Cancer cachexia: an overview of diagnostic criteria and therapeutic approaches for the accredited practicing dietitian.

BACKGROUND: Cancer cachexia (CC) is a multifactorial syndrome characterised by ongoing skeletal muscle loss that leads to progressive functional impairment driven by reduced food intake and abnormal metabolism. Despite the traditional use of non-volitional weight loss as the primary marker of CC, there is no consensus on how to diagnose and manage CC. METHODS: The aim of this narrative review was to describe and discuss diagnostic criteria and therapeutic approaches for the accredited practicing dietitian with respect to identifying and managing CC. RESULTS: Available diagnostic criteria for cachexia include the cancer-specific (Fearon and Cachexia Score) and general criteria (Evans and Global Leadership Initiative on Malnutrition). These include phenotypic criteria [weight loss, body mass index, (objective) muscle mass assessments, quality of life] and aetiological criteria (disease burden, inflammation, energy expenditure, anorexia and inadequate food intake) and can be incorporated into the nutrition care process (NCP). This informs the nutrition diagnosis of 'chronic disease- or condition-related malnutrition (undernutrition) as related to increased nutrient needs, anorexia or diminished intake due to CC'. Optimal nutrition care and management of CC is multidisciplinary, corrects for increased energy expenditure (via immunonutrition/eicosapentaenoic acid), suboptimal protein/energy intake and poor nutrition quality of life, and includes a physical exercise intervention. Monitoring of intervention efficacy should focus on maintaining or slowing the loss of muscle mass, with weight change as an alternative gross indicator. CONCLUSIONS: Dietitians and the NCP can play an essential role with respect to identifying and managing CC, focusing on aspects of nutrition screening, assessment and intervention.

Replicating group-based education interventions for the management of type 2 diabetes: a review of intervention reporting.

AIMS: To assess the completeness of reporting of group-based education interventions for the management of type 2 diabetes. METHODS: A previous systematic review of group-based education programmes for adults with type 2 diabetes identified eligible intervention studies. Data were extracted and assessed using the Template for Intervention Description and Replication ('TIDieR') checklist. Missing data were sourced from other published material, or by contacting authors. RESULTS: Fifty-three publications describing 47 studies were included. No publications sufficiently described all items. Authors of 43 of the 47 included studies (91%) were contacted via e-mail to obtain missing data in order to complete the TIDieR checklist. Seven (16%) did not respond. Additional data were obtained for 33/47 studies (70%). Most studies (45/47, 96%) described the intervention duration and frequency, detailed the procedures and rationale (40/47, 85%), provided a brief intervention name and explained any individual tailoring (38/47, 81%), defined whether providers received training and adequately described how the programme was delivered (37/47, 79%). However, few described any modifications (28/47, 60%), whether the intervention was delivered as planned (27/47, 57%), where it was delivered (21/47, 45%), whether materials were provided (19/47, 40%), and who delivered the intervention (13/47, 28%). CONCLUSIONS: Group-based education interventions for the management of type 2 diabetes are poorly reported. To translate effective research into practice, practitioners need sufficient detail to implement evidence-based interventions. Researcher adoption of the TIDieR checklist will assist the translation and replication of published interventions.

Multicentre factorial randomized clinical trial of perioperative immunonutrition versus standard nutrition for patients undergoing surgical resection of oesophageal cancer.

