Nutrition in palliative care: issues, perceptions and opportunities to improve care for patients.

Dietary advice, the provision of timely nutritional support and the alleviation of diet-related issues, should be an essential component of a holistic approach to palliative and end-of-life care, adjusted to account for the stage in the patient's journey, including prognosis. With an ageing population and increasing numbers of people living with not just one life-limiting disease but several, the dietary management of these patients is becoming more complex. This article considers the issues patients and families experience, how nurses can play a key role in identifying and alleviating nutrition- and diet-related issues in palliative care, including the use of tools to screen, assess and guide nutrition conversations and interventions. The content of the article is mostly drawn from the literature relating to palliative cancer care, knowledge derived from stakeholder engagement, clinical observations in a dietetic role in a hospice setting and qualitative research on the role of diet in palliative care as perceived by patients, carers, and health professionals.

Individualised Nutritional Care for Disease-Related Malnutrition: Improving Outcomes by Focusing on What Matters to Patients.

Delivering care that meets patients' preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients' preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient's specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.

Evidence-based management of disease-related malnutrition: updated guidance.

This article outlines the updated guidelines produced by the Managing Adult Malnutrition in the Community panel, which aims to assist and support health and social care professionals working in the community to identify and manage malnutrition, particularly that related to ageing, disease and long-term medical conditions.

Recovery Focused Nutritional Therapy across the Continuum of Care: Learning from COVID-19.

Targeted nutritional therapy should be started early in severe illness and sustained through to recovery if clinical and patient-centred outcomes are to be optimised. The coronavirus disease 2019 (COVID-19) pandemic has shone a light on this need. The literature on nutrition and COVID-19 mainly focuses on the importance of nutrition to preserve life and prevent clinical deterioration during the acute phase of illness. However, there is a lack of information guiding practice across the whole patient journey (e.g., hospital to home) with a focus on targeting recovery (e.g., long COVID). This review paper is of relevance to doctors and other healthcare professionals in acute care and primary care worldwide, since it addresses early, multi-modal individualised nutrition interventions across the continuum of care to improve COVID-19 patient outcomes. It is of relevance to nutrition experts and non-nutrition experts and can be used to promote inter-professional and inter-organisational knowledge transfer on the topic. The primary goal is to prevent complications and support recovery to enable COVID-19 patients to achieve the best possible nutritional, physical, functional and mental health status and to apply the learning to date from the COVID-19 pandemic to other patient groups experiencing acute severe illness.

Impaired Nutritional Condition After Stroke From the Hyperacute to the Chronic Phase: A Systematic Review and Meta-Analysis.

BACKGROUND: Malnutrition is common after stroke and can affect rehabilitation and healthcare costs. A comprehensive overview of stroke patients' nutritional condition from the hyperacute to the chronic phase is lacking. This systematic review aimed to investigate the prevalence of impaired nutritional condition (INC) across the continuum of care in specific phases after stroke. METHODS: CAB ABSTRACTS, Embase, MEDLINE, were used to collect studies published between 01-01-1999 and 26-08-2020. Primary and secondary outcomes were prevalence of INC and prevalence of malnutrition, respectively. Exploratory outcomes were prevalence of INC at follow-up, nutritional examination methods, prevalence of dysphagia, stroke severity, adverse events, and continent-specific prevalence of INC. A random-effects meta-analysis model was used to estimate the phase-specific pooled prevalence of INC and malnutrition. RESULTS: The dataset consisted of 78 study groups selected over a total of 1,244 identified records. The pooled prevalence of INC and malnutrition were 19% (95%CI:7-31) (N = 4) and 19% (95%CI:9-29) (N = 3), 34% (95%CI:25-43) (N = 34) and 26% (95%CI:18-35) (N = 29), 52% (95%CI:43-61) (N = 34) and 37% (95%CI:28-45) (N = 31), 21% (95%CI:12-31) (N = 3) and 11% (95%CI:0-24) (N = 3) and 72% (95%CI:41-100) (N = 3) and 30% (95%CI:0-76) (N = 2) in the hyperacute, acute, early subacute, late subacute, and chronic phase, respectively. CONCLUSION: INC and malnutrition are highly prevalent in all stages of stroke care. Since malnutrition has been shown to negatively affect clinical outcomes, mortality, and overall healthcare expenditure in stroke survivors, it is essential to examine and monitor the nutritional status of stroke patients throughout their care journey to guide and plan, timely nutritional support and dietary modification.

Supporting people who have eating and drinking difficulties.

Eating and drinking are essential for maintenance of nutrition and hydration, but are also important for pleasure and social interactions. The ability to eat and drink hinges on a complex and coordinated system, resulting in significant potential for things to go wrong.The Royal College of Physicians (RCP) has published updated guidance on how to support people who have eating and drinking difficulties, particularly towards the end of life.Decisions about nutrition and hydration and when to start, continue or stop treatment are some of the most challenging to make in medical practice. The newly updated guidance aims to support healthcare professionals to work together with patients, their families and carers to make decisions around nutrition and hydration that are in the best interests of the patient. It covers the factors affecting our ability to eat and drink, strategies to support oral nutrition and hydration, techniques of clinically-assisted nutrition and hydration, and the legal and ethical framework to guide decisions about giving and withholding treatment, emphasising the two key concepts of capacity and best interests.This article aims to provide an executive summary of the guidance.

