Guidance for assessment of the muscle mass phenotypic criterion for the Global Leadership Initiative on Malnutrition diagnosis of malnutrition

The Global Leadership Initiative on Malnutrition (GLIM) provides consensus criteria for the diagnosis of malnutrition that can be widely applied. The GLIM approach is based on the assessment of three phenotypic (weight loss, low body mass index, and low skeletal muscle mass) and two etiologic (low food intake and presence of disease with systemic inflammation) criteria, with diagnosis confirmed by any combination of one phenotypic and one etiologic criterion fulfilled. Assessment of muscle mass is less commonly performed than other phenotypic malnutrition criteria, and its interpretation may be less straightforward, particularly in settings that lack access to skilled clinical nutrition practitioners and/or to body composition methodologies. In order to promote the widespread assessment of skeletal muscle mass as an integral part of the GLIM diagnosis of malnutrition, the GLIM consortium appointed a working group to provide consensus-based guidance on assessment of skeletal muscle mass. When such methods and skills are available, quantitative assessment of muscle mass should be measured or estimated using dual-energy x-ray absorptiometry, computerized tomography, or bioelectrical impedance analysis. For settings where these resources are not available, then the use of anthropometric measures and physical examination are also endorsed. Validated ethnic- and sex-specific cutoff values for each measurement and tool are recommended when available. Measurement of skeletal muscle function is not advised as surrogate measurement of muscle mass. However, once malnutrition is diagnosed, skeletal muscle function should be investigated as a relevant component of sarcopenia and for complete nutrition assessment of persons with malnutrition.     

Toward the Development of Predictive Equations for Resting Metabolic Rate in Acutely Ill Spontaneously Breathing Patients

Background: There are many equations used for calculating energy needs of nutrition support patients but few developed specifically for the subset of spontaneously breathing acutely ill patients. The purpose of the current study was to validate existing equations and to start developing new equations for this cohort. Methods: Acutely ill patients not requiring mechanical ventilation had their resting metabolic rate measured using an indirect calorimeter. Metabolic rate was also calculated using the Mifflin–St Jeor equation, the Ireton‐Jones equation for spontaneously breathing patients, and a modification of the Penn State equation in which the minute ventilation‐dependent variable was removed. These calculated values were compared with measured expenditure and considered accurate if they fell within 10% of the measurement. Results: Fifty‐five patients were measured successfully. The modified Penn State equation was accurate in 71% of patients compared with 44% for Ireton‐Jones and 42% for Mifflin–St Jeor. Several forms of a new equation were outlined but not validated. The equation with the highest R² (0.82) was as follows: resting metabolic rate (kcal/d) = weight in kg (20) ? age in years (3) + male sex (197) + body mass index in kg/m² (25.9) + mean heart rate in beats/min (9.4) + 89. Conclusions: A modification of the Penn State equation for predicting resting metabolic rate was shown to accurately predict resting metabolic rate in acutely ill, spontaneously breathing patients if body mass index was ≥20.5 kg/m². A new set of population‐specific equations was outlined but should not be used until validated.     

营养支持的不同途径对重症急性胰腺炎治疗结局的影响

目的评价经鼻空肠内营养支持在重症急性胰腺炎(SAP)治疗中应用的安全性和有效性。方法通过鼻空肠管实施肠内营养(EN)支持加肠外营养(PN)15例,和完全胃肠外营养(TPN)25例进行比较。结果EN+PN组较TPN组的并发症少(6人次vs43人次,P<0.05),营养状况改善明显,胰腺感染(1人次vs7人次,P<0.05)和二重感染(0人次vs8人次,P<0.05)发生率低,住院时间短(24.20dvs35.46d,P<0.05),住院费用低(3.74万元vs5.82万元,P<0.05)。结论SAP患者实施EN支持是安全和有效的,对消化道功能的恢复,保护肠道粘膜屏障,防止感染,改善机体营养状况大有裨益,但需注意EN的时机。     

An evaluation of a community dietetics intervention on the management of malnutrition for healthcare professionals