BACKGROUND: Preoperative immunonutrition has been proposed to reduce the duration of hospital stay and infective complications following major elective surgery in patients with gastrointestinal malignancy. A multicentre 2 × 2 factorial RCT was conducted to determine the impact of preoperative and postoperative immunonutrition versus standard nutrition in patients with oesophageal cancer. METHODS: Patients were randomized before oesophagectomy to immunonutrition (IMPACT® ) versus standard isocaloric/isonitrogenous nutrition, then further randomized after operation to immunonutrition versus standard nutrition. Clinical and quality-of-life outcomes were assessed at 14 and 42 days after operation on an intention-to-treat basis. The primary outcome was the occurrence of infective complications. Secondary outcomes were other complications, duration of hospital stay, mortality, nutritional and quality-of-life outcomes (EuroQol EQ-5D-3 L™, European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and EORTC QLQ-OES18). Patients and investigators were blinded until the completion of data analysis. RESULTS: Some 278 patients from 11 Australian sites were randomized; two were excluded and data from 276 were analysed. The incidence of infective complications was similar for all groups (37 per cent in perioperative standard nutrition group, 51 per cent in perioperative immunonutrition group, 34 per cent in preoperative immunonutrition group and 40 per cent in postoperative immunonutrition group; P = 0·187). There were no significant differences in any other clinical or quality-of-life outcomes. CONCLUSION: Use of immunonutrition before and/or after surgery provided no benefit over standard nutrition in patients undergoing oesophagectomy. Registration number: ACTRN12611000178943 ( https://www.anzctr.org.au).

Community-Living Older Adults' Perceptions of Body Weight, Signs of Malnutrition and Sources of Information: a Descriptive Analysis of Survey Data.

BACKGROUND: Community-living older adults may be susceptible to malnutrition (undernutrition) due to both physiological and non-physiological causes. The condition develops over time and the early signs and symptoms may not be obvious. Therefore awareness and early identification of nutrition risk factors may prevent, or at least slow, the progression of malnutrition. OBJECTIVE: To describe community-living older adults' understanding of the signs of malnutrition, where they would seek malnutrition information and their self-perception of body weight. DESIGN: Older adults (aged ≥ 65 years) living in the community setting completed an online or paper based questionnaire between May and August 2016. The questionnaire contained a mix of closed and open questions which related to weight perception, weight changes, perceived signs of malnutrition and sources of malnutrition information. Body mass index (BMI) from self-reported data was classified using BMI reference ranges for older adults and compared to self-perceived weight status. Textual data regarding the signs of malnutrition were analysed and reviewed by two authors using content analysis. Descriptive statistics were used to describe participant characteristics. RESULTS: A total of 344 responses were received, the majority (90%) completed online. Mean participant age was 73 years and 57% of participants were female. Most (92%) reported their health to be good/very good. Body weight was perceived to be just right or more than it should be by 87% of underweight women and 97% of underweight men. Although 71% of the participants indicated their body weight had remained stable in the past six months, 37% reported they had been trying to change their weight. Signs of malnutrition resulted in four key categories of (i) psychological, (ii) physical appearance, (ii) bodily function and (iv) weight change. Very few reported the need to locate malnutrition information and indicated the top three sources for information would be (i) general practitioner, (ii) dietitian or (iii) internet. CONCLUSION: This paper has presented useful data about malnutrition from the perspective of the community-living older adult. We found there may be uncertainty about the best weight, for older age. As many indicated they had been trying to change their weight, awareness needs to be raised regarding the impact of weight changes on health outcomes in this population. In this study, the internet appeared to be a key provider of nutrition information. Healthcare professionals need to consider how this can be used in an informative manner among community living older adults as a tool for raising awareness about nutrition risk and malnutrition.

Could habits hold the key to weight loss maintenance? A narrative review.

Despite the significance placed on lifestyle interventions for obesity management, most weight loss is followed by weight regain. Psychological concepts of habitual behaviour and automaticity have been suggested as plausible explanations for this overwhelming lack of long-term weight loss success. Interventions that focus on changing an individual's behaviour are not usually successful at changing an individual's habits because they do not incorporate the strategies required to break unhealthy habits and/or form new healthy habits. A narrative review was conducted and describes the theory behind habit formation in relation to weight regain. The review evaluated the effectiveness of using habits as tools to maintain weight loss. Three specific habit-based weight loss programmes are described: '10 Top Tips', 'Do Something Different' and 'Transforming Your Life'. Participants in these interventions achieved significant weight loss compared to a control group or other conventional interventions. Habit-based interventions show promising results in sustaining behaviour change. Weight loss maintenance may benefit from incorporating habit-focused strategies and should be investigated further.

Effectiveness of group-based self-management education for individuals with Type 2 diabetes: a systematic review with meta-analyses and meta-regression.

