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ISSN 1815-7262

Science supporting
better nutrition
2012 Volume 8, Issue 4

In this issue

Importance of nutritional management

in comprehensive diabetes care
Clinical nutrition abstracts
Highlights of the ESPEN 2012 Congress

Science supporting
better nutrition
2012 Volume 8, Issue 4

Feature article

Importance of nutritional management in

comprehensive diabetes care
Alice PS Kong, Lorena TF Cheung, Juliana CN Chan

Health economic perspective

Clinical nutrition abstracts




Critical care










Medical nutrition therapy




Highlights of the 34th ESPEN Congress


811 September 2012

Barcelona, Spain

Conference calendar


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Feature article

Importance of nutritional
management in
comprehensive diabetes care
Alice PS Kong,1,2 Lorena TF Cheung3 and Juliana CN Chan1,2
Department of Medicine and Therapeutics
Li Ka Shing Institute of Health Sciences
The Chinese University of Hong Kong
Hong Kong SAR, China
Nestl Health Science, Asia, Oceania, Africa Region


Burden of diabetes and its multiple


The global increase in the prevalence of diabetes and its

complications has made prevention and control of diabetes

Diabetes can be a silent and devastating disease and is often

a top public health priority. Globally in 2012, an estimated

associated with cardiovascular disease (CVD), which is

371 million individuals had diabetes (8.3% of the total adult

among the leading causes of mortality and morbidity in many

population aged 2079 years) and an additional 187 million

countries. In recent years there has been increasing recognition

people were undiagnosed.1 In the United States (US) in 2010,

of other frequent comorbidities of diabetes, such as cancer,

25.8 million people, or 8.3% of the entire population, had

end-stage renal disease, sepsis and mental illnesses.5

diabetes; for those older than 65 years, the prevalence was

In many developing countries, rapid socioeconomic,

26.9%. In many Asian countries, the proportion of people

cultural, information and technological changes have led

with type 2 diabetes has also surged dramatically due to

to changes in food supply, choices and consumption, which

rapid socioeconomic development, and changes in lifestyle

promote unbalanced nutrition and positive energy balance.3

and nutrition habits. Compared to Western populations,

Taking China and India as examples, the traditional

people in Asia tend to develop diabetes at a younger age

high-carbohydrate, low-fat, high-fiber diets are being replaced

and, hence, suffer longer with a higher chance of developing

by high-fat, high-energy and low-fiber diets that contribute

diabetes-related complications. Obesity in childhood and

to the rising trends of obesity and diabetes.6-8 In China, the

adolescence, an important predisposing factor for early

percentage of energy from dietary fat has increased from

onset type 2 diabetes, has increased substantially and the

19.3% in 1989 to 27.3% in 1997. These dietary changes

health consequences of this epidemic threaten to overwhelm

were particularly evident in urban compared with rural

healthcare systems worldwide. Advocacy for lifestyle changes,

populations (53% versus 40%, respectively).7 In India, the

in particular nutritional management, is the first step in

respective figures were 32% and 17%.8 In addition, increased

comprehensive diabetes care.

urbanization and sedentary lifestyles have led to reduced

Nutritional management, or medical nutrition therapy

(MNT), is a cornerstone in primary prevention of diabetes in

physical activity levels, contributing to the energy surplus and

development of obesity and type 2 diabetes.

high-risk subjects, eg, individuals with obesity and pre-diabetes,

secondary prevention of diabetes complications and tertiary
prevention of further progression of diabetes complications.


Quality diabetes care requires a multidisciplinary approach

Multifaceted role of MNT in the

management of diabetes

to promote patient self-management. The responsibility for

MNT should not be limited just to registered dietitians; all

MNT in primary prevention of diabetes

healthcare professionals of the multidisciplinary diabetes

All diabetes associations recognize MNT as an integral

management team, including doctors, diabetes educators,

component in a comprehensive diabetes care program. There is

nurses and pharmacists, should be equipped with knowledge

conclusive evidence from different populations, including those

about MNT to educate and reinforce to their patients the

in the US, China and Europe, which support the importance

importance of nutrition in order to optimize care and prevent

of MNT in primary prevention of type 2 diabetes.9-12 In these

complications. There is no clear single approach to diabetes

structured lifestyle modification programs, MNT was often

MNT that applies to all patients with diabetes. Rather, the

given in conjunction with advice on physical activity to achieve

approach and interventions should be customized, and

significant weight loss. Compared with the control group,

adapted to the patients needs and goals of therapy.

lifestyle modification in subjects with impaired glucose tolerance

resulted in an average 7% reduction in body weight. This delayed

insulin.34 Thus, glycemic control by increasing doses of insulin

incident type 2 diabetes by 11 years, representing an absolute risk

and anti-diabetic agents (eg, sulphonylureas) may be offset by

reduction of 20%.9,13 In the US Diabetes Prevention Program

weight gain with increased blood pressure and dyslipidemia.

The Look AHEAD (Action for Health in Diabetes) was

cost-effective than treatment with the oral anti-diabetic agent

a multicenter, randomized trial comparing the effects of an

metformin.9,13 Of note, while lifestyle modification was effective

intensive lifestyle intervention (ILI) and diabetes support and

in all age groups, the effect of metformin was less evident in

education (DSE) in 5,145 overweight or obese individuals with

persons older than 65 years. In a recent study from Spain, a

type 2 diabetes mellitus in the US. The ILI participants had a

Mediterranean diet reduced the incidence of diabetes in high-risk

greater percentage weight loss than DSE participants (-6.15%

subjects by 52% compared with a low-fat diet, despite the lack

vs -0.88%; P < 0.001), which was associated with improved

of weight reduction, increased physical activity and caloric

control of blood glucose, blood pressure and blood lipids.

restriction. These data support the importance of quality of diet

Based on the interim 4-year study results, adherence rates to

on disease prevention, in addition to caloric restriction.

the program, percentage of weight loss and improvement in


Feature article

(DPP), the benefit of lifestyle modification was greater and more

cardiovascular risk factors were similar between severely and

MNT in secondary prevention of diabetes


clinicians, the Look AHEAD study was halted prematurely

Optimal glycemic control prevents complications in both type

in October 2012 because of futility.36 Although the study

mildly obese participants.35 However, to the dismay of many

In the United Kingdom Prospective

found weight loss had many positive health benefits in type 2

Diabetes Study (UKPDS), which enrolled newly diagnosed

diabetes patients, the weight loss did not reduce the number

type 2 diabetes patients, HbA1c was 7.9% in the conventional

of cardiovascular events at 11 years follow-up (5% vs -1%

treatment group versus 7.0% in the intensive treatment group

weight loss in ILI and DSE participants, respectively).

1 and type 2 diabetes.


over 10 years.


This 0.9% reduction in HbA1c reduced the

endpoints by 12%. Similar to the long-term follow-up data of

MNT in tertiary prevention of progression of

diabetes complications

the Diabetes Control and Complications Trial (DCCT)15 and

In patients with diabetic nephropathy, salt (sodium) and

risk of microvascular complications by 25% and all diabetes

the Kumamoto study, this early and intensive glycemic control

protein restrictions are recommended to reduce fluid

had a legacy effect in reducing the risk of onset and progression

retention, blood pressure and rate of decline of renal function

of all-diabetes events, including CVD and death, in the 10-year

(Tables 1 and 2). In type 1 and type 2 diabetes patients with

post-trial period.17

microalbuminuria,37-40 restriction of daily protein intake


In this context, MNT has been shown to reduce HbA1c

(0.81.0 g per kg body weight) attenuated the rate of increase

by an average of 12% in type 2 diabetes patients18-20 with

in urinary albumin excretion and decline in glomerular

some studies reporting 0.252.9% reduction at 36 months. In

filtration rate. In type 1 diabetes with macroalbuminuria,

most of these studies, short disease duration and availability of

restriction of daily protein intake to 0.8 g per kg body weight

a registered dietitian to provide dietary advice were associated

slowed the rate of decline in renal function.41

with greater glycemic improvements.21-28 In other studies,

MNT was also found to reduce blood pressure and improve
lipid profiles.29-31

MNT has been shown to reduce

Nutritional recommendations of
international diabetes associations
Professional diabetes associations from the US, Canada,

HbA1c by an average of 12% in

United Kingdom (UK) and Europe recognize the importance

type 2 diabetes patients

diabetes management guidelines. Table 1 summarizes the

of MNT and provide nutritional recommendations in their

European Association for the Study of Diabetes (EASD),

Many conventional anti-diabetic agents, such as sulphonylureas

Canadian Diabetes Association (CDA) and UK National

and insulin, can cause weight gain. In obese type 2 diabetes

Institute for Health and Clinical Excellence (NICE).20,42-46

patients, adiposity can worsen insulin resistance due to increased

Since diet is a culture-specific behavior, there is a need to

release of free fatty acids, adipokines and cytokines, resulting

take into consideration the trans-cultural attributes in guiding

in increased drug usage; thus, setting up a vicious cycle.32 In a

nutritional recommendations in clinical practice.42,47,48 Table

6-month study, type 2 diabetes patients treated with intensive

2 lists the nutritional recommendations from five Asian

insulin therapy had a reduction in HbA1c of 2.6%, but gained

countries/cities.42,47,48 Although there are some differences in

In the UKPDS, most patients gained

the nutritional recommendations between the East and the

body weight over 10 years, particularly those treated with

West, as well as between different countries and cities, there

an average of 8.7 kg.



guidelines from the American Diabetes Association (ADA),

is a general consensus regarding the importance of weight

A meta-analysis of 14 randomized controlled trials,

loss in overweight and obese individuals as well as adequate

including 356 subjects (203 with type 1 and 153 with type

fiber intake. In fact, many of the dietary guidelines for people

2 diabetes), found that low GI diets reduced HbA1c by

with diabetes are similar to those for the general population.

0.43% compared with high GI diets.53 In this context, there

Feature article

is increasing evidence, albeit not without controversies,

Professional diabetes associations

recognize the importance of MNT
and provide nutritional
recommendations in their diabetes
management guidelines

suggesting that post-prandial hyperglycemia might be an

independent risk factor for CVD.54-58 As such, low GI foods
may have the potential to reduce cardiovascular risk in diabetic
populations, although more evidence is needed to confirm
these benefits. Meanwhile, many diabetes associations, such
as those in Australia, Canada and Europe, encourage the use
of low GI and low glycemic load (GL) diets; however, not all
diabetes associations concur or include such recommendations
(Tables 1 and 2).

MNT for patients requiring nutritional


Dietary fat and cholesterol

Saturated and trans fatty acids are the principal dietary
determinants of plasma low-density lipoprotein (LDL)

There are situations where diabetic patients require special

cholesterol, which is atherogenic. To reduce the risk for

nutritional support, which can be on either a short- or long-term

CVD, all diabetes associations recommend that individuals

basis. These may include, but are not limited to: frail elderly

with diabetes should restrict dietary saturated fatty acids

patients living in nursing homes; patients with suboptimal

to less than 10% of daily energy requirements, or in some

nutrition during the pre- and postoperative periods; patients

cases even lower (<7%) (Tables 1 and 2). Trans fatty acids

with acute conditions, such as sepsis; or during the post-stroke

should be minimized and daily intake of dietary cholesterol

or -myocardial infarction rehabilitation periods. When patients

should be limited to 300 mg and in some cases even lower

are unable to take an oral diet, tube feeding is the preferred route

(<200 mg). Although the US guideline does not have a

of feeding. Tube feeding is associated with fewer complications

specific recommendation on monounsaturated fatty acids

than parenteral nutrition, particularly in terms of glycemic

(MUFA), both the European and Canadian guidelines

control, metabolic abnormalities and infection risk.59

encourage dietary MUFA intake. Guidelines differ on the

recommended percentage of total fat from energy.

Glycemic index and glycemic load

The role of the quality and quantity of dietary carbohydrates
in influencing glycemic control of diabetic patients remains
an ongoing debate. Clinical attention has been drawn to the
role of glycemic index (GI) in MNT of diabetic patients.49
In the 1980s, Jenkins and colleagues first introduced the
concept of GI in the management of diabetes.50 The index

Diabetes-specific formula
may be considered to provide
energy, as well as macroand micronutrients, as a
component of MNT in diabetic
patients with special needs


is used to characterize the glycemic potential of different

carbohydrate-rich foods. It is defined as the area under the

Diabetes-specific formulas are typically formulated with

glucose response curve after consumption of a carbohydrate-

less carbohydrate, slowly digested carbohydrates, and more

containing food compared with that due to intake of 2550 g

fiber and fat than standard formulas, with a large proportion

The higher the GI of a

of fat from MUFA. Compared to standard formulas, the

food, the greater the area under the curve. In clinical practice,

higher fat and fiber content of diabetes-specific formulas

it is important to understand that many factors can influence

can delay gastric emptying and intestinal absorption of

the GI value of food and that GI should be considered in the

carbohydrate, resulting in a smaller post-prandial glycemic

context of a healthy diet. Factors that tend to increase the

rise. In a systematic review including 23 trials (19 randomized

GI value of carbohydrate-rich foods include higher degree of

controlled trials, three controlled clinical trials and one

processing and preparation, longer cooking time and greater

clinical trial),60 the authors concluded that diabetes-specific

ripeness or maturity of the food. On the other hand, food with

formulas given as oral supplements or tube feeds resulted in

high fat, protein or fiber, especially soluble fiber, content tends

less increase in postprandial blood glucose (1.03 mmol/L; 95%

to have a lower GI value due to slower gastric emptying.

confidence interval [CI] 0.581.47), peak blood glucose (1.59

carbohydrate from a control food.