Background: Healthcare professionals working in the community setting have limited knowledge of the evidence‐based management of malnutrition. The present study aimed to evaluate a community dietetics intervention, which included an education programme for healthcare professionals in conjunction with the introduction of a community dietetics service for patients ‘at risk’ of malnutrition. Changes in nutritional knowledge and the reported management of malnourished patients were investigated and the acceptability of the intervention was explored. Methods: An education programme, incorporating ‘Malnutrition Universal Screening Tool (MUST)’ training, was implemented in eight of 10 eligible primary care practices (14 general practitioners and nine practice nurses attended), in seven private nursing homes (20 staff nurses attended) and two health centres (53 community nurses attended) in conjunction with a community dietetics service for patients at risk of malnutrition. Nutritional knowledge was assessed before, immediately after, and 6 months after the intervention using self‐administered, multiple‐choice questionnaires. Reported changes in practice and the acceptability of the education programme were considered using self‐administered questionnaires 6 months after the intervention. Results: A significant increase in nutritional knowledge 6 months after the intervention was observed (P < 0.001). The management of malnutrition was reported to be improved, with 69% (38/55) of healthcare professionals reporting to weigh patients ‘more frequently’, whereas 80% (43/54) reported giving dietary advice to prevent or treat malnutrition. Eighty‐percent (44/55) of healthcare professionals stated that ‘MUST’ was an acceptable nutrition screening tool. Conclusion: An education programme supported by a community dietetics service for patients ‘at risk’ of malnutrition increased the nutritional knowledge and improved the reported management of malnourished patients in the community by healthcare professionals.     

早期肠内营养和肠外营养支持重型颅脑损伤的效果观察

目的探讨早期营养支持对重型颅脑损伤患者营养状况的效果影响。方法回顾性分析我院2004年1月～2008年10月间收治的重型颅脑损伤患者38例,随机分为肠内营养加肠外营养支持组(观察组)19例和全肠外营养支持组(对照组)19例。观察组早期肠内营养(enteral nutrition,EN)和肠外营养(parenteral nutrition,PN)结合,10天后转为全肠道营养,对照组10天内行全肠外营养支持,观察血糖、血浆白蛋白、淋巴细胞计数,并发症发生率及预后。结果观察组能获得充足的能量和蛋白质合成物,1周时的血糖控制程度、血浆白蛋白及外周血淋巴细胞总数优于对照组(P<0.05),观察组并发症少于对照组。观察组10天后病死率为(15.79%)明显低于对照组(31.58%)。结论重型颅脑损伤行早期肠内营养和肠外营养结合符合病人的病理、生理要求,能使该类病人营养状况和生存率提高。     

早期肠内营养和肠外营养支持重型颅脑损伤的效果观察

目的探讨早期营养支持对重型颅脑损伤患者营养状况的效果影响。方法回顾性分析我院2004年1月-2008年10月间收治的重型颅脑损伤患者38例,随机分为肠内营养加肠外营养支持组（观察组）19例和全肠外营养支持组（对照组）19例。观察组早期肠内营养（enteral nutrition,EN）和肠外营养（parenterl nutrition,PN）结合,10天后转为全肠道营养,对照组10天内行全肠外营养支持,观察血糖、血浆白蛋白、淋巴细胞计数,并发症发生率及预后。结果观察组能获得充足的能量和蛋白质合成物,1周时的血糖控制程度、血浆白蛋白及外周血淋巴细胞总数优于对照组（P〈0．05）,观察组并发症少于对照组。观察组10天后病死率为（15．79％）明显低于对照组（31．58％）。结论重型颅脑损伤行早期肠内营养和肠外营养结合符合病人的病理、生理要求,能使该类病人营养状况和生存率提高。     

Development and Validation of Nutrition Literacy Questionnaire for the Chinese Elderly

(1) Background: Improving nutrition literacy is crucial for maintaining a healthier state of the elderly to achieve healthy ageing. Therefore, it is necessary to develop a Nutrition Literacy Questionnaire for the Chinese Elderly (NLQ-E). (2) Methods: an NLQ-E was developed according to the core components of nutrition literacy for the elderly. Internal consistency, exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to validate the reliability and validity of the NLQ-E. A cross-sectional study of 1490 elderly people was used to analyze the application of the NLQ-E. (3) Results: The NLQ-E was constructed with 3 domains (knowledge and understanding, healthy lifestyle and dietary behavior and skill), with a total of 25 questions. The overall NLQ-E had acceptable reliability and validity (Cronbach’s α = 0.678, χ²/DF = 4.750, RMSEA = 0.045, PCFI = 0.776 and PNFI = 0.759). The average nutrition literacy score of the subjects in this cross-sectional study was 65.95 (65.95 ± 10.93). The OR between the nutrition literacy score and multimorbidity was 0.965 (95% CI: 0.954, 0.976); (4) Conclusions: We developed and validated the NLQ-E and found that the nutrition literacy level of the Chinese elderly was generally low. This study is of great value to improve the nutrition literacy of the elderly and effectively prevent nutrition-related chronic diseases and multimorbidity.     

