Timothy C. Crowe

Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system.

Malnutrition is a debilitating and highly prevalent condition in the acute hospital setting, with Australian and international studies reporting rates of approximately 40%. Malnutrition is associated with many adverse outcomes including depression of the immune system, impaired wound healing, muscle wasting, longer lengths of hospital stay, higher treatment costs and increased mortality. Referral rates for dietetic assessment and treatment of malnourished patients have proven to be suboptimal, thereby increasing the likelihood of developing such aforementioned complications. Nutrition risk screening using a validated tool is a simple technique to rapidly identify patients at risk of malnutrition, and provides a basis for prompt dietetic referrals. In Australia, nutrition screening upon hospital admission is not mandatory, which is of concern knowing that malnutrition remains under-reported and often poorly documented. Unidentified malnutrition not only heightens the risk of adverse complications for patients, but can potentially result in foregone reimbursements to the hospital through casemix-based funding schemes. It is strongly recommended that mandatory nutrition screening be widely adopted in line with published best-practice guidelines to effectively target and reduce the incidence of hospital malnutrition.

Nutritional status, nutrition practices and post-operative complications in patients with gastrointestinal cancer.

BACKGROUND Malnutrition and its associated complications are a considerable issue for surgical patients with upper gastrointestinal and colorectal cancer. The present study aimed to determine whether specific perioperative nutritional practices and protocols are associated with improved patient outcomes in this group. METHODS Patients admitted for elective upper gastrointestinal or colorectal cancer surgery (n = 95) over a 19-month period underwent a medical history audit assessing weight changes, nutritional intake, biochemistry, post-operative complications and length of stay. A subset of patients (n = 25) underwent nutritional assessment by subjective global assessment prior to surgery in addition to assessment of post-operative medical outcomes, nutritional intake and timing of dietetic intervention. RESULTS Mean (SD) length of stay for patients was 14.0 (12.2) days, with complication rates at 35%. Length of stay was significantly longer in patients who experienced significant preoperative weight loss compared to those who did not [17.0 (15.8) days versus 10.0 (6.8) days, respectively; P < 0.05]. Low albumin and post-operative weight loss were also predictive of increased length of stay. Of patients who underwent nutritional assessment, 32% were classified as mild-moderately malnourished and 16% severely malnourished. Malnourished patients were hospitalised twice as long as well-nourished patients [15.8 (12.8) days versus 7.6 (3.5) days; P < 0.05]. Time taken [6.9 (3.6) days] to achieve adequate nutrition post surgery was a factor in post-operative outcomes, with a positive correlation with length of stay (r = 0.493; P < 0.01), a negative correlation with post-operative weight change (r = -0.417; P < 0.05) and a greater risk of complications (52% versus 13%; P < 0.01). CONCLUSIONS Malnutrition is prevalent among surgical patients with gastrointestinal cancer. Poor nutritional status coupled with delayed and inadequate post-operative nutrition practices are associated with worse clinical outcomes.

Safety of low-carbohydrate diets

Low‐carbohydrate diets have re‐emerged into the public spotlight and are enjoying a high degree of popularity as people search for a solution to the populations ever‐expanding waistline. The current evidence though indicates that low‐carbohydrate diets present no significant advantage over more traditional energy‐restricted diets on long‐term weight loss and maintenance. Furthermore, a higher rate of adverse side‐effects can be attributed to low‐carbohydrate dieting approaches. Short‐term efficacy of low‐carbohydrate diets has been demonstrated for some lipid parameters of cardiovascular risk and measures of glucose control and insulin sensitivity, but no studies have ascertained if these effects represent a change in primary outcome measures. Low‐carbohydrate diets are likely effective and not harmful in the short term and may have therapeutic benefits for weight‐related chronic diseases although weight loss on such a program should be undertaken under medical supervision. While new commercial incarnations of the low‐carbohydrate diet are now addressing overall dietary adequacy by encouraging plenty of high‐fibre vegetables, fruit, low‐glycaemic‐index carbohydrates and healthier fat sources, this is not the message that reaches the entire public nor is it the type of diet adopted by many people outside of the world of a well‐designed clinical trial. Health effects of long‐term ad hoc restriction of inherently beneficial food groups without a concomitant reduction in body weight remains unanswered.

Energy density of foods and beverages in the Australian food supply: influence of macronutrients and comparison to dietary intake

Objectives: The energy density (ED) of the diet is considered an important determinant of total energy intake and thus energy balance and weight change. We aimed to compare relationships between ED and macronutrient content in individual food and beverage items as well as population diet in a typical Western country.Design: Nutrient data for 3673 food items and 247 beverage items came from the Australian Food and Nutrient database (AusNut). Food and beverage intake data came from the 1995 Australian National Nutrition Survey (a 24-h dietary recall survey in 13 858 people over the age of 2). Relationships between ED and macronutrient and water content were analysed by linear regression with 95% prediction bands.Results: For both individual food items and population food intake, there was a positive relationship between ED and percent energy as fat and negative relationships between ED and percent energy as carbohydrate and percent water by weight. In all cases, there was close agreement between the slopes of the regression lines between food items and dietary intake. There were no clear relationships between ED and macronutrient content for beverage items. Carbohydrate (mostly sucrose) contributed 91, 47, and 25% of total energy for sugar-based, fat-based, and alcohol-based beverages respectively.Conclusions: The relationship between ED and fat content of foods holds true across both population diets and individual food items available in the food supply in a typical Western country such as Australia. As high-fat diets are associated with a high BMI, population measures with an overall aim of reducing the ED of diets may be effective in mediating the growing problem of overweight and obesity.Sponsorship: None

