Review : nurses can improve patient nutrition in intensive care

Aims and objectives. To review the literature and identify opportunities for nutritional practice improvement in the critically ill and opportunities to improve nurses’ knowledge relating to enteral feeding.

Background. The literature reports varying nutritional practices in intensive care.

Design. Systematic review.

Methods. A systematic search, selection, analysis and review of nursing, medical and dietetic primary research articles was undertaken. Fifteen studies met the selection criteria.

Results. Delivery of nutrition to the critically ill varied widely. Patients were frequently underfed and less frequently, overfed. Both under- and overfeeding have been linked with unacceptable consequences including infections, extended weaning from mechanical ventilation, increased length of stay and increased mortality. Underfeeding was related to slow initiation and advancement of nutrition support and avoidable feed interruptions. The most common reasons for interrupting feeds were gastrointestinal intolerance and fasting for procedures. Certain nursing practices contributed to underfeeding such as the management of gastric residual volumes.

Conclusions. Consistent and reliable nutrition support in intensive care units is hampered by a lack of evidence leading to varying nutrition practices. Factors impeding delivery of enteral nutrition were considered avoidable. A new concept of a therapeutic range of energy delivery in the critically ill has emerged implying the need for re-evaluation of energy recommendations and improved delivery of enteral nutrition.

Relevance to clinical practice. This review supports the multi-disciplinary development and implementation of an evidence-based enteral feeding protocol in intensive care units as a strategy to improve adequacy of nutritional intake. Critical care nurses are well placed to improve this process.

Reducing the energy density of an entrée decreases children’s energy intake at lunch

Background: Strategies need to be developed to reduce preschool children’s energy intake.

Objective: To test the effect of reducing the energy density of an entrée on children’s ad libitum energy intake.

Subjects: Subjects were 2- to 5-year-old children (37 boys and 40 girls) in a university day-care facility.

Intervention: In this within-subjects crossover study, children were served a test lunch once per week for 6 weeks. Two versions of a macaroni and cheese entrée were formulated to differ in energy density while maintaining similar palatability. Each version was served to children three times. The higher-energy-density entrée had 2.0 kcal/g and the other entrée was 30% lower in energy density. Lunch, consumed ad libitum, also included broccoli, applesauce, and milk.

Main outcome measures: Food intake and energy intake were measured.

Statistical analyses: A mixed linear model tested effect of energy density of the entrée on food intake and energy intake. Results are reported as mean±standard error.

Results: Decreasing the energy density of the entrée by 30% significantly (P<0.0001) reduced children’s energy intake from the entrée by 25% (72.3±8.3 kcal) and total lunch energy intake by 18% (71.8±7.9 kcal). Children consumed significantly more of the lower-energy-density entrée (10.1±4.2 g; P<0.05). Children’s sex-specific body mass index–for-age percentiles did not affect the relationship between energy density of the entrée and children’s intakes.

Conclusions: Decreasing the energy density of a lunch entrée resulted in a reduction in children’s energy intake from the entrée and from the total meal. Reducing the energy density of foods may be an effective strategy to moderate children’s energy intake.

Hospital malnutrition : prevalence, identification and impact on patients and the healthcare system

Malnutrition is a debilitating and highly prevalent condition in the acute hospital setting, with Australian and international studies reporting rates of approximately 40%. Malnutrition is associated with many adverse outcomes including depression of the immune system, impaired wound healing, muscle wasting, longer lengths of hospital stay, higher treatment costs and increased mortality. Referral rates for dietetic assessment and treatment of malnourished patients have proven to be suboptimal, thereby increasing the likelihood of developing such aforementioned complications. Nutrition risk screening using a validated tool is a simple technique to rapidly identify patients at risk of malnutrition, and provides a basis for prompt dietetic referrals. In Australia, nutrition screening upon hospital admission is not mandatory, which is of concern knowing that malnutrition remains under-reported and often poorly documented. Unidentified malnutrition not only heightens the risk of adverse complications for patients, but can potentially result in foregone reimbursements to the hospital through casemix-based funding schemes. It is strongly recommended that mandatory nutrition screening be widely adopted in line with published best-practice guidelines to effectively target and reduce the incidence of hospital malnutrition.

