The international declaration on the human right to nutritional care: A global commitment to recognize nutritional care as a human right

Access to nutritional care is frequently limited or denied to patients with disease-related malnutrition (DRM), to those with the inability to adequately feed themselves or to maintain their optimal healthy nutritional status which goes against the fundamental human right to food and health care. That is why the International Working Group for Patient's Right to nutritional care is committed to promote a human rights based approach (HRBA) in the field of clinical nutrition. Our group proposed to unite efforts by launching a global call to action against disease-related malnutrition through The International Declaration on the Human Right to Nutritional Care signed in the city of Vienna during the 44th ESPEN congress on September 5th 2022. The Vienna Declaration is a non-legally binding document that sets a shared vision and five principles for implementation of actions that would promote the access to nutritional care. Implementation programs of the Vienna Declaration should be promoted, based on international normative frameworks as The United Nations (UN) 2030 Agenda for Sustainable Development, the Rome Declaration of the Second International Conference on Nutrition and the Working Plan of the Decade of Action on Nutrition 2016-2025. In this paper, we present the general background of the Vienna Declaration, we set out an international normative framework for implementation programs, and shed a light on the progress made by some clinical nutrition societies. Through the Vienna Declaration, the global clinical nutrition network is highly motivated to appeal to public authorities, international governmental and non-governmental organizations and other scientific healthcare societies on the importance of optimal nutritional care for all patients.

Safety of increasing protein delivery with an enteral nutrition formula containing very high protein (VHP) and lower carbohydrate concentrations compared to conventional standard (SF) and high protein (HP) formulas

BACKGROUND & AIMS

Studies demonstrate that caloric restriction in the first seven days in the ICU is safe. The amount of protein that should be delivered, however, is still unclear with clinical trials suggesting mixed results. Despite some capacity to customize the delivery of protein using supplemental modules, protein delivered is best determined by the concentration of protein contained in enteral formula (EF) ordered. This fact provides an opportunity to explore the potential clinical effects of protein delivery and lower carbohydrate intake on clinical outcomes compared with conventional enteral formulas.

METHODS

Retrospective analysis of clinical outcomes according to the amount of protein delivered in critically ill patients admitted to intensive care units at Geisinger Health System.

RESULTS

2000 encounters (1899 patients) in patients on enteral nutrition were divided into three groups receiving EF with either ≤20% protein (standard formula - SF), 21-25% protein (high protein - HP) or > 25% protein (VHP). Protein intake increased up to day 7 (p < 0.0001). Patients on VHP received more protein than other groups (p < 0.0001). Multivariable regression analysis showed no evidence of harm. In fact, we observed increased mortality with SF and HP formulas at 30-days post-discharge when compared to patients on VHP even when the effects of other variables (including age, BMI, sex, primary diagnosis, diabetes, history of dialysis, ICU days kept NPO) were taken into consideration.

CONCLUSIONS

Increasing protein intake while reducing carbohydrate intake appears to be safe. Further research aimed at defining a causative effect of increasing protein delivery while reducing carbohydrate load on outcomes is warranted.

Clinical Nutrition Research and the COVID-19 Pandemic: A Scoping Review of the ASPEN COVID-19 Task Force on Nutrition Research

The purpose of this scoping review by the American Society for Parenteral and Enteral Nutrition (ASPEN) Coronavirus Disease 2019 (COVID-19) Nutrition Task Force was to examine nutrition research applicable to the COVID-19 pandemic. The rapid pace of emerging scientific information has prompted this activity to discover research/knowledge gaps. This methodology adhered with recommendations from the Joanna Briggs Institute. There were 2301 citations imported. Of these, there were 439 articles fully abstracted, with 23 main topic areas identified across 24 article types and sourced across 61 countries and 51 specialties in 8 settings and among 14 populations. Epidemiological/mechanistic relationships between nutrition and COVID-19 were reviewed and results mapped to the Population, Intervention, Comparator, Outcome, and Time (PICO-T) questions. The aggregated data were analyzed by clinical stage: pre-COVID-19, acute COVID-19, and chronic/post-COVID-19. Research gaps were discovered for all PICO-T questions. Nutrition topics meriting urgent research included food insecurity/societal infrastructure and transcultural factors (pre-COVID-19); cardiometabolic-based chronic disease, pediatrics, nutrition support, and hospital infrastructure (acute COVID-19); registered dietitian nutritionist counseling (chronic/post-COVID-19); and malnutrition and management (all stages). The paucity of randomized controlled trials (RCTs) was particularly glaring. Knowledge gaps were discovered for PICO-T questions on pediatrics, micronutrients, bariatric surgery, and transcultural factors (pre-COVID-19); enteral nutrition, protein-energy requirements, and glycemic control with nutrition (acute COVID-19); and home enteral and parenteral nutrition support (chronic/post-COVID-19). In conclusion, multiple critical areas for urgent nutrition research were identified, particularly using RCT design, to improve nutrition care for patients before, during, and after COVID-19.

