Patricia M. Sheean

An Introduction to Qualitative Research for Food and Nutrition Professionals

The purpose of this article is to define qualitative research, explain its design, explore its congruence with quantitative research, and provide examples of its applications in dietetics. Also, methods to ensure validity, reliability, and relevance are addressed. Readers will gain increased knowledge about qualitative research and greater competency in evaluating this type of research. The hope is that food and nutrition professionals will be inspired to conduct and publish qualitative research, adding to the body of peer-reviewed dietetics-related qualitative publications. This type of research must be methodically planned and implemented with attention to validity, reliability, and relevance. This rigorous approach boosts the probability that the research will add to the scientific literature and qualify for publication.

Intensive Nutrition in Acute Lung Injury A Clinical Trial (INTACT)

BACKGROUND Despite extensive use of enteral (EN) and parenteral nutrition (PN) in intensive care unit (ICU) populations for 4 decades, evidence to support their efficacy is extremely limited. METHODS A prospective randomized trial was conducted evaluate the impact on outcomes of intensive medical nutrition therapy (IMNT; provision of >75% of estimated energy and protein needs per day via EN and adequate oral diet) from diagnosis of acute lung injury (ALI) to hospital discharge compared with standard nutrition support care (SNSC; standard EN and ad lib feeding). The primary outcome was infections; secondary outcomes included number of days on mechanical ventilation, in the ICU, and in the hospital and mortality. RESULTS Overall, 78 patients (40 IMNT and 38 SNSC) were recruited. No significant differences between groups for age, body mass index, disease severity, white blood cell count, glucose, C-reactive protein, energy or protein needs occurred. The IMNT group received significantly higher percentage of estimated energy (84.7% vs 55.4%, P < .0001) and protein needs (76.1 vs 54.4%, P < .0001) per day compared with SNSC. No differences occurred in length of mechanical ventilation, hospital or ICU stay, or infections. The trial was stopped early because of significantly greater hospital mortality in IMNT vs SNSC (40% vs 16%, P = .02). Cox proportional hazards models indicated the hazard of death in the IMNT group was 5.67 times higher (P = .001) than in the SNSC group. CONCLUSIONS Provision of IMNT from ALI diagnosis to hospital discharge increases mortality.

Nutritional Status and Risk Factors for Chronic Disease in Urban-Dwelling Adults With Down Syndrome

Nutritional status and biochemical risk factors for chronic disease were assessed in 48 community-dwelling adults with Down syndrome in the Chicago area. Dietary intake was measured using a food frequency questionnaire completed by the participants primary caregiver; anthropometric measures included height and weight and waist circumference. Plasma glucose and lipid concentrations were assessed following a 10-hour fast. Overall, 89% of participants were overweight or obese, 54% had large waist circumferences, and none met the current guidelines for fruit and vegetable intake. Mean concentrations for lipids and glucose, however, were within normal limits; and prevalence for hypertension, elevated lipids, and glucose were less than those for the general population of the United States.

The prevalence of sarcopenia in patients with respiratory failure classified as normally nourished using computed tomography and subjective global assessment.

BACKGROUND Declines in nutrition status and adverse body composition changes frequently occur in the critically ill. The objective of this cross-sectional study was to examine the prevalence of sarcopenia and its occurrence in patients classified as normal nourished using subjective global assessment (SGA). METHODS Exploiting diagnostic CT images, skeletal muscle mass at the L3 region was quantified and used to determine sarcopenia and its association with normal nutrition status in 56 patients with respiratory failure. Sarcopenia was defined as an L3 skeletal muscle index of ≤38.5 cm(2)/m(2) for women and ≤52.4 cm(2)/m(2) for men. CT imaging and SGA classifications completed within 14, 10 and 7 days of each other were analyzed to assess sarcopenia and the influence of time between scans on misclassification (ie, normal nourished and sarcopenic). Descriptive statistics were conducted. RESULTS The average patient was 59.2 (± 15.6) years old, admitted with sepsis/infection, an APACHE II score of 26 (± 8.0), and BMI of 28.3 (± 5.8). Sarcopenia and sarcopenic obesity were prevalent in a minimum of 56% and 24% of patients, respectively, depending on the number of days between CT imaging and SGA assessment. Misclassified individuals were predominantly male, minority and overweight or obese. Controlling for age, no significant differences were noted for patients classified as normal nourished vs malnourished by SGA for lumbar muscle cross-sectional, whole-body lean mass, or skeletal muscle index. CONCLUSIONS Sarcopenia is highly prevalent among patients with respiratory failure requiring mechanical ventilation (MV) and not readily detected in patients classified as normal nourished using SGA.

