Nutrition Therapy Research Articles

Toward Precision in Nutrition Therapy.

Precision in critical care nutrition is paramount, as it focuses nutrition interventions on those patients most likely to benefit, or those who might potentially be harmed. Critical care nutrition must therefore be tailored to individual metabolic needs as determined by factors that control the capacity for tissue homeostasis and anabolic responses. This ideally involves the accurate and timely assessment of macronutrient and micronutrient requirements, a careful evaluation of metabolic response mechanisms and the identification of circumstances that might interfere with the productive utilization of dietary substrates. Specific surrogate markers of metabolic response, such as blood glucose levels, urea levels, or nitrogen balance, might be used to evaluate the metabolic readiness for nutrition and to establish the timing, nature, and clinical effectiveness of nutrition interventions. Despite the pressing need to further develop more targeted approaches in critically ill patients, indices of immediate metabolic responses that correlate with favorable clinical outcomes are lacking. In addition, the development of precision approaches might address timely adjustments in protein, energy, or micronutrient supplementation based on evolving clinical conditions. Here, we review why precision tools are needed in critical care nutrition, our progress thus far, as well as promising approaches and technologies by which multidisciplinary healthcare teams can improve quality of care and clinical outcomes by individualizing nutrition interventions.

Urinary Metabolite Profiles of Participants with Overweight and Obesity Prescribed a Weight Loss High Fruit and Vegetable Diet: A Single Arm Intervention Study.

Thus far, no studies have examined the relationship between fruit and vegetable (F and V) intake, urinary metabolite quantities, and weight change. Therefore, the aim of the current study was to explore changes in urinary metabolomic profiles during and after a 10-week weight loss intervention where participants were prescribed a high F and V diet (7 servings daily). Adults with overweight and obesity (n = 34) received medical nutrition therapy counselling to increase their F and V intakes to national targets (7 servings a day). Data collection included weight, dietary intake, and urine samples at baseline at week 2 and week 10. Urinary metabolite profiles were quantified using 1H NMR spectroscopy. Machine learning statistical approaches were employed to identify novel urine-based metabolite biomarkers associated with high F and V diet patterns at weeks 2 and 10. Metabolic changes appearing in urine in response to diet were quantified using Metabolite Set Enrichment Analysis (MSEA). Energy intake was significantly lower (p = 0.02) at week 10 compared with baseline. Total F and V intake was significantly higher at week 2 and week 10 (p < 0.05). In total, 123 urinary metabolites were quantified. At week 10, 21 metabolites showed significant changes relative to baseline. Of these, 11 metabolites also significantly changed at week 2. These overlapping metabolites were acetic acid, dimethylamine, choline, fumaric acid, glutamic acid, L-tyrosine, histidine, succinic acid, uracil, histamine, and 2-hydroxyglutarate. Ridge Classifier and Linear Discriminant Analysis provided best prediction accuracy values of 0.96 when metabolite level of baseline was compared to week 10. Urinary metabolites quantified represent potential candidate biomarkers of high F and V intake, associated with a reduction in energy intake. Further studies are needed to validate these findings in larger population studies.

Diet and Microbiota Modulation for Chronic Pouchitis: Evidence, Challenges, and Opportunities

Chronic pouchitis occurs in about 50% of patients undergoing a restorative proctocolectomy for ulcerative colitis. This affection represents a significant therapeutic challenge, particularly for symptomatic patients who do not respond to antibiotic treatments and biologic therapies. Several dietary approaches, including low FODMAP diets and the Mediterranean diet, have shown promising results in improving symptoms and disease burden. The rationale for dietary intervention lies in the reduction in inflammation and modulation of gut microbiota. However, conflicting results and methodological heterogeneity jeopardize the transition of these approaches from the field of research to clinical practice. Together with a nutritional approach, innovative methods of microbiota modulation, including probiotics and fecal microbiota transplantation, are emerging as safe and effective strategies in managing chronic pouchitis. This narrative review analyzes recent advancements in nutritional therapies and microbiota modulation as innovative and complementary approaches for managing chronic pouchitis. After examining microbiota modulation strategies, specifically the effectiveness of probiotics, prebiotics, and fecal microbiota transplantation in restoring microbial diversity and their potential role in alleviating symptoms, the review assesses the available clinical evidence concerning dietary interventions and their impact on gut microbiota. A comprehensive understanding of interventions aimed at modulating the microbiota is crucial for enhancing the effectiveness of conventional therapies. Such strategies may lead to significant improvements in patients’ quality of life and their perception of the disease. However, the variability in microbiota composition, the use of restrictive diets, and the lack of standardized methods for evaluating these interventions remain significant challenges. Future research is essential to improve our understanding of the underlying mechanisms and optimize clinical application.

