Clinical Nutrition Practice Research Articles

ESPEN guidelines on definitions and terminology of clinical nutrition

A lack of agreement on definitions and terminology used for nutrition-related concepts and procedures limits the development of clinical nutrition practice and research. This initiative aimed to reach a consensus for terminology for core nutritional concepts and procedures. The European Society of Clinical Nutrition and Metabolism (ESPEN) appointed a consensus group of clinical scientists to perform a modified Delphi process that encompassed e-mail communication, face-to-face meetings, in-group ballots and an electronic ESPEN membership Delphi round. Five key areas related to clinical nutrition were identified: concepts; procedures; organisation; delivery; and products. One core concept of clinical nutrition is malnutrition/undernutrition, which includes disease-related malnutrition (DRM) with (eq. cachexia) and without inflammation, and malnutrition/undernutrition without disease, e.g. hunger-related malnutrition. Over-nutrition (overweight and obesity) is another core concept. Sarcopenia and frailty were agreed to be separate conditions often associated with malnutrition. Examples of nutritional procedures identified include screening for subjects at nutritional risk followed by a complete nutritional assessment. Hospital and care facility catering are the basic organizational forms for providing nutrition. Oral nutritional supplementation is the preferred way of nutrition therapy but if inadequate then other forms of medical nutrition therapy, i.e. enteral tube feeding and parenteral (intravenous) nutrition, becomes the major way of nutrient delivery. An agreement of basic nutritional terminology to be used in clinical practice, research, and the ESPEN guideline developments has been established. This terminology consensus may help to support future global consensus efforts and updates of classification systems such as the International Classification of Disease (ICD). The continuous growth of knowledge in all areas addressed in this statement will provide the foundation for future revisions.

SUN-P198: Applying Informatics Technology in Clinical Nutrition Practice in Atertiary Hospital

SUN-P198: Applying Informatics Technology in Clinical Nutrition Practice in Atertiary Hospital

Promotion of healthy nutrition in clinical practice: A cross-sectional survey of practices and barriers among physiotherapists in southeast Nigeria.

Background:Healthy diet counselling is an important concept in health promotion. Physiotherapists are well positioned to initiate or support healthy nutrition in addition to physical activity counselling, in routine patient consultation.Objective:To determine the practices about and barriers to diet counselling practices among physiotherapists in Southeast Nigeria.Methods:In this cross-sectional survey, a total of 140 questionnaires were distributed among physiotherapists.Results:Overall, 103 physiotherapists responded. Physiotherapists are confident and consider the incorporation of dietary counselling very important and of high priority in their daily clinical work. They, however, assessed and counselled on dietary status opportunistically in patients. Notwithstanding, physiotherapists believed that the diet counselling they give could be effective in helping patients change their unhealthy dieting practices. Patients were also amenable to physiotherapists advocating on diet issues as part of their consultation. Several barriers to incorporating diet counselling into physiotherapy practice were identified, including lack of access to a dietician/health promotion staff/counsellors, lack of proper patient education materials, lack of expertise in relation to dietary risk factors’ assessment and management, and uncertainty about what dietary services to provide.Conclusion:Although physiotherapists consider it important to incorporate diet counselling in their daily clinical practice, development and implementation of strategies to improve physiotherapists’ diet counselling knowledge, competence, skills, and practice are warranted.

Early Enteral Nutrition in Trauma: Is There Still Any Doubt?