Table 1. Major nutritional recommendations in management guidelines for diabetes from North America and Europe
Canadian Diabetes
Association (CDA)

United Kingdom National

Institute for Health and
Clinical Excellence
(NICE) (2008)46

Energy balance and

body weight

For overweight and

obese individuals: Deficit
in caloric intake by
5001,000 kcal/d; target
to decrease body weight
by 510%

For overweight individuals,

caloric intake should
be reduced and energy
expenditure be increased

Not specified

Target an initial body

weight loss of 510% for
overweight individuals

Carbohydrates (CHO)

Not specified; Refer to

RDA of average minimum
of 130g/d

4560% TEI

4560% TEI


Glycemic index
(GI) / Glycemic
load (GL)

GI and GL provide a
modest additional benefit
that is observed when
total CHO is considered

CHO-rich, low GI foods are


Choose low GI foods more


Encourage high-fibre, low

GI sources of CHO


Sucrose can be
substituted for other CHO
sources, but avoid excess
energy intake

<10% TEI from sucrose

(up to 50 g/d)

Up to 10% TEI from


Limited substitution of
sucrose-containing foods
for other CHO

Dietary fiber

14 g/1,000 kcal/d and

foods containing whole
grains (one half of grain

40 g/d (or 20 g/1,000

kcal/d), about half of
which should be soluble

25-50 g/d from a variety

of sources, including
soluble and cereal fibers

Encourage high fiber



1520% TEI for normal

renal function;
0.81.0 g/kg body
weight/d in earlier stage
of CKD; 0.8 g/kg/d in later
stage of CKD

1020% TEI for normal

renal function;
0.8 g/kg body weight/d if
nephropathy is established

1520% TEI

Not discussed


Not specified

<35% TEI (<30% if


35% TEI

Not discussed

Saturated fat

<7% TEI

<10% TEI (saturated fat

and trans fat)

7% TEI

Not discussed

Trans fat

Should be minimized

<8% TEI if LDL-C

Should be minimized

Not discussed


<200 mg/d

<300 mg/d and be further

reduced if LDL-C

<200 mg/d

Not discussed

fatty acids (MUFA)

Not specified

Encourage MUFA which

may provide 1020% TEI

MUFA instead of saturated

fat more often

Not discussed

fatty acids (PUFA)

Not specified;
2 servings of fish intake
per week to provide n-3

10% TEI
23 servings of oily fish
weekly and plant sources
of n-3 PUFA

<10% TEI (food rich in n-3

and plant oils)

Not discussed

Sodium / Salt

Reduced sodium intake

(eg, 2,300 mg/d) in
normotensive and
hypertensive individuals

<6 g salt/d and further

restriction for those with
elevated blood pressure

Not discussed

Not discussed

Vitamin and mineral


No clear evidence of
benefit in those who
do not have underlying
A daily multivitamin
supplement may be
appropriate, especially for
older adults with reduced
energy intake

Not discussed

Routine supplementation
is not necessary, except
for vitamin D in persons
aged >50 years and folic
acid in women planning

Not discussed


Limit to 1 drink/d for

women and 2 drinks/d
for men

Moderate use of alcohol

(up to 10 g/d for women
and 20 g/d for men)

Limit to 12 drinks /d
(14 standard drinks/
week for men and 9/
week for women)


CKD, chronic kidney disease; CHO, carbohydrate; GI, glycemic index; GL, glycemic load; LDL-C, low density lipoprotein cholesterol; MUFA; monounsaturated fatty acids; PUFA, polyunsaturated fatty acids; RDA: recommended daily allowance; TEI, total energy intake


European Association
for the Study of Diabetes
(EASD) (2004)45

Feature article

American Diabetes
Association (ADA) (2008
and 2012)43,44


Feature article

Table 2. Major nutritional recommendations in diabetes management guidelines from five Asian cities or countries


PR China42,47

Hong Kong SAR42,47



Energy balance and

body weight

Weight loss for

overweight and
obese individuals

Weight loss for

overweight and
obese individuals

Weight loss for

overweight and
obese individuals

Weight loss for

overweight and
obese individuals
(slow reduction of
710% over 1 year)

Weight loss for

overweight and
obese individuals
(510% initial
body weight over 6

Carbohydrates (CHO)

Amount not
recommend to
distribute amongst
three main meals
per day

<5565% TEI and

not <130 g/d

4565% TEI

6070% TEI

5060% TEI

Glycemic index
(GI) / Glycemic
load (GL)

Not discussed

Not discussed

Not discussed

Not discussed

Choice of low GI
foods in place of
conventional or high
GI foods has a small
effect on medium
term glycemic
control. GI must be
used to complement
established dietary


Not discussed

Not discussed

Not discussed

Not discussed

Limit to 10% TEI

Dietary fiber

15 g/1,000 kcal

Not discussed

Not discussed

Not discussed

2030 g/d


1520% TEI

<20% TEI

1520% TEI

1218% TEI

15% TEI
or 0.81.0 g/kg/day


Not discussed

<30% TEI

<30% TEI

2025% TEI

2530% TEI

Saturated fat

<7% TEI

Not discussed

<10% TEI

<7% TEI

<710% TEI

Trans fat

Not discussed

Not discussed

Not discussed

Not discussed



<200 mg/d

<300 mg/d

<300 mg/d;
<200 mg/d if LDL
>100 mg/dL (or 2.6

<200 mg/d

300 mg/d

fatty acids (MUFA)

Not discussed

Not discussed

Not discussed

Not discussed


fatty acids (PUFA)

Not discussed

Not discussed

Not discussed

Not discussed

47% TEI

Sodium / Salt

<2,400 mg/d

Not discussed

Not discussed

Not discussed

<2,400 mg/d

Vitamin and mineral


Not discussed

Not discussed

Not discussed

Not discussed

Supplement is
indicated with
confirmed deficiency


Not discussed

Not discussed

Not discussed

Not discussed

Limit to 1drink/d
for women and 2
drinks/d for men

CHO, carbohydrate; GI, glycemic index; GL, glycemic load; LDL-C, low density lipoprotein cholesterol; MUFA; monounsaturated fatty acids; PUFA, polyunsaturated fatty acids; TEI, total energy intake

mmol/L; 0.862.32) and glucose area under curve (7.96 mmol/

may be considered to provide energy as well as macro- and

l*l-1*min-1; 2.2513.66) compared with standard formulas.

micronutrients as a component of MNT in diabetic patients

Given the epidemiological data that has identified an association

with special needs.42

between postprandial hyperglycemia and cardiovascular

morbidity and mortality in diabetes and pre-diabetes,54-58 these

MNT during pregnancy

favorable glycemic effects of diabetes-specific formulas may be

translated to long-term benefits on cardiovascular outcomes.

In women with gestational diabetes mellitus (GDM), several


small studies have suggested that low GI diets might safely





decrease maternal body weight, reduce the need for insulin

primary, secondary and tertiary management of diabetes.

The optimal ratio of carbohydrate-to-fat in the prevention of
diabetes is not known.74 Despite quite a number of functional

of previously delivering an infant >4 kg and without diabetes

foods and supplements, such as fiber-enriched products and

in their second pregnancy, were randomized to receive no

margarines containing plant sterols, that are being actively


dietary intervention or a low GI diet from early pregnancy.

promoted or marketed, many of the claims in preserving health

Although there was no significant difference between the two

and preventing or controlling disease are not supported by

groups, there was a trend for less gestational weight gain and

sufficient clinical evidence.45

lower rate of glucose intolerance in the intervention compared

From a practical perspective, the challenges encountered

by diabetic patients in understanding the variety of food choices

with the control arm.


Pregnancy in obese women with GDM requires special

and compositions, including counting of macronutrients

nutritional consideration. While hypocaloric diets in these

especially on carbohydrates, cannot be over-emphasized. Spiegel

women can result in ketonemia and ketonuria, moderate caloric

and colleagues recently reported results from a randomized

restriction (eg, 30% reduction of estimated energy needs) may

controlled nutrition interventional trial to improve carbohydrate

improve glycemic control without ketonemia. However, there

counting among adolescents with type 1 diabetes.75 Although

are limited data on the effects of caloric restriction on fetal

HbA1c decreased in both intervention and control groups

outcomes and there are only few data from randomized clinical

after 3 months, the change in the intervention group was not

trials regarding dietary intervention in pregnant women with

statistically significant; thereby, further research is needed to

GDM. In a clinical trial including 1,000 women with GDM

translate nutrition education into improved health outcomes.

(490 randomized to the intervention group and 510 to routine

Patients should be encouraged to regularly monitor

care), intervention (dietary advice, blood glucose monitoring

their post-prandial blood glucose levels to ascertain their food

and insulin therapy, if needed) significantly reduced serious

choices, and ensure that carbohydrate counts are accurate. The

perinatal complications (1% versus 4%; relative risk 0.33; 95%

recent advances in blood glucose monitoring technology, such

CI 0.14-0.75: P = 0.01).

as the use of a continuous glucose monitoring device (CGMS),


Feature article

A recently published

randomized controlled trial including 800 women, with history

and lower the risk of macrosomia.


can assist with meal planning for patients with diabetes.

MNT Controversies and challenges

Despite the advocacy for use of a low GI diet by some diabetes
associations, its role in the management of obesity and
prevention of diabetes remains inconclusive.66 Modern food
processing technology produces many food products with
refined carbohydrates and high GI, which may cause accelerated
and transient surges in blood glucose and insulin, reduced

Furthermore, such technology can facilitate effective counselling

to improve glycemic control, and provide on-going feedback
on glucose levels to empower our diabetic patients. Here, more
translational studies are needed to evaluate different strategies
to educate, engage and enable patients in choosing healthy
food choices.


satiety and excessive caloric intake. These post-prandial events

may cause neurohormonal dysregulation (eg, hyperinsulinemia

Based on a large body of evidence, most international

and activation of sympathetic nervous system) and endothelial

diabetes associations recommend MNT as an integral part

in the prevention and management strategies of diabetes
and its complications. The diabetes associations have a


whole grains and dietary fiber can reduce risk of diabetes

general consensus regarding the importance of weight loss

remains to be proven.73 Similarly, the beneficial effect of low

in overweight and obese individuals, adequate dietary fiber

GI foods on plasma lipid levels remains controversial. In

intake, and restrictions on dietary saturated fat, trans fat and

a preliminary interim analysis of an ongoing randomized

cholesterol intakes. However, there is no unified agreement

controlled trial of 100 obese school children aged 1518 years

on specific distribution of protein, carbohydrates and fat from

in Hong Kong ( Ref. No.: NCT 01278563),

total energy. All members of the multidisciplinary diabetes

subjects assigned to a low GI diet had greater weight reduction

management team should be aware of the importance and

after 6 months, but similar glycemic, lipid and blood pressure

be equipped with knowledge to help patients to implement

profiles, to those taking traditional Chinese diets (Kong A, et al.;

MNT as part of their comprehensive diabetes treatment

unpublished data).

plan. Prescription of MNT should also be individualized,

dysfunction (hyperglycemia and oxidative stress).


Apart from carbohydrate, there are ongoing deliberations

patient-centered and take into consideration cultural and

on the effects of the quantity and quality of dietary fat on

social factors to facilitate successful patient implementation.


On the

other hand, whether low GI diets and increased intake of



Feature article


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35. Unick JL, Beavers D, Jakicic JM, et al. Effectiveness of lifestyle interventions for individuals with severe
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37. Dullaart RP, Beusekamp BJ, Meijer S, van Doormaal JJ, Sluiter WJ. Long-term effects of proteinrestricted diet on albuminuria and renal function in IDDM patients without clinical nephropathy and
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38. Pomerleau J, Verdy M, Garrel DR, Nadeau MH. Effect of protein intake on glycaemic control and renal

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39. Narita T, Koshimura J, Meguro H, et al. Determination of optimal protein contents for a protein
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40. Pijls LT, de Vries H, van Eijk JT, Donker AJ. Protein restriction, glomerular filtration rate and albuminuria
in patients with type 2 diabetes mellitus: a randomized trial. Eur J Clin Nutr 2002;56:1200-1207.
41. Hansen HP, Tauber-Lassen E, Jensen BR, Parving HH. Effect of dietary protein restriction on prognosis
in patients with diabetic nephropathy. Kidney Int 2002;62:220-228.
42. Mechanick JI, Marchetti AE, Apovian C, et al. Diabetes-specific nutrition algorithm: a transcultural
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47. Su HY, Tsang MW, Huang SY, et al. Transculturalization of a diabetes-specific nutrition algorithm: Asian
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older women. Am J Clin Nutr 2000;71:921-930.
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load, and incidence of type 2 diabetes mellitus in middle-aged Chinese women. Arch Intern Med
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risk of type 2 diabetes in US black women. Arch Intern Med 2007;167:2304-2309.
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risk--a meta-analysis of observational studies. Am J Clin Nutr 2008;87:627-637.
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intake, and measures of insulin sensitivity, secretion, and adiposity in the Insulin Resistance Atherosclerosis Study. Diabetes Care 2005;28:2832-2838.
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75. Spiegel G, et al. Randomized nutrition education intervention to improve carbohydrates counting
in adolescents with type 1 diabetes study: Is more intensive education needed? J Acad Nutr Diet

Acknowledgements: The data of some of the studies described in this manuscript were supported by the
Research Grant Committee (CUHK 467410), Li Ka Shing Institute of Health Science and Hong Kong Institute
of Diabetes and Obesity, under the auspices of The Chinese University of Hong Kong.

