Communication skills teaching for student dietitians using experiential learning and simulated patients.

BACKGROUND: Dietitians require communication competencies for effective dietetic practice. There is little evidence on how student dietitians experience and value communication skills teaching. The present study aimed to measure attitudes of student dietitians with respect to communication skills teaching and how experiential learning using simulated patients impacts confidence in their communication skills. METHODS: Communication skills teaching adopting an experiential skills-based approach including practice with simulated patients, feedback and reflection were developed. A 67-item questionnaire with three sections: (i) views regarding the importance of communication skills to dietetic practice; (ii) attitudes to learning communication skills using a modified Communication Skills Attitude Scale; and (iii) confidence in their own communication skills, was completed by students before and after the course, with responses recorded on a five-point Likert scale and analysed pairwise using McNemar's test. RESULTS: Over three academic years, 112 students (91.8% response rate) completed the evaluation. After training, students rated communication skills as important for patient satisfaction (100%) and relationships with patients (99.1%). Student dietitians had positive attitudes to learning communication skills with positive attitudes scale score before teaching of mean (SD) 53.6 (5.3) and after of 54.0 (5.8) (P = 0.162). Following experiential teaching, the proportion of students feeling 'very or extremely confident' in understanding a patient's perspective increased from 27.7% to 41.1% (P = 0.008) and for reaching agreement with a patient from 4.5% to 17.9% (P = 0.001). CONCLUSIONS: Student dietitians consider communication skills important for dietetic practice. They receive teaching positively and an experiential skills-based approach can improve self-rated confidence.

Perceptions and psychosocial impact of food, nutrition, eating and drinking in people with inflammatory bowel disease: a qualitative investigation of food-related quality of life.

INTRODUCTION: Extensive research has provided an important understanding of the impact of inflammatory bowel disease (IBD) on nutrient intake, requirements and metabolism. By contrast, there has been limited research examining the psychosocial aspects of food, eating and drinking in IBD. The present study aimed to address this unmet need. METHODS: Qualitative semi-structured interviews regarding the perceptions and psychosocial impact of food, eating and drinking were undertaken with 28 purposively selected people with IBD. Interviews were audio-recorded and transcribed verbatim. Colaizzi's framework was used to structure the data analysis. RESULTS: Five major themes were identified. IBD symptoms and both surgical and medical treatments were described as having a direct impact on eating and drinking, with participants also using different food-related strategies to control IBD symptoms. These included a process of experimentation to identify trigger foods, following a severely restricted and limited diet, eating small portions, and eating more frequently. However, their limited knowledge about if, and how, food affected their symptoms, often resulted in negative coping strategies that impacted on psychosocial functioning, including a lack of enjoyment of eating, being afraid to eat and finding social occasions stressful. Managing food and drinking also made food shopping and preparation more burdensome, creating problems with families, at work and for social life, as well as the need for careful preparation and advanced planning of activities. CONCLUSIONS: Inflammatory bowel disease has a profound impact on psychosocial aspects of food and nutrition, which impacts on 'food-related quality of life' (FRQoL). Further research is required to identify interventions that will improve FRQoL in patients with IBD.

Nutritional status, the development and persistence of malnutrition and dietary intake in oesophago-gastric cancer: a longitudinal cohort study.

BACKGROUND: Patients with oesophago-gastric (OG) cancer may be at risk of malnutrition, troublesome gastrointestinal symptoms (GI) and reduced dietary intake in view of the tumour location and multimodality curative treatment approach. Longitudinal research is lacking. The present study aimed to assess (i) nutritional status and how it evolved over the first year; (ii) the association between nutritional status scores and GI symptom scores; and (iii) the nutrient and food group intake pattern. METHODS: This was a prospective, observational study of patients with an OG lesion planned for radical treatment, with assessment at diagnosis, 3 months and 12 months after the start of treatment. Nutritional assessment was performed using the Patient-Generated Subjective Global Assessment, GI symptoms measured using the modified Gastrointestinal Symptom Rating Scale and dietary intake assessed using a semi-quantitative food frequency approach. RESULTS: Eighty patients (61 males, 19 females; aged 46-89 years) were recruited. At baseline, 3 (n = 68) and 12 months (n = 57), 61%, 62% and 60%, respectively, were moderately/severely malnourished. Higher symptom burden was associated with poorer nutritional status at baseline (r = 0.55, P < 0.001), 3 months (r = 0.51, P < 0.001) and 12 months (r = 0.42, P = 0.001). At each respective time point, 37%, 38% and 42% were meeting their estimated average requirement for energy. No change in mean (SD) intake of energy, fibre, nutrient and food groups was observed over time. CONCLUSIONS: Patients with OG cancer have progressive weight loss, with malnutrition present over the majority of the 12-month study period. Optimising nutritional status and symptom management throughout the treatment pathway should be a clinical priority.

