Vitamin and Mineral Deficiencies Are Highly Prevalent in Newly Diagnosed Celiac Disease Patients

Malabsorption, weight loss and vitamin/mineral-deficiencies characterize classical celiac disease (CD). This study aimed to assess the nutritional and vitamin/mineral status of current “early diagnosed” untreated adult CD-patients in the Netherlands. Newly diagnosed adult CD-patients were included (n = 80, 42.8 ± 15.1 years) and a comparable sample of 24 healthy Dutch subjects was added to compare vitamin concentrations. Nutritional status and serum concentrations of folic acid, vitamin A, B6, B12, and (25-hydroxy) D, zinc, haemoglobin (Hb) and ferritin were determined (before prescribing gluten free diet). Almost all CD-patients (87%) had at least one value below the lower limit of reference. Specifically, for vitamin A, 7.5% of patients showed deficient levels, for vitamin B6 14.5%, folic acid 20%, and vitamin B12 19%. Likewise, zinc deficiency was observed in 67% of the CD-patients, 46% had decreased iron storage, and 32% had anaemia. Overall, 17% were malnourished (>10% undesired weight loss), 22% of the women were underweight (Body Mass Index (BMI) < 18.5), and 29% of the patients were overweight (BMI > 25). Vitamin deficiencies were barely seen in healthy controls, with the exception of vitamin B12. Vitamin/mineral deficiencies were counter-intuitively not associated with a (higher) grade of histological intestinal damage or (impaired) nutritional status. In conclusion, vitamin/mineral deficiencies are still common in newly “early diagnosed” CD-patients, even though the prevalence of obesity at initial diagnosis is rising. Extensive nutritional assessments seem warranted to guide nutritional advices and follow-up in CD treatment

Study protocol: Cost-effectiveness of transmural nutritional support in malnourished elderly patients in comparison with usual care

BACKGROUND: Malnutrition is a common consequence of disease in older patients. Both in hospital setting and in community setting oral nutritional support has proven to be effective. However, cost-effectiveness studies are scarce. Therefore, the aim of our study is to investigate the effectiveness and cost-effectiveness of transmural nutritional support in malnourished elderly patients, starting at hospital admission until three months after discharge. METHODS: This study is a randomized controlled trial. Patients are included at hospital admission and followed until three months after discharge. Patients are eligible to be included when they are > or = 60 years old and malnourished according to the following objective standards: Body Mass Index (BMI in kg/m2) < 20 and/or > or = 5% unintentional weight loss in the previous month and/or > or = 10% unintentional weight loss in the previous six months. We will compare usual nutritional care with transmural nutritional support (energy and protein enriched diet, two additional servings of an oral nutritional supplement, vitamin D and calcium supplementation, and consultations by a dietitian). Each study arm will consist of 100 patients. The primary outcome parameters will be changes in activities of daily living (determined as functional limitations and physical activity) between intervention and control group. Secondary outcomes will be changes in body weight, body composition, quality of life, and muscle strength. An economic evaluation from a societal perspective will be conducted alongside the randomised trial to evaluate the cost-effectiveness of the intervention in comparison with usual care. CONCLUSION: In this randomized controlled trial we will evaluate the effect of transmural nutritional support in malnourished elderly patients after hospital discharge, compared to usual care. Primary endpoints of the study are changes in activities of daily living, body weight, body composition, quality of life, and muscle strength. An economic evaluation will be performed to evaluate the cost-effectiveness of the intervention in comparison with usual care. TRIAL REGISTRATION: Netherlands Trial Register (ISRCTN29617677, registered 14-Sep-2005)

Nutritional support strategies for malnourished cancer patients

A large body of evidence exists, which demonstrates the importance of nutritional support in cancer. The nutritional needs of patients with cancer may differ from those of the healthy population due to hypermetabolism, impaired organ function, increased nutrient losses and therapy-related malnutrition. Patients with cancer often have increased requirements for both macro- and micronutrients due to long periods of undernutrition prior to diagnosis. The aim of nutritional support should be the prevention or reversal of malnutrition, and this should be initiated as early as possible to improve outcomes. Oral supplementation is a simple, non-invasive method of increasing the nutrient intake of those patients who are unable to meet nutritional requirements, despite dietary counselling. Enteral tube feeding is indicated for patients who are unable to meet their nutritional needs by oral intake alone, and has been shown to improve clinical outcomes. Novel approaches in oral supplementation include the use of eicosapentaenoic acid (EPA), a compound under investigation for its role in preventing and treating cancer-associated malnutrition. Individual studies suggest that EPA attenuates cancer-associated wasting and improves immune function. In addition, it has been shown to have anti-tumour effects and improve clinical outcomes. However, results are not consistent for all patient groups and further research is required