- most frequent cause
of new cases of
blindness in adults
(2074 years)6,9

- 40% of patients on
dialysis are diabetics6,10

- important comorbidity and cause of death12
- premature death from cancer and infectious diseases13
CHD, coronary heart disease; CVD, cardiovascular disease

Health economic perspective

Worldwide burden of diabetes
and its multiple morbidities
Claire Takizawa PharmD, MSc

Alice Pik-Shan Kong FRCP

Nestl Health Science


Department of Medicine and Therapeutics

The Chinese University of Hong Kong
Hong Kong SAR

Figure 1. Global burden of diabetes and its multiple

- 4.6 million adults in 20124
- 6-8% all-cause mortality (all ages)4 - CVD: a leading cause
of death, up to 50%
or more in some
- up to 50% of
diabetes patients6,11
- CHD: 2- to 4-times
increased risk6,7
Renal disease
371 million
increased risk6,8
- leading cause of
kidney failure6,10
- 40% of patients on
- most frequent cause
dialysis are diabetics6,10
of new cases of
blindness in adults
(2074 years)6,9
- important comorbidity and cause of death12
- premature death from cancer and infectious diseases


Figure 2. Productivity and healthcare as percentage of GDP15

Total cost as %
of GDP

Healthcare costs 0.2

Total cost as %
of GDP

Healthcare costs 0.3

Productivity loss 0.1

Healthcare costs 0.2

Total cost as %
of GDP

Healthcare costs 0.9

Productivity loss 1.9

Productivity loss 0.3

GDP, gross domestic product

plus moderate exercise) reduced the risk of developing type 2

diabetes by 58% versus control.16 Based on these clinical
results, Palmer et al. showed an incremental cost-effectiveness
ratio (ICER) of 6,381 (USD 8,166)/life-year gained for ILC
versus control (2002 costs).17 The DPP group also found
that ILC was more cost-effective than control. Furthermore,
from both a health system and societal perspective, ILC is
more cost-effective than metformin in terms of cost/qualityadjusted life year (QALY) and cost/case prevented (Table).18
Table. Cost-effectiveness analysis of Intensive Lifestyle
Change versus metformin in diabetes18
DPP group
Costs [USD]

CHD, coronary heart disease; CVD, cardiovascular disease

In the United States (US), the total medical expenditure

related to diabetes increased from USD 1.7 billion in 1969 to
USD 44.4 billion in 1997.14 Total costs of diagnosed diabetes
in the US in 2007 were estimated at USD 174 billion; direct
medical costs represented USD 116 billion and indirect
costs USD 58 billion (ie, disability, work loss, premature
mortality).6 After adjusting for population, age and sex
differences, average medical expenditure among people
with diagnosed diabetes was 2.3 times greater than in those
without diabetes.6
Expressed as a percentage of gross domestic product
(GDP), India currently bears the heaviest cost burden for
accounting for approximately
2.1% of GDP (Figure
Total cost as %
Total costUS
as % faces the biggest
2). Among
costs 0.2
Healthcare costs 0.2
of GDP
of GDP
Productivity loss cost
burden, with
an estimated
to 1.2%
in 2007. The United Kingdom faces costs of 0.4% of GDP,
while Denmark incurs costs equivalent to 0.6% of GDP. Lost
costs alone for China areUSequivalent to 0.6% of
Total cost as20.5
cost as %for China may not
Healthcare costs
Healthcare costs 0.9
of GDP
of GDP
0.4 on face
Productivity loss 0.3 it
seem large
the 1.2
general population,
represents over 20% of GDP per capita.1
In domestic
most product
countries, 5% to 18% of healthcare
GDP, gross
expenditure is on diabetes. In 2012, an estimated USD
471 billion was spent on diabetes worldwide, mainly for
treating complications.1
One study from the Diabetes Prevention Program
(DPP) concluded that Intensive Lifestyle Change (ILC Diet

Productivity loss 0.4

Total cost as %
of GDP

Health economic

As of 2012, an estimated 371 million individuals worldwide

had diabetes (8.3% of the total adult population), of which
187 million people were undiagnosed.1 Moreover, an
additional 280 million people had impaired glucose tolerance
(6.4%).2 The prevalence of diabetes is expected to reach 552
million by 2030, with major increases forecast in the Middle
East and Africa (8390% increase, with 81% undiagnosed
today) and South-east Asia (69% increase).1,3 Diabetes is
associated with multiple morbidities (Figure 1), which place
a significant burden on healthcare resources worldwide.

Health system perspective

Societal perspective

Per prevented/delayed Per QALY Per prevented/delayed Per QALY

diabetes case
diabetes case

Lifestyle inter- 15,700

vention (ILC)









Adapted from Diabetes Prevention Program (DPP).18 QALY: quality-adjusted life year

Similar results were found in a study conducted

in Finland by Eriksson et al.19 The combination of diet
and exercise was most effective in reversing the insulin
resistance syndrome compared with each of these
components separately.
Diabetes is running at record levels worldwide and
half of the people estimated to have the disease are as of
yet undiagnosed. Diabetes can lead to serious and costly
complications, with a significant worldwide economic
burden. Dietary intervention should be considered as part
of the solution as it is a worthwhile investment as part of a
diabetes prevention and management program.
1. International Diabetes Federation. IDF Diabetes Atlas. 5th Edition. 2012 Update. Accessed: 19 November
2012. 2. International Diabetes Federation. IDF Global Burden. Available at:
the-global-burden. Accessed: 26 November 2012. 3. International Diabetes Federation. IDF Diabetes Atlas.
Regional overviews. Available at: Accessed: 26
November 2012. 4. Roglic G, Unwin N. Diabetes Res Clin Pract 2010;87:15-19. 5. International Diabetes Federation. Factsheet: Diabetes and Cardiovascular disease. Available at:
Accessed: 26 November 2012. 6. Center for Disease Control and Prevention. National Diabetes Fact Sheet:
national estimates and general information on diabetes and prediabetes in the United States, 2011. Available at: Accessed: 19 November 2012. 7. Haffner SM, et al. N
Engl J Med 1998;339:229-334. 8. Kannel WB, et al. Am Heart J 1990;120:672-676. 9. Fong DS, et al. Diabetes
Care 2004;27(Suppl 1):S84-S87. 10. Ritz E, et al. Am J Kidney Dis 1999;34:795-808. 11. Boulton AJ, et al.
Diabetes Care 2004;27:1458-1486. 12. Kong AP, Chan JC. Curr Diab Rep 2012;12:325-328. 13. The Emerging
Risk Factors Collaboration. N Engl J Med 2011;364:829-841. 14. Logeminiene Z, et al. Medicina (Kaunas)
2004;40:16-26. 15. Silent epidemic An economic study of diabetes in developed and developing countries.
The Economist 2011. Available at:
silent_epidemic. Accessed: 19 November 2012 16. The Diabetes Prevention Program Research Group. N Engl
J Med 2002;346:393-403. 17. Palmer AJ, et al. Clin Ther 2004;26:304-321. 18. Diabetes Prevention Program
Research Group. Diabetes Care 2003;26:2518-2523. 19. Eriksson J, et al. Diabetologia 1999;42:793-801.



Perioperative nutrition support in cancer patients

Clinical nutrition

Nutr Clin Pract 2012 Oct;27(5):586-592.

Huhmann MB, August DA.
Department of Nutritional Science, University of Medicine and Dentistry of New
Jersey, Newark, New Jersey, USA.

Malnutrition and weight loss negatively affect outcomes in

surgical cancer patients. Decades of research have sought
to identify the most appropriate use of nutrition support in
these patients. National and international guidelines help to
direct clinicians use of nutrition support in surgical patients,
but a number of specific issues concerning the use of nutrition
support continue to evolve. This review focuses on five key
issues related to perioperative nutrition support in cancer
patients: (1) Which perioperative cancer patients should
receive nutrition support?; (2) How can the nutrition status
and requirements of these patients be optimally assessed?;
(3) What is the optimal route of administration (parenteral
nutrition vs enteral nutrition) and composition of nutrition
support in this setting?; (4) When should feedings be initiated?;
(5) What is the role of glycemic control in these patients?


Intra-abdominal pressure as a prognostic factor

for tolerance of enteral nutrition in critical patients


JPEN J Parenter Enteral Nutr 2012 Oct 15. [Epub ahead of print]
Bejarano N, Navarro S, Rebasa P, Garca-Esquirol O, Hermoso J.
Department of Surgery, Intensive Care Unit, Hospital Universitario, Barcelona, Spain.


BACKGROUND: The purpose of this study is to establish

a relationship between tolerance of enteral nutrition (EN)
and intra-abdominal pressure (IAP) in critical patients,
establish an objective measure for monitoring tolerance,
and determine a threshold value for IAP. MATERIALS AND
METHODS: Prospective and observational study at the
critical care unit. Seventy-two patients were recruited with
an expected stay of more than 72 hours and scheduled to
receive EN. We recorded IAP and clinical and laboratory
variables to describe predictive ones for tolerance of EN
at the start of nutrition. RESULTS: The largest group was
polytrauma patients (41.7%). Of the patients, 40.3% had
undergone surgery prior to inclusion in the study. Most
patients (87.5%) were fed via nasogastric tube. Physiological
POSSUM (Physiological and Operative Severity Score for
the enUmeration of Mortality and Morbidity) on admission
was 26.4 7.6, and surgical POSSUM was 22.4 8.0. The
mean Acute Physiology and Chronic Health Evaluation II

(APACHE II) score was 13.6 6.0. Mortality was 31.9%. In

all, 70.8% tolerated EN. The univariate analysis revealed a
statistically significant relation between tolerance of EN and
surgical POSSUM, APACHE II, and baseline IAP. The multivariate analysis showed a relationship between APACHE
II score, baseline IAP, and the tolerance of EN. So, on the
basis of these two variables, logistic regression analysis
can predict whether a patient will tolerate the diet with an
overall precision of 80.3%. CONCLUSIONS: In critically
ill patients, there is a relation between IAP values and the
tolerance of EN. The baseline IAP with the APACHE II score
can predict the tolerance of EN.

The effects of probiotics in early enteral nutrition

on the outcomes of trauma: A meta-analysis of
randomized controlled trials
JPEN J Parenter Enteral Nutr 2012 Oct 12. [Epub ahead of print]
Gu WJ, Deng T, Gong YZ, Jing R, Liu JC.
Department of Anaesthesiology, The First Affiliated Hospital, Guangxi Medical
University, Nanning, Guangxi, Peoples Republic of China.

BACKGROUND: The role of probiotics in trauma

patients remains unclear. We undertook a meta-analysis
of published randomized controlled trials (RCTs) to assess
the effects of probiotics on the clinical outcomes of trauma
patients. METHODS: A systematic electronic literature
search was conducted to identify RCTs comparing the use
of probiotics with a control in trauma patients. Results
were expressed as risk ratios (RRs) or standardized mean
differences (SMDs) with accompanying 95% confidence
intervals (CIs). The primary outcome measurement was
the incidence of nosocomial infections. Secondary outcome
measurements included the incidence of ventilator-associated
pneumonia (VAP), length of intensive care unit (ICU) stay,
and mortality. The meta-analysis was performed with the
fixed-effect or random-effect model according to the heterogeneity. RESULTS: Five studies involving 281 patients met
our inclusion criteria. The use of probiotics was associated
with a reduction in the incidence of nosocomial infections
(five trials; RR, 0.65; 95% CI, 0.450.94, P = 0.02), VAP
(three trials; RR, 0.59; 95% CI, 0.420.81, P = 0.001), and
length of ICU stay (two trials; SMD, -0.71; 95% CI, -1.09
0.34, P < 0.001) but no reduction in mortality (four trials;
RR, 0.63; 95% CI, 0.321.26, P = 0.19). CONCLUSIONS:
The use of probiotics is associated with a reduction in the
incidence of nosocomial infections, VAP, and length of ICU
stay but is not associated with an overall mortality advantage.
However, the results should be interpreted cautiously due to
the heterogeneity among study designs. Further large-scale,
well-designed RCTs are needed.

The abstracts included in this section were selected from a search on clinical nutrition and related topics of the PubMed database of the United States National Library of
Medicine. PubMed may be accessed via the National Library of Medicine Web site at

Permissive underfeeding versus target enteral

feeding in adult critically ill patients (PermiT trial):
A study protocol of a multicenter randomized
controlled trial
Trials 2012 Oct 12;13(1):191.
Arabi YM, Haddad SH, Aldawood AS, Al-Dorzi HM, Tamim HM, Sakkijha M, Jones G,
McIntyre L, Mehta S, Solaiman O, Sadat M, Afesh L, Sami B.
King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.

Combined enteral feeding and total parenteral

nutritional support improves outcome in surgical
intensive care unit patients
J Chin Med Assoc 2012 Sep;75(9):459-463.
Hsu MH, Yu YE, Tsai YM, Lee HC, Huang YC, Hsu HS.
Institute of Emergency and Critical Care Medicine, National Yang-Ming University
School of Medicine, Taipei, Taiwan, ROC.

Barriers to feeding critically ill patients:

A multicenter survey of critical care nurses
J Crit Care 2012 Dec;27(6):727-734.
Cahill NE, Murch L, Cook D, Heyland DK; On behalf of the Canadian Critical Care
Trials Group.
Department of Community Health and Epidemiology, Queens University, Kingston,
Ontario, Canada; Clinical Evaluation Research Unit, Kingston General Hospital,
Kingston, Ontario, Canada.

PURPOSE: The aims of this study were to describe the

barriers to enterally feeding critically ill patients from a
nursing perspective and to examine whether these barriers
differ across centers. MATERIALS AND METHODS: A
cross-sectional survey was conducted in five hospitals in
North America. A 45-item questionnaire was administered
to critical care nurses to evaluate the barriers to enterally
feeding patients. RESULTS: A total of 138 of 340 critical
care nurses completed the questionnaire (response rate of
41%). The five most important barriers to nurses were as
follows: (1) other aspects of patient care taking priority
over nutrition; (2) not enough feeding pumps available; (3)
enteral formula not available on the unit; (4) difficulties
in obtaining small bowel access in patients not tolerating
enteral nutrition; and (5) no or not enough dietitian coverage
during weekends and holidays. For 18 (81%) of 22 potential
barriers, the rated magnitude of importance was similar
across the five intensive care units. CONCLUSION: Nurses
in our multicenter survey identified important barriers to
providing adequate enteral nutrition to their critically ill
patients. The importance of these barriers does not appear
to differ significantly across different clinical settings. Future
research is required to evaluate if tailoring interventions to
overcome these identified barriers is an effective strategy of
improving nutrition practice.

