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Protein-energy wasting (PEW) is prevalent in maintenance hemodialysis (MHD) patients, and is one of the major risk factors for poor outcomes and death. This study aimed to investigate the effects of non-protein calorie supplements on the nutritional status of MHD patients with PEW. MHD patients with PEW were enrolled in this multi-center, open-label, randomized controlled trial. Then, they were randomly assigned to the intervention group to receive the non-protein calorie supplements containing 280 kcal of energy every day for 6 months or the control group to complete all aspects of the study without receiving supplements. Patients in both groups received dietary counselling from dietitians. Data on nutritional assessments, anthropometric measurements, blood analysis and dietary recall were collected at the baseline and at six months from both groups. Statistical analyses were performed using analysis of covariance (ANCOVA) adjusted for sex and baseline values. Ninety-two MHD patients completed the study. A significant increase in the subjective global assessment (SGA) score was found in the intervention group compared with the control group (4.88 ± 1.41 vs. 4.40 ± 1.16, p = 0.044). The ratio of PEW patients (diagnosed with SGA ≤5) in the intervention group (61.2%) was also significantly lower than that in the control group (83.7%) ( p < 0.001). Moreover, significant improvements in body mass index (20.81 ± 2.46 kg m -2 vs. 19.51 ± 2.60 kg m -2 , p < 0.001), nutrition risk screening 2002 (2.45 ± 1.40 vs. 3.12 ± 1.37, p = 0.038), mid-upper arm circumference (23.30 ± 2.78 cm vs. 21.75 ± 2.87 cm, p = 0.001), and mid-arm muscle circumference (20.51 ± 2.32 cm vs. 19.06 ± 2.92 cm, p = 0.005) were observed in the intervention group compared with the control group. Patients in the intervention group took in more dietary energy than the control group (26.96 ± 4.75 kcal per kg body weight per day vs. 24.33 ± 2.68 kcal per kg body weight per day, p < 0.001). In conclusion, non-protein calorie supplements may improve the nutritional status of MHD patients with PEW.

Issue Addressed: Protein-energy malnutrition (PEM) is a condition of involuntary weight and muscle loss caused by inadequate nutritional intake. In Australia, it is predominantly associated with chronic diseases, as are common in the older population. Given the ageing population of Australia, and the poor outcomes associated with PEM, there is a need to identify the contributing factors, and to explore strategies to prevent PEM., Methods: Two databases were searched for pertinent keywords, including malnutrition, Australia and elderly, with relevant articles selected for inclusion. The citations and references of these articles were also searched for further articles., Results: PEM is associated with increasing age and institutionalisation. The contributing factors are multifactorial, and include physiological, pathophysiological and structural causes. PEM is a significant public health issue for Australia, in terms of its consequences on both quality of life for older adults, and the burden on the healthcare system. However, there are strategies that can be implemented at the community, organisation and policy level to prevent PEM., Conclusion: PEM is a common problem for older Australians, and this has important physiological and public health consequences, especially in the context of the ageing Australian population. However, there is significant scope for preventing PEM. SO WHAT?: Readers can be advised that PEM is a significant public health issue that will increase in importance as the population continues to age. It is important that communities, organisations and governments develop strategies to prevent PEM., (© 2021 Australian Health Promotion Association.)

Nursing home (NH) residents with (risk of) malnutrition are at particular risk of low protein intake (PI). The aim of the present analysis was (1) to characterize usual PI (total amount/day (d) and meal, sources/d and meal) of NH residents with (risk of) malnutrition and (2) to evaluate the effects of an individualized nutritional intervention on usual PI. Forty residents (75% female, 85 ± 8 years) with (risk of) malnutrition and inadequate dietary intake received 6 weeks of usual care followed by 6 weeks of intervention. During the intervention phase, an additional 29 ± 11 g/d from a protein-energy drink and/or 2 protein creams were offered to compensate for individual energy and/or protein deficiencies. PI was assessed with two 3-day-weighing records in each phase and assigned to 4 meals and 12 sources. During the usual care phase, mean PI was 41 ± 10 g/d. Lunch and dinner contributed 31 ± 11% and 32 ± 9% to daily intake, respectively. Dairy products (median 9 (interquartile range 6-14) g/d), starchy foods (7 (5-10) g/d) and meat/meat products (6 (3-9) g/d) were the main protein sources in usual PI. During the intervention phase, an additional 18 ± 10 g/d were consumed. Daily PI from usual sources did not differ between usual care and intervention phase (41 ± 10 g/d vs. 42 ± 11 g/d, p = 0.434). In conclusion, daily and per meal PI were very low in NH residents with (risk of) malnutrition, highlighting the importance of adequate intervention strategies. An individualized intervention successfully increased PI without affecting protein intake from usual sources.

Multi-factors, such as anorexia, activation of renin-angiotensin system, inflammation, and metabolic acidosis, contribute to malnutrition in chronic kidney disease (CKD) patients. Most of these factors, contributing to the progression of malnutrition, worsen as CKD progresses. Protein restriction, used as a treatment for CKD, can reduce the risk of CKD progression, but may worsen the sarcopenia, a syndrome characterized by a progressive and systemic loss of muscle mass and strength. The concomitant rate of sarcopenia is higher in CKD patients than in the general population. Sarcopenia is also associated with mortality risk in CKD patients. Thus, it is important to determine whether protein restriction should be continued or loosened in CKD patients with sarcopenia. We may prioritize protein restriction in CKD patients with a high risk of end-stage kidney disease (ESKD), classified to stage G4 to G5, but may loosen protein restriction in ESKD-low risk CKD stage G3 patients with proteinuria <0.5 g/day, and rate of eGFR decline <3.0 mL/min/1.73 m 2 /year. However, the effect of increasing protein intake alone without exercise therapy may be limited in CKD patients with sarcopenia. The combination of exercise therapy and increased protein intake is effective in improving muscle mass and strength in CKD patients with sarcopenia. In the case of loosening protein restriction, it is safe to avoid protein intake of more than 1.5 g/kgBW/day. In CKD patients with high risk in ESKD, 0.8 g/kgBW/day may be a critical point of protein intake.

Some children with declining height and BMI SDS fail to respond to optimisation of nutritional intake. As well as poor growth, they have muscle wasting and relative preservation of body fat. This is termed protein energy wasting (PEW). The process results from an interaction of chronic inflammation alongside poor nutritional intake. This review discusses the causes and potential preventative therapies for PEW.