Hunger and the transition from parenteral nutrition in hospitalized adults: A descriptive cohort study.

Parenteral nutrition (PN) provides nutrition to patients who cannot use the digestive tract. Some patients experience delayed appetite recovery after PN, but the factors contributing to this remain unclear. This study aimed to investigate whether hospitalized patients receiving PN experience reduced hunger or appetite. A descriptive cohort study was conducted on adults who underwent PN between April 2022 and July 2023. Data on patient characteristics and nutritional support were collected from medical records. Hunger and satiety were assessed using a validated tool during three phases: clinical stability with calorie-protein targets on PN, transition to oral/enteral feeding, and PN withdrawal. The primary outcome was the absence of hunger assessed by the tool. Of 231 screened patients, 102 were included. Among these, 62.7% reported hunger during PN. Lipid doses and energy reduction strategies did not affect hunger or satiety. Transition success to oral/enteral nutrition was 2.38 times higher in patients who experienced hunger compared to those who did not (95% CI: 1.59-3.54). Poisson regression identified higher age, inflammation, and metastatic cancer as independent factors associated with the absence of hunger. This study suggests that PN does not suppress hunger and that factors other than nutritional therapy (age, inflammation, and cancer) could explain the absence of appetite. Considering individual conditions and needs, these findings could guide decision-making strategies regarding the transition from PN to oral/enteral feeding.

Practical Study on the Participation of Clinical Pharmacists in Multi-Disciplinary Teams Dealing With Nutrition Intervention Management in Ovarian Cancer.

This study aimed to explore the role of clinical pharmacists in guiding nutritional treatment in a multi-disciplinary team for patients with ovarian cancer (OC) and the significance of pharmaceutical nutritional intervention in overall management and drug administration. Fifty-nine patients with OC in our gynaecological oncology ward were retrospectively investigated. The patients were divided into a conventional therapy (CT) group (n = 30) and a pharmaceutical management (PM) group (n = 29) according to different nutritional therapies received. Nutritional monitoring indicators and clinical response indicators were used to evaluate the intervention effect. Serum albumin (ALB), haemoglobin (HGB) and prealbumin (PAB) levels at admission and discharge, exhaust time, time to return to a normal diet, time to first postoperative chemotherapy and length of hospital stay were measured. The PAB and ALB indicators in the PM group returned to the admission levels; the difference between the two groups was statistically significant (p < 0.05). There was no significant difference in HGB levels between the two groups (p > 0.05). The time to flatus, time to return to normal diet and time to first postoperative chemotherapy in the PM group were significantly shorter than those in the CT group, and the differences had statistical significance (p < 0.05). Patients in the PM group had a significantly shorter hospital stay than those in the CT group (12.5 ± 3.2 days vs 16.8 ± 4.1 days; p = 0.022). Nutritional treatment management by clinical pharmacists plays a key role in the antitumour treatment of patients with OC, effectively improving their nutritional status and thus promoting rapid postoperative recovery.

Interventions Targeting Insulin Resistance in Patients with Type 1 Diabetes: A Narrative Review.

Background and Objectives: Insulin resistance (IR) is the most important factor involved in the pathogenesis of type 2 diabetes but may also develop in type 1 diabetes (T1DM). Developing IR in patients with T1DM may generate a burden in achieving glycemic targets and may deteriorate the overall prognosis. This review aims to describe the pathogenesis of IR in T1DM, summarize the common associations of IR with other conditions in patients with T1DM, describe the consequences of developing IR in these patients, and present the interventions that target IR in people with T1DM. Results: The occurrence of IR in T1DM is multifactorial; however, it is frequently linked to overweight or obesity and sedentary lifestyle. Besides impairments in glycemic control and increased insulin requirements, the presence of IR is associated with an increased cardiovascular risk in patients with T1DM. Considering that patients with T1DM are insulin-treated, IR may be evaluated only using surrogate biomarkers, the most frequently used being the estimated glucose disposal rate. The most important interventions that are shown to be feasible in improving insulin sensitivity in patients with T1DM are lifestyle optimizations, including nutrition therapy or physical activity and pharmacotherapy with metformin, sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists, and thiazolidinediones. Conclusions: Targeting the improvement of IR in patients with T1DM is a key element in achieving optimal glycemic control, as well as improving the overall patient's prognosis besides glycemic control.

