Improving the assessment of older adult's nutrition in primary care: recommendations for a proactive, patient-centred and aetiology approach

BACKGROUND The nature of the problem The UK has an ageing population, with the greatest increase in those aged over 85. While most will have long periods of good health, many will live with long- term conditions, and some will become frail requiring continued support in the community or in care and nursing homes. Prevalence of malnutrition in older adults differs significantly, depending on the healthcare setting (figure 1). Causes of malnutrition in older people are multifactorial, some such as vitamin B12 deficiency are age related, and others such as low vitamin D status reflect reduced mobility impacting time spent outdoors. Also, older people are more likely to be prescribed multiple medications may be underhydrated, suffer alterations to taste and swallowing, have reduced access to food, or difficulties in shopping for, and preparing meals. In conditions, such as chronic obstructive pulmonary disease, inflammation- induced catabolism is greater, with reduced weight and increased risk of sarcopenia is prevalent. Patients may also present with metabolic syndrome issues or obesity with sarcopenia. There is overlap between malnutrition, sarcopenia, frailty and functional ability. A systematic review of 178 644 participants shows that unintentional weight loss has a significant impact on mortality regardless of overweight or obesity, and risk is greater with age. We recognise the complexities of the health economics evidence base including the implications of funding and publication bias, the relative lack of studies in primary care and challenges of demonstrating outcomes for a diverse array of non- commercial interventions. The heterogeneity in the evidence base for nutritional interventions is challenging. The Nutrition Education Policy for Health Care Practice initiative of the NNEdPro Global Institute seeks to disseminate evidence informed practice patterns to build more precise nutrition capacity within the healthcare workforce. We propose this biopsychosocial model practice pattern as a pragmatic and ethical approach to improve the nutrition of older adults by earlier identification of malnutrition and initiating relevant actions by any healthcare professional (HCP)

COVID-19’s impact on food environment in the Indian states of Telangana, Maharashtra, West Bengal, Tamil Nadu and Punjab: a descriptive qualitative study to build further research in India’s food environment resilience building

Background and aim Globally, COVID-19 has had a profound impact on food and nutrition security. This paper aims to gather the perspective from Transforming India’s Green Revolution by Research and Empowerment for Sustainable food Supplies (TIGR2ESS) Flagship Project 6 (FP-6) team on the impact of COVID-19 on the food systems in India. The responses collected will be used for further research projects after TIGR2ESS ends in March 2022. Method Members of the TIGR2ESS FP-6 team in India were invited to complete an online open-ended questionnaire with 21 questions exploring the impact of the COVID-19 pandemic on food systems and environments in India. The questionnaire and data analysis were guided by the food environment framework developed by Turner et al and the adaptations proposed by the United Nations System Standing Committee on Nutrition. Discussions and organisation of codes under the respective themes and subthemes were held online using the virtual platform Miro. 35 individual codes and 65 subcodes were agreed on. Responses were collated and analysed using the template with support from NVivo software and synthesised the relevant themes under Turner et al’s framework. Results The organisation representatives from TIGR2ESS FP-6 (n=16) captured the perceived impact of the COVID-19 on food systems and the environment from the Indian states of Maharashtra, Punjab, Tamil Nadu, Telangana and West Bengal. Negative disruptions were caused by the COVID-19 restrictions across all the themes affecting food actors and consumers. Myths and misconception on dietary intake were reported across the state affecting especially the consumption of poultry. Positive aspects such as home cooking and awareness around healthy food emerged. Conclusion Potential research areas were identified and involve the effects of supply chain resilience building, farmers selling their produce directly to consumer and the revival of local and traditional food’s impact on diets, understanding the harm for consumers by implementing restrictions, how indigenous and local food may impact peoples’ diets, how to build on the encouragement of healthy home cooking during the pandemic, investigate the negative and positive effects of digital environments during the pandemic and dispelling myths and misconception while advocating for healthy diets

Addressing nutritional gaps and suggesting a practical framework to reduce the risk of malnutrition and improve nutrition security in santhal tribal communities in India