Ondervoeding in verpleeghuizen Prevalentie, preventie, behandeling en beleid

In developed countries there is growing awareness of the importance of recognizing, rating, and treating malnutrition in health care. The objective of this study was to provide data on a large scale concerning the prevalence, screening, treatment and quality indicators, with regard to malnutrition in nursing homes in the Netherlands, in 2006 This cross sectional multi-centre point prevalence study, performed in 2004, 2005 and 2006, included in 2006 10.923 patients of nursing homes .The results presented are part of The Annual Dutch Prevalence Study on Care Problems (LPZ) performed by Universiteit Maastricht. The study uses a standardised questionnaire which is divided in three parts: (1) the profile of the health care institution (kind of institution, quality indicators), (2) the profile of the department (kind of department, quality indicators), and (3) patient characteristics (demographic data, reason of admission, and prevention and treatment of 4 care problems: pressure ulcers, incontinence, intertrigo and malnutrition.). Nutritional status was assessed by BMI, undesired weight loss and nutritional intake In 2006, 202 health care organisations participated in the LPZ, including 78 nursing homes. Results show that one out of four patients was malnourished in the participating nursing homes. The older the patient was and the more diseases the patient had, the higher the prevalence rate of malnutrition. Less then 50% of the patients were screened for malnutrition and a dietician was consulted in less than 50% of the cases. Furthermore, focussing on the quality indicators reveals that there is no structural and uniform policy concerning malnutrition in most of the participating nursing homes. One out of four patients is malnourished in nursing homes.This requires actions towards a more structural nutritional policy in Dutch nursing homes to target this relevant care problem

Systematic screening for undernutrition in hospitals: Predictive factors for success.

BACKGROUND & AIMS: Since 2007, systematic screening for undernutrition has become a performance indicator (PI) for hospitals within the National Benchmarks on Quality of Care of the Dutch Health Care Inspectorate (HCI). Its introduction was guided by a national implementation program. The aim of this study was to evaluate the screening results from 2007 to 2010 and to identify predictive factors for achieved screening results. METHODS: All 97 Dutch hospitals were obliged to report screening results to the HCI. An additional questionnaire was developed to determine hospital characteristics, including hospital type, size, participation in implementation program, screening tool used, use of electronic records, presence of hospital-wide or ward task forces, and protocol-defined referral. Multivariate linear regression analysis was used to identify predictive factors for the obtained screening results in 2010. RESULTS: The mean screening percentage increased from 51 ± 28% in 2007 (n = 75 hospitals, n = 340,000 patients) to 72 ± 17% in 2010 (n = 97; n = 1,050,000) (p < 0.01). Eighty-one hospitals returned the questionnaire. A higher screening percentage was associated with more clinical admissions (highest vs. lowest tertile: β = 14.0, 95% CI 3.9-20.5; p < 0.01; middle vs. lowest: β = 7.3, -0.8 to 15.6; p = 0.05), presence of protocol-defined referral to a dietician (β = 10.5, 2.9-18.0; p < 0.01), and use of the SNAQ screening tool (vs. MUST: β = 9.1, 1.7-16.6; p = 0.02). CONCLUSION: Screening percentages have increased significantly since the introduction of the PI. Screening was more frequent in hospitals which have more patient admissions, protocol-defined referral to a dietician, and who use the SNAQ screening tool. This information may assist in improving Dutch screening rates and in implementation in other countries

Cancer Cachexia: Identification by Clinical Assessment versus International Consensus Criteria in Patients with Metastatic Colorectal Cancer

Background: Cancer cachexia is associated with poorer outcomes and is often diagnosed by the Fearon criteria. Oncologists clinically identify cachexia based on a patient’s presentation. In this study agreement between these identification methods was evaluated and associations with outcomes were studied in patients with metastatic colorectal cancer. Methods: Fearon criteria comprised weight loss >5% OR weight loss >2% with either BMI <20 kg/m2 or sarcopenia (determined by CT-imaging). Clinical assessment by the oncologist was based on the patient’s clinical presentation. Agreement was tested with Kappa. Associations with treatment tolerance and progression free survival (PFS) were tested with logistic regressions and Cox proportional hazards, respectively. Results: Of 69 patients, 52% was identified as cachectic according to Fearon criteria and 9% according to clinical assessment. Agreement between both methods was slight (Kappa 0.049, P = 0.457). Clinically cachectic patients had a shorter PFS than clinically non-cachectic patients (HR 3.310, P = 0.016). No other differences in outcomes were found between cachectic vs. non-cachectic patients using both methods. Conclusions: The agreement between cancer cachexia identification by clinical assessment vs. Fearon criteria was slight. Further improvement of cachexia criteria is necessary to identify cachectic patients at risk of poorer outcomes, who may benefit from targeted cachexia interventions