Context: Nutritional risk (NR) screening is the first step of nutrition care process. Few data are available in literature about its prevalence, nor, to our knowledge, is a universally accepted reference method for the intensive care unit (ICU)., Objective: The aim for this systematic review was to summarize evidence regarding the prevalence of NR and the predictive validity of different tools applied for NR screening of critically ill patients., Data Sources: The PubMed, Embase, and Scopus databases were searched up to December 2019 using the subject headings related to critically ill patients and NR screening. The current systematic review is registered with PROSPERO (identifier: CRD42019129668)., Data Extraction: Data on NR prevalence, predictive validity of nutritional screening tools, and interaction between caloric-protein balance and NR in outcome prediction were collected., Data Analysis: Results were summarized qualitatively in text and tables, considering the outcomes of interest., Results: From 15 669 articles initially identified, 36 fulfilled the inclusion criteria, providing data from 8 nutritional screening tools: modified Nutrition Risk in the Critically Ill (mNUTRIC; n = 26 studies) and Nutritional Risk Screening-2002 (NRS-2002; n = 7 studies) were the most frequent; the NR prevalence was 55.9% (range, 16.0% to 99.5%). Nutritional risk was a predictor of 28-day and ICU mortality in 8 studies. Interactions between caloric-protein balance and NR on outcome prediction presented were scarcely tested and presented heterogeneous results (n = 8)., Conclusions: Prevalence of NR in patients in the ICU varies widely; a satisfactory predictive validity was observed, especially when mNUTRIC or NRS-2002 were applied., (© The Author(s) 2020. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Protein-energy malnutrition (PEM) commonly arises after stroke. We investigated the effects of preventing PEM on spontaneous recovery of forelimb use, infarct size, and the acute phase response in the chronic post-stroke period. Male, adult, Sprague-Dawley rats were acclimatized to control diet (12.5% protein), tested for pre-stroke forelimb use symmetry in the cylinder test, and exposed to photothrombotic cortical stroke or sham surgery. Food intake was monitored daily, and body weight weekly. Forelimb use was tested on day 4 after surgery, before assignment to control diet or PEM (0.5% protein), with subsequent testing on days 16 and 29. Blood, brain, and liver were collected on day 30. The low protein diet resulted in PEM, measured by decreased body weight ( p < 0.001) and food intake ( p = 0.016) and increased liver lipid ( p < 0.001). Stroke ( p = 0.016) and PEM ( p = 0.001) independently elicited increases in serum α-2-macroglobulin concentration, whereas PEM alone decreased albumin ( p < 0.001). PEM reduced recovery of forelimb use symmetry during exploration on days 16 ( p = 0.024) and 29 ( p = 0.013) but did not influence infarct size ( p = 0.775). Stroke reduced reliance on the stroke-affected forelimb to initiate exploration up until day 29 ( p < 0.001); PEM had no influence ( p ≥ 0.463). Preventing post-stroke PEM appears to yield direct benefits for certain types of motor recovery. Novelty Preventing post-stroke malnutrition benefits certain types of motor recovery. An acute phase response may contribute to the poorer recovery with malnutrition.

This review aims to highlight the strengths and weaknesses emerging from diagnostic evaluations and prescriptions in an intent to prevent progression over time of malnutrition and/or protein-energy wasting (PEW) in hemodialysis (HD) patients. In particular, indications of the most effective pathway to follow in diagnosing a state of malnutrition are provided based on a range of appropriate chemical-clinical, anthropometric and instrumental analyses and monitoring of the nutritional status of HD patients. Finally, based on the findings of recent studies, therapeutic options to be adopted for the purpose of preventing or slowing down malnutrition have been reviewed, with particular focus on protein-calorie intake, the role of oral and/or intravenous supplements and efficacy of some classes of amino acids. A new determining factor that may lead inexorably to PEW in hemodialysis patients is represented by severe amino acid loss during hemodialysis sessions, for which mandatory compensation should be introduced.

Historically, eating during the hemodialysis treatment has been associated with increased risk for adverse intradialytic symptoms and events, risks that have resulted in the implementation of restrictive in-center nutrition policies. Recent studies, however, have recorded a shift in clinical practice with a higher proportion of physicians following the view that administration of intradialytic meals and supplements represents a simple and effective approach to enhance caloric intake and improve nutritional status among patients on hemodialysis. This shift towards less restrictive in-center nutrition practices is mainly supported by evidence from observational studies associating intradialytic nutritional supplementation with improvements in protein-energy wasting, inflammatory state, and health-related quality of life. In sharp contrast, earlier and recent interventional studies have documented that feeding during the hemodialysis treatment provokes a rapid postprandial decline in blood pressure and raises the incidence of symptomatic intradialytic hypotension. Furthermore, other studies have shown that postprandial redistribution in intravascular volume and enhanced blood supply to the gastrointestinal circulation may interfere with the adequacy of the delivered hemodialysis. Those who defend the position that intradialytic nutritional support is beneficial do not dispute the physiology of postprandial hemodynamic response, but they argue against its clinical significance. In this article, we provide an overview of studies that explored the effect of eating during the hemodialysis treatment on intradialytic hemodynamic stability and adequacy of the delivered hemodialysis. We reason that these risks have important clinical implications that are not counteracted by anticipated benefits of this strategy on caloric intake and nutritional status.

Background: Protein energy malnutrition (PEM) is an important health burden in most developing countries mainly in sub-Saharan Africa, where it contributes to high rates of child morbidity and mortality. This study evaluated the efficacy of compositing with snail meat powder (SMP) on protein nutritional quality of sorghum-wheat buns using a rat bioassay. Nine diets -seven isonitrogenous diets, based on six variations of buns and a reference diet made using skimmed milk powder, in addition to the basal diet meant to estimate the endogenous nitrogen excretion and a 16% protein rehabilitation diet - were fed to male weanling albino rats. Protein efficiency ratio (PER), and food efficiency ratio (FER), net protein retention ratio (NPRR), apparent protein digestibility (APD), and true protein digestibility (TPD), protein digestibility corrected amino acid score (PDCAAS), and digestible indispensable amino acid score (DIAAS) indices of protein quality were determined., Results: Fortification with SMP significantly (P < 0.05) enhanced PER from 0.21% to 2.70%, FER from 0.02% to 0.27%, APD from 81.17% to 88.28%, and TPD from 87.48% to 95.38%. PDCAAS and DIAAS increased from 45% to 78% and 44% to 69% respectively in unfortified buns to buns fortified with 25% SMP., Conclusion: Complementary diets fortified with SMP promote growth and rehabilitate emaciated rats, whereas unfortified diet did not support weight gain. Thus, supplementation of buns with SMP might enhance a faster recovery in children affected by PEM. © 2020 Society of Chemical Industry., (© 2020 Society of Chemical Industry.)

Skeletal muscle loss is the most important hallmark of protein energy wasting syndrome as it contributes to declines in physical independence, poor quality of life, and higher mortality risk in individuals with ESRD on maintenance hemodialysis (HD). As such, exercise and nutritional interventions have been investigated with the goal to preserve skeletal muscle mass and overall quality of life. Unfortunately, current efforts are unable to confirm the capacity of exercise to mitigate ESRD-associated muscle wasting. However, the inconclusive data are often accompanied by suboptimal exercise prescriptions. Exercise sessions are often implemented in-clinic during the catabolic and proinflammatory period of dialysis treatment and without concurrent nutritional support. Additionally, indirect considerations like exercise intolerance and exercise program compliance/adherence also inhibit exercise training potential. These shortcomings all stem from the current lack of understanding in skeletal muscle mass regulation within the context of ESRD and intermittent HD. As such, this review summarizes the current understanding of exercise regulation on skeletal muscle mass and ESRD-related obstacles of anabolism to contextualize the ineffectiveness of current exercise interventions for HD patients., (© 2019 Wiley Periodicals, Inc.)