Background The double burden of malnutrition is a growing problem, which is disproportionately represented across the Indian population, with undernutrition dominating rural areas. This study aimed to identify nutritional gaps in traditional recipes of Santhal tribes, create a recipe book to address deficiencies and support diet diversity. Methods Food Frequency Questionnaires (FFQ) were conducted to analyse dietary patterns of Santhal communities. Recipes were collected from five villages and shortlisted into 37 dishes based on availability, acceptability and popularity. Commonly consumed templates were based on FFQ findings and individual dishes. Nutritics software was used to identify nutritional gaps. In total, 24 recommended templates, were created to satisfy adequate intake of nutrients. Mann-Whitney and unpaired t-test were performed and findings were presented as mean (standard deviation(SD)) and median (25th–75th percentile). Results Less than one-fifth of consumed templates met energy requirements, 27% met protein recommendations, and 4% met requirements for fibre, total fat, monounsaturated and polyunsaturated fat. Other nutrients of concern included vitamins B12, B9, iodine, calcium and iron. Recommended templates significantly increased energy (Consumed (C): 996.0kcal(930-1090); Recommended (R): 1183.0kcal(1094-1341); p<0.0001), protein (C: 25.0g(8.4); R: 40.5g(33.2-52.3); p<0.0001), total fat (C: 7.4g(6.1-8.8); R: 17.2g(14.1-22.9); p<0.0001) and fibre (C: 5.0g(4.0-6.5); R: 8.2g(5.8-11.7); p=0.0013) compared to consumed templates. Additionally, calcium (C: 108.5mg(36.0-302.5); R: 245.5mg(152.3-528.3); p=0.0121), iron (C: 5.3mg(2.1-8.2); R: 10.7mg(8.2-13.2); p=0.0002), vitamin B6 (C: 0.4mg(0.3-0.7); R: 1.1mg(0.6-1.6); p=0.0001), B9 (C: 54.5ug(36.3-172.8); R: 252ug(179.4); p=0.0026) and B12 (C: 0ug(0-0); R: 1.0ug(0-2.1); p=0.0001) were also significantly increased. Conclusion This study provides a novel insight on the nutritional adequacy of indigenous Santhal recipes and highlights the need to enhance the nutrition status of these communities. Concerted efforts should be made to increase communication for nutritional advocacy, both nationally and internationally. Future research should evaluate the acceptability, practicality, and uptake of this recipe book in addressing malnutrition in rural communities

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

COVID-19’s impact on food environment in the Indian states of Telangana, Maharashtra, West Bengal, Tamil Nadu and Punjab: a descriptive qualitative study to build further research in India’s food environment resilience building

Peer reviewed: TruePublication status: PublishedBackground and aimGlobally, COVID-19 has had a profound impact on food and nutrition security. This paper aims to gather the perspective from Transforming India’s Green Revolution by Research and Empowerment for Sustainable food Supplies (TIGR2ESS) Flagship Project 6 (FP-6) team on the impact of COVID-19 on the food systems in India. The responses collected will be used for further research projects after TIGR2ESS ends in March 2022.MethodMembers of the TIGR2ESS FP-6 team in India were invited to complete an online open-ended questionnaire with 21 questions exploring the impact of the COVID-19 pandemic on food systems and environments in India. The questionnaire and data analysis were guided by the food environment framework developed by Turneret aland the adaptations proposed by the United Nations System Standing Committee on Nutrition. Discussions and organisation of codes under the respective themes and subthemes were held online using the virtual platform Miro. 35 individual codes and 65 subcodes were agreed on. Responses were collated and analysed using the template with support from NVivo software and synthesised the relevant themes under Turneret al’s framework.ResultsThe organisation representatives from TIGR2ESS FP-6 (n=16) captured the perceived impact of the COVID-19 on food systems and the environment from the Indian states of Maharashtra, Punjab, Tamil Nadu, Telangana and West Bengal. Negative disruptions were caused by the COVID-19 restrictions across all the themes affecting food actors and consumers. Myths and misconception on dietary intake were reported across the state affecting especially the consumption of poultry. Positive aspects such as home cooking and awareness around healthy food emerged.ConclusionPotential research areas were identified and involve the effects of supply chain resilience buidling, farmers selling their produce directly to consumer and the revival of local and traditional food’s impact on diets, understanding the harm for consumers by implementing restrictions, how indigenous and local food may impact peoples’ diets, how to build on the encouragement of healthy home cooking during the pandemic, investigate the negative and positive effects of digital environments during the pandemic and dispelling myths and misconception while advocating for healthy diets.</jats:sec

2 Addressing nutritional gaps and suggesting a practical framework to reduce the risk of malnutrition and improve nutrition security in santhal tribal communities in India