Nutrition assessment: The reproducibility of subjective global assessment in patients requiring mechanical ventilation

Background/Objectives:The detection of malnutrition in the intensive care unit (ICU) is critical to appropriately address its contribution on outcomes. The primary objective of this investigation was to determine if nutritional status could be reliably classified using subjective global assessment (SGA) in mechanically ventilated (MV) patients.Subjects/Methods:Fifty-seven patients requiring MV >48 h in a university-affiliated medical ICU were evaluated in this cross-sectional study over a 3-month period. Nutritional status was categorized independently by two registered dietitians using SGA. Frequencies, means (+ s.d.), χ 2 and t-tests were used to describe the population characteristics; agreement between raters was evaluated using the κ statistic.Results:On admission, the average patient was 50.4 (±14.2) years of age, overweight (body mass index: 29.0±9.2kg/m2), had an acute physiology and chronic health evaluation II score of 24 (±10) and respiratory failure. Fifty percent (n=29) of patients were categorized as malnourished. Agreement between raters was 95% before consensus, reflecting near perfect agreement (κ=0.90) and excellent reliability. Patients categorized as malnourished were more often admitted to the hospital floor before the ICU (n=32; 56%), reported decreased dietary intake (69 vs 46%, P=0.02) and exhibited signs of muscle wasting (45 vs 7%, P<0.001, respectively) and fat loss (52 vs 7%, P<0.001, respectively) on physical exam when compared with normally nourished individuals.Conclusions:SGA can serve as a reliable nutrition assessment technique for detecting malnutrition in patients requiring MV. Its routine use should be incorporated into future studies and clinical practice.

Body composition changes in females treated for breast cancer: a review of the evidence.

Body composition changes cannot be precisely captured using body weight or body mass index measures. Therefore, the primary purpose of this review was to characterize the patterns of body composition change in females treated for breast cancer including only studies that utilize imaging technologies to quantify adipose tissue and lean body mass (LBM). We reviewed PubMed for studies published between 1971 and 2012 involving females diagnosed with breast cancer where computed axial tomography , dual-energy X-ray absorptiometry, or magnetic resonance imaging were employed for body composition assessment. Of the initial 440 studies, 106 papers were evaluated and 36 papers met all eligibility criteria (15 observational and 21 intervention trials). Results of these studies revealed that body weight did not consistently increase. Importantly, studies also showed that body weight did not accurately depict changes in lean or adipose tissues. Further findings included that sarcopenic obesity as a consequence of breast cancer treatment was not definitive, as menopausal status may be a substantial moderator of body composition. Overall, the behavioral interventions did not exhibit consistent or profound effects on body composition outcomes; approximately half showed favorable influence on adiposity while the effects on LBM were not apparent. The use of tamoxifen had a clear negative impact on body composition. The majority of studies were conducted in predominantly white survivors, highlighting the need for trials in minority populations. Collectively, these studies were limited by age, race, and/or menopause status matched control groups, overall size, and statistical power. Very few studies simultaneously collected diet and exercise data—two potential factors that impact body composition. Future breast cancer trials should prioritize precise body composition methodologies to elucidate how these changes impact recurrence, prognosis, and mortality, and to provide clinicians with appropriate advice regarding lifestyle recommendations in this growing sector of the population.

Publishing Nutrition Research: Validity, Reliability, and Diagnostic Test Assessment in Nutrition-Related Research

This is the sixth in a series of monographs on research design and analysis. The purpose of this article is to describe and discuss several concepts related to the measurement of nutrition-related characteristics and outcomes, including validity, reliability, and diagnostic tests. The article reviews the methodologic issues related to capturing the various aspects of a given nutrition measures reliability, including test-retest, inter-item, and interobserver or inter-rater reliability. Similarly, it covers content validity, indicators of absolute vs relative validity, and internal vs external validity. With respect to diagnostic assessment, the article summarizes the concepts of sensitivity and specificity. The hope is that dietetics practitioners will be able to both use high-quality measures of nutrition concepts in their research and recognize these measures in research completed by others.

