Laura Byham-Gray

Prevalence of vitamin D [25(OH)D] deficiency and effects of supplementation with ergocalciferol (vitamin D2) in stage 5 chronic kidney disease patients.

OBJECTIVE This study investigated the prevalence of vitamin D deficiency, its association with nutrition-related parameters, and the effects of ergocalciferol supplementation in stage 5 chronic kidney disease (CKD). Measures of interest included serum albumin, glycosylated hemoglobin (HgA1c), hemoglobin, phosphorus, corrected calcium, parathyroid hormone (iPTH), equilibrated normalized protein catabolic rate (enPCR), and quality-of life-survey physical component score (SF-36 PCS). DESIGN AND SETTING This retrospective study was conducted at five dialysis centers in western Massachusetts. Patient records were examined for a 6-month period in 2006, after initiation of a protocol to assess serum 25(OH)D and implement treatment with ergocalciferol if the level of serum 25(OH)D were <40 ng/mL. RESULTS Over 90% (i.e., 92.4%) of patients had vitamin D levels of less than 40 ng/mL; 80% had vitamin D levels at 31 ng/mL or less. Ergocalciferol supplementation (50,000 IU/week x 24) was associated with significant improvements in serum 25(OH)D from baseline (18.4 +/- 9.0 ng/mL; mean +/- SD) to 6 months (42.0 +/- 24.7 ng/mL) (P < .0005). The level of glycosylated hemoglobin decreased from 6.9% +/- 1.9% at baseline to 6.4% +/- 1.5% at 6 months (P < .0005), while hemoglobin improved from 12.1 +/- 1.6 g/dL to 12.3 +/- 1.4 g/dL (P < .0005). Corrected calcium decreased from 8.7 +/- 0.8 mg/dL to 8.5 +/- 0.9 mg/dL at 6 months (P = .002). Phosphorus and iPTH exhibited a downward trend, though not significantly. Albumin remained stable, while enPCR increased (0.91 +/- 0.23 at baseline, vs. 0.98 +/- 0.32 at 6 months) (P = .01). The SF-36 PCS scores did not differ significantly from baseline (35.4 +/- 11.8) at 6 months (35.0 +/- 11.1). CONCLUSIONS Vitamin D [25(OH)D] deficiency appears to be widely prevalent in stage 5 CKD. Repletion with ergocalciferol may assist in improving glycemic control in the management of diabetes. Additional research is needed to confirm these results and determine the optimal levels of serum 25(OH)D.

The impact of implementation of a nutrition support algorithm on nutrition care outcomes in an intensive care unit.

BACKGROUND A nutrition support algorithm is an operational version of a guideline that is adapted to local requirements and easy to apply in clinical practice. The purpose of this study was to determine the impact of implementing a nutrition support algorithm on nutrition care outcomes in an intensive care unit (ICU) in Switzerland without a designated dietitian. METHODS The retrospective study included data collection on 2 cohorts of critically ill patients before (n = 56) and after (n = 56) implementation of a nutrition support algorithm based on the guidelines published by the Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition guidelines. RESULTS There were significant differences between groups for the mean delivery of total energy in the pre- vs postimplementation group (909 ± 444 vs 1097 ± 420 kcal/d; P = .023) and mean delivery of protein per day (35 ± 17.9 vs 59.1 ± 27.3 g; P < .001). For patients staying at least 7 days in the ICU, the cumulative energy deficit decreased from -5664 ± 3613 kcal in the preimplementation group to -2972 ± 2420 kcal (P = .011) in the postimplementation group. No significant differences in the route of feeding and timing of enteral nutrition initiation were found. CONCLUSIONS Implementation of a nutrition support algorithm resulted in improved provision of energy and protein delivery. This may be further improved with routine nutrition assessment by a dietitian or a designated nutrition support team.

Nutritional Status Based on Body Mass Index Is Associated With Morbidity and Mortality in Mechanically Ventilated Critically Ill Children in the PICU.

Objective:To determine the influence of admission anthropometry on clinical outcomes in mechanically ventilated children in the PICU. Design:Data from two multicenter cohort studies were compiled to examine the unique contribution of nutritional status, defined by body mass index z score, to 60-day mortality, hospital-acquired infections, length of hospital stay, and ventilator-free days, using multivariate analysis. Setting:Ninety PICUs from 16 countries with eight or more beds. Patients:Children aged 1 month to 18 years, admitted to each participating PICU and requiring mechanical ventilation for more than 48 hours. Measurements and Main Results:Data from 1,622 eligible patients, 54.8% men and mean (SD) age 4.5 years (5.1), were analyzed. Subjects were classified as underweight (17.9%), normal weight (54.2%), overweight (14.5%), and obese (13.4%) based on body mass index z score at admission. After adjusting for severity of illness and site, the odds of 60-day mortality were higher in underweight (odds ratio, 1.53; p < 0.001) children. The odds of hospital-acquired infections were higher in underweight (odds ratio, 1.88; p = 0.008) and obese (odds ratio, 1.64; p < 0.001) children. Hazard ratios for hospital discharge were lower among underweight (hazard ratio, 0.71; p < 0.001) and obese (hazard ratio, 0.82; p = 0.04) children. Underweight was associated with 1.3 (p = 0.001) and 1.6 (p < 0.001) fewer ventilator-free days than normal weight and overweight, respectively. Conclusions:Malnutrition is prevalent in mechanically ventilated children on admission to PICUs worldwide. Classification as underweight or obese was associated with higher risk of hospital-acquired infections and lower likelihood of hospital discharge. Underweight children had a higher risk of mortality and fewer ventilator-free days.

