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CLINICAL
NUTRITION
HIGHLIGHTS
Science supporting
better nutrition
2012 Volume 8, Issue 4
In this issue
CLINICAL
NUTRITION
HIGHLIGHTS
Science supporting
better nutrition
2012 Volume 8, Issue 4
Feature article
2
10
Cancer
10
Critical care
10
Dysphagia
13
Diabetes
14
Geriatrics
15
Immunonutrition
15
16
Pediatrics
17
19
Conference calendar
24
Feature article
Importance of nutritional
management in
comprehensive diabetes care
Alice PS Kong,1,2 Lorena TF Cheung3 and Juliana CN Chan1,2
Department of Medicine and Therapeutics
Li Ka Shing Institute of Health Sciences
The Chinese University of Hong Kong
Hong Kong SAR, China
3
Nestl Health Science, Asia, Oceania, Africa Region
1
Introduction
10
Feature article
diabetes patients, the weight loss did not reduce the number
11,12,14
over 10 years.
12
post-trial period.17
16
Nutritional recommendations of
international diabetes associations
Professional diabetes associations from the US, Canada,
33
including 356 subjects (203 with type 1 and 153 with type
Feature article
basis. These may include, but are not limited to: frail elderly
cases even lower (<7%) (Tables 1 and 2). Trans fatty acids
are unable to take an oral diet, tube feeding is the preferred route
Diabetes-specific formula
may be considered to provide
energy, as well as macroand micronutrients, as a
component of MNT in diabetic
patients with special needs
food, the greater the area under the curve. In clinical practice,
45,50-52
Table 1. Major nutritional recommendations in management guidelines for diabetes from North America and Europe
Canadian Diabetes
Association (CDA)
(2008)20
Not specified
Carbohydrates (CHO)
4560% TEI
4560% TEI
Individualized
Glycemic index
(GI) / Glycemic
load (GL)
GI and GL provide a
modest additional benefit
that is observed when
total CHO is considered
alone
Sucrose
Sucrose can be
substituted for other CHO
sources, but avoid excess
energy intake
Limited substitution of
sucrose-containing foods
for other CHO
Dietary fiber
Protein
1520% TEI
Not discussed
Fat
Not specified
35% TEI
Not discussed
Saturated fat
<7% TEI
7% TEI
Not discussed
Trans fat
Should be minimized
Should be minimized
Not discussed
Cholesterol
<200 mg/d
<200 mg/d
Not discussed
Monounsaturated
fatty acids (MUFA)
Not specified
Not discussed
Polyunsaturated
fatty acids (PUFA)
Not specified;
2 servings of fish intake
per week to provide n-3
PUFA
10% TEI
23 servings of oily fish
weekly and plant sources
of n-3 PUFA
Not discussed
Sodium / Salt
Not discussed
Not discussed
No clear evidence of
benefit in those who
do not have underlying
deficiencies;
A daily multivitamin
supplement may be
appropriate, especially for
older adults with reduced
energy intake
Not discussed
Routine supplementation
is not necessary, except
for vitamin D in persons
aged >50 years and folic
acid in women planning
pregnancy
Not discussed
Alcohol
Limit to 12 drinks /d
(14 standard drinks/
week for men and 9/
week for women)
Individualized
CKD, chronic kidney disease; CHO, carbohydrate; GI, glycemic index; GL, glycemic load; LDL-C, low density lipoprotein cholesterol; MUFA; monounsaturated fatty acids; PUFA, polyunsaturated fatty acids; RDA: recommended daily allowance; TEI, total energy intake
European Association
for the Study of Diabetes
(EASD) (2004)45
Feature article
American Diabetes
Association (ADA) (2008
and 2012)43,44
Feature article
Table 2. Major nutritional recommendations in diabetes management guidelines from five Asian cities or countries
Taiwan42,47
PR China42,47
India42,47
Malaysia42,47,48
Carbohydrates (CHO)
Amount not
specified;
recommend to