Refeeding Syndrome: Recognition Is the Key to Prevention and Management

Refeeding syndrome is a life-threatening constellation of cardiovascular, pulmonary, hepatic, renal, neuromuscular, metabolic, and hematological abnormalities following inappropriate alimentary resuscitation in severely malnourished or starved individuals. Clinical observations of refeeding syndrome were originally described and reported around the time of World War II when prisoners of war and semi-starved war protestors experienced cardiac failure following nutrition repletion (1,2). Today, anorexia nervosa is one of the more frequent clinical presentations at risk of refeeding syndrome; however, malnourished elderly patients, oncology patients receiving chemotherapy, and postoperative patients may also be at risk. Recognizing individuals prone to refeeding syndrome and understanding the compensatory physiologic mechanisms and resulting nutritional implications are crucial to avoiding the morbidity and mortality associated with this phenomenon.

Exploitation of diagnostic computed tomography scans to assess the impact of nutrition support on body composition changes in respiratory failure patients.

BACKGROUND Assessment of nutritional status in intensive care unit (ICU) patients is limited. Computed tomography (CT) scans that include the first to fifth lumbar region completed for diagnostic purposes measures fat and lean body mass (LBM) depots and are frequently done in ICU populations and can be used to quantify fat and LBM depots. The purpose of this study was to assess if these scans could measure change in skeletal muscle (SKT), visceral adipose (VAT), and intermuscular adipose (IMAT) tissue and to examine the association between the amount of energy and protein received and changes in these depots. METHODS Cross-sectional area of SKT, VAT, and IMAT from CT scans at the third lumbar region was quantified at 2 time points (CT1 and CT2). Change scores between CT1 and CT2 for each of these depots and the percentage of estimated energy/protein needs received were determined in 33 adults that with acute respiratory failure. Descriptive statistics and multiple regression was used to evaluate the influence of baseline characteristics and the percentage energy/protein needs received between CT1 and CT2 on percentage change/day between CT1 and CT2 on SKM, IMAT, and VAT. RESULTS Participants were on average (SD) 59.7 (16) years old, received 41% of energy and 57% of protein needs. The average time between CT1 and CT2 was 10 (5) days. SKM declined 0.49%/day (men P = .07, women P = .09) and percentage of energy needs received reduced loss (β = 0.024, P = .03). No change in VAT or IMAT occurred. CONCLUSIONS CT scans can be exploited to assess change in body composition in ICU patients and may assist in detecting the causal link between nutritional support and outcomes in future clinical trials.

Measuring Abdominal Circumference and Skeletal Muscle From a Single Cross-Sectional Computed Tomography Image: A Step-by-Step Guide for Clinicians Using National Institutes of Health ImageJ.

Diagnostic computed tomography (CT) scans provide numerous opportunities for body composition analysis, including quantification of abdominal circumference, abdominal adipose tissues (subcutaneous, visceral, and intermuscular), and skeletal muscle (SM). CT scans are commonly performed for diagnostic purposes in clinical settings, and methods for estimating abdominal circumference and whole-body SM mass from them have been reported. A supine abdominal circumference is a valid measure of waist circumference (WC). The valid correlation between a single cross-sectional CT image (slice) at third lumbar (L3) for abdominal SM and whole-body SM is also well established. Sarcopenia refers to the age-associated decreased in muscle mass and function. A single dimensional definition of sarcopenia using CT images that includes only assessment of low whole-body SM has been validated in clinical populations and significantly associated with negative outcomes. However, despite the availability and precision of SM data from CT scans and the relationship between these measurements and clinical outcomes, they have not become a routine component of clinical nutrition assessment. Lack of time, training, and expense are potential barriers that prevent clinicians from fully embracing this technique. This tutorial presents a systematic, step-by-step guide to quickly quantify abdominal circumference as a proxy for WC and SM using a cross-sectional CT image from a regional diagnostic CT scan for clinical identification of sarcopenia. Multiple software options are available, but this tutorial uses ImageJ, a free public-domain software developed by the National Institutes of Health.