Background and Aim: Reducing post-absorptive (fasting) phase by eating late evening snacks (LESs) is a potential intervention to improve substrate utilization and reverse sarcopenia. This study analyzed the results of published randomized controlled trials and controlled clinical trials to evaluate the effects of LES on liver function of patients with cirrhosis., Methods: A meta-analysis was conducted. The search strategy included electronic database searches, and 300 articles were searched. Eight of these articles provided qualified data for pooling and analysis. Outcomes assessments included serum albumin, total bilirubin, alanine aminotransferase, prothrombin time, and aspartate aminotransferase, complications of cirrhosis, severity of liver disease, and blood glucose levels., Results: Our analysis included eight studies comprising 341 patients (167 in LES groups and 174 in control groups). The results showed that LES intervention helped to maintain liver reserves. These eight studies demonstrated that LES intervention had significant effects for liver biochemical parameters on albumin, ammonia, and prothrombin time, with respective effect sizes of 0.233, -0.425, and -0.589; liver enzymes include aspartate aminotransferase and alanine aminotransferase, with respective effect sizes of -0.320 and -0.284. Studies on clinical signs of liver dysfunction showed lower occurrence rates of ascites and hepatic encephalopathy than in the control group. LES had no significant effect on Child-Pugh score., Conclusions: The overall results of the meta-analysis indicated that having LES can improve liver function reserve for patients with liver cirrhosis, with or without hepatocellular carcinoma. LES is a promising intervention for reversing anabolic resistance and the sarcopenia of cirrhosis, resulting in an improved quality of life for patients with cirrhosis., (© 2019 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Considerable efforts have been directed towards stimulating healthy ageing regarding protein intake and malnutrition, yet large-scale consumer studies are scarce and fragmented. This study aims to profile older adults in the European Union (EU) according to appetite (poor/good) and protein intake (lower/higher) strata, and to identify dietary and physical activity behaviours. A survey with older (aged 65 years or above) adults ( n = 1825) in five EU countries (Netherlands, United Kingdom, Finland, Spain and Poland) was conducted in June 2017. Four appetite and protein intake strata were identified based on simplified nutritional appetite questionnaire (SNAQ) scores (≤14 versus >14) and the probability of a protein intake below 1.0 g/kg adjusted BW/day (≥0.3 versus <0.3) based on the 14-item Pro55+ screener: "appi"-Poor appetite and lower level of protein intake (12.2%); "APpi"-Good appetite but lower level of protein intake (25.5%); "apPI"-Poor appetite but higher level of protein intake (14.8%); and "APPI"-Good appetite and higher level of protein intake (47.5%). The stratum of older adults with a poor appetite and lower level of protein intake (12.2%) is characterized by a larger share of people aged 70 years or above, living in the UK or Finland, having an education below tertiary level, who reported some or severe financial difficulties, having less knowledge about dietary protein and being fussier about food. This stratum also tends to have a higher risk of malnutrition in general, oral-health related problems, experience more difficulties in mobility and meal preparation, lower confidence in their ability to engage in physical activities in difficult situations, and a lower readiness to follow dietary advice. Two multivariate linear regression models were used to identify the behavioural determinants that might explain the probability of lower protein intake, stratified by appetite status. This study provides an overview and highlights the similarities and differences in the strata profiles. Recommendations for optimal dietary and physical activity strategies to prevent protein malnutrition were derived, discussed and tailored according to older adults' profiles.

Background/aim: Disease related malnutrition is a major problem in hospitals. Malnutrition in hospitalized patients is caused by many factors. Among these factors are decreased appetite and early satiety, and reaching nutritional requirements in nutritional risk patients is a challenge when using ordinary energy and protein dense food. The aim of this study was to examine if total protein and energy intake in medical and surgical patients at nutritional risk could be improved by protein fortified and energy rich in-between meals., Methods: An assortment of fortified in-between meals including 10 g of protein was developed based on patient preferences and served in the Departments of Lung Medicine and Abdominal Surgery for a period of three months. Nutrition intake was recorded before and after intervention., Results: Food intake records were collected from a total of 92 patients, (46 before and 46 after intervention). The total amount of protein intake per in-between meal was increased from 2,6 g to 10,3 g. Total daily protein intake increased from 49% to 88% (p < 0.00) and total energy intake from 74% to 109% (p < 0.00) of requirements., Conclusion: Protein and energy intake for surgical and medical patients at in-between meals as well as total daily intake increased significantly. Recommended average level for individually measured requirements was reached., (Copyright © 2019. Published by Elsevier Ltd.)

Introduction: One anastomosis gastric bypass (OAGB) is now a recognized mainstream bariatric procedure being adopted by an increasing number of surgeons. The purpose of this review was to present an evidence-based summary of its key technical aspects and prevention and management of its specific complications., Evidence Acquisition: We examined PubMed for all published articles on OAGB, including the ones published under one of its various other names., Evidence Synthesis: An ideal OAGB procedure has a long, narrow pouch constructed carefully to avoid going too close to the greater curvature of the stomach especially at the bottom of the pouch and maintains a safe distance from the angle of His. A bilio-pancreatic limb length of 150 cm appears to be safest and a limb length of >200 cm is associated with a significantly increased incidence of protein-calorie malnutrition. We recommend routine closure of Petersen's space to prevent Petersen's hernia and suggest a protocol for micronutrient supplementation. This review also presents evidence-based algorithms for prevention and management of marginal ulcers, protein-calorie malnutrition, and gastroesophageal reflux disease after OAGB. We suggest lifelong supplementation with two multivitamin/mineral supplements (each containing at least 1.0 mg copper and 15 mg zinc) daily, 1.5 mg vitamin B12 orally daily or 3-monthly injection with 1 mg vitamin B12, 120 mg elemental iron daily, 1500 mg elemental calcium daily, and 3000 international units of vitamin D daily., Conclusions: This review examines key technical steps of OAGB. We also discuss how to prevent and manage its specific complications.

This study evaluated an alternative ocean-based fish protein, Advanced Protein Powder (APP) as a feasible, environmentally sustainable protein source to reduce childhood malnutrition. We completed a rodent feeding study to evaluate growth and development in young growing mice on a purified diet containing APP as compared to mice-fed diets using other common protein sources - casein, whey, and soy. Results suggested APP to be an effective and safe protein source and ensured normal body growth, bone development, and brain function in APP diet-fed mice. Evidence provided in this study supports considering the use of APP to reduce malnutrition among children worldwide.

Background: Carnitine deficiency is common in patients on hemodialysis. However, the efficacy of L-carnitine supplementation for improving lean body mass (LBM) and physical function has not yet been evaluated., Methods: In this multicenter, prospective, parallel, randomized, controlled trial, 91 patients on hemodialysis who developed carnitine deficiency were randomly assigned to receive injections of 1,000 mg L-carnitine 3 times per week after each hemodialysis session (L-carnitine group) or no injections (control group) with monitoring for 12 months., Results: The data for 84 of the 91 patients were available for analysis (L-carnitine group, n = 42; control group, n = 42). Dry weight and body mass index did not significantly change in the L-carnitine group, but significantly decreased in the control group. Arm muscle area (AMA) did not change significantly in the L-carnitine group but decreased significantly in the control group; the difference in mean AMA between the groups was 6.22% (95% confidence interval [CI] 1.90-10.5; P = 0.037). Hand grip strength did not change significantly in the L-carnitine group, but decreased significantly in the control group. The difference in change in hand grip strength between the groups was 4.27% (95% CI 0.42-8.12; P = 0.030). Furthermore, LBM did not change significantly in the L-carnitine group but decreased significantly in the control group; the difference in mean LBM between the groups was 2.92 % (95% CI 1.28-4.61; P = 0.0007)., Conclusions: L-carnitine supplementation is useful in patients who develop carnitine deficiency on hemodialysis because it maintains physical function and LBM.

