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Disease-related malnutrition (MN) is common in patients with liver cirrhosis (LC), short bowel syndrome (SBS), and chronic pancreatitis (CP). Different MN risk screening tools and diagnostic criteria of the European Society for Clinical Nutrition and Metabolism (ESPEN) and Global Leadership Initiative on Malnutrition (GLIM) algorithms were analyzed for their diagnostic accuracy and role as specific drivers to diagnose MN in patients with LC, SBS, and CP.A total of 187 patients with LC, SBS, and CP, as well as control patients were prospectively recruited in a multicenter cross-sectional study. MN risk was screened using Nutritional Risk Screening 2002 (NRS-2002), the Malnutrition Universal Screening Tool (MUST), and the Royal Free Hospital Nutritional Prioritizing Tool (RFH-NPT), and diagnosed using the ESPEN, GLIM, and GLIMNRS-2002 was only sensitive in conjunction with ESPEN, while MUST was sensitive additionally with the GLIM algorithm. RFH-NPT worked the best for LC. GLIM and GLIMRFH-NPT and MUST performed better in conjunction with the GLIM algorithm than NRS-2002. MN was diagnosed more frequently by GLIM than the ESPEN algorithm in LC, SBS, and CP. Individual criteria acted as specific drivers in MN in chronic gastrointestinal diseases.

Muscle wasting represents a constant pathological feature of common chronic gastrointestinal diseases, including liver cirrhosis (LC), inflammatory bowel diseases (IBD), chronic pancreatitis (CP) and pancreatic cancer (PC), and is associated with increased morbidity and mortality. Recent clinical and experimental studies point to the existence of a gut‐skeletal muscle axis that is constituted by specific gut‐derived mediators which activate pro‐ and anti‐sarcopenic signalling pathways in skeletal muscle cells. A pathophysiological link between both organs is also provided by low‐grade systemic inflammation. Animal models of LC, IBD, CP and PC represent an important resource for mechanistic and preclinical studies on disease‐associated muscle wasting. They are also required to test and validate specific anti‐sarcopenic therapies prior to clinical application. In this article, we review frequently used rodent models of muscle wasting in the context of chronic gastrointestinal diseases, survey their specific advantages and limitations and discuss possibilities for further research activities in the field. We conclude that animal models of LC‐, IBD‐ and PC‐associated sarcopenia are an essential supplement to clinical studies because they may provide additional mechanistic insights and help to identify molecular targets for therapeutic interventions in humans.

Purpose Two-thirds of cancer patients report taste disorders during and after chemotherapy. Taste disorders impact on nutritional status which is highly relevant for treatment efficacy and overall prognosis. Improvement of taste disorder is of particular importance for cancer patients' outcomes, thus the TASTE trial was conducted to improve taste disorders with a taste and smell training. Methods In this trial, patients undergoing chemotherapy were screened for taste disorders. Subsequently, patients were allocated based on the detection of taste disorders (≤8 taste strips points) to an intervention group with a taste and smell training at baseline and week 3-5 or were only followed up, if no taste disorder was detected (≥9 taste strips points) (non-intervention group). At baseline, all patients received a nutritional counseling. The primary endpoint was the minimal clinically relevant improvement of taste strips score by 2 taste strips points in at least 50% of the patients with taste disorders. Results The trial included 62 patients (48 women [77%], 14 male [23%], age 54.5±11.6 years) who had gastrointestinal (n=29), breast (n=31), or lung cancer (n=2). Taste disorders were more frequent in gastrointestinal than in breast cancer patients. Out of 62 patients screened, 30 patients showed taste disorders. The primary endpoint was met with 92% (n=23 of 25) of the patients completing the intervention. In the intervention group, the patients' taste significantly improved from baseline (median taste strips: 7.0 points) to week 12 (median taste strips: 10.0 points) (P≤0.001). Patients of the non-intervention group who completed the reassessment (n=27 of 32) experienced no change in taste perception in the 3-month follow-up (P=0.897). Conclusion Intensified nutritional counseling with taste and smell training may improve taste perception of patients undergoing chemotherapy. A confirmatory randomized trial is planned.

