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Background & Aims: The European Society for Clinical Nutrition and Metabolism published its first clinical guidelines for use of micronutrients (MNs) in 2022. A two-day web symposium was organized in November 2022 discussing how to apply the guidelines in clinical practice. The present paper reports the main findings of this symposium., Methods: Current evidence was discussed, the first day being devoted to clarifying the biology underlying the guidelines, especially regarding the definition of deficiency, the impact of inflammation, and the roles in antioxidant defences and immunity. The second day focused on clinical situations with high prevalence of MN depletion and deficiency., Results: The importance of the determination of MN status in patients at risk and diagnosis of deficiencies is still insufficiently perceived, considering the essential role of MNs in immune and antioxidant defences. Epidemiological data show that deficiencies of several MNs (iron, iodine, vitamin D) are a global problem that affects human health and well-being including immune responses such as to vaccination. Clinical conditions frequently associated with MN deficiencies were discussed including cancer, obesity with impact of bariatric surgery, diseases of the gastrointestinal tract, critical illness, and aging. In all these conditions, MN deficiency is associated with worsening of outcomes. The recurrent problem of shortage of MN products, but also lack of individual MN-products is a worldwide problem., Conclusion: Despite important progress in epidemiology and clinical nutrition, numerous gaps in practice persist. MN depletion and deficiency are frequently insufficiently searched for in clinical conditions, leading to inadequate treatment. The symposium concluded that more research and continued education are required to improve patient outcome., Competing Interests: Conflict of interest The authors declare no conflict of interest. There was no external funding., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

This opinion paper presents a short review of the potential impact of protein on muscle anabolism in cancer, which is associated with better patient outcomes. Protein source is a topic of interest for patients and clinicians, partly due to recent emphasis on the supposed non-beneficial effect of proteins; therefore, misconceptions involving animal-based (e.g., meat, fish, dairy) and plant-based (e.g., legumes) proteins in cancer are acknowledged and addressed. Although the optimal dietary amino acid composition to support muscle health in cancer is yet to be established, animal-based proteins have a composition that offers superior anabolic potential, compared to plant-derived proteins. Thus, animal-based foods should represent the majority (i.e., ≥65%) of protein intake during active cancer treatment. A diet rich in plant-derived proteins may support muscle anabolism in cancer, albeit requiring a larger quantity of protein to fulfill the optimal amino acid intake. We caution that translating dietary recommendations for cancer prevention to cancer treatment may be inadequate to support the pro-inflammatory and catabolic nature of the disease. We further caution against initiating an exclusively plant-based (i.e., vegan) diet upon a diagnosis of cancer, given the presence of elevated protein requirements and risk of inadequate protein intake to support muscle anabolism. Amino acid combination and the long-term sustainability of a dietary pattern void of animal-based foods requires careful and laborious management of protein intake for patients with cancer. Ultimately, a dietary amino acid composition that promotes muscle anabolism is optimally obtained through combination of animal- and plant-based protein sources., Competing Interests: Conflict of interest K.L.F has no conflicts to declare. J.A. reports receiving honoraria from Baxter, B. Braun, Berg-Apotheke, Falk, Fresenius-Kabi, Helsinn, Nestlè and Nutricia. P.J.A. reports consultancy fees and research income from Abbott Nutrition and Fresenius-Kabi. M.P.K.J.E has no conflicts to declare. T.J.M.G. reports receiving consulting fees for honoraria for lectures at industry-sponsored events; consulting fees from Nestlé Health Science and Nutricia. A.L. reports receiving consulting fees for honoraria for lectures at industry-sponsored events; consulting fees from Abbott, Baxter, BBraun, Fresenius Kabi, Nestlé Health Science, Nutricia, and Smartfish; and research grant from Freseni usKabi. D.N.L. has no conflicts to declare. S.M.P. reports grants from US National Dairy Council, during the conduct of the study; personal fees from the US National Dairy Council, non-financial support from Enhanced Recovery, outside the submitted work; In addition, Dr. Phillips has a patent Canadian 3052324 issued to Exerkine, and a patent US 20200230197 pending to Exerkine but reports no financial gains. P.R. has no conflicts to declare. N.E.P.D reports grants from Abbott Nutrition, Department of Defense, and National Institutes of Health, and honoraria from Abbott Nutrition. C.M.P. reports receiving honoraria and/or paid consultancy from Abbott Nutrition, Nutricia, Nestle Health Science, Fresenius Kabi, Pfizer, and Helsinn., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: This practical guideline is based on the current scientific ESPEN guidelines on nutrition in cancer patients., Methods: ESPEN guidelines have been shortened and transformed into flow charts for easier use in clinical practice. The practical guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with cancer., Results: A total of 43 recommendations are presented with short commentaries for the nutritional and metabolic management of patients with neoplastic diseases. The disease-related recommendations are preceded by general recommendations on the diagnostics of nutritional status in cancer patients., Conclusion: This practical guideline gives guidance to health care providers involved in the management of cancer patients to offer optimal nutritional care., Competing Interests: Conflicts of interest No conflict of interest., (Copyright © 2021 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd.. All rights reserved.)