Early enteral nutrition support has been standard in the care of the injured patient for nearly three decades. The Eastern Association for the Surgery of Trauma (EAST) provided the most recent management recommendations for nutritional support of trauma patients in 2004. Simply stated, the recommendation provided by the authors described the superiority of support via the enteral route within the first 72 h of injury when feasible. This statement implied that both the timing of initiation and route of support had potential to impact patient outcomes. The American Society of Parenteral and Enteral Nutrition (ASPEN) in conjunction with the Society of Critical Care Medicine (SCCM) published a broader set of guidelines in 2009 and 2016 that generally agreed with the EAST recommendations and were applicable to critically ill patients. The superiority of the enteral route for delivery of nutritional support has been theorized to be associated with the non-nutritional benefits of substrate provision at the level of the gastrointestinal tract within a 72-h therapeutic window. These concepts, at least in part, were the product of trials performed by surgeons in the setting of severe trauma and are now applied broadly to critically ill patients. However, as is clearly stated in the above guidelines, there are significant limitations inherent in the available literature. The breadth of literature in clinical nutrition has been plagued with issues including small trial size, the presence of multiple confounding variables, diverse control groups, and heterogeneous patient populations. Trials examining the role of early enteral nutrition support in injured patients have similar limitations. Over the last decade several significant trials have been conducted examining questions regarding nutrition support in the ICU, many of which conflict with historical findings. As a result of these trials, the practice of clinical nutrition is evolving rapidly. The objectives of this review include the following: discussion of the historical perspective on nutrition support in the setting of trauma, brief summary of existing data and more recent trials of importance, and how these trials may impact longstanding dogma.

Have the Answers to Common Legal Questions Concerning Nutrition Support Changed Over the Past Decade? 10 Questions for 10 Years.

Clinical nutrition specialists (CNSs) are often confronted with technological, ethical, and legal questions, that is, what can be done technologically, what should be done ethically, and what must be done legally, which conflict at times. The conflict represents a "troubling trichotomy" as discussed in the lead article of this issue of Nutrition in Clinical Practice (NCP). During Clinical Nutrition Week in 2006, a symposium covering these 3 topics was presented, and later that year, an article covering the same topic was published in NCP In this article, we revisit several legal questions/issues that were raised 10 years ago and discuss current answers and approaches. Some of the answers remain unchanged. Other answers have been modified by additional legislation, court decisions, or regulations. In addition, new questions/issues have arisen. Some of the most common questions regarding nutrition support involve the following: liability, informed consent, medical decisional incapacity vs legal competence, advance directive specificity, surrogate decision making, physician orders for life-sustaining treatment and electronic medical orders for life-sustaining treatment, legal definition of death, patient vs family decision making, the noncompliant patient, and elder abuse obligations. In the current healthcare environment, these questions and issues are best addressed via a transdisciplinary team that focuses on function rather than form. The CNS can play a pivotal role in dealing with these challenges by applying the acronym ACT: being Accountable and Communicating with all stakeholders while actively participating as an integral part of the transdisciplinary Team.

Editorial introductions

Editorial introductions

Practice of clinical nutrition in pediatric intensive care units: results of the “nutriped-2015” research

The secondstudy of nutritional support in the pediatric intensive care unit in critical conditions in Russia "NutriPed-2015" were presented. The authors noted that modern clinical nutrition technologies were widely used among 167 critical patients aged 0 to 18 years in 31 PICU in Russia. The number ofpatients receiving all components of the preparations for parenteral nutrition has increased significantly in comparison with the study NutriPed-2013. There were the wider use of last generation lipids for parenteral nutrition, multi-chamber containers in children older than 2 years were used in 2 times more often, the vast number ofpatients was carried out calculation of energy needs in the present time. The main problems for solve are the individual methods ofcalculating energy andprotein needs, resolution dysfunction ofthe gastrointestinal tract, the active introduction of assessing the effectiveness of nutritional support in the PICU.

The rise of clinical nutrition science in North-East Asia.