Background The double burden of malnutrition is a growing problem, which is disproportionately represented across the Indian population, with undernutrition dominating rural areas. This study aimed to identify nutritional gaps in traditional recipes of Santhal tribes, create a recipe book to address deficiencies and support diet diversity. Methods Food Frequency Questionnaires (FFQ) were conducted to analyse dietary patterns of Santhal communities. Recipes were collected from five villages and shortlisted into 37 dishes based on availability, acceptability and popularity. Commonly consumed templates were based on FFQ findings and individual dishes. Nutritics software was used to identify nutritional gaps. In total, 24 recommended templates, were created to satisfy adequate intake of nutrients. Mann-Whitney and unpaired t-test were performed and findings were presented as mean (standard deviation(SD)) and median (25th–75th percentile). Results Less than one-fifth of consumed templates met energy requirements, 27% met protein recommendations, and 4% met requirements for fibre, total fat, monounsaturated and polyunsaturated fat. Other nutrients of concern included vitamins B12, B9, iodine, calcium and iron. Recommended templates significantly increased energy (Consumed (C): 996.0kcal(930-1090); Recommended (R): 1183.0kcal(1094-1341); p<0.0001), protein (C: 25.0g(8.4); R: 40.5g(33.2-52.3); p<0.0001), total fat (C: 7.4g(6.1-8.8); R: 17.2g(14.1-22.9); p<0.0001) and fibre (C: 5.0g(4.0-6.5); R: 8.2g(5.8-11.7); p=0.0013) compared to consumed templates. Additionally, calcium (C: 108.5mg(36.0-302.5); R: 245.5mg(152.3-528.3); p=0.0121), iron (C: 5.3mg(2.1-8.2); R: 10.7mg(8.2-13.2); p=0.0002), vitamin B6 (C: 0.4mg(0.3-0.7); R: 1.1mg(0.6-1.6); p=0.0001), B9 (C: 54.5ug(36.3-172.8); R: 252ug(179.4); p=0.0026) and B12 (C: 0ug(0-0); R: 1.0ug(0-2.1); p=0.0001) were also significantly increased. Conclusion This study provides a novel insight on the nutritional adequacy of indigenous Santhal recipes and highlights the need to enhance the nutrition status of these communities. Concerted efforts should be made to increase communication for nutritional advocacy, both nationally and internationally. Future research should evaluate the acceptability, practicality, and uptake of this recipe book in addressing malnutrition in rural communities

Incidence, clinical features, and outcomes of posterior circulation ischemic stroke: insights from a large multiethnic stroke database

Background: Posterior cerebral circulation ischemic stroke (PCS) comprises up to 25% of all strokes. It is characterized by variable presentation, leading to misdiagnosis and morbidity and mortality. We aim to describe PCS in large multiethnic cohorts. Methods: A retrospective review of a large national stroke database from its inception on the 1st of January 2014 till 31 December 2020. Incidence per 100,000 adult population/year, demographics, clinical features, stroke location, and outcomes were retrieved. We divided the cohort into patients from MENA (Middle East and North Africa) and others. Results: In total, 1,571 patients were identified. The incidence of PCS was observed to be rising and ranged from 6.3 to 13.2/100,000 adult population over the study period. Men were 82.4% of the total. The mean age was 54.9 ± 12.7 years (median 54 years, IQR 46, 63). MENA patients comprised 616 (39.2%) while others were 954 (60.7%); of these, the majority (80.5%) were from South Asia. Vascular risk factors were prevalent with 1,230 (78.3%) having hypertension, 970 (61.7%) with diabetes, and 872 (55.5%) having dyslipidemia. Weakness (944, 58.8%), dizziness (801, 50.5%), and slurred speech (584, 36.2%) were the most commonly presenting symptoms. The mean National Institute of Health Stroke Score (NIHSS) score was 3.8 ± 4.6 (median 3, IQR 1, 5). The overall most frequent stroke location was the distal location (568, 36.2%). The non-MENA cohort was younger, less vascularly burdened, and had more frequent proximal stroke location (p < 0.05). Dependency or death at discharge was seen in 39.5% and was associated with increasing age, and proximal and multilocation involvement; while at 90 days it was 27.4% and was associated with age, male sex, and having a MENA nationality (p < 0.05). Conclusion: In a multiethnic cohort of posterior circulation stroke patients from the MENA region and South Asia, we noted a rising incidence over time, high prevalence of vascular risk factors, and poor outcomes in older men from the MENA region. We also uncovered considerable disparities between the MENA and non-MENA groups in stroke location and outcome. These disparities are crucial factors to consider when tailoring individualized patient care plans. Further research is needed to thoroughly investigate the underlying reasons for these variations.Scopu

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research