The low FODMAP diet in the management of irritable bowel syndrome: an evidence-based review of FODMAP restriction, reintroduction and personalisation in clinical practice.

Dietary restriction of fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) is effective in the management of functional gastrointestinal symptoms that occur in irritable bowel syndrome (IBS). Numerous reviews have been published regarding the evidence for their restriction in the low FODMAP diet; however, few reviews discuss the implementation of the low FODMAP diet in practice. The aim of this review is to provide practical guidance on patient assessment and the implementation and monitoring of the low FODMAP diet. Broadly speaking, the low FODMAP diet consists of three stages: FODMAP restriction; FODMAP reintroduction; and FODMAP personalisation. These stages can be covered in at least two dietetic appointments. The first appointment focuses on confirmation of diagnosis, comprehensive symptom and dietary assessment, detailed description of FODMAPs and their association with symptom induction, followed by counselling regarding FODMAP restriction. Dietary counselling should be tailored to individual needs and appropriate resources provided. At the second appointment, symptoms and diet are re-assessed and, if restriction has successfully reduced IBS symptoms, education is provided on FODMAP reintroduction to identify foods triggering symptoms. Following this, the patient can follow FODMAP personalisation for which a less restrictive diet is consumed that excludes their personal FODMAP triggers and enables a more diverse dietary intake. This review provides evidence and practice guidance to assist in delivering high-quality clinical service in relation to the low FODMAP diet.

Long-term impact of the low-FODMAP diet on gastrointestinal symptoms, dietary intake, patient acceptability, and healthcare utilization in irritable bowel syndrome.

BACKGROUND: The low-FODMAP diet is a frequently used treatment for irritable bowel syndrome (IBS). Most research has focused on short-term FODMAP restriction; however, guidelines recommend that high-FODMAP foods are reintroduced to individual tolerance. This study aimed to assess the long-term effectiveness of the low-FODMAP diet following FODMAP reintroduction in IBS patients. METHODS: Patients with IBS were prospectively recruited to a questionnaire study following completion of dietitian-led low-FODMAP education. At baseline and following FODMAP restriction (short term) only, gastrointestinal symptoms were measured as part of routine clinical care. Following FODMAP reintroduction, (long term), symptoms, dietary intake, acceptability, food-related quality of life (QOL), and healthcare utilization were assessed. Data were reported for patients who continued long-term FODMAP restriction (adapted FODMAP) and/or returned to a habitual diet (habitual). KEY RESULTS: Of 103 patients, satisfactory relief of symptoms was reported in 12% at baseline, 61% at short-term follow-up, and 57% at long-term follow-up. At long-term follow-up, 84 (82%) patients continued an 'adapted FODMAP' diet (total FODMAP intake mean 20.6, SD 14.9 g/d) compared with 19 (18%) of patients following a 'habitual' diet (29.4, SD 22.9 g/d, P=.039). Nutritional adequacy was not compromised for either group. The 'adapted FODMAP' group reported the diet cost significantly more than the 'habitual' group (P<.001) and affected social eating (P<.01) but there was no effect on food-related QOL. Healthcare utilization was similar between both groups. CONCLUSION AND INFERENCES: Low-FODMAP education is effective for long-term IBS management, enables a nutritionally adequate diet, and is broadly acceptable to patients.

Autophagy supports generation of cells with high CD44 expression via modulation of oxidative stress and Parkin-mediated mitochondrial clearance.

