Guidance for assessment of the inflammation etiologic criterion for the GLIM diagnosis of malnutrition: A modified Delphi approach

BACKGROUND & AIMS

The Global Leadership Initiative on Malnutrition (GLIM) approach to malnutrition diagnosis is based on assessment of three phenotypic (weight loss, low body mass index, and reduced skeletal muscle mass) and two etiologic (reduced food intake/assimilation and disease burden/inflammation) criteria, with diagnosis confirmed by fulfillment of any combination of at least one phenotypic and at least one etiologic criterion. The original GLIM description provided limited guidance regarding assessment of inflammation and this has been a factor impeding further implementation of the GLIM criteria. We now seek to provide practical guidance for assessment of inflammation in support of the etiologic criterion for inflammation.

METHODS

A GLIM-constituted working group with 36 participants developed consensus-based guidance through a modified-Delphi review. A multi-round review and revision process served to develop seven guidance statements.

RESULTS

The final round of review was highly favorable with 99 % overall "agree" or "strongly agree" responses. The presence of acute or chronic disease, infection or injury that is usually associated with inflammatory activity may be used to fulfill the GLIM disease burden/inflammation criterion, without the need for laboratory confirmation. However, we recommend that recognition of underlying medical conditions commonly associated with inflammation be supported by C-reactive protein (CRP) measurements when the contribution of inflammatory components is uncertain. Interpretation of CRP requires that consideration be given to the method, reference values, and units (mg/dL or mg/L) for the clinical laboratory that is being used.

CONCLUSION

Confirmation of inflammation should be guided by clinical judgement based upon underlying diagnosis or condition, clinical signs, or CRP.

Comparison between self-reported and actigraphy-derived sleep measures in patients receiving home parenteral nutrition: Secondary analysis of observational data

BACKGROUND

Patients receiving home parenteral nutrition (HPN) frequently report disrupted sleep. However, there are often inconsistencies between objectively measured and questionnaire-derived sleep measures. We compared sleep measures estimated from wrist actigraphy and self-report in adults receiving HPN.

METHODS

In this secondary analysis, we pooled data from two sleep-related studies enrolling adults receiving habitual HPN. We compared measures from 7-day averages of wrist actigraphy against comparable responses to a sleep questionnaire. Sleep measures included bedtime, wake time, time in bed, total sleep time, and sleep onset latency (SOL). Spearman correlation coefficients, Bland-Altman plots, and linear regression models for each set of sleep measures provided estimates of agreement.

RESULTS

Participants (N = 35) had a mean age of 52 years, body mass index of 21.6 kg/m2 , and 77% identified as female. Correlation coefficients ranged from 0.35 to 0.90, were highest for wake time (r = 0.90) and bedtime (r = 0.74), and lowest for total sleep time (r = 0.35). Actigraphy overestimated self-reported bedtime, wake time, and total sleep time and underestimated self-reported time in bed and SOL. Regression coefficients indicated the highest calibration for bedtime and wake time and lower calibration for time in bed, total sleep time, and SOL.

CONCLUSION

We observed strong-to-moderate agreement between sleep measures derived from wrist actigraphy and self-report in adults receiving HPN. Weaker correlations for total sleep time and SOL may indicate low wrist actigraphy sensitivity. Low-quality sleep resulting from sleep disruptions may have also contributed to an underreporting of perceived sleep quantity and lower concordance.

Guidance for assessment of the inflammation etiologic criterion for the GLIM diagnosis of malnutrition: A modified Delphi approach

BACKGROUND

The Global Leadership Initiative on Malnutrition (GLIM) approach to malnutrition diagnosis is based on assessment of three phenotypic (weight loss, low body mass index, and reduced skeletal muscle mass) and two etiologic (reduced food intake/assimilation and disease burden/inflammation) criteria, with diagnosis confirmed by fulfillment of any combination of at least one phenotypic and at least one etiologic criterion. The original GLIM description provided limited guidance regarding assessment of inflammation, and this has been a factor impeding further implementation of the GLIM criteria. We now seek to provide practical guidance for assessment of inflammation.

METHODS

A GLIM-constituted working group with 36 participants developed consensus-based guidance through a modified Delphi review. A multiround review and revision process served to develop seven guidance statements.