Background: Disease-related malnutrition (DRM) and sarcopenia are common complications in chronic or severe disease, with a prevalence in general patient population of 20–50% and 0.1–85.4%, respectively. In many patient populations, malnutrition and sarcopenia are present in parallel and often manifest clinically through a combination of decreased nutrient intake, inflammation, and decreased body weight, along with a decrease in muscle mass, strength, and/or physical function, resulting in a clinical condition termed malnutrition-sarcopenia syndrome. Summary: DRM and sarcopenia are associated with increases in all-cause mortality, morbidity, length of hospital stay, and functional impairments (including disabilities and fractures) that lead to a loss of independence and higher costs. Different mortality rates are reported in malnourished patients and well-nourished patients after hospitalization, and higher mortality is the most common complication in patients with sarcopenia. Sarcopenia is a predictor of cancer survival in patients with gastrointestinal, respiratory, and urothelial cancer, and is also related to worse outcomes in patients with liver failure, intestinal insufficiency, and intestinal failure. Length of hospital stay has been found to be longer in DRM and sarcopenic patients in several studies. Prolonged hospitalization due to higher complication rates is often accompanied by demographic changes, resulting in higher hospital and health insurance costs. There are more frequent readmissions by patients with sarcopenia than nonsarcopenic patients. In addition, postoperative complications, duration of hospital stay, and costs increase with advancing sarcopenia stage. A significantly higher complication rate is also reported for DRM, leading to delayed mobilization, lower values in health-related quality of life and more adverse events. DRM is independently associated with poorer clinical outcomes in intensive care unit patients. Muscle dysfunction, as reflected by a decreased handgrip strength, is a well-known consequence of DRM and a good marker of immediate postoperative complications. Most of these outcomes have potential direct or indirect effects on hospital and health care costs, both for the patient and the society at large. Key Messages: Consistent and robust data show DRM and sarcopenia are clinically relevant. They are an increasing problem with relevant medical consequences as well as socioeconomic implications.

Background Edema is commonly seen after surgical fixation of ankle fractures. Rest, ice, compression, and elevation (RICE) is an established combination to prevent swelling but hardly able to stimulate lymphatic resorption. Recently, an epicutaneously applied negative pressure suction apparatus (LymphaTouch®) has been introduced to stimulate lymphatic flow. While postoperative recovery, soft tissue, and osseous healing as well as functional outcome are probably linked to the amount of postoperative swelling, estimates on this relative to prevention (RICE) or prevention + stimulated resorption (RICE+) of fluid are scarce. Methods and analysis This is a single-center, evaluator-blinded randomized pilot trial to investigate postoperative swelling in adults requiring surgical fixation of a closed unilateral ankle fracture. A total of 50 patients will be recruited and randomly assigned to RICE or RICE+ prior to surgery. All patients will undergo evaluator-blinded measurements of the ankle volume the day before surgery and subsequently from the evening of the 2nd postoperative day every 24 h until discharge. RICE will be initiated right after surgery and continued until discharge from the hospital in all patients. Additional application of negative pressure therapy (RICE+) will be initiated on the morning of the 2nd postoperative day and repeated every 24 h until the time of discharge from the hospital. Outcome measures are (i) the relative amount and the time course of the postoperative swelling, (ii) the demand for analgesic therapy (type and amount) together with the perception of pain, (iii) the rate of complications, and (iv) mobility of the ankle joint and the recovery of walking abilities during a 12-weeks follow-up period. Serum and urine samples taken prior to sugery and during postoperative recovery will allow to evaluate the ratio of naturally occurring stable calcium isotopes (δ44/42Ca) as a marker of skeletal calcium accrual. Ethics and dissemination The protocol was approved by the institutional Ethics Committee (Rostock University Medical Center, Rostock, Germany) in accordance with the Declaration of Helsinki (approval number: A 2020-0092). The results of this study will be actively disseminated through scientific publications and conference presentations. Trial registration DRKS, DRKS00023739. Registered on 14 December 2020

Background and aim Malnutrition is a frequent complication of chronic pancreatitis. Adequate nutritional support is imperative, but there is still uncertainty about the optimal nutritional treatment. This work systematically compiles evidence from randomized controlled trials investigating dietary interventions in chronic pancreatitis and, in a further step, contrasts those findings with existing dietary recommendations. Methods The literature search (PubMed and Cochrane Central Register of Controlled Trials) included English and German full-text articles, which had been published in peer-reviewed journals. Two independent reviewers identified and selected studies. For meta-analysis, forest plots with 95% confidence intervals were generated using a random-effects model. Results Eleven randomized controlled trials fulfilled all selection criteria. In these trials, the following dietary interventions were tested: antioxidant treatment (n = 6), vitamin D supplementation (n = 3), supplementation with oral nutritional supplements (n = 1), and symbiotics supplementation (n = 1). Studies were of good methodological quality (mean Jadad score of 3.6) but heterogeneous in terms of interventions and study populations. Only for vitamin D, there was convincing evidence for efficacy of supplementation. We found no effect for antioxidant treatment on pain relief (standardized mean difference = -0.12; 95% confidence interval -0.73 to 0.48) and limited generalizability for interventions with oral nutritional supplements and symbiotics. Conclusions Nutritional management in chronic pancreatitis remains challenging. As well-designed randomized controlled trials are scarce, in large part, recommendations can only be based on low-level evidence studies or expert opinion. For now, consumption of a balanced diet remains the cornerstone recommendation for prevention, whereas more goal-directed interventions are indicated for specific nutrient deficiencies.