High CD44 expression is associated with enhanced malignant potential in esophageal squamous cell carcinoma (ESCC), among the deadliest of all human carcinomas. Although alterations in autophagy and CD44 expression are associated with poor patient outcomes in various cancer types, the relationship between autophagy and cells with high CD44 expression remains incompletely understood. In transformed oesophageal keratinocytes, CD44Low-CD24High (CD44L) cells give rise to CD44High-CD24-/Low (CD44H) cells via epithelial-mesenchymal transition (EMT) in response to transforming growth factor (TGF)-ß. We couple patient samples and xenotransplantation studies with this tractable in vitro system of CD44L to CD44H cell conversion to investigate the functional role of autophagy in generation of cells with high CD44 expression. We report that high expression of the autophagy marker cleaved LC3 expression correlates with poor clinical outcome in ESCC. In ESCC xenograft tumours, pharmacological autophagy inhibition with chloroquine derivatives depletes cells with high CD44 expression while promoting oxidative stress. Autophagic flux impairment during EMT-mediated CD44L to CD44H cell conversion in vitro induces mitochondrial dysfunction, oxidative stress and cell death. During CD44H cell generation, transformed keratinocytes display evidence of mitophagy, including mitochondrial fragmentation, decreased mitochondrial content and mitochondrial translocation of Parkin, essential in mitophagy. RNA interference-mediated Parkin depletion attenuates CD44H cell generation. These data suggest that autophagy facilitates EMT-mediated CD44H generation via modulation of redox homeostasis and Parkin-dependent mitochondrial clearance. This is the first report to implicate mitophagy in regulation of tumour cells with high CD44 expression, representing a potential novel therapeutic avenue in cancers where EMT and CD44H cells have been implicated, including ESCC.

Validity and reliability of the Bristol Stool Form Scale in healthy adults and patients with diarrhoea-predominant irritable bowel syndrome.

BACKGROUND: The Bristol Stool Form Scale (BSFS) is a 7-point scale used extensively in clinical practice and research for stool form measurement, which has undergone limited validity and reliability testing. AIM: To determine the validity and reliability of the BSFS in measuring stool form in healthy adults and patients with diarrhoea-predominant irritable bowel syndrome (IBS-D). METHODS: One hundred and sixty-nine healthy volunteers provided a stool sample and used the BSFS to classify stool form, which was compared with measured stool water content and with values from 19 patients with IBS-D. Eighty-six volunteers used the BSFS to classify 26 stool models to determine accuracy and reliability. RESULTS: Volunteers' classifications of stool type correlated with stool water (Spearman's rho = 0.491, P < 0.001), which increased in hard (Types 1-2), normal (Types 3-5) and loose stools (Types 6-7) (P < 0.001). The BSFS detected differences in stool form between healthy volunteers (mean 3.7, s.d. 1.5) and IBS-D patients (mean 5.0, s.d. 1.2) (P < 0.001). Overall, 977/1204 (81%) stool models were correctly classified (substantial accuracy, κ = 0.78), although <80% of Types 2, 3, 5 and 6 were classified correctly. On 852/1118 (76%) occasions, volunteers classified covert duplicate models to the same stool type (substantial reliability, κ = 0.72), but with only moderate reliability for Types 2 (63%, κ = 0.57) and 3 (62%, κ = 0.55). CONCLUSIONS: The BSFS demonstrated substantial validity and reliability, although difficulties arose around clinical decision points (Types 2, 3, 5, 6) that warrant investigation in larger clinical populations. Potential for improving validity and reliability through modifications to the BSFS or training in its use should be explored.

Systematic review with meta-analysis: effect of fibre supplementation on chronic idiopathic constipation in adults.

BACKGROUND: Chronic idiopathic constipation is a common symptom-based gastrointestinal disorder responsible for a substantial economic health service burden. Current guidelines recommend the use of fibre as a first-line treatment. AIM: To investigate the effect of fibre (including prebiotic) supplementation on global symptom response, stool output, gut microbiota composition and adverse events in adults with chronic idiopathic constipation. METHODS: Medline, EmBase, Web of Science, Scopus and the Cochrane central register of controlled trials were searched through to February 2016. Conference proceedings from 2003 to 2015 were hand-searched. There were no language restrictions. Forest plots with 95% CIs were generated using a random-effects model. RESULTS: The search strategy generated 1072 citations, of which seven individual randomised controlled trials were eligible. Overall, 113 of 147 (77%) patients assigned to fibre responded to therapy, compared with 61 of 140 (44%) allocated to placebo (RR of success to respond 1.71, 95% CI 1.20-2.42, P = 0.003). Fibre significantly increased stool frequency (SMD, standardised mean difference = 0.39; 95% CI 0.03-0.76; P = 0.03) and softened stool consistency (SMD = 0.35; 95% CI 0.04-0.65; P = 0.02) compared with placebo. Flatulence was significantly higher with fibre compared to placebo (SMD 0.56, 0.12-1.00, P = 0.01). Overall quality of evidence was low. CONCLUSIONS: This meta-analysis demonstrates that fibre is moderately effective, but also causes moderate gastrointestinal side effects. However, these findings need to be treated with caution due to a high risk of bias. Accordingly, further large, methodologically rigorous trials are required, before any definitive recommendation regarding its risk-benefit profile can be made. PROSPERO registration number CRD42014007005.