Association of low serum 25-hydroxyvitamin D

levels and acute kidney injury in the critically ill
Crit Care Med 2012 Dec;40(12):3170-3179.
Braun AB, Litonjua AA, Moromizato T, Gibbons FK, Giovannucci E, Christopher KB.
Renal Division, Brigham and Womens Hospital (ABB); Channing Laboratory and
Pulmonary and Critical Care Division (AAL); The Nathan E. Hellman Memorial
Laboratory, Renal Division (TM, KBC), Brigham and Womens Hospital, Boston,
Massachusetts, USA; Pulmonary Division, Massachusetts General Hospital (FKG),
Boston, Massachusetts, USA; Departments of Nutrition and Epidemiology (EG),
Harvard School of Public Health, Boston, Massachusetts, USA.

OBJECTIVE: Given the importance of inflammation in acute

kidney injury and the relationship between vitamin D and
inflammation, we sought to elucidate the effect of vitamin
D on acute kidney injury. We hypothesized that deficiency


BACKGROUND: For intensive care unit (ICU) patients with

gastrointestinal dysfunction and in need of total parenteral
nutrition (TPN) support, the benefit of additional enteral
feeding is not clear. This study aimed to investigate whether
combined TPN with enteral feeding is associated with better
outcomes in surgical intensive care unit (SICU) patients.
METHODS: Clinical data of 88 patients in SICU were retrospectively collected. Variables used for analysis included
route and percentage of nutritional support, total caloric
intake, age, gender, body weight, body mass index, admission
diagnosis, surgical procedure, Acute Physiology and Chronic
Health Evaluation (APACHE) II score, comorbidities, length
of hospital stay, postoperative complications, blood glucose
values and hospital mortality. RESULTS: Wound dehiscence
and central catheter infection were observed more frequently
in the group of patients receiving TPN calories less than
90% of total calorie intake (P = 0.004 and 0.043, respectively). APACHE II scores were higher in nonsurvivors than
in survivors (P = 0.001). More nonsurvivors received TPN

Clinical nutrition

BACKGROUND: Nutritional support is an essential part of

the management of critically ill patients. However, optimal
caloric intake has not been systematically evaluated. We
aim to compare two strategies of enteral feeding: permissive
underfeeding versus target feeding. METHOD/DESIGN: This
is an international multicenter randomized controlled trial in
critically ill medical-surgical adult patients. Using a centralized
allocation, 862 patients will be randomized to permissive
underfeeding or target feeding. Patients in the permissive
group receive 50% (acceptable range is 40% to 60%) of the
calculated caloric requirement, while those in the targeted
group receive 100% (acceptable range 70% to 100%) of
the calculated caloric requirement. The primary outcome is
90-day all-cause mortality. Secondary outcomes include ICU
and hospital mortality, 28-day, and 180-day mortality as
well as health care-associated infections, organ failure, and
length of stay in the ICU and hospital. The trial has 80%
power to detect an 8% absolute reduction in 90-day mortality
assuming a baseline risk of death of 25% at an alpha level of
0.05. DISCUSSION: Patient recruitment started in November
2009 and is currently active in five centers. The Data
Monitoring Committee advised continuation of the trial after
the first interim analysis. The study is expected to finish by
November 2013.

calories exceeding 90% of total calorie intake and were in need

of dialysis during ICU admission (P = 0.005 and 0.013, respectively). Multivariate analysis revealed that the percentage of
TPN calories over total calories and APACHE II scores were
independent predictors of ICU mortality in patients receiving
supplementary TPN after surgery. CONCLUSION: In SICU
patients receiving TPN, patients who could be fed enterally
more than 10% of total calories had better clinical outcomes
than patients receiving less than 10% of total calorie intake
from enteral feeding. Enteral feeding should be given whenever
possible in severely ill patients.


Clinical nutrition

in 25-hydroxyvitamin D prior to hospital admission would

be associated with acute kidney injury in the critically ill.
DESIGN: Two-center observational study of patients treated
in medical and surgical intensive care units. SETTING: Two
hundred nine medical and surgical intensive care beds in two
teaching hospitals in Boston, Massachusetts. PATIENTS:
Two thousand seventy-five patients, aged 18 yrs, in
whom serum 25-hydroxyvitamin D was measured prior
to hospitalization between 1998 and 2009. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS:
The exposure of interest was preadmission serum
25-hydroxyvitamin D and categorized a priori as
deficiency (25-hydroxyvitamin D 15 ng/mL), insufficiency (25-hydroxyvitamin D1530 ng/mL), or sufficiency
(25-hydroxyvitamin D 30 ng/mL). The primary outcome was
acute kidney injury defined as meeting Risk, Injury, Failure,
Loss, and End-stage kidney disease (RIFLE) Injury or Failure
criteria. Logistic regression examined the RIFLE criteria
outcome. Adjusted odds ratios were estimated by multivariate
logistic regression models. Preadmission 25-hydroxyvitamin
D deficiency is predictive of acute kidney injury. Patients
with 25-hydroxyvitamin D deficiency have an odds ratio for
acute kidney injury of 1.73 (95% confidence interval [CI]
1.302.30; P < 0.0001) relative to patients with 25-hydroxyvitamin D sufficiency. 25-Hydroxyvitamin D deficiency remains
a significant predictor of acute kidney injury following
multivariable adjustment (adjusted odds ratio 1.50; 95% CI
1.422.24; P < 0.0001). Patients with 25-hydroxyvitamin D
insufficiency have an odds ratio for acute kidney injury of 1.49
(95% CI 1.151.94; P = 0.003) and an adjusted odds ratio of
1.23 (95% CI 1.121.72; P = 0.003) relative to patients with
25-hydroxyvitamin D sufficiency. In addition, preadmission
25-hydroxyvitamin D deficiency is predictive of mortality.
Patients with 25-hydroxyvitamin D insufficiency have an odds
ratio for 30-day mortality of 1.60 (95% CI 1.182.17; P =
0.003) and an adjusted odds ratio of 1.61 (95% CI 1.061.57;
P = 0.004) relative to patients with 25-hydroxyvitamin D
sufficiency. CONCLUSION: Deficiency of 25-hydroxyvitamin D prior to hospital admission is a significant predictor
of acute kidney injury and mortality in a critically ill
patient population.


Predicting energy expenditure in sepsis:

Harris-Benedict and Schofield equations versus
the Weir derivation


Crit Care Resusc 2012 Sep;14(3):202-210.

Subramaniam A, McPhee M, Nagappan R.
Intensive Care Unit, Box Hill Hospital, Melbourne, Victoria, Australia.

BACKGROUND: Given the difficulties of using indirect

calorimetry in many intensive care units, clinicians routinely
employ predictive equations (the Harris-Benedict equation
[HBE] and Schofield equation are commonly used) to estimate
energy expenditure in critically ill patients. Some extrapolate
CO2 production (V CO2) and O2 consumption (V O2) by
the Weir derivation to estimate energy expenditure. These
derivative methods have not been compared with predictive
equations. OBJECTIVE: To compare prediction of energy
expenditure by the HBE and Schofield equation with energy

expenditure as estimated by the Weir derivation in a cohort

of critically ill patients. METHODS: Between June 2009 and
May 2010, we conducted a prospective single-center study
of 60 mechanically ventilated patients with sepsis of varying
severity in the ICU of a metropolitan hospital. Three groups
of patients were compared: those with systemic inflammatory
response syndrome (SIRS), severe sepsis and septic shock.
The HBE and Schofield equation are age-based, weight-determined, sex-specific derivations that may incorporate stress
and/or activity factors. Total energy expenditure (TEE) values
calculated from these equations (TEE(HBE) and TEE(SCH),
respectively) were compared with the measured energy expenditure (MEE) calculated by the Weir derivation. We derived V
CO2 from end-tidal CO2 and deduced V O2 assuming a respiratory quotient of 0.8381. RESULTS: Mean ( SD) APACHE
II score for the 60 patients was 25.7 8.4. All patients received
nutrition (51 enteral, eight parenteral and one combined) in
addition to standard management for sepsis and multiorgan
supportive therapy. Overall, 45 patients required inotropes
and four received continuous renal replacement therapy.
TEE derived from both predictive equations correlated well
with MEE derived from the Weir equation (mean TEE(HBE),
7810.7 1669.2 kJ/day; mean TEE(SCH), 8029.1 1418.6
kJ/day; mean MEE, 7660.8 2092.2 kJ/day), being within
8% of each other. Better correlations between TEE and MEE
were observed in patients with APACHE II scores <25 (vs
those with scores 25) and patients with SIRS or severe sepsis
(vs those with septic shock). CONCLUSION: In a cohort of
patients with sepsis, TEE values calculated by the HBE and
Schofield equation matched reasonably well with MEE values
derived from the Weir equation. Correlation was better in
patients with less severe sepsis (SIRS and severe sepsis and
APACHE II score <25). Our results suggest that predictive
equations have sufficient validity for ongoing regular use in
clinical practice.

Nourishing the dysfunctional gut and whey protein

Curr Opin Clin Nutr Metab Care 2012 Sep;15(5):480-484.
Abraho V.
ETERNU Multidisciplinary Nutritional Team/Rio de Janeiro Casa de Sade So
Jos, Hospital Badim, Hospital Pasteur, Hospital Israelita Albert Sabin, Hospital
Cardiotrauma, Casa de Sade Santa Lcia, Brazil.

PURPOSE OF REVIEW: This review discusses the mechanisms of the dysfunctional gut during the critical illness
and the possibility that an immunonutrient such as whey
protein can play a role in better tolerance of enteral
nutrition, also decreasing inflammation and increasing antiinflammatory defenses. RECENT FINDINGS: Impaired
gastric motor function and associated feed intolerance
are common issues in critically ill patients. Some studies
have been published with enteral nutrition enriched with
whey protein as a dietary protein supplement that provides
antimicrobial activity, immune modulation, improving
muscle strength and body composition, and preventing
cardiovascular disease and osteoporosis. SUMMARY: Early
enteral feeding will enhance patient recovery and the use of
enteral diets enriched with whey protein may play a role in
these patients.

A multicenter, randomized controlled trial

comparing early nasojejunal with nasogastric
nutrition in critical illness
Crit Care Med 2012 Aug;40(8):2342-2348.
Davies AR, Morrison SS, Bailey MJ, Bellomo R, Cooper DJ, Doig GS, Finfer SR,
Heyland DK; ENTERIC Study Investigators; ANZICS Clinical Trials Group.
Intensive Care Unit, Alfred Hospital, Department of Epidemiology and Preventive
Medicine, Monash University, Melbourne, Victoria, Australia.

J Trauma Acute Care Surg 2012 Jul;73(1):202-208.

McMillen MA, Boucher N, Keith D, Gould DS, Gave A, Hoffman D.
Department of Surgery, Beth Israel Medical Center, New York, USA.

BACKGROUND: Most surgical critical care literature reflects

practices at trauma centers and tertiary hospitals. Surgical
critical care needs and practices may be quite different at
nontrauma center teaching hospitals. As acute care surgery
develops as a component of surgical critical care and trauma,
the opportunities and challenges of the nontrauma centers


Nutrition assessment and intervention in the

patient with dysphagia: Challenges for quality
Nestl Nutr Inst Workshop Ser 2012;72:77-83.
Ochoa JB.
Nestl HealthCare Nutrition, Nestl Health Science, Florham Park, New Jersey, USA.

Dysphagia, a symptom characterized by difficulty swallowing,

is an independent predictor of poor outcome, worsening
morbidity, increasing the risk for hospital readmissions,
health care costs and mortality. Dysphagia is a result of a
number of illnesses including neurological diseases, after
surgery for head and neck pathology, observed in the intensive
care unit after prolonged endotracheal intubation among
others, and is particularly frequent in the elderly. Dysphagia
increases the incidence of malnutrition, which in turn delays
patient recovery. Treatment of dysphagia can be successful,
but requires the use of multidisciplinary teams. A focus on


Maintaining quality of care 24/7 in a nontrauma

surgical intensive care unit

Clinical nutrition

OBJECTIVE: Current guidelines recommend enteral nutrition

in critically ill adults; however, poor gastric motility often
prevents nutritional targets being met. We hypothesized
that early nasojejunal nutrition would improve the delivery
of enteral nutrition. DESIGN: Prospective, randomized,
controlled trial. SETTING: Seventeen multidisciplinary, closed,
medical/surgical, intensive care units in Australia. PATIENTS:
One hundred and eighty-one mechanically ventilated adults
who had elevated gastric residual volumes within 72 hrs of
intensive care unit admission. INTERVENTIONS: Patients
were randomly assigned to receive early nasojejunal nutrition
delivered via a spontaneously migrating frictional nasojejunal tube, or to continued nasogastric nutrition. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the
proportion of the standardized estimated energy requirement
that was delivered as enteral nutrition. Secondary outcomes
included incidence of ventilator-associated pneumonia, gastrointestinal hemorrhage, and in-hospital mortality rate. There
were 92 patients assigned to early nasojejunal nutrition and
89 to continued nasogastric nutrition. Baseline characteristics were similar. Nasojejunal tube placement into the small
bowel was confirmed in 79 (87%) early nasojejunal nutrition
patients after a median of 15 (interquartile range 732) hrs.
The proportion of targeted energy delivered from enteral
nutrition was 72% for the early nasojejunal nutrition and 71%
for the nasogastric nutrition group (mean difference 1%, 95%
confidence interval -3% to 5%, P = 0.66). Rates of ventilatorassociated pneumonia (20% vs 21%, P = 0.94), vomiting,
witnessed aspiration, diarrhea, and mortality were similar.
Minor, but not major, gastrointestinal hemorrhage was more
common in the early nasojejunal nutrition group (12 [13%]
vs 3 [3%], P = 0.02). CONCLUSIONS: In mechanically ventilated patients with mildly elevated gastric residual volumes
and already receiving nasogastric nutrition, early nasojejunal
nutrition did not increase energy delivery and did not appear to
reduce the frequency of pneumonia. The rate of minor gastrointestinal hemorrhage was increased. Routine placement of a
nasojejunal tube in such patients is not recommended.

