Marianna Milosavljevic

Poor nutritional status of older subacute patients predicts clinical outcomes and mortality at 18 months of follow-up

Background/Objectives:Older malnourished patients experience increased surgical complications and greater morbidity compared with their well-nourished counterparts. This study aimed to assess whether nutritional status at hospital admission predicted clinical outcomes at 18 months follow-up.Subjects/Methods:A retrospective analysis of N=2076 patient admissions (65+ years) from two subacute hospitals, New South Wales, Australia. Analysis of outcomes at 18 months, according to nutritional status at index admission, was performed in a subsample of n=476. Nutritional status was determined within 72 h of admission using the Mini Nutritional Assessment (MNA). Outcomes, obtained from electronic patient records, included hospital readmission rate, total Length of Stay (LOS), change in level of care at discharge and mortality. Survival analysis, using a Cox proportional hazards model, included age, sex, Major Disease Classification, mobility and LOS at index admission as covariates.Results:At baseline, 30% of patients were malnourished and 53% were at risk of malnutrition. LOS was higher in malnourished and at risk, compared with well-nourished patients (median (interquartile range): 34 (21, 58); 26 (15, 41); 20 (14, 26) days, respectively; P<0.001). Hazard rate for death in the malnourished group is 3.41 (95% confidence interval: 1.07–10.87; P=0.038) times the well-nourished group. Discharge to a higher level of residential care was 33.1%, 16.9% and 4.9% for malnourished, at-risk and well-nourished patients, respectively; P⩽0.001).Conclusion:Malnutrition in elderly subacute patients predicts adverse clinical outcomes and identifies a need to target this population for nutritional intervention following hospital discharge.

Pregnancy and Glycemic Index Outcomes study: effects of low glycemic index compared with conventional dietary advice on selected pregnancy outcomes

BACKGROUND Eating carbohydrate foods with a high glycemic index (GI) has been postulated to result in fetoplacental overgrowth and higher infant body fat. A diet with a low glycemic index (LGI) has been shown to reduce birth percentiles and the ponderal index (PI). OBJECTIVES We investigated whether offering LGI dietary advice at the first antenatal visit would result in a lower fetal birth weight, birth percentile, and PI than providing healthy eating (HE) advice. This advice had to be presented within the resources of routine antenatal care. DESIGN The Pregnancy and Glycemic Index Outcomes study was a 2-arm, parallel-design, randomized, controlled trial that compared the effects of LGI dietary advice with HE advice on pregnancy outcomes. Eligible volunteers who attended for routine antenatal care at <20 wk of gestation were randomly assigned to either group. RESULTS A total of 691 women were enrolled, and 576 women had final data considered. In the LGI group, the GI was reduced from a mean (± SEM) of 56 ± 0.3 at enrollment to 52 ± 0.3 (P < 0.001) at the final assessment. There were no significant differences in primary outcomes of fetal birth weight, birth percentile, or PI. In a multivariate regression analysis, the glycemic load was the only significant dietary predictor (P = 0.046) of primary outcomes but explained <1% of all variation. CONCLUSION A low-intensity dietary intervention with an LGI diet compared with an HE diet in pregnancy did not result in any significant differences in birth weight, fetal percentile, or PI.

Feasibility of implementing routine nutritional screening for older adults in Australian general practices: a mixed-methods study