Disruption of cytochrome c oxidase function induces the Warburg effect and metabolic reprogramming.

Defects in mitochondrial oxidative phosphorylation complexes, altered bioenergetics and metabolic shift are often seen in cancers. Here we show a role for the dysfunction of the electron transport chain component cytochrome c oxidase (CcO) in cancer progression. We show that genetic silencing of the CcO complex by shRNA expression and loss of CcO activity in multiple cell types from the mouse and human sources resulted in metabolic shift to glycolysis, loss of anchorage-dependent growth and acquired invasive phenotypes. Disruption of the CcO complex caused loss of transmembrane potential and induction of Ca2+/Calcineurin-mediated retrograde signaling. Propagation of this signaling includes activation of PI3-kinase, IGF1R and Akt, Ca2(+)-sensitive transcription factors and also TGFß1, MMP16 and periostin, which are involved in oncogenic progression. Whole-genome expression analysis showed the upregulation of genes involved in cell signaling, extracellular matrix interactions, cell morphogenesis, cell motility and migration. The transcription profiles reveal extensive similarity to retrograde signaling initiated by partial mitochondrial DNA depletion, although distinct differences are observed in signaling induced by CcO dysfunction. The possible CcO dysfunction as a biomarker for cancer progression was supported by data showing that esophageal tumors from human patients show reduced CcO subunits IVi1 and Vb in regions that were previously shown to be the hypoxic core of the tumors. Our results show that mitochondrial electron transport chain defect initiates a retrograde signaling. These results suggest that a defect in the CcO complex can potentially induce tumor progression.

An eDNA assay for Irish Petromyzon marinus and Salmo trutta and field validation in running water.

This pilot study presents an environmental DNA (eDNA) assay for sea lamprey Petromyzon marinus and brown trout Salmo trutta, two species of economic and conservation importance in the Republic of Ireland. The results demonstrate the effectiveness of eDNA for assessing presence of low-abundance taxa (here, P. marinus) for environmental managers, and they highlight the potential for assessing relative abundance of rare or invasive freshwater species.

Clinical effectiveness and economic costs of group versus one-to-one education for short-chain fermentable carbohydrate restriction (low FODMAP diet) in the management of irritable bowel syndrome.

BACKGROUND: Restriction of fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) is an effective dietary treatment for irritable bowel syndrome (IBS). Patient dietary education is essential but labour intensive. Group FODMAP education may alleviate this somewhat but has not previously been investigated. The present study aimed to investigate the clinical effectiveness of low FODMAP group education in patients with IBS and to explore the cost of a group pathway. METHODS: Patients with IBS (n = 364) were assessed for their suitability to attend dietitian-led group education or traditional one-to-one education in a novel group pathway. Clinical effectiveness (global symptom question, symptom prevalence, stool output) were compared at baseline and follow-up using the chi-squared test. The costs of the novel group pathway were assessed using a decision model. RESULTS: The global symptom question indicated more patients were satisfied with their symptoms following dietary advice, in both group education [baseline 48/263 (18%) versus follow-up 142/263 (54%), P < 0.001] and one-to-one education [baseline 5/101 (5%) versus follow-up 61/101 (60%), P < 0.001], with no difference between group and one-to-one education at follow-up (P = 0.271). Overall, there was a significant decrease in symptom severity from baseline to follow-up (P < 0.001 for both groups) but no difference in symptom response between group and one-to-one education. The cost for the group education pathway for all 364 patients was £31 713.36. CONCLUSIONS: The present study shows that dietitian-led FODMAP group education is clinically effective and the costs associated with a FODMAP group pathway are worthy of further consideration for routine clinical care.

Mitochondrial SOD2 regulates epithelial-mesenchymal transition and cell populations defined by differential CD44 expression.