Preoperative immunonutrition and its effect on postoperative outcomes in well-nourished and malnourished gastrointestinal surgery patients: a randomised controlled trial

Background/Objectives:Invasive procedures such as surgery cause immunosuppression, leading to increased risk of complications, infections and extended hospital stay. Emerging research around immune-enhancing nutrition supplements and their ability to reduce postoperative complications and reduce treatment costs is promising. This randomised controlled trial aims to examine the effect of preoperative immunonutrition supplementation on length of hospital stay (LOS), complications and treatment costs in both well-nourished and malnourished gastrointestinal surgery patients.Subjects/Methods:Ninety-five patients undergoing elective upper and lower gastrointestinal surgery were recruited. The treatment group (n=46) received a commercial immuno-enhancing supplement 5 days preoperatively. The control group (n=49) received no supplements. The primary outcome measure was LOS, and secondary outcome measures included complications and cost.Results:A nonsignificant trend towards a shorter LOS within the treatment group was observed (7.1±4.1 compared with 8.8±6.5 days; P=0.11). For malnourished patients, this trend was greater with hospital stay reduced by 4 days (8.3±3.5 vs 12.3±9.5 days; P=0.21). Complications and unplanned intensive care admission rates were very low in both the groups. The average admission cost was reduced by AUD1576 in the treatment group compared with the control group (P=0.37).Conclusions:Preoperative immunonutrition therapy in gastrointestinal surgery has the potential to reduce the LOS and cost, with greater treatment benefit seen in malnourished patients; however, there is a need for additional research with greater patient numbers.

Actions of short-term fasting on human skeletal muscle myogenic and atrogenic gene expression

Background: Skeletal muscle mass is governed by multiple IGF-1-sensitive positive regulators of muscle-specific protein synthesis (myogenic regulatory factors which includes myoD, myogenin and Myf5) and negative regulators, including the atrogenic proteins myostatin, atrogin-1 and muscle ring finger 1 (MuRF-1). The coordinated control of these myogenic and atrogenic factors in human skeletal muscle following short-term fasting is currently unknown. Method: Healthy adults (n = 6, age 27.6 years) undertook a 40-hour fast. Skeletal muscle biopsy (vastus lateralis) and venous blood samples were taken 3, 15 and 40 h into the fast after an initial standard high-carbohydrate meal. Gene expression of the myogenic regulator factors (myoD, myogenin and Myf5) and the atrogenic factors (myostatin, atrogin-1 and MuRF-1) were determined by real-time PCR analysis. Plasma myostatin and IGF-1 were determined by ELISA. Results: There were no significant alterations in either the positive or negative regulators of muscle mass at either 15 or 40 h, when compared to gene expression measured 3 h after a meal. Similarly, plasma myostatin and IGF-1 were also unaltered at these times. Conclusions: Unlike previous observations in catabolic and cachexic diseased states, short-term fasting (40 h) fails to elicit marked alteration of the genes regulating both muscle-specific protein synthesis or atrophy. Greater periods of fasting may be required to initiate coordinated inhibition of myogenic and atrogenic gene expression.

A combination of omega-3 fatty acids, folic acid and B-group vitamins is superior at lowering homocysteine than omega-3 alone: A meta-analysis.

The aim of the study was to assess whether omega-3 polyunsaturated fatty acid supplementation alone or in combination with folic acid and B-group vitamins is effective in lowering homocysteine. The Medline Ovid, Embase and Cochrane databases were searched for randomized-controlled trial studies that intervened with omega-3 supplementation (with or without folic acid) and measured changes in homocysteine concentration. Studies were pooled using a random effects model for meta-analysis. Three different models were analyzed: all trials combined, omega-3 polyunsaturated fatty acid trials, and omega-3 polyunsaturated fatty acids with folic acid and B-group vitamin trials. Nineteen studies were included, consisting of 3267 participants completing 21 trials. Studies were heterogeneous; varying by dose, duration and participant health conditions. Across all trials, omega-3 supplementation was effective in lowering homocysteine by an average of 1.18μmol/L (95%CI: (-1.89, -0.48), P=.001). The average homocysteine-lowering effect was greater when omega-3 supplementation was combined with folic acid and B-group vitamins (-1.37μmol/L, 95%CI: (-2.38, -0.36), P<.01) compared to omega-3 supplementation alone (-1.09μmol/L 95%CI: (-2.04, -0.13), P=.03). Omega-3 polyunsaturated fatty acid supplementation was associated with a modest reduction in homocysteine. For the purposes of reducing homocysteine, a combination of omega-3s (0.2-6g/day), folic acid (150 - 2500μg/day) and vitamins B6 and B12 may be more effective than omega-3 supplementation alone.