Background & Aims: Polymorbidity (also known as multimorbidity) - defined as the co-occurrence of at least two chronic health conditions - is highly prevalent, particularly in the hospitalized population. Nonetheless, clinical guidelines largely address individual diseases and rarely account for polymorbidity. The aim of this project was to develop guidelines on nutritional support for polymorbid patients hospitalized in medical wards., Methods: The methodology used for the development of the current project follows the standard operating procedures for ESPEN guidelines. It started with an initial meeting of the Working Group in January 2015, where twelve key clinical questions were developed that encompassed different aspects of nutritional support: indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. Systematic literature searches were conducted in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g. published guidelines), until April 2016. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations, which were followed by submission to Delphi voting rounds., Results: From a total of 4532 retrieved abstracts, 38 relevant studies were analyzed and used to generate a guideline draft that proposed 22 recommendations and four statements. The results of the first online voting showed a strong consensus (agreement of >90%) in 68% of recommendations and 75% of statements, and consensus (agreement of >75-90%) in 32% of recommendations and 25% of statements. At the final consensus conference, a consensus greater than 89% was reached for all of the recommendations., Conclusions: Despite the methodological difficulties in creating non-disease specific guidelines, the evidence behind several important aspects of nutritional support for polymorbid medical inpatients was reviewed and summarized into practical clinical recommendations. Use of these guidelines offer an evidence-based nutritional approach to the polymorbid medical inpatient and may improve their outcomes., (Copyright © 2017 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd.. All rights reserved.)

Cancers are among the leading causes of morbidity and mortality worldwide, and the number of new cases is expected to rise significantly over the next decades. At the same time, all types of cancer treatment, such as surgery, radiation therapy, and pharmacological therapies are improving in sophistication, precision and in the power to target specific characteristics of individual cancers. Thus, while many cancers may still not be cured they may be converted to chronic diseases. All of these treatments, however, are impeded or precluded by the frequent development of malnutrition and metabolic derangements in cancer patients, induced by the tumor or by its treatment. These evidence-based guidelines were developed to translate current best evidence and expert opinion into recommendations for multi-disciplinary teams responsible for identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients. The guidelines were commissioned and financially supported by ESPEN and by the European Partnership for Action Against Cancer (EPAAC), an EU level initiative. Members of the guideline group were selected by ESPEN to include a range of professions and fields of expertise. We searched for meta-analyses, systematic reviews and comparative studies based on clinical questions according to the PICO format. The evidence was evaluated and merged to develop clinical recommendations using the GRADE method. Due to the deficits in the available evidence, relevant still open questions were listed and should be addressed by future studies. Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. They may be driven by inadequate food intake, decreased physical activity and catabolic metabolic derangements. To screen for, prevent, assess in detail, monitor and treat malnutrition standard operating procedures, responsibilities and a quality control process should be established at each institution involved in treating cancer patients. All cancer patients should be screened regularly for the risk or the presence of malnutrition. In all patients - with the exception of end of life care - energy and substrate requirements should be met by offering in a step-wise manner nutritional interventions from counseling to parenteral nutrition. However, benefits and risks of nutritional interventions have to be balanced with special consideration in patients with advanced disease. Nutritional care should always be accompanied by exercise training. To counter malnutrition in patients with advanced cancer there are few pharmacological agents and pharmaconutrients with only limited effects. Cancer survivors should engage in regular physical activity and adopt a prudent diet., (Copyright © 2016 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd.. All rights reserved.)