Epithelial-mesenchymal transition (EMT) promotes cancer cell invasion, metastasis and treatment failure. EMT may be activated in cancer cells by reactive oxygen species (ROS). EMT may promote conversion of a subset of cancer cells from a CD44(low)-CD24(high) (CD44L) epithelial phenotype to a CD44(high)-CD24(-/low) (CD44H) mesenchymal phenotype, the latter associated with increased malignant properties of cancer cells. ROS are required for cells undergoing EMT, although excessive ROS may induce cell death or senescence; however, little is known as to how cellular antioxidant capabilities may be regulated during EMT. Mitochondrial superoxide dismutase 2 (SOD2) is frequently overexpressed in oral and esophageal cancers. Here, we investigate mechanisms of SOD2 transcriptional regulation in EMT, as well as the functional role of this antioxidant in EMT. Using well-characterized genetically engineered oral and esophageal human epithelial cell lines coupled with RNA interference and flow cytometric approaches, we find that transforming growth factor (TGF)-ß stimulates EMT, resulting in conversion of CD44L to CD44H cells, the latter of which display SOD2 upregulation. SOD2 induction in transformed keratinocytes was concurrent with suppression of TGF-ß-mediated induction of both ROS and senescence. SOD2 gene expression appeared to be transcriptionally regulated by NF-κB and ZEB2, but not ZEB1. Moreover, SOD2-mediated antioxidant activity may restrict conversion of CD44L cells to CD44H cells at the early stages of EMT. These data provide novel mechanistic insights into the dynamic expression of SOD2 during EMT. In addition, we delineate a functional role for SOD2 in EMT via the influence of this antioxidant upon distinct CD44L and CD44H subsets of cancer cells that have been implicated in oral and esophageal tumor biology.

What role do bacteria play in persisting fistula formation in idiopathic and Crohn's anal fistula?

AIM: The aetiology of Crohn's disease-related anal fistula remains obscure. Microbiological, genetic and immunological factors are thought to play a role but are not well understood. The microbiota within anal fistula tracts has never been examined using molecular techniques. The present study aimed to characterize the microbiota in the tracts of patients with Crohn's and idiopathic anal fistula. METHOD: Samples from the fistula tract and rectum of patients with Crohn's and idiopathic anal fistula were analysed using fluorescent in situ hybridization, Gram staining and scanning electron microscopy were performed to identify and quantify the bacteria present. RESULTS: Fifty-one patients, including 20 with Crohn's anal fistula, 18 with idiopathic anal fistula and 13 with luminal Crohn's disease and no anal fistula, were recruited. Bacteria were not found in close association with the luminal surface of any of the anal fistula tracts. CONCLUSION: Anal fistula tracts generally do not harbour high levels of mucosa-associated microbiota. Crohn's anal fistulas do not seem to harbour specific bacteria. Alternative explanations for the persistence of anal fistula are needed.

Resting metabolic rate and anthropometry in older people: a comparison of measured and calculated values.

BACKGROUND: Accurate assessment of energy expenditure and anthropometry in older people is important for targeted nutritional support. The present study aimed to compare measured and calculated resting metabolic rate (m-RMR and c-RMR) and measured, calculated and estimated weight and height in older people aged ≥70 years. METHODS: Participants were healthy older people aged ≥70 years. Indirect calorimetry using a ventilated hood calorimeter was performed for 30 min on fasted participants, and was compared with c-RMR, as calculated using six commonly used equations. Measured, calculated and estimated height and weight were compared. RESULTS: Subjects comprised 14 males and 20 females and mean (SD) m-RMR was 5243 (845) kJ day(-1) [1253 (202) kcal day(-1) ]. The Mifflin St-Jeor equation was the most consistently accurate, with the smallest mean difference between m-RMR and c-RMR of 58 (553) kJ day(-1) [14 (132) kcal day(-1) ] and c-RMR was within 10% of m-RMR in the greatest number of participants (n = 24; 70%). The Schofield equation was among the least accurate in this age group. In older males, self-reported height and weight were accurate, whereas, in females or those unable to self-report height, ulna length was the most accurate alternative to measured height. CONCLUSIONS: Current equations used to calculate RMR in older people have inaccuracies, although the Mifflin St-Jeor equation was most accurate. Future studies should investigate the validity, reliability, cost and practicality of using fat free mass as an item in novel equations to calculate RMR in this age group. Self-reported height and weight in males, and height calculated from ulna length in females, were the most accurate alternatives to measured values in the present study.

Cellular senescence checkpoint function determines differential Notch1-dependent oncogenic and tumor-suppressor activities.

