Perspectives on enteral tube feeding in Japan

[Introduction] The purpose of this study was to investigate the differences in the preference of enteral tube feeding between elderly inhabitants of Mugi town, Tokushima Prefecture, Japan, and their parents in various physical conditions. [Methods] This population-based questionnaire survey studied 300 randomly selected participants aged 65–80 years. Respondents were to consider a situation where eating was difficult, and were questioned on their desire for tube feeding, using a visual analogue scale (VAS) ranging from “do not want tube feeding (0)” to “want tube feeding (100).” [Results] Valid responses of 103 (34.4%) participants were analyzed. Under conditions of being “healthy,” “bedridden,” “with dementia,” and “bedridden and with dementia,” the median (IQR) of the VAS values for the desire for tube feeding were 31.8 (3.3 to 83.8), 19.3 (2.4 to 52.3), 5.2 (0.7 to 18.9), 4.0 (0.3 to 15.2) for respondents and 55.2 (11.6 to 92.2), 48.7 (5.5 to 85.5), 9.0 (1.2 to 46.8), 5.1 (0.1 to 36.5) for parents, respectively. The VAS values for the parents were significantly higher (p=0.001, 0.002, 0.001, and 0.01, respectively for the four conditions described) for the same items. [Conclusion] Surrogate decisions made by family members often differ from what the patients would have desired

Decisions about feeding after stroke

In the acute stages of stroke where the patient experiences dysphagia or reduced levels of consciousness, clinicians make decisions on how a patient's food and fluid needs will be met. These decisions include whether the patient should take oral diet, or whether nutrition should be administered via a Nasogastric (NG) or Percutaneous Endoscopic Gastrostomy (PEG) tube. This qualitative study investigates the process by which clinicians make decisions over the timing and mode of nutrition or hydration interventions available to them. Data were collected from twenty patient participants and twenty-four clinicians from two NHS Trusts. The patient data comprised both clinical case note data and observational data taken from clinical discussions on the ward during their admission. In-depth interviews were undertaken with clinicians to explore their experiences and views on decision making for nutrition and hydration. The data were analysed to generate substantive theory following the principles of grounded theory. The findings suggest that the decision making process follows a normative pathway of 'not to feed' the patient which is based on three key beliefs. These were that; nutrition and hydration were viewed as distinct and different interventions, with nutrition not being considered essential to recovery after stroke; the risk of pulmonary aspiration was perceived to outweigh the benefits of providing nutrition; and, that nutritional interventions could prolong a poor Quality of Life for a patient. Deviation from this normative pathway by clinicians was influenced by four key themes; views about the patient's prognosis; beliefs about the nutrition and hydration interventions available; perceived responsibilities of those involved; and, personal conscience issues. The findings from the study are discussed in the context of clinical practice and the implications for future researc

From bench to bedside : the development of a location indicating nasogastric tube

BackgroundNasogastric tubes are frequently used in clinical practice. Correct placement in the stomach must be verified on passing the tube and before every feed or administration of medicine. Current methods of confirming placement are limited and complications related to incorrect placement are well documented. The need for an easy, safe, reliable bedside method for verifying nasogastric tube placement has been identified.AimTo develop a manufactured prototype of an effective, sensitive and reliable nasogastric tube which self-indicates its position and is ready for clinical investigation in patients.MethodsA pH sensitive redox polymer, vitamin K1, was applied to the tip of 40 hand adapted nasogastric tubes (iteration 1) that were then assessed in pH solutions and clinical samples. Results were used to inform the design of manufactured prototype tubes (iteration 2). A total of 60 iteration 2 tubes were prepared and evaluated in a range of fluids, resected stomach tissue, gastric fluid and sputum. Documentation for regulatory approval of the new device was prepared and the intellectual property protected in preparation for licensing with a commercial partner. A User Network was established to inform the design and development of the device.ResultsA total of 100 prototype tubes were evaluated. One third of iteration 1 prototypes and all of iteration 2 manufactured prototypes, generated a measurable current. Variation in the size and nature of the gastric tissue samples limited definitive conclusions that could be drawn from these experiments, but guided design choices in an iterative manner. However experiments with human gastric fluid demonstrated that, using linear sweep voltammetry, zero current potential gave clearer distinction of pH than amperometry in the desired pH range. Patent protection (granted in Australia, USA and Canada and pending in Europe) of the associated intellectual property and completion of the regulatory approvals process enabled negotiations with a number of companies interested in manufacturing the novel medical device for clinical trials. A User Network was established and a range of communication strategies developed to ensure that the development of the device was informed by current experience of lay and professional users.ConclusionThis thesis documents a translational research study in which understanding of electrochemistry was applied to a current clinical problem generating new knowledge. It was demonstrated that, when a redox polymer is applied to the distal tip of a nasogastric tube, the electrochemical reaction can be measured at the proximal end and assessment of the zero current potential distinguishes fluids of different pH values. New understanding of the reality of user involvement in the development of medical devices was generated and a flexible approach of a User Network is advocated. A commercially manufactured device, with appropriate regulatory approvals was produced ready for clinical trials and patents granted or pending across the globe

