Educación alimentaria nutricional: Estrategias para mejorar la adherencia al plan dietoterapéutico

RESUMEN La educación alimentaria nutricional es la combinación de estrategias educativas, acompañadas de apoyos ambientales, diseñadas para facilitar la adopción voluntaria de elecciones alimentarias que conducen a un estado óptimo de salud y bienestar. La educación alimentaria nutricional tiene tres componentes: 1) motivación, 2) acción y 3) ambiente. Para elegir la técnica de educación adecuada para cada persona, se deben considerar las características psicoemocionales individuales, especialmente las motivaciones para el cambio y el tipo de personalidad, ya que ambos han mostrado ser buenos predictores de la conducta alimentaria. Dentro de los recursos educativos posibles de utilizar para realizar la educación en alimentación nutricional se encuentran indicaciones verbales, material escrito, uso de internet, dispositivos portátiles, aplicaciones de teléfonos inteligentes, e incluso la clase de cocina. La evidencia demuestra que la educación alimentaria nutricional impacta favorablemente la adherencia a las intervenciones nutricionales, lo cual a la vez se ve reflejado en efectos positivos en la salud.

ABSTRACT Food and nutrition education is the combination of educational strategies, accompanied by environmental supports designed to facilitate voluntary adoption of food choices conducive of health and well-being. It has a motivational phase, an action phase, and an environmental component. To choose the right educational technique for each patient, their individual psychoemotional characteristics must be considered; especially what their motivations for change are, as well as their personality type, because both are good predictors of food behavior. Among the resources that can be used to perform nutrition education are verbal indications, written material, the internet, mobile devices, smartphone applications, and even the kitchen as a place for education. Evidence shows that nutrition education has a favorable impact on diet adherence in different conditions that have an important nutritional component, such as celiac disease, inflammatory bowel disease, diabetes and obesity, which at the same time produces positive health outcomes.

Profesionalismo en el nutricionista: ¿Qué es y cómo incorporarlo en la formación de pregrado?

RESUMEN El profesionalismo es un pilar fundamental en la formación y ejercicio profesional de un nutricionista que implícitamente se ha incluido y desarrollado en los estándares de práctica. Recientemente se ha intentado establecer una terminología común para su definición, esta se basa en cuatro aspectos centrales: a) atributos personales como empatía, autoconciencia e inteligencia emocional, b) comunicación interpersonal, tanto con pares, otros profesionales de la salud y usuarios, c) actuar centrado en la práctica, que considera el entorno laboral en cuanto a las leyes y normativas que rigen el actuar profesional y 4) compromiso con el aprendizaje permanente, como el proceso de reflexión y autoevaluación del propio trabajo. Para garantizar un actuar profesional, la enseñanza del profesionalismo debe ser considerada de manera formal en el plan curricular, implementando distintas técnicas educativas y evaluaciones correspondientes que permitan la adquisición de conocimientos y habilidades necesarias. En el proceso formativo cobra especial relevancia el contexto y ambiente en el que se desempeñan los estudiantes para un óptimo uso de recursos.

ABSTRACT Professionalism is a fundamental aspect in the training and professional practice of a dietitian that has been implicitly included and developed in standards of practice. However, recently, an attempt to establish a common terminology for its definition has been made. The concept of professionalism is based on four central aspects: a) personal attributes such as empathy, self-awareness and emotional intelligence, b) interpersonal communication, both with peers, other health professionals and users, c) approach to practice, which considers the laws and regulations that govern professional actions, and 4) commitment to lifelong learning, such as the process of reflection and self-evaluation. To guarantee professionalism in dietitians, the teaching of professionalism must be considered formally in the plan of study, implementing different educational techniques and corresponding evaluations that guarantee the acquisition of necessary knowledge and skills. In the training process, the context and environment in which students work is especially relevant for an optimal use of resources.

Factores que limitan la adherencia a la dieta y la calidad de vida en enfermos celiacos chilenos durante COVID-19 / Factors that limit adherence to diet and quality of life in Chilean celiac patients during COVID-19

La enfermedad por coronavirus (COVID-19) es altamente contagiosa y las medidas de confinamiento dinámico han demostrado que reducen significativamente el número de contagios, sin embargo, pueden alterar la disponibilidad de alimentos afectando la adherencia a la dieta libre de gluten (DLG) y la calidad de vida (CV) en la enfermedad celiaca (EC). El objetivo de este estudio fue evaluar los factores que limitan, la adherencia a la dieta libre de gluten y la calidad de vida en personas con enfermedad celiaca en periodo de pandemia por COVID-19. Métodos Se aplicaron encuestas on-line respecto a adherencia a la DLG, CV y acerca de los factores que han generado dificultad para llevar una DLG en este escenario. Resultados Se analizaron 216 encuestas de enfermos celiacos, mayores de 15 años, de los cuales un 91% eran mujeres con un promedio de edad de 36 + 10,7 años y con 5,8 + 6,0 años de enfermedad. El 56,48% tenía una excelente adherencia a la DLG y un 43,52% una buena CV. El costo elevado de los alimentos sin gluten fue la pregunta con mayor porcentaje de respuesta, asociándose con regular y mala adherencia a la DLG (valor p=0,001) y con pobre CV (valor p=0,023). Conclusión En periodo de pandemia por COVID-19, el costo de los alimentos se asocia con adherencia regular y mala a la DLG y con pobre CV(AU)