Involvement of young Australian adults in meal preparation : cross-sectional associations with abdominal obesity and body mass index

Previous research has shown that involvement in meal preparation is positively associated with better diet quality. However, it is unclear whether there is an association between involvement in meal preparation and being overweight or obese. This study investigated whether the level of involvement in meal preparation was associated with objectively measured weight status in young adults. During 2004-2006, a national sample of 1,996 Australian adults aged 26 to 36 years completed a self-administered questionnaire including questions on sociodemographic characteristics, diet, and physical activity. Participants were asked to report who usually prepared the main meal on working days and responses were categorized as “myself,” “shared,” or “someone else.” Waist circumference, weight, and height were measured by trained staff. Moderate abdominal obesity was defined as waist circumference >94 cm for men and >80 cm for women. Overweight was defined as body mass index (calculated as kg/m2) >25. Prevalence ratios were calculated using log binomial regression. After adjusting for age, education, and leisure time physical activity, men who shared the meal preparation had a slightly lower prevalence of moderate abdominal obesity (prevalence ratio=0.92; 95% confidence interval [CI]: 0.86 to 0.99) than those whose meals were usually prepared by someone else. There was no association with having sole responsibility (prevalence ratio=0.99; 95% CI: 0.92 to 1.06). There were no associations between level of involvement in meal preparation and being overweight (shared responsibility prevalence ratio=0.99; 95% CI: 0.92 to 1.07; sole responsibility prevalence ratio=0.98; 95% CI: 0.91 to 1.05). For women, level of involvement was not associated with moderate abdominal obesity (shared responsibility prevalence ratio=0.93; 95% CI: 0.84 to 1.03; sole responsibility prevalence ratio=0.94; 95% CI: 0.86 to 1.03) or being overweight (shared responsibility prevalence ratio=0.93; 95% CI: 0.84 to 1.02; sole responsibility prevalence ratio=0.93; 95% CI: 0.85 to 1.02). In this sample of young adults, level of involvement in meal preparation was not strongly related to weight status.

Fruit and vegetable consumption and the risk of proximal colon, distal colon and rectal cancers in a case-control study in Western Australia

Background Fruits and vegetables (F/V) have been examined extensively in nutrition research in relation to colorectal cancer (CRC). However, their protective effect is subject to debate, possibly because of different effects on different subsites of the large bowel.

Objective To determine whether any association between F/V consumption and risk of CRC differed by subsite of the bowel (proximal colon, distal colon, and rectum).

Design The Western Australian Bowel Health Study is a population-based, case-control study conducted between June 2005 and August 2007. Complete food frequency questionnaire data were analysed from 834 CRC cases and 939 controls. Logistic regression analysis was used to estimate the effects of quartiles of F/V intake on risk of CRC at different subsites. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for CRC overall and for the three separate subsites.

Results Risk of proximal colon cancer and rectal cancer was not associated with intakes of total F/V, total vegetable, or total fruit. Brassica vegetable intake was inversely related with proximal colon cancer (Q4 vs Q1 OR 0.62; 95% CI 0.41 to 0.93). For distal colon cancer, significant negative trends were seen for total F/V, and total vegetable intake. Distal colon cancer risk was significantly decreased for intake of dark yellow vegetables (Q4 vs Q1 OR 0.61; 95% CI 0.41 to 0.92) and apples (Q4 vs Q1 OR 0.51; 95% CI 0.34 to 0.77). An increased risk for CRC was found to be associated with intake of fruit juice (Q4 vs Q1 OR 1.74; 95% CI 1.24 to 2.45).

Conclusions Our results suggest that different F/V may confer different risks for cancer of the proximal colon, distal colon, or rectum. Future studies might consider taking into account the location of the tumor when examining the relation between F/V consumption and risk of CRC.

Quantities of foods consumed by 12- to 24-month-old New Zealand children

Aim:  The present study aimed to estimate small, median and large daily quantities of frequently consumed foods and identify which food groups are important sources of key micronutrients for 12- to 24-month-old New Zealand children.

Methods:  A community-based cross-sectional survey was conducted in three cities in the South Island of New Zealand. Healthy toddlers (n = 188) were randomly selected using multistage sampling. Three non-consecutive 1-day weighed food records were collected from each child and the frequencies and daily quantities of foods and beverages, and important sources of iron and zinc, were determined.

Results:  Fifty percent or more of the children consumed the following foods at least once over 3 days (median gram intake among toddlers who consumed the food): milk (366 g), white bread (29 g), banana (70 g), potato (34 g), cheese (12 g), apple (39 g), ‘Weetbix’ whole-wheat breakfast cereal (16 g), yeast extract spread (‘Marmite’, ‘Vegemite’) (2 g), carrot (17 g) and margarine (4 g). Dairy, cereals and the meat/fish/poultry/eggs/nuts food group were the most important sources of iron and zinc in the toddlers' diets, providing 69.1% of iron and 86.3% of zinc.

Conclusion:  This research provides dietitians, other health professionals, researchers and policy-makers with detailed information on daily quantities of foods and beverages frequently consumed by toddlers that can be used for dietetic counselling, dietary assessment, and to develop food-based dietary guidelines specifically for toddlers.