Depression symptoms and lower health-related quality of life (HRQoL) are associated with inflammation. This multicenter dietary intervention was shown to reduce inflammation in older people. This was the main outcome. Here, we describe the effects on HRQoL, anxiety, and depressive symptoms according to inflammation status. Overall, 125 healthy older subjects (65−80 year) were recruited (Italy, France, and Germany) and randomized into four arms (A, Healthy diet (HD); B, HD plus De Simone Formulation probiotic blend; C, HD plus AISA d-Limonene; D, HD plus Argan oil). The HD was weight maintaining, rich in antioxidant vitamins, polyphenols, polyunsaturated fatty acids (n6: n3 ratio = 3:1), and fiber. Data on inflammatory parameters, mental (MCS) and physical (PCS) component summaries of HRQoL (SF−36), anxiety symptoms (STAI state), and depressive symptoms (CES-D) were collected before and after 56 days of intervention. Body fat mass proportion (BFM) was considered a co-variable. A decrease of CES-D score was seen in the four arms (A: −40.0%, p = 0.001; B: −32.5%, p = 0.023; C: −42.8%, p = 0.004; and D: −33.3%, p = 0.21). Within the subgroups of subjects with medium/high inflammation a similar decrease in CES-D score occurred in all groups (A: −44.8%, p = 0.021; B, −46.7%, p = 0.024; C, −52.2%, p = 0.039; D, −43.8%, p = 0.037). The effect of interventions on CES-D was not related to baseline inflammation. MCS-HRQoL improved in A and C. There was no change in anxiety or PCS-HRQoL. In this trial with no control group, a decrease in depressive symptoms in healthy older volunteers was observed after a 2-month healthy diet intervention, independently of inflammation but with possible limitations due to participation.

Hintergrund Die Leichte Vollkost (LVK) wird seit 1978 durch das Rationalisierungsschema fast unverandert als eigenstandige Kostform beschrieben. Ihre Hauptcharakteristik besteht darin, Lebensmittel wegzulassen, die bei mehr als 5 % der Patienten unspezifische Unvertraglichkeiten auslosen. Die Auswahl der unvertraglichen Lebensmittel basiert hauptsachlich auf einer Untersuchung von Rottka aus dem Jahre 1978. Das Ziel der vorliegenden Untersuchung war es, Daten zur Relevanz der LVK und Prazision der Vorgaben von Handlungstragern der Speisenproduktion und Ausbildungsstatten fur Diatetik zu erhalten. Material und Methodik Online-Befragung von 173 Verantwortlichen der Speisenproduktion von Gesundheitseinrichtungen und 29 Ausbildungsstatten fur Diatetik in Deutschland und Osterreich. Ergebnisse Mehr als 75 % der Verantwortlichen der Speisenproduktion aber weniger als 50 % der Ausbildungsstatten hielten die Vorgaben fur praxisrelevant und gut umsetzbar. Gleichzeitig beurteilten 61 % der Verantwortlichen fur die Speisenproduktion bzw. 96 % der Ausbildungsstatten die Vorgaben als uberarbeitungsbedurftig und nur 42 bzw. 33 % hielten sich an die Vorgaben. Ein Drittel der Verantwortlichen der Speisenproduktion und 89 % der Ausbildungsstatten waren der Meinung, dass die bisherigen Vorgaben nicht ausreichend sind, um daraus Richtlinien fur die Gemeinschaftsverpflegung abzuleiten. Bei deren weiterer Befragung wurden besonders „fette Speisen“, „suse und fette Backwaren“, „Kartoffelsalat“ und „Susigkeiten“ als nicht eindeutig beschrieben genannt. Grundsatzlich bejahten knapp 90 % der Befragten aus beiden Gruppen, dass fur die LVK in der Gemeinschaftsverpflegung konkrete Angaben zum Lebensmitteleinsatz verankert werden sollten. Schlussfolgerung Die LVK hat sich in der Praxis gewahrt. Einerseits besteht eine hohe Akzeptanz, andererseits gibt es aber auch Hinweise auf Aktualisierungsbedarf und eine unzureichende Beschreibung der zu eliminierenden Lebensmittel.