RESULTS

The final round of review was highly favorable, with 99% overall "agree" or "strongly agree" responses. The presence of acute or chronic disease, infection, or injury that is usually associated with inflammatory activity may be used to fulfill the GLIM disease burden/inflammation criterion, without the need for laboratory confirmation. However, we recommend that recognition of underlying medical conditions commonly associated with inflammation be supported by C-reactive protein (CRP) measurements when the contribution of inflammatory components is uncertain. Interpretation of CRP requires that consideration be given to the method, reference values, and units (milligrams per deciliter or milligram per liter) for the clinical laboratory that is being used.

CONCLUSION

Confirmation of inflammation should be guided by clinical judgment based on underlying diagnosis or condition, clinical signs, or CRP.

Glycemic and sleep effects of daytime compared with those of overnight infusions of home parenteral nutrition in adults with short bowel syndrome: A quasi-experimental pilot trial

BACKGROUND

Patients with short bowel syndrome (SBS) dependent on home parenteral nutrition (HPN) commonly cycle infusions overnight, likely contributing to circadian misalignment and sleep disruption.

METHODS

The objective of this quasi-experimental, single-arm, controlled, pilot trial was to examine the feasibility, safety, and efficacy of daytime infusions of HPN in adults with SBS without diabetes. Enrolled patients were fitted with a continuous glucose monitor and wrist actigraph and were instructed to cycle their infusions overnight for 1 wk, followed by daytime for another week. The 24-h average blood glucose, the time spent >140 mg/dL or <70 mg/dL, and sleep fragmentation were derived for each week and compared using Wilcoxon signed-rank test. Patient-reported quality-of-life outcomes were also compared between the weeks.

RESULTS

Twenty patients (mean age, 51.7 y; 75% female; mean body mass index, 21.5 kg/m2) completed the trial. Overnight infusions started at 21:00 and daytime infusions at 09:00. No serious adverse events were noted. There were no differences in 24-h glycemia (daytime-median: 93.00 mg/dL; 95% CI: 87.7-99.9 mg/dL, compared with overnight-median: 91.1 mg/dL; 95% CI: 89.6-99.0 mg/dL; P = 0.922). During the day hours (09:00-21:00), the mean glucose concentrations were 13.5 (5.7-22.0) mg/dL higher, and the time spent <70 mg/dL was 15.0 (-170.0, 22.5) min lower with daytime than with overnight HPN. Conversely, during the night hours (21:00-09:00), the glucose concentrations were 16.6 (-23.1, -2.2) mg/dL lower with daytime than with overnight HPN. There were no differences in actigraphy-derived measures of sleep and activity rhythms; however, sleep timing was later, and light at night exposure was lower with daytime than with overnight HPN. Patients reported less sleep disruptions due to urination and fewer episodes of uncontrollable diarrhea or ostomy output with daytime HPN.

CONCLUSIONS

Daytime HPN was feasible and safe in adults with SBS and, compared with overnight HPN, improved subjective sleep without increasing 24-h glucose concentrations. This trial was registered at clinicaltrials.gov as NCT04743960 (https://classic.

CLINICALTRIALS

gov/ct2/show/NCT04743960).

Infusion timing and sleep habits of adults receiving home parenteral and enteral nutrition: A patient-oriented survey study

BACKGROUND

The emerging field of chrononutrition investigates the effects of the timing of nutritional intake on human physiology and disease pathology. It remains largely unknown when patients receiving home nutrition support routinely administer home parenteral nutrition (HPN) and/or home enteral nutrition (HEN).

METHODS

The present descriptive study included data collected from a patient-oriented survey designed to assess the timing of infusions and sleep habits of patients receiving HPN and HEN in the United States.

RESULTS

A total of 100 patients were included. Patients had a mean age of 44.1 years and 81% were female. Among 73 patients supported with HPN and 27 patients supported with HEN, 86% and 44% reported overnight infusions, respectively. The median start and end times of overnight infusions were 2100 (interquartile range [IQR] = 1900-2200) and 0800 (IQR = 0700-1000), respectively, for HPN and 2000 (IQR = 1845-2137) and 0845 (IQR = 0723-1000), respectively, for HEN. Overnight infusions started 2.0 h (IQR = 1.1-3.0) and 2.0 h (IQR = 0.6-3.3) before bedtime for HPN and HEN, respectively, and stopped 12.9 min (IQR = -21.3 to 29.1) and 30.0 min (IQR = -17.1 to 79.3) after wake time for HPN and HEN, respectively. Sleep disruption because of nutrition support or urination was most common among patients receiving infusions overnight compared with those receiving infusions continuously or during the daytime.

