Angela Vivanti

Contribution of thickened drinks, food and enteral and parenteral fluids to fluid intake in hospitalised patients with dysphagia.

BACKGROUND Studies amongst older people with acute dysphagic stroke requiring thickened fluids have assessed fluid intakes from combinations of beverage, food, enteral and parenteral sources, but not all sources simultaneously. The present study aimed to comprehensively assess total water intake from food, beverages, enteral and parenteral sources amongst dysphagic adult in-patients receiving thickened fluids. METHODS Patients requiring thickened fluid following dysphagia diagnosis were recruited consecutively from a tertiary teaching hospitals medical and neurosurgical wards. Fluid intake from food and beverages was assessed by wastage, direct observation and quantified from enteral and parenteral sources through clinical medical records. RESULTS No patients achieved their calculated fluid requirements unless enteral or parenteral fluids were received. The mean daily fluid intake from food was greater than from beverages whether receiving diet alone (food: 807 +/- 363 mL, food and beverages: 370 +/- 179 mL; P < 0.001) or diet with enteral or parenteral fluid support (food: 455 +/- 408 mL, food and beverages: 263 +/- 232 mL; P < 0.001). Greater daily fluid intakes occurred when receiving enteral and parenteral fluid in addition to oral dietary intake, irrespective of age group, whether assistance was required, diagnosis and whether stage 3 or stage 2 thickened fluids were required (P < 0.05). After enteral and parenteral sources, food provided the most important contribution to daily fluid intakes. CONCLUSIONS The greatest contribution to oral fluid intake was from food, not beverages. Designing menus and food services that promote and encourage the enjoyment of fluid dense foods, in contrast to thickened beverages, may present an important way to improve fluid intakes of those with dysphagia. Supplemental enteral or parenteral fluid may be necessary to achieve minimum calculated fluid requirements.

A randomised control trial comparing lifestyle groups, individual counselling and written information in the management of weight and health outcomes over 12 months

Objective:To investigate the effect of an 8-week group-based cognitive behaviour therapy lifestyle intervention with monthly follow-up to 6 months and further follow up at 12 months on change in weight and other weight-related variables, change in physical activity and change in health and well being compared to individualised dietetic treatment or giving an information booklet only (BO).Design:A randomised controlled trial of two intervention groups, a group-based cognitive behaviour therapy lifestyle intervention, Fat Booters Incorporated – (FBI) and individualised dietetic treatment (IDT) and control group receiving an information booklet only (BO). The intervention groups involved weekly contact for 8 weeks with monthly follow-up to 6 months and further follow-up at 12 months, conducted in real practice setting.Subjects:A total of 176 adults with body mass index (BMI)>27 kg/m2, mean (±s.d.) age 48±13 years, mean BMI 34±5.5 kg/m2.Main outcome measures:Weight, percent body fat, waist circumference, physical activity, health status, self-efficacy and satisfaction with life were measured at baseline, 3, 6 and 12 months.Results:A statistically significant difference between groups was observed for weight change over time (P=0.05). The change in weight (mean±s.e.) for the FBI group was significantly greater than the BO group at 3 and 12 months (−2.8±0.7 compared to −1.0±0.6 kg, P<0.05 and −2.9±0.9 compared to +0.5±0.9 kg, P<0.005, respectively). Change in weight in the IDT group did not differ from the FBI group at any time point. For all groups, waist circumference was significantly less than baseline at all time points (P<0.001). Significant differences in self-efficacy were observed over time (P=0.02), with both intervention groups having greater self-efficacy than the BO group. Significant drop-outs occurred over time for all three groups.Conclusions:A cognitive behaviour-based lifestyle intervention was more effective than providing an information booklet alone and as effective as intensive individualised dietetic intervention in weight loss and improvements in self-efficacy.

Malnutrition associated with increased risk of frail mechanical falls among older people presenting to an emergency department.

Objective:  To identify associations between malnutrition falls risk and hospital admission among older people presenting to ED.

Short‐term body weight fluctuations in older well‐hydrated hospitalised patients

BACKGROUND The usual daily weight fluctuations of well-hydrated older hospitalised people have not been documented internationally. To date, dehydration assessments based on a short-term body weight change defined as >2% have been drawn from healthy population data. The present pilot study aimed to describe usual body weight fluctuation at the same time of day over a 3-day time frame in well-hydrated older hospitalised adults. METHODS An observational study of non-acute inpatients (n = 10) admitted to a Geriatric and Rehabilitation Unit, aged ≥60 years, assessed as well-hydrated, mobile, non-amputee and without conditions that influenced fluid status, was conducted. Participants were weighed hourly over a 9-h period for 3 days. Food and fluid intake, clothing items added or removed, and urine and faecal output were recorded. RESULTS Weight fluctuation for each participant [mean (SD) 80.2 (4.2) years; male 60.0%, n = 10] over 3 days ranged from 1.1% to 3.6%. Over 3 days, 40.0% (4/10) of participants had weight fluctuations of >2% and 20% (2/10) had weight fluctuations of >3%. Time of weigh-in accounted for 99.8% of the variation in weight fluctuation (P < 0.05), with the lowest fluctuations observed when weights were compared at the same time each day (≤0.4 kg). CONCLUSIONS Weights recorded at the same time daily had the greatest accuracy. Given that the range 1.1-3.6% was within normal weight fluctuations for well-hydrated older hospitalised participants, the weight change indicative of dehydration remains to be established in this setting but appears greater than conventionally used figures.