Dietary Management of Blood Glucose in Medical Critically Ill Overweight and Obese Patients: An Open-Label Randomized Trial

BACKGROUND

Enteral nutrition (EN) increases hyperglycemia due to high carbohydrate concentrations while providing insufficient protein. The study tested whether an EN formula with very high-protein- and low-carbohydrate-facilitated glucose control delivered higher protein concentrations within a hypocaloric protocol.

METHODS

This was a multicenter, randomized, open-label clinical trial with parallel design in overweight/obese mechanically ventilated critically ill patients prescribed 1.5 g protein/kg ideal body weight/day. Patients received either an experimental very high-protein (37%) and low-carbohydrate (29%) or control high-protein (25%) and conventional-carbohydrate (45%) EN formula.

RESULTS

A prespecified interim analysis was performed after enrollment of 105 patients (52 experimental, 53 control). Protein and energy delivery for controls and experimental groups on days 1-5 were 1.2 ± 0.4 and 1.1 ± 0.3 g/kg ideal body weight/day (P = .83), and 18.2 ± 6.0 and 12.5 ± 3.7 kcals/kg ideal body weight/day (P < .0001), respectively. The combined rate of glucose events outside the range of >110 and ≤150 mg/dL were not different (P = .54, primary endpoint); thereby the trial was terminated. The mean blood glucose for the control and the experimental groups were 138 (-SD 108, +SD 177) and 126 (-SD 99, +SD 160) mg/dL (P = .004), respectively. Mean rate of glucose events >150 mg/dL decreased (Δ = -13%, P = .015), whereas that of 80-110 mg/dL increased (Δ = 14%, P = .0007). Insulin administration decreased 10.9% (95% CI, -22% to 0.1%; P = .048) in the experimental group relative to the controls. Glycemic events ≤80 mg/dL and rescue dextrose use were not different (P = .23 and P = .53).

CONCLUSIONS

A very high-protein and low-carbohydrate EN formula in a hypocaloric protocol reduces hyperglycemic events and insulin requirements while increasing glycemic events between 80-110 mg/dL.

Very high-protein and low-carbohydrate enteral nutrition formula and plasma glucose control in adults with type 2 diabetes mellitus: a randomized crossover trial

BACKGROUND AND OBJECTIVES

Standard enteral nutrition (EN) formulas can  worsen hyperglycemia in diabetic patients. We hypothesized that altering the proportion of macronutrients in a formula; increasing protein while decreasing carbohydrate concentrations would improve glycemic response. The objective of this study was to demonstrate that an EN formula containing a very high concentration of protein (in the form of whey peptides) and low concentration of carbohydrate provide better control of postprandial blood glucose relative to a very high-protein/higher-carbohydrate formula.

SUBJECTS AND METHODS

This was a randomized crossover clinical trial of 12 ambulatory adult subjects with type 2 diabetes. The primary outcome was glycemic response following a bolus of isocaloric amounts of two EN formulas; the secondary outcome was insulin response. Subjects were randomized to the experimental or the control formula, on two separate days, 5-7 days apart.

RESULTS

Mean blood glucose concentrations at 10-180 min post-infusion and mean area under the curve for glucose over 240 min post-infusion were significantly lower with the experimental formula than with the control formula (71.99 ± 595.18 and 452.62 ± 351.38, respectively; p = 0.025). There were no significant differences in the mean insulin concentrations over time, insulinogenic indices, and first-phase insulin measurements.

CONCLUSIONS

An EN formula containing high-protein and low-carbohydrate loads can significantly improve glucose control in subjects with type 2 diabetes in ambulatory settings as evidenced by observed improved glucose control without significant difference in insulin response.

Effects of arginine-based immunonutrition on inpatient total costs and hospitalization outcomes for patients undergoing colorectal surgery

OBJECTIVE

The aim of this study was to assess the effects of an arginine-based immunonutrition intervention for patients undergoing elective colorectal surgery on postsurgical utilization and cost outcomes.

METHODS

This analysis was based on data from two Washington State databases: Surgical Care and Outcomes Assessment Program (SCOAP) linked to the Comprehensive Hospital Abstract Reporting System (CHARS). The sample (N=722) comprises adult patients who underwent elective colorectal surgery with anastomosis in a Washington State hospital that participated in the Strong for Surgery (S4S) initiative between January 1, 2012, and December 31, 2013. A generalized linear model was used to predict the outcomes, adjusting for demographic characteristics and patient health conditions within a multivariate regression framework.

RESULTS

Findings from this study demonstrated significantly fewer readmissions and hospital days for the intervention group during the 180 d after index hospitalization. Clinical benefits included decreased risk for infections and venous thromboembolism. There was a similar pattern toward lower total costs in the immunonutrition patient group; however, these were not statistically different compared with the control group at any time point. Savings in the immunonutrition group were substantial-mean total costs per patient were less by ∼$2500 at index hospitalization, $3500 less through 30 d of follow-up, and $5300 less over 180 d compared with the control group.