BackgroundNutrition screening in older adults is not routinely performed in Australian primary care settings. Low awareness of the extent of malnutrition in this patient group, lack of training and time constraints are major barriers that practice staff face. This study aimed to demonstrate the feasibility of including a validated nutrition screening tool and accompanying nutrition resource kit for use with older patients attending general practice. Secondary aims were to assess nutrition-related knowledge of staff and to identify the extent of malnutrition in this patient group.MethodsNine general practitioners, two general practice registrars and 11 practice nurses from three participating general practices in a rural, regional and metropolitan area within a local health district of New South Wales, Australia were recruited by convenience sampling.Individual in-depth interviews, open-ended questionnaires and an 11-item knowledge questionnaire were completed three months following in-practice group workshops on the Mini Nutritional Assessment Short Form (MNA-SF). Staff were encouraged to complete the MNA-SF within the Medicare-funded 75+ Health Assessment within this time period. Staff interviews were digitally recorded, transcribed verbatim and analysed thematically using qualitative analysis software QSR NVivo 10.ResultsFour key themes were determined regarding the feasibility of performing MNA –SF: ease of use; incorporation into existing practice; benefit to patients’ health; and patients’ perception of MNA-SF. Two key themes related to the nutrition resource kit: applicability and improvement. These findings were supported by open ended questionnaire responses. Knowledge scores of staff significantly improved from baseline (52% to 66%; P < 0.05). Of the 143 patients that had been screened, 4.2% (n = 6) were classified as malnourished, 26.6% (n = 38) `at risk’ of malnutrition and 69.2% (n = 99) as well-nourished.ConclusionIt is feasible to include the MNA-SF and a nutrition resource kit within routine general practice, but further refinement of patients’ electronic clinical records in general practice software would streamline this process.

Consumer support for healthy food and drink vending machines in public places

Objective: To investigate the feasibility of introducing vending machines for healthier food into public places, and to examine the effectiveness of two front‐of‐pack labelling systems in the vending machine context.

Does a Low Glycaemic Index (GI) Diet Cost More during Pregnancy

The aim of this study was to examine the monetary cost of dietary change among pregnant women before and after receiving low glycaemic index (GI) dietary advice. The pregnant women in this study were a subgroup of participants in the Pregnancy and Glycaemic Index Outcomes (PREGGIO) study. Twenty women from the low GI dietary advice group, who had completed their pregnancies, were randomly chosen. All these women had completed three day food records at 12–16 weeks and again around 36 weeks of gestation. Consumer food prices were applied to recorded dietary intake data. The mean ± SD GI of the diet reduced from 55.1 ± 4.3 to 51.6 ± 3.9 (p = 0.003). The daily cost of the diet (AUD) was 9.1 ± 2.7 at enrolment and 9.5 ± 2.1 prior to delivery was not significantly different (p = 0.52). There were also no significant differences in the daily energy intake (p = 0.2) or the daily cost per MJ (p = 0.16). Women were able to follow low GI dietary advice during pregnancy with no significant increase in the daily costs.

Evolution of the clinical educator role to increase student placement capacity: From traditional to innovative

Aim To evaluate the role of the clinical educator position in a specific teaching hospital setting on its ability to increase clinical student supervision capacity while maintaining staff productivity and sustaining staff morale. Methods A Clinical Educator position (0.5 full-time equivalent) was established as a manager of student placements as opposed to the traditional ‘hands-on’ clinical supervision or student team teaching role. This position developed two strategies to increase capacity for clinical placements: a peer support program, ‘INSITE’ (Innovative and Novel System to Improve the Teaching Experience) and ‘supervisory teams’. Over four years (2008–2011), the effect on staff productivity, staff morale and students was assessed using a range of measures including investigation of staff attitudes (focus groups and surveys), student perception of the placement (survey) and review of departmental productivity measures. Results Staff participation in supervision increased from 42% to 98%. Thematic analysis of the focus groups found four main themes considered as components of an effective and manageable student placement program: communication, management of student progress, opportunities for professional growth and the management of challenges in supervision. With the introduction of INSITE, staff surveys found a noticeable improvement in the perception of their ability to manage students. A survey reported that students were satisfied or very satisfied with the clinical placement. Department activity statistics were maintained across the four years despite a 165% increase in clinical placement activity. Conclusion The development of the Clinical Educator from ‘ hands-on’ to manager increased the departments capacity to facilitate clinical placements while maintaining productivity and staff morale.