Background/objectives: Septic Surgery Center (SSC) patients are at a particularly high risk of protein-energy malnutrition (PEM), with a prevalence of 35-85% found in various studies. Previous collaboration between our hospital's SSC and its Clinical Nutrition Team (CNT) only focussed on patients with severe PEM. This study aimed to determine whether it was possible to improve the quality of nutritional care in septic surgery patients with help of a nutritional policy using the Nutritional Risk Score (NRS)., Subjects/methods: Nutritional practices in the SSC were observed over three separate periods: in the 3 months leading up to the implementation baseline, 6 months after implementation of preventive nutritional practices, and at 3 years. The nutritional care quality indicator was the percentage of patients whose nutritional care, as prescribed by the SSC, was adapted to their specific requirements. We determined the septic surgery team's NRS completion rate and calculated the nutritional policy's impact on SSC length of stay. Data before (T 0 ) and after (T 1  + T 2 ) implementation of the nutritional policy were compared., Results: Ninety-eight patients were included. The nutritional care-quality indicator improved from 26 to 81% between T 0 and T 2 . During the T 1 and T 2 audits, septic surgery nurses calculated NRS for 100% and 97% of patients, respectively. Excluding patients with severe PEM, SSC length of stay was significantly reduced by 23 days (p = 0.005)., Conclusions: These findings showed that implementing a nutritional policy in an SSC is possible with the help of an algorithm including an easy-to-use tool like the NRS.

Background/objectives: Malnutrition risk screening represents a crucial starting point for the successful management of malnourished patients. This study was conducted to (1) examine the effect of the use of a malnutrition screening tool on process indicators of nutritional care and (2) explore healthcare professionals' perceptions and opinions regarding this tool., Methods: A mixed methods design was used. A controlled pretest-posttest study was conducted to carry out quantitative analyses, and semi-structured, qualitative interviews were held. Quantitative data were analysed with descriptive statistics, Chi-squared tests, Student's t-tests and Kruskal-Wallis H tests, using SPSS 23. Qualitative data were analysed by performing a qualitative content analysis using MAXQDA 12. Two comparable hospitals participated in the study, representing one intervention group (IG) and one control group (CG). The Graz Malnutrition Screening Tool (GMS) was implemented and used in the IG for at least 1 month, while the CG received no intervention., Results: The use of the screening tool positively correlated with significant improvements in the process indicators of nutritional care after 1 month, in terms of the number of nutritional interventions and the frequency of documentation of the diagnosis and the patient's weight and height. The content of the interviews revealed that nearly all professionals involved perceived the overall screening process positively. Few barriers were identified., Conclusions: The results of this study show that the use of a screening tool has a positive, short-term impact on the hospital's process quality of nutritional care. Ongoing efforts are required to sustainably maintain these positive changes. During this process, positive attitudes, nomination of motivated 'opinion-leaders' and concerted management support are helpful facilitators.

Background and Aims: Here we describe a dietary intervention for hyperphosphatemia in dialysis patients based on the partial replacement of meat and fish, which are one of the main sources of alimentary phosphorous, with egg white, a virtually phosphorous-free protein source. This intervention aims to reduce phosphorous intake without causing protein wasting., Patients and Methods: As many as 23 hyperphosphatemic patients (15 male and 8 female, mean age 53.0 ± 10.0 years) on chronic standard 4 h, three times weekly, bicarbonate hemodialysis were enrolled in this open-label, randomized controlled trial. Patients in the intervention group were instructed to replace fish or meat with egg white in three meals a week for three months whereas diet was unchanged in the control group., Results: Serum phosphate concentrations were significantly lower in the intervention group than in controls after three (4.9 ± 1.0 vs 6.6 ± 0.8; p < 0.001) but not after one month of treatment. Phosphate concentrations decreased more from baseline in the intervention than in the control group both after one (-1,2 ± 1,1 vs 0,5 ± 1,1; p = 0.004) and after three (-1,7 ± 1,1 vs -0,6 ± 1,1; p < 0.001) months of follow-up. No change either in body weight or in body composition assessed with bioelectrical impedance analysis or in serum albumin concentration was observed in either group., Conclusion: The partial replacement of meat and fish with egg white induces a significant decrease in serum phosphate without causing protein malnutrition and could represent a useful instrument to control serum phosphate levels in hemodialysis patients. CLINICALTRIALS., Gov Identifier: NCT03236701., (Copyright © 2018 The Italian Society of Diabetology, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition, and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.)

To prevent protein energy malnutrition (PEM) and accumulation of waste products, dialysis patients require diet adjustments. Dietary intake assessed by self-reported intakes often provides biased information and standard 24-h urinary excretion is inapplicable in dialysis patients. We aimed to assess dietary intake via a complementary, less biased biomarker method, and to compare this to dietary diaries. Additionally, we investigated the prospective association of creatinine excretion rate (CER) reflecting muscle mass with mortality. Complete intradialytic dialysate and interdialytic urinary collections were used to calculate 24-h excretion of protein, sodium, potassium, phosphate and creatinine in 42 chronic dialysis patients and compared with protein, sodium, potassium, and phosphate intake assessed by 5-day dietary diaries. Cox regression analyses were employed to investigate associations of CER with mortality. Mean age was 64 ± 13 years and 52% were male. Complementary biomarker assessed (CBA) and dietary assessed (DA) protein intake were significantly correlated ( r = 0.610; p < 0.001), but there was a constant bias, as dietary diaries overestimated protein intake in most patients. Correlations were found between CBA and DA sodium intake ( r = 0.297; p = 0.056), potassium intake ( r = 0.312; p = 0.047) and phosphate uptake/intake ( r = 0.409; p = 0.008). However, Bland-Altman analysis showed significant proportional bias. During a median follow-up of 26.6 (25.3⁻31.5) months, nine dialysis patients (23%) died. CER was independently and inversely associated with survival (HR: 0.59 (0.42⁻0.84); p = 0.003). Excretion measurements may be a more reliable assessment of dietary intake in dialysis patients, as this method is relatively free from biases known to exist for self-reported intakes. CER seems to be a promising tool for monitoring PEM.

Background: Macronutrient delivery during pediatric ECMO therapy can be challenging. We examined predictors of nutrient delivery in the first 2 weeks of extracorporeal membrane oxygenation (ECMO) therapy in the pediatric intensive care unit (ICU)., Methods: Details of macronutrient delivery were recorded in children (newborn-18 years of age) who survived 24 hours after cannulation to ECMO over a 3-year period (2012-2015)., Results: We analyzed data from 54 consecutive eligible patients, 43% female, with median (interquartile range) ECMO duration of 8.5 (6-24) days, age 0.1 (0, 16) months, ICU length of stay 32 (21, 60) days, and 28-day mortality 13%. Median weight for age z score declined from -0.1 at admission to -1.2 at 30 days (P = 0.013). At least 80% goal energy and protein was delivered in 35 (65%) and 33 (61%) patients, respectively, by day 7; 10% of energy and 11% protein goal was delivered enterally. Parenteral nutrition (PN) was utilized in 47 (87%) patients, initiated by day 1 (1, 3). Enteral nutrition (EN) was successfully delivered in 49 (94%) patients (35% postpyloric), initiated by day 6 (2, 16). Younger age (P = 0.01) and venoarterial mode of ECMO (P = 0.0014) were associated with lower EN delivery. Use of umbilical artery catheters or vasoactive infusions did not impede EN delivery. Late PN delivery was associated with cumulative protein deficits (P = 0.019) and failure to achieve nutrient delivery goals by day 7., Conclusions: Optimal nutrient delivery was achieved in most patients by day 7, predominantly via PN. Early EN is feasible in low volumes, but PN may be essential to prevent cumulative energy and protein deficits during the first week of ECMO., (© 2018 American Society for Parenteral and Enteral Nutrition.)

