Compliance with a high-protein and energy-dense oral nutritional supplement in patients with disease-related malnutrition: a randomized open-label crossover trial

Introduction

Patient compliance with oral nutritional supplements (ONS) is not optimal for meeting energy and nutritional requirements in a high proportion of patients with disease-related malnutrition (DRM). Energy density or prescribed volume of ONS may impact compliance.

Methods

A randomized, open-label crossover trial was conducted in outpatients with DRM to compare compliance with a high energy-dense ONS (edONS, 2.4 kcal/mL) and a reference ONS (heONS, 2.0 kcal/mL; NCT05609006). Patients were randomly assigned to two 8-week treatment sequences of four-weeks periods: edONS + heONS (sequence A) or heONS + edONS (sequence B). Patients daily reported the amount of product left over gastrointestinal tolerance and satisfaction with ONS. A non-inferiority analysis was performed to compare the compliance rate (percentage of consumed energy over the prescribed) for each period and sequence.

Results

Fifty-three patients were assigned to sequence A and 50 to sequence B (55.7 ± 13.9 years, 37.0% female, 67.1% oncology patients). In sequence A, the compliance rates were 88.6% ± 14.3% vs. 84.1 ± 21.8% (p = 0.183), while in sequence B, they were 78.9% ± 23.8% vs. 84.4% ± 21.4% (p < 0.01). In both sequences, the lower range of the confidence interval for compliance with edONS was greater than the non-inferiority threshold (for sequence A Δ_Comp^A was 4.5% [95% CI, -2.0% to 10.0%], and for sequence, B Δ_Comp^B was 5.6% [95% CI, -3.0% to 14.0%]). The total discarded cost for each ONS was higher for heONS than edONS, being the difference statistically significant in sequence B. BMI increased slightly and not significantly in both sequences, and the percentage of patients with severe malnutrition was reduced. The frequency of gastrointestinal symptoms was low for both sequences, and satisfaction with ONS was slightly higher for edONS.

Conclusion

Our findings highlight that edONS was non-inferior to heONS in terms of consumed energy over the prescribed, with a lower amount of edONS discarded, which suggests a higher efficiency of edONS.

Nutritional Challenges in Metabolic Syndrome

Metabolic Syndrome (MetS) is a combination of risk factors for the development of cardiovascular disease (CVD) and type 2 diabetes. Different diagnostic criteria were proposed, but a consensus was reached in 2009 based on values of waist circumference, blood pressure, fasting glycemia, triglycerides, and high-density lipoprotein (HDL)-cholesterol levels. The main underlying etiologic factor is insulin resistance. The quality and quantity of individual macronutrients have an influence on the development and resolution of this syndrome. However, the main treatment goal is weight loss and a decrease in insulin resistance. A controlled energy dietary recommendation, together with moderate levels of physical activity, may positively change the parameters of MetS. However, there is no single dietary or exercise prescription that works for all patients. Dietary patterns such as Mediterranean-style, dietary approaches to stop hypertension (DASH), low-carbohydrate, and low-fat diets can ameliorate insulin resistance and MetS. Long-term adherence to a healthy lifestyle is key in assuring that individuals significantly reduce the risk of CVD and diabetes mellitus.

Economy matters to fight against malnutrition: Results from a multicenter survey

BACKGROUND AND AIM

Malnutrition represents a serious health care threat, as it increases morbidity, mortality and health care cost. The effective screening and treatment with enteral (EN) or parenteral (PN) nutrition are the key elements of the policy called Optimal Nutrition Care for All (ONCA). The study tried to analyze the impact of the state's economy on the implementation of EN and PN to define its role in ONCA.

MATERIAL AND METHODS

an international survey in twenty two European countries was performed between January and December 2014. An electronic questionnaire was distributed to 22 representatives of clinical nutrition (PEN) societies. The questionnaire comprised questions regarding country economy, reimbursement, education and the use EN and PN. Return rate was 90.1% (n = 20).