Impact of Medically Tailored Meals on Clinical Outcomes Among Low-Income Adults with Type 2 Diabetes: A Pilot Randomized Trial.

Adults with type 2 diabetes (T2DM) and adverse social determinants of health experience barriers to healthful eating, and achieve poorer glycemic control and clinical outcomes. To examine the impact of medically tailored meals (MTM) with medical nutrition therapy (MNT) on clinical outcomes among adults with DM. Pilot randomized controlled trial. English-speaking adults with DM and hemoglobin A1c (A1c) levels > 8% insured by Maryland Medicaid plans. The treatment group received home delivery of 12 medically tailored, frozen meals and a fresh produce bag weekly for 3months, and individual calls with a registered dietitian monthly for 6months in addition to usual care. The control group received usual care. Outcomes were change from baseline to 6months in A1c (primary), body mass index (BMI), blood pressure, food insecurity, and diabetes-related quality of life, knowledge, and self-efficacy (secondary). We randomized 74 adults; 77% completed data collection. The mean age was 48years, 40% were male, 77% were Black, and the mean A1c was 10.3%. Eighty-six percent of meals were delivered, and on average 4.8 nutrition visits were completed. At 6months, both groups had similar improvements in A1c (- 0.7 vs. - 0.6%); the control group reported more favorable changes in diabetes medications. Changes in systolic blood pressure and BMI at 6months did not differ between groups. Diabetes-related quality of life, knowledge, and self-efficacy improved modestly, but not differently by group. Food insecurity decreased significantly from baseline to 3months in the intervention (53 to 17%) compared to control (48 to 44%; p < 0.05), which lessened but remained significant at 6months. Recruitment and retention of an at-risk group of adults with DM was feasible. Intervention uptake was good but did not improve clinical outcomes. More comprehensive and clinically integrated interventions are likely needed to achieve significant clinical benefits. NCT04034511.

Potential of isothiocyanate sulforaphane from broccoli to combat obesity and type 2 diabetes: involvement of NRF2 regulatory pathway

Biologically active food components are now considered to be remedies for the prevention and treatment of metabolic disorders of different etiology. The aim of this review was to analyze the current data on the application of isothiocyanate sulforaphane, found in broccoli and other cruciferous plants, for the treatment of T2DM, obesity, and their comorbidities with the presentation of established molecular, particularly dependent on NF-E2-related factor-2 (Nrf2), and signaling mechanisms of therapeutic effects. Keywords: broccoli sprouts, Nrf2, nutritional therapy, obesity, preventive health, sulforaphane, type 2 diabetes mellitus

Evaluation of the Impact of Enteral Nutrition Support on Anthropometric Measurements and Micronutrient Levels in Malnourished Children.

Malnutrition is a critical clinical condition that requires early intervention due to its potential for causing preventable fatalities and complications. This study aims to assess the impact of outpatient enteral nutrition support (ENS) as a therapeutic intervention on anthropometric measurements, intolerance, and micronutrient values in malnourished children. This observational study included 344 patients in ages 1 to 18 treated with standard enteral nutrition (1.5 kcal/mL energy with fiber). Patient data recorded at admission, in 3 and 6 months, including weight, height, body mass index (BMI), intolerance symptoms, and micronutrient levels. Data were also compared by age groups (1-2, 3-5, 6-12, and 13-18 years of age). Malnutrition was prevalent in the 1- to 5-year age group (63.6%). Age-based analysis showed significant height and BMI z-score improvement in all age groups (P = .009 and P < .001, for all age groups, respectively), except the 13- to 18-year age group (P = .102 and P = .091, respectively). Micronutrient values remained within healthy ranges with minimal fluctuations. The ENS was well tolerated by 62.5% of patients, and the most common intolerance symptoms were constipation (15.4%), vomiting (8.1%), and nausea (7.3%). This study demonstrates that outpatient ENS therapy for 6 months significantly improved anthropometric measurements in malnourished children and was well tolerated. The 1 to 2 age group exhibited the most substantial response to treatment, whereas the 1 to 5 age group required at least 6 months of nutritional therapy to prevent stunting. However, the effect of ENS therapy on height and BMI z-scores in the 13 to 18 age group appeared insufficient after 3 months.