Objectives: To evaluate whether body composition monitor (BCM) could be a practical instrument for nephrologists to assess nutritional status in patients on hemodialysis (HD) and whether it is more effective in identifying patients at highest risk of developing protein-energy wasting (PEW) alone or in combination with other tools currently used for that purpose., Design: Observational cross-sectional study in 91 HD patients (60 ± 14 years, 70.3% male, 24 ± 4.1 kg/m 2 body mass index) from 2 different locations., Methods: Nutritional status was evaluated by anthropometric methods (biceps and triceps skinfold thickness, waist circumference, and arm muscular circumference), biochemical nutritional markers, malnutrition-inflammation score (MIS), and BCM. The patients were grouped into those with and without PEW by using classical criteria and then classified as being adequately or inadequately nourished according to a BCM flow chart to detect those requiring preferential nutritional intervention. A multivariate approach was used to calculate the risk of developing PEW., Results: Anthropometric measurements revealed significantly lower body mass index (<23 kg/m 2 ; odds ratios [OR] = 13.3 and P = 0.001) and arm muscular circumference < p10 (OR = 34, P < 0.001) in the PEW group. MIS was above 5 in all the patients classified as having PEW. BCM showed that fat tissue index < p10 was significantly lower in this group (OR = 1.52), and a decision tree using the lean tissue index < p10, fat tissue index < p10, and extracellular water > 15% revealed that 42.9% of the patients would need nutritional monitoring. On multivariate analysis, insufficient nutritional status detected by BCM decision tree was an independent prognostic factor for developing PEW. About 9.89% of the patients were classified as PEW, with MIS > 5, and insufficient nutritional status detected by BCM required preferential nutritional intervention., Conclusion: BCM is a practical instrument for nephrologists to assess nutritional status in patients on HD and is useful for the early prevention and detection of PEW, as is able to identify differences in body composition, predict clinically important outcomes, and classify patients requiring preferential nutritional intervention., (Copyright © 2018 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Interventions such as oral nutritional supplements (ONS), fortified meals and mid-meals, feeding assistants and Protected Mealtimes have shown some impact on nutritional intake in research studies, but embedding them in practise remains challenging. This study monitored nutritional intake of older medical inpatients as dietary and mealtime interventions were progressively implemented into routine practise., Methods: Series of three prospectively evaluated patient cohorts allowed comparison of nutritional intake of 320 consented medical inpatients aged 65 + years: cohort 1 (2007-8), cohort 2 (2009) and cohort 3 (2013-14) as nutrition care interventions were progressively introduced and embedded. Interventions focused on 'assisted mealtimes', fortified meals and mid-meals, and ONS. Energy and protein intake were calculated from visual plate waste of individual meal and mid-meal components on day 5 of admission. Nutrition care processes were evaluated by mealtime audits of diet type, assistance and interruptions on the same day. One-way ANOVA and chi square tests were used for comparison between cohorts., Results: Significant, progressive improvements in energy and protein intake were seen between cohorts (energy: cohort 1: 5073 kJ/d; cohort 2: 5403 kJ/d; cohort 3: 5989 kJ/d, p = 0.04; protein: cohort 1: 48 g/d, cohort 2: 50 g/d, cohort 3: 57 g/d, p = 0.02). Greater use of fortified meals and mid-meals and sustained improvements in mealtime assistance likely contributed to these improvements., Conclusions: Multi-faceted system-level approach to nutrition care, including changes to dietary and mealtime care processes, was associated with measureable and sustained improvements in nutritional intake of older inpatients over a seven year period., (Copyright © 2017 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.)

This study aimed to identify the determinants of nutritional status of children in India with a special focus on dietary diversity at the state level. Household-level consumption data from three rounds of the Consumer Expenditure Survey of the National Sample Survey Organization (1993-2012) were used. Information on the nutritional status of children was taken from the National Family Health Survey (2005-06). Dietary diversity indices were constructed at the state level to examine diversity in quantity of food consumed and food expenditure. Multilevel regression analysis was applied to examine the association of state-level dietary diversity and other socioeconomic factors with the nutritional status of children. It was observed that significant variation in childhood stunting, wasting and underweight could be explained by community- and state-level factors. The results indicate that dietary diversity has increased in India over time, and that dietary diversity at the state level is significantly associated with the nutritional status of children. Moreover, percentage of households with a regular salaried income in a state, percentage of educated mothers and mothers receiving antenatal care in a community are important factors for improving the nutritional status of children. Diversity in complementary child feeding is another significant determinant of nutritional status of children. The study thus concludes that increasing dietary diversity at the state level is an effective measure to reduce childhood malnutrition in India.

Poor nutritional status and protein-energy wasting are common among maintenance dialysis patients and associated with unfavorable outcomes. Providing foods, meal trays, snack boxes, and/or oral nutritional supplements during hemodialysis can improve nutritional status and might also reduce inflammation, enhance health-related quality of life, boost patient satisfaction, and improve survival. Potential challenges include postprandial hypotension and other hemodynamic instabilities, aspiration risk, gastrointestinal symptoms, hygiene issues, staff burden, reduced solute removal, and increased costs. Differing in-center nutrition policies exist within organizations and countries around the world. Recent studies have demonstrated clinical benefits and highlight the need to work toward clear guidelines. Meals or supplements during hemodialysis may be an effective strategy to improve nutritional status with limited reports of complications in real-world scenarios. Whereas larger multicenter randomized trials are needed, meals and supplements during hemodialysis should be considered as a part of the standard-of-care practice for patients without contraindications., (Copyright © 2017. Published by Elsevier Inc.)

Protein-energy malnutrition (PEM) has adversely affected the generations of developing countries. It is a syndrome that in severity causes death. PEM generally affects infants of 1-5 age group. This manifestation is maintained till adulthood in the form of poor brain and body development. The developing nations are continuously making an effort to curb PEM. However, it is still a prime concern as it was in its early years of occurrence. Transgenic crops with high protein and enhanced nutrient content have been successfully developed. Present article reviews the studies documenting genetic engineering-mediated improvement in the pulses, cereals, legumes, fruits and other crop plants in terms of nutritional value, stress tolerance, longevity and productivity. Such genetically engineered crops can be used as a possible remedial tool to eradicate PEM.

Vitamin A deficiency (VAD) is a serious and widespread public health problem and the leading cause of preventable blindness in young children. It is also associated with increased rates of death from severe infections, especially in developing countries. Over the past 35 years, researchers have examined the numerous activities of vitamin A in different tissues of the human body. VAD can lead to a series of ocular symptoms, anemia, and weak resistance to infection, which can increase the severity of infectious diseases and the risk of death. Cell development, vision, growth, and normal metabolism are among the vital processes that are insufficiently supported in the presence of VAD. VAD leads to impaired tissue function especially during the developmental periods of infancy, childhood, pregnancy, and lactation. We describe a multidirectional model of VAD that demonstrates how VAD can have progressive, negative effects on vital processes of the human body throughout the life cycle. This model starts with impaired intake and its link to decreased absorption and digestion and includes outcomes such as malnutrition, inflammation, and improper growth processes, including possible mechanisms. Together, these clinical and biochemical manifestations contribute to the vicious cycle of VAD.

