Oral Nutritional Support Research Articles

The use of prealbumin as a predictor of malnutrition in cirrhotic patients and the effect of nutritional support in patients with low prealbumin levels

Background/aimMalnutrition is an important and commonly seen prognostic factor in patients with cirrhosis. The diagnosis of malnutrition in cirrhosis patients may be challenging, and an easily measured and widely usable marker is lacking. Prealbumin, however, is an easily measured marker. In the current study we measured prealbumin levels in cirrhotic patients with no clinically apparent malnutrition and used it as a malnutrition marker. Another aim of this study was to evaluate the effect of nutritional support on patient with low prealbumin levels. Materials and methodsFifty-two patients with Child A and Child B cirrhosis were selected for the study. Prealbumin levels were studied, and Child and MELD scores were calculated. Patients with prealbumin levels ˂180 mg/L were considered to have malnutrition, and two different types of nutritional products were given to these patients. The patients given nutritional support were investigated a month later, and parameters were compared. ResultsAccording to the prealbumin threshold of 180 mg/L, malnutrition frequencies were 59.3% for Child A and 95% for Child B cirrhosis. After the provision of nutritional support statistically significant improvements in albumin and INR levels were detected. In addition, the MELD score decreased; however, it was not statistically significant (P: 0.088). A statistically significant decrease in the MELD score was only obtained in patients with Child B cirrhosis (P: 0.033). When the oral replacement therapies were investigated separately, a statistically significant decrease in MELD scores was detected with product 1 (P: 0.043).Conclusion Prealbumin can be used as an easily measured parameter for earlier detection of malnutrition in patients with cirrhosis and without clinically apparent malnutrition. Oral nutritional support, especially with products containing relatively high carbohydrate levels and low protein, may have a favorable effect on MELD scores.

Effects of comprehensive and intensive pulmonary rehabilitation and nutritional support on quality of life and functional status in patients with chronic obstructive pulmonary disease.

ObjectiveTo investigate the effects of pulmonary rehabilitation (PR) and combined nutritional support therapy on quality of life (QoL) and functional status in patients with chronic obstructive pulmonary disease (COPD).MethodsThis pre-and post-intervention prospective exploratory study involved 64 patients with stable stage three to four COPD. Oral nutritional support and personalized diet were combined with an intense and comprehensive PR program. Baseline and 8-week follow-up scores were compared for the 6-minute walk test (6MWT), incremental shuttle walking test (ISWT), St. George’s Respiratory Questionnaire (SGRQ), pulmonary function tests (PFT), PImax-PEmax, arterial blood gas (ABG), respiratory rate (RR), handgrip strength, Borg and modified Medical Research Council dyspnoea scale scores and fat-free mass index.ResultsSignificant improvements were found in functional status (6MWT: 86.72 m, ISWT: 76.24 m), QoL (SGRQ total: 13.86), PFT, ABG, RR, dyspnoea, upper extremity muscle strength and hand-body composition.ConclusionNutritional support with comprehensive and intensive PR can significantly improve physical performance, QoL, dyspnoea and body composition in COPD. The improvement in QoL was greater than that reported in previous studies. Because two modalities were combined in this study, future randomized controlled studies are needed to confirm the extent and contribution of these modalities to the outcomes.

Energy-dense, low-volume paediatric oral nutritional supplements improve total nutrient intake and increase growth in paediatric patients requiring nutritional support: results of a randomised controlled pilot trial