distribute amongst
three main meals
per day
4565% TEI
6070% TEI
5060% TEI
Glycemic index
(GI) / Glycemic
load (GL)
Not discussed
Not discussed
Not discussed
Not discussed
Choice of low GI
foods in place of
conventional or high
GI foods has a small
effect on medium
term glycemic
control. GI must be
used to complement
established dietary
concerns
Sucrose
Not discussed
Not discussed
Not discussed
Not discussed
Dietary fiber
15 g/1,000 kcal
Not discussed
Not discussed
Not discussed
2030 g/d
Protein
1520% TEI
<20% TEI
1520% TEI
1218% TEI
15% TEI
or 0.81.0 g/kg/day
Fat
Not discussed
<30% TEI
<30% TEI
2025% TEI
2530% TEI
Saturated fat
<7% TEI
Not discussed
<10% TEI
<7% TEI
<710% TEI
Trans fat
Not discussed
Not discussed
Not discussed
Not discussed
Minimize
Cholesterol
<200 mg/d
<300 mg/d
<300 mg/d;
<200 mg/d if LDL
>100 mg/dL (or 2.6
mmol/L)
<200 mg/d
300 mg/d
Monounsaturated
fatty acids (MUFA)
Not discussed
Not discussed
Not discussed
Not discussed
Maximize
Polyunsaturated
fatty acids (PUFA)
Not discussed
Not discussed
Not discussed
Not discussed
47% TEI
Sodium / Salt
<2,400 mg/d
Not discussed
Not discussed
Not discussed
<2,400 mg/d
Not discussed
Not discussed
Not discussed
Not discussed
Supplement is
indicated with
confirmed deficiency
Alcohol
Not discussed
Not discussed
Not discussed
Not discussed
Limit to 1drink/d
for women and 2
drinks/d for men
CHO, carbohydrate; GI, glycemic index; GL, glycemic load; LDL-C, low density lipoprotein cholesterol; MUFA; monounsaturated fatty acids; PUFA, polyunsaturated fatty acids; TEI, total energy intake
Pending
definitive
evidence,
diabetes-specific
formulas
64
groups, there was a trend for less gestational weight gain and
64
outcomes and there are only few data from randomized clinical
CI 0.14-0.75: P = 0.01).
65
Feature article
A recently published
61-63
Conclusions
67-72
unpublished data).
45
On the
66
Feature article
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November 2012.
2. Centers for Disease Control and Prevention. National Diabetes Fact Sheet: national estimates and
general information on diabetes and prediabetes in the United States, 2011. Available at: http://www.
cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed: 15 November 2012.
3. Chan JC, Malik V, Jia W, et al. Diabetes in Asia: epidemiology, risk factors, and pathophysiology. JAMA
2009;301:2129-2140.
4. Kong AP, Chow CC. Medical consequences of childhood obesity: a Hong Kong perspective. Res Sports
Med 2010;18:16-25.
5. Kong AP, Chan JC. Cancer risk in type 2 diabetes. Curr Diab Rep 2012;12:325-328.
6. Popkin BM, Horton S, Kim S, Mahal A, Shuigao J. Trends in diet, nutritional status, and diet-related
noncommunicable diseases in China and India: the economic costs of the nutrition transition. Nutr
Rev 2001;59:379-390.
7. Du S, Lu B, Zhai F, Popkin BM. A new stage of the nutrition transition in China. Public Health Nutr
2002;5:169-174.
8. Shetty PS. Nutrition transition in India. Public Health Nutr 2002;5:175-182.
9. Herman WH, Hoerger TJ, Brandle M, et al. The cost-effectiveness of lifestyle modification or
metformin in preventing type 2 diabetes in adults with impaired glucose tolerance. Ann Intern Med
2005;142:323-332.
10. Salas-Salvado J, Bullo M, Babio N, et al. Reduction in the incidence of type 2 diabetes with the
Mediterranean diet: results of the PREDIMED-Reus nutrition intervention randomized trial. Diabetes
Care 2011;34:14-19.
11. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment
of diabetes on the development and progression of long-term complications in insulin-dependent
diabetes mellitus. New Engl J Med 1993;329:977-986.
12. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas
or insulin compared with conventional treatment and risk of complications in patients with type 2
diabetes (UKPDS 33). Lancet 1998;352:837-853.
13. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with
lifestyle intervention or metformin. N Engl J Med 2002;346:393-403.
14. Ohkubo Y, Kishikawa H, Araki E, et al. Intensive insulin therapy prevents the progression of diabetic
microvascular complications in Japanese patients with NIDDM: a randomised prospective 6-year
study. Diab Res Clin Pract 1995;28:103-117.
15. Nathan DM, Cleary PA, Backlund JY, et al. Intensive diabetes treatment and cardiovascular disease in
patients with type 1 diabetes. N Engl J Med 2005;353:2643-2653.
16. Shichiri M, Kishikawa H, Ohkubo Y, Wake N. Long-term results of the Kumamoto Study on optimal
diabetes control in type 2 diabetic patients. Diabetes Care 2000;23(Suppl 2):B21-B29.
17. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10-year follow-up of intensive glucose control
in type 2 diabetes. N Engl J Med 2008;359:1577-1589.
18. Pastors JG, Franz MJ, Warshaw H, Daly A, Arnold MS. How effective is medical nutrition therapy in
diabetes care? J Am Diet Assoc 2003;103:827-831.
19. Pastors JG, Warshaw H, Daly A, Franz M, Kulkarni K. The evidence for the effectiveness of medical
nutrition therapy in diabetes management. Diabetes Care 2002;25:608-613.
20. Canadian Diabetes Association. Canadian Diabetes Association 2008 Clinical Practice Guidelines of
the Prevention and Management of Diabetes in Canada. Can J Diabetes 2008;32(Suppl 1):S40-S46.
21. Franz MJ, Monk A, Barry B, et al. Effectiveness of medical nutrition therapy provided by dietitians in
the management of non-insulin-dependent diabetes mellitus: a randomized, controlled clinical trial. J
Am Diet Assoc 1995;95:1009-1017.
22. Miller CK, Edwards L, Kissling G, Sanville L. Nutrition education improves metabolic outcomes among
older adults with diabetes mellitus: results from a randomized controlled trial. Prev Med 2002;34:252259.
23. Graber AL, Elasy TA, Quinn D, Wolff K, Brown A. Improving glycemic control in adults with diabetes
mellitus: shared responsibility in primary care practices. South Med J 2002;95:684-690.
24. Goldhaber-Fiebert JD, Goldhaber-Fiebert SN, Tristan ML, Nathan DM. Randomized controlled
community-based nutrition and exercise intervention improves glycemia and cardiovascular risk
factors in type 2 diabetic patients in rural Costa Rica. Diabetes Care 2003;26:24-29.
25. Wilson C, Brown T, Acton K, Gilliland S. Effects of clinical nutrition education and educator discipline on
glycemic control outcomes in the Indian health service. Diabetes Care 2003;26:2500-2504.
26. Lemon CC, Lacey K, Lohse B, et al. Outcomes monitoring of health, behavior, and quality of life after
nutrition intervention in adults with type 2 diabetes. J Am Diet Assoc 2004;104:1805-1815.
27. Logminiene Z, Norkus A, Valius L. Direct and indirect diabetes costs in the world. Medicina (Kaunas)
2004;40:16-26.
28. Gaetke LM, Stuart MA, Truszczynska H. A single nutrition counseling session with a registered dietitian
improves short-term clinical outcomes for rural Kentucky patients with chronic diseases. J Am Diet
Assoc 2006;106:109-112.
29. Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood
pressure. DASH Collaborative Research Group. N Engl J Med 1997;336:1117-1124.
30. Van Horn L, McCoin M, Kris-Etherton PM, et al. The evidence for dietary prevention and treatment of
cardiovascular disease. J Am Diet Assoc 2008;108:287-331.
31. Wing RR. Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in
individuals with type 2 diabetes mellitus: four-year results of the Look AHEAD trial. Arch Intern Med
2010;170:1566-1575.