Protein-energy malnourishment is commonly encountered in patients with end-stage liver disease who undergo liver transplantation. Malnutrition may further increase morbidity, mortality and costs in the post-transplantation setting. The importance of carefully assessing the nutritional status during the work-up of patients who are candidates for liver replacement is widely recognized. The metabolic abnormalities induced by liver failure render the conventional assessment of nutritional status to be challenging. Preoperative loss of skeletal muscle mass, namely, sarcopenia, has a significant detrimental impact on post-transplant outcomes. It is essential to provide sufficient nutritional support during all phases of liver transplantation. Oral nutrition is preferred, but tube enteral nutrition may be required to provide the needed energy intake. Herein, the latest currently employed perioperative nutritional interventions in liver transplant recipients are thoroughly illustrated including synbiotics, micronutrients, branched-chain amino acid supplementation, immunonutrition formulas, fluid and electrolyte balance, the offering of nocturnal meals, dietary counselling, exercise and rehabilitation., Competing Interests: The authors declare no conflict of interest.

Objective: To investigate the effect of dietary counselling on the nutritional status of end-stage renal disease patients undergoing maintenance haemodialysis., Methods: This study was conducted at the Institute of Kidney Diseases, Peshawar, Pakistan, from November to December 2015, and comprised patients of either gender with protein energy wasting. The nutritional status assessment was based on four categories, including biochemical indicators (haemoglobin, serum albumin and cholesterol), measure of body mass index, reduced body fatness, decreased muscle mass and low protein or energy intake. Energy and nutrients intake of patients before and after counselling were estimated by 24-hour dietary recall method. SPSS 20 was used for data analysis., Results: Of the 100 patients, 74(74%) were males and 26(26%) were females. The overall mean age was 41.45±17.44 years. Dietary counselling was significantly effective in increasing the intake of energy (p=0.010), protein (p=0.003) and fats (p=0.002). There was significant improvement in mid-upper arm circumference (p<0.0001) and tricep fat fold (p<0.0001) after counselling. Statistically significant effect was seen in improving serum cholesterol levels (p=0.039)., Conclusions: Dietary counselling was found to be effective in improving the nutritional status and dietary intake of end-stage renal disease patients.

Background: Early use of enteral nutrition (EN) is indicated following surgical resection of esophageal cancer. However, early EN support does not always meet the optimal calorie or protein requirements, and the benefits of supplementary parenteral nutrition (PN) remain unclear. We aimed to evaluate the efficacy and safety of early supplementary PN following esophagectomy., Materials and Methods: We enrolled 80 consecutive patients who underwent esophagectomy. Resting energy expenditure and body composition measurements were performed in all patients preoperatively and postoperatively. EN was administered after surgery, followed by randomization to either EN+PN or EN alone. The amount of PN administered was calculated to meet the full calorie requirement, as measured by indirect calorimetry, and 1.5 g protein/kg fat-free mass (FFM) per day was added as determined by body composition measurement. The clinical characteristics were compared between the 2 groups., Results: Patients in the EN+PN group but not in the EN group preserved body weight (0.18 ± 3.38 kg vs -2.15 ± 3.19 kg, P < .05) and FFM (1.46 ± 2.97 kg vs -2.08 ± 4.16 kg) relative to preoperative measurements. Length of hospital stay, postoperative morbidity rates, and standard blood biochemistry profiles were similar. However, scores for physical functioning (71.5 ± 24.3 vs 60.4 ± 27.4, P < .05) and energy/fatigue (62.9 ± 19.5 vs 54.2 ± 23.5, P < .05) were higher in the EN+PN group 90 days following surgery., Conclusion: Early use of supplemental PN to meet full calorie requirements of patients who underwent esophagectomy led to better quality of life 3 months after surgery. Moreover, increased calorie and protein supplies were associated with preservation of body weight and FFM.

Background: Poor physical performance and protein-energy wasting (PEW) are health issues of major concern in haemodialysis patients. The conventional haemodialysis (CHD) regime, three times per week 3-5 h, is subject of discussion because of high morbidity and mortality rates. When patients switch from CHD to longer dialysis sessions, i.e. nocturnal haemodialysis (NHD), improvement in protein intake and increase in body weight is seen. However, it is unclear whether physical performance and more important aspects of PEW, such as body composition, improve as well. Therefore, the aim of this study is to investigate whether physical performance improves and PEW decreases, when patients switch from CHD to NHD. A second aim is to assess the influence of NHD on the biomarkers fibroblast growth factor-23 and sclerostin which are thought to be associated with malnutrition and mortality in patients on haemodialysis., Methods: This study is a prospective multicentre cohort study with an inclusion aim of 50 patients: 25 patients in a control group (three times per week, 3-5 h CHD) and 25 patients in a nocturnal group (three times per week, 7-9 h NHD). Primary outcome is change in physical performance, measured by the Short Physical Performance Battery. Additional measurements are a 6-min walk test, handgrip strength, a physical activity questionnaire and physical activity monitoring. The secondary outcome of the study is PEW, which will be evaluated by body weight, dual-energy X-ray absorptiometry, bio-electrical impedance spectroscopy, mid-upper arm muscle circumference, subjective global assessment, visual analogue scale for appetite and dietary records. Laboratory measurements including fibroblast growth factor-23 and sclerostin, and quality of life assessed with the Kidney Disease Quality of Life-Short Form are also studied. In every patient, four repeated measurements will be performed during one year of follow-up., Discussion: This study will investigate whether physical performance improves and PEW decreases when patients switch from CHD to NHD, compared to a control group who continue treatment with CHD. Strengths of this study are the comparison with a conventional haemodialysis cohort, and the broad variety of objective measurements combined with patient-reported outcomes of physical performance and PEW., Trial Registration: NTR4715 , Netherlands Trial Register. Registered 30 July 2014.

Introduction:: Protein-energy malnutrition in Crohn's disease (CD) has been reported in 20 to 92% of patients, and is associated with increased morbidity and mortality and higher costs for the health system. Anti-TNF drugs are a landmark in the clinical management, promoting prolonged remission in patients with CD. It is believed that the remission of this disease leads to nutritional recovery. The effect of biological therapy on body composition and nutritional status is unclear., Method:: Prospective study of body assessment by bioelectrical impedance method in patients with moderate to severe CD undergoing treatment with infliximab. The main outcome was the body composition before and after 6 months of anti-TNF therapy., Results:: There was a predominance of females (52%) with a mean age of 42±12 years. Most patients were eutrophic at baseline and remained so. There was an increase in all parameters of body composition after anti-TNF treatment: BMI (22.9±3.2 versus 25±3.8; p=0.005), waist circumference (88.1±6.7 versus 93.9±7.7; p=0.002), lean mass index (17.5±2.2 versus 18.2±2.3; p=0.000) and fat mass index (5.5±2.3 versus 6.8±2.3; p=0.000). Phase angle remained unchanged (6.2 versus 6.8; p=0.94)., Conclusion:: After therapy with IFX, all components of body composition increased, except for phase angle. The substantial increase in fat mass index and waist circumference led to concern regarding cardiovascular risk and, thus, to the need for further studies.