Coronavirus disease (COVID-19) is highly contagious and dynamic confinement measures have shown to significantly reduce the number of infections, however, they can alter the availability of food, affecting adherence to a gluten-free diet (GFD) and quality of life (QoL) in celiac disease (CD). The objective of this study was to evaluate the limiting factors, adherence to a gluten-free diet and quality of life in people with celiac disease in a COVID-19 pandemic period. Methods. On-line surveys were applied regarding adherence to the GFD, CV, and factors that have generated difficulty in carrying out a GFD in this setting. Results. 216 surveys of celiac patients over 15 years of age were analyzed, of which 91% were women with an average age of 36 + 10.7 years and with 5.8 + 6.0 years of the disease. 56.48% had excellent adherence to the GFD and 43.52% had a good QoL. The high cost of gluten-free foods was the question with the highest response percentage, associated with regular and poor adherence to the GFD (p-value = 0.001) and with poor QoL (p-value = 0.023). Conclusion. In a COVID-19 pandemic period, the cost of food is associated with regular and poor adherence to the GFD and with poor QoL(AU)

Microbiota, hábitos alimentarios y dieta en enfermedad inflamatoria intestinal / Microbiota, dietary habits and diet in inflammatory bowel disease

RESUMEN La enfermedad de Crohn y Colitis Ulcerosa corresponden a Enfermedades Inflamatorias Intestinales (EII). En la actualidad aún no se ha establecido la cura de estas enfermedades; sin embargo, se han desarrollado diversas terapias dirigidas a disminuir la inflamación de la mucosa (5 aminosalicílicos) y a disminuir la respuesta del sistema inmune (ejemplo: inmunomoduladores y tratamientos biológicos). Otro pilar de manejo de los pacientes con EII es la nutrición, esta es fundamental en el tratamiento por su capacidad de disminuir síntomas gastrointestinales. La alimentación tiene un impacto en la microbiota intestinal (MI), al asociarse la dieta occidental a un cambio en la biodiversidad de la microbiota. En este sentido, la MI podría tener un rol en la patogenia de la enfermedad, al existir una disminución de la biodiversidad y un aumento de bacterias que podrían favorecer la inflamación y generar una disminución en la producción de ácidos grasos de cadena corta. En EII, los hábitos alimentarios tienden a ser restrictivos y el estado nutricional se caracteriza por desnutrición, pérdida de masa muscular, sarcopenia, déficit de vitamina D y hierro. Por ello en periodos de remisión no se debe restringir la alimentación. En periodos de crisis, las dietas de exclusión de alimentos disminuyen los síntomas y, nutrientes específicos como las antocianinas y ácidos grasos w-3 podrían tener un efecto en la inflamación.

ABSTRACT Crohn's disease and Ulcerative Colitis correspond to Inflammatory Bowel Diseases (IBD). At present, its cure is not known, however nutrition is a fundamental pillar in treatment due to its ability to reduce gastrointestinal symptoms. Food has an impact on intestinal microbiota (IM), as the Western Diet is associated with a change in microbiota biodiversity. In this sense, IM could have a role in the pathogenesis of the disease, since there is a decrease in biodiversity and an increase in bacteria that could favor inflammation and generate a decrease in the production of short-chain fatty acids. In IBD, eating habits tend to be restrictive and nutritional status is characterized by malnutrition, loss of muscle mass, sarcopenia, and vitamin D and iron deficiency. Therefore, during periods of remission, feeding should not be restricted. In periods of crisis, exclusion diets decrease specific symptoms and nutrients such as anthocyanins and w-3 fatty acids could have an effect on inflammation.

Atención clínico nutricional: ¿cómo estructurar el trabajo del nutricionista? / Nutritional clinical care: how to structure the work of the nutritionist?