Difficulties in recruiting frail older inpatients to intervention studies

Aim To describe difficulties experienced with recruitment of frail, malnourished inpatients aged 65+ years to a 12-week multidisciplinary home-based nutrition and physical activity intervention (SUSTAIN) and to identify factors associated with non-participation. Methods A multidisciplinary team approach to recruitment involved monthly team meetings, weekly clinician case conferences and strategic planning to accommodate patient needs (provision of transport, easy access to facilities, appropriate written/verbal information). Intensive recruitment occurred in eligible inpatients from a major acute tertiary and rehabilitation hospitals in a local health district over seven months. Results Of the 124 patients screened, 88 were not eligible, 32 declined, and 4 consented. Neither socio-demographic nor clinical characteristics (age, gender, clinical diagnosis, birthplace, cognitive function, length of stay or nutritional status) explained non-participation or ineligibility or refusals rates. Conclusions The advanced age and poor overall health status of this population necessitates alternative recruitment strategies to improve participation in clinical trials and improve generalisability for clinical practice.

Nutrition-related hospital presentations and admissions among radiotherapy outpatients: a systematic literature review

BACKGROUND Unplanned presentations and admissions to hospital among outpatients with cancer are a key indicator of quality care in cancer services. Nutritional issues including malnutrition and dehydration, which fall under the dietitians scope of practice, can result in unplanned contacts. The present review focused on cancer outpatients undergoing radiotherapy as a particular at risk group and aimed to provide a comprehensive overview of the range and prevalence of nutrition-related unplanned contacts and the associated factors, including the role of dietetic intervention. METHODS A systematic review analysed studies published between 1990 and August 2016 from five databases. Eligible studies reported rates of nutrition-related unplanned contacts among adult nonhaematological cancer outpatients, treated with nonpalliative radiotherapy. Studies were screened for eligibility, extracted, descriptively analysed and synthesised. RESULTS Fifteen studies were included. Common causes of nutrition-related unplanned contacts included dehydration and enteral feeding commencement and complications. Factors that influenced nutrition-related unplanned contacts included tumour location and stage, treatment modality and the presence of a feeding tube. There were issues in determining the prevalence and identifying dietetic interventions partly as a result of the heterogeneity in reported study designs and varying definitions of nutrition-related unplanned contacts. CONCLUSIONS Nutrition-related problems appear to be associated with unplanned contacts in cancer outpatients undergoing radiotherapy. Hence, there is a strategic need for dietetic involvement aiming to reduce these. Further research is required to define the role of the dietitian in managing nutrition-related unplanned contacts, particularly for dehydration. This may help to define the full scope of practice for dietitians caring for these nutritionally vulnerable and complex outpatients.

The prevalence of diabetes after gestational diabetes – An Australian perspective

Women with gestational diabetes mellitus (GDM) are likely to develop diabetes in later life. International reports and reviews indicate a variable but generally high rate of conversion. However, data from international reports are difficult to apply to an Australian population.

Burnout levels among dietitians working in the New South Wales public hospital system: A cross-sectional statewide survey

Aim The concept of burnout has been examined in the literature for over 35 years, and has been historically associated with those professions that deal with particularly complex cases. Although dietitians have received less attention, they face similar pressures and must cope with an environment that may not support dietetics processes. The aim of the present study was to examine the burnout level among public hospital dietitians in New South Wales (NSW) and to determine the variables associated with burnout and to compare these findings to other studies among health-care professionals. Methods The Maslach Burnout Inventory-Human Services Survey and a demographic questionnaire were distributed to hospital dietitians employed within the NSW public hospital system during a six-week period from April to May 2011. Results The dietitians surveyed had low to moderate burnout levels, r = 0.201 (P = 0.003). The three domains of the burnout measure, emotional exhaustion, depersonalisation and personal accomplishment, were investigated separately. The level/grading of the dietitian was associated with higher levels of emotional exhaustion with r = 0.192 (P = 0.004). Depersonalisation was negatively associated with number of children, r = −0.147 (P = 0.02), and positively associated with the number of hours worked, r = 0.154 (P = 0.021). Personal achievement was positively associated with number of children, r = 0.304 (P = 0.006), and negatively associated with the hours of work, r = −0.198 (P = 0.021). Conclusions The main findings were the following. The career stage, the size of the hospital and hours of work were the variables significantly associated with the levels of burnout experienced by NSW public hospital dietitians. It also appeared that those dietitians with children and who work part-time experienced far less emotional exhaustion and depersonalisation than their full-time counterparts and, interestingly, part-time workers had higher levels of personal accomplishment.