Children with or at risk of faltering growth require nutritional support and are often prescribed oral nutritional supplements (ONS). This randomised controlled trial investigated the effects of energy-dense paediatric ONS (2.4 kcal/ml, 125 ml: cONS) versus 1.5 kcal/ml, 200 ml ONS (sONS) in community-based paediatric patients requiring oral nutritional support. Fifty-one patients (mean age 5.8 years (SD 3)) with faltering growth and/or requiring ONS to meet their nutritional requirements were randomised to cONS (n = 27) or sONS (n = 24) for 28 days. Nutrient intake, growth, ONS compliance and acceptability, appetite and gastro-intestinal tolerance were assessed. Use of the cONS resulted in significantly greater mean total daily energy (+ 531 kcal/day), protein (+ 10.1 g/day) and key micronutrient intakes compared with the sONS group at day 28 and over time, due to high ONS compliance (81% of patients ≥ 75%), maintained intake from diet alone and improved appetite in the cONS group, compared with the sONS group. Although growth increased in both intervention groups, results were significant in the cONS group (weight (p = 0.007), height (p < 0.001) and height z-score (p = 0.006)).Conclusions: This study shows that use of energy-dense (2.4 kcal/ml) low-volume paediatric-specific ONS leads to improved nutrient intakes, growth and appetite in paediatric patients requiring oral nutrition support compared with standard energy density ONS.Trial registration: The trial is registered at clinicaltrials.gov, identification number NCT02419599.What is Known:• Faltering growth is the failure of children to achieve adequate growth at a normal rate for their age and requires nutritional support, including the use of oral nutritional supplements (ONS).• Energy-dense, low-volume ONS have benefits over standard ONS in adults.What is New:• This is the first RCT to investigate the effects of energy-dense, low-volume ONS (2.4 kcal/ml, 125 ml) in children with faltering growth, showing significant improvements in total nutrient intake and increased growth.• Energy-dense, low-volume ONS can play a key role in the management of faltering growth.

Oral nutritional supplements for preventing surgical site infections: protocol for a systematic review and meta-analysis

BackgroundSurgical site infections (SSIs) are among the most common healthcare-associated infections. Under-nutrition is an important risk factor for SSIs and can lead to delayed wound healing and longer hospital stays. Oral nutritional supplements are prescribed to reduce the risk of infection and improve health status, but data from randomised controlled trials (RCTs) have shown mixed results. Thus, the objective of our planned systematic review is to evaluate oral nutritional supplements on preventing SSIs in adult surgical patientsMethodsRCTs conducted in adult surgical patients who receive oral nutritional support will be included. The primary outcome will be the incidence of SSIs (within 30 days of surgery or within 90 days for joint replacement surgery). Secondary outcomes will be changes in nutritional status, mortality, health-related quality of life and costs. Literature searches will be conducted in several electronic databases (from inception onwards): MEDLINE, Embase, CINAHL and The Cochrane Central Register of Controlled Trials (CENTRAL). Grey literature will be identified through searching clinical trial registers and dissertation databases. Two reviewers will independently screen all citations, full-text articles and abstract data. The study methodological quality (or bias) will be appraised using the Cochrane risk of bias tool. If feasible, we will conduct random effects meta-analysis where appropriate.DiscussionThis systematic review will evaluate the evidence for pre- and post-surgical intervention with oral nutritional supplements in adults. Findings from this planned review may inform subsequent nutritional interventions for hospitalised patients who undergo surgery.Systematic review registrationPROSPERO CRD42020140954

Nutrition interventions implemented in hospital to lower risk of sarcopenia in older adults: A systematic review of randomised controlled trials.

AimThere is no standardised interventional approach to preventing or treating sarcopenia in older adults in hospital. The aim of this review was to systematically identify and synthesise the effects of nutritional interventions on markers of sarcopenia in hospitalised patients aged 65 years and older.MethodsFour databases were searched using terms for intervention, population and setting. Eligibility screening of title and abstract and then full‐text papers was competed in duplicate, independently. The final included papers were assessed for quality, and outcome data extracted independently and in duplicate. Outcome data were synthesised by meta‐analysis, where possible, or narratively.ResultsSeven hundred and thirty‐two articles were screened for eligibility yielding six studies for inclusion. All studies provided oral nutritional support that aimed to increase protein intake ranging from an additional 10 to 40 g/d, each with a unique formulation of amino acids and/or micronutrients; three studies combined nutritional intervention with an enhanced physical activity program. Five studies measured hand grip strength, the mean difference was 1.97 kg (95% CI 0.55‐3.39, P = .006) greater in the intervention group (n = 166) compared with control group (n = 165). Assessment of muscle mass and activities of daily living were heterogeneous and the changes inconsistent between studies.ConclusionsFew studies inform nutritional management of inpatients with sarcopenia or at risk of sarcopenia. High quality, large intervention trials are needed urgently to identify the optimal nutrition and physical activity intervention combinations to manage sarcopenia in older hospitalised adults. These studies need to include outcome measures of physical function and muscle quality.