Background: In our published randomized trial in colorectal cancer, group 1 (n = 37) received individualized nutritional counseling and education about regular foods, group 2 (n = 37) received dietary supplements and consumed their usual diet of regular foods, and group 3 (n = 37) consumed their usual diet of regular foods. Neither group 2 nor group 3 received individualized counseling. Early nutritional counseling during radiotherapy was highly effective at reducing acute radiotherapy toxicity and improving nutritional intake/status and quality of life (QoL). Efficacy persisted for 3 mo after the intervention., Objective: The objective was to perform long-term follow-up in survivors of that clinical trial to specifically evaluate survival, late toxicity, QoL, and nutritional variables., Design: Medical data were collected from patients' records, and prescheduled interviews were conducted by dietitians for individualized evaluations. Analyses and comparisons between groups (adjusted for stage) were performed after a median follow-up of 6.5 (range: 4.9-8.1) y., Results: Patients complied with the Radiotherapy Department's follow-up protocol. Nutritional deterioration was higher (P < 0.001) in group 3 (n = 26) and group 2 (n = 29) than in group 1 (n = 34). Adequate nutritional status was maintained in 91% of group 1 patients but not in any of the group 3 patients (P < 0.002). Intakes in group 1 were similar to reference values, and the patients adhered to the prescribed recommendations. Intakes in groups 2 and 3 were lower than recommended intakes: group 3 ≃ group 2 < group 1 (P = 0.001). Median survival in group 3 was 4.9 y (30% died), in group 2 was 6.5 y (22% died), and in group 1 was 7.3 y (only 8% died): group 3 > group 2 > group 1 (P < 0.01). Late radiotherapy toxicity was higher in group 3 (n = 17; 65%) and group 2 (n = 17; 59%) than in group 1 (n = 3; 9%): group 3 ≃ group 2 > group 1 (P < 0.001). QoL was worse in groups 3 and 2 than in group 1: group 3 ≃ group 2 < group 1 (P < 0.002). Worse radiotherapy toxicity, QoL, and mortality were associated with deteriorated nutritional status and intake (P < 0.001). Likewise, depleted intake, nutritional status, and QoL predicted shorter survival and late toxicity (HR: 8.25; 95% CI: 2.74, 1.47; P < 0.001)., Conclusions: This study conveys novel information about the effectiveness of nutrition at improving long-term prognosis in colorectal cancer. Overall, the data indicate that early individualized nutritional counseling and education during radiotherapy is valuable for patients.