RESULTS

EN and PN were used in all countries surveyed (100%), but to different extent. The country's income significantly influenced the reimbursement for EN and PN (p < 0.05). It was also associated with the overall use of tube feeding and PN (p = 0.05), but not with the use of oral nutritional supplements (p = 0.165). The use of both, EN and PN at hospitals was not depended on the economy (p > 0.05). Education was actively carried out in all countries, however the teaching at the pre-graduate level was the least widespread, and also correlated with the country income (p = 0.042).

CONCLUSIONS

Results indicated that economic situation influences all aspects of ONCA, including education and treatment. The reimbursement for EN and PN seemed to be the key factor of effective campaign against malnutrition.

Clinical management of hyperglycaemic patients receiving total parenteral nutrition

We evaluated the course of total parenteral nutrition (TPN) therapy in patients with hyperglycaemia. We studied 1) incidence of hyperglycaemia, 2) amount of glucose and insulin provided and 3) incidence of metabolic problems in patients receiving TPN who required insulin to attain metabolic control. The group included 91 patients, 38 women (64 +/- 15 years) and 53 men (64 +/- 12 years), who developed glycaemia higher than 200 mg/dl. Nine patients had a previous diagnosis of IDDM, 36 NIDDM and 46 secondary hyperglycaemia.. Total caloric requirements were initially supplied at 132 +/- 20% the basal energy expenditure (Harris-Benedict formula), and 1.4 +/- 0.3 g/kg of amino-acids. Initially, TPN provided 150-200 g/day of glucose (2.1 mg/kg/min). Regular insulin was added to the bag. The annual incidence of hyperglycaemia was estimated to be 121 per 1000 patients. Mean insulin requirements were 50 U/day (25 to 150 U/day), 0.7 +/- 0.3 U/kg. Comparing with prehospitalization insulin dose, 22% needed similar doses, and 11% lower doses. IDDM patients needed 1.7 times their pre-admission dose (1-4.5 times). The ratio of insulin:glucose in TPN was 0.3 +/- 0.1 U/g (0.1-1.2 U/g). Patients with renal failure had similar insulin requirements (56 +/- 26 U/day) than patients with normal renal function (49 +/- 19 U/day). None of the patients developed glycemic complications. In conclusion, diabetic patients receiving TPN have an acceptable metabolic control if individualized prescriptions and supplemental insulin are used.

ESPEN Guidelines on Enteral Nutrition: Gastroenterology

Undernutrition as well as specific nutrient deficiencies have been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome (SBS). The present guideline gives evidence-based recommendations for the indication, application and type of formula of enteral nutrition (EN) (oral nutritional supplements (ONS) or tube feeding (TF)) in these patients. It was developed in an interdisciplinary consensus-based process in accordance with officially accepted standards and is based on all relevant publications since 1985. ONS and/or TF in addition to normal food is indicated in undernourished patients with CD or CU to improve nutritional status. In active CD EN is the first line therapy in children and should be used as sole therapy in adults mainly when treatment with corticosteroids is not feasible. No significant differences have been shown in the effects of free amino acid, peptide-based and whole protein formulae for TF. In remission ONS is recommended only in steroid dependent patients in CD. In patients with SBS TF should be introduced in the adaptation phase and should be changed with progressing adaptation to ONS in addition to normal food.

Home parenteral nutrition in adults: a european multicentre survey in 1997. ESPEN-Home Artificial Nutrition Working Group