32. Kong AP, Chan NN, Chan JC. The role of adipocytokines and neurohormonal dysregulation in metabolic
syndrome. Cur Diabetes Rev 2006;2:397-407.
33. Henry RR, Gumbiner B, Ditzler T, et al. Intensive conventional insulin therapy for type II diabetes.
Metabolic effects during a 6-mo outpatient trial. Diabetes Care 1993;16:21-31.
34. Turner RC, Cull CA, Frighi V, Holman RR. Glycemic control with diet, sulfonylurea, metformin, or insulin
in patients with type 2 diabetes mellitus: progressive requirement for multiple therapies (UKPDS 49).
UK Prospective Diabetes Study (UKPDS) Group. JAMA 1999;281:2005-2012.
35. Unick JL, Beavers D, Jakicic JM, et al. Effectiveness of lifestyle interventions for individuals with severe
obesity and type 2 diabetes: results from the Look AHEAD trial. Diabetes Care 2011;34:2152-2157.
36. National Institutes of Health. NIH News; October 2012. Available at: www.nih.gov/news/health/
oct2012/niddk-19.htm. Accessed: 19 November 2012.
37. Dullaart RP, Beusekamp BJ, Meijer S, van Doormaal JJ, Sluiter WJ. Long-term effects of proteinrestricted diet on albuminuria and renal function in IDDM patients without clinical nephropathy and
hypertension. Diabetes Care 1993;16:483-492.
38. Pomerleau J, Verdy M, Garrel DR, Nadeau MH. Effect of protein intake on glycaemic control and renal
Acknowledgements: The data of some of the studies described in this manuscript were supported by the
Research Grant Committee (CUHK 467410), Li Ka Shing Institute of Health Science and Hong Kong Institute
of Diabetes and Obesity, under the auspices of The Chinese University of Hong Kong.
Retinopathy
- most frequent cause
of new cases of
blindness in adults
(2074 years)6,9
- 40% of patients on
dialysis are diabetics6,10
Cancer
- important comorbidity and cause of death12
- premature death from cancer and infectious diseases13
CHD, coronary heart disease; CVD, cardiovascular disease
13
Denmark
Total cost as %
of GDP
0.6
UK
Total cost as %
of GDP
0.4
US
Total cost as %
of GDP
1.2
India
Total cost as %
of GDP
2.1
Health economic
perspective
Societal perspective
31,500
24,400
51,600
Metformin
99,600
34,500
99,200
1,300
Adapted from Diabetes Prevention Program (DPP).18 QALY: quality-adjusted life year
Clinical nutrition
abstracts
CRITICAL CARE
JPEN J Parenter Enteral Nutr 2012 Oct 15. [Epub ahead of print]
Bejarano N, Navarro S, Rebasa P, Garca-Esquirol O, Hermoso J.
Department of Surgery, Intensive Care Unit, Hospital Universitario, Barcelona, Spain.
10
The abstracts included in this section were selected from a search on clinical nutrition and related topics of the PubMed database of the United States National Library of
Medicine. PubMed may be accessed via the National Library of Medicine Web site at www.nlm.nih.gov.
Clinical nutrition
abstracts
11
Clinical nutrition
abstracts
12
PURPOSE OF REVIEW: This review discusses the mechanisms of the dysfunctional gut during the critical illness
and the possibility that an immunonutrient such as whey
protein can play a role in better tolerance of enteral
nutrition, also decreasing inflammation and increasing antiinflammatory defenses. RECENT FINDINGS: Impaired
gastric motor function and associated feed intolerance
are common issues in critically ill patients. Some studies
have been published with enteral nutrition enriched with
whey protein as a dietary protein supplement that provides
antimicrobial activity, immune modulation, improving
muscle strength and body composition, and preventing
cardiovascular disease and osteoporosis. SUMMARY: Early
enteral feeding will enhance patient recovery and the use of
enteral diets enriched with whey protein may play a role in
these patients.