The mean dietary protein intake at different stages of chronic kidney disease is higher than current guidelines

The actual dietary protein intake of adults without and with different stages of chronic kidney disease is not known. To evaluate this we performed cross-sectional analyses of 16,872 adults (20 years of age and older) participating in the National Health and Nutrition Examination Survey 2001-2008 who completed a dietary interview by stage of kidney disease. Dietary protein intake was assessed from 24-h recall systematically collected using the Automated Multiple Pass Method. Complex survey analyses were used to derive population estimates of dietary protein intake at each stage of chronic kidney disease. Using dietary protein intake of adults without chronic kidney disease as the comparator, and after adjusting for age, the mean dietary protein intake was 1.30 g/kg ideal body weight/day (g/kgIBW/d) and was not different from stage 1 or stage 2 (1.28 and 1.25 g/kgIBW/d, respectively), but was significantly different in stage 3 and stage 4 (1.22 and 1.13 g/kgIBW/d, respectively). These mean values appear to be above the Institute of Medicine requirements for healthy adults and the NKF-KDOQI guidelines for stages 3 and 4 chronic kidney disease. Thus, the mean dietary protein intake is higher than current guidelines, even after adjusting for age.

Academy of Nutrition and Dietetics and National Kidney Foundation: Revised 2014 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nephrology Nutrition

Compelling evidence indicates that the incidence of chronic kidney disease (CKD) is increasing because of an aging population and a higher prevalence of cardiovascular disease, diabetes, and hypertension. Nutrition management of patients with CKD requires early disease recognition, appropriate interpretation of the markers and stages of CKD, and collaboration with other health care practitioners. Better management of CKD can slow its progression, prevent metabolic complications, and reduce cardiovascular related outcomes. Caring for patients with CKD necessitates specialized knowledge and skills to meet the challenges associated with this growing epidemic. The Academy of Nutrition and Dietetics Renal Dietitians Practice Group and the National Kidney Foundation Council on Renal Nutrition, with guidance from the Academy of Nutrition and Dietetics Quality Management Committee, have updated the 2009 Standards of Practice in Nutrition Care and Standards of Professional Performance as a tool for registered dietitian nutritionists working in nephrology nutrition to assess their current skill levels and to identify areas for additional professional development in this practice area. The Standards of Practice apply to the care of patients/clients with kidney disease. The Standards of Professional Performance consist of six domains of professionalism, including: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Within each standard, specific indicators provide measurable action statements that illustrate how nephrology nutrition principles can be applied to practice. The indicators describe three skill levels (ie, competent, proficient, and expert) for registered dietitian nutritionists working in nephrology nutrition.

The Effect of Medical Nutrition Therapy by a Registered Dietitian Nutritionist in Patients with Prediabetes Participating in a Randomized Controlled Clinical Research Trial

BACKGROUND Prior studies have provided evidence that lifestyle change prevents or delays the occurrence of type 2 diabetes mellitus. The challenge is to translate research evidence for type 2 diabetes mellitus prevention into health care settings. OBJECTIVE We investigated the effect of medical nutrition therapy (MNT) compared with usual care on fasting plasma glucose values, glycated hemoglobin (HbA1c), serum lipid levels, and Diabetes Risk Score, from baseline to the end of a 12-week intervention in overweight or obese adults with prediabetes. DESIGN Prospective, randomized, parallel group study of 76 adults with impaired fasting plasma glucose or an HbA1c of 5.7% to 6.4%, recruited between April 2010 and May 2011 who completed a 12-week intervention period. MAIN OUTCOME MEASURES The primary outcome measure was fasting plasma glucose. Secondary outcome measures were HbA1c, serum lipid levels, and Diabetes Risk Score. STATISTICAL ANALYSES A factorial repeated measures analysis of variance was used to make comparisons between the two groups (the MNT and usual care groups) and two measures of time (baseline and 12 weeks postintervention). Data analysis was performed using the Statistical Package for the Social Sciences (release 19.0, 2010, SPSS Inc). RESULTS There was a significant interaction for group assignment and HbA1c (P=0.01), with the MNT group experiencing significantly lower HbA1c levels than the usual care group (5.79% vs 6.01%) after the 12-week intervention. There was a significant interaction for group assignment and Diabetes Risk Score (P=0.001). Diabetes Risk Score for the MNT group decreased from 17.54±3.69 to 15.31±3.79 compared with the usual care group score, which went from 17.23±4.69 to 16.83±4.73. Regardless of group assignment, both groups experienced a reduction in total cholesterol (P=0.01) and low-density lipoprotein cholesterol (P=0.04) level. CONCLUSIONS The results demonstrate that individualized MNT is effective in decreasing HbA1c level in patients diagnosed with prediabetes.