Background A lack of agreement on definitions and terminology used for nutrition-related concepts and procedures limits the development of clinical nutrition practice and research. Objective This initiative aimed to reach a consensus for terminology for core nutritional concepts and procedures. Methods The European Society of Clinical Nutrition and Metabolism (ESPEN) appointed a consensus group of clinical scientists to perform a modified Delphi process that encompassed e-mail communication, face-to-face meetings, in-group ballots and an electronic ESPEN membership Delphi round. Results Five key areas related to clinical nutrition were identified: concepts; procedures; organisation; delivery; and products. One core concept of clinical nutrition is malnutrition/undernutrition, which includes disease-related malnutrition (DRM) with (eq. cachexia) and without inflammation, and malnutrition/undernutrition without disease, e.g. hunger-related malnutrition. Over-nutrition (overweight and obesity) is another core concept. Sarcopenia and frailty were agreed to be separate conditions often associated with malnutrition. Examples of nutritional procedures identified include screening for subjects at nutritional risk followed by a complete nutritional assessment. Hospital and care facility catering are the basic organizational forms for providing nutrition. Oral nutritional supplementation is the preferred way of nutrition therapy but if inadequate then other forms of medical nutrition therapy, i.e. enteral tube feeding and parenteral (intravenous) nutrition, becomes the major way of nutrient delivery. Conclusion An agreement of basic nutritional terminology to be used in clinical practice, research, and the ESPEN guideline developments has been established. This terminology consensus may help to support future global consensus efforts and updates of classification systems such as the International Classification of Disease (ICD). The continuous growth of knowledge in all areas addressed in this statement will provide the foundation for future revisions.

Summary Background & aims Although up-to-date definitions for nutrition assessment integrate behavioural components, it is not clear what behavioural components are to be assessed. Since behavioural modification is linked to effective therapeutic dietetic interventions, assessing behaviour and factors influencing behaviour might be beneficial to improve personalized dietetic outcome. The aim of the following report is to emphasize the role of behavioural components and factors affecting behaviour at baseline nutrition assessment in personalized dietetic intervention. Methods The present work is part of the EU-funded project IMPECD (“Improvement of Education and Competences in Dietetics”, www.impecd.eu ). The project aims to improve the clarity and consistency of national dietetic process models to unify education and training of future dietitians. Experts from five European Universities of Applied Sciences (UAS) in Antwerp (BE), Fulda (DE), Groningen (NL), Neubrandenburg (DE) and St. Polten (AT) developed a Massive Open Online Course (MOOC) consisting of several clinical cases. It warranted a detailed evaluation of all dietetic care process steps, starting with nutrition assessment. Results Results for motivation assessed during nutrition assessment are not consistently positively associated with outcome and the added value of assessing them at baseline is still unclear. However, depressive symptoms, emotional distress, and anxiety negatively affect eating and physical activity and therefore limit the efficacy of the dietetic intervention. Assessing behavioural components including nutrition literacy is an important precondition for influence on behavioural modification. Conclusion Indisputably, baseline assessment of behavioural components and factors influencing behaviour are important to increase the therapeutic efficacy of personalized dietetic interventions.

[Background] In wheat-dependent exercise-induced anaphylaxis (WDEIA), cofactors such as exercise, acetylsalicylic acid (ASA), alcohol or unfavorable climatic conditions are required to elicit a reaction to wheat products. The mechanism of action of these cofactors is unknown, but an increase of gliadin absorption has been speculated. Our objectives were to study gliadin absorption with and without cofactors and to correlate plasma gliadin levels with factors influencing protein absorption in healthy volunteers., [Methods] Twelve healthy probands (six males, six females; aged 20–56 years) ingested 32 g of gluten without any cofactor or in combination with cofactors aerobic and anaerobic exercise, ASA, alcohol and pantoprazole. Gliadin serum levels were measured up to 120 min afterwards and the intestinal barrier function protein zonulin in stool was collected before and after the procedure; both were measured by ELISA. Stool microbiota profile was obtained by 16S gene sequencing., [Results] Within 15 min after gluten intake, gliadin concentrations in blood serum increased from baseline in all subjects reaching highly variable peak levels after 15–90 min. Addition of cofactors did not lead to substantially higher gliadin levels, although variability of levels was higher with differences between individuals (p, [Conclusion] The adsorption of gliadin in the gut in healthy volunteers is less dependent on cofactors than has been hypothesized. Patients with WDEIA may have a predisposition needed for the additional effect of cofactors, e.g., hyperresponsive or damaged intestinal epithelium. Alternatively, other mechanisms, such as cofactor-induced blood flow redistribution, increased activity of tissue transglutaminase, or increases in plasma osmolality and acidosis inducing basophil and mast cell histamine release may play the major role in WDEIA., This work was supported by the German Research Foundation (DFG) and the Technical University of Munich (TUM) in the framework of the Open Access Publishing Program.