Effects of Conjugated Linoleic Acid on Myogenic and Inflammatory Responses in a Human Primary Muscle and Tumor Coculture Model

The antiproliferative and anti-inflammatory properties of conjugated linoleic acid (CLA) make it a potentially novel treatment in chronic inflammatory muscle wasting disease, particularly cancer cachexia. Human primary muscle cells were grown in coculture with MIA PaCa-2 pancreatic tumor cells and exposed to varying concentrations of c9,t11 and t10,c12 CLA. Expression of myogenic (Myf5, MyoD, myogenin, and myostatin) and inflammatory genes (CCL-2, COX-2, IL-8, and TNF-α) were measured by real-time PCR. The t10,c12 CLA isomer, but not the c9,t11 isomer, significantly decreased MIA PaCa-2 proliferation by between 15% and 19%. There was a marked decrease in muscle MyoD and myogenin expression (78% and 62%, respectively), but no change in either Myf5 or myostatin, in myotubes grown in coculture with MIA PaCa-2 cells. CLA had limited influence on these responses. A similar pattern of myogenic gene expression changes was observed in myotubes treated with TNF-α alone. Several-fold significant increases in CCL-2, COX-2, IL-8, and TNF-α expression in myotubes were observed with MIA PaCa-2 coculture. The c9,t11 CLA isomer significantly decreased basal expression of TNF-α in myotubes and could ameliorate its tumor-induced rise. The study provides insight into the anti-inflammatory and antiproliferative actions of CLA and its application as a therapeutic agent in inflammatory disease states.

Can early dietetic intervention improve outcomes in patients with hip fracture

Aim To assess whether the introduction of a new approach to nutritional care for hip fracture patients, in both acute and subacute admissions, can improve nutritional status, length of stay and pressure injuries. Methods Medical records of patients admitted to Austin Health, Melbourne, Australia with a fractured hip between January and June 2014 after implementation of a new nutritional care guideline were compared to a historical control group admitted between January and June 2013 prior to introduction of the guideline. Data were collected for both acute and subacute admissions and included length of stay, date of first contact with a dietitian, subjective global assessment category and occurrence of pressure injuries. Results There was a significantly shorter length of stay overall for patients who received care under the new guideline (21.6 ± 15.1 vs 26.4 ± 20.4 days; P = 0.043) and during the subacute admission (20.1 ± 10.6 vs 28.8 ± 15.8 days; P < 0.001); however, there was no significant difference in the acute hospital length of stay period. The post-guideline group had a significantly shorter time between admission and first contact with a dietitian (4.8 ± 3.3 vs 7.5 ± 6.2 days; P < 0.001). Post-guideline patients also had a significantly lower incidence of pressure injuries with 29, compared to 41 in pre-guideline patients (P = 0.045). There were significantly less malnourished patients in the post-guideline group compared to the pre-guideline group across both acute and subacute admissions (29% vs 35%; P = 0.015). Conclusions A nutritional care guideline for patients with hip fractures is associated with improved patient outcomes with a significant reduction in overall and subacute length of stay and pressure injury incidence and earlier dietetic assessment and intervention.

Nutritional management of gastrointestinal surgical patients in Victoria's public hospitals

Aim Poor nutritional status has negative effects on post-operative outcomes, further compounded by surgical stress and fasting, places gastrointestinal surgery patients at high risk of malnutrition. Recent published research has challenged historic surgical nutrition practices; however, changes to practice in Australia have been slow. The aim of this study was to investigate current nutritional management of gastrointestinal surgery patients and compare this with the best practice guidelines, while exploring enablers to implementation of best practice. Methods A 30-question telephone survey was developed to explore demographics and nutritional management of gastrointestinal surgical patients during pre-admission, inpatient stay and post-operative care. Forty-one gastrointestinal surgery dietitians were identified and contacted from 31 public hospitals in Victoria, Australia, and invited to participate. Results Twenty-five dietitians participated in the survey (response rate 61%). Very few dietitians (12%) were funded for pre-admission clinics or outpatient clinics, and, overwhelmingly, dietitians reported not being involved in nutritional decision-making, and reported feeling unsatisfied with current nutritional management of patients. Despite half the hospitals reporting following best practice guidelines, only 22% implemented guidelines completely. There was no correlation observed between dietitian experience, department size or full-time equivalents allocated to surgery and nutritional intervention; however, the presence of a care pathway made a significant difference to the dietitians overall satisfaction with dietetic care (P = 0.002). Conclusions Current nutritional management of gastrointestinal surgery patients in Victorian hospitals is far from best practice. The implementation of a care pathway is the most effective way of ensuring best practice nutritional management of gastrointestinal surgical patients.