The evolving role of post-ligament of Trietz nasojejunal feeding in enteral nutrition and the need for improved feeding tube design and placement methods

Nutrition support is an important link in the chain of therapy for intensive care unit patients. The early institution of nutrition support significantly reduces the incidence of septic complications, reduces mortality, and shortens hospital stay. Unfortunately, impaired gastrointestinal function, particularly gastric atony, restricts the use of nasogastric enteral tube feeding, and the use of this route of administration in these patients can lead to regurgitation, aspiration, and the development of pneumonia. Postpyloric enteral feeding was heralded as a means of overcoming many of these problems. Overall, the results of controlled studies do not support a role of postpyloric duodenal feeding in reducing the incidence of aspiration pneumonia. As a consequence, post-ligament of Treitz nasojejunal enteral feeding is proposed as the technique of choice in these patients. Feeding tube design must incorporate a gastric aspiration port to overcome problems of gastroesophageal acid reflux, duodenogastric bile reflux, and increased gastric acid secretion, problems that occur during "downstream" jejunal feeding. Tube placement technique will need to be refined and patients will need to receive a predigested enteral diet. In postoperative surgical patients in the intensive care unit, there is also a need for a newly designed dual-purpose nasogastric tube capable initially of providing a means of undertaking gastric aspiration and decompression and subsequently a means of initiating nasogastric enteral feeding.     

An Evaluation of the Nutrition Services for the Elderly

No abstract available for this article.     

机械通气患者营养支持及护理进展

本文结合近年来一些国内外文献以及研究成果，较详细介绍了机械通气患者营养支持的适应证、营养管的置入途径、营养的时机、给与方式、营养品的选择；阐明早期给营养支持对危重病人的重要意义及对现存问题的护理干预；强调合理的营养支持可以提高患者的免疫力、减少并发症的发生，有利于患者平稳脱机。高质量的护理可保证营养支持发挥其最大效应。     

Nutrition therapy for the critically ill surgical patient: we need to do better!

Background: To identify opportunities for quality improvement, the nutrition adequacy of critically ill surgical patients, in contrast to medical patients, is described. Methods: International, prospective, and observational studies conducted in 2007 and 2008 in 269 intensive care units (ICUs) were combined for purposes of this analysis. Sites provided institutional and patient characteristics and nutrition data from ICU admission to ICU discharge for maximum of 12 days. Medical and surgical patients staying in ICU at least 3 days were compared. Results: A total of 5497 mechanically ventilated adult patients were enrolled; 37.7% had surgical ICU admission diagnosis. Surgical patients were less likely to receive enteral nutrition (EN) (54.6% vs 77.8%) and more likely to receive parenteral nutrition (PN) (13.9% vs 4.4%) (P < .0001). Among patients initiating EN in ICU, surgical patients started EN 21.0 hours later on average (57.8 vs 36.8 hours, P < .0001). Consequently, surgical patients received less of their prescribed calories from EN (33.4% vs 49.6%, P < .0001) or from all nutrition sources (45.8% vs 56.1%, P < .0001). These differences remained after adjustment for patient and site characteristics. Patients undergoing cardiovascular and gastrointestinal surgery were more likely to use PN, were less likely to use EN, started EN later, and had lower total nutrition and EN adequacy rates compared with other surgical patients. Use of feeding and/or glycemic control protocols was associated with increased nutrition adequacy. Conclusions: Surgical patients receive less nutrition than medical patients. Cardiovascular and gastrointestinal surgery patients are at highest risk of iatrogenic malnutrition. Strategies to improve nutrition performance, including use of protocols, are needed.     

