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Background: Green leafy vegetables (GLV) contain inorganic nitrate, an anion with potential prebiotic effects on the oral microbiome. However, it remains unclear whether GLV and pharmacological supplementation [potassium nitrate (PN)] with a nitrate salt induce similar effects on the oral microbiome., Objectives: This study aimed to compare the effect of GLV with PN supplementation on the oral microbiome composition and salivary biomarkers in individuals with high blood pressure., Methods: Seventy individuals were randomly allocated to 3 different groups to follow a 5-wk dietary intervention. Group 1 consumed 300 mg/d of nitrate in form of GLV. Group 2 consumed pills with 300 mg/d of PN and low-nitrate vegetables. Group 3 consumed pills with potassium chloride (placebo: PLAC) and low-nitrate vegetables. The oral microbiome composition and salivary biomarkers of oral health were analyzed before and after the dietary intervention., Results: The GLV and PN groups showed similar microbial changes, probably nitrate-dependent, including an increase in the abundance of Neisseria, Capnocytophaga, Campylobacter species, and a decrease in Veillonella, Megasphaera, Actinomyces, and Eubacterium species after the treatment. Increased abundance of Rothia species, and reduced abundance of Streptococcus, Prevotella, Actinomyces, and Mogibacterium species were observed in the GLV group, which could be nitrate-independent. GLV and PN treatments increased salivary pH, but only GLV treatment showed an increase in the salivary buffering capacity and a reduction of lactate., Conclusion: The combination of nitrate-dependent and nitrate-independent microbial changes in the GLV group has a stronger effect to potentially improve oral health biomarkers compared with PN., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: A diagnosis of drug-resistant epilepsy is life changing for a family. Ketogenic diet therapy (KDT) can offer hope when other treatments have failed. However, it often requires a significant change in daily routine and dietary habits. This qualitative descriptive study aimed to explore families' experiences of epilepsy and KDT., Methods: Parents of a child aged ≤18 years with epilepsy, currently or recently treated with KDT, were recruited from the UK and internationally via UK Ketogenic Diet (KD) centres, charities, and social media. Semi-structured interviews were audio recorded, transcribed verbatim, anonymised, coded using Nvivo (V12), and inductive thematic analysis undertaken., Results: Twenty-one parents participated. Four themes and 12 subthemes emerged: 1. 'Epilepsy is all consuming' explored the impact of epilepsy on the family. 2. 'KD provides a window to new opportunities' explores the motivators for KDT and positive outcomes. 3. 'The reality of KD' explores day to day life and how families adapt to KD. 4. 'Looking to the future' explores the factors that may make KD easier for families. All were glad their child trialled KD, even when less successful. The importance of a support network including family, friends, charity organisations and the KD team was evident across all themes., Conclusions: We conclude with five recommendations to help support families in their management of KDT; Improved access to KDT and transition to adult services, access to quality education and support, enhanced variety of KD foods, regular social education and finally consideration of peer mentoring., Competing Interests: Declaration of competing interest The funders had no involvement in the study design, conduct, analysis or write up., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Purpose: Clinical trials on childhood epilepsy treated with ketogenic diet (KD) use a wide range of outcomes, however, patients and decision-makers often do not perceive the outcomes used as the most important. We sought parental opinion on outcomes of importance and compared these to outcomes reported in published research., Methods: Ethical approval (London-Surrey-REC19/LO/1680). A scoping review identified outcomes reported in previous studies of childhood epilepsy and KD. Parents were recruited from nine KD centres (UK), charities and social media (international), then interviewed (Jan-April 2020) to explore priority outcomes. Content analysis identified all outcomes in transcripts. Parent identified outcomes were compared with those in the scoping review. Outcomes were collated and grouped into domains according to the COMET Taxonomy., Results: Of 2663 articles;147 met inclusion criteria. 