should be considered. METHODS: In 2001, a new surgical

critical care service was created for an 800-bed urban teaching
hospital with a 12-bed surgical intensive care unit (SICU).
Consults, daily rounds, daily notes, and adherence to best
practices were standardized over the next 9 years for a team
of postgraduate year-1 and -2 surgical residents, physician
assistants and surgical intensivists. The Fundamentals of
Critical Care Support course was given as basic introduction,
and published guidelines for ventilators, hemodynamics,
cardiac, infections, and nutrition management were
implemented. A beyond FCCS curriculum was repeated
every resident rotation. A 12-bed stepdown unit was developed
for the more stable patients, mostly run by SICU physician
assistants with SICU attending coverage. The first 5 years,
night coverage was by the daytime intensivist from home. The
last 4 years, night coverage was in-unit surgical intensivists
or cardiac surgeons. RESULTS: Data for 13,020 patients
drawn from 152,154 operations over 9 years is reported.
Surgery grew 89% to 24,000 cases/year in 2010. Half the
patients were general, gastrointestinal oncology, or vascular
surgery. Ninety-two percent were perioperative. The 8%
nonoperative patients were mostly gastrointestinal bleeding,
abdominal pain, or pancreatitis. In the first year, annual SICU
mortality decreased from an average of 4.5% the 5 previous
years to 1.96% (2002) and remained 1.75% (2003), 2.1%
(2004), 1.9% (2005), 1.5% (2006), 1.5% (2007), 2.2%
(2008), 2.4% (2009), and 2.1% (2010). CONCLUSION:
Annual mortality immediately improved at a busy nontrauma
hospital with rapid, structured consultation by the SICU
team, comprehensive daily rounds guided by critical care
best practices, and daytime in-unit surgical intensivists. Low
mortality was maintained over 9 years as surgery volume
nearly doubled but did not improve further with 24/7 in-unit
coverage by surgical intensivists and cardiac surgeons. The
process of care in an SICU may be more important than 24
hour a day, 7 days a week intensivists.


the management of malnutrition including prevention and

treatment is essential. Perhaps the biggest challenge is the lack
of awareness of the presence of dysphagia and malnutrition, so
that only a minority of patients are identified and successfully
treated. We propose that better identification and treatment
of dysphagia could occur with the systematic implementation
of clinical practice improvement processes with a consequent
decrease in morbidity, mortality and cost.


Perioperative glycaemic control for diabetic

patients undergoing surgery


Clinical nutrition

Cochrane Database Syst Rev 2012 Sep 12;9:CD007315.

Buchleitner AM, Martnez-Alonso M, Hernndez M, Sol I, Mauricio D.
Department of Endocrinology and Nutrition, Hospital Universitari Arnau de Vilanova,
Institut de Recerca Biomdica de Lleida (IRBLLEIDA), Lleida, Spain.


BACKGROUND: Patients with diabetes mellitus are at

increased risk of postoperative complications. Data from
randomized clinical trials and meta-analyses point to a
potential benefit of intensive glycemic control, targeting nearnormal blood glucose, in patients with hyperglycemia (with
and without diabetes mellitus) being submitted to surgical
procedures. However, there is limited evidence concerning
this question in patients with diabetes mellitus undergoing
surgery. OBJECTIVES: To assess the effects of perioperative
glycemic control for diabetic patients undergoing surgery.
SEARCH METHODS: Trials were obtained from searches
of The Cochrane Library, MEDLINE, EMBASE, LILACS,
CINAHL and ISIS (all up to February 2012). SELECTION
CRITERIA: We included randomized controlled clinical trials
that prespecified different targets of perioperative glycemic
control (intensive versus conventional or standard care). DATA
COLLECTION AND ANALYSIS: Two authors independently
extracted data and assessed risk of bias. We summarized
studies using meta-analysis or descriptive methods. MAIN
RESULTS: Twelve trials randomized 694 diabetic participants
to intensive control and 709 diabetic participants to conventional glycemic control. The duration of the intervention
ranged from just the duration of the surgical procedure up to
90 days. The number of participants ranged from 13 to 421,
and the mean age was 64 years. Comparison of intensive with
conventional glycemic control demonstrated the following
results for our predefined primary outcomes: analysis
restricted to studies with low or unclear detection or attrition
bias for infectious complications showed a risk ratio (RR) of
0.46 (95% confidence interval (CI) 0.18 to 1.18), P = 0.11,
627 participants, eight trials, moderate quality of the evidence
(grading of recommendations assessment, development and
evaluation [GRADE]). Evaluation of death from any cause
revealed an RR of 1.19 (95% CI 0.89 to 1.59), P = 0.24, 1,365
participants, 11 trials, high quality of the evidence (GRADE).
On the basis of a posthoc analysis, there is the hypothesis that
intensive glycemic control may increase the risk of hypoglycemic episodes if longer-term outcome measures are analyzed
(RR 6.92, 95% CI 2.04 to 23.41), P = 0.002, 724 patients,
three trials, low quality of the evidence (GRADE). Analysis

of our predefined secondary outcomes revealed the following

findings: cardiovascular events had an RR of 1.03 (95% CI
0.21 to 5.13), P = 0.97, 682 participants, six trials, moderate
quality of the evidence (GRADE) when comparing the two
treatment modalities; and renal failure also did not show
significant differences between intensive and regular glucose
control (RR 0.61, 95% CI 0.34 to 1.08), P = 0.09, 434 participants, two trials, moderate quality of the evidence (GRADE).
We did not meta-analyse length of hospital stay and intensive
care unit (ICU) stay due to substantial unexplained heterogeneity. Mean differences between intensive and regular glucose
control groups ranged from -1.7 days to 2.1 days for ICU stay
and between -8 days to 3.7 days for hospital stay (moderate
quality of the evidence [GRADE]). One trial assessed healthrelated quality of life in 12/37 (32.4%) of participants in the
intervention group and 13/44 (29.5%) of participants in the
control group, and did not show an important difference (low
quality of the evidence [GRADE]) in the measured physical
health composite score of the short-form 12-item health
survey (SF-12). None of the trials examined the effects of
the interventions in terms of costs. AUTHORS CONCLUSIONS: The included trials did not demonstrate significant
differences for most of the outcomes when targeting intensive
perioperative glycemic control compared with conventional
glycemic control in patients with diabetes mellitus. However,
posthoc analysis indicated that intensive glycemic control
was associated with an increased number of patients experiencing hypoglycemic episodes. Intensive glycemic control
protocols with near-normal blood glucose targets for patients
with diabetes mellitus undergoing surgical procedures are
currently not supported by an adequate scientific basis. We
suggest that insulin treatment regimens, patient- and healthsystem relevant outcomes, and time points for outcome
measures should be defined in a thorough and uniform way in
future studies.

Nutritional therapy for the management of diabetic

gastroparesis: Clinical review
Diabetes Metab Syndr Obes 2012;5:329-335.
Sadiya A.
Lifestyle Clinic, Rashid Centre for Diabetes and Research, Ministry of Health, Ajman,
United Arab Emirates.

Diabetic gastroparesis (DGP), or slow emptying of the stomach,

is a well-established complication of diabetes mellitus and is
typically considered to occur in individuals with long-standing
type 1 and type 2 diabetes mellitus. Clinical consequences
of DGP include induction of gastrointestinal (GI) symptoms
(early satiety, abdominal distension, reflux, stomach spasm,
postprandial nausea, vomiting), alteration in drug absorption,
and destabilization of glycemic control (due to mismatched
postprandial glycemic and insulin peaks). Effective nutritional
management not only helps in alleviating the symptoms, but
also in facilitating better glycemic control. Although there
have been no evidence-based guidelines pertaining to the
nutrition care process of the DGP, the current dietary recommendations are based on expert opinions or observational
studies. The dietary management of gastroparesis needs to
be tailored according to the severity of malnutrition and kind

of upper GI symptom by changing the volume, consistency,

frequency, fiber, fat, and carbohydrates in the meal. Small
frequent meals, using more liquid calories, reducing high fat
or high fiber, consuming bezoar forming foods, and adjusting
meal carbohydrates based on medications or insulin helps
in improving the upper GI symptoms and glycemic control.
Enteral nutrition can be an option for patients who fail to
stabilize their weight loss, or for those who cannot gain
weight with oral feedings, while total parenteral nutrition is
rarely necessary for the patient with gastroparesis.


Sarcopenia in older adults

Curr Opin Rheumatol 2012 Nov;24(6):623-627.
Walston JD.
Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of
Medicine, Baltimore, Maryland, USA.


Curr Opin Clin Nutr Metab Care 2012 Sep;15(5):485-488.

Braga M.
Professor of Surgery, San Raffaele University, Milan, Italy.

PURPOSE OF REVIEW: In the last year, several metaanalyses focused on the potential clinical benefits of perioperative immunonutrition in surgical patients. Purpose of this
review is to summarize their results and to draw recommendations about the current indication of immunonutrition in
surgery. RECENT FINDINGS: Standard enteral preparations have been modified by adding specific nutrients, such
as arginine, omega-3 fatty acids and others, which have been

World J Surg Oncol 2012 Jul 6;10(1):136.

Mauskopf JA, Candrilli SD, Chevrou-Sverac H, Ochoa JB.
RTI Health Solutions, Durham, North Carolina, USA; Nestl Health Sciences, Vevey,
Switzerland; Nestl Healthcare Nutrition and University of Pittsburgh, Pittsburgh,

BACKGROUND: Oral or enteral dietary supplementation

with arginine, omega-3 fatty acids and nucleotides (known
as immunonutrition) significantly improve outcomes in
patients undergoing elective surgery. The objective of the
study was to determine the impact on hospital costs of
immunonutrition formulas used in patients undergoing
elective surgery for gastrointestinal cancer. METHODS:
US hospital costs of stay with and without surgical infectious complications, and average cost per day in the hospital
for patients undergoing elective surgery for gastrointestinal
cancer were estimated using data from the Healthcare Cost
and Utilization Projects 2008 Nationwide Inpatient Sample.
These costs were then used to estimate the impact of perioperative immunonutrition on hospital costs using estimates of
reduction in infectious complications or length of stay from a
meta-analysis of clinical trials in patients undergoing elective
surgery for gastrointestinal cancer. Sensitivity of the results
to changes in baseline complication rates or length of stay
was tested. RESULTS: From the meta-analysis estimates, use
of immunonutrition resulted in savings per patient of $3,300
with costs based on reduction in infectious complication
rates or $6,000 with costs based on length of hospital stay.
Cost savings per patient were present for baseline complication rates above 3.5% or when baseline length of stay
and infectious complication rates were reduced to reflect
recent US data for those with upper and lower GI elective
cancer surgery (range, $1,200 to $6,300). CONCLUSIONS: Use of immunonutrition for patients undergoing
elective surgery for gastrointestinal cancer is an effective and
cost-saving intervention.


Perioperative immunonutrition and gut function

Immunonutrition for patients undergoing elective

surgery for gastrointestinal cancer: Impact on
hospital costs

Clinical nutrition

PURPOSE OF REVIEW: Sarcopenia, or the decline of

skeletal muscle tissue with age, is one of the most important
causes of functional decline and loss of independence in
older adults. The purpose of this article is to review the
current definitions of sarcopenia, its potential causes and
clinical consequences, and the potential for intervention.
RECENT FINDINGS: Although no consensus diagnosis
has been reached, sarcopenia is increasingly defined by both
loss of muscle mass and loss of muscle function or strength.
Its cause is widely regarded as multifactorial, with neurological decline, hormonal changes, inflammatory pathway
activation, declines in activity, chronic illness, fatty infiltration, and poor nutrition, all shown to be contributing
factors. Recent molecular findings related to apoptosis,
mitochondrial decline, and the angiotensin system in skeletal
muscle have highlighted biological mechanisms that may
be contributory. Interventions in general continue to target
nutrition and exercise. SUMMARY: Efforts to develop a
consensus definition are ongoing and will greatly facilitate
the development and testing of novel interventions for sarcopenia. Although pharmaceutical agents targeting multiple
biological pathways are being developed, adequate nutrition
and targeted exercise remain the gold standard for therapy.

shown to upregulate immune response, to control inflammatory response, and to improve gut function after surgery.
The majority of the randomized trials found that perioperative immunonutrition improved short-term outcome
in patients, who underwent elective major gastrointestinal
(GI) surgery. Four meta-analyses including a large number
of randomized clinical trials reported that perioperative
immunonutrition is associated with a substantial reduction
in both infection rate and length of hospital stay. These
results have been found in both upper and lower GI patients,
regardless of their baseline nutritional status. Promising
results have been found also in head and neck surgery.
SUMMARY: In the light of these findings the use of perioperative immunonutrition should be implemented in patients
undergoing elective major GI surgery. This should result in
a considerable reduction in both postoperative morbidity
and costs for healthcare systems. Larger trials are required
before recommending immunonutrition as a routine practice
in head and neck surgery.



Enteral nutrition in the chronic obstructive

pulmonary disease (COPD) patient

Clinical nutrition

J Pharm Pract 2012 Dec;25(6):583-585.

Debellis HF, Fetterman JW Jr.
South University School of Pharmacy, Savannah, Georgia, USA.