Prevalence of hospital malnutrition in patients using nutritional support.

To investigate the prevalence of malnutrition in hospitalized patients using nutritional support, considering it's difficult to achieve nutritional goal and great risk to increase malnutrition. A cross-sectional study with 102 patients over 18 years in use of enteral and/or parenteral nutritional therapy and monitored by the Nutritional Therapy Committee between December 2021 and August 2022. All data were collected from electronic medical records. Patients were diagnosed with Subjective Global Assessment (SGA) and Global Leadership Initiative on Malnutrition (GLIM) tools by the researchers. A total of 102 patients were evaluated, with a mean age of 57.5 years (±16.7) and 63.7% were male. According to the SGA, 26.5% were classified as moderately and 44.1% as severely malnourished. According to the GLIM, 19.6% were moderately and 43.1% were severely malnourished. The two diagnoses showed a moderate agreement (0.46). When evaluating only the 26 patients with overweight or obesity, the GLIM identified one patient with malnutrition and the SGA identified six patients. The SGA and the GLIM tool identified a high prevalence of malnutrition in patients using nutritional support in the hospital. The use of GLIM for diagnosis of malnutrition in hospitalized patients using nutritional support proved to be an excellent and practical tool, despite being less sensitive for patients with obesity. Subjective Global Assessment was a more sensitive tool in evaluating patients with malnutrition and using nutritional support. More studies are needed to confirm the use of lean mass reduction markers to identify the degree of malnutrition defined by GLIM in hospitalized patients.

Effectiveness of Providing Murotal Therapy of Surah Ar-Rahman on Pain of NY R with Post-Op Thyroidectomy in the Late Room of Prof. Dr. Margono Soekarjo Hospital

Nursing care is an integral part of health services for patients diagnosed with thyroid tumors. This study aims to explore the nursing care provided to Ms. R, a patient diagnosed with thyroid tumors in the Teratai Room, Prof. Dr. Margono Soekarjo Hospital. The method used is the nursing process including assessment, nursing diagnosis, planning, implementation, and evaluation. The results of the assessment showed that there were main complaints in the form of swelling in the neck area, swallowing disorders, and anxiety. The nursing diagnoses found included ineffective airway, nutritional imbalance, and anxiety. The interventions provided included airway management, adequate nutrition, and psychological therapy to reduce anxiety. The evaluation showed an improvement in the patient's clinical condition after the intervention was carried out continuously. This study concludes that comprehensive and focused nursing care can improve the quality of life of patients with thyroid tumors.

Parenteral Nutrition in the Health-Care Setting: A Comprehensive Review

Parenteral Nutrition (PN) is a critical therapeutic technique that delivers necessary nutrients straight into the circulation, bypassing the gastrointestinal system. This strategy is critical for people who are unable to acquire appropriate nourishment through oral or enteral routes owing to a variety of medical issues. PN first appeared in the mid-twentieth century, primarily to help those who were very malnourished or recuperating from significant surgery. As medical understanding of nutrition grew, so did the complexity and customization of PN formulations, allowing for personalized nutritional support depending on metabolic demands. The indications for PN are diverse, including gastrointestinal diseases, cancer therapies, severe illnesses, neurological issues, and pediatric demands. Patients suffering with Crohn's illness, short gut syndrome, and severe malnutrition caused by cancer therapies frequently rely on PN to maintain their nutritional status. Furthermore, critically sick patients in intensive care settings typically encounter elevated metabolic demands, needing efficient nutritional therapies that oral feeding cannot deliver. While PN has considerable advantages, such as increased recovery, malnutrition prevention, and quality of life, it is not without hazards. Infections, metabolic abnormalities, and liver dysfunction are all possible complications, emphasizing the importance of thorough monitoring and following best practices in PN administration. A multidisciplinary approach including healthcare specialists from several professions is required to achieve the best outcomes for patients seeking PN. Looking ahead, technological developments, personalized dietary techniques, and artificial intelligence integration promise to improve the safety and efficacy of PN. Continuous research and innovation are required to solve current difficulties and enhance the overall quality of care for patients requiring parenteral feeding. As the healthcare environment shifts, PN will remain an important component of nutritional support, requiring continuing attention and development in clinical practice.

