A transatlantic survey of nutrition practice in acute pancreatitis

BACKGROUND

Many guidelines exist for the nutritional management of acute pancreatitis; however, little is known regarding current practice. We aimed to investigate feeding practices, including the use of parenteral/enteral nutrition.

METHODS

The study design was a cross-sectional, descriptive survey. Electronic surveys were sent to dietitians in the UK, the Republic of Ireland and Canada. Of 253 dietitians surveyed, 204 saw patients with acute pancreatitis regularly or occasionally and were included in the analyses.

RESULTS

Most dietitians (92.8%) considered early feeding to mean <48 h after presentation. Over half (54.2%) favoured early feeding in severe disease, less in obesity (42%) and more with pre-existing malnutrition (81.9%). There was a tendency to feed earlier in university hospitals (P = 0.015), especially in obesity (P = 0.011). There was a tendency towards enteral (versus parenteral) nutrition in university hospitals (P = 0.000). The majority preferred the jejunal route (64.2%), although this was lower in the UK (43.8%) than in Canada (77.8%) or Ireland (54.2%). Under one-quarter of UK dietitians (23.2%) reported the existence of a pancreatic multidisciplinary team in their institutions, although this was lower in Ireland and Canada.

CONCLUSIONS

Despite guidelines, there are gaps in the nutritional management of acute pancreatitis, including a continued reliance on parenteral feeding.

An obesity clinic model

The high incidence of obesity in Ireland is of growing concern. The Irish Universities Nutrition Alliance North/South Food Consumption Survey found that 18 % of the population are obese and 39% overweight. Obesity and overweight increase the risk of developing CHD, type 2 diabetes, hypertension and some forms of cancer. It is well accepted that the best treatment for obesity is a combination of energy intake reduction and regular exercise. Previously, dietary compliance has been shown to improve when monitored on a regular basis. The lengthy delay between clinic visits to the dietitian has been reported by those who failed to lose weight to be the main reason for poor compliance. A weight monitoring clinic was designed to offer those requiring regular support and encouragement the opportunity to monitor their weights on a more regular basis, while waiting for their return visit to the dietitian in the Outpatient Departments. As resources were limited, an efficient use of time was essential. The clinic design was: 1 h/week; eight to fourteen appointments per clinic; weekly or fortnightly visit; return patients only. The clinic was started on a trial basis in June 1999, and was evaluated in December 2000. Referrals were only taken from other dietitians, and each participant was informed in advance of the necessity of having a return Outpatient Department appointment for full dietary review. Forty-eight participants attended more than three times up to and including December 2000 (seven males, forty-one females). The number of clinic visits ranged from three to twenty-eight. Mean weight at start of clinic was 92.94 kg. Of the group attending, 67 % (thirty-two) successfully lost weight and maintained this weight loss. This ranged from 0.1 kg to 23.5 kg. While in total 31% (fifteen) of attendees had gained weight at December 2000, all attendees, including this fifteen, had lost weight at some point during the clinic. Self-reported reasons given for weight regain included: (1) non-attendance at weight clinic (40%); (2) Christmas or holidays (13%); (3) stress related to family, work (13%); (4) ill-health or medication (13%). The remaining 20% reported no reason. Other findings included better compliance with diet and improved overall balance. There was an overall improvement in other dietary-related problems, e.g. reduced cholesterol, improved glycaemic control, reduced blood pressure. The participants attending the clinic reported decreased clothes size and improved self-image and confidence. They were more enthusiastic about dietary compliance, and all attendees expressed their satisfaction with the clinic and the service.