Life-Sustaining Technologies and the Elderly

A report on OTA has conducted a study of a wide range of topics, some of which have recently been receiving a great deal of scrutiny inside and outside the government. In order to derive information specific enough to guide possible congressional action and to be responsive to the requesting Committees, this examination of the issues is specifically tied to particular life-sustaining technologies and their use with patients who are elderly. At the same time, much of this information is applicable to life-sustaining technology in general and to citizens of all ages

The Psychosocial impact of food and nutrition on hospitalised oncological palliative care patients and their carers

Food provides more than simply a nurturing of physiological requirements; it encompasses social and emotional aspects that together can create an enjoyable experience. That however, is often altered at the end of life. Currently little is known about the psychosocial impact of food and nutrition in cancer patients admitted to the palliative care unit for end of life care.«br /» «br /» «strong»Aim:«/strong» This thesis investigates the lived experience of patients, carers and health care workers dealing with the changes in food intake of terminal cancer patients in the palliative care unit of a Sydney hospital. The meaning of food at this time in one’s life will also be determined.«br /» «br /» «strong»Method:«/strong» Nineteen patients, 14 nurses, 10 carers, seven medical officers, and four food service officers participated in phenomenologically informed interviews and focus groups investigating food and nutrition at the end of life. «br /» «br /» «strong»Results:«/strong» Themes and sub-themes were derived from the data of each participant group along with overarching themes common across groups. The meaning of food was derived using Max Van Manen’s approach to phenomenological analysis. The three meanings identified were that food means life, food is a demonstration of love and food acts as a social glue bringing people together to partake in a shared experience.«br /» «br /» As one’s intake declines at the end of life, significant changes often occur in the relationship between patient and carer as conflict and tension over food divide the two parties. While many patients and carers express the desire to fight for life, participant groups used various strategies to prolong life.«br /» «br /» «strong»Conclusion:«/strong» Because of its psychosocial impact, food continues to be of high importance in the terminal phase of life.«br /» «br /» Thus clinicians should address the role and concerns of patients and carers around food and nutrition in the last weeks of life because these significantly impact the quality of life of people dying of cancer, along with the harmony in their relationships with loved ones. «div» «div» «div» «/div» «/div» «/div

Nutritional status and related factors in nursing home residents : Comparative study in elderly migrants and native Germans