Nutritional management of patients during and after COVID-19 illness.

The impact of nutrition on recovery from various illnesses is well recognised. Malnutrition can affect duration of hospitalisation and impede recovery, and therefore it is important to monitor this condition, especially in at-risk groups, such as older adults and those with chronic disease. Underlying malnutrition impairs the immune system, potentially making people more vulnerable to infections such as COVID-19 and impacting recovery. Patients recovering from severe illness are likely to have muscle wasting or feel weak and may have increased protein needs. In addition individuals who have been discharged from hospital may need ongoing nutritional rehabilitation. This article explores the range of symptoms of COVID-19 that can interfere with dietary intake, such as respiratory issues, loss of taste and smell and fatigue and weakness. It goes on to describe how community nurses can identify risk of malnutrition and dietary issues when working remotely. Additionally, it signposts to a range of resources developed to assist patients and carers in accessing appropriate dietary advice.

What more can community nurses do to manage adult malnutrition.

This article gives an outline of the key groups at risk of malnutrition in the community and the effects and clinical consequences of not identifying and managing these groups. It outlines the potential health and social costs of not identifying and treating malnutrition in the community and advises how malnutrition arises in these 'at-risk' groups. As 93% of those affected by malnutrition are living in our communities, advice is given on how community nurses can play a pivotal role in identifying malnutrition by initiating conversations about dietary intake with patients and integrating screening and nutritional care into pathways of care.

Clinical application of dietary therapies in irritable bowel syndrome.

BACKGROUND AND AIMS: Diet appears to play a pivotal role in symptom generation in Irritable Bowel Syndrome (IBS). First line dietary therapy for IBS has focused on advice concerning healthy eating and lifestyle management. Research recently has focused on the role of a diet low in fermentable oligo-, di-, and mono-saccharides and polyols (FODMAPs), gluten free (GFD) and wheat free (WFD) diets for the relief of symptoms in IBS. METHODS: A round table discussion with gastroenterologists and dietitians with a specialist interest in dietary therapies in IBS was held in Sheffield, United Kingdom in May 2017. Existing literature was reviewed. PubMed and EMBASE were searched with the MeSH terms irritable bowel syndrome/diet/diet therapy/gluten/low FODMAP in different combinations to identify relevant articles. A consensus on the application of these dietary therapies into day-to-day practice was developed. RESULTS: Fourteen randomized trials in IBS evaluating the low FODMAP diet (n studies = 9), GFD (n = 4) and WFD (n = 1) were included in this review. The total number of patients recruited from randomized trials reviewed was: n=580 low FODMAP diet (female, n=430), n=203 GFD (female, n=139), n=276 WFD (female, n=215). There was no significant difference in the gender of patients recruited for both the low FODMAP and GFD randomized studies (p=0.12). The response rate in the literature to a low FODMAP diet ranged between 50-76%, and to GFD ranged between 34-71%. Percentage of IBS patients identified as wheat sensitive was reported as 30% in the literature. CONCLUSION: There are no head-to-head trials to date utilizing the low FODMAP diet, GFD and WFD for dietary treatment of IBS and still a number of concerns for diets, including nutritional inadequacy and alteration of the gut microbiota. The consensus suggests that there is evidence for the use of the low FODMAP diet, GFD and WFD as dietary therapies for IBS; the decision-making process for using each individual therapy should be directed by a detailed history by the dietitian, involving the patient in the process.

Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology.

A multidisciplinary panel of 18 physicians and 3 non-physicians from eight countries (Sweden, UK, Argentina, Australia, Italy, Finland, Norway and the USA) reviewed the literature on diagnosis and management of adult coeliac disease (CD). This paper presents the recommendations of the British Society of Gastroenterology. Areas of controversies were explored through phone meetings and web surveys. Nine working groups examined the following areas of CD diagnosis and management: classification of CD; genetics and immunology; diagnostics; serology and endoscopy; follow-up; gluten-free diet; refractory CD and malignancies; quality of life; novel treatments; patient support; and screening for CD.

A systematic review of compliance to oral nutritional supplements.

BACKGROUND & AIMS: Oral nutritional supplements (ONS) play a key role in the management of malnutrition. This systematic review examined patients' compliance with ONS across healthcare settings and the influence of patient and ONS-related factors. METHODS: A systematic review identified 46 studies (n = 4328) of ONS in which data on compliance (% of prescribed quantity of ONS consumed) was available. Pooled mean %compliance was assessed overall and according to study design and healthcare setting. Inter-relationships between compliance and ONS-related and patient-related factors, and total energy intake were assessed. RESULTS: Overall mean compliance with ONS was 78% (37%-100%; 67% hospital, 81% community; overall mean ONS intake 433 kcal/d). Percentage compliance was similar in randomised (79%) and non-randomised (77%) trials, with little variation between diagnostic groups. Compliance across a heterogeneous group of unmatched studies was positively associated with higher energy-density ONS and greater ONS and total energy intakes, negatively associated with age, and unrelated to amount or duration of ONS prescription. CONCLUSIONS: This systematic review suggests that compliance to ONS is good, especially with higher energy-density ONS, resulting in improvements in patients' total energy intakes that have been linked with clinical benefits. Further research is required to address the compliance and effectiveness of other common methods of oral nutritional support.