A working partnership between health and social care in the care of patients on home enteral feeds

The Reablement Service (social care) supports those living in their own home to remain independent with support on the development of skills and completion of tasks for a period of up to 6 weeks. The Reablement team employed 0.5wte of a senior dietitian who mainly supported those requiring oral nutrition support. As part of an ongoing improvement plan, an extension of the service in order to support those with bolus percutaneous endoscopic gastrostomy (PEG) feeds was identified.

Nutritional outcomes in head and neck cancer patients: is intensive nutritional care worth it?

ObjectiveThis study aimed to compare nutritional outcomes before and after implementation of weekly dietetic counseling (intensive nutritional care) in head and neck cancers patients. MethodsA retrospective study with all head and neck patients, who received radiotherapy between January 2010 and December 2017 were performed. The main outcome was significant weight loss. Compliance to caloric and protein recommendations were also evaluated. ResultsIn all, 472 patients were included. Weight loss was not different between before and after implementation (-6.7%; IQ -10.5/-1.9 vs -5.0%; IQ -9.8/-0.7;p=0.06).There were no significant difference in terms of meeting the recommended intake. Higher baseline body mass index and oral nutritional support predicted significant weight loss. ConclusionImplementation of intensive nutritional care did not have an impact on weight loss and energy and protein intake in head and neck cancer patients. Further research would be of value to determine the appropriate service-delivery model to achieve optimal patient outcomes.

Influence of Geriatric Patients' Food Preferences on the Selection of Discharge Destination.

BackgroundThe nonprotein calorie/nitrogen (NPC/N) ratio of food remains poorly investigated. Thus, this study examined the nutritional factors that influence the choice of discharge destination for geriatric patients.MethodsWe retrospectively investigated the patient characteristics, clinical laboratory test results, and hospital food consumption of 65 geriatric patients (80.0 ± 8.2 years; 31 males, 34 females), who were receiving oral nutritional support at a small mixed-care hospital and further explored their discharge destinations. The NPC/N ratios were calculated according to the menus for the meals provided during the first 4 weeks after admission. For logistic regression analysis, the objective variables were discharge destinations (i.e., nursing care facilities including home or medical institutions) whereas the predictor variables were age, sex, nursing care level, hospitalization duration, serum albumin level (Alb), estimated glomerular filtration rate (eGFR), and NPC/N ratio.ResultsCompared with age and nursing care level, sex (partial regression coefficient (B) = -5.140, P = 0.002), hospitalization duration (B = 0.077, P = 0.004), Alb (B = 3.223, P = 0.013), eGFR (B = -0.071, P = 0.019), and NPC/N ratio (B = -0.224, P = 0.001) are significantly correlated with the selection of discharge destination.ConclusionsFor geriatric patients who went to medical institutions, the need for prolonged hospitalization, male sex, hospitalization duration, stable serum Alb, low eGFR, low NPC/N ratio (i.e., high protein proportion), and the quantity of hospital food consumed were the possible factors that influence their discharge destination.