Summary Background & aims Dietetic interventions contribute to certain health objectives and other outcomes, but are mostly part of a multimodal and multidisciplinary approach what makes evaluating the actual effects of dietitians' involvement rather complex. Although monitoring and outcome evaluation (M&OE) can provide routine data to prove the effectiveness of dietetic interventions, this has not been established yet in different dietetic settings. Methods A comprehensive framework for M&OE in dietetics was developed by dietetic experts from five European higher education institutes for dietetics in the course of the EU sponsored project “Improvement of Education and Competences in Dietetics (IMPECD)”. Results Firstly, clear definitions on M&OE are proposed to facilitate the use of consistent terminology, with a specific emphasis on the term “impact” covering macro-level outcomes such as cost-effectiveness. Secondly, the Dietetic Care Process (DCP) was merged into a logic model to demonstrate the position of M&OE in relation to intervention planning and implementation, in both group and individual settings. Thirdly, selecting the appropriate indicators is indispensable to monitor and evaluate outcomes, and requires a high level of dietitians’ critical reasoning. A categorized overview of indicators is provided to support this process. Lastly, the consortium developed a checklist to give dietitians a handle on what elements could be included in their M&OE plan and trigger them to perform M&OE in practice. Conclusions Innovative M&OE models may help dietitians to demonstrate their effectiveness in improving clinical outcomes and justify their role in health care.

Malnutrition is a frequent feature in Crohn’s disease (CD), affects patient outcome and must be recognised. For chronic inflammatory diseases, recent guidelines recommend the development of combined malnutrition and inflammation risk scores. We aimed to design and evaluate a new screening tool that combines both malnutrition and inflammation parameters that might help predict clinical outcome. In a prospective cohort study, we examined fifty-five patients with CD in remission (Crohn’s disease activity index (CDAI)

BACKGROUND Visceral adipose tissue (VAT) could affect Crohn's disease (CD); however, no prospective clinical studies have explored the issue. METHODS We measured VAT with magnetic resonance imaging and total fat mass (FM) with air-displacement plethysmography in 31 women with CD in remission and 19 matched control women. We assessed the VAT/FM ratio as index of VAT accumulation, measured cytokines, and monitored clinical features (duration of remission, disease behavior, and outcome) in patients with CD retrospectively and prospectively. We also tested whether ultrasound could provide a surrogate marker of VAT in patients with CD. RESULTS Patients with CD had higher percentage of FM (37 ± 10% versus 31 ± 10%, P = 0.03), VAT (1885 ± 1403 mL versus 941 ± 988 mL, P = 0.02), and VAT/FM ratio (65 ± 24 mL/kg versus 37 ± 25 mL/kg, P = 0.004) than control women. In patients with CD, VAT/FM ratio was associated with leptin (P = 0.009) and interleukin 6 (P = 0.032) concentrations, and higher in short-term than in long-term remission (72.6 ± 27.1 mL/kg versus 54.8 ± 16.1 mL/kg, P = 0.079). Patients with CD with stricturing/fistulizing disease had a higher VAT/FM ratio than patients with nonstricturing/nonfistulizing behavior (79 ± 0.15 mL/kg versus 63 ± 28 mL/kg, P = 0.067). A higher baseline VAT/FM ratio was associated with an increased disease activity at follow-up (P = 0.029). The ultrasound-determined thickness between the abdominal wall and the aorta was strongly associated with VAT as measured by magnetic resonance imaging (P < 0.001). CONCLUSIONS VAT accumulation could be a prospective risk factor for increased disease activity in CD.