921 verbatim outcomes were sorted into 90 discrete outcomes, reduced to 70 in consultation with the study advisory group, then classified into 21 domains. Parents (n = 21) identified 39 outcomes as important from the scoping review and seven new outcomes. They prioritised both physiological and functional outcomes in contrast to past studies, which prioritised physiological outcomes., Conclusion: Little consistency exists in the outcomes used in childhood epilepsy and KD research. Those traditionally used do not adequately reflect parents' important outcomes for their child. Clinical trials should consider the broader priorities of parents when choosing outcomes, in particular, functional outcomes. Identified outcomes will inform an international two-round Delphi-study with parent, professional and researcher participants to develop a core outcome set for this clinical area (COMET registration #1116)., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background & Aims: Malnutrition in older adults results in significant personal, social, and economic burden. To combat this complex, multifactorial issue, evidence-based knowledge is needed on the modifiable determinants of malnutrition. Systematic reviews of prospective studies are lacking in this area; therefore, the aim of this systematic review was to investigate the modifiable determinants of malnutrition in older adults., Methods: A systematic approach was taken to conduct this review. Eight databases were searched. Prospective cohort studies with participants of a mean age of 65 years or over were included. Studies were required to measure at least one determinant at baseline and malnutrition as outcome at follow-up. Study quality was assessed using a modified version of the Quality in Prognosis Studies (QUIPS) tool. Pooling of data in a meta-analysis was not possible therefore the findings of each study were synthesized narratively. A descriptive synthesis of studies was used to present results due the heterogeneity of population source and setting, definitions of determinants and outcomes. Consistency of findings was assessed using the schema: strong evidence, moderate evidence, low evidence, and conflicting evidence., Results: Twenty-three studies were included in the final review. Thirty potentially modifiable determinants across seven domains (oral, psychosocial, medication and care, health, physical function, lifestyle, eating) were included. The majority of studies had a high risk of bias and were of a low quality. There is moderate evidence that hospitalisation, eating dependency, poor self-perceived health, poor physical function and poor appetite are determinants of malnutrition. Moderate evidence suggests that chewing difficulties, mouth pain, gum issues co-morbidity, visual and hearing impairments, smoking status, alcohol consumption and physical activity levels, complaints about taste of food and specific nutrient intake are not determinants of malnutrition. There is low evidence that loss of interest in life, access to meals and wheels, and modified texture diets are determinants of malnutrition. Furthermore, there is low evidence that psychological distress, anxiety, loneliness, access to transport and wellbeing, hunger and thirst are not determinants of malnutrition. There appears to be conflicting evidence that dental status, swallowing, cognitive function, depression, residential status, medication intake and/or polypharmacy, constipation, periodontal disease are determinants of malnutrition., Conclusion: There are multiple potentially modifiable determinants of malnutrition however strong robust evidence is lacking for the majority of determinants. Better prospective cohort studies are required. With an increasingly ageing population, targeting modifiable factors will be crucial to the effective treatment and prevention of malnutrition., (Copyright © 2018 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Allogeneic haematopoietic cell transplantation (HCT) is often associated with poor oral intake due to painful mucositis and gastrointestinal sequalae that occur following a preparative regimen of intensive chemotherapy and/or total body radiation. Although attractive to assume that optimal nutrition improves HCT outcomes, there are limited data to support this. It is also unclear whether artificial nutrition support should be provided as enteral tube feeding or parenteral nutrition (PN)., Methods: We analysed day-100 non-relapse mortality (NRM), incidence of acute graft-versus-host disease (GvHD), acute gastrointestinal GvHD, 5-year survival and GvHD-free/relapse-free survival (GRFS) according to both route and adequacy of nutritional intake prior to neutrophil engraftment, together with other known prognostic factors, in a retrospective cohort of 484 patients who underwent allogeneic HCT for haematologic malignancy between 2000 and 2014., Results: Multivariate analyses showed increased NRM with inadequate nutrition (hazard ratio (HR) 4.1; 95% confidence interval (CI) 2.2-7.2) and adequate PN (HR 2.9; 95% CI 1.6-5.4) compared to adequate enteral nutrition (EN) both P < .001. There were increased incidences of gastrointestinal GvHD of any stage and all GvHD ≥ grade 2 in patients who received PN (odds ratio (OR) 2.0; 95% CI 1.2-3.3; P = .006, and OR 1.8; 95% CI 1.1-3.0; P = .018, respectively), compared to adequate EN. Patients who received adequate PN and inadequate nutrition also had reduced probabilities of survival and GRFS at 5 years., Conclusion: Adequate EN during the early transplantation course is associated with reduced NRM, improved survival and GRFS at 5 years. Furthermore, adequate EN is associated with lower incidence of overall and gut acute GvHD than PN, perhaps because of its ability to maintain mucosal integrity, modulate the immune response to intensive chemo/radiotherapy and support the gastrointestinal tract environment, including gut microflora., (Copyright © 2018 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background & Aims: Dietitians in acute adult services need to prioritise dietetic referrals in order to manage their daily workload and ensure effective treatment of patients. Newly qualified dietitians do not usually receive specific training on prioritisation and could be helped with an evidence-based, effective, decision-training tool that is based on the practice of experienced dietitians. We developed an internationally available web-based decision-training tool designed to improve novice dietitians' ability to make dietetic prioritisation decisions. The training tool comprised of a pre-training task, a post-training task and training materials. The aim of this study was to test the effectiveness of the training tool on novices' ability for dietetic prioritisation., Methods: Pre-registration dietitians and recent graduates (one-year) from across the UK were invited to participate in this randomised controlled trial (RCT). Each participant made prioritisation decisions on a set of dietetic referral scenarios: 53 scenarios at pre-training and 27 at post-training. After pre-training the intervention group was presented with the training materials, whereas the control group was told to carry on with the post-training task. Participants did not know which group they had been randomly allocated to. We calculated i) level of agreement between decisions made by each novice and experts' consensus using Pearson correlation, intra-class correlation (ICC(2,1)); ii) intra-rater consistency using ICC(1,1) and iii) intra-group consistency using ICC (2,1). We compared group means at pre-training and post-training; estimated effect size using the degree of change from pre- to post-training, and 2-factor mixed ANOVA to assess overall effect of the training across the groups and time-points., Results: 151 participants (69 in control and 82 in intervention) completed the trial. The groups did not differ in demographic characteristics. Both Pearson and ICC(2,1) correlations increased with training intervention; a moderate effect of training was found for both metrics, d = 0.69 (r = 0.32) for the former and d = 0.54 (r = 0.26) for the latter. Intra-rater consistency improved with training but with a small effect size, d = 0.32 (r = 0.16). The intra-group consistency also improved with training: ICC = 0.48 pre-training to 0.61 post-training., Conclusions: The training tool was found to be effective in improving the novice dietitian's ability to prioritise referrals in the acute adult setting. The training tool is freely available at www.dietitianreferral.org for use by all student or early career dietitians internationally., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Recent evidence suggests that nutritional interventions may improve muscle outcomes in malnutrition and sarcopenia., Objectives: We evaluated the effects of 2 high-quality oral nutritional supplements (ONS) differing in amount and type of key nutrients in older adult men and women., Design: A multicenter, randomized, double-blinded, controlled clinical trial., Participants: Malnourished and sarcopenic men and women, 65 years and older (n = 330)., Intervention: A 24-week intervention period with 2 energy-rich (330 kcal) ONS treatment groups: Control ONS (C ONS , 14 g protein; 147 IU vitamin D 3 ) versus Experimental ONS (E ONS , 20 g protein; 499 IU vitamin D 3 ; 1.5 g CaHMB) taken twice daily. Both ONS also contained other vitamins, minerals, and nutrients in varying amounts., Measurements: Isokinetic peak torque (PT, Nm) leg strength, grip strength (kg), and gait speed (m·s -1 ) were assessed at baseline and 12 and 24 weeks. Left and right leg muscle mass (LMM, kg) were assessed by dual-energy x-ray absorptiometry (DXA). Muscle quality (MQ) was leg strength expressed relative to the tested LMM (Nm·kg -1 ). Subgroup analyses were performed: severe sarcopenia (low skeletal mass index, low grip strength [<30 kg men; <20 kg women], low gait speed [<0.8 m·s -1 ]) and mild-moderate sarcopenia (low skeletal mass index, normal gait speed, or normal grip strength)., Results: Both ONS groups (E ONS and C ONS ) improved PT, MQ, grip strength, and gait speed from baseline with no treatment differences. Those with severe sarcopenia (44%) exhibited lower baseline PT and MQ, with no differences in strength improvements between treatments. However, participants with mild-moderate sarcopenia exhibited higher baseline PT and MQ, with differences in strength improvements at 12 weeks (E ONS  > C ONS , P = .032) in those with normal grip strength. There were no treatment differences based on sarcopenic severity for either grip strength or gait speed., Conclusion: ONS improved strength outcomes in malnourished older adults with sarcopenia. In those with mild-moderate sarcopenia, but not severe sarcopenia, consumption of the E ONS improved leg muscle strength and quality compared with the standard C ONS ., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

This pilot study developed an appropriate procedure to evaluate the paladai cup compared to bottle feeding in preterm infants, using weighed napkins and video analysis to assess amount of spillage, volume consumed, time taken and physiological stability. Paladai results demonstrated increased spillage, increased feed times with more stress cues.