Identifying Components of Advanced-Level Clinical Nutrition Practice: A Delphi Study

The dietetics profession lacks a comprehensive definition of advanced-level practice. Using a three-round Delphi study with mailed surveys, expert consensus on four dimensions of advanced-level practice that define advanced practice registered dietitians (RDs) in clinical nutrition was explored. Purposive sampling identified 117 RDs who met advanced-level practice criteria. In round 1, experts rated the essentiality of statements on a 7-point ordinal scale and generated open-ended practice activity statements regarding the following four dimensions of advanced-level practice: professional knowledge, abilities and skills, approaches to practice, roles and relationships, and practice behaviors. Median ratings of 1.0 to 3.0 were defined as essential, 4.0 was neutral, and 5.0 to 7.0 were nonessential. In rounds 2 and 3, experts re-rated statements not reaching consensus by evaluating their previous responses, group median rating, and comments. Consensus was reached when the interquartile range of responses to a statement was ≤2.0. Eighty-five experts enrolled (72.6%); 76 (89.4%) completed all rounds. In total, 233 statements were rated, with 100% achieving consensus; 211 (90.6%) were essential to advanced practice RD clinical practice. Having a masters degree; completing an advanced practice residency; research coursework; and advanced continuing education were essential, as were having 8 years of experience; clinical nutrition knowledge/expertise; specialization; participation in research activities; and skills in technology and communication. Highly essential approaches to practice were systematic yet adaptable and used critical thinking and intuition and highly essential values encompassed professional growth and service to patients. Roles emphasized patient care and leadership. Essential practice activities within the nutrition care process included provision of complex patient-centered nutrition care using application of advanced knowledge/expertise and interviewing and counseling strategies approached in a comprehensive yet discriminating manner. Communication with patients and the health care team is a priority. An advanced-level practice model in clinical nutrition was proposed depicting the requisite attributes and activities within four dimensions of professional practice.

American Dietetic Association and the National Kidney Foundation Standards of Practice and Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Nephrology Care

The American Dietetic Association (ADA) Renal Dietitians Practice Group (RPG) and the National Kidney Foundation Council on Renal Nutrition (NKF CRN), under the guidance of the ADA Quality Management Committee and Scope of Dietetics Practice Framework Sub-Committee, have developed the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitians (Generalist, Specialty, and Advanced) in Nephrology Care (Supplementary Figures 1, 2, and 3 are available only online at www.jrnjournal.org). The SOP and SOPP documents are based upon the 2008 Revised Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitians (RDs)(1), which are part of ADAs Scope of Dietetics Practice Framework(2). The 2008 Revised SOP in Nutrition Care and SOPP, along with the Code of Ethics(3), guide the practice and performance of RDs in all settings.

2005 American society for parenteral and enteral nutrition (A.S.P.E.N.) standards and guidelines survey

An online survey about the use and format of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Standards and Guidelines documents was conducted. The survey was sent to A.S.P.E.N. members, and an acceptable number of responses were received (470, or 9% of those surveyed). Most respondents indicated an overall satisfaction with the standards and guidelines and suggested format changes, many of which will be incorporated into future guidelines and standards. The results of this survey are presented here for general interest. Changes in the process with which A.S.P.E.N. produces standards and guidelines are discussed.

Early Oral Feeding as Compared With Traditional Timing of Oral Feeding After Upper Gastrointestinal Surgery: A Systematic Review and Meta-analysis.

Objective: To compare the effects of early oral feeding to traditional (or late) timing of oral feeding after upper gastrointestinal surgery on clinical outcomes. Background: Early postoperative oral feeding is becoming more common, particularly as part of multimodal or fast-track protocols. However, concerns remain about the safety of early oral feeding after upper gastrointestinal surgery. Methods: Comprehensive literature searches were conducted across 5 databases from January 1980 until June 2015 without language restriction. Risk of bias of included studies was appraised and random-effects model meta-analyses were performed to synthesize outcomes of anastomotic leaks, pneumonia, nasogastric tube reinsertion, reoperation, readmissions, and mortality. Results: Fifteen studies comprising 2112 adult patients met all the inclusion criteria. Mean hospital stay was significantly shorter in the early-fed group than in the late-fed group [weighted mean difference = −1.72 d, 95% confidence interval (CI) −1.25 to −2.20, P < 0.01). Postoperative length of stay was also significantly shorter (weighted mean difference = −1.44 d, 95% CI −0.68 to −2.20, P < 0.01). There was no significant difference in risk of anastomotic leak, pneumonia, nasogastric tube reinsertion, reoperation, readmission, or mortality in the randomized controlled trials (RCTs). The pooled RCT and non-RCT results, however, showed a significantly lower risk of pneumonia in early-fed as compared with late-fed group (odds ratio = 0.6, 95% CI 0.41–0.89, P = 0.01). Conclusions: Early postoperative oral feeding as compared with traditional (or late) timing is associated with shorter hospital length of stay and is not associated with an increase in clinically relevant complications.