Liver cirrhosis is frequently accompanied by disease-related malnutrition (DRM) and sarcopenia, defined as loss of skeletal muscle mass and function. DRM and sarcopenia often coexist in cirrhotic patients and are associated with increased morbidity and mortality. The clinical manifestation of both comorbidities are triggered by multifactorial mechanisms including reduced nutrient and energy intake caused by dietary restrictions, anorexia, neuroendocrine deregulation, olfactory and gustatory deficits. Maldigestion and malabsorption due to small intestinal bacterial overgrowth, pancreatic insufficiency or cholestasis may also contribute to DRM and sarcopenia. Decreased protein synthesis and increased protein degradation is the cornerstone mechanism to muscle loss, among others mediated by disease- and inflammation-mediated metabolic changes, hyperammonemia, increased myostatin and reduced human growth hormone. The concise pathophysiological mechanisms and interactions of DRM and sarcopenia in liver cirrhosis are not completely understood. Furthermore, most knowledge in this field are based on experimental models, but only few data in humans exist. This review summarizes known and proposed molecular mechanisms contributing to malnutrition and sarcopenia in liver cirrhosis and highlights remaining knowledge gaps. Since, in the prevention and treatment of DRM and sarcopenia in cirrhotic patients, more research is needed to identify potential biomarkers for diagnosis and development of targeted therapeutic strategies.

Body mass index (BMI) and mortality in old adults from the general population have been related in a U-shaped or J-shaped curve. However, limited information is available for elderly nursing home p ...

Summary Purpose The nomenclature in clinical nutrition differs locally, among (para)medical disciplines, and both nationally and internationally. The inconsistencies hamper public, professional and scientific discussions. A working group of the German Society of Nutritional Medicine (DGEM) was established to work out definitions for the relevant terms used in nutritional support within Germany. Methods Terms were searched in (inter)national hard print technical literature (medical dictionaries, text books, (inter)national guidelines and online (PubMed, Embase, CINAHL, Google Scholar, general internet). (Inter)nationally agreed definitions published by Clinical Nutrition Societies were preferred to other reports. Results The terms were organised into four categories totaling 53 definitions: 1. Fields and structure: medical nutrition, clinical nutrition, nutrition steering committee, nutritional care, care catering, dietetics (dietary advice), obesity as part of clinical nutrition (obesity team), nutritional support (nutrition support team, malnutrition screening, nutritional support therapy), functional nutrition, nutritional assessment, nutrition therapy plan, nutritional therapy, 2. Nutritional conditions: disease-related malnutrition (starvation induced malnutrition, chronic disease-related malnutrition, acute disease-related malnutrition), cachexia, sarcopenia, specific nutrient deficiencies, refeeding syndrome, 3. Forms of nutrition: diet (regular diet, therapeutic diet, fortified food), artificial nutritional support (oral nutritional supplementation, enteral nutrition, parenteral nutrition) 4. Products: oral nutritional supplements and enteral formulas (whole protein formula, peptide-based formula, free amino acid formula, standard formula), parenteral solutions (total nutrient admixtures, multi-chamber systems, multiple bottle systems). Conclusion A comprehensive list of definitions for terms in nutritional support has been established for the first time and is made available to the international community for further development and discussions.

Summary Background & aims The selection of appropriate outcome variables in clinical nutrition is particularly challenging, since nutrition is an adjunct therapy in most cases. Therefore, its effect may be confounded with the primary therapy, and classic biomedical outcomes may not reflect the effect of the nutritional intervention. This paper scrutinizes different alternatives to the biomedical perspective. Results Five different outcome models are proposed and analyzed for their suitability in clinical nutrition studies: biomedical, patient-centered/-reported, health economic, decision-making, and integration of classical and patient-reported endpoints. Most published studies in the field of clinical nutrition make use of biomedical endpoints, but the growing importance of patient-centered/-reported and health economic outcomes is recognized. We recommend avoiding to focus solely on biomedical endpoints in clinical nutrition studies. The availability and value of a broader set of outcome-models should be acknowledged. Conclusion Patient-centered/-reported, health economic or combined endpoints are particularly useful to assess the effect of nutritional therapies, especially when applied in conjunction with a primary therapy. The proposed outcome models can also contribute to refine clinical nutrition guidelines in assessing the clinical relevance of the study results.