CONCLUSIONS

Our survey study focusing on a novel and medically relevant dimension of nutrition found that most HPN-dependent and HEN-dependent patients receive infusions overnight while asleep. Our findings suggest that overnight infusions coinciding with sleep may result in sleep and circadian disruption.

Sleep patterns of patients receiving home parenteral nutrition: A home-based observational study

BACKGROUND

Patients supported with home parenteral nutrition (HPN) often report poor sleep; however, limited research has been conducted to objectively measure sleep patterns of HPN-dependent patients.

METHODS

We aimed to characterize the sleep patterns of patients receiving HPN through 7-day actigraphy in a home-based observational study. Sleep measures of clinical importance were derived from actigraphy, including sleep duration, sleep efficiency, sleep onset latency, and wake after sleep onset. Participants also completed validated sleep surveys.

RESULTS

Twenty participants completed all study procedures (mean [SD]: age = 51.6 [13.9] years, body mass index = 21.4  [4.6], and 80% female). The population median (IQR) for sleep duration, sleep efficiency, sleep onset latency, and wake after sleep onset was 6.9 (1.1) h, 83.3% (7.8%), 11.8 (7.1) min, and 57.2 (39.9) min, respectively, and 55%, 60%, 35%, and 100% of participants did not meet the recommendations for these measures from the National Sleep Foundation. Sixty-five percent of participants reported napping at least once during the 7-day period. Based on the Insomnia Severity Index, 70% of participants were classified as having subthreshold or more severe insomnia. Based on the Pittsburgh Sleep Quality Index, 85% were classified as having significant sleep disturbance.

CONCLUSION

Most HPN-dependent patients likely have disrupted sleep largely driven by difficulty maintaining sleep. The extent to which HPN contributed to poor sleep cannot be elucidated from this observational study. Addressing known factors that contribute to sleep disruption and considering sleep interventions may improve the overall quality of life of patients receiving HPN.

Learn Intestinal Failure Tele-ECHO Project: An innovative online telementoring and case-based learning clinic

Intestinal failure (IF) is a rare chronic disease requiring intravenous (IV) fluids or parenteral nutrition (PN) dependency for optimal patient health and sustenance. The complex care is best managed by specialized multidisciplinary teams. Patients who have limited access to intestinal rehabilitation centers often receive IV/PN care from clinicians lacking specialty expertise. An innovative videoconferencing project was launched in May 2019 to provide online telementoring and case-based learning in IF. The Extension for Community Healthcare Outcomes (ECHO) model was adopted to provide education and virtual support via the Learn Intestinal Failure Tele-ECHO (LIFT-ECHO) project. Online clinics include patient case presentations, moderated discussion, best-practice recommendations, and didactic continuing education lectures on IF- and PN-related topics. Participation is interprofessional and international. Via knowledge dissemination and specialty mentorship, LIFT-ECHO is expected to improve healthcare for patients with IF and transform care delivery by overcoming the limitations in access to expertise.

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.

Nutrition Management of Home Parenteral Nutrition Among Patients With Enterocutaneous Fistula in the Sustain Registry

BACKGROUND

Home parenteral nutrition (HPN) is a vital therapy for patients who have the diagnosis of enterocutaneous fistula (ECF), yet little is known about how these patients are managed. This research compares nutrition management of adults with ECF as the indication for HPN therapy to those with other indications.

METHODS

This is an analysis of data from adult HPN patients in the Sustain registry enrolled between August 2011 and February 2014 who have the diagnosis of ECF or other indication for HPN who served as the control group. Differences between the ECF and control group were assessed by t test, analysis of variance, or χ² as appropriate.

RESULTS

There were 141 HPN patients with ECF and 632 control patients. Patients with ECF were older (55 vs 50 years, P < .001), more frequently had a goal for future surgery (30% vs 15%, P = .010), had greater prevalence of overweight/obesity (33% vs 20%, P = .04), and had a lower serum albumin (2.98 ± 0.65 g/dL vs 3.16 ± 0.66 g/dL, P = .006) than controls. The diet order was more frequently nil per os (NPO) in patients with ECF (48% vs 22%, P < .001), and amino acid content of HPN was greater (111.90 ± 29.11 vs 102.06 ± 27.84, P < .001) than in controls. There were no differences in patterns of weight change by ECF or control groups, although underweight patients gained, normal-weight patients maintained, and overweight/obese patients lost weight and serum albumin increased similarly.