A retrospective survey on home parenteral nutrition (HPN) in Europe was performed from January to December 1997. Data were compared to a similar study performed in 1993. A questionnaire of HPN practice was designed by the members of the ESPEN-HAN group. This involved adult patients (older than 16 years) newly registered in an HPN program between 1 January and 31 December 1997 and included: number of patients, underlying diseases and a 6-12 month outcome. Incidence and prevalence (at 1.1.1998) of adult HPN were calculated according to the estimated total population in 1997 for the countries in which more than 80% of HPN patients were reported.A total of 494 patients were registered in 73 centres from nine countries (Belgium (B), Denmark (D), France (F), Poland (P), Spain (S), Sweden (Sw), United Kingdom (UK), The Netherlands (N) and Germany (G). The underlying diseases for HPN in 494 patients were cancer (39%), Crohn's (19%), vascular diseases (15%), radiation enteritis (7%), AIDS (2%), other diseases with intestinal failure (18%). Incidence (patients/million inhabitants/year) were in N (3), F. (2.9), D. (2.8), B. (2.6), UK (1. 2), S (0.7) and P (0.36), respectively. Prevalence were in D. (12.7). U.K. (3.7), N. (3.7), F (3.6), B (3.0), P (1.1), S (0.65). After this 6-12 months follow-up (n=284), the mortality was respectively 4% in Crohn's disease, 13% in vascular diseases, 16% in others, 21% in radiaton enteritis, 34% in AIDS, 74% in cancer. Incidences and prevalences modestly increased in these seven European countries in 1997 in comparison to 1993. The percentages of underlying diseases in these countries remained similar except for AIDS that significantly decreased (from 7% to 2%). Outcomes did not significantly differ in the 4-year period except for AIDS (34% instead of 88% mortality) and could have been related to newer, more efficacious therapy.

Pituitary-thyroid function in patients with septic shock and its relation with outcome

OBJECTIVE

To study the time course of thyroid function abnormalities and their relation to outcome in patients with septic shock.

DESIGN

Prospective study in a cohort of consecutive patients.

SETTING

Intensive Care Unit in a University Hospital.

PATIENTS AND METHODS

We studied 27 patients (mean age 50 +/- 19 years, Apache II score 18.4 +/- 5.2, 15 survivors) diagnosed of septic shock. Total T4 (T4) and total T3 (T3) (RIA) were determined on days 1 and 5 after admission. We also measured TSH (ultrasensitive RIA) at 08.00, 20.00 and 01.00 hours (on days 1 and 5), and the TSH response to TRH (400 microg intravenous) on days 2 and 6. Data are mean +/- SD.

RESULTS

Whereas low thyroid hormones concentrations were present on day 1 in all patients, only survivors presented a significant increase in T3 and T4 on day 5. Basal TSH levels and the area under the curve of the TSH response to TRH on day 2 were significantly higher in survivors than in non survivors (0.89 +/- 0.63 vs. 0.34 +/- 0.42 microIU/ml, and 229 + 157 vs. 101 + 101). The normal nocturnal (01.00 hr) surge of TSH (the difference between TSH concentrations at 8 am and at 1 am) was abolished in both survivors and non survivors on day 1 but it was recovered on day 5 only in survivors.

CONCLUSIONS

Our data indicate that patients with septic shock present an altered hypothalamic-pituitary-thyroid axis, and that survivors thyroid function differs from that of non survivors shortly after diagnosis. Survivors are characterised by a greater TSH response to TRH, indicating a less deranged hypothalamic-pituitary-thyroid axis. Thyroid function improves in survivors, but not in non survivors, during the course of their illness.

Home parenteral nutrition in adults: a multicentre surveyin Europe in 1993

A retrospective survey was performed in 1994, involving 496 adult home parenteral nutrition (HPN) cases, newly enrolled in the year 1993 from 13 European countries from 75 centres. From the 8 countries having registered more than 80% of cases (423 patients), incidence and prevalence ranged from 0.2 to 4.6 and 0.3 to 12.2 patients/10(6) population/year. In the patients studied, the diagnosis was cancer (42%), Crohn's disease (15%), vascular diseases (13%), radiation enteritis (8%), AIDS (4%) and other nonmalignant non-AIDS diseases (18%). Short bowel syndrome and intestinal obstruction were the two major indications for HPN in 31% and 22%, respectively. Seventy-three percent of the centres had a nutrition team. HPN was administered through a tunnelled venous central catheter in 73%, cyclical nocturnal infusions were used in 90% of patients, and intravenous feeding was the sole source of nutrition in 33%. Only 44% undertook HPN unaided. The present report indicates that cancer has now become the main indication for HPN in Europe; there was, however, a heterogeneous distribution of diseases amongst the reporting countries. The observed 9 (6-12)-month probability of survival was poor in AIDS (n = 8; 12%) and cancer patients (n = 78; 29%) but better for the other HPN indications (n = 115; 92%).