Aims: To assess and compare the rates of malnutrition in Hammersmith Hospital NHS Trust over a 5-year period following changes in hospital nutrition care strategies., Design: Three consecutive cross-sectional studies carried out in 1998, 2000 and 2003., Setting: Inpatients at Hammersmith Hospital NHS Trust., Participants: A total of 2283 inpatients aged over 16 years old, 686 in 1998, 780 in 2000, 817 in 2003. Inpatients excluded: ventilated patients, ante/post-natal women and people aged <16., Interventions: Improvements in the catering service and nutrition education provision in 2000, and the implementation of a nutrition screening tool and 'Better Hospital Food' in 2003., Main Outcome Measure: Prevalence of malnutrition., Results: There was a reduction in the prevalence of malnutrition in 2000 and 2003 from baseline data in 1998 (1998: 23.5%, 161/686; 2000: 20.4%, 159/780; 2003: 19.1%, 156/817; P<0.001). The odds ratio of being either at risk of malnutrition or malnourished was reduced in both 2000 and 2003 by approximately 33% (P=0.001). Indicators of good nutritional practice also improved: Weighing patients on admission increased from 37.5% (257/686) in 1998, to 42.9% (335/780) in 2000, and 59.6% (487/817) in 2003 (P0.001). Dietetic referrals also increased from 31.5% (216/686) in 1998 to 41.6% (340/817) in 2003 (P<0.001)(no change in 2000, 31%, 242/780). Appropriate referrals also improved, results showing that the proportion of malnourished patients who were referred showed a dramatic increase in 2003 (1998: 91/161, 56.5%; 2000: 85/159, 53.5%; 2003: 111/156, 71.2%; P=0.003)., Conclusions: The prevalence of malnutrition in hospital can be influenced by the implementation of a variety of nutrition care strategies, which target identification of malnutrition and its treatment.

Background & Aims: The measurement of quality of life adds a holistic dimension to the assessment of a clinical state or the response to an intervention. The relationship between quality of life and nutritional status is not well studied. This study aimed to investigate this relationship in a group of sick elderly in-patients., Methods: We used data from a RCT investigating the benefits of intensive feeding support on acute medicine for the elderly wards. The EuroQol EQ-5D questionnaire was administered to patients on admission and the results were then related to parameters of nutritional status, physical function, depression and serum albumin collected at the same time., Results: Two hundred and thirty-three patients completed the EQ-5D questionnaire. Comparisons with UK norms for community living elderly showed significantly lower scores. No direct relationship was found between the EQ-5D scores and markers of nutritional status. However, clear differences were observed between patients with and without swallowing problems, those with good and poor appetite and those with good and poor physical function. Increasing risk of depression had a profound effect on quality of life scores., Conclusions: Nutritional status does not appear to directly influence quality of life, as measured by the EQ-5D, but may affect it through the consequences of reduced physical function. Additionally, factors that directly affect a persons food intake seem to have a greater impact on quality of life, which underlines the importance of food and eating as an aspect of life quality.

Background & Aims: Malnutrition is common in sick elderly people on admission to hospital and in the community. We conducted a randomised controlled trial to determine if nutritional supplementation after discharge from hospital improved nutritional status and functional outcomes, or reduced health-care costs., Methods: Elderly malnourished subjects were randomised to 8 weeks of supplementation or no supplementation post discharge, and followed up for 24 weeks. Weight, body mass index, anthropometrics, handgrip strength, quality of life and requirements for health-care professionals' services and social services were measured throughout the study., Results: Nutritional status improved significantly from baseline to week 24 in the intervention group (P<0.05), but not in the control group. There was no significant difference in nutritional status between groups at week 24. Handgrip strength improved significantly in the intervention group during supplementation, and was significantly different from that of the control group at week 8, but decreased thereafter. There was no significant difference in quality of life or health economic outcomes between groups at week 24., Conclusions: In already malnourished elderly subjects, it may be too late to expect to improve function or quality of life or to reduce health-care costs simply by providing nutritional supplements after hospitalisation. Prevention is key. All elderly patients should be nutritionally assessed as part of their routine care, and appropriate intervention initiated early.

Background & Aims: Malnutrition is common in the elderly and increases morbidity and mortality. Most attempts to reverse malnutrition have used liquid supplements, but the findings are inconsistent. This study tests a new approach using a randomised-controlled design. The aim was to examine whether health care assistants, trained to provide additional support with feeding, can improve acutely ill elderly in-patients' clinical outcomes., Methods: The study was carried out on three acute medicine for the elderly wards at Hammersmith Hospitals NHS Trust, London. In all, 592 patients, all over 65 years old, were recruited., Results: The results showed that the median time patients received feeding support was 16 days, and the assisted group was given less intravenous antibiotics (P=0.007). However, the groups did not differ in markers of nutritional status, Barthel score, grip strength, length of stay or mortality., Conclusion: It was concluded that the use of health care assistants in this specialised role, in an acute setting, without change to the food provision or without targeting higher risk patients, reduced the need for intravenous antibiotics. However, the intervention did not improve nutritional status or have an effect on length of stay in the time span studied. The results highlight the difficulties of improving the intake of acutely ill elderly patients during a hospital stay.