CONCLUSIONS

The HPN management of patients with ECF is similar to other HPN patients other than greater provision of protein, more frequent NPO status, and a goal for future surgery.

American Society of Parenteral and Enteral Nutrition Presidential Address: Food for Thought: It's More Than Nutrition

Three issues were highlighted in the 30(th) Presidential Address to the society: (1) A.S.P.E.N.'s unique interdisciplinary structure; (2) support of the A.S.P.E.N. Rhoads Research Foundation; and (3) the meaning of food from the perspective of the patient who is receiving life-sustaining home enteral or parenteral nutrition. A.S.P.E.N., founded as a multidisciplinary society in the 1970s has evolved into an interdisciplinary society with an expanded and diverse membership of health care professionals and scientists with overlapping interests in clinical nutrition and metabolism. A.S.P.E.N. envisions an environment in which every patient receives safe, efficacious, and high quality patient care. The society is committed to advancing the science and practice of nutrition support therapy. In support of this direction, the A.S.P.E.N. Rhoads Research Foundation exists to fund research grants, promote evidence-based practice, and foster training and mentorship in nutrition and metabolic research. The scientific advances and technologic innovations that have enabled our profession to provide enteral and parenteral nutrition to patients has caused practitioners to forget that the meaning of food extends beyond nutrient value. Some individuals receiving long term enteral nutrition or home parenteral nutrition have expressed feelings of anger, anxiety, and depression resulting from the inability to eat normally, from losses of independence, and control of body functions. The ritual of eating may be altered when the enteral or intravenous feedings provide nourishment and, for some, the loss of the eating function is a distressing experience, especially given the cultural focus on social gatherings and meals. The emotional meaning attributed to food, and changes in food preferences and eating behaviors, may become a source of conflict for individuals who have substantial dietary restrictions, or for those individuals dependent on enteral or parenteral nutrition therapy. The value of food intake on social patterns, self-esteem, pleasure, and enjoyment, may impact quality of life. While nutrition support can provide the basic need for nutrients, its impact on human needs associated with food requires further investigation.

Quality of Life in Adult Home Parenteral Nutrition Patients

BACKGROUND

Home parenteral nutrition (HPN) is life-sustaining therapy in some disease states. Patients, however, report alterations in physical, psychologic, and social function that negatively affect perceived quality of life (QOL). Many generic tools have been used to evaluate QOL during HPN, but there is no gold standard measurement. QOL improvement can only result from identifying and addressing patient-specific problems. The purpose of this study was to identify the tools used by others to measure QOL in adults receiving long-term HPN and to identify factors that affect QOL in this population.

METHODS

An electronic search of CINAHL, MEDLINE, and Health and Psychosocial Instruments databases was conducted to identify studies of HPN and QOL in adults.

RESULTS

Thirty-four publications on HPN and QOL were identified. Twenty-four studies of HPN and QOL were included in this review; 10 papers were review articles or editorials. QOL was worse in HPN patients compared with healthy populations. Impaired QOL was associated with decreased physical, psychologic, and social function. Depression, drug dependency, sleep disturbance, frequent urination, fear of therapy-related complications, and inability to eat negatively affected QOL.

CONCLUSIONS

Use of different QOL instruments, scales, and lifestyle domains limited comparison among studies. QOL is poor in patients receiving HPN and worse in the presence of depression and narcotic dependency. The technical aspects of HPN administration interfere with routine activities. It is difficult to determine whether HPN itself or the impact of the disease affected QOL. Development of an HPN-specific QOL tool may help in this differentiation.

ASPEN-FELANPE Clinical Guidelines

BACKGROUND

The management of patients with enterocutaneous fistula (ECF) requires an interdisciplinary approach and poses a significant challenge to physicians, wound/stoma care specialists, dietitians, pharmacists, and other nutrition clinicians. Guidelines for optimizing nutrition status in these patients are often vague, based on limited and dated clinical studies, and typically rely on individual institutional or clinician experience. Specific nutrient requirements, appropriate route of feeding, role of immune-enhancing formulas, and use of somatostatin analogues in the management of patients with ECF are not well defined. The purpose of this clinical guideline is to develop recommendations for the nutrition care of adult patients with ECF.

METHODS

A systematic review of the best available evidence to answer a series of questions regarding clinical management of adults with ECF was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group. An anonymous consensus process was used to develop the clinical guideline recommendations prior to peer review and approval by the ASPEN Board of Directors and by FELANPE.