Association of Nutritional Support With Clinical Outcomes Among Medical Inpatients Who Are Malnourished or at Nutritional Risk

Malnutrition affects a considerable proportion of the medical inpatient population. There is uncertainty regarding whether use of nutritional support during hospitalization in these patients positively alters their clinical outcomes. To assess the association of nutritional support with clinical outcomes in medical inpatients who are malnourished or at nutritional risk. For this updated systematic review and meta-analysis, a search of the Cochrane Library, MEDLINE, and Embase was conducted from January 1, 2015, to April 30, 2019; the included studies were published between 1982 and 2019. A prespecified Cochrane protocol was followed to identify trials comparing oral and enteral nutritional support interventions with usual care and the association of these treatments with clinical outcomes in non-critically ill medical inpatients who were malnourished. Two reviewers independently extracted data and assessed risk of bias; data were pooled using a random-effects model. The primary outcome was mortality. The secondary outcomes included nonelective hospital readmissions, length of hospital stay, infections, functional outcome, daily caloric and protein intake, and weight change. A total of 27 trials (n = 6803 patients) were included, of which 5 (n = 3067 patients) were published between 2015 and 2019. Patients receiving nutritional support compared with patients in the control group had significantly lower rates of mortality (230 of 2758 [8.3%] vs 307 of 2787 [11.0%]; odds ratio [OR], 0.73; 95% CI, 0.56-0.97). A sensitivity analysis suggested a more pronounced reduction in the risk of mortality in recent trials (2015 or later) (OR, 0.47; 95% CI, 0.28-0.79) compared with that in older studies (OR, 0.94; 95% CI, 0.72-1.22), in patients with established malnutrition (OR, 0.52; 95% CI, 0.34-0.80) compared with that in patients at nutritional risk (OR, 0.85; 95% CI, 0.62-1.18), and in trials with high protocol adherence (OR, 0.67; 95% CI, 0.54-0.84) compared with that in trials with low protocol adherence (OR, 0.88; 95% CI, 0.44-1.76). Nutritional support was also associated with a reduction in nonelective hospital readmissions (14.7% vs 18.0%; risk ratio, 0.76; 95% CI, 0.60-0.96), higher energy intake (mean difference, 365 kcal; 95% CI, 272-458 kcal) and protein intake (mean difference, 17.7 g; 95% CI, 12.1-23.3 g), and weight increase (0.73 kg; 95% CI, 0.32-1.13 kg). No significant differences were observed in rates of infections (OR, 0.86; 95% CI, 0.64-1.16), functional outcome (mean difference, 0.32; 95% CI, -0.51 to 1.15), and length of hospital stay (mean difference, -0.24; 95% CI, -0.58 to 0.09). This study's findings suggest that despite heterogeneity and varying methodological quality among trials, nutritional support was associated with improved survival and nonelective hospital readmission rates among medical inpatients who were malnourished and should therefore be considered when treating this population.

Oxalate Content of Enteral Nutrition Formulas.

Patients requiring oral and/or enteral nutrition support, delivered via nasogastric, gastric, or intestinal routes, have a relatively high incidence of calcium oxalate (CaOx) kidney stones. Nutrition formulas are frequently made from corn and/or or soy, both of which contain ample oxalate. Excessive oxalate intake contributes to hyperoxaluria (>45 mg urine oxalate/day) and CaOx stones especially when unopposed by concomitant calcium intake, gastrointestinal malabsorption is present, and/or oxalate degrading gut bacteria are limiting or absent. Our objective was to assess the oxalate content of commonly used commercial enteral nutrition formulas. Enteral nutrition formulas were selected from the formulary at our clinical inpatient institution. Multiple samples of each were assessed for oxalate concentration with ion chromatography. Results from 26 formulas revealed highly variable oxalate concentration ranging from 4 to 140 mg oxalate/L of formula. No definitive patterns for different types of formulas (eg, flavored vs unflavored, high protein vs not) were evident. Coefficients of variation for all formulas ranged from 0.68% to 43% (mean ± SD 19% ± 12%; median 18%). Depending on the formula and amount delivered, patients requiring nutrition support could obtain anywhere from 12 to 150 mg oxalate/day or more and are thus at risk for hyperoxaluria and CaOx stones.