The history of dialysis and diet can be viewed as a series of battles waged against potential threats to patients' lives. In the early years of dialysis, potassium was identified as "the killer", and the lists patients were given of forbidden foods included most plant-derived nourishment. As soon as dialysis became more efficient and survival increased, hyperphosphatemia, was identified as the enemy, generating an even longer list of banned aliments. Conversely, the "third era" finds us combating protein-energy wasting. This review discusses four questions and four paradoxes, regarding the diet-dialysis dyad: are the "magic numbers" of nutritional requirements (calories: 30-35 kcal/kg; proteins > 1.2 g/kg) still valid? Are the guidelines based on the metabolic needs of patients on "conventional" thrice-weekly bicarbonate dialysis applicable to different dialysis schedules, including daily dialysis or haemodiafiltration? The quantity of phosphate and potassium contained in processed and preserved foods may be significantly different from those in untreated foods: what are we eating? Is malnutrition one condition or a combination of conditions? The paradoxes: obesity is associated with higher survival in dialysis, losing weight is associated with mortality, but high BMI is a contraindication for kidney transplantation; it is difficult to limit phosphate intake when a patient is on a high-protein diet, such as the ones usually prescribed on dialysis; low serum albumin is associated with low dialysis efficiency and reduced survival, but on haemodiafiltration, high efficiency is coupled with albumin losses; banning plant derived food may limit consumption of "vascular healthy" food in a vulnerable population. Tailored approaches and agreed practices are needed so that we can identify attainable goals and pursue them in our fragile haemodialysis populations.

Background: The leading cause of death in children in developing countries is protein-energy malnutrition. In Viet Nam, 25.9% of children under 5 experience stunted growth and 6.6% are moderately wasted. Iron deficiency anaemia and vitamin A deficiency contribute to these and other malnutrition conditions., Objectives: Given these factors, more evidence based approaches are required to improve understanding of current attitudes, opinions and behaviours of mothers with young children, in order to operationalise social marketing of nutrition commodities in Viet Nam., Methods and Study Design: A literature review supported a rapid assessment and response method involving semi-structured interviews with 77 stakeholders and focus group discussions with 80 program beneficiaries from four geographic locations in the north and south of Viet Nam. Discussion agendas were developed to address key program issues with grounded theory utilized for data analysis., Results: Data analysis highlighted challenges and opportunities within the six Ps of social marketing: Supply and demand side issues included: cost and the quality of products, the limited scale of interventions and promotional activities. Policy issues identified related to current policies that inhibited the broader promotion and distribution of micronutrient products, and opportunities for improved dialogue with policy partners. Partnerships further emphasized the need for public private partnerships to support the social change process., Conclusion: Implications for theory, policy, and practice indicates that rapid assessment and response is a cost-effective, pragmatic method of public health research, in resource constrained settings, to explore policies and behaviours amenable to change and build stakeholder engagement in the program.

Objective: To evaluate the effect of individually tailored dietary counseling on nutritional status among home care clients aged 75 years or older., Design: Non-randomised controlled study., Setting and Participants: The study sample consisted of 224 home care clients (≥ 75 years) (intervention group, n = 127; control group, n = 100) who were at protein-energy malnutrition (PEM) or risk of PEM (MNA score <24 and plasma albumin <35 g/L)., Intervention: Individually tailored dietary counseling; the persons were instructed to increase their food intake with energy-dense food items, the number of meals they ate and their consumption of energy-, protein- and nutrient-rich snacks for six months., Measurements: The Mini Nutritional Assessment (MNA), Body Mass Index (BMI) and plasma albumin were used to determine nutritional status at the baseline and after the six-month intervention., Results: The mean age of the home care clients was 84.3 (SD 5.5) in the intervention group and 84.4 (SD 5.3) in the control group, and 70 percent were women in both groups. After the six-month nutritional intervention, the MNA score increased 2.3 points and plasma albumin 1.6 g/L in the intervention group, against MNA score decreased -0.2 points and plasma albumin -0.1 g/L in the control group., Conclusions: Individually tailored dietary counseling may improve nutritional status among older home care clients., Competing Interests: The authors do not have any conflicts of interest to disclose.

Dietary modification is recommended in the management of chronic kidney disease (CKD). Individuals with CKD often have multiple comorbidities, such as high blood pressure, diabetes, obesity, and cardiovascular disease, for which dietary modification is also recommended. As CKD progresses, nutrition plays an important role in mitigating risk for cardiovascular disease and decline in kidney function. The objectives of nutrition interventions in CKD include management of risk factors, ensuring optimal nutritional status throughout all stages of CKD, preventing buildup of toxic metabolic products, and avoiding complications of CKD. Recommended dietary changes should be feasible, sustainable, and suited for patients' food preferences and clinical needs., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The aim of this review is to present scientific evidence on the biological, dietary, cultural and economic advantages of cow´s milk and dairy products intake in adults, with emphasis on the elderly. The role of milk and dairy products as part of the regular diet, as well as their contribution to a healthy diet for the aged population is described. The updated scientific references on the importance of milk and dairy products on the dietary management of the most prevalent diseases of the eldery -among these energy-protein malnutrition, sarcopenia, obesity, sarcopenic obesity, osteoporosis, diabetes and cardiovascular diseases- are presented.

Background/aim: Undernutrition affects about 40% of patients in hospitals. Ordinary food is recommended as the first choice to prevent and correct undernutrition. Meanwhile, sufficient intake, especially regarding protein, is difficult to reach, in patients at nutritional risk. The aim of this study was to improve protein intake at breakfast to at least 20% of total daily requirement or at least 20 g., Methods: A protein rich breakfast including 20 g of protein was served in the departments of heart and lung surgery and vascular surgery for three months. Nutrition intake was registered before and after intervention., Results: Food intake records were collected from 32 and 30 patients respectively, mean age 69 (SD 8) years. At breakfast, protein intake was improved from 14% of individual requirements to 22% (p<0.001) and energy intake was improved from 18% to 25% (p=0.01). Total amount of protein intake for breakfast was increased from 14 g to 20 g (p<0.002). Total daily protein intake increased from 64% to 77% (p=0.05) and total energy intake from 76% to 99% (p<0.01) of requirements., Conclusion: Protein and energy intake for surgical patients at breakfast as well as total daily intake was significantly increased to meet recommended average level for minimum individually measured requirements., (Copyright © 2016 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.)

Background & Aims: Patients who underwent endoscopic gastrostomy (PEG) present protein-energy malnutrition, but little is known about Trace Elements (TE), Zinc (Zn), Copper (Cu), Selenium (Se), Iron (Fe), Chromium (Cr). Our aim was the evaluation of serum TE in patients who underwent PEG and its relationship with serum proteins, BMI and nature of underlying disorder., Methods: A prospective observational study was performed collecting: patient's age, gender, underlying disorder, NRS-2002, BMI, serum albumin, transferrin and TE concentration. We used ferrozine colorimetric method for Fe; Inductively Coupled Plasma-Atomic Emission Spectroscopy for Zn/Cu; Furnace Atomic Absorption Spectroscopy for Se/Cr. The patients were divided into head and neck cancer (HNC) and neurological dysphagia (ND)., Results: 146 patients (89 males), 21-95 years: HNC-56; ND-90. Low BMI in 78. Low values mostly for Zn (n = 122) and Fe (n = 69), but less for Se (n = 31), Cu (n = 16), Cr (n = 7); low albumin in 77, low transferrin in 94 and 66 with both proteins low. Significant differences between the groups of underlying disease only for Zn (t140.326 = -2,642, p < 0.01) and a correlation between proteins and TE respectively albumin and Zn (r = 0.197, p = 0.025), and albumin and Fe (r = 0.415, p = 0.000)., Conclusions: When gastrostomy was performed, patients display low serum TE namely Zn, but also Fe, less striking regarding others TE. It was related with prolonged fasting, whatever the underlying disease. Low proteins were associated with low TE. Teams taking care of PEG-patients should use Zn supplementation and include other TE evaluation as part of the nutritional assessment of PEG candidates., (Copyright © 2015 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

A holistic approach in assessment and plan for intervention in childhood malnutrition is the need of the hour. This is in the context of nutrition education program (NEP), undertaken under the National IAP action plan, 2015. In the crusade against malnutrition, an ABCDEFQ assessment scale is recommended, with aspects covering anthropometric, biochemical, clinical, dietary, ecological/epidemiological, functional parameters and quality of life. In the dietary assessment, a scoring system based on the ten interventions related to infant and young child feeding (IYCF) practices recommended by UNICEF and the food frequency table score are incorporated. In the evaluation of quality of life and plan for intervention, a tool called IMPACT (IAP Malnutrition Proactive Assessment: A Comprehensive Tool) is proposed.