Malnutrition is common in older adults and a functioning gastrointestinal tract is important to maintain a good nutritional status. Thus, it is reasonable to ask if aging itself leads to compromised function of the gastrointestinal tract and predisposes older humans to nutritional risk independent of disease. In the gastrointestinal tract many changes occur with physiological aging, such as loss neuronal loss, decrease olfaction, changed oropharyngeal capacities, earlier satiation, delayed gastric emptying, prolonged colonic transit time, and increased risk of constipation. Hardly any of them has clinical significance in the absence of disease. Physiological aging can increase gastrointestinal symptoms and discomfort, but is unlikely to affect nutritional status up to the age of about 80 years. However, in disease with polypharmacy, care-dependence, and altered diet, physiological aging of the intestinal tract makes older people far more vulnerable for malnutrition and causes significant deterioration of intestinal permeability and detrimental shifts in gut microbiota.

Background Reduced muscle strength is a cardinal feature in cachexia. We investigated whether weight loss is associated differently with muscle strength in men and women in a large cohort of hospitalized patients. Methods One thousand five hundred hospitalized patients (whereof 718 men, mean age 57.6 ± 16.0 years, mean body mass index (BMI) 24.6 ± 4.8 kg/m²) were included in the study. Non-edematous involuntary weight loss was determined with Subjective Global Assessment; isometric maximal muscle strength was evaluated by hand grip strength. Mid-upper arm circumference and triceps skinfold were used to calculate arm muscle area. Interrelationship between sex and weight loss was evaluated by regression analysis performed with the general linear model (GLM) allowing adjustment for continuous and categorical variables and corrected for age, arm muscle area (AMA), BMI, and diagnosis category (benign/malignant disease) as potentially confounding covariates. Results Both men and women exhibited a significant stepwise decrease of hand grip strength with increasing weight loss. Age, sex, moderate and severe weight loss, BMI, and AMA were significant predictors of hand grip strength. The GLM moreover revealed a significant sex × weight loss effect, since grip strength was similarly decreased in moderate weight loss in men and women when compared to control patients without weight loss (8.5% in men and 10.5% in women, not significant (n.s.)), but the further reduction of grip strength in severe weight loss was significantly different between men and women (10.6% vs. 4.1%, P = 0.033). Conclusions Our findings indicate sex-specific differences in muscle strength response to weight loss.

Phase angle (PhA), a parameter of bioelectrical impedance analysis, is a well-known predictor of morbidity and mortality in various diseases. The causes of decreased PhA are, however, not yet completely understood. We therefore investigated determinants of PhA in 777 hospitalised patients in a retrospective analysis. PhA was assessed by bioelectrical impedance analysis at 50 KHz. Subjective global assessment (SGA) was used to evaluate nutritional status. Age, sex, BMI as well as nutritional status (SGA), benign or malignant disease and C-reactive protein (CRP) were investigated as potential determinants of PhA and standardised PhA (SPhA) = (observed PhA − mean PhA of reference values)/standard deviation of reference values in a general linear model regression analysis. Next to age (estimated effect size, 46·6 %; P P P P P P P

A modified version of the nutritionDay project was developed for nursing homes (NHs) to increase malnutrition awareness in this area. This report aims to describe the first results from the NH setting.On February 22, 2007, 8 Austrian and 30 German NHs with a total of 79 units and 2137 residents (84+/-9 years of age, 79% female) participated in the NH-adapted pilot test. The NHs participated voluntarily using standardized questionnaires. The actual nutritional intake at lunch time was documented for each resident. Six-month follow-up data were received from 1483 residents (69%).Overall, 9.2% and 16.7% of residents were classified as malnourished subjectively by NH staff and by BMI criteria (20 kg/m(2)), respectively. Independent risk factors for malnutrition included age90 years, immobility, dementia, and dysphagia (all p0.001). In total, 89% of residents ate at least half of the lunch meal, and 46% of residents received eating assistance for an average of 15 min. Six-month mortality was higher in residents with low nutritionDay BMI (20 kg/m(2): 22%, 20-21.9 kg/m(2): 17%) compared to residents with BMIor= 22 kg/m(2) (10%, p0.001). Six-month weight lossor= 6 kg was less common in residents with nutritionDay BMI22 kg/m(2) compared to residents with higher nutritionDay BMI (3.4% vs 12.4%, p0.001).The first nutritionDay in NH provided valuable data on the nutritional status of NH residents and called attention to the remarkable time investment required by NH staff to adequately provide eating assistance to residents. Participation in the nutritionDay project appears to increase malnutrition awareness as reflected in the outcome weight results.