UNDERESTIMATED PROTEIN ENERGETIC MALNUTRITION (PEM) IN PATIENTS AFFECTED BY RETROPERITONEAL SARCOMA (RPS)

RPS are mesenchymal non-epithelial neoplasms. Prevalence of PEM in patients with RPS is unknown. A prospective feasibility study enrolled 35 patients affected by primary RPS candidate to surgery. Patients were screened for PEM (according to SINPE Guidelines 2002). Preoperative high protein-beta-hydroxy-beta-methyl butyrate oral nutritional support (ONS) was provided according to PEM degree (Figure1). After surgery, nutritional support followed standard practice targeting 20-25 Kcal/Kg/die within 3rd postoperative day (pod). PEM was re-evaluated before surgery, at 10th pod, at 4 and 12 months. Primary outcome was patient's compliance to preoperative ONS. PEM was documented in 46% patients; although only 8.6% had been clinically undernourished. ONS had a 91% adherence, overall well tolerated. After ONS, PEM lowered to 38% (P=.45). Postoperative caloric target was reached on day 4.1 (SE±2.7), with 51% of protocol adherence. In 34% patients a naso-jejunal tube was positioned; Delayed gastric emptying (DGE) occurred in 38% patients. On 10th pod the majority of patients experienced serious PEM, and worsening was greater after resection of ≥4 organs (P=.06). At 4 and 12 months, almost all fully recovered (Figure 2). Relevant PEM prevalence in RPS, at risk to be clinically underestimated, is documented for the first time. In this setting, preoperative ONS was feasible and safe, and partially recovered PEM. Disease-related factors for PEM and ideal perioperative caloric target need to be further investigated. A wider use of jejunal access should be evaluated, considered the incidence of DGE. Nutritional support should be included in ERAS programs for RPS.

MON-PO551: Characteristics of Hospitalized Adult Patients Using Oral Nutrition Support at a Tertiary Referral Center in Mexico City

MON-PO551: Characteristics of Hospitalized Adult Patients Using Oral Nutrition Support at a Tertiary Referral Center in Mexico City

Böbrek Hastalıklarında Klinik Nütrisyon Yaklaşımı

Kronik böbrek yetmezliği (KBY), glomerül filtrasyon hızının (GFH) böbrek işlevlerinde saptanabilir düzeyde değişikliklere neden olacak kadar kalıcı bir şekilde azaldığı durum olarak tanımlanabilir. Son dönem böbrek yetmezliği (SDBY), endojen böbrek işlevinin geri dönüşümsüz kaybı ile karakterize ve hayatı tehdit eden üremiden korunmak için hastaya devamlı olarak diyaliz veya transplantasyon gibi renal replasman tedavilerinin uygulandığı klinik tabloyu oluşturur. SDBY insidansı ve prevalansı tüm dünyada artmaktadır. Kronik böbrek yetmezliğine eşlik eden üremik sendrom iştah kaybıyla, azalmış oral besin alımıyla sonuçlanan gastrointestinal yan etkilerle, metabolik asidoz, üremik toksisite, protein katabolizmasının başlamasıyla ilişkilidir. Malnütrisyon SDBY olan hastalarda önemli bir sorundur. Protein enerji malnütrisyonunun varlığı SDBY’de artmış mortalite ve morbidite ile ilişkilidir. Malnütrisyon sık görüldüğü için, beslenme durumunun periyodik olarak değerlendirilmesi, erken tanı ve uygun tedavide diyaliz hastalarının rutin bakımının bir parçasıdır. Öncelikle tıbbi beslenme tedavisi bireysel olarak düzenlenmeli, oral yolla yeterli enerji ve besin ögesi alamayan hastalar ve beden kütle indeksi &lt;20 kg/m2, 6 ayda %10’dan fazla ağırlık kaybı, serum albümin &lt;3.5 g/dL ve serum prealbümin &lt;30 mg/dL gibi düşük nütrisyonel parametreleriyle belirlenen beslenme yetersizliği olan hastalar için mutlak beslenme desteği verilmelidir. Hastalar hastalığına özel diyet ve/veya oral nütrisyonel destek ile günlük beslenme gereksinmesini karşılayamadığında önce tüple enteral beslenme önerilir. Enteral beslenme uygulanamıyor ise total parenteral beslenme veya hemodiyaliz anında intradiyalitik parenteral beslenme uygulanmalıdır. Bu derleme makalede, böbrek hastalıklarında beslenme destek tedavi yöntemlerine odaklanılacaktır.