Short-term oral nutritional intervention with protein and vitamin D decreases falls in malnourished older adults

OBJECTIVES: To evaluate the effects of a short-term nutritional intervention with protein and vitamin D on falls in malnourished older adults. DESIGN: Randomized controlled trial. SETTING: From hospital admission until 3 months after discharge. PARTICIPANTS: Malnourished older adults (≥ 60) newly admitted to an acute hospital (n = 210). INTERVENTION: Participants were randomized to receive nutritional intervention (energy- and protein-enriched diet, oral nutritional supplements, calcium-vitamin D supplement, telephone counseling by a dietitian) for 3 months after discharge or usual care. MEASUREMENTS: Number of participants who fell, fall incidents, serum 25-hydroxyvitamin D, and dietary intake. Measurements were performed on admission to hospital and 3 months after discharge. RESULTS: Three months after discharge, 10 participants (10%) in the intervention group had fallen at least once, compared with 24 (23%) in the control group (hazard ratio = 0.41, 95% confidence interval (CI) = 0.19-0.86). There were 57 fall incidents (16 in the intervention group; 41 in the control group). A significantly higher intake of energy (280 kcal, 95% CI = 37-524 kcal) and protein (11 g, 95% CI = 1-25 g) and significantly higher serum 25-hydroxyvitamin D levels (10.9 nmol/L, 95% CI = 2.9-18.9 nmol/L) were found in participants in the intervention group than in controls. CONCLUSION: A short-term nutritional intervention consisting of oral nutritional supplements and calcium and vitamin D supplementation and supported by dietetic counseling in malnourished older adults decreases the number of patients who fall and fall incidents

Effectiveness and cost-effectiveness of early screening and treatment of malnourished patients

BACKGROUND: About 25-40% of hospital patients are malnourished. With current clinical practices, only 50% of malnourished patients are identified by the medical and nursing staff. OBJECTIVE: The objective of this study was to report the cost and effectiveness of early recognition and treatment of malnourished hospital patients with the use of the Short Nutritional Assessment Questionnaire (SNAQ). DESIGN: The intervention group consisted of 297 patients who were admitted to 2 mixed medical and surgical wards and who received both malnutrition screening at admission and standardized nutritional care. The control group consisted of a comparable group of 291 patients who received the usual hospital clinical care. Outcome measures were weight change, use of supplemental drinks, use of tube feeding, use of parenteral nutrition and in-between meals, number of consultations by the hospital dietitian, and length of hospital stay. RESULTS: The recognition of malnutrition improved from 50% to 80% with the use of the SNAQ malnutrition screening tool during admission to the hospital. The standardized nutritional care protocol added approximately 600 kcal and 12 g protein to the daily intake of malnourished patients. Early screening and treatment of malnourished patients reduced the length of hospital stay in malnourished patients with low handgrip strength (ie, frail patients). To shorten the mean length of hospital stay by 1 d for all malnourished patients, a mean investment of 76 euros (91 US dollars) in nutritional screening and treatment was needed. The incremental costs were comparably low in the whole group and in the subgroup of malnourished patients with low handgrip strength. CONCLUSIONS: Screening with the SNAQ and early standardized nutritional care improves the recognition of malnourished patients and provides the opportunity to start treatment at an early stage of hospitalization. The additional costs of early nutritional care are low, especially in frail malnourished patients

Assessment of malnutrition parameters in head and neck cancer and their relation to postoperative complications

Background. Malnutrition is reported frequently in head and neck cancer patients. The impact of malnutrition on surgical outcome is not clearly understood. The purpose of this study was to define the usefulness of six different parameters in scoring malnutrition and to determine the nutritional parameter primarily related to postoperative complications. Methods. Sixty- four patients undergoing major surgery for advanced head and neck cancer were studied prospectively, and six different parameters were used to define malnutrition. Logistic regression was used to relate nutritional parameters to postoperative complications. Results. The parameters applied all identified different aspects of the nutritional status, as malnutrition varied between 20% and 67%. Logistic regression analysis identified a weight loss of more than 10% to be the most prominent predictive parameter for the occurrence of major postoperative complications. Conclusions. Patients with weight loss more than 10% during the six months before surgery are at a great risk for the occurrence of major postoperative complications