Chronic obstructive pulmonary disease (COPD) is a

progressive, chronic disease, in which malnutrition can have
an undesirable effect. Therefore, the patients nutritional
status is critical for optimizing outcomes in COPD. The initial
nutrition assessment is focused on identifying calorically
compromised COPD patients in order to provide them with
appropriate nutrition. Nutritional intervention consists of
oral supplementation and enteral nutrition to prevent weight
loss and muscle mass depletion. Evaluation of nutritional
status should include past medical history (medications, lung
function, and exercise tolerance) and dietary history (patients
dietary habits, food choices, meal patterns, food allergy information, and malabsorption issues), in addition to physiological stress, visceral proteins, weight, fat-free mass, and body
mass index. The current medical literature conflicts regarding
the appropriate type of formulation to select for nutritional
intervention, especially regarding the amount of calories from
fat to provide COPD patients. This review article focuses on
the enteral product formulations currently available, and how
they are most appropriately utilized in patients with COPD.

Feeding tube placement: Errors and complications


Nutr Clin Pract 2012 Dec;27(6):738-748.

Stayner JL, Bhatnagar A, McGinn AN, Fang JC.
Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA.

Feeding tube placement for enteral nutrition (EN) support

is widely used in both critically ill and stable chronically ill
patients who are unable to meet their nutrition needs orally.
Nasal or oral feeding tubes can be performed blindly at the
bedside or with fluoroscopic or endoscopic guidance into
the stomach or small bowel. Percutaneous feeding tubes are
used when EN support is required for longer periods (>46
weeks) and are most commonly placed endoscopically or
radiographically. Although generally safe and effective, there
is a wide spectrum of known complications associated with
feeding tube placement. Errors made at the time of feeding
tube placement can result in a number of these procedural and
postprocedural complications. In many cases, a single error at
the time of placement can result in numerous complications.
A thorough knowledge of these errors and avoiding them in
practice will decrease iatrogenic complications in a vulnerable
population. In addition, early recognition and management
of complications will further minimize morbidity and even
mortality in enteral feeding tube placement. This article
reviews the common errors leading to complications of enteral
feeding tube placement and their prevention and management.

Guidelines for perioperative care in elective rectal/

pelvic surgery: Enhanced recovery after surgery
(ERAS) society recommendations
World J Surg 2012 Oct 6. [Epub ahead of print]


Nygren J, Thacker J, Carli F, Fearon KC, Norderval S, Lobo DN, Ljungqvist O, Soop
M, Ramirez J.
Department of Surgery, Ersta Hospital, Karolinska Institutet, Stockholm, Sweden.

BACKGROUND: This review aims to present a consensus

for optimal perioperative care in rectal/pelvic surgery, and to
provide graded recommendations for items for an evidencedbased enhanced recovery protocol. METHODS: Studies were
selected with particular attention paid to meta-analyses,
randomized controlled trials and large prospective cohorts.
For each item of the perioperative treatment pathway,
available English-language literature was examined, reviewed
and graded. A consensus recommendation was reached after
critical appraisal of the literature by the group. RESULTS:
For most of the protocol items, recommendations are based
on good-quality trials or meta-analyses of good-quality
trials (evidence grade: high or moderate). CONCLUSIONS:
Based on the evidence available for each item of the multimodal perioperative care pathway, the Enhanced Recovery
After Surgery (ERAS) Society, European Society for Clinical
Nutrition and Metabolism (ESPEN) and International Association for Surgical Metabolism and Nutrition (IASMEN)
present a comprehensive evidence-based consensus review of
perioperative care for rectal surgery.

Guidelines for perioperative care in elective colonic

surgery: Enhanced recovery after surgery (ERAS)
society recommendations
World J Surg 2012 Oct 6. [Epub ahead of print]
Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N,
McNaught CE, Macfie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN,
Fearon K, Ljungqvist O.
Department of Surgery, Ersta Hospital, Stockholm, Sweden.

BACKGROUND: This review aims to present a consensus for

optimal perioperative care in colonic surgery and to provide
graded recommendations for items for an evidenced-based
enhanced perioperative protocol. METHODS: Studies were
selected with particular attention paid to meta-analyses,
randomized controlled trials and large prospective cohorts.
For each item of the perioperative treatment pathway,
available English-language literature was examined, reviewed
and graded. A consensus recommendation was reached after
critical appraisal of the literature by the group. RESULTS:
For most of the protocol items, recommendations are based
on good-quality trials or meta-analyses of good-quality trials
(quality of evidence and recommendations according to the
GRADE system). CONCLUSIONS: Based on the evidence
available for each item of the multimodal perioperative care
pathway, the Enhanced Recovery After Surgery (ERAS)
Society, International Association for Surgical Metabolism
and Nutrition (IASMEN) and European Society for Clinical
Nutrition and Metabolism (ESPEN) present a comprehensive
evidence-based consensus review of perioperative care for
colonic surgery.

A.S.P.E.N. Clinical Guidelines: Nutrition support of

adult patients with hyperglycemia
JPEN J Parenter Enteral Nutr 2012 Jun 29. [Epub ahead of print]
McMahon MM, Nystrom E, Braunschweig C, Miles J, Compher C; American Society
for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors.
Mayo Clinic, Rochester, Minnesota, USA.


Nutrition support in critically ill children:

Underdelivery of energy and protein compared with
current recommendations
J Acad Nutr Diet 2012 Dec;112(12):1987-1992.
Kyle UG, Jaimon N, Coss-Bu JA.
Section of Critical Care Medicine, Department of Pediatrics, Baylor College of
Medicine/Texas Childrens Hospital, Houston, Texas, USA.

Effect of exclusive enteral nutrition on gut

microflora function in children with Crohns disease
Scand J Gastroenterol 2012 Dec;47(12):1454-1459.
Tjellstrm B, Hgberg L, Stenhammar L, Magnusson KE, Midtvedt T,
Norin E, Sundqvist T.
Department of Microbiology, Karolinska Institute, Tumor and Cell Biology,
Stockholm, Sweden.

OBJECTIVE: Exclusive enteral nutrition (EEN) is a first-line

treatment in children with active Crohns disease (CD) but is
seldom used in adults with active disease. The mode of action of
EEN in suppressing mucosal inflammation is not fully understood,
but modulation of intestinal microflora activity is one possible
explanation. The aim of this study was to investigate the effect of
6-week EEN in children with active CD, with special reference to
intestinal microflora function. MATERIALS AND METHODS:
Fecal samples from 18 children (11 boys, 7 girls; median age 13.5
years) with active CD (13 children with small bowel/colonic and
5 with perianal disease) were analyzed for short chain fatty acid
(SCFA) pattern as marker of gut microflora function. The children
were studied before and after EEN treatment. Results from 12
healthy teenagers were used for comparison. RESULTS: Eleven
(79%) of the children with small bowel/colonic CD responded
clinically positively to EEN treatment showing decreased levels
of pro-inflammatory acetic acid as well as increased concentrations of anti-inflammatory butyric acids and also of valeric
acids, similar to the levels in healthy age-matched children. In
children with active perianal CD, however, EEN had no positive
effect on clinical status or inflammatory parameters. CONCLUSIONS: The authors present new data supporting the hypothesis
that the well-documented anti-inflammatory effect of EEN in
children with active small bowel/colonic CD is brought about by
modulation of gut microflora activity, resulting in an anti-inflammatory SCFA pattern. By contrast, none of the children with
perianal disease showed clinical or biochemical improvement
after EEN treatment.

Nutritional practices and their relationship to

clinical outcomes in critically ill children An
international multicenter cohort study
Crit Care Med 2012 Jul;40(7):2204-2211.
Mehta NM, Bechard LJ, Cahill N, Wang M, Day A, Duggan CP, Heyland DK.
Division of Critical Care Medicine, Department of Anesthesiology, Pain and
Perioperative Medicine at Childrens Hospital Boston, Boston, Massachusetts, USA.

OBJECTIVES: To examine factors influencing the adequacy of

energy and protein intake in the pediatric intensive care unit and


Critically ill children are at high risk for developing nutritional

deficiencies, and hospital undernutrition is known to be a risk
factor for morbidity and mortality in children. This studys aims
were to examine current nutrition practices and the adequacy
of nutrition support in the pediatric intensive care unit (PICU).
This retrospective chart review included 240 PICU patients
admitted to PICU for longer than 48 hours and documented all
intravenous (IV), parenteral, and enteral energy and protein for
the first 8 days. Basal metabolic rate and protein requirements
were estimated by Schofield equation and the American Society
for Parenteral and Enteral Nutrition Clinical Guidelines, respectively. Moderate/severe acute malnutrition was defined as weight
for age greater than -2 z scores, and moderate/severe chronic
malnutrition (growth stunting) was defined as height for age
greater than -2 z scores, using 2000 Centers for Disease Control
and Prevention growth charts. During the first 8 days of PICU
stay, the actual energy intake for all patient-days was an average
of 75.7% 56.7% of basal metabolic rate and was significantly

lower than basal metabolic rate (P < 0.001); the actual protein
intake for all patient-days met an average of 40.4% 44.2%
of protein requirements and was significantly lower than the
American Society for Parenteral and Enteral Nutrition guidelines (P < 0.001). Delivery of energy and protein were inadequate on 60% and 85% of patient-days, respectively. Only 75%
of estimated energy and 40% of protein requirements were
met in the first 8 days of PICU stay. These data demonstrate
a high prevalence of critically ill children who are not meeting
their recommended levels of protein and energy. In order to
avoid undernutrition of these children, providers must conduct
ongoing assessment of protein and energy intake compared with
protein and energy requirements.

Clinical nutrition

BACKGROUND: Hyperglycemia is a frequent occurrence in

adult hospitalized patients who receive nutrition support. Both
hyperglycemia and hypoglycemia (resulting from attempts to
correct hyperglycemia) are associated with adverse outcomes in
diabetic as well as nondiabetic patients. This American Society for
Parenteral and Enteral Nutrition (A.S.P.E.N.) Clinical Guideline
summarizes the most current evidence and provides guidelines
for the desired blood glucose goal range in hospitalized patients
receiving nutrition support, the definition of hypoglycemia,
and the rationale for use of diabetes-specific enteral formulas
in hospitalized patients. METHOD: A systematic review of the
best available evidence to answer a series of questions regarding
glucose control in adults receiving parenteral or enteral nutrition
was undertaken and evaluated using concepts adopted from the
Grading of Recommendations, Assessment, Development and
Evaluation working group. A consensus process was used to
develop the clinical guideline recommendations prior to external
and internal review and approval by the A.S.P.E.N. Board of
Directors. RESULTS/ CONCLUSIONS: 1. What is the desired
blood glucose goal range in adult hospitalized patients receiving
nutrition support? We recommend a target blood glucose
goal range of 140180 mg/dL (7.810 mmol/L). (Strong) 2.
How is hypoglycemia defined in adult hospitalized patients
receiving nutrition support? We recommend that hypoglycemia be defined as a blood glucose concentration of <70
mg/dL (<3.9 mmol/L). (Strong) 3. Should diabetes-specific
enteral formulas be used for adult hospitalized patients with
hyperglycemia? We cannot make a recommendation at this
time. (Further research needed).


Clinical nutrition

to describe their relationship to clinical outcomes in mechanically ventilated children. DESIGN, SETTING, PATIENTS: We
conducted an international prospective cohort study of consecutive children (ages 1 month to 18 yrs) requiring mechanical
ventilation longer than 48 hrs in the pediatric intensive care
unit. Nutritional practices were recorded during the pediatric
intensive care unit stay for a maximum of 10 days, and patients
were followed up for 60 days or until hospital discharge.
Multivariate analysis, accounting for pediatric intensive care
unit clustering and important confounding variables, was used
to examine the impact of nutritional variables and pediatric
intensive care unit characteristics on 60-day mortality and
the prevalence of acquired infections. MAIN RESULTS: 31
pediatric intensive care units in academic hospitals in eight
countries participated in this study. Five hundred patients
with mean (SD) age 4.5 (5.1) yrs were enrolled and included
in the analysis. Mortality at 60 days was 8.4%, and 107 of
500 (22%) patients acquired at least one infection during
their pediatric intensive care unit stay. Over 30% of patients
had severe malnutrition on admission, with body mass index
z-score > 2 (13.2%) or < -2 (17.1%) on admission. Mean
prescribed goals for daily energy and protein intake were
64 kcals/kg and 1.7 g/kg respectively. Enteral nutrition was
used in 67% of the patients and was initiated within 48 hrs
of admission in the majority of patients. Enteral nutrition
was subsequently interrupted on average for at least 2 days
in 357 of 500 (71%) patients. Mean (SD) percentage daily
nutritional intake (enteral nutrition) compared to prescribed
goals was 38% for energy and 43% (44) for protein. A higher
percentage of goal energy intake via enteral nutrition route
was significantly associated with lower 60-day mortality
(Odds ratio for increasing energy intake from 33.3% to
66.6% is 0.27 [0.11, 0.67], P = 0.002). Mortality was higher
in patients who received parenteral nutrition (odds ratio 2.61
[1.3, 5.3], P = 0.008). Patients admitted to units that utilized a
feeding protocol had a lower prevalence of acquired infections
(odds ratio 0.18 [0.05, 0.64], P = 0.008), and this association
was independent of the amount of energy or protein intake.
CONCLUSIONS: Nutrition delivery is generally inadequate
in mechanically ventilated children across the world. Intake
of a higher percentage of prescribed dietary energy goal via
enteral route was associated with improved 60-day survival;
conversely, parenteral nutrition use was associated with higher
mortality. Pediatric intensive care units that utilized protocols
for the initiation and advancement of enteral nutrient intake
had a lower prevalence of acquired infections. Optimizing
nutrition therapy is a potential avenue for improving clinical
outcomes in critically ill children.