Purpose of Review: Muscle wasting is dramatic in critically ill patients and related to worsened outcome. The question is whether this can be prevented or reduced by adequate protein feeding. Recommendations for protein requirements are different between different societies, because of limited and weak evidence. Most studies, on which these recommendations are based, use nitrogen balance as primary outcome. However, nitrogen balance to estimate protein needs over short periods, is not reliable., Recent Findings: Studies using tracer methodology to assess the effects of feeding on whole-body protein synthesis, breakdown and balance, show that both adult and pediatric critically ill patients can utilize parenterally and enterally given proteins or amino acids to build body protein, and that the extra amino acids are not oxidized., Summary: Recent studies show a positive correlation between protein intake and protein balance, with many patients reaching a positive protein balance. However, many questions remain. Especially whether adult patients should have a constant positive protein balance, whether the route of administration affects utilization, which proteins are synthesized and whether these are beneficial, is more protein better and what is the upper limit, and whether a positive protein balance affects clinical outcome?

Background: From the 1950s to the mid-1970s, United Nations (UN) agencies were focused on protein malnutrition as the major worldwide nutritional problem. The goal of this review is to examine this era of protein malnutrition, the reasons for its demise, and the aftermath., Summary: The UN Protein Advisory Group was established in 1955. International conferences were largely concerned about protein malnutrition in children. By the early 1970s, UN agencies were ringing the alarm about a 'protein gap'. In The Lancet in 1974, Donald McLaren branded these efforts as 'The Great Protein Fiasco', declaring that the 'protein gap' was a fallacy. The following year, John Waterlow, the scientist who led most of the efforts on protein malnutrition, admitted that a 'protein gap' did not exist and that young children in developing countries only needed sufficient energy intake. The emphasis on protein malnutrition waned. It is recently apparent that quality protein and essential amino acids are missing in the diet and may have adverse consequences for child growth and the reduction of child stunting. Key Messages: It may be time to re-include protein and return protein malnutrition in the global health agenda using a balanced approach that includes all protective nutrients., Competing Interests: no conflicts of interest, (© 2016 S. Karger AG, Basel.)

Background: Macronutrient deficit in the surgical intensive care unit (ICU) is associated with worse in-hospital outcomes. We hypothesized that increased caloric and protein deficit is also associated with a lower likelihood of discharge to home vs transfer to a rehabilitation or skilled nursing facility., Materials and Methods: Adult surgical ICU patients receiving >72 hours of enteral nutrition (EN) between March 2012 and May 2014 were included. Patients with absolute contraindications to EN, <72-hour ICU stay, moribund state, EN prior to surgical ICU admission, or previous ICU admission within the same hospital stay were excluded. Subjects were dichotomized by cumulative caloric (<6000 vs ≥ 6000 kcal) and protein deficit (<300 vs ≥ 300 g). Baseline characteristics and outcomes were compared using Wilcoxon rank and χ(2) tests. To test the association of macronutrient deficit with discharge destination (home vs other), we performed a logistic regression analysis, controlling for plausible confounders., Results: In total, 213 individuals were included. Nineteen percent in the low-caloric deficit group were discharged home compared with 6% in the high-caloric deficit group (P = .02). Age, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II), and initiation of EN were not significantly different between groups. On logistic regression, adjusting for BMI and APACHE II score, the high-caloric and protein-deficit groups were less likely to be discharged home (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.08-0.96; P = .04 and OR, 0.29; 95% CI, 0.0-0.89, P = .03, respectively)., Conclusions: In surgical ICU patients, inadequate macronutrient delivery is associated with lower rates of discharge to home. Improved nutrition delivery may lead to better clinical outcomes after critical illness., (© 2015 American Society for Parenteral and Enteral Nutrition.)

Objective: Dietary phosphorus restriction and intake adequate amount of protein play a prominent role in control of hyperphosphatemia and prevention of protein-energy malnutrition for chronic kidney disease (CKD) and dialysis patients. To reduce dietary phosphorus intake, we focused on boiling, which can affect the bioavailability of nutrients by changing mineral solubility and breaking down food structure. The aim of this study was to assess the effect of boiling on the phosphorus and protein content of beef. We boiled beef in differing fluid mediums, varied the size of the meat, method of boiling and cooking time, and compared the effects on phosphorus reduction., Design and Methods: We evaluated the retention values of phosphorus, protein, and phosphorus to protein ratio in beef before and after boiling. We used differing fluid mediums (soft water, hard water, 5% solution of acetate, and 0.5% sodium bicarbonate water), varied the size of the meat (block, sliced, and cubed), different boiling methods (normal pan and pressure cooker [PC]), and different cooking time (10 and 30 minutes)., Results: The soft water sample had lower phosphorus to protein ratio compared with the hard water, 5% solution of acetate, and 0.5% sodium bicarbonate water sample. The phosphorus content of the sliced meat sample at 30 minutes was almost half the content of the uncut block of sample at 10 minutes. The block PC sample for 10 minutes had a phosphorus content almost equal to the block normal pan sample for 30 minutes. Moreover, the sliced PC sample at 30 minutes had the lowest phosphorus to protein ratio of all the samples., Conclusions: Our results show that boiling with soft water, sliced food and a PC is the preferable cooking procedure for chronic kidney disease and dialysis patients because it allows for a reduction of the phosphorus content while preserving protein content, and it would bring the suppression of protein-energy malnutrition., (Copyright © 2015 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Protein Energy Wasting (PEW) is a pathological condition characterized by a progressive reduction of protein and energy stores. PEW has a high prevalence among patients with CKD/ESRD (Chronic Kidney Disease/End Stage Renal Disease) and is closely associated with adverse clinical outcomes and increased rate of hospitalization, complications and mortality. The multifactorial pathogenesis of PEW is complex. A key role is played both by the reduced intake of nutrients and the condition of hypercatabolism/reduced anabolism typical of renal patients. The approach to prevent or treat PEW has several milestones such as reduction of potential risk factors, improvement in lifestyle and correction of any factor related to dialysis. It also needs a periodic assessment of nutritional status by using biochemical markers, body and muscle mass variables, nutritional scores and instrumental methods, aiming for an early diagnosis. In case of reduced protein and energy intake, the administration of nutrients during dialysis, or the use of oral supplements specific for renal patients are the first nutritional interventions recommended. In fact, oral nutritional supplementation represents the most effective nutritional approach to PEW prevention and treatment. It is simple and safe and it has a positive impact on quality of life and survival of haemodialysis patients. In the case of failure of oral supplementation, nutritional support should be enhanced by using intradialytic parenteral nutrition (IDPN). If the patient has difficulty in swallowing or IDPN is insufficient, total enteral nutrition should be considered.