DYSPHAGIA
Clinical nutrition
abstracts
13
DIABETES
Clinical nutrition
abstracts
14
GERIATRICS
IMMUNONUTRITION
PURPOSE OF REVIEW: In the last year, several metaanalyses focused on the potential clinical benefits of perioperative immunonutrition in surgical patients. Purpose of this
review is to summarize their results and to draw recommendations about the current indication of immunonutrition in
surgery. RECENT FINDINGS: Standard enteral preparations have been modified by adding specific nutrients, such
as arginine, omega-3 fatty acids and others, which have been
Clinical nutrition
abstracts
shown to upregulate immune response, to control inflammatory response, and to improve gut function after surgery.
The majority of the randomized trials found that perioperative immunonutrition improved short-term outcome
in patients, who underwent elective major gastrointestinal
(GI) surgery. Four meta-analyses including a large number
of randomized clinical trials reported that perioperative
immunonutrition is associated with a substantial reduction
in both infection rate and length of hospital stay. These
results have been found in both upper and lower GI patients,
regardless of their baseline nutritional status. Promising
results have been found also in head and neck surgery.
SUMMARY: In the light of these findings the use of perioperative immunonutrition should be implemented in patients
undergoing elective major GI surgery. This should result in
a considerable reduction in both postoperative morbidity
and costs for healthcare systems. Larger trials are required
before recommending immunonutrition as a routine practice
in head and neck surgery.
15
Clinical nutrition
abstracts
16
Nygren J, Thacker J, Carli F, Fearon KC, Norderval S, Lobo DN, Ljungqvist O, Soop
M, Ramirez J.
Department of Surgery, Ersta Hospital, Karolinska Institutet, Stockholm, Sweden.
PEDIATRICS
lower than basal metabolic rate (P < 0.001); the actual protein
intake for all patient-days met an average of 40.4% 44.2%
of protein requirements and was significantly lower than the
American Society for Parenteral and Enteral Nutrition guidelines (P < 0.001). Delivery of energy and protein were inadequate on 60% and 85% of patient-days, respectively. Only 75%
of estimated energy and 40% of protein requirements were
met in the first 8 days of PICU stay. These data demonstrate
a high prevalence of critically ill children who are not meeting
their recommended levels of protein and energy. In order to
avoid undernutrition of these children, providers must conduct
ongoing assessment of protein and energy intake compared with
protein and energy requirements.
Clinical nutrition
abstracts
17
Clinical nutrition
abstracts
CLINICAL NUTRITION HIGHLIGHTS 2012 Volume 8, Issue 4
18
to describe their relationship to clinical outcomes in mechanically ventilated children. DESIGN, SETTING, PATIENTS: We
conducted an international prospective cohort study of consecutive children (ages 1 month to 18 yrs) requiring mechanical
ventilation longer than 48 hrs in the pediatric intensive care
unit. Nutritional practices were recorded during the pediatric
intensive care unit stay for a maximum of 10 days, and patients
were followed up for 60 days or until hospital discharge.
Multivariate analysis, accounting for pediatric intensive care
unit clustering and important confounding variables, was used
to examine the impact of nutritional variables and pediatric
intensive care unit characteristics on 60-day mortality and
the prevalence of acquired infections. MAIN RESULTS: 31
pediatric intensive care units in academic hospitals in eight
countries participated in this study. Five hundred patients
with mean (SD) age 4.5 (5.1) yrs were enrolled and included
in the analysis. Mortality at 60 days was 8.4%, and 107 of
500 (22%) patients acquired at least one infection during
their pediatric intensive care unit stay. Over 30% of patients
had severe malnutrition on admission, with body mass index
z-score > 2 (13.2%) or < -2 (17.1%) on admission. Mean
prescribed goals for daily energy and protein intake were
64 kcals/kg and 1.7 g/kg respectively. Enteral nutrition was
used in 67% of the patients and was initiated within 48 hrs
of admission in the majority of patients. Enteral nutrition
was subsequently interrupted on average for at least 2 days
in 357 of 500 (71%) patients. Mean (SD) percentage daily
nutritional intake (enteral nutrition) compared to prescribed
goals was 38% for energy and 43% (44) for protein. A higher
percentage of goal energy intake via enteral nutrition route
was significantly associated with lower 60-day mortality
(Odds ratio for increasing energy intake from 33.3% to
66.6% is 0.27 [0.11, 0.67], P = 0.002). Mortality was higher
in patients who received parenteral nutrition (odds ratio 2.61
[1.3, 5.3], P = 0.008). Patients admitted to units that utilized a
feeding protocol had a lower prevalence of acquired infections
(odds ratio 0.18 [0.05, 0.64], P = 0.008), and this association
was independent of the amount of energy or protein intake.
