prevention. Washington, DC: The National Academies Press. https://doi.org/10.17226/11622. Accessed May 25, 2017. Google Scholar , 4 Platt M.J. Outcomes in preterm infants. Public Health. 2014; 128: 399-403 Crossref PubMed Scopus (123) Google Scholar Nutrition interventions may address some effects of prematurity. However, current, comprehensive, evidence-based nutrition practice guidelines (EBNPGs) for preterm infants are lacking in the literature. 5 Raiten D.J. Steiber A.L. Carlson S.E. et al. Working group reports: Evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project. Am J Clin Nutr. 2016; 103: 648S-678S Crossref PubMed Scopus (24) Google Scholar , 6 Raiten D.J. Steiber A.L. Hand R.K. Executive summary: Evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project. Am J Clin Nutr. 2016; 103: 599S-605S Crossref PubMed Scopus (20) Google Scholar Existing guidelines for preterm infants are not based on comprehensive systematic reviews (SRs) and may not represent the current population of preterm infants seen in the neonatal intensive care unit (NICU), which include smaller and less developmentally mature infants. 5 Raiten D.J. Steiber A.L. Carlson S.E. et al. Working group reports: Evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project. Am J Clin Nutr. 2016; 103: 648S-678S Crossref PubMed Scopus (24) Google Scholar In addition, treatment options for preterm infants are continually evolving, and current guidelines must address relevant practices in the NICU. L. Moloney is nutrition researcher at the Academy of Nutrition and Dietetics, Chicago, IL. M. Rozga is nutrition researcher at the Academy of Nutrition and Dietetics, Chicago, IL. T. R. Fenton is nutrition research lead, Nutrition Services, Alberta Health Services, and associate professor, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.

EPS5.07 Evaluating the impact of 2006 clinical practice guidelines for nutrition in children with cystic fibrosis in Australia

EPS5.07 Evaluating the impact of 2006 clinical practice guidelines for nutrition in children with cystic fibrosis in Australia

Academy of Nutrition and Dietetics Evidence-Based Practice Guideline for the Management of Heart Failure in Adults

Academy of Nutrition and Dietetics Evidence-Based Practice Guideline for the Management of Heart Failure in Adults

Nutrition in the ICU: new trends versus old-fashioned standard enteral feeding?

The narrative review aims to summarize the relevant studies from the last 2 years and provide contextual information to understand findings. Recent ICU studies have provided insight in the pathophysiology and time course of catabolism, anabolic resistance, and metabolic and endocrine derangements interacting with the provision of calories and proteins.Early provision of high protein intake and caloric overfeeding may confer harm. Refeeding syndrome warrants caloric restriction and to identify patients at risk phosphate monitoring is mandatory.Infectious complications of parenteral nutrition are associated with overfeeding. In recent studies enteral nutrition is no longer superior over parenteral nutrition.Previously reported benefits of glutamine, selenium, and fish oil seem to have vanished in recent studies; however, studies on vitamin C, thiamine, and corticosteroid combinations show promising results. Studies from the last 2 years will have marked impact on future nutritional support strategies and practice guidelines for critical care nutrition as they challenge several old-fashioned concepts.

The effectiveness of a stage-based lifestyle modification intervention for obese children

BackgroundInterventions that encompass behavioural modifications of dietary intake and physical activity are essential for the management of obesity in children. This study assessed the effectiveness of a stage-based lifestyle modification intervention for obese children.MethodsA total of 50 obese children (7–11 years old) were randomized to the intervention group (IG, n = 25) or the control group (CG, n = 25). Data were collected at baseline, at follow-up (every month) and at six months after the end of the intervention. IG received stage-based lifestyle modification intervention based on the Nutrition Practice Guideline for the Management of Childhood Obesity, while CG received standard treatment. Changes in body composition, physical activity and dietary intake were examined in both the intervention and control groups.ResultsBoth groups had significant increases in weight (IG: 1.5 ± 0.5 kg; CG: 3.9 ± 0.6 kg) (p < 0.01) and waist circumference (IG: 0.1 ± 0.5 cm; CG: 2.2 ± 0.7 cm) (p < 0.05), but the increases were significantly higher in CG than IG. Body Mass Index (BMI)-for-age z scores decreased significantly in IG (− 0.2 ± 0.0, p < 0.01) but not in CG. The physical activity of the IG significantly increased (0.44 ± 0.13) compared with that of CG (− 0.28 ± 0.18), and the difference in mean change between groups was statistically significant (p < 0.05). Dietary intake was not significantly different between the two groups. However, calorie and carbohydrate intake decreased significantly in both groups.ConclusionsA stage-based intervention that modified dietary and physical activity behaviour may be effective in weight management for obese children.Trial registrationNCT03429699 retrospectively registered 9 February 2018.