Clinical observations of the effect of continuous enteral nutritional support through an indwelling jejunal feeding tube in the abdominal wall on improving subjective well-being after surgery and during chemotherapy

Background: Oral nutritional support is a general means of nutritional support after gastric cancer surgery and during postoperative chemotherapy. The main deficiency of oral nutritional support is that patients, due to various factors, cannot intake enough calories, resulting in poor nutritional support. Therefore, it is necessary to explore a nutritional support means that can ensure energy intake and to explore the significance of continuous enteral nutrition in improving the subjective tolerance of patients after gastric cancer surgery and during postoperative chemotherapy. Methods: Twenty-eight patients with gastric cancer were divided into 2 groups: 13 cases in group A and 15 cases in group B. Group A was the observation group, in which an indwelling jejunal feeding tube was placed intraoperatively through the abdominal wall; enteral nutritional support was provided during postoperative treatment and postoperative chemotherapy and continued until the end of chemotherapy. In group B, a jejunal feeding tube was not placed during surgery; therefore, enteral nutritional support was not provided during postoperative chemotherapy. The subjective overall well-being and subjective physical status of patients in the 2 groups during chemotherapy were observed and compared. Results: The subjective overall well-being and subjective physical status of patients in group A were better than those in group B. However, there was no significant difference in subjective overall well-being, but there was a significant difference in subjective physical status. Conclusions: Enteral nutritional support with an indwelling jejunal feeding tube after gastric cancer surgery until the end of chemotherapy is one a feasible measure and is beneficial to the rehabilitation of patients and the implementation of chemotherapy. However, further studies with larger samples and more clinical data are needed.

SUN-316 INTENSIVE NUTRITION THERAPY IN RENAL DISEASE

Oral nutrition support (ONS) is frequently used in malnourished patients with End Stage Kidney Disease (ESKD) requiring haemodialysis (HD). We describe the case of a 46 year old man (“DM”) who rapidly progressed to ESKD and the nutritional management required to stabilise worsening malnutrition during a prolonged hypermetabolic state. This case outlines the nutrition support used to aggressively treat a catabolic HD patient.

Perioperative nutrition for the treatment of bladder cancer by radical cystectomy.