Introduction: Elderly migrants represent an ever increasing portion of German nursing home residents. However, the nutritional status of elderly migrants and related problems are still largely unknown. The primary aim of this comparative study was to investigate the nutritional status and related health factors of elderly migrants living in German nursing homes in comparison to a matched group of native German residents living in the same nursing homes. The specific objectives were to find out the prevalence of undernourishment, identify nutritional issues and to assess the dependency in daily activities, in order to reveal if there are specific needs of elderly migrants living in nursing homes.Methods: All migrants (>65 y) living in two German nursing homes were enrolled. A group of non migrants living in the same nursing homes, matched in age and gender, was selected for comparison. Nutritional status was assessed by using the body mass index (BMI, 2), calf circumference (CC, Results: Twenty-three migrants took part in the study and the majority of them (87%) had a Turkish background. A group of 37 non migrants was matched (migrants; mean age 76 ±6 y, 52% female, non migrants; 78 ±7 y, 59% female). Almost half of the migrants were seriously in need of care (48% vs. 11%), one third of them were bedridden (30% vs. 8%) and five of them were tube fed (22% vs. 3%). The prevalence of undernourishment was significantly higher among migrants than non migrants by almost every method applied. The prevalence was the highest in both groups according to CC (migrants; 57%, non migrants; 22%), followed by BMI (39% vs. 11%) and MNA (22% vs. 3%). Only one of the non migrants had a low MUAC level. 83% of the migrants had 3 or more nutritional problems (non migrants; 27%). The main problems in migrants and non migrants were eating noticeably little (61% vs. 21%), refusal to eat (56% vs. 25%) and loss of appetite (56% vs. 19%). Nutritional problems were highly correlative with a low BMI as well as with the activities of daily living (ADL-score). The majority of the migrants were more dependent than non migrants in ADL (61% vs. 24%). Dementia was the most common diagnosed disease (48%) in migrants whereas in non migrants was hypertension (49%). Consumption of pureed diet was higher in migrants (17%) compared to non migrants. Participants from both groups did not reach the recommended energy intake of 6.9 MJ (women) and 8.3 MJ (men) for individuals of 65 y and older. Proportion of carbohydrate intake was lower (44 E% and 42 E%) and of fat intake was higher (40 E% and 43 E%) than the recommended in both groups. More than 50% participants fall below D-A-CH’s reference values for vitamin B1, B6, C, D, E, folate, calcium, iron and magnesium. Additionally, 61% of the migrants had a low B12 intake. Conclusions: The group investigated in this study was relatively small and restricted to two nursing homes. Therefore, our findings can not be generalized to the broader community and are less representative for the whole population. Nevertheless, the results indicated that undernourishment was more frequent in elderly migrants and associated with more nutritional problems and decreased functional ability than in matched non migrants. By increasing attention to the nutritional status and dietary habits of elderly migrants, it might be possible to reduce the prevalence of their undernourishment and increase their quality of life. Individualizing residents’care by serving food they want and enjoy or familiar ethnic food can also help to improve nutritional status.Ernährungsstatus und beeinflussende Faktoren bei Altenheimbewohnern in Deutschland - Eine vergleichende Studie bei Senioren mit und ohne MigrationshintergrundEinleitung: Die Zahl der Bewohner mit Migrationshintergrund in deutschen Einrichtungen der Altenpflege nimmt stetig zu. Über den Ernährungszustand älterer Migrantinnen und Migranten und die damit zusammenhängenden Probleme sind nur wenige Informationen verfügbar. Das Ziel dieser vergleichenden Studie war daher, Daten über den Ernährungs- und Gesundheitszustand dieses Personenkreises zu erheben und mit denen von deutschen Bewohnern von Altenheimen zu vergleichen. Im Vordergrund stand dabei, die Prävalenz von Unterernährung zu ermitteln, Ernährungsprobleme zu erkennen, sowie die Fähigkeiten zur Bewältigung alltäglicher Aktivitäten zu beurteilen, um zu untersuchen, ob ältere Migranten hier spezifische Bedürfnisse aufweisen. Methoden: Alle Bewohner (>65 J.) mit Migrationshintergrund in zwei deutschen Altenheimen wurden in die Studie aufgenommen. Bewohner mit deutscher Nationalität wurden als Vergleichsgruppe in Alter und Geschlecht angeglichen ausgewählt. Der Ernährungszustand wurde durch die Messung folgender Parameter erhoben: Body Mass Index (BMI, 2), Wadenumfang (WU, Ergebnisse: 23 Bewohner mit Migrationshintergrund nahmen an der Studie teil, die Mehrheit (87%) war türkischer Herkunft. Die Gruppe der deutschen Probanden umfasste 37 Personen (Migranten: 76 ±6 Jahre, 52% weiblich; deutsche Probanden: 78 ±7 Jahre, 59% weiblich). Nahezu die Hälfte der Migranten war stark pflegebedürftig (48% vs. 11%), ein Drittel war bettlägerig (30% vs. 8%). Fünf wurden über eine Sonde ernährt (22% vs. 3%). Fast mit allen Untersuchungsmethoden ergab sich für die nicht-deutschen Probanden eine höhere Prävalenz von Unterernährung: einen niedrigen WU zeigten 56% der Migranten und 22% der nicht Migranten, BMI: 39% vs. 11%; sowie MNA: 22% vs. 3%. Nur einer der deutschen Probanden hatte einen geringen OAU. 83% der Zuwanderer hatten gleichzeitig 3 oder mehr Probleme bei der Nahrungsaufnahme (deutsche Probanden: 27%). Die wesentlichen Probleme in beiden Gruppen waren die Aufnahme zu geringer Mengen bei den Mahlzeiten (61% vs. 21%), das Verweigern des Essens (56% vs. 25%) oder Inappetenz (56% vs. 19%). Die Probleme der Nahrungsaufnahme korrelierten deutlich mit einem niedrigen BMI und eingeschränkter täglicher körperlicher Aktivität (ADL Score). Die Hilfsbedürftigkeit bei alltäglichen Aktivitäten war bei den Zuwanderern größer als bei der Gruppe der deutschen Senioren (ADL 61% vs. 24%). Die Diagnose Demenz war bei den Migranten die häufigste (48%), bei den deutschen Probanden war es Bluthochdruck (49%). Der Verzehr pürierter Nahrung war bei der Gruppe der Zuwanderer höher (17%). Die Teilnehmer beider Gruppen erreichten im Mittel die für Personen im Alter von 65 Jahren und älter empfohlene Energieaufnahme von 6.9 MJ (Frauen) und 8.3 MJ (Männer) nicht. In beiden Gruppen war der Anteil von Kohlenhydraten an der Energieaufnahme niedriger (44 E% und 42 E%) und der von Fett höher als empfohlen (40 E% und 43 E%). Mehr als die Hälfte der Teilnehmer unterschritt bei der Aufnahme von Vit. B1, B6, C, D, E, Folat, Calcium, Eisen und Magnesium die D-A-CH Referenzwerte. Hinzu kam bei den Zuwanderern ein niedriger Wert bei der Aufnahme von Vit. B12.Schlussfolgerung: Die für diese Untersuchung zur Verfügung stehende Personengruppe war relativ klein. Nur in 2 Einrichtungen konnten die Erhebungen durchgeführt werden. Daher können unsere Ergebnisse nicht verallgemeinert und als repräsentativ angesehen werden. Die Ergebnisse weisen jedoch darauf hin, dass bei den betagten Migranten Unterernährung häufiger vorkommt und mit Problemen bei der Nahrungsaufnahme und täglichen Routinetätigkeiten einhergeht, als es bei vergleichbaren einheimischen Senioren der Fall zu sein scheint. Durch eine intensivere Beachtung des Ernährungszustands und der Essgewohnheiten älterer Migranten sollte es möglich sein, das Vorkommen von Unterernährung zu reduzieren und deren Lebensqualität zu verbessern. Eine persönlichere Betreuung der Bewohner mit Migrationshintergrund durch das Anbieten von Speisen, die in Zusammensetzung und Zubereitung auf deren ethnische Zugehörigkeit Rücksicht nehmen, kann dazu beitragen, deren Ernährungssituation zu verbessern