Subjective global nutritional assessment in

critically ill children
JPEN J Parenter Enteral Nutr 2012 Jun 22. [Epub ahead of print]
Vermilyea S, Slicker J, El-Chammas K, Sultan M, Dasgupta M, Hoffmann RG,
Wakeham M, Goday PS.
Childrens Hospital of Wisconsin, Milwaukee, Wisconsin, USA.

BACKGROUND: Underweight children admitted to the

pediatric intensive care unit (PICU) have a higher risk
of mortality than normal-weight children. The authors

hypothesized that subjective global nutrition assessment

(SGNA) could identify malnutrition in the PICU and predict
nutrition-associated morbidities. METHODS: The authors
prospectively evaluated the nutrition status of 150 children
(aged 31 days to 5 years) admitted to the PICU with the use
of SGNA and commonly used objective anthropometric and
laboratory measurements. Each child was administered the
SGNA by a dietitian while anthropometric measurements
were performed by an independent assessor. To test interrater reproducibility, 76 children had SGNA performed
by another dietitian. Occurrence of nutrition-associated
complications was documented for 30 days after admission.
RESULTS: SGNA ratings of well nourished, moderately
malnourished, or severely malnourished demonstrated
moderate to strong correlation with several standard anthropometric measurements (P < 0.05). The laboratory markers
did not demonstrate any correlation with SGNA. Interrater
agreement showed moderate reliability ( = 0.671). Length
of stay, pediatric logistic organ dysfunction, and Pediatric
Risk of Mortality III were not significantly different across
the groups and did not correlate with SGNA.

Malnutrition may worsen the prognosis of critically

ill children with hyperglycemia and hypoglycemia
JPEN J Parenter Enteral Nutr 2012 Aug 28. [Epub ahead of print]
Leite HP, de Lima LF, de Oliveira Iglesias SB, Pacheco JC, de Carvalho WB.
Federal University of So Paulo, So Paulo, Brazil.

OBJECTIVES: To determine whether hyperglycemia and

hypoglycemia are associated with higher mortality, longer
length of intensive care unit (ICU) stay, and fewer ventilator-free days in critically ill children while taking into
account the clinical severity and nutrition status. Patients
and METHODS: A prospective observational cohort study
was conducted on 221 children admitted to the ICU. Blood
glucose levels were analyzed in the first 72 hours. Potential
exposure variables for adverse prognosis included hyperglycemia (blood glucose >150 mg/dL), hypoglycemia (blood
glucose 60 mg/dL), age <1 year, sex, nutrition status, the
revised Pediatric Index of Mortality (PIM 2), and the Pediatric
Logistic Organ Dysfunction (PELOD). RESULTS: Of the
patients, 47.1% were malnourished. Controlling for nutrition
status, both hyperglycemia and hypoglycemia increased the
risk of mortality in the malnourished patients compared with
the well-nourished ones. Adjusting for clinical severity, the
odds ratio of mortality was higher in malnourished patients
with hyperglycemia (odds ratio [OR], 3.98; 95% confidence
interval [CI], 1.1413.94; P = 0.03), whereas no significant
associations were detected in the well-nourished patients.
After controlling for nutrition status, hypoglycemia was
associated with longer length of ICU stay (OR, 6.5; 95% CI,
1.3032.57; P < 0.01) and fewer ventilator-free days (OR,
4.11; 95% CI, 1.2613.40; P < 0.01) only in the malnourished group of patients. CONCLUSIONS: Compared with the
well nourished, malnourished patients with hyperglycemia are
at a greater risk of mortality, independent of clinical severity.
Hypoglycemia was shown to be associated with mortality,
longer length of ICU stay, and fewer ventilator-free days only
in malnourished patients.

Highlights of the

34th ESPEN Congress

811 September 2012 Barcelona, Spain

Nestl Nutrition Institute

Satellite Symposium
Synergy in motion:
Combining nutrition and exercise
for optimal physical function
The role of nutrition in optimizing
strength and function
F Landi (Italy)
Sarcopenia plays an important etiologic role in the frailty process
of older people. It is a key player in the early, non-manifest phase
of frailty and explains many aspects of frailty itself.
Diagnosis of sarcopenia requires the documentation of
performance.1 Such criteria are included in the European
Working Group on Sarcopenia in Older People algorithm for
case finding/screening for sarcopenia.1
Sarcopenia is a common condition with adverse
consequences. In a study conducted in Italy, 32.8% of residents
in nursing homes were affected by sarcopenia; the prevalence
was higher in men than in women (68% vs 21%, respectively).2
The most important risk factors identified were low body mass
index (BMI) and inactivity. Residents with a BMI of 21 kg/m2
or greater and those who participated in physical activity for
leisure (1 hour or more per day) were less likely to be affected.1
The mortality rate in residents with sarcopenia was higher than

and strength. Options to optimize post-prandial anabolic

action of dietary proteins include an increase in protein
intake, an increase in amino acid availability and the use of
specific substrates.7 High quality protein such as whey with
high leucine content and essential amino acids stimulates
protein synthesis at the muscle level by activation of the
mammalian target of rapamycin (mTOR) system.8 Protein
in combination with resistance exercise has been shown to
increase protein synthesis.9 The key role of vitamin D in
muscle function, physical performance and falls prevention
is well established, and there is biological plausibility for its
role in muscle function due to its anabolic, metabolic and
anti-inflammatory effects.10






consequences of sarcopenia warrant identification through

screening, and that management with adequate protein
( 1 g/kg/day), energy and vitamin D intake in combination
with adequate physical activity may help prevent sarcopenia.

Highlights of the
34th ESPEN Congress

low muscle mass plus either low muscle strength or low physical

The amount of protein available in the diet plays a

key role in an individuals ability to develop muscle mass


Cruz-Jentoft AJ, et al. Age Ageing 2010;39:412-423.

Landi F, et al. J Gerontol A Biol Sci Med Sci 2012;67:48-55.
Landi F, et al. J Am Med Dir Assoc 2012;13:121-126.
Landi F, et al. Clin Nutr 2012;31:652-658.
Landi F, et al. J Am Med Dir Assoc 2010;11:268-274.
Landi F, et al. Eur J Nutr 2012;(Epub ahead of print 25 August 2012).
Paddon-Jones D, et al. Am J Clin Nutr 2008;87:1562S-1566S.
Casperson SL, et al. Clin Nutr 2012;31:512-519.
Biolo G,et al. Am J Physiol 1997;273(1 Pt 1):E122-E129.
Landi F. Aging Clin Exp Res 2012;In press.

for those without sarcopenia (adjusted hazard ratio [HR] 2.34;

95% confidence interval [CI] 1.045.24).3 Community-dwelling
older people affected by sarcopenia are more than three times as
95% CI 1.258.29).4

P Soler (Spain)

Anorexia is one of the most important risk factors

The relationship between nutrition and aging is not clear.

for the onset of sarcopenia and has been shown to have a

The observation in animals that calorie restriction is

negative impact on function in older people.5,6 Anorexia of

associated with a healthier, longer life does not hold true for

aging, especially in the early stage, may be correlated with

humans.1,2 The relationship between BMI and mortality is

a high risk of qualitative low intake of single nutrients,

also complex. The BMI that confers lowest risk of mortality

in particular, protein and certain vitamins. It could be

in adults (median age at baseline 58 years) is 22.5 kg/m2 in

hypothesized that this selective malnutrition for example,

women and 23 kg/m2 in men.3 Recent studies show that this

in terms of single macro- or micronutrients is directly

is not the case for older people; BMI in the normal to obese

correlated with sarcopenia.

range is associated with lowest mortality in older people.4-6


likely to fall than those without sarcopenia (adjusted HR 3.23;

Functional decline and nutritional

status in the older adult


This has recently been confirmed in the Survey in Europe on

rates in physical activity are low. Physical activity declines with

Nutrition and the Elderly, a Concerted Action (SENECA)

increasing age from childhood to older age, and fails to reach

study where a BMI of 27.1 kg/m2 was found to confer the

levels recommended in government guidelines.2 The challenge

lowest risk of mortality in older people.

remains to understand how to develop systems, values and

Highlights of the
34th ESPEN Congress

Nutrition in older adults is complex and multifactorial,

cultures that encourage more people to be active.

affected by physiological, functional, cognitive, psychological

The Physical Activity Guidelines for Americans

and social factors. Nutrition is one of the main contributors

published in 2008 recommend that older people follow the

to healthy and active aging. Good nutrition plays a major role

same guidance given for the adult population in general or, if

in the maintenance of function and mental health, reducing

not possible, to be as physically active as permitted by abilities

the risk of illness and disability, while poor nutrition may

and conditions.1 Professor Nelson stressed that there is no

contribute to the development of chronic diseases, disability,

need for medical clearance before exercising; in fact, being

dependence and death. Professor Soler suggested that it is not

sedentary and not exercising is more high-risk. To improve

longevity but quality of life that is most important; function

overall health in older adults, an exercise program should

may be more important than survival. Function, rather than

incorporate both aerobic exercise and strength training,

disease burden or comorbidity, is the main health index in

with balance training of importance for older people at risk

this population group.

of falls.1

Professor Soler presented results from the ongoing

Professor Nelson gave an overview of two programmes:

Frailty and Dependency in Albacete (FRADEA) longitudinal

the StrongWomen Initiative ( a

cohort study (unpublished data). He showed that a BMI of

United States evidence-based community exercise and nutrition

2530 kg/m2 in older adults is associated with lower prevalent

program targeted to women from midlife and older, which

disability, followed by a BMI of 3035 kg/m2. Frailty and

has been shown to improve physical fitness3; and Vitality,

disability are strong predictors of incident disability in basic

Independence and Vigor in Elders (VIVE), an ongoing study

activities of daily living (BADL). Nutritional risk is a better

investigating whether a community-based targeted exercise

predictor of incident disability in BADL than BMI, especially

and nutrition program can improve functional performance

when associated with frailty (HR 2.5 [Mini Nutritional

and health in frail older people.

Assessment(MNA) <12 + Frailty]). Anorexia, weight loss

She concluded that to be successful, strategies to

and mobility impairment are the strongest MNA items

improve physical activity need to be targeted at the individual,

associated with loss of BADL. Professor Soler suggested

community and national level, and that changes are needed to

that nutritional risk (using MNA), anorexia and weight

our physical and social environment across home, community,

loss could be added to the range of indicators predictive

work place and society.

of activities of daily living (ADL) disability identified in a


recent review.8

1. Physical Activity Guidelines Advisory Committee. 2008. Wasington D.C., U.S. Department of Health
and Human Services.
2. Troiano RP, et al. Med Sci Sports Exerc 2008;40:181-188.
3. Seguin RA, et al. Health Educ Behav 2012;39:183-190.

He concluded that that the identification of older

adults at nutritional risk must be a priority.




Colman RJ, et al. Science 2009;325:201-204.

Kalm LM and Semba RD. J Nutr 2005;135:1347-1352.
Berrington de GA, et al. N Engl J Med 2010;363:2211-2219.
Stessman J, et al. J Am Geriatr Soc 2009;57:2232-2238.
Kvamme JM, et al. J Epidemiol Community Health 2012;66:611-617.
Grabowski DC, et al. J Am Geriatr Soc 2001;49:968-979.
de Hollander EL, et al. J Nutr Health Aging 2012;16:100-106.
Vermeulen J, et al. BMC Geriatr 2011;11:33.

Physical activity programs for the

older adult: Success factors
M Nelson (United States)
The benefits of physical activity are well established. A

Related topics: Body composition

and risks
UG Kyle (United States)
K Kaspar (Switzerland)
A Molfino (Italy)
Bio-electrical impedence (BIA) is a practical replacement
for dual-energy x-ray absorptiometry (DEXA) for
assessment of low appendicular skeletal muscle mass with
good sensitivity and specificity.1

review of longitudinal studies looking at the relationship

A six-item self-administered malnutrition screening tool

between physical activity levels at different referent points

(Self-MNA) has been shown to have excellent sensitivity

and mobility disability outcomes showed that the odds ratio

and specificity in detecting subjects at risk of malnu-

for mobility disability outcomes decreases with increasing

trition when compared to the MNA-SF administered by a

physical activity levels. The same was true in a review that

healthcare professional.2

combined ADL, instrumental activities of daily living (IADL)

Cardiac mass is shown to be correlated to lean body mass

and global outcomes; being physically active was shown to

(LBM) in wasted patients with cancer and renal failure. As

be protective for older adults.1 Yet, despite this, participation

a result echocardiography could offer a less invasive and

less costly tool for routine assessment and monitoring of

in the diet. The impact of disease must also be considered, for

LBM in patients with cachexia or at risk of cachexia.

example on absorption and utilization of amino acids. In aging

1. Kyle UG, et al. Clin Nutr 2012; 7(Suppl 1):1.
2. Huhmann MB, et al. Clin Nutr 2012;7(Suppl 1):2.
3. Molfino A, et al. Clin Nutr 2012;7(Suppl 1):3.

there is decreased sensitivity to leucine6 and impaired muscle

anabolic response to insulin,7 possibly due to a defect in the
regulation of the mTOR signalling pathway.
In the presence of anabolic resistance muscle anabolic
threshold is increased, which needs to be considered in

Sir David Cuthbertson Lecture

targeting protein synthesis after meal intake. There is evidence

The language of protein nutrition:

How does food speak to our

threshold.8,9 Lipotoxicity could be of importance, since adiposity

Y Boirie (France)
Sir David Cuthbertson studied the effects of trauma, illness
and immobility on the metabolism of surgical patients, with a
particular focus on protein metabolism. This topic is as relevant
today as it was in the 1930s, and our understanding of it continues
to deepen. During trauma, muscle releases amino acids for the
immune system to produce acute phase proteins and to aid in
repair. These amino acids are released into the bloodstream for
synthesis of proteins; however, as a result of anabolic resistance
most of the amino acids are used for oxidation. The same occurs
when patients with anabolic resistance are fed; amino acids are
used for oxidation.
What are the mechanisms of anabolic resistance? In the
post-absorptive state, protein breakdown outstrips protein
After ingestion of a meal, stimulation of protein synthesis
and inhibition of protein breakdown leads to neutral protein
balance. Behind this process lies complex intracellular
machinery.1 Insulin is an important signal during meal intake
that acts on this machinery together with amino acids and
energy to stimulate protein synthesis, but at the same time to
inhibit protein breakdown. Stress signals, such as cytokines,
can directly stimulate protein breakdown and inhibit
protein synthesis so that the balance between both signals is
very important.
Aging has an important impact on muscle, so how does
this apply to sarcopenia? The definition of sarcopenia has been
clarified as a decrease in muscle mass with a decrease in muscle

may be deleterious for muscle protein synthesis.10,11 Sarcopenic

obesity has been associated with adverse clinical effects, such
as poor functional status, reduced survival, and the potential
for chemotherapy toxicity in obese patients with lung and
gastrointestinal cancer.12 Vitamin D has been shown to potentiate
the effect of insulin and leucine on muscle anabolism.13 Chronic
disease, immobilization and impaired muscle blood flow may
also be modulators of muscle anabolic resistance.
To respond to this resistance, the availability of amino
acids to the muscle needs to be improved through dietary
manipulation. An increased proportion of leucine may be
required for optimal stimulation of muscle protein synthesis
in older people.14-16 Protein pulse-feeding stimulates muscle
protein synthesis and improves nitrogen retention in the
elderly.17,18 Protein digestion rate may be important; in
older people, fast proteins (meat and whey) may increase
postprandial whole body protein anabolism.19,20
Professor Boirie reminded delegates that Sir David
Cuthbertson had observed the importance of the timing
of work in relation to the taking of food. Physical exercise
could be considered as an anabolic signal.21 In summary,
the best synergistic combination to improve protein gain
involves nutrition, physical activity, hormones and possibly
pharmacological options. This lecture focused on protein
synthesis, but future research needs to focus on protein
breakdown, regeneration and apoptosis. The relationship
between the muscle and other organs, muscle metabolomics
and epigenetic regulation of muscle metabolism are amongst
a host of other possible perspectives in protein nutrition that
warrant further investigation.

accumulation of muscle mass peaks during adulthood and


also observed in other models beyond aging, for example in

the catabolic crisis model and in chronic organ disease, such as
chronic obstructive pulmonary disease.
During aging there is an impaired response of muscle
protein synthesis to intake of amino acids and glucose.4,5 This
lower anabolic response by muscle to meal intake may be
related to alterations in intake, absorption, availability, muscle
sensitivity or hormonal response. There is much debate about
the optimal level of protein intake, the ideal protein to energy
ratio and the most suitable composition and source of protein

Glass DJ. Int J Biochem Cell Biol 2005;37:1974-1984.

Cruz-Jentoft AJ, et al. Age Ageing 2010;39:412-423.
Muscaritoli M, et al. Clin Nutr 2010;29:154-159.
Mosoni L, et al. Am J Physiol 1995;268(2 Pt 1):E328-E335.
Volpi E, et al. J Clin Endocrinol Metab 2000;85:4481-4490.
Dardevet D, et al. J Nutr 2000;130:2630-2635.
Guillet C, et al. FASEB J 2004;18:1586-1587.
Smith GI, et al. Am J Clin Nutr 2011;93:402-412.
Tardif N, et al. Clin Nutr 2011;30:799-806.
Guillet C, et al. J Clin Endocrinol Metab 2009;94:3044-3050.
Guillet C, et al. Curr Opin Clin Nutr Metab Care 2011;14:89-92.
Prado CM, et al. Lancet Oncol 2008;9:629-635.
Salles J, et al. Clin Nutr 2012;7(Suppl 1):227.
Paddon-Jones D, et al. Am J Physiol Endocrinol Metab 2004;286:E321-E328.
Katsanos CS, et al. Am J Physiol Endocrinol Metab 2006;291:E381-E387.
Rieu I, et al. J Physiol 2006;575(Pt 1):305-315.
Arnal MA, et al. Am J Clin Nutr 1999;69:1202-1208.
Arnal MA, et al. J Nutr 2002;132:1002-1008.
Boirie Y, et al. Proc Natl Acad Sci U S A 1997;94:14930-14935.
Remond D, et al. Am J Clin Nutr 2007;85:1286-1292.
Irving BA, et al. Ageing Res Rev 2012;11:374-389.


function (strength/performance).2,3 Similarly to bone mass, the

subsequently declines during aging. However, sarcopenia is

Highlights of the
34th ESPEN Congress

synthesis resulting in negative protein balance in the muscle.

that omega-3 fatty acids and oleate may alter the anabolic


Related topics: Protein metabolism

D Dardevet (France)
V Baglio (Italy)
C de Betue (Netherlands)
During aging, immobilization contributes to the development of sarcopenia. In rats with immobilized limbs,
diets high in protein and whey induce significant muscle
mass gain during the recovery phase and in non-immobilized limbs the same diet helps to attenuate muscle
mass loss.1
Increasing protein intake (up to the Population Reference
Intake [PRI, European Food Safety Authority 2012])
improves muscle contractility and insulin sensitivity in
elite elderly athletes.2

similar change across many more European countries.

For more information visit

Medical Nutrition International

Industry Grant
J Griesel (Germany)
M Chourdakis (Greece)
A Brotherton (United Kingdom)
The Medical Nutrition International Industry (MNI)
mission is to bring together companies that provide
products and services to optimize patient outcome
through specialized nutritional solutions. The main
objectives of the MNI are to work in close collaboration
with the European Society for Clinical Nutrition and

Intake of a protein-energy enriched formula increases

Metabolism (ESPEN) to contribute to the Fight Against

arginine appearance and nitric oxide synthesis in criti-

Malnutrition initiative through raising awareness for the

cally ill infants with viral bronchiolitis, compared with a

existence and impact of malnutrition, to help build an

standard formula.3

environment to transition scientific evidence related to


nutritional status and patient outcome and its effect on

1. Magne H, et al. Clin Nutr 2012;7(Suppl 1):6.

2. Baglio V, et al. Clin Nutr 2012;7(Suppl 1):7.
3. de Betue CT, et al. Clin Nutr 2012;7(Suppl 1):7.

healthcare costs, and through supporting the development

of protocols and models for effective nutrition support.
The MNI report Oral Nutritional Supplements to Tackle

Highlights of the
34th ESPEN Congress

Malnutrition: A summary of the Evidence Base and the

Fight against malnutrition:

Joint session ESPEN
and Medical Nutrition
International Industry
Medical and political perspectives


P Singer (Israel)
O Ljungqvist (Sweden)


MNI Grant are two ways in which this is achieved.

The MNI Grant aims to support and reward
infrastructure projects that are relevant to drive national
nutrition policy and serve as a protocol to improve
the nutritional status of patients. The grant has been
awarded for 5 years, and in 2012 was awarded to the
Hellenic Society for Clinical Nutrition and Metabolism
for achievements that included educational activities,
facilitating legislative changes to ensure that malnutrition
is on the political agenda despite the challenging financial

The European Nutrition for Health Alliance (EHNA) is

environment, and for the introduction of mandatory

a charity that brings together 10 key European Union

screening and nutrition support teams in all public

(EU) stakeholders working in health and nutrition

hospitals. Dr Michael Chourdakis presented an overview

with the key objective to ensure that routine nutri-

of achievements.

tional screening and follow-up is implemented for all

On behalf of the British Association for Parenteral

individuals at risk of malnutrition across Europe. The

and Enteral Nutrition (BAPEN), a previous MNI Grant

EHNA has made significant progress in recent years

award-winning organization, Dr Alisa Brotherton gave

developing strategic alliances with European patient

an update on the fight against malnutrition in the United

organizations to help promote education of patients and

Kingdom. She outlined the national challenges, BAPENs

physicians to improve patient care, and with the World

strategy and vision, the value of describing and measuring

Health Organization to ensure that the issue of malnu-

the problem through the national Nutrition Week

trition in Europe is not overlooked. In addition, the

surveys, and the development of recommendations for

EHNA is a co-developer of the EU program Active and

action and practical tools. Factors that have contributed

Healthy Ageing, which will address the issue of under-

to BAPENs success include lobbying government,

nutrition and is a key partner in the priority action area

focusing on quality improvement, networking and

Prevention and early diagnosis of functional decline,

collaborating with multiple partners, and ensuring that

both physical and cognitive, in older people. In the

BAPEN is recognized as the leading multidisciplinary

future, the EHNA will build on the success of the imple-


mentation of a pilot nutritional screening project in

For more information visit www.medicalnutritionindustry.

Belgium in 2012, with the aim of driving and supporting

com, and







Clinical outcomes: A summary of

oral communications
I Correia (Brazil)
M Heismayr (Austria)
S Wong (United Kingdom)
H Awadie (Israel)
E Cereda (Italy)
In many countries healthcare resources are under pressure.
Efforts to understand how limited resources can be best used
to improve healthcare outcomes continue to be a key focus for
all involved in nutritional care. Understanding the impact of
nutritional factors on clinical outcome provides a springboard
to develop effective nutritional strategies focused on improving
clinical outcome.
Lack of nutritional intake due to enforced periods of
fasting is associated with poor clinical outcome. In a study
of hospitalized adult patients in Brazil (n = 1,097, in 10
hospitals) median prolonged preoperative fasting (POF)
was 14 hours (range 2216 hours) with 84% of patients
experiencing POF of >8 hours and 54% for >12 hours,
well above the 68 hour fasting period normally prescribed.
POF was found to be significantly correlated with length of
hospital stay (LOS) with a POF of >12 hours associated with
an increased LOS of 2 days in patients undergoing surgery
for cancer or a major gastrointestinal procedure.1
From the NutritionDay data it has already been
established that low nutrient intake (during lunch/dinner) is
A new analysis focused on how this association is affected
by age. The study found that risk of death from low intake
increases dramatically with age, and that medically-driven

than 40% of patients were at risk of malnutrition, and

they had a significantly longer LOS than those not at risk
of malnutrition (median LOS [sd]: 129 [102.1] vs 85 days
[84.6]; P = 0.012) and greater 12-month mortality (9.2% vs
1.4%; P = 0.036).3
A study designed to investigate the relevance of
malnutrition to patient outcomes found that 37% of 13,922
patients were at risk of malnutrition (Malnutrition Universal
Screening Tool [MUST] score 2). Patients were stratified by
severity of background disease (using the Charlson Co-morbidity
Index [CCI]) for analysis. In the lowest CCI group complicated
hospitalization (bloodstream infection prolonged hospital stay
death affecting a single patient) affected 5% of patients at low
risk versus 12% of patients at high risk for malnutrition. In the
high CCI group 25% versus 48% experienced complicated
hospitalization (low versus high risk respectively, odds ratio =
Cereda et al. evaluated the relationship between nutritional
risk (measured using the Geriatric Nutritional Index [GRNI])
and functional status (measured using the Barthel Index [BI])
and their association with mortality in a prospective cohort
study of older people in long-term care (n = 346). Functional
status was independently associated with age (P = 0.045), arm
muscle area (P = 0.048) and nutritional risk using GNRI (P <
0.001). Patients with high nutritional risk had a higher rate
of cardiovascular mortality (HR = 1.93; 95% CI, 1.282.91;
P < 0.001) demonstrating that nutritional risk is an independent
predictor of functional status and mortality in this patient

periods of no intake (ie, fasting) are most detrimental in the


oldest patients.


Malnutrition and nutritional risk is related to poor

clinical outcome. In a multicenter, prospective, cross-

Dias AL, et al. Clin Nutr 2012;7(Suppl 1):20.

Heismayr MJ, et al. Clin Nutr 2012;7(Suppl 1):21.
Wong S, et al. Clin Nutr 2012;7(Suppl 1):20.
Awadie H, et al. Clin Nutr 2012;7(Suppl 1):21.
Cereda E, et al. Clin Nutr 2012;7(Suppl 1):22.

Highlights of the
34th ESPEN Congress

strongly associated with mortality in hospitalized patients.

centers in the UK were included in the study (n = 150). More

sectional and longitudinal study, Wong et al. investigated

whether risk of malnutrition (assessed using the validated
Spinal Nutrition Screening Tool) was associated with adverse

The views expressed in this publication are those of the

clinical outcome. Adult inpatients in four spinal cord injury

presenters and participants, not the Nestl Nutrition Institute.



Conference Calendar 2013

January 2013

April 2013

42nd Critical Care Congress

28th International Conference of

Alzheimers Disease International

1923 January 2013

San Juan, Puerto Rico

1820 April 2013

Taipei, Taiwan

Society of Critical Care Medicine


Web site:

Alzheimers Disease International and Taiwan

Alzheimers Disease Association
Web site:

February 2013

Clinical Nutrition Week 2013

Experimental Biology 2013

912 February 2013

Phoenix, Arizona, USA

2024 April 2013

Boston, Massachusetts, USA


American Society for Parenteral and Enteral Nutrition

Web site:

28th Annual Meeting of the Japanese

Society for Parenteral and Enteral
2122 February 2013
Kanazawa, Japan

Japanese Society for Parenteral and Enteral Nutrition

Web site:

March 2013

2013 Aging in America Conference

Conference calendar

1216 March 2013

Chicago, Illinois, USA

American Society on Aging

Web site:

2013 Dysphagia Research Society

(DRS) Annual Meeting
1316 March 2013
Seattle, Washington, USA


Dysphagia Research Society


Web site:

Long Term Care Medicine 2013

2124 March 2013
Washington, DC, USA

American Medical Directors Association

Web site:


American Society for Nutrition and various

Web site:

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