Effective clinical nutrition practice depends on a sound knowledge of biomedical, societal and environmental science and the skills to diagnose, prevent and manage the health problems related to food patterns, energy equilibrium (mostly to do with physical activity) and nutrient metabolism. Its delivery needs to be accessible, equitable, affordable and sustainable. Ordinarily, this will require both local and widely distributed health services. In North-East (NE) Asia, these requisites are being met to an ever increasing extent. The roots of this progress are steeped in cultures which acknowledge the food-health connections and support education which pays regard to these connections. As elsewhere, however, the food and health systems, their safety and security are threatened by exploitative operatives. In China, a concerted effort was made in the mid-1980s to foster clinical nutrition in major hospitals throughout the country by programs directed at medical graduates, nursing and kitchen staff; dietetics has appeared much more recently. By contrast, Japan has had an extensive and well-trained dietetic workforce for much longer, alongside a vibrant basic nutrition science constituency in its universities and foodnutraceutical industry. South Korea and Taiwan have traversed a similar course to that in Japan. Now, all of these NE Asian economies have gathered rapid momentum in the publication of innovative approaches to public health and clinical nutrition which have the prospect of not only improving health outcomes, but also reducing the societal and financial burden of health care. This is particularly important in rapidly ageing societies, which they are. It is also a growing challenge where climate change threatens to engulf the lives and destinies of hundreds of millions of Asians on account of natural disasters, water and food insecurity.

Parenteral Nutrition Electrolyte and Mineral Product Shortage Considerations.

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is a professional society of physicians, nurses, dietitians, pharmacists, other allied health professionals, and researchers. A.S.P.E.N. envisions an environment in which every patient receives safe, efficacious, and high-quality patient care. A.S.P.E.N.’s mission is to improve patient care by advancing the science and practice of clinical nutrition and metabolism. A.S.P.E.N. has developed parenteral nutrition (PN) shortage considerations in order to assist its members and other clinicians in coping with PN shortages for their patients. These parenteral nutrition electrolyte and mineral product shortage considerations were approved by the A.S.P.E.N. Clinical Practice Committee and the Board of Directors.

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).

A.S.P.E.N. and SCCM are both nonprofit organizations composed of multidisciplinary healthcare professionals. The mission of A.S.P.E.N. is to improve patient care by advancing the science and practice of clinical nutrition and metabolism. The mission of SCCM is to secure the highest quality care for all critically ill and injured patients. Guideline Limitations: These A.S.P.E.N.−SCCM Clinical Guidelines are based on general conclusions of health professionals who, in developing such guidelines, have balanced potential benefits to be derived from a particular mode of medical therapy against certain risks inherent with such therapy. However, practice guidelines are not intended as absolute requirements. The use of these practice guidelines does not in any way project or guarantee any specific benefit in outcome or survival. The judgment of the healthcare professional based on individual circumstances of the patient must always take precedence over the recommendations in these guidelines. The guidelines offer basic recommendations that are supported by review and analysis of the current literature, other national and international guidelines, and a blend of expert opinion and clinical practicality. The population of critically ill patients in an intensive care unit (ICU) is not homogeneous. Many of the studies on which the guidelines are based are limited by sample size, patient heterogeneity, variability in disease severity, lack of baseline nutritional status, and insufficient statistical power for analysis. Periodic Guideline Review and Update: This particular report is an update and expansion of guidelines published by A.S.P.E.N. and SCCM in 2009 (1). Governing bodies of both A.S.P.E.N. and SCCM have mandated that these guidelines be updated every three to five years. The database of randomized controlled trials (RCTs) that served as the platform for the analysis of the literature was assembled in a joint “harmonization process” with the Canadian Clinical Guidelines group. Once completed, each group operated separately in their interpretation of the studies and derivation of guideline recommendations (2). The current A.S.P.E.N. and SCCM guidelines included in this paper were derived from data obtained via literature searches by the authors through December 31, 2013. Although the committee was aware of landmark studies published after this date, these data were not included in this manuscript. The process by which the literature was evaluated necessitated a common end date for the search review. Adding a last-minute landmark trial would have introduced bias unless a formalized literature search was re-conducted for all sections of the manuscript. Target Patient Population for Guideline: The target of these guidelines is intended to be the adult (≥ 18 years) critically ill patient expected to require a length of stay (LOS) greater than 2 or 3 days in a medical ICU (MICU) or surgical ICU (SICU). The current guidelines were expanded to include a number of additional subsets of patients who met the above criteria, but were not included in the previous 2009 guidelines. Specific patient populations addressed by these expanded and updated guidelines include organ failure (pulmonary, renal, and liver), acute pancreatitis, surgical subsets (trauma, traumatic brain injury [TBI], open abdomen [OA], and burns), sepsis, postoperative major surgery, chronic critically ill, and critically ill obese. These guidelines are directed toward generalized patient populations but, like any other management strategy in the ICU, nutrition therapy should be tailored to the individual patient. Target Audience: The intended use of these guidelines is for all healthcare providers involved in nutrition therapy of the critically ill, primarily physicians, nurses, dietitians, and pharmacists. Methodology: The authors compiled clinical questions reflecting key management issues in nutrition therapy. A committee of multidisciplinary experts in clinical nutrition composed of physicians, nurses, pharmacists, and dietitians was jointly convened by the two societies.