Development of a Nutrition Care Process implementation package for hospital dietetic departments

Aim The Academy of Nutrition and Dietetics has led the development and dissemination of the Nutrition Care Process (NCP), incorporating the Nutrition Care Process Terminology as the standardised language. This research investigates and compares the views of Australian dietitians pre and post NCP implementation to inform development of an NCP implementation package. Methods Dietitians from two hospitals that had undergone informal NCP implementation (post-implementers, n = 35) and three hospitals yet to implement NCP (pre-implementers, n = 35) completed an online questionnaire (ASK NCP) surveying demographics and constructs relating to knowledge, familiarity, confidence, support, value, barriers, training and NCP education. Results Post-implementers had higher knowledge scores (P < 0.05), were more familiar with NCP (P < 0.01), confident to implement (P < 0.01) and supported to use NCP (P < 0.01) than pre-implementers. Lack of knowledge, support, training and resources was identified as a barrier by pre-implementers. Busy workloads and work status were identified as barriers by post-implementers. Pre-implementers felt they had insufficient NCP training; however, if further training and support were to be provided, almost all reported they would be more confident to implement. Keys to successful implementation included allocated time to practice and regular tutorials; support and leadership from their management and NCP department leader; and professional growth through understanding how change could benefit practice. Conclusions The results of the study were used to inform the development of an NCP implementation package. Kotters eight stages of change were identified as the most appropriate change management model with the framework incorporated into the package development.

Development of the Rapid Assessment, Prioritisation and Referral Tool (RAPaRT) for multidisciplinary teams in emergency care settings.

Objective This investigation utilised the expertise of allied members of multidisciplinary teams working in emergency care settings to develop and validate a Rapid Assessment Prioritisation and Referral Tool (RAPaRT). This instrument is intended for use among patients (with non-life threatening acuity) presenting to emergency care settings to indicate when referral to an allied member of the multidisciplinary team is warranted. Method This three stage instrument development and validation study included: a Delphi panel process to determine key criteria to guide instrument development and identify potential items to be carried forward for testing (stage 1); a prospective cohort of consecutive admissions (n=153) to investigate item sensitivity and specificity and retain only the most suitable items (stage 2); then final consultation with the Delphi panel to ensure the final instrument was clinically amenable (stage 3). Results 23 potential items were identified following stage 1. At the completion of item sensitivity and specificity analysis and in consultation with the Delphi panel, seven items were retained in the instrument. Area under the receiver operating characteristic curve was 0.803 for these seven items in predicting when a referral was warranted. Final consultation with the Delphi panel members also resulted in the addition of an open ended (eighth) item to allow description of any infrequent, but important, reason for referral. Conclusions The RAPaRT has demonstrated substantial promise as an efficient clinically amenable instrument to assist multidisciplinary teams in emergency care settings. Further research to investigate the wider implementation of the RAPaRT is warranted.

Variances of dietary preparation for suppression of physiological 18F-FDG myocardial uptake in the presence of cardiac sarcoidosis: A systematic review

AbstractBackground18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) is used in the diagnosis and management of patients with cardiac sarcoidosis (CS). Various preparation protocols have been proposed to minimise myocardial 18F-FDG uptake and improve scan readability. The aim of this systematic review was to identify the optimal dietary prescription for suppression of physiological 18F-FDG myocardial uptake to enhance clinical diagnosis of CS. Methods and ResultsMEDLINE and PubMed databases identified 13 studies meeting inclusion criteria for review. Articles were assessed using the Australian National Health and Medical Research Council levels of evidence and categorised as sarcoidosis (human) or non-sarcoidosis (human, animal). Visual uptake scales (qualitative) and/or standardised uptake values (SUV) (quantitative) were used in all the studies reviewed. Nine of 11 human studies showed statistically significant improvements in PET scan interpretation with carbohydrate-restricted diets compared with fasting only, and when carbohydrates were restricted for a longer period of time. Two animal studies showed statistically significant improvements following very low carbohydrate diet preparation (0.01% and 0.4% carbohydrate diets) compared with higher carbohydrate diets.ConclusionsVariation in measures used, dietary prescriptions, fasting times, species and study quality makes result comparison and applicability difficult. Definitive dietary recommendations are not possible based on current evidence.