Nutrition screening by nurses in dialysis

Aims and objectives : To determine whether a nurse-completed dialysis nutritional screening tool improves referral rates for nutritional support and compare nutrition sensitive biochemical indices, mortality rates and patient-centred quality of life outcomes between referred and non-referred dialysis patients.

Background : People with chronic kidney disease requiring dialysis are nutritionally at risk. Nutrition screening has been shown to identify dialysis patients who are nutritionally at risk to refer to dietitian expertise.

Design : Prospective cluster-randomised control trial.

Methods : Monthly nurse-completed nutrition screening was completed for six consecutive months using a validated four-item instrument measuring weight change, serum phosphate, serum potassium and appetite. Participants (n = 81) were haemodialysis patients from four satellite haemodialysis centres in one Australian metropolitan health service. Primary outcome measure was rate of referral to dietetic services for nutrition support for intervention vs. control groups at six months. Secondary outcome measures were blood pressure, biochemical indices and mortality for referred vs. non-referred patients at six and nine months, and generic and dialysis-specific quality of life for referred vs. non-referred at nine months was examined.

Results : There were three times as many dietetic referrals in the intervention group than in the control group (26·3 vs. 9·3%). Serum phosphate increased significantly more in the referred patients than the non-referred patients. There were no clinically significant changes between groups in quality of life, blood pressure, mortality rates or other biochemical indices at either six or nine months.

Conclusion : Nurse-completed nutritional screening can lead to appropriate dietetic referrals for nutritional support by nutritional expert clinicians.

Relevance to clinical practice : This study is the first to demonstrate that monthly systematic nurse-completed nutritional screening can facilitate appropriate dietetic referrals that may lead to increased nutritional care for people in satellite dialysis centres.

Transitions in reflective practice: exploring student development and preferred methods of engagement

Aim: Health-care professional students are required to demonstrate their reflective practice skills during their degree training programme. Online and digital technologies are increasingly being used to support this skill development. Our study aimed to explore whether different technology-based methods supported student growth and skill development in reflective practice at separate developmental time points (novice and competent). Methods: Third- (n = 23) and fourth-year undergraduate dietetic students (n = 22) from a single university were cross-sectionally surveyed via an online anonymous questionnaire at the end of the academic year. The mixed methods survey of 37 questions investigated the student experience of different reflective practice activities, their effect on a student's ability to self-reflect and whether using them aided a student's perceived transition towards becoming a competent dietitian. The data analysis included brief thematic enquiry, descriptive and independent t-test statistical examination. Results: Differences emerged in the way students engaged in reflection over time. Fourth-year students preferred to use more independent methods such as e-journaling (fourth- vs third-year students, P = 0.003) and engaged in reflection for reasons outside assessment (fourth- vs third-years, P = 0.027). Fourth-year students also identified fewer negative barriers to participating in reflection and reported being comfortable engaging in reflective practice. Conclusions: Overall, offering students a range of ways to engage in reflective practice over time supported their understanding and increased confidence in their reflective practice skills, thus potentially enabling a smoother transition into their profession where reflective practice is an essential and autonomous skill. © 2014 Dietitians Association of Australia.

Nutritional management of gastrointestinal surgical patients in Victoria's public hospitals

Aim: Poor nutritional status has negative effects on post-operative outcomes, further compounded by surgical stress and fasting, places gastrointestinal surgery patients at high risk of malnutrition. Recent published research has challenged historic surgical nutrition practices; however, changes to practice in Australia have been slow. The aim of this study was to investigate current nutritional management of gastrointestinal surgery patients and compare this with the best practice guidelines, while exploring enablers to implementation of best practice. Methods: A 30-question telephone survey was developed to explore demographics and nutritional management of gastrointestinal surgical patients during pre-admission, inpatient stay and post-operative care. Forty-one gastrointestinal surgery dietitians were identified and contacted from 31 public hospitals in Victoria, Australia, and invited to participate. Results: Twenty-five dietitians participated in the survey (response rate 61%). Very few dietitians (12%) were funded for pre-admission clinics or outpatient clinics, and, overwhelmingly, dietitians reported not being involved in nutritional decision-making, and reported feeling unsatisfied with current nutritional management of patients. Despite half the hospitals reporting following best practice guidelines, only 22% implemented guidelines completely. There was no correlation observed between dietitian experience, department size or full-time equivalents allocated to surgery and nutritional intervention; however, the presence of a care pathway made a significant difference to the dietitian's overall satisfaction with dietetic care (P = 0.002). Conclusions: Current nutritional management of gastrointestinal surgery patients in Victorian hospitals is far from best practice. The implementation of a care pathway is the most effective way of ensuring best practice nutritional management of gastrointestinal surgical patients.

Current approaches to obesity management in UK Primary Care: the Counterweight Programme

Background/Aims Primary care is expected to develop strategies to manage obese patients as part of coronary heart disease and diabetes national service frameworks. Little is known about current management practices for obesity in this setting. The aim of this study is to examine current approaches to obesity management in UK primary care and to identify potential gaps in care.