The State of Nutrition Education at US Medical Schools

Purpose. To assess the state of nutrition education at US medical schools and compare it with recommended instructional targets. Method. We surveyed all 133 US medical schools with a four-year curriculum about the extent and type of required nutrition education during the 2012/13 academic year. Results. Responses came from 121 institutions (91% response rate). Most US medical schools (86/121, 71%) fail to provide the recommended minimum 25 hours of nutrition education; 43 (36%) provide less than half that much. Nutrition instruction is still largely confined to preclinical courses, with an average of 14.3 hours occurring in this context. Less than half of all schools report teaching any nutrition in clinical practice; practice accounts for an average of only 4.7 hours overall. Seven of the 8 schools reporting at least 40 hours of nutrition instruction provided integrated courses together with clinical practice sessions. Conclusions. Many US medical schools still fail to prepare future physicians for everyday nutrition challenges in clinical practice. It cannot be a realistic expectation for physicians to effectively address obesity, diabetes, metabolic syndrome, hospital malnutrition, and many other conditions as long as they are not taught during medical school and residency training how to recognize and treat the nutritional root causes.

Analysis of Nutrition Education in Osteopathic Medical Schools

Purpose. Describe nutrition education at US colleges of osteopathic medicine; determine if it meets recommended levels. Method. We surveyed 30 US colleges of osteopathic medicine (US COM) with a four-year curriculum about the amount and form of required nutrition education during the 2012/13 academic year. The online survey asked about hours of required nutrition across all 4 years and also in what types of courses this instruction occurred. We performed descriptive statistics to analyze the data. Results. Twenty-six institutions (87% response rate) completed the survey. Most responding US COM (22/26, 85%) do not meet the recommended minimum 25 hours of nutrition education; 8 (31%) provide less than half as much. Required nutrition instruction is largely confined to preclinical courses, with an average of 15.7 hours. Only 7 of the 26 responding schools report teaching clinical nutrition practice, providing on average 4.1 hours. Conclusions. Most US COM are inadequately preparing osteopathic physicians for the challenges they will face in practice addressing the nutritional concerns of their patients. Doctors of osteopathy cannot be expected to properly treat patients or guide the prevention of cardiovascular disease, obesity, cancer, diabetes, and metabolic syndrome if they are not trained to identify and modify the contributing lifestyle factors.

Glycemic Variability: Assessing Glycemia Differently and the Implications for Dietary Management of Diabetes

The primary therapeutic target for diabetes management is the achievement of good glycemic control, of which glycated hemoglobin (HbA1c) remains the standard clinical marker. However, glycemic variability (GV; the amplitude, frequency, and duration of glycemic fluctuations around mean blood glucose) is an emerging target for blood glucose control. A growing body of evidence supports GV as an independent risk factor for diabetes complications. Several techniques have been developed to assess and quantify intraday and interday GV. Additionally, GV can be influenced by several nutritional factors, including carbohydrate quality, quantity; and distribution; protein intake; and fiber intake. These factors have important implications for clinical nutrition practice and for optimizing blood glucose control for diabetes management. This review discusses the available evidence for GV as a marker of glycemic control and risk factor for diabetes complications. GV quantification techniques and the influence of nutritional considerations for diabetes management are also discussed.