Nutrition Assessment Score validation and the implications for usage

Introduction Malnutrition in hospital is a well‐documented and significant problem and contributes to increased recovery times, length of stays, cost to the NHS and patient mortality and morbidity. Malnutrition in hospitals has been found to be in excess of 40% of admissions. In spite of the fact that nutritional support has been found to benefit patients, referral rates to dietetic services do not reflect these levels. A study was carried out in Hairmyres Hospital to validate a nutritional assessment score (NAS) and assess the benefits and costs of introducing this assessment as a routine part of nursing care. Methods An NAS was completed for all patients admitted to two medical and two surgical wards over a 4‐week period and nutritionally assessed by a dietitian. Assessment was carried out on admission and weekly thereafter, for 118 patients, resulting in a total of 150 assessments. Results With a scoring system of: On Admission: Refer if score is 6 or above, On Review: Refer if score is 4 or above, it was found that 92% of patients at risk of malnutrition would be appropriately referred on admission and 100% of those patients not appropriately referred would be referred on review. Discussion and conclusions The study shows the NAS to be a valid tool for nutritional assessment and a useful aid to nursing staff in assessing risk of malnutrition and need for nutritional support. It suggests that the NAS could be used to indicate the need for nursing and dietetic intervention. The Dietetic Department could anticipate approximately 1880 new nutritional support referrals per year from general medical and surgical wards. The introduction of such an assessment tool has resource implications for dietitians, nurses and catering staff but should provide benefits to the patients and the hospital.     

胃癌合并糖尿病病人术后早期肠内营养的疗效分析

目的:对于胃癌合并糖尿病的病人,探讨术后早期肠内营养(EEN)对病人术后恢复情况的影响.方法:回顾性地比较102例胃癌合并糖尿病的病人接受EN(n =48)或全肠外营养(TPN,n=54)的疗效,了解两组病人术后恢复情况和血糖控制情况的差异. 结果:与TPN组病人比,EN组病人平均肛门排气时间和住院时间较短(P＜0.05),术后第7天空腹血糖较低(P＜0.05),但胃肠道症状发生率较高(P＜0.05). 结论:对胃癌合并糖尿病的病人术后EEN仍然适用,但在营养支持过程中需要更精心地护理,以减少胃肠道并发症.     

International Consensus Guidelines for Nutrition Therapy in Pancreatitis

Guidelines for nutrition support in pancreatitis have been inconsistently adapted to clinical practice. The International Consensus Guideline Committee (ICGC) established a pancreatitis task force to review published guidelines for pancreatitis in nutrition support. A PubMed search using the terms pancreatitis, acute pancreatitis, chronic pancreatitis, nutrition support, parenteral nutrition, enteral nutrition, and guidelines was conducted for the period from January 1999 to May 2011. Eleven guidelines were identified for review. The ICGC used the following process to develop unified guideline statements: summarize the strength of evidence (grading) of the guidelines; establish level of evidence for ICGC statements as high, intermediate, and low; assign published guideline levels of evidence; and define an ICGC grading system. International Pancreatitis Guideline Grades were established as follows: platinum—high level of evidence and consistent agreement among the guidelines; gold—acceptable level of evidence and no conflicting statements in guidelines; and silver—single existing guideline statement with no conflict in other guidelines. Eighteen ICGC statements were derived from the 11 published pancreatitis guidelines. Uniform agreement from widely disparate groups (United States, Europe, Japan, and China) resulted in 4 platinum‐level guideline statements for nutrition in pancreatitis: nutrition support therapy (NST) is generally not needed for mild to moderate disease, NST is needed for severe disease, enteral nutrition (EN) is preferred over parenteral nutrition (PN), and use PN when EN is contraindicated or not feasible. This methodology provides a template for future ICGC nutrition guideline development.     

A national food guide for the UK? Background and development

The development of a National Food Guide for the United Kingdom is a priority in the action plans of the Nutrition Task Force. Pictorial food guides to translate nutrient recommendations into guidance for food choice have been in use in other parts of the world for many years. However, there has not, until the present time, been a nationally recognized guide in the United Kingdom. Such a tool would enable those involved in nutrition education programmes to address the public with consistent messages through a variety of different channels, thus reducing the potential for misinformation and misunderstanding. This paper describes a brief history of food guides, gives the background to the development of a guide in the United Kingdom and outlines the research and development process including consultation with a wide range of organizations. The development of dietetic and nutritional characteristics of the Guide format preferences and performance study results are described in accompanying papers in this issue on pages 323–334 and 335–351.     

营养强化政策概述

1营养强化的意义目前,全世界约有超过半数的人营养不良,并且已威胁到他们的身体健康、认知能力、生产能力甚至是生命。在一些国家,由于维生素和矿物质缺乏而导致的死亡、残疾和劳动力丧失,造成的损失占其国内生产总值的百分之五以上。一般来说,改善人群微量营养素缺乏的主要措施有膳食改善、营养强化和应用营养素补充剂三种。膳食改善主要是针对营养素的缺乏状况,在膳食中增加富含某种(些)微量营养素的食物。然而,这一措施在实施中需要充足的食物供应和适当的经济条件;需要有适当的营养学知识来进行合理的食物搭配;及需要较长的时间才能见效…