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Evidence based medicine has preferably been based on prospective randomized controlled trials (PRCT's) and subsequent meta-analyses in many fields including nutrition and metabolism. These meta-analyses often yield convincing, contradictory or no proof of effectiveness. Consequently recommendations and guidelines of varying validity and quality have been published, often failing to convince the medical, insurance and government worlds to support nutritional care. Causes for lack of adequate proof of effectiveness are manifold. Many studies and meta-analyses lacked pathophysiological depth in design and interpretation. Study populations were not homogenous and endpoints not always clearly defined. Patients were included not at nutritional risk, unlikely to benefit from nutritional intervention. Others received nutrients in excess of requirements or tolerance due to organ failure. To include all available studies in a meta-analysis, study quality and homogeneity were only assessed on the basis of formal study design and outcome rather than on patient characteristics. Consequently, some studies showed benefit but included patients suffering harm, other studies were negative but contained patients that benefited. Recommendations did not always emphasize these shortcomings, confusing the medical and nutritional community and creating the impression that nutritional support is not beneficial. Strong reliance on meta-analyses and guidelines shifts the focus of education from studying clinical and nutritional physiology to memorizing guidelines. To prevent or improve malnutrition more physiological knowledge should be acquired to personalize nutritional practices and to more correctly value and evaluate the evidence. This also applies to the design and interpretation of PRCT's and meta-analyses., (Copyright © 2015 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

As early as the 1970s, articles were published on the role of dietitians in nutrition support. Both the American Society for Parenteral and Enteral Nutrition and The American Dietetic Association addressed the issues of specialization and certification. Development of a specialty area credential requires a strong demand by practicing clinicians, a unique area of clinical practice with a distinct body of knowledge and the commitment to evolve with clinical practice. Numerous dietitians were involved in the inception, development, and leadership that brought forth certification in nutrition support. This article documents the efforts and participation of a dedicated group of professionals whose common goals resulted in the establishment of a successful, sustaining certification in a specialty area of clinical dietetics: certified nutrition support dietitian. The certified nutrition support dietitian program is now in its 15th year with 2,000 dietitians currently certified both nationally and internationally. A primary focus of the credential is to recognize minimum competency for dietitians practicing in the field of enteral and parenteral nutrition and to provide safe and effective nutrition support therapy. This article provides a framework for persons in other specialty areas attempting to develop certification programs.

Clinical Nutrition Support--defined as nutrition for hospitalized patients suffering from metabolic stress--plays a limited role in the therapeutic routine of the physician. This is not surprising as most research in the field of clinical nutrition is disappointing with regard to the objective outcomes: morbidity and mortality. These reflections advocate a more 'pharmaceutical approach' to nutrition in order to perform more proper studies on the potential effectiveness of this treatment modality. To provide all patients in the Academic Medical Centre (AMC) in Amsterdam, The Netherlands, with optimum clinical nutrition support, a Nutrition Support Team (NST) was established in 1996. This NST is coaching the dieticians and physicians in the AMC regarding clinical nutrition support. In practice this coaching consists of providing clear guidelines on what is supposed to be optimum nutrition, a basic course in parenteral nutrition and further continuous education. The concept of optimum nutrition is spread by the NST through various ways of education, both nationally and internationally. For adults, optimum nutrition is defined as the amount of protein, that stimulates whole body protein synthesis maximally (1.7 g/kg actual body weight) and covers anabolic energy need (35 kcal/kg actual body weight). The dietician is considered to be the expert in the field of optimum nutrition by oral, enteral or parenteral route. The Dietetic Department has increased its influence in the care of the patient by placing nutritional status and care on the chart of the patient's treatment. To provide optimal Nutrition Support for children and severe ill patients (Intensive care department) specialized teams were started which were co-ordinated by the central NST. The central NST has a co-ordinating and educating role, while the Specialized Nutrition Support Teams (Specialized NST) construct guidelines, undertake research and provide continuous optimum nutrition care., (Copyright 2001 Harcourt Publishers Ltd.)