Developing an Advanced Practice Credential for Registered Dietitian Nutritionists in Clinical Nutrition Practice

A T ENTRY-LEVEL, REGISTERED dietitian nutritionists (RDNs) have a broad set of skills intended to support practice in a variety of areas. As RDNs progress beyond entry-level (defined as the first 3 years of practice), personal preference or job demands may create a need for deeper levels of knowledge and skill. Many RDNs elect to concentrate on a particular facet of dietetics, accumulating focused knowledge and experience within a narrow practice area, and may become credentialed specialists. A small group of RDNs accumulate advanced practice skills and experience beyond and different from specialist practice. RDNs who perform their jobs with autonomy, expertise, intuition, leadership, and initiative have been described as advanced practitioners. Formalizing an advanced practice role would benefit patients, clients, and employers, and could also increase the visibility of RDN expertise and provide career advancement opportunities. E f f o r t s t o i d en t i f y and define advanced-level practice (ALP) have been complicated by a lack of widespread understanding of what constitutes advanced practice in dietetics. Previous attempts to define advanced practice have focused on all RDNs, independent of practice area. However, results from the 2007 Commission on Dietetic Registration (CDR) advanced practice audit suggested that narrowing the focus of advanced practice would aid in detecting an advanced practice skill set. Based on ongoing interest in advanced practice and prior Academy and CDR task force and committee work, CDR appointed a task force to identify advanced practice skills among RDNs who provide patient or client care. Traditionally, “clinical” patient or client care has been in acute-care settings. However, to expand the definition of clinical and include the increasing number of RDNs practicing outside of acute-care settings, advanced clinical nutrition practice was not considered setting-specific. Thus, the task force defined clinical nutrition practice as the “provision of direct nutrition care to individuals or groups.” This population offered the advantage of being the largest practice segment in the dietetics profession, with more than 60% of RDNs providing direct nutrition care to individuals and/or groups. Given that Bradley estimated that less than 10% of the profession practiced at an advanced level, this population would afford the largest sample of ALP RDNs. This article outlines the steps taken to establish the need and justification for an advanced practice certification program for RDNs in clinical nutrition practice and the processes used to develop the advanced-level clinical practice audit. A complementary research paper describes the practice audit results.

Editorial introductions

Editorial introductions

Carbohydrate loading in the preoperative setting.

Nutrition support is an evolving field, and modern clinical nutrition practice should actively incorporate strategies to enhance various clinical outcomes. In surgical patients, clinical benefits can be maximised by nutritional support protocols that minimise and manage the perioperative fasting period. This approach, which includes the perioperative provision of clear carbohydrate-containing fluids, has been shown to be safe, is evidence based, and is supported by many professional societies. Such a strategy has been shown to aid the anaesthetic process and maintain an optimal metabolic state, including improved insulin sensitivity and blunted muscle catabolic activity. Some important consequences of this improved metabolic control include shorter hospital stay and fewer postoperative complications. A proactive multidisciplinary team approach is essential to use this nutrition support strategy with success across a hospital's surgical service.

Evidence-based approach to inform clinical nutrition practice.

Evidence-based approach to inform clinical nutrition practice.

American society for parenteral and enteral nutrition (a.s.p.e.N.) standards of practice for nutrition support pharmacists.

American society for parenteral and enteral nutrition (a.s.p.e.N.) standards of practice for nutrition support pharmacists.

A.S.P.E.N. Standards for Nutrition Support: Home and Alternate Site Care.

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is a professional society of physicians, nurses, dietitians, pharmacists, nurse practitioners, physician assistants, other allied health professionals, and researchers. A.S.P.E.N. envisions an environment in which every patient receives safe, efficacious, and high-quality nutrition care. A.S.P.E.N.'s mission is to improve patient care by advancing the science and practice of clinical nutrition and metabolism. These combined Standards for Nutrition Support: Home Care and Alternate Site Care are an update of the 2005 and 2006 standards.

The NOVEL Project Update

The NOVEL Project Update