QUESTIONS

In adult patients with enterocutaneous fistula: (1) What factors best describe nutrition status? (2) What is the preferred route of nutrition therapy (oral diet, enteral nutrition, or parenteral nutrition)? (3) What protein and energy intake provide best clinical outcomes? (4) Is fistuloclysis associated with better outcomes than standard care? (5) Are immune-enhancing formulas associated with better outcomes than standard formulas? (6) Does the use of somatostatin or somatostatin analogue provide better outcomes than standard medical therapy? (7) When is home parenteral nutrition support indicated?

Central venous catheter infections in home parenteral nutrition patients: Outcomes from Sustain: American Society for Parenteral and Enteral Nutrition's National Patient Registry for Nutrition Care

BACKGROUND

Home parenteral nutrition (HPN) is a high-cost, complex nutrition support therapy that requires the use of central venous catheters. Central line-associated bloodstream infections (CLABSIs) are among the most serious risks of this therapy. Sustain: American Society for Parenteral and Enteral Nutrition's National Patient Registry for Nutrition Care (Sustain registry) provides the most current and comprehensive data for studying CLABSI among a national cohort of HPN patients in the United States. This is the first Sustain registry report detailing longitudinal data on CLABSI among HPN patients.

OBJECTIVE

To describe CLABSI rates for HPN patients followed in the Sustain registry from 2011-2014.

METHODS

Descriptive, χ², and t tests were used to analyze data from the Sustain registry.

RESULTS

Of the 1,046 HPN patients from 29 sites across the United States, 112 (10.7%) experienced 194 CLABSI events during 223,493 days of HPN exposure, for an overall CLABSI rate of 0.87 episodes/1,000 parenteral nutrition-days. Although the majority of patients were female (59%), adult (87%), white (75%), and with private insurance or Medicare (69%), CLABSI episodes per 1,000 parenteral nutrition-days were higher for men (0.69 vs 0.38), children (1.17 vs 0.35), blacks (0.91 vs 0.41), and Medicaid recipients (1.0 vs 0.38 or 0.39). Patients with implanted ports or double-lumen catheters also had more CLABSIs than those with peripherally inserted or central catheters or single-lumen catheters. Staphylococci were the most commonly reported pathogens. These data support findings of smaller studies about CLABSI risk for children and by catheter type and identify new potential risk factors, including gender, race, and insurance type.

CONCLUSIONS

Additional studies are needed to determine effective interventions that will reduce HPN-associated CLABSI.

Technology Dependence in Home Care: Impact on Patients and Their Family Caregivers

BACKGROUND

The purpose of this review is to explore how home technology care affects patients, family caregivers, and quality of life (QOL).

METHODS

A literature search was conducted to identify studies of home parenteral nutrition (HPN) and other technology prescribed home care.

RESULTS

Technology dependence influences health-related QOL. Patients and their family caregivers must balance the positive aspects of being in the home environment with the challenges of administering complex therapies at home. Patients and caregivers need additional support to reduce the physical, emotional, social, and financial burdens they experience.

CONCLUSIONS

More research is needed to address effective interventions to reduce patient and caregiver burdens and to improve outcomes for technology-dependent individuals. A greater level of preparedness for managing home technology and technology-related problems may improve quality of life.

Predictive versus measured energy expenditure using limits-of-agreement analysis in hospitalized, obese patients

BACKGROUND

Accuracy of predictive formulae is crucial for therapeutic planning because indirect calorimetry measurement is not always possible or cost effective. Energy requirements are more difficult to predict in the acutely ill obese patient compared with lean patients because of an increased resting energy expenditure per lean body mass and a variable stress response to illness.

METHODS

A retrospective review of 726 patients identified 57 patients (32 spontaneous breathing, S; 25 ventilator dependent, V) with body mass indexes of 30-50 kg/m2. Limits-of-agreement analysis determined bias (the mean difference between measured and predicted values) and precision (the standard deviation of the bias) to evaluate the accuracy of predictive formulae compared with measured resting energy expenditure (MREE) by a Deltatrac Metabolic Monitor. Predictive accuracy was determined within+/-10% MREE. The predictive formulae examined were: variations of the Harris-Benedict equations using ideal, adjusted weights of 25% and 50% and actual weights with stress factors ranging from 1.0 to 1.5; the Ireton-Jones equation for obesity; the Ireton-Jones equations for hospitalized patients (S and V); and the ratio of 21 kcalories per kilogram actual weight.