ESPEN Guideline: Clinical Nutrition in inflammatory bowel disease

Introduction: The ESPEN guideline presents a multidisciplinary focus on clinical nutrition in inflammatory bowel disease (IBD). Methodology: The guideline is based on extensive systematic review of the literature, but relies on expert opinion when objective data were lacking or inconclusive. The conclusions and 64 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required. Results: IBD is increasingly common and potential dietary factors in its aetiology are briefly reviewed. Malnutrition is highly prevalent in IBD – especially in Crohn's disease. Increased energy and protein requirements are observed in some patients. The management of malnu-trition in IBD is considered within the general context of support for malnourished patients. Treatment of iron deficiency (parenterally if necessary) is strongly recommended. Routine provision of a special diet in IBD is not however supported. Parenteral nutrition is indicated only when enteral nutrition has failed or is impossible. The recommended perioperative man-agement of patients with IBD undergoing surgery accords with general ESPEN guidance for patients having abdominal surgery. Probiotics may be helpful in UC but not Crohn's disease. Primary therapy using nutrition to treat IBD is not supported in ulcerative colitis, but is mod-erately well supported in Crohn's disease, especially in children where the adverse conse-quences of steroid therapy are proportionally greater. However, exclusion diets are generally not recommended and there is little evidence to support any particular formula feed when nutritional regimens are constructed. Conclusions: Available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 64 recommendations, of which 9 are very strong recom-mendations (grade A), 22 are strong recommendations (grade B) and 12 are based only on sparse evidence (grade 0); 21 recommendations are good practice points (GPP)

Clinical Nutrition: Recent Advances and Remaining Challenges

Nutrition, often along with physical activity, is by now acknowledged as a cornerstone in the prevention and even more so the treatment of many diseases. Indeed, food and nutritional intake nowadays are often thought to be the main source of wellbeing sometimes over- but also underestimating the impact of nutritional intake, dietary pattern and food-derived natural compounds in their impact on human health. In this Special Issue entitled `Clinical Nutrition: Recent Advances and Remaining Challenges´ a broad overview and summary on recent findings in various fields of clinical nutrition with special focus on chronic and degenerative diseases like metabolic diseases, cancers, neurodegenerative diseases, inflammatory bowel diseases, sarcopenia but also malnutrition in elderly, infants and children is provided. Nutrition, often along with physical activity, is by now acknowledged as a cornerstone in the prevention and even more so the treatment of many diseases. Indeed, food and nutritional intake nowadays are often thought to be the main source of wellbeing sometimes over- but also underestimating the impact of nutritional intake, dietary pattern and food-derived natural compounds in their impact on human health. In this Special Issue entitled `Clinical Nutrition: Recent Advances and Remaining Challenges´ a broad overview and summary on recent findings in various fields of clinical nutrition with special focus on chronic and degenerative diseases like metabolic diseases, cancers, neurodegenerative diseases, inflammatory bowel diseases, sarcopenia but also malnutrition in elderly, infants and children is provided