Background & Aims: We aimed to test the capacity in identifying patients at nutritional risk, by comparing BMI, recent %weight loss,Nutritional Risk Screening 2002(NRS-2002),Malnutrition Universal Screening Tool(MUST) and Nutritional Risk Index(NRI) with Subjective Global Assessment(SGA),considered the Standard. The main purpose was to select the most consistent screening method for effective integration in daily surgical wards' practice., Methods: 300 surgical patients were assessed at admission: BMI(categorized by WHO's criteria), weight loss ≥ 5% in previous 6 months, NRS-2002, MUST, NRI, SGA. Concordances, correlations, sensitivity, specificity, positive(PPV) and negative predictive values(NPV) were calculated to evaluate methods' performance vs the Standard., Results: Prevalence of nutritional risk was 66% by NRS-2002 + MUST, and 87% by NRI. By SGA, 64% patients were undernourished. All methods agreed with SGA(k = 0.85-0.91,p < 0.001), except BMI & NRI(k = 0.07-0.34,p < 0.05). NRS-2002, MUST and %weight loss effectively detected patients at risk: sensitivity 0.8-0.89, specificity 0.89-0.93, PPV 81%-89%, NPV 89%-100%. Conversely, BMI & NRI were ineffective: sensitivity 0.29-0.43, specificity 0.27-0.39, PPV 24%-35%, NPV 27%-31%; %weight loss alone vs MUST/NRS-2002 was explored: sensitivity 0.79-0.87, specificity 0.85-0.89, PPV 84%-85%, NPV 87%-89%, thus successfully identifying undernutrition risk., Conclusions: In surgical patients, MUST + NRS-2002 are valid for nutritional screening; recent weight loss ≥ 5% also proved highly efficient; its easy/quick calculation may facilitate adherence/integration by health professionals as a minimum obligatory in clinical practice., (Copyright © 2011 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background & Aims: NF-kappaB may promote carcinogenesis by altering cell cycle, inflammatory responses and apoptosis-related gene expression, though cell mechanisms relating diet and colorectal cancer (CRC) remain unveiled in humans. This study in patients with CRC aimed to explore potential interactions between the dietary pattern, nutrient intake, expression of NF-kappaB, apoptosis and tumour histological aggressiveness., Methods: Usual diet was assessed by diet history; nutrient composition was determined by DIETPLAN software. Histologically classified patient tissue samples (adenoma, adenocarcinoma and normal surrounding mucosa) were obtained via biopsies during colonoscopy (n=16) or surgery (n=8). NF-kappaB expression was determined by immunohistochemistry and apoptosis by TUNEL assay., Results: NF-kappaB expression and apoptosis were higher in tumours (p<0.01), greater along with histological aggressiveness (p<0.01). Highest intake terciles of animal protein, refined carbohydrates, saturated fat, n-6 fatty acids and alcohol were associated with higher NF-kappaB, apoptosis and histological aggressiveness (p<0.01); the opposite tissue characteristics were associated with highest intake terciles of n-3 fatty acids, fibre, vitamin E, flavonoids, isoflavones, beta-carotene and selenium (p<0.002). Additionally, higher n-6:n-3 fatty acids ratio (median 26:1) was associated with higher NF-kappaB (p<0.006) and apoptosis (p<0.01), and more aggressive histology (p<0.01). Conversely, lower n-6:n-3 fatty acids ratio (median 6:1) was associated with lower NF-kappaB (p<0.002) and apoptosis (p<0.002), and less aggressive histology (p<0.002)., Conclusions: NF-kappaB expression and apoptosis increased from adenoma to poorly differentiated adenocarcinoma. This degenerative transition, recognized as key in carcinogenesis, appear to have been influenced by a diet promoting a pro-inflammatory milieu that can trigger NF-kappaB., (Copyright 2009 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

To devise a meaningful nutritional therapy in cancer, a greater understanding of nutritional dimensions as well as patients' expectations and disease impact is essential. We have shown that nutritional deterioration in patients with gastrointestinal and head and neck cancer was multifactorial and mainly determined by the tumour burden and location. In a larger cohort, stage and location were yet again the major determinants of patients' quality of life (QoL), despite the fact that nutritional deterioration combined with intake deficits were functionally more relevant than cancer stage. Based on this framework, the potential role of integrated oral nutritional support on outcomes was investigated. In a pilot study using individualized nutritional counselling on a heterogeneous patient population, the achieved improvement of nutritional intake was proportional to a better QoL. The role of early nutritional support was further analysed in a prospective randomized controlled trial in head and neck cancer patients stratified by stage undergoing radiotherapy. Pre-defined outcomes were: nutritional status and intake, morbidity and QoL, at the end and 3 months after radiotherapy. Nutritional interventions, only given during radiotherapy, consisted of three randomization arms: (1) individualized nutritional counselling vs. (2) ad libitum diet+high protein supplements vs. (3) ad libitum diet. Nutritional interventions 1 and 2 positively influenced outcomes during radiotherapy; however, 3 months after its completion individualized nutritional counselling was the single method capable of sustaining a significant impact on patients' outcomes. The early provision of the appropriate mixture of foods and textures using regular foods may modulate outcomes in cancer patients.