CONCLUSIONS: Nutrition delivery is generally inadequate
in mechanically ventilated children across the world. Intake
of a higher percentage of prescribed dietary energy goal via
enteral route was associated with improved 60-day survival;
conversely, parenteral nutrition use was associated with higher
mortality. Pediatric intensive care units that utilized protocols
for the initiation and advancement of enteral nutrient intake
had a lower prevalence of acquired infections. Optimizing
nutrition therapy is a potential avenue for improving clinical
outcomes in critically ill children.
Highlights of the
Landi
concluded
that
the
adverse
Highlights of the
34th ESPEN Congress
low muscle mass plus either low muscle strength or low physical
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
P Soler (Spain)
associated with a healthier, longer life does not hold true for
is not the case for older people; BMI in the normal to obese
19
Highlights of the
34th ESPEN Congress
of falls.1
References
recent review.8
1. Physical Activity Guidelines Advisory Committee. 2008. Wasington D.C., U.S. Department of Health
and Human Services.
2. Troiano RP, et al. Med Sci Sports Exerc 2008;40:181-188.
3. Seguin RA, et al. Health Educ Behav 2012;39:183-190.
1.
2.
3.
4.
5.
6.
7.
8.
20
healthcare professional.2
References
1. Kyle UG, et al. Clin Nutr 2012; 7(Suppl 1):1.
2. Huhmann MB, et al. Clin Nutr 2012;7(Suppl 1):2.
3. Molfino A, et al. Clin Nutr 2012;7(Suppl 1):3.
Y Boirie (France)
Sir David Cuthbertson studied the effects of trauma, illness
and immobility on the metabolism of surgical patients, with a
particular focus on protein metabolism. This topic is as relevant
today as it was in the 1930s, and our understanding of it continues
to deepen. During trauma, muscle releases amino acids for the
immune system to produce acute phase proteins and to aid in
repair. These amino acids are released into the bloodstream for
synthesis of proteins; however, as a result of anabolic resistance
most of the amino acids are used for oxidation. The same occurs
when patients with anabolic resistance are fed; amino acids are
used for oxidation.
What are the mechanisms of anabolic resistance? In the
post-absorptive state, protein breakdown outstrips protein
After ingestion of a meal, stimulation of protein synthesis
and inhibition of protein breakdown leads to neutral protein
balance. Behind this process lies complex intracellular
machinery.1 Insulin is an important signal during meal intake
that acts on this machinery together with amino acids and
energy to stimulate protein synthesis, but at the same time to
inhibit protein breakdown. Stress signals, such as cytokines,
can directly stimulate protein breakdown and inhibit
protein synthesis so that the balance between both signals is
very important.
Aging has an important impact on muscle, so how does
this apply to sarcopenia? The definition of sarcopenia has been
clarified as a decrease in muscle mass with a decrease in muscle
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Highlights of the
34th ESPEN Congress
that omega-3 fatty acids and oleate may alter the anabolic
21
standard formula.3
References
Highlights of the
34th ESPEN Congress
P Singer (Israel)
O Ljungqvist (Sweden)
22
of achievements.
charity
for
tackling
malnutrition
in
the
UK.
References
oldest patients.
1.
2.
3.
4.
5.
Highlights of the
34th ESPEN Congress
April 2013
Organizer:
February 2013
Organizer:
March 2013
Conference calendar
24
Organizer:
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