The usefulness of an application-supported nutritional intervention on non-high-density lipoprotein cholesterol in people with a risk of lifestyle-related diseases.

Lifestyle-related diseases, such as diabetes, are mostly caused by poor lifestyle habits; therefore, modifying these habits is important. In Japan, a system of specific health checkups (SHC) and specific health guidance (SHG) was introduced in 2008. The challenges faced include low retention rates and difficulty in maintaining results. Digital technologies can support self-management and increase patient convenience, although evidence of the usefulness of this technology for SHG is limited. This study evaluated the usefulness of nutritional guidance using a smartphone application (app) added to conventional SHG. We recruited eligible participants for SHG in Japan from November 2018 to March 2020. We assigned them to "Intervention Group: Application-Supported Nutrition Therapy" or "Control Group: Human Nutrition Therapy" based on their desire to use the app. The primary outcome was a change in non-high-density lipoprotein cholesterol (non-HDL-C) levels post-intervention. The secondary outcomes were a change in lipid profile, metabolic indices, and frequency of logins to the app. We assessed 109 participants in two cohorts: 3-month (short-term) and 6-month (long-term). The short-term cohort had 23 intervention and 29 control participants, while the long-term cohort had 35 and 22, respectively. There was a significant improvement in non-HDL-C levels in the short-term intervention group compared to the control group. There was no significant difference in non-HDL-C levels in the long-term groups or at 1 year. There were significant improvements in body weight (BW) in the short-term cohort until 1 year compared within the groups. The retention rate remained high in the short-term cohort (92%) but decreased to 57.8% at 6 months in the long-term cohort. Using an app system to facilitate dietary recordings and guidance for patients at risk of lifestyle-related diseases led to improved lipid levels and BW. These benefits persisted to some extent after 1 year. This app may partially supplement conventional SHG.

Nutrition Management in Pediatric Traumatic Brain Injury: An Exploration of Knowledge Gaps and Challenges

AbstractTraumatic brain injury (TBI) stands as the leading cause of morbidity and mortality among children, as evidenced by the most contemporary statistics. Undernutrition in pediatric TBI (PTBI) leads to increased mortality, heightened infectious complications, and more severe neurological consequences. Therefore, timely and effective nutritional therapy is crucial in managing PTBI to improve patient prognosis and outcomes. Limited investigations have been conducted on the nutritional requirements specific to these patients and management often relies on data from adults with TBI for guidance. We have meticulously searched different databases to compile a broad range of the most up-to-date clinical research. This review analyses the challenges associated with providing nutritional support to children with TBI and provides a clearer understanding of the current evidence-based recommendations for optimal nutritional therapy. The review primarily focuses on recommendations and suggestions for energy requirements, nutritional assessment, initiation of nutrition, various feeding methods offered, identification of malnutrition, the impact of malnutrition on patient outcomes, and areas of further research.

Summary of Evidence on Nutritional Management for Patients Undergoing Chemotherapy.

This paper aims to consolidate the most robust evidence on nutritional strategies for patients undergoing chemotherapy, offering evidence-based guidance for clinical practice. The review highlights critical evidence gaps in nutritional therapy for advanced gastric cancer (AGC) patients undergoing systemic therapy, integrating findings from both prospective and retrospective studies. According to the "6S" evidence resource pyramid model, clinical decision-making tools, guidelines, expert consensus, and systematic reviews on nutritional management for chemotherapy patients were systematically retrieved from national and international databases. The methodological quality of the selected literature was evaluated using AGREE II for guidelines, the JBI Evidence-Based Healthcare Center's standards for systematic reviews, and expert consensus developed by evidence-based practice experts. A total of 47 articles were analyzed, consisting of 12 guidelines, 12 expert consensus statements, and 23 systematic reviews. The findings were categorized into five dimensions: interdisciplinary collaboration, nutritional screening and assessment, nutritional requirements, nutritional therapy, and discharge and follow-up, resulting in the identification of 62 pieces of relevant evidence. The study provides comprehensive, evidence-based recommendations for nutritional management in chemotherapy patients. Application of the evidence should be adapted to specific clinical scenarios, patient conditions, preferences, and expert judgment to ensure both feasibility and relevance in clinical practice. This review consolidates diverse nutritional management strategies into a unified framework, addressing evidence gaps in AGC under systemic therapy. Integrating prospective and retrospective studies with interdisciplinary insights provides evidence-based recommendations to enhance patient care through personalized and standardized approaches.