Adipokines are fat-derived hormones and cytokines with immune-modulating and metabolic properties. Most of them are associated with insulin resistance. The aim of the present investigation was to evaluate circulating levels of adipokines and glucose homeostasis in patients with inflammatory bowel disease (IBD) and to evaluate possible associations with the course and characteristics of the disease.Serum leptin, resistin, visfatin, retinol-binding protein-4, adiponectin, glucose, insulin, and inflammatory parameters were analyzed in 93 patients with inactive IBD (49 with Crohn's disease [CD], 44 with ulcerative colitis [UC]), 35 patients with active IBD (18 with CD, 17 with UC), and 37 age- and body mass index-matched healthy controls. Ninety-two patients were followed for 6 mo.Leptin was similar in patients with IBD and controls, whereas resistin and visfatin were increased in patients with active disease but not in those in remission. In active and inactive disease, adiponectin was decreased (P0.001) and retinol-binding protein-4 was increased (P0.001) compared with controls. About 60% of patients with IBD showed increased levels of insulin, whereas serum glucose remained normal, resulting in increased homeostasis model assessment values in most patients. Hyperinsulinemia was associated with the decrease in adiponectin (r = -0.572, P0.001) and proved to be an independent protective factor for 6-mo maintenance of remission (P = 0.016).IBD led to largely similar alterations in circulating adipokines and hyperinsulinemia in patients with CD and those with UC. The unexpected protective effect of hyperinsulinemia on relapse rate denotes the role of the metabolic-inflammatory response as a modulator in IBD.

Summary Background Gastroduodenal and small intestinal permeability are increased in patients with Crohn's disease (CD) and intensive care patients. The relevance of colonic permeability has not yet been adequately investigated. The aim of this study was to investigate the clinical value of sucralose excretion as indicator for colonic permeability in these patient groups. Design After oral administration of four sugars and subsequent analysis of urinary excretion, gastroduodenal and intestinal permeability were calculated from saccharose excretion and lactulose/mannitol (L/M) ratio over 5 h, and sucralose excretion from 5 to 26 h in 100 healthy controls, 29 CD and 35 patients after coronary surgery (CABG). Results In controls, sucralose excretion was highly variable (0·67 ± 0·92%) and not related to small intestinal permeability. In CD and CABG, L/M ratio was increased (0·054 ± 0·060; 0·323 ± 0·253 vs. 0·018 ± 0·001 in controls). Sucralose excretion was increased in 77% of CABG but only in 7% of CD. There was an association between gastroduodenal and intestinal permeability in CD and CABG (r = 0·72, and r = 0·51), but sucralose excretion was not related to either one of these two parameters. Other than a weak association between sucralose and length of stay in intensive care in CABG patients (P = 0·099), sucralose excretion was not related to clinical outcome. Conclusions The proposed cut-off for normal sucralose excretion is 2·11%, but its high variability and lack of association to gastrointestinal permeability or clinical outcome leave it open, if it can provide information beyond established permeability tests.

Summary Background & aims Data regarding the nutritional status, antioxidant compounds and plasma fatty acid (FA) composition in inactive IBD are conflicting. We compared plasma levels of antioxidants and FA of patients with inactive IBD with active IBD and controls. Methods Plasma levels of vitamin C, vitamin E, carotenoids, saturated, monounsaturated and polyunsaturated FA, inflammatory markers and nutritional status were determined after an overnight fast in 132 patients with quiescent IBD (40.6 ± 13.2 years, 87F/45M), 35 patients with active disease (37.9 ± 12.1 years, 25F/10M) and 45 age- and BMI-matched healthy controls (38.1 ± 10.5 years, 39F/6M). Results are expressed as mean ± SD or median [25th percentile;75th percentile]. Results Body mass index (BMI) was normal in inactive (23.9 ± 4.7 kg/m2), active IBD (22.7 ± 4.2 kg/m2) and controls (22.3 ± 1.9 kg/m2). Compared with controls patients with quiescent IBD showed significantly decreased plasma levels of carotenoids (1.85 [1.37;2.56] vs 1.39 [0.88;1.87] μmol/L) and vitamin C (62.3 [48.7;75.0] vs 51.0 [36.4;77.6] μmol/L), increased levels of saturated FA (3879 [3380;4420] vs 3410 [3142;3989] μmol/L) and monounsaturated FA (2578 [2258;3089] vs 2044 [1836;2434] μmol/L) and similar levels of vitamin E and polyunsaturated FA. Results in active disease were similar to inactive disease. Conclusion This study shows that antioxidant status and FA profile in a larger population of IBD patients are disturbed independently from disease activity and despite normal overall nutritional status.