RESUMEN El trabajo del nutricionista clínico implica realizar una evaluación y diagnóstico nutricional basados en el pensamiento crítico y razonamiento clínico, para una atención nutricional adecuada, y tomar una decisión de intervención basada en la evidencia científica disponible. Luego, se debe monitorizar los resultados de la intervención, para generar un impacto a corto y largo plazo en las patologías que requieren tratamiento nutricional. Para lograr esto, es necesario implementar en los programas curriculares del pregrado un proceso estructurado de enseñanza que siga una secuencia lógica dependiente del nivel de formación, para adquirir habilidades del trabajo clínico en nutrición. El siguiente ensayo tiene por objetivo realizar un análisis de la literatura con respecto a la adquisición de habilidades del pensamiento crítico y razonamiento clínico, junto con conocer los modelos de atención nutricional para generar una propuesta de atención nutricional para aplicar en la práctica clínica.

ABSTRACT The activities of a clinical dietitian involve nutritional assessment and diagnosis based on critical thinking and clinical reasoning. The objective is to offer proper nutritional care and deciding on interventions based on available scientific evidence. The results of the intervention should be monitored to generate short- and long-term impact on the pathologies that require nutritional treatment. To achieve this goal, it is necessary to implement a structured teaching process in the undergraduate program that follows a logical sequence depending on the level of training. The following essay aims to conduct an analysis of the literature regarding the acquisition of critical thinking skills and clinical reasoning, together with knowing the models of nutritional care to generate a nutritional care proposal for application in clinical practice.

Esofagitis eosinofílica: diagnóstico y manejo / Diagnosis and management of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease, induced by food allergens, clinically characterized by symptoms of esophageal dysfunction. Pathologically there is a predominant eosinophilic inflammation. This disease is relatively new, and its definitions have evolved over time. Its prevalence and incidence are increasing and causes clinical problems both in children and adults. Its symptoms include food impaction, dysphagia, symptoms that resemble gastroesophageal reflux, abdominal pain, and vomiting. It can also have extra-digestive symptoms such as rhinosinusitis, chronic cough, recurrent croup and hoarseness. EoE can be associated with other atopic conditions, such as asthma, eczema and food allergies. The diagnosis is made by the analysis of endoscopic biopsies (> 15 eosinophils per high power field). Proton pump inhibitors (PPIs) are currently accepted as a treatment for EoE. The clinical and pathological improvement with the use PPIs ceased to be a criterion to define Esophageal eosinophilia responsive to PPIs as a differential diagnosis, since this condition is currently considered within the EoE spectrum. There are three main treatment approaches for EoE: diet, drugs and dilation. Its diagnosis and early treatment are key to avoid or delay its complications, such as stenosis and severe esophageal dysfunction.

Sobrepeso y obesidad en la enfermedad celiaca activa: posibles mecanismos fisiopatológicos / Overweight and obesity in active celiac disease: possible pathophysiological mechanisms

RESUMEN La enfermedad celiaca (EC) es una enteropatía crónica del intestino delgado, mediado por una respuesta inmune, gatillada por la exposición al gluten en individuos genéticamente susceptibles. La presentación clínica de la EC es variada y conduce a mala absorción. El estado nutricional en el momento del diagnóstico de la EC depende del tiempo en que la enfermedad ha estado activa, la extensión de la inflamación intestinal, grado de mala absorción e ingesta alimentaria. Sin embargo, en los últimos años se ha observado un cambio epidemiológico del estado nutricional en los pacientes celiacos al momento del diagnóstico. La presente revisión tuvo por objetivo realizar un análisis descriptivo de la presencia de obesidad en pacientes celiacos y de los posibles mecanismos fisiopatológicos que la explicarían.

ABSTRACT Celiac disease (CD) is a chronic enteropathy of the small intestinal, mediated by an immune response triggered by exposure to dietary gluten in genetically predisposed individuals. The clinical presentation of CD is varied and leads to malabsorption. Nutritional status at the time of diagnosis of CD depends on the time in which the disease has been active, the extent of intestinal inflammation, degree of malabsorption, and dietary intake. However, in recent years an epidemiological change of nutritional status has been observed in celiac patients at the time of diagnosis. The objective of this review was to perform a descriptive analysis of the presence of obesity in celiac patients and the possible physiopathological mechanisms that would explain it.

Heteroplasmia de la mutación del ADN mitocondrial m.3243A>G en la diabetes y sordera de herencia materna / Mitochondrial DNA heteroplasmy of the m.3243A>G mutation in maternally inherited diabetes and deafness

