Tuesday, April 28, 2015

Should enteral nutrition be started in the first week of critical illness?

Martindale R, Warren M. Should enteral nutrition be started in the first week of critical illness? Curr Opin Clin Nutr Metab Care. 2015;18(2):202-206.


            This study looks at the early initiation of enteral nutrition for patients who are critically ill. Authors admit that there is a lack of trials that contain a large number of participants and are randomized. A majority of the supporting studies on this topic were done on animal models and not human patients.

            Results from this study show that the initiation of enteral nutrition within the first week of being in the intensive care unit promotes gut-mediated immunity, lowers metabolic response to stress, maintains microbial diversity, and improves clinical outcomes versus standard of care or parenteral nutrition.

            This is important because of the time frame and what’s going on. This is a very stressful time for the patient and family and feeding of any kind can often be associated with end of life circumstances. While there are a number of things that can go on during this time this study shows how important it is to start enteral feeding as soon as possible for patients in critical care.

Effect of glutamine enriched nutrition support on surgical patients with gastrointestinal tumors: A meta-analysis of randomized controlled trials

Kang K, Shu X, Zhang Y, Liu X, Zhao J. Effect of glutamine enriched nutrition support on surgical patients with gastrointestinal tumors: A meta-analysis of randomized controlled trials. Chin Med J.2015;128(2):245-251


            This study a meta-analysis that looks at the addition of glutamine supplementation in patients with severe traumatic stress or tumor bearing states. The meta-analysis showed that glutamine enriched nutrition support improved immune function, reduced incidence of infectious complications postoperatively, and shortened the length of hospital stays.
            A number of the trials were conducted on patients with post-operative GI cancer patients, but the results seem to be applicable to any severe traumatic stress situation.
            All studies were randomized, but not all studies were blind. For specific dosing of glutamine an investigation of individual studies would have to be done.
            Some of the mechanisms associated with these results are an increase in serum albumin, serum prealbumin, and serum transferring.

Comparison of a novel, simple nutrition screening tool for adult oncology inpatients and the Malnutrition Screening Tool(MST) against the Patient-Generated Subjective Global Assessment(PG-SGA).

Shaw C, Fleuret C, Pickard J, Mohammed K, Black G, Wedlake, L. Comparison of a novel, simple nutrition screening tool for adult oncology inpatients and the Malnutrition Screening Tool(MST) against the Patient-Generated Subjective Global Assessment(PG-SGA). Support Care CancerI.2015;23(1):47-54.


            This article evaluates the specificity and sensitivity of different methods of assessing nutrition status. What is different is that this article is looking to find a the best one for a specific disease.

            While some screening tools are better than others overall for identifying malnutrition in patients, no one tool is the best for everyone. More than the contents of this study  the idea itself is what is important. Instead of a tool or method that is used throughout dietetics or through a hospital  using one that has been proven to me the most effective at identifying malnutrition within a specific disease state is the most appropriate course of action.
            Malnutrition can have a number of different manifestations, each disease state can cause signs and symptoms that are different from each other, but all indicate malnutrition of some time. This is why a master tool can not be as effective as custom tools.
            Some outside of medical professions may not see the importance of what tool to use or what method should be standard. Statistics show that 1/3 of those who are malnourished upon admission go unidentified. Two-thirds of that population becomes even more malnourished while in the hospital.

            Malnourishment can exacerbate current disease symptoms, hinder the healing process, reduce quality of life, increase stays in hospital, and increase mortality.
           While it's not feasible for a disease specific screening form to be used on every individual who comes into a hospital because a number have yet to be diagnosed, it is very possible for specialty physicians to use custom screening forms for those who have already been diagnosed or who are likely to have a particular disease.


Current Status of Nutrition Training in Graduate Medical Education From a Survey of Residency Program Directors: A Formal Nutrition Education Course is Necessary

Daley BJ, Cherry-Bukowiec J, Van Way III CW, et al. Current status of nutrition training in graduate medical education from a survery of residency program directors: A formal nutrition education course is necessary. J parenter Enteral Nut. 2015;XX(X):1-5.


            Among dietitians it is sometimes a sore subject as to whether or not they are allowed to prescribe diet orders. It changes from state to state and from hospital to hospital. The questions arise as to who is more knowledgeable in regard to diets and if doctors are prescribing diet orders then what is the point of clinical dietetics? Well, this article surveyed graduate medical education facilities to determine what level of nutrition education was being giving. Of the 72 residencies programs that responded only 19(26.4%) had a formal course in nutrition, and of these 19 institutions only 16 required that the courses be taken. The statistics go on to show that not only are nutrition classes not being given, when they are they are typically not mandatory, and even when they are given they are not effectively educating on clinical dietetics.

            This article goes on to encourage the education of physicians in nutrition at the undergrad and graduate level. They realistically state that getting a greater number of physician educators to focus on nutrition is unlikely.

            The questions really are, why are they still the ones making nutrition related decisions in clinical settings and why increase their scoop when there is an ENTIRE field of healthcare related to nutrition? This isn’t the first study to purport that physicians are undereducated in regard to nutrition and likely won’t be the last. Instead of insisting on physicians being required to get even more education, why not shift the responsibility to those who have gone to school and been trained for the sole purpose of managing food intake in relation to disease?