Radical cystectomy (RC) is the primary surgical treatment for muscle-invasive urothelial carcinoma of the bladder. This major operation is typically associated with an extended hospital stay, a prolonged recovery period and potentially major complications. Nutritional interventions are beneficial in some people with other types of cancer and may be of value in this setting too.To assess the effects of perioperative nutrition in people undergoing radical cystectomy for the treatment of bladder cancer.We performed a comprehensive search using multiple databases (Evidence Based Medicine Reviews, MEDLINE, Embase, AMED, CINAHL), trials registries, other sources of grey literature, and conference proceedings published up to 22 February 2019, with no restrictions on the language or status of publication.We included parallel-group randomised controlled trials (RCTs) of adults undergoing RC for bladder cancer. The intervention was any perioperative nutrition support.Two review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias and the quality of evidence using GRADE. Primary outcomes were postoperative complications at 90 days and length of hospital stay. The secondary outcome was mortality up to 90 days after surgery. When 90-day outcome data were not available, we reported 30-day data.The search identified eight trials including 500 participants. Six trials were conducted in the USA and two in Europe.1. Parenteral nutrition (PN) versus oral nutrition: based on one study with 157 participants, PN may increase postoperative complications within 30 days (risk ratio (RR) 1.40, 95% confidence interval (CI) 1.07 to 1.82; low-quality evidence). We downgraded the quality of evidence for serious study limitations (unclear risk of selection, performance and selective reporting bias) and serious imprecision. This corresponds to 198 more complications per 1000 participants (95% CI 35 more to 405 more). Length of hospital stay may be similar (mean difference (MD) 0.5 days higher, CI not reported; low-quality evidence).2. Immuno-enhancing nutrition versus standard nutrition: based on one study including 29 participants, immuno-enhancing nutrition may reduce 90-day postoperative complications (RR 0.31, 95% CI 0.08 to 1.23; low-quality evidence). These findings correspond to 322 fewer complications per 1000 participants (95% CI 429 fewer to 107 more). Length of hospital stay may be similar (MD 0.20 days, 95% CI 1.69 lower to 2.09 higher; low-quality evidence). We downgraded the quality of evidence of both outcomes for very serious imprecision.3. Preoperative oral nutritional support versus normal diet: based on one study including 28 participants, we are very uncertain if preoperative oral supplements reduces postoperative complications. We downgraded quality for serious study limitations (unclear risk of selection, performance, attrition and selective reporting bias) and very serious imprecision. The study did not report on length of hospital stay.4. Early postoperative feeding versus standard postoperative management: based on one study with 102 participants, early postoperative feeding may increase postoperative complications (very low-quality evidence) but we are very uncertain of this finding. We downgraded the quality of evidence for serious study limitations (unclear risk of selection and performance bias) and very serious imprecision. Length of hospital stay may be similar (MD 0.95 days less, CI not reported; low-quality evidence). We downgraded the quality of evidence for serious study limitations (unclear risk of selection and performance bias) and serious imprecision.5. Amino acid with dextrose versus dextrose: based on two studies with 104 participants, we are very uncertain whether amino acids reduce postoperative complications (very low-quality evidence). We are also very uncertain whether length of hospital stay is similar (very low-quality evidence). We downgraded the quality of evidence for both outcomes for serious study limitations (unclear and high risk of selection bias; unclear risk of performance, detection and selective reporting bias), serious indirectness related to the patient population and very serious imprecision.6. Branch chain amino acids versus dextrose only: based on one study including 19 participants, we are very uncertain whether complication rates are similar (very low-quality evidence). We downgraded the quality of evidence for serious study limitations (unclear risk of selection, performance, detection, attrition and selective reporting bias), serious indirectness related to the patient population and very serious imprecision. The study did not report on length of hospital stay.7. Perioperative oral nutritional supplements versus oral multivitamin and mineral supplement: based on one study with 61 participants, oral supplements compared to a multivitamin and mineral supplement may slightly decrease postoperative complications (low-quality evidence). These findings correspond to 135 fewer occurrences per 1000 participants (95% CI 256 fewer to 65 more). Length of hospital stay may be similar (low-quality evidence). We downgraded the quality of evidence of both outcomes for study limitations and imprecision.Based on few, small and dated studies, with serious methodological limitations, we found limited evidence for a benefit of perioperative nutrition interventions. We rated the quality of evidence as low or very low, which underscores the urgent need for high-quality research studies to better inform nutritional support interventions for people undergoing surgery for bladder cancer.

The Renal Dietetic Outcome Tool (RDOT) in clinical practice

Providing cost- and clinically-effective services is essential in today's NHS, but it can be difficult to capture this data in day to day practice. The identification and development of outcome measures for dietetics is an ongoing challenge. This article describes how the Renal Nutrition Group of the British Dietetic Association developed three renal-specific Dietetic Outcome Models and a Renal Dietetic Outcome Tool (RDOT) to measure dietetic outcomes in potassium and phosphate management and oral nutrition support in patients with chronic kidney disease for use in daily clinical practice

Effect of two different nutritional supplements on postprandial glucose response and energy- and protein intake in hospitalised patients with COPD: A randomised cross-over study