Nutrient intake assessed with Diet History Questionnaire II, in relation to long-term calcium-phosphate control in hemodialysis patients with end-stage renal failure.

Diet is a key factor that determines proper alignment of calcium-phosphate and nutritional status among hemodialysis (HD) patients. To assess the nutrient intake in relation to long-term calcium-phosphate control in HD patients with end-stage renal failure. The study included 107 patients (66 men, 41 women) from 10 dialysis centers in the Upper Silesia region of Poland. To analyze the diet composition during the previous year, a portion-sized version of the Diet History Questionnaire II (DHQ-II) from National Institutes of Health was used. The nutrient intake was assessed in accordance with the most complex recommendations on HD patients' nutrition - K/DOQI Clinical Practice Guidelines for nutrition in chronic renal failure. Poor long-term alignment of calcium-phosphate homeostasis was defined as the presence of over 50% monthly phosphorus concentrations exceeding 5 mg/dL, and for calcium 10.2 mg/dL, during the last 6-month period. Lower than recommended protein intake was found in 63% of HD patients (average consumption: 0.9 ±0.5 g/kg/day). Most of the patients consumed too much fat (33.5 ±6.7% of daily energy intake) and sodium (2912 ±1542 mg/day). In 42% of patients, dietary phosphorus intake was consistent with the recommendations (13.3 ±7.5 mg/kg/day). Protein intake over 1.2 g/kg/day resulted in an increased consumption of phosphorous, but did not increase the risk of misalignment of phosphorus concentrations (OR = 1.15 [0.40-3.27]); p = 0.8). Poor control of serum phosphorus concentrations was observed in 69% of patients (they were on average 8 years younger). The average intake of protein and phosphate in the groups with good or not satisfactory serum phosphorus alignment did not differ significantly. Adequate control of protein intake is not sufficient to obtain phosphorus alignment, especially in younger HD patients.

Position of the Academy of Nutrition and Dietetics: The Role of Medical Nutrition Therapy and Registered Dietitian Nutritionists in the Prevention and Treatment of Prediabetes and Type 2 Diabetes

It is the position of the Academy of Nutrition and Dietetics that for adults with prediabetes or type 2 diabetes, medical nutrition therapy (MNT) provided by registered dietitian nutritionists (RDNs) is effective in improving medical outcomes and quality of life, and is cost-effective. MNT provided by RDNs is also successful and essential to preventing progression of prediabetes and obesity to type 2 diabetes. It is essential that MNT provided by RDNs be integrated into health care systems and public health programs and be adequately reimbursed. The Academy’s evidence-based nutrition practice guidelines for the prevention of diabetes and the management of diabetes document strong evidence supporting the clinical effectiveness of MNT provided by RDNs. Cost-effectiveness has also been documented. The nutrition practice guidelines recommend that as part of evidence-based health care, providers caring for individuals with prediabetes or type 2 diabetes should be referred to an RDN for individualized MNT upon diagnosis and at regular intervals throughout the lifespan as part of their treatment regimen. Standards of care for three levels of diabetes practice have been published by the Diabetes Care and Education Practice Group. RDNs are also qualified to provide additional services beyond MNT in diabetes care and management. Unfortunately, barriers to accessing RDN services exist. Reimbursement for services is essential. Major medical and health organizations have provided support for the essential role of MNT and RDNs for the prevention and treatment of type 2 diabetes.

Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for Indian Scenario.