Friday, April 24, 2015

Just Two Weeks of Drinking Sugar-Sweetened Beverages May Increase Risk of Heart Disease

I previously wrote an article about how sugar-sweetened beverages may decrease the body's stress response. Now, there is another study out suggesting that drinking sugar-sweetened beverages may increase the risk of heart disease. It is important to keep in mind that how the studies were conducted and if there is other research out there to back it up. It is also important to remember moderation is key when it comes to what we eat and drink.

This study is the first to show a direct dose-dependent relationship between the amount of added sugar consumed in sugar-sweetened beverages and increases in specific risk factors for cardiovascular disease. There are other studies that show an increase in sugar-sweetened beverages correlates with an increase in cardiovascular disease. There were 85 participants both men and women between the ages of 18-40 years old who were divided into four different groups. The study followed these participants for 15 days while they consumed sugar-sweetened beverages with high-fructose corn syrup in 0 percent, 10 percent, 17.5 percent, and 25 percent of total daily calorie requirements.  It is important to note that the 0 percent group was the control group and they were given aspartame, an artificial sweetener.

At the beginning and end of the study the participants had their blood drawn hourly to monitor lipoproteins, triglycerides, and uric acid, all markers associated with cardiovascular disease. The study found that the higher the level of high-fructose corn syrup the higher the blood levels of lipoproteins, triglycerides, and uric acid. The study also found that men's blood levels increased more than the women's blood levels. The blood levels were independent of body weight gain. There is more research needed in this area, especially a longer time frame, since most people consume sugar-sweetened beverages regularly.

Kimber Stanhope et al. A dose-response study of consuming high-fructose corn syrup–sweetened beverages on lipid/lipoprotein risk factors for cardiovascular disease in young adultsAm J Clin Nutr, April 2015 DOI:10.3945/ajcn.114.100461


Tuesday, April 21, 2015

Green Tea and Apples May Protect Health

New research may suggest that compounds in apples and green tea may help to protect our health. Other dietary studies have shown that consuming diets high in fruits and vegetables reduces the chance of developing chronic diseases like heart disease, diabetes, and cancer. There could be multiple reasons for this. One reason may be the fact that fruits and vegetables contain polyphenols, which may help to protect our health. 

In this study it was shown that polyphenols that are in green tea and apples block a signaling molecule called VEGF, which can trigger atherosclerosis in the body and anti-cancer drugs. In the body VEGF drives blood cell formation by a process called angiogenesis. Angiogenesis is a major contributor to cancer progression and the formation of plaque and plaque rupture, which can cause a heart attack or stroke. Using cells that were from human blood vessels, the researchers found that low levels of EGCG the polyphenol in green tea and procyanidin from apples stopped an important signaling function of VEGF. If this mechanism were to happen in the body as well, polyphenols will be very helpful in protection of our health. 

The polyphenols also activated another enzyme that makes nitric oxide in the blood. Nitric oxide helps to widen blood vessels and prevent damage. This was not expected. VEGF also activates nitric oxide while, anti-cancer drugs try and reduce nitric oxide. This could potentially lead to an increase in hypertension with some people. More research is needed to determine if this mechanism happens in the body and to what extent nitric oxide is being activated and reduced. 

Christina W. A. Moyle, Ana B. Cerezo, Mark S. Winterbone, Wendy J. Hollands, Yuri Alexeev, Paul W. Needs, Paul A. Kroon. Potent inhibition of VEGFR-2 activation by tight binding of green tea epigallocatechin gallate and apple procyanidins to VEGF: Relevance to angiogenesisMolecular Nutrition & Food Research, 2015; 59 (3): 401 DOI: 10.1002/mnfr.201400478


Monday, April 20, 2015

Nutrition Recommendations to Prevent Kidney Stones: Realistic Dietary Goals and Expectations

There is no standard diet to prevent kidney stones because there are various types of kidney stones and risk factors associated with each one of them. In order to provide individualized nutrition therapy, dietitians need to look at the medical history, current/past dietary pattern, type of stone, 24-hour urine parameters, and medications.

The followings are some types of kidney stones:
·      Calcium oxalate stones (which is caused by: high urinary calcium excretion, high urinary oxalate excretion, low urinary citrate/magnesium excretion or low urine volume.
·      Calcium phosphate stone (which is caused by: high urinary calcium excretion, low urinary citrate excretion, high urine pH, or low urine volume)
·      Uric acid stones (which is caused by: genetic problem, or some diseases such as leukemia, lymphoma, multiple myeloma, and sickle cell disease. These might result in high urinary uric acid excretion, low (acid) urine pH, or low urine volume)
·      Cystine Stones (occur genetically where the kidney is unable to filter the cystine. May need to control the methionine in diet)

Dietitians need to check for excessive sodium intake, high acidic food, excessive calcium intake, magnesium deficiency, or medications that causes hypocitraturia. Dietitians also need to check contributing health conditions that might affect urine PH such as obesity or insulin resistance. Weather the stones resulted from dietary factor or not, diet plays important role in treating/preventing the occurrence/recurrence of kidney stones. It is essential for the RD to know the stone composition and the associated causes and risk factors.


Penniston, K. L. (2015). Nutrition Recommendations to Prevent Kidney Stones: Realistic Dietary Goals and Expectations. In Kidney Stone Disease (pp. 187-200). Springer International Publishing.