Notch activity regulates tumor biology in a context-dependent and complex manner. Notch may act as an oncogene or a tumor-suppressor gene even within the same tumor type. Recently, Notch signaling has been implicated in cellular senescence. Yet, it remains unclear as to how cellular senescence checkpoint functions may interact with Notch-mediated oncogenic and tumor-suppressor activities. Herein, we used genetically engineered human esophageal keratinocytes and esophageal squamous cell carcinoma cells to delineate the functional consequences of Notch activation and inhibition along with pharmacological intervention and RNA interference experiments. When expressed in a tetracycline-inducible manner, the ectopically expressed activated form of Notch1 (ICN1) displayed oncogene-like characteristics inducing cellular senescence corroborated by the induction of G0/G1 cell-cycle arrest, Rb dephosphorylation, flat and enlarged cell morphology and senescence-associated ß-galactosidase activity. Notch-induced senescence involves canonical CSL/RBPJ-dependent transcriptional activity and the p16(INK4A)-Rb pathway. Loss of p16(INK4A) or the presence of human papilloma virus (HPV) E6/E7 oncogene products not only prevented ICN1 from inducing senescence but permitted ICN1 to facilitate anchorage-independent colony formation and xenograft tumor growth with increased cell proliferation and reduced squamous-cell differentiation. Moreover, Notch1 appears to mediate replicative senescence as well as transforming growth factor-ß-induced cellular senescence in non-transformed cells and that HPV E6/E7 targets Notch1 for inactivation to prevent senescence, revealing a tumor-suppressor attribute of endogenous Notch1. In aggregate, cellular senescence checkpoint functions may influence dichotomous Notch activities in the neoplastic context.

Systematic review: the effect of prunes on gastrointestinal function.

BACKGROUND: Prunes (dried plums) are high in fibre and are perceived to promote healthy gastrointestinal (GI) function. AIM: To assess the effect of prunes on GI function through a systematic review of randomised controlled trials (RCTs). METHODS: Sixteen electronic databases were searched, a hand search was performed and key opinion leaders were contacted. RCTs investigating the effect of prunes on GI function were included. Two reviewers independently screened relevant articles, extracted data and assessed risk of bias. RESULTS: Four trials met the inclusion criteria, one in constipation and three in non-constipated subjects. In constipation, 3 weeks of prune consumption (100 g/day) improved stool frequency (3.5 vs. 2.8 CSBM per week, P = 0.006) and stool consistency (3.2 vs. 2.8 on Bristol stool form scale, P = 0.02) compared with psyllium (22 g/day). In non-constipated subjects, prunes softened stool consistency in one trial and increased stool weight (628 g vs. 514 g/72 h wet weight, P = 0.001) in another trial, compared with control. No trials found differences in GI symptoms between prunes and comparator. Meta-analysis was not appropriate due to heterogeneity in populations and methods. Two of the trials were limited by unclear risk of bias. CONCLUSIONS: In constipation, prunes appear superior to psyllium for improving stool frequency and consistency, however, the evidence for other outcomes and the effects in non-constipated subjects is weak. Although prunes may be a promising intervention for the management of constipation and increasing stool weight, this needs to be confirmed by further rigorous research.

Current practice in relation to nutritional assessment and dietary management of enteral nutrition in adults with Crohn's disease.

BACKGROUND: Nutritional assessment and dietary intervention, particularly enteral nutrition, are important in the management of Crohn's disease (CD). National audits have reported that dietetic resourcing in gastroenterology is inadequate. The present study aimed to identify current practice in the nutritional assessment and dietary management of enteral nutrition in CD, as well as investigate the factors that influenced it. METHODS: A nationwide questionnaire survey adopting complete population sampling of all 296 U.K. acute hospitals was undertaken aiming to determine dietetic resourcing for gastroenterology. In addition, the case-note review method was used to investigate approaches to nutritional assessment and dietary management of enteral nutrition as treatment for active CD. RESULTS: Data were returned from 149 (56%) hospitals, providing assessment and management information on 190 patients. The median number of dietetic sessions dedicated to gastroenterology was 2 per week (interquartile range 4). Hospitals with five or more sessions per week dedicated to gastroenterology used a greater number of components in their nutritional assessment [mean (SD) 21.5 ( 5.0)] than those with fewer sessions [mean (SD) 19.6 (SD) 6.1, P = 0.05]. Enteral nutrition was perceived to be effective in 100 (55%) of 182 patients. The major reasons for limited success were poor compliance and inadequate volumes consumed, as well as insufficient treatment duration. CONCLUSIONS: The components included in a nutritional assessment of CD patients are significantly lower in hospitals with fewer dietetic gastroenterology sessions. Focus on improving compliance and duration of enteral nutrition is urgently required to maximise the success of enteral nutrition in the treatment of CD.