Background and Aim:Intensive-care practices and settings may differ for India in comparison to other countries. While international guidelines are available to direct the use of enteral nutrition (EN), there are no recommendations specific to Indian settings. Advisory board meetings were arranged to develop the practice guidelines specific to Indian context, for the use of EN in critically ill patients and to overcome challenges in this field.Methods:Various existing guidelines, meta-analyses, randomized controlled trials, controlled trials, and review articles were reviewed for their contextual relevance and strength. A systematic grading of practice guidelines by advisory board was done based on strength of the supporting evidence. Wherever Indian studies were not available, references were taken from the international guidelines.Results:Based on the literature review, the recommendations for developing the practice guidelines were made as per the grading criteria agreed upon by the advisory board. The recommendations were to address challenges regarding EN versus parenteral nutrition; nutrition screening and assessment; nutrition in hemodynamically unstable; route of nutrition; tube feeding and challenges; tolerance; optimum calorie-protein requirements; selection of appropriate enteral feeding formula; micronutrients and immune-nutrients; standard nutrition in hepatic, renal, and respiratory diseases and documentation of nutrition practices.Conclusion:This paper summarizes the optimum nutrition practices for critically ill patients. The possible solutions to overcome the challenges in this field are presented as practice guidelines at the end of each section. These guidelines are expected to provide guidance in critical care settings regarding appropriate critical-care nutrition practices and to set up Intensive Care Unit nutrition protocols.

Implementing Evidence-Based Nutrition Practice Guidelines for Type 2 Diabetes Mellitus in Lebanon

Lebanon is a Middle Eastern country experiencing a surge in the prevalence of type 2 diabetes mellitus among adults. This pilot study evaluated the feasibility and outcomes of implementing the Academy of Nutrition and Dietetics Evidence-Based Nutrition Practice Guidelines (EBNPGs) as part of medical care for patients newly diagnosed with type 2 diabetes mellitus. Seventy-five patients were recruited from 3 Lebanese hospitals, received nutrition care according to EBNPGs, and were followed up for 12 months. Patients achieved significant improvement in clinical outcomes between baseline and 3, 6, and 12 months. Further research is recommended to confirm the benefits of using EBNPGs.

Short Term Results of Intestinal Transplantation in Czech Republic

Introduction: Commencing a new intestinal transplantation program is a complex process. We started in 2006 with animal experiments and proposal for Center for intestinal rehabilitation. The clinical program has started with the first multivisceral transplantation in December 2014. Aim: To describe process of starting intestinal/multivisceral transplant program in Czech Republic and to present short-term results. Methods: Narration of steps towards program formation. Analysis of short term results. Results: 1. Database of patients on parenteral nutrition: Collecting information about patients suffering of intestinal failure resulted in founding Society of home parenteral nutrition specialists, patient database, practice guidelines, and scientific meetings. 2. Experimental procedures. We performed animal experiment on 63 pigs, mainly focused on surgical technique and diagnosis of ACR. 3. Proposed Intestinal failure and rehabilitation center and waiting list: We collected more than 70 patients with severe abdominal disorders who underwent a complex treatment (mainly surgery for short bowel syndrome, fistulas and complex abdominal disorders). Those steps resulted in close national cooperation with gastroenterologists, surgeons and nutritional specialists who have started to send their patients. It resulted in active waiting list. 5. Clinical program: From December 2014- January 2017, 6 adult patients (3 males) average age 42, median 39 (range 27-60) were transplanted by MVT. Median waiting time was 52 days. One patient died during the procedure and she was excluded from statistic. Those who survived had average CIT 302 minutes, median 310 (range 258-360). Average WIT was 67 minutes, median 55. Three patients are currently alive. Actual survival is 380 days, median 131 (range 63-763). Median hospital stay was 63 days (range 33-86). IS was based on alemtuzumab induction (30 mg 0 and 3 POD)., tacrolimus titrated to serum concentrations of 15-20 ng/mL for 14 days post-transplant, 8-12 ng/mL to 2 months, and 6-12 ng/mL to 1 year. Initial steroid administration was tapered according to the post-transplant course. Mild and intermediated ACR was diagnosed in all patients during the first three month and was managed with increased IS and steroid boluses in one case. One patient progressed to severe ACR. One patient had severe mycotic infection. All three survived patients are at home on full enteral nutrition with excellent quality of life. Conclusion: General acceptance of a new program needs a long process, which require a close cooperation and trust from different specialists. We managed to establish a functional active program currently the only one in a region of so-called Eastern European Countries.