Protein-Energy malnutrition exists and is associated with negative outcomes in morbidly obese hospital patients

Prevalence of protein-energy malnutrition (PEM), food intake inadequacy and associated health-related outcomes in morbidly obese (Body Mass Index ≥ 40 kg/m2) acute care patients are unknown. This study reports findings in morbidly obese participants from the Australasian Nutrition Care Day Survey (ANCDS) conducted in 2010. The ANCDS was a cross-sectional survey involving acute care patients from 56 Australian and New Zealand hospitals. Hospital-based dietitians evaluated participants’ nutritional status (defined by Subjective Global Assessment, SGA) and 24-hour food intake (as 0%, 25%, 50%, 75%, and 100% of the offered food). Three months later, outcome data, including length of stay (LOS) and 90-day in-hospital mortality, were collected. Of the 3122 participants, 4% (n = 136) were morbidly obese (67% females, 55 ± 14 years, BMI: 48 ± 8 kg/m2). Eleven percent (n = 15) of the morbidly obese patients were malnourished, and most (n = 11/15, 73%)received standard hospital diets without additional nutritional support. Malnourished morbidly obese patients had significantly longer LOS and greater 90-day in-hospital mortality than well-nourished counterparts (23 days vs. 9 days, p = 0.036; 14% vs. 0% mortality, p = 0.011 respectively). Thirteen morbidly obese patients (10%) consumed only 25% of the offered meals with a significantly greater proportion of malnourished (n = 4, 27%) versus well-nourished (n = 9, 7%) (p = 0.018). These results provide new knowledge on the prevalence of PEM and poor food intake in morbidly obese patients in Australian and New Zealand hospitals. For the first time internationally, the study establishes that PEM is significantly associated with negative outcomes in morbidly obese patients and warrants timely nutritional support during hospitalisation.Abstract of an oral paper that was presented at the Dietitians Association of Australia 31st National Conference. Incorporating: 2nd World Forum on Nutrition Research Translating the Principles of the Mediterranean Diet, 15-17 May 2014, Brisbane Convention and Exhibition Centre, Brisbane, Queensland, Australia. Disciplines Medicine and Health Sciences | Social and Behavioral Sciences Publication Details Needham, A., Beck, E. & Tapsell, L. (2014). Does a standardised dinner meal consumed the evening prior to testing add methodological integrity to an acute meal test study design?. Nutrition and Dietetics, 71 (Suppl. S1), 26-26. This journal article is available at Research Online: http://ro.uow.edu.au/smhpapers/2739 Does a Standardised Dinner Mealconsumed the Evening Prior to Testing add Methodological Integrity to an Acute Meal Test Study Design? Anita Needham, Eleanor Beck, Linda Tapsell University of Wollongong, NSW Sorghum is an ancient, gluten-free cereal grain that has slow digestibility in vitro and high polyphenol content that may attenuate blood glucose and insulin responses and potentially increase satiety and antioxidant potential in humans. A randomised, double-blind meal test study was conducted to determine the acute effects of different sorghum-based breakfast meals on measures of acute satiety, prospective food intake and antioxidant capacity. The aim of this paper is to discuss whether a standardised pre-test dinner meal added mechanistic value and research quality to this study design. Using a within-subjects, repeated measures design, 40 healthy subjects (20 men and 20 women), aged 20-50 years attended a Clinical Trials Unit on 4 occasions after a 12-hour overnight fast. The evening before the testing day, each subject consumed a frozen dinner meal of energy value stratified to his or her usual intake. The key rationale for this condition was to standardise the level of polyphenolic compounds, and therefore potential antioxidants, present in the plasma of subjects at baseline on each test day. Standardisation of energy, macroand micronutrients was a secondary effect. This paper reviews evidence on standardisation of intake before meal test studies, particularly reviewing the baseline plasma antioxidant capacity in the current study, after consumption of the standardised meal on the evening prior to testing. These results may inform the design of future meal test studies that specifically investigate food intake and antioxidant outcome measures.words: 248 58

O3.20: Non-invasive clinical and physical signs, symptoms and indications for identification of impending and current water-loss dehydration in older people: a diagnostic accuracy systematic review

Introduction Water-loss dehydration is common in older people and associated with excess morbidity and mortality, but it is unclear which signs/symptoms identify dehydration in this group. Diagnostic accuracy of possible clinical and physical signs, symptoms and indications of water-loss dehydration in older people were assessed against serum osmolality or weight change (reference standards)1. Methods Structured searches were run in seven databases. Assessment of inclusion, data extraction and assessment of validity were duplicated. Where data sets included index tests and a reference standard, but were not analysed for diagnostic accuracy, reviewers analysed the data. Diagnostic accuracy of each sign, symptom or indicator was assessed against the best reference standard, and data presented in sensitivity and specificity forest plots. Pre-set minimum sensitivity was 60%, specificity 75%. Secondary analyses created receiver operating characteristic (ROC) curves for continuous tests. Results We included 24 studies (3 using published data, 21 analysing raw data sets) reporting 67 tests. No index tests were reproducibly usefully diagnostic of water-loss dehydration in older people, but promising signs/symptoms, which need further assessment, are shown in the table. There was sufficient evidence to suggest that some signs/symptoms should not be used to indicate dehydration (table). Conclusions No single sign/symptom was diagnostic of water-loss dehydration in older people. Individual signs should not be used in this population to indicate dehydration as they will miss many with dehydration, and wrongly label those adequately hydrated. Promising signs identified by this review need to be further assessed. 1. Hooper L et al, Cochrane Library (protocol) 2011: CD009647-DOI:1002/14651858.