Maternally Inherited Diabetes and Deafness (MIDD) is caused by mutations in mitochondrial DNA (mtDNA), mainly m.3243A>G. Severity, onset and clinical phenotype of MIDD patients are partially determined by the proportion ofmutant mitochondrial DNA copies in each cell and tissue (heteroplasmy). The identification ofMIDD allows a corred treatment with insulin avoiding drugs that may interfere with mitochondrial electrón chain transpon. We estimated the degree of heteroplasmy ofthe mutation m.3243A>G from blood, saliva, hair root and a muscle biopsy using quantitative PCR (qPCR) in a femóle adult patient. For this purpose, PCR producís were inserted in a vector creatingplasmids with 3243A or G. Mutant and wild-type vectors were mixed in different proportions to créate a calibration curve used to interpólate heteroplasmy percentages with qPCR threshold cycles. The proportions of m.3243A>G heteroplasmy were 62% (muscle), 14% (saliva), 6% (blood leukocytes) and 3% in hair root. Quantitative analysis of heteroplasmy showed marked variations in different tissues (highest in muscle and lowest in blood). Given the relatively high heteroplasmy found in saliva, this type of biológical sample may represent an adequate non-invasive way for assessing the presence of m.3243A>G mutations in epidemiologic studies.

Proteína C Reactiva en la EPOC y su relación con la gravedad de la enfermedad, las exacerbaciones y las comorbilidades / C-Reactive protein levels in patients with chronic obstructive pulmonary disease

Background: Patients with chronic obstructive pulmonary disease (COPD) have elevated serum levels of ultrasensitive C reactive protein (CRPus). This raise may be related directly to COPD and its associated systemic inflammation or secondary to other factors such as smoking status, disease severity, acute exacerbations, or associated complications. Aim: To evaluate the potential causes of raised levels of CRPus in stable COPD patients. Patients and Methods: Cohorts of 133 mild-to-very severe COPD patients (41 current smokers), 31 never-smokers, and 33 current smoker controls were compared. Clinical assessments included body mass index (BMI), fat (FM) and fat-free mass (FFM) measurement by DEXA, forced expiratory volume in one second (FEV1), arterial oxygen tension (PaO2), six-minute walking test (SMWT), emphysema (EMPH) and right thigh muscle cross-sectional area (TMCSA), both quantified by high resolution computed tomography. Results: Serum CRPus levels were significantly higher in COPD patients than in controls (7 ± 4.2 and 3.7 ± 2.7 mg/L respectively; p < 0.0001). Being smoker did not influence CRPus levels. These levels were significantly correlated with FM (r = 0.30), BMI (r = 0.21), FEV1 (r = -0.21), number of acute exacerbations of the disease in the last year (r = 0.28), and PaO2 (r = -0.27). Using multivariate analysis FM, PaO2, and number of acute exacerbations of the disease in the last year had the strongest association with CRPus levels. Conclusions: CRPus is elevated in COPD patients, independent of smoking status. It is weakly associated with fat mass, arterial oxygen tension and frequency of exacerbations.

Reducción de la actividad física en pacientes con enfermedad pulmonar obstructiva crónica / Reduction of physical activity in patients with chronic obstructive pulmonary disease

Background: Patients with chronic obstructive pulmonary disease (COPD) decrease their physical activity. However, it is unknown at which stage of the disease the reduction occurs and whether dyspnea is a limiting factor. Aim: To compare physical activity between patients with COPD and controls of similar age and to assess its association with disease severity. Material and Methods: We studied 112 patients with mild to very severe COPD and 55 controls. Lung function, six-minutes walking test (SMWT), and physical activity through the International Physical Activity Questionnaire (IPAQ) were measured. Results: Compared to controls, physical activity was significantly reduced in COPD patients (1823 ± 2598 vs. 2920 ± 3040 METs min/week; p = 0.001). Patients were more frequently sedentary (38 vs. 11%), while controls were more often very active (31 vs. 19%) or moderately active (58 vs. 43%). Physical activity was reduced from Global Initiative for Obstructive Chronic Lung Disease (GOLD) stage 2 and from Modified Medical Research Council (MMRC) dyspnea grade 1. Weak relationships were observed between lung function, SMWT and physical activity. Conclusions: Physical activity decreases early in the course of the disease and when dyspnea is still mild, among patients with COPD. (Rev Med Chile 2011; 139:1562-1572).

El gluten: Su historia y efectos en la enfermedad celíaca / History of gluten and its effects on celiac disease

The global prevalence of celiac disease is of one person per 250 inhabitants. The disease is induced by gluten, a peptide contained in wheat, rye and barley that during small intestinal digestion generates smaller peptides. Some of these are resistant to hydrolysis and cross through the epithelium into the mucosa, inducing a cascade of immune reactions leading to the appearance of the disease in susceptible individuals. Gluten appeared as a consequence of agricultural practices initiated 10000 years ago in the Fertile Crescent of southwest Asia. Celiac disease epidemiology is complicated since consumption of gluten differs depending on the origin of populations. Treatment of celiac disease consists of withdrawing gluten from the diet, a task that becomes difficult in the long term. The concept of gluten-free food has changed along time. This article updates the concept of celiac disease, the history of gluten consumption in the world, the characteristics of a gluten free diet and the difficulties to adhere to it.