AIMS: Patient education for the management of Type 2 diabetes can be delivered in various forms, with the goal of promoting and supporting positive self-management behaviours. This systematic review aimed to determine the effectiveness of group-based interventions compared with individual interventions or usual care for improving clinical, lifestyle and psychosocial outcomes in people with Type 2 diabetes. METHODS: Six electronic databases were searched. Group-based education programmes for adults with Type 2 diabetes that measured glycated haemoglobin (HbA1c ) and followed participants for ≥ 6 months were included. The primary outcome was HbA1c , and secondary outcomes included fasting blood glucose, weight, body mass index, waist circumference, blood pressure, blood lipid profiles, diabetes knowledge and self-efficacy. RESULTS: Fifty-three publications describing 47 studies were included (n = 8533 participants). Greater reductions in HbA1c occurred in group-based education compared with controls at 6-10 months [n = 30 studies; mean difference (MD) = 3 mmol/mol (0.3%); 95% confidence interval (CI): -0.48, -0.15; P = 0.0002], 12-14 months [n = 27 studies; MD = 4 mmol/mol (0.3%); 95% CI: -0.49, -0.17; P < 0.0001], 18 months [n = 3 studies; MD = 8 mmol/mol (0.7%); 95% CI: -1.26, -0.18; P = 0.009] and 36-48 months [n = 5 studies; MD = 10 mmol/mol (0.9%); 95% CI: -1.52, -0.34; P = 0.002], but not at 24 months. Outcomes also favoured group-based education for fasting blood glucose, body weight, waist circumference, triglyceride levels and diabetes knowledge, but not at all time points. Interventions facilitated by a single discipline, multidisciplinary teams or health professionals with peer supporters resulted in improved outcomes in HbA1c when compared with peer-led interventions. CONCLUSIONS: Group-based education interventions are more effective than usual care, waiting list control and individual education at improving clinical, lifestyle and psychosocial outcomes in people with Type 2 diabetes.

ESPEN guidelines on nutrition in cancer patients

Cancers are among the leading causes of morbidity and mortality worldwide, and the number of new cases is expected to rise significantly over the next decades. At the same time, all types of cancer treatment, such as surgery, radiation therapy, and pharmacological therapies are improving in sophistication, precision and in the power to target specific characteristics of individual cancers. Thus, while many cancers may still not be cured they may be converted to chronic diseases. All of these treatments, however, are impeded or precluded by the frequent development of malnutrition and metabolic derangements in cancer patients, induced by the tumor or by its treatment. These evidence-based guidelines were developed to translate current best evidence and expert opinion into recommendations for multi-disciplinary teams responsible for identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients. The guidelines were commissioned and financially supported by ESPEN and by the European Partnership for Action Against Cancer (EPAAC), an EU level initiative. Members of the guideline group were selected by ESPEN to include a range of professions and fields of expertise. We searched for meta-analyses, systematic reviews and comparative studies based on clinical questions according to the PICO format. The evidence was evaluated and merged to develop clinical recommendations using the GRADE method. Due to the deficits in the available evidence, relevant still open questions were listed and should be addressed by future studies. Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. They may be driven by inadequate food intake, decreased physical activity and catabolic metabolic derangements. To screen for, prevent, assess in detail, monitor and treat malnutrition standard operating procedures, responsibilities and a quality control process should be established at each institution involved in treating cancer patients. All cancer patients should be screened regularly for the risk or the presence of malnutrition. In all patients - with the exception of end of life care - energy and substrate requirements should be met by offering in a step-wise manner nutritional interventions from counseling to parenteral nutrition. However, benefits and risks of nutritional interventions have to be balanced with special consideration in patients with advanced disease. Nutritional care should always be accompanied by exercise training. To counter malnutrition in patients with advanced cancer there are few pharmacological agents and pharmaconutrients with only limited effects. Cancer survivors should engage in regular physical activity and adopt a prudent diet.

The nutrition and food-related roles, experiences and support needs of female family carers of malnourished older rehabilitation patients.