Background and Aims: To assess the relationships between food intake and colorectal cancer risk., Methods: Systematic review of available prospective studies on dietary intake and colorectal cancer., Results: Twelve out of 15 studies found no significant relationship between vegetable intake and colorectal cancer risk; also, 11 out of 14 studies found no relationship with fruit consumption. Conversely, the combined consumption of vegetables and fruit reduced colorectal cancer risk in three out of six studies, although the relationship was somewhat inconsistent between genders and anatomical localizations. Most studies found no relationship between cancer risk and red meat (15 in 20) or processed meat (seven out of 11) consumption; still, most of the reported relative risks were above unity, suggesting that high consumption of red or processed meat might increase colorectal cancer risk. The consumption of white meat, fish/seafood, dairy products, coffee or tea was mostly unrelated to colorectal cancer risk, although the consumption of smoked or salted fish actually increased risk., Conclusions: The relationships between dietary intake and colorectal cancer risk might be less important than previously reported. The combined consumption of vegetables and fruit might be protective, whereas excessive consumption of meat or smoked/salted/processed food appears to be deleterious.

Background & Aims: This survey aimed to provide a nationwide overview about the current practice of nutrition., Methods: Questionnaires designed by the Portuguese Association of Parenteral Enteral Nutrition were sent, with postage-paid addressee envelopes, to all hospitals and primary-care institutions., Results: Hospitals' response rate was 44/100 (44%), reaching 274/359 (60%) in primary care, P=0.02. A Nutrition Support Team (NST) was reported in 34% hospitals, 40% of which were teaching hospitals. In 3/15 (9%) hospitals, NST nutrition prescriptions covered the whole hospital population; in 16% the NST only acted on a consultant basis; in 30% they were involved in purchasing nutrition products and in 18% the NST promoted teaching/training. Physicians alone prescribed oral, enteral and parenteral nutrition in 50%, 64% and 74% hospitals, respectively, and also monitored parenteral nutrition in 69% hospitals; monitoring oral/enteral nutrition involved dietitians in 46% and 41% hospitals, respectively; nurses were never involved in NSTs and seldom participated in nutritional management. Most primary-care institutions with hospital units (91%) provided nutrition therapy and nurses were then the most involved professionals, P=0.001, even prescribing regimens while physicians favoured monitoring., Conclusions: Nutrition therapy is mostly unidisciplinary; the concept of a NST and its roles is wrongly perceived; education and training are eagerly awaited.

Background and Aims: Concurrent therapies are not accounted for nutritional intake. This prospective clinical audit in an intensive care unit aimed at assessing the influence of fluid therapy and drugs containing nutrients on total nutrient delivery., Methods: Forty-four patients, 25M: 19F, age 63+/-12 (17-83)years, Acute Physiological and Chronic Health Evaluation II: 24+/-9, with length of stay >72h, were evaluated. Basal energy expenditure was estimated by the Harris-Benedict formula. All nutrients conveyed by oral, enteral, parenteral nutrition, IV solutions and drugs were daily registered and summed at the end of respiratory intensive care unit stay., Results: Mean estimated basal energy expenditure (BEE), 1372+/-432 kcal/day, was lower than mean caloric intake 2034+/-432 kcal/day (P<0.05), >BEE in 54% of patients. When dextrose/propofol were excluded, mean energy intake, 1375+/-430 kcal/day, was similar to BEE; 93% and 86% of patients had an adequate carbohydrate and lipid intake, respectively. Dextrose determined an excessive carbohydrate delivery, higher than 58% of calories, in 43% of patients, while 84% had an excessive lipid delivery due to propofol. Excessive sodium from normal saline was administered to 91% of patients, though 43% had overt oedema., Conclusions: Hypernutrition ensued from non-quantified fluid therapy/drugs. Sodium loads may aggravate lung and gut dysfunction. The provision of "occult" calories and minerals may be quite substantial and should be taken into consideration.