Oral nutrition support is frequently used in treatment of malnutrition in patients with chronic obstructive pulmonary disease (COPD). Considering the use of corticoidsteroids in patients with COPD, little is known about the effect on postprandial glucose response and if they might interfere with glucose control. Our aims were to compare the effect of a liquid oral nutritional supplement (ONS) and semi solid inbetween meal snack (snack) on postprandial glucose and energy- and protein intake, and to compare the effect of timing of each intervention on postprandial glucose and energy- and protein intake. Patients with COPD (n=17) admitted to the Department of Pulmonary Medicine, Iceland and defined as at low or medium nutritional risk (score 0-3) were recruited. In a randomised cross-over design, subjects consumed ONS or snack either in a fasting state (study 1) or following breakfast (study 2) and postprandial glucose responses were assessed at regular intervals for two hours (t=15, t=30, t=45, t=60, t=90, t=120min). Energy- and protein intake was estimated using a validated plate diagram sheet. Wilcoxon Signed-Rank test was used to compare the two interventions. In study 2, following breakfast, postprandial glucose was significantly higher after consuming ONS than the snack after 60min (9.7±2.4mmol/L vs. 8.2±3.2mmol/L, p=0.013 and 120min 9.2±3.2mmol/L vs. 7.9±2.4mmol/L, p=0.021, respectively). No difference was found in postprandial glucose concentrations between ONS and the snack when consumed after overnight fasting (study 1). No difference in energy or protein intake from hospital food was seen between supplement types neither in study 1 or 2. Lower postprandial glucose concentrations were associated with the snack compared to ONS when taken after a meal compared to either type directly after overnight fasting. The clinical relevance of higher postprandial blood glucose after consuming a liquid ONS after breakfast compared with a semi solid snack needs to be studied further.

Longitudinal alterations in nutrient intake and food pattern in patients with non-small cell lung cancer during anti-neoplastic treatment: a cohort study.

Unintentional weight loss is frequently observed in cancer patients. Nutritional therapy is essential, and dietary counselling is the first step. The present study aimed to explore the nutrient intake and food patterns in weight-stable and weight-losing patients with non-small cell lung cancer (NSCLC) during anti-neoplastic treatment. Patients with NSCLC (n=62) were observed during first-line systemic anti-neoplastic treatment. Body weight and dietary intake were assessed on the first and second cycle, and after completing three cycles of treatment. Longitudinal changes were analysed in three groups: weight stable, weight losers and mixed weight. Nutrient intake did not change during treatment in weight stable, although weight losers significantly increased the relative protein intake. Weight stable maintained the food pattern during treatment apart from a decreased consumption of oral nutritional support (ONS). At baseline, weight losers were characterised by pretreatment weight loss, high consumption of ONS, as well as low consumption of grains and animal products. During treatment, weight losers increased the consumption of protein, fatty foods and ONS but decreased the consumption of sweets and alcohol. Large heterogeneity in nutrient and food intake was observed in NSCLC patients during anti-neoplastic treatment. Weight losers and weight stable had a similar nutrient intake although protein intake increased in weight losers. Grains and animal products were lower and ONS higher in weight losers compared to weight stable during treatment. Weight losers further increased the consumption of ONS and fatty foods, while the consumption of sweets and alcohol decreased during treatment.

Pharmacy Technician Review of Oral Nutritional Supplements (ONS) within Care Homes.

Up to 42% of patients admitted to care homes are at risk of malnutrition. Oral nutritional supplements (ONS) can be prescribed to increase nutritional intake when diet alone is insufficient to meet daily nutritional requirements. Where ONS are inappropriately initiated or continued beyond treatment goals this can contribute to significant waste and unnecessary costs. This study reviewed whether pharmacy technicians working in care home settings can support the cost-effective use of ONS. A quality improvement project using Plan-Do-Study-Act (PDSA) methodology was undertaken by pharmacy technicians working in care homes to review the prescribing and monitoring of ONS. A sample of 330 residents were reviewed across 5 care homes. 45 residents were prescribed ONS, 16 of whom were unknown to dietitians. In collaboration with the dietetic service an oral nutritional support flow chart was developed and tested. Thirteen of the 16 residents unknown to the dietetic team did not require ONS and could be considered for alternative dietary options. Through collaborative working with dietetic services, pharmacy technicians can support effective use and review of ONS for care home residents, reduce unnecessary prescribing, and ensure appropriate referral to dietitians where indicated.