RESULTS

The mean MREE was 21 kcal/kg actual weight. The adjusted Harris-Benedict average weight equation was optimal for predicting MREE for the combined S and V sets (bias = 182+/-123; 67%+/-10% MREE), as well as the S subset (bias = 159+/-112; 69%+/-10% MREE).

CONCLUSIONS

The Harris-Benedict equations using the average of actual and ideal weight and a stress factor of 1.3 most accurately predicted MREE in acutely ill, obese patients with BMIs of 30-50 kg/m2. Predictive formulae were least accurate for obese, ventilator-dependent patients.

Standards of practice for the nutrition support dietitian: importance and value to practitioners

OBJECTIVE

To determine whether the American Society for Parenteral and Enteral Nutrition (ASPEN) standards of practice for nutrition support dietitians reflect current practice.

DESIGN

A mailed survey questionnaire was used to determine how important nine functions of the nutrition support dietitian are to the practice of nutrition support dietetics, how important the ASPEN standards are to practitioners, the frequency of application of each standard to patients, and demographic data of the respondents.

SAMPLE

The survey was sent to 1,048 randomly selected dietitian members of The American Dietetic Association's Dietitians in Nutrition Support dietetic practice group and ASPEN. The final sample included 460 dietitians, a return rate of 44%. For purposes of comparison, dietitian respondents were categorized into three groups: nutrition support dietitians (n = 286); non-nutrition support dietitians (n = 136); and supervisors of nutrition support dietitians (n = 38).

STATISTICAL ANALYSES PERFORMED

Descriptive data are reported as frequency or mean +/- standard deviation. Differences in importance ratings of the standards by nutrition support dietitians, non-nutrition support dietitians, and supervisors of nutrition support dietitians were compared with one-way analysis of variance ANOVA and Scheffe post hoc tests. chi 2 Analysis was used to compare group differences in the frequency of application of each standard to patients. Probability was set at the .05 level.

RESULTS

Nutrition support functions rated as very important included performing nutrition assessments, identifying high-risk patients, implementing and monitoring parenteral and enteral nutrition, supervising transitional feeding, and documentation. The standards of practice were all rated as very important by nutrition support dietitians, non-nutrition support dietitians, and supervisors, and there was no difference in perceived importance. More than half of the respondents applied each standard with 75% to 100% of their patients; however, there was a higher frequency of application by nutrition support dietitians.

APPLICATIONS/CONCLUSIONS

The findings give validity to the standards of practice. Practitioners evaluate them as being important in practice and in theory. The standards of practice for nutrition support dietitians were approved for use by the House of Delegates of The American Dietetic Association in October 1992.

Education, research, and practice: bridging the gap

The purpose of this study was to identify the research activities that were part of dietetic internship and coordinated undergraduate programs. Data about required research courses, research-related experiences, curriculum competencies, student publications, and faculty needs were obtained from 79 dietetic internship and 46 coordinated undergraduate program directors. Research courses were required in 60% of the programs and most often included basic statistics and review of the literature. Attendance at research conferences and observation of research dietitians were the most frequent learning experience activities. A wide variety of research projects were required by 71% of the programs, but there were few student opportunities to participate in faculty-sponsored research. The ability to evaluate literature critically, knowledge of research concepts, and application of research findings to dietetic practice were the most frequently cited competency statements. Less than 2% of graduates in a 3-year period had published in professional journals. Faculty members believed they needed more time, money, educational materials, professional development, and access to research facilities to improve the research component of the program. These findings suggest that research competencies may need to be prioritized differently in view of changing needs in dietetic practice.

Use of retinol-binding protein and prealbumin as indicators of the response to nutrition therapy

There is no single available measurement for evaluating the short-term response to nutrition therapy. The ideal parameter should have high sensitivity and specificity and should be unaffected by non-nutritional factors. A literature review suggested that plasma retinol-binding protein and prealbumin concentrations change earlier than albumin and transferrin levels and appear to correlate better with nitrogen balance during nutrition therapy. That conclusion was supported by our own findings in patients receiving total parenteral nutrition and following the transition to oral or enteral feedings. Although concentrations of these plasma proteins have been shown to be affected by stress and renal and hepatic disease, they appear to be more sensitive indicators of the adequacy of nutrition support than other more commonly used assessment parameters.