CONCLUSION

These findings suggest that arginine-based immunonutrition should be thoroughly evaluated for incorporation into clinical practice for patients undergoing elective surgery. Moreover, there is a need to assess the effects of the intervention in other hospitals both within and outside Washington.

Will We Ever Agree on Protein Requirements in the Intensive Care Unit?

The precise value of the normal adult protein requirement has long been debated. For many reasons-one of them being the difficulty of carrying out long-term nutrition experiments in free-living people-uncertainty is likely to persist indefinitely. By contrast, the controlled environment of the intensive care unit and relatively short trajectory of many critical illnesses make it feasible to use hard clinical outcome trials to determine protein requirements for critically ill patients in well-defined clinical situations. This article suggests how the physiological principles that underlie our understanding of normal protein requirements can be incorporated into the design of such clinical trials. The main focus is on 3 principles: (1) the rate of body nitrogen loss roughly predicts an individual's minimum protein requirement and is thus essential to measure to identify individual patients and clinical situations in which the minimum protein requirement is importantly increased, (2) existing muscle mass sets an upper limit on the rate at which amino acids can be mobilized from muscle for transfer to central proteins and sites of injury and is thus important to monitor to identify patients who are at greatest risk of protein deficiency-related adverse outcomes, and (3) negative energy balance increases the dietary protein requirement, so calorie-deprived patients-whether obese or not-should be enrolled in hard clinical outcome trials that compare the current practice of "permissive underfeeding" (underprovision of all nutrients, including protein) with hypocaloric nutrition supplemented by a suitably generous amount of protein.

How Much and What Type of Protein Should a Critically Ill Patient Receive?

Protein loss, manifested as loss of muscle mass, is observed universally in all critically ill patients. Depletion of muscle mass is associated with impaired function and poor outcomes. In extreme cases, protein malnutrition is manifested by respiratory failure, lack of wound healing, and immune dysfunction. Protecting muscle loss focused initially on meeting energy requirements. The assumption was that protein was being used (through oxidation) as an energy source. In healthy individuals, small amounts of glucose (approximately 400 calories) protect muscle loss and decrease amino acid oxidation (protein-sparing effect of glucose). Despite expectations of the benefits, the high provision of energy (above basal energy requirements) through the delivery of nonprotein calories has failed to demonstrate a clear benefit at curtailing protein loss. The protein-sparing effect of glucose is not clearly observed during illness. Increasing protein delivery beyond the normal nutrition requirements (0.8 g/k/d) has been investigated as an alternative solution. Over a dozen observational studies in critically ill patients suggest that higher protein delivery is beneficial at protecting muscle mass and associated with improved outcomes (decrease in mortality). Not surprisingly, new Society of Critical Care Medicine/American Society for Parenteral and Enteral Nutrition guidelines and expert recommendations suggest higher protein delivery (>1.2 g/kg/d) for critically ill patients. This article provides an introduction to the concepts that delineate the basic principles of modern medical nutrition therapy as it relates to the goal of achieving an optimal management of protein metabolism during critical care illness, highlighting successes achieved so far but also placing significant challenges limiting our success in perspective.

Acquired Amino Acid Deficiencies: A Focus on Arginine and Glutamine

Nonessential amino acids are synthesized de novo and therefore not diet dependent. In contrast, essential amino acids must be obtained through nutrition since they cannot be synthesized internally. Several nonessential amino acids may become essential under conditions of stress and catabolic states when the capacity of endogenous amino acid synthesis is exceeded. Arginine and glutamine are 2 such conditionally essential amino acids and are the focus of this review. Low arginine bioavailability plays a pivotal role in the pathogenesis of a growing number of varied diseases, including sickle cell disease, thalassemia, malaria, acute asthma, cystic fibrosis, pulmonary hypertension, cardiovascular disease, certain cancers, and trauma, among others. Catabolism of arginine by arginase enzymes is the most common cause of an acquired arginine deficiency syndrome, frequently contributing to endothelial dysfunction and/or T-cell dysfunction, depending on the clinical scenario and disease state. Glutamine, an arginine precursor, is one of the most abundant amino acids in the body and, like arginine, becomes deficient in several conditions of stress, including critical illness, trauma, infection, cancer, and gastrointestinal disorders. At-risk populations are discussed together with therapeutic options that target these specific acquired amino acid deficiencies.

Quick Fix for Hospital-Acquired Malnutrition?

Hospital-acquired malnutrition is universally present across the globe. Little progress has been made on overcoming hospital-acquired malnutrition despite known presence for at least 40 years. Technologies and methods to deliver the recommended calories and protein are available in most healthcare settings. Despite this, inadequate nutrient delivery continues to be a problem. Correia and colleagues propose a simplified algorithm that assists clinicians in becoming aware of poor nutrient intake and suggest nutrition interventions.