Nutritional therapy among adult patients with severe burns: A retrospective observational study.

The objective of this study was to examine the effects of nutritional therapy in adult patients with severe burns. Sixty adult patients with severe burns were enrolled. Data on nutritional intake through enteral nutrition (EN) or parenteral nutrition (PN) on days 7, 14, 21, and 28 post-injury were collected. Patients were divided into target and non-target groups according to whether their energy or protein intake reached the target. Age, length of ventilation, and total bilirubin (TBIL), albumin (ALB), prealbumin (pALB), and C-reactive protein (CRP) concentrations of patients were recorded. The percentage of protein targets with protein delivery was lower than that of energy target with energy delivery. The ratio of PN protein to total protein was lower than that of PN energy to total energy on days 7, 14, 21, and 28 (p<0.001, p<0.001, p=0.001, and p=0.003, respectively). Compared to the non-target group on day 21, the target group was younger, had lower TBIL on day 7, higher ALB and pALB on day 21, and lower CRP on day 14 (p=0.025, p=0.021, p=0.028, p=0.029, and p=0.049, respectively). Multivariate logistic regression analysis showed that older age and longer ventilation were independent risk factors in patients who did not meet the nutritional target on day 21 (p=0.026 and p=0.043, respectively). The protein intake of adult patients with severe burns was low. Compared to the non-target group, the target group had better laboratory test results. Older age and longer ventilation were independent risk factors for patients not meeting the nutritional target.

Nutritional support therapy is also an important part of rehabilitation after abdominoplasty surgeries

Nutritional support therapy is also an important part of rehabilitation after abdominoplasty surgeries

Extracellular fluid volume as a key indicator in home-care management of chronic heart failure: The role of nutritional and exercise therapy.

Extracellular fluid volume, rather than body weight, should guide chronic heart failure management in home-care patients. Enhancing muscle mass through pharmacotherapy, nutrition, and exercise is essential to prevent heart failure exacerbation.

Dallas Nephrology Associates' journey to value-based care.

In 2016, Dallas Nephrology Associates recognized that the economic, humanistic, and societal burden of end-stage kidney disease was unsustainable and the fee-for-service model of reimbursement did not support a value-based care approach. We decided to be proactive by creating new workflows, education, and disease management so that patients could make well-informed choices, ultimately resulting in better outcomes. Our shift toward value-based care focused on patient engagement, education, integrated infrastructure, collaboration, and monitoring of metrics associated with improved outcomes. Our practice invested millions of dollars in a population health division, which includes nurse navigators and data analysts focused on managing chronic kidney disease (CKD), delaying progression, and promoting transplantation and home-based dialysis. This retrospective review demonstrates improved outcomes, lower costs, and increased quality of care. Performance metrics have consistently met or exceeded targets. Seventy-three percent of patients now experience an optimal planned start to dialysis. Preemptive transplantation referrals have increased from 7% in 2017 to 61% through June 2023. Referral of patients with stage 4 CKD to educational workshops increased from 38% to 68%, and medical nutrition therapy referrals increased from 23% to 67%. Although reimbursement challenges persist, our commitment to improving care and slowing CKD progression remains steadfast. We emphasize teamwork, robust analytics, and continuous improvement. Future initiatives include encouraging patients receiving in-center hemodialysis to convert to home-based dialysis, addressing behavioral health, and focusing on preventable complications in high-risk patients. By embracing value-based models, we have demonstrated that a patient-centered approach can lead to improved outcomes and value for payers.

Efficacy and safety of individual nutrition support in patients with hepatitis B virus-related acute-on-chronic liver failure at nutrition risk: a study protocol for a randomised controlled clinical trial

IntroductionMalnutrition is a common complication of hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) typically associated with poor prognosis. Despite nutritional treatment, the outcomes for these patients are limited by the...