Method A total of 141 general practitioners (GPs) and 66 practice nurses (PNs) from 40 primary care practices participated in structured interviews to examine clinician self-reported approaches to obesity management. Medical records were also reviewed for 100 randomly selected obese patients from each practice [body mass index (BMI) ≥30 kg m−2, n = 4000] to review rates of diet counselling, dietetic or obesity centre referrals, and use of anti-obesity medication. Computerized medical records for the total practice population (n = 206 341, 18–75 years) were searched to examine the proportion of patients with a weight/BMI ever recorded.

Results Eighty-three per cent of GPs and 97% of PNs reported that they would raise weight as an issue with obese patients (P < 0.01). Few GPs (15%) reported spending up to 10 min in a consultation discussing weight-related issues, compared with PNs (76%; P < 0.001). Over 18 months, practice-based diet counselling (20%), dietetic (4%) and obesity centre (1%) referrals, and any anti-obesity medication (2%) were recorded. BMI was recorded for 64.2% of patients and apparent prevalence of obesity was less than expected.

Conclusion Obesity is under-recognized in primary care even in these 40 practices with an interest in weight management. Weight management appears to be based on brief opportunistic intervention undertaken mainly by PNs. While clinicians report the use of external sources of support, few patients are referred, with practice-based counselling being the most common intervention.

Digestibilidade aparente de dietas contendo diferentes níveis de amido para coelhos em crescimento

Com o objetivo de avaliar a influência do amido dietético sobre a digestibilidade aparente dos nutrientes, para coelhos em fase de crescimento, quatro dietas experimentais foram elaboradas de forma a conter níveis crescentes de amido de milho (23, 28, 33 e 38% de amido total na base da matéria seca (MS), os quais foram fornecidas a 20 coelhos da raça Nova Zelândia Branco, distribuídos em gaiolas de metabolismo individuais, segundo delineamento inteiramente casualizado. Os resultados obtidos demonstraram efeito linear crescente para os coeficientes de digestibilidade aparente da MS, matéria orgânica (MO), fibra em detergente neutro (FDN) e amido, à medida que aumentou o nível de amido dietético nas dietas experimentais. O nível de 38% de amido dietético proporcionou, portanto, o melhor coeficiente de digestibilidade para o amido (87,26%). Não foram observadas diferenças para os coeficientes de digestibilidade aparente da proteína bruta (PB), energia bruta (EB) e fibra em detergente ácido (FDA), em relação aos diferentes níveis de amido nas dietas experimentais. No entanto, para o teor de extrato etéreo (EE), foi verificado melhor aproveitamento (89,46%) para os animais alimentados com a dieta contendo 23% de amido. Os coelhos foram eficientes em digerir o amido de milho, quando este apresentou alta participação na porção carboidrato total da dieta.

Aproveitamento do resíduo da produção de etanol a partir de farelo de mandioca, como fonte de fibras dietéticas

O presente trabalho teve por objetivo analisar resíduos do farelo de mandioca resultantes de processos de hidrólise enzimática para obtenção de etanol; visando o aproveitamento destes como fonte de fibras dietéticas. Foram realizados quatro ensaios enzimáticos utilizando as enzimas amilolíticas, a-amilase e amiloglucosidase, complementadas ou não com celulase e/ou pectinase. Os resíduos foram caracterizados quanto à composição centesimal, pH, acidez, perfil de açúcares e quanto às fibras (FDA, FDN, celulose, hemicelulose, lignina, açúcares neutros). Realizou-se também a análise microscópica dos resíduos. Pelos resultados obtidos na caracterização dos resíduos calculou-se a energia metabolizável aparente (EM). Observou-se que independente do ensaio enzimático todos os resíduos podem ser usados como fonte de fibras insolúveis. Os resíduos resultantes dos ensaios com pectinase apresentaram uma proporção aproximada de 1:1:1 de amido, fibras e açúcares, sendo a glicose o açúcar majoritário, e com energia metabolizável aparente de cerca de 2,6 kcal/g. Já os resíduos, onde não se utilizou a pectinase a proporção foi de 2:1:1 aproximadamente e a energia 3,1 kcal/g. A análise microscópica dos resíduos mostrou a presença de amido não hidrolisado preso às células em todos os ensaios enzimáticos sendo que, nos resíduos dos ensaios com pectinase a quantidade observada foi bem inferior aos demais. Uma possível alternativa para diminuir o valor calórico dos resíduos seria a lavagem com água após a prensagem para extração do hidrolisado para fermentação.

Long-term nutrition education reduces several risk factors for type 2 diabetes mellitus in Brazilians with impaired glucose tolerance

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)