BACKGROUND: To improve perceived value of nutrition support and patient outcomes, the present study aimed to determine the nutrition and food-related roles, experiences and support needs of female family carers of community-dwelling malnourished older adults admitted to rehabilitation units in rural New South Wales, Australia, both during admission and following discharge. METHODS: Four female family carers of malnourished rehabilitation patients aged ≥65 years were interviewed during their care-recipients' rehabilitation admission and again at 2 weeks post-discharge. The semi-structured interviews were audiotaped, transcribed and analysed reflecting an interpretative phenomenological approach by three researchers. A series of 'drivers' relevant to the research question were agreed upon and discussed. RESULTS: Three drivers were identified. 'Responsibility' was related to the agency who assumed responsibility for providing nutrition support and understanding family carer obligation to provide nutrition support. 'Family carer nutrition ethos' was related to how carer nutrition beliefs, knowledge and values impacted the nutrition support they provided, the high self-efficacy of family carers and an incongruence with an evidence-based approach for treating malnutrition. 'Quality of life' was related to the carers' focus upon quality of life as a nutrition strategy and outcome for their care-recipients, as well as how nutrition support impacted upon carer burden. CONCLUSIONS: Rehabilitation units and rehabilitation dietitians should recognise and support family carers of malnourished patients, which may ultimately lead to an improved perceived benefit of care and patient outcomes. Intervention research is required to make strong recommendations for practice.

Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF) is a valid screening tool in chemotherapy outpatients.

PURPOSE: In the oncology population where malnutrition prevalence is high, more descriptive screening tools can provide further information to assist triaging and capture acute change. The Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF) is a component of a nutritional assessment tool which could be used for descriptive nutrition screening. The purpose of this study was to conduct a secondary analysis of nutrition screening and assessment data to identify the most relevant information contributing to the PG-SGA SF to identify malnutrition risk with high sensitivity and specificity. METHODS: This was an observational, cross-sectional study of 300 consecutive adult patients receiving ambulatory anti-cancer treatment at an Australian tertiary hospital. Anthropometric and patient descriptive data were collected. The scored PG-SGA generated a score for nutritional risk (PG-SGA SF) and a global rating for nutrition status. Receiver operating characteristic curves (ROC) were generated to determine optimal cut-off scores for combinations of the PG-SGA SF boxes with the greatest sensitivity and specificity for predicting malnutrition according to scored PG-SGA global rating. RESULTS: The additive scores of boxes 1-3 had the highest sensitivity (90.2 %) while maintaining satisfactory specificity (67.5 %) and demonstrating high diagnostic value (AUC = 0.85, 95 % CI = 0.81-0.89). The inclusion of box 4 (PG-SGA SF) did not add further value as a screening tool (AUC = 0.85, 95 % CI = 0.80-0.89; sensitivity 80.4 %; specificity 72.3 %). CONCLUSIONS: The validity of the PG-SGA SF in chemotherapy outpatients was confirmed. The present study however demonstrated that the functional capacity question (box 4) does not improve the overall discriminatory value of the PG-SGA SF.

Resistivity coefficients for body composition analysis using bioimpedance spectroscopy: effects of body dominance and mixture theory algorithm.

Body composition is commonly predicted from bioelectrical impedance spectroscopy using mixture theory algorithms. Mixture theory algorithms require the input of values for the resistivities of intra-and extracellular water of body tissues. Various derivations of these algorithms have been published, individually requiring resistivity values specific for each algorithm. This study determined apparent resistivity values in 85 healthy males and 66 healthy females for each of the four published mixture theory algorithms. The resistivity coefficients determined here are compared to published values and the inter-individual (biological) variation discussed with particular reference to consequential error in prediction of body fluid volumes. In addition, the relationships between the four algorithmic approaches are derived and methods for the inter-conversion of coefficients between algorithms presented.

From Hospital to Home: Limited Nutritional and Functional Recovery for Older Adults.

BACKGROUND: The post-hospital period may be a vulnerable time for elders recovering from acute illness. Few studies have examined nutrition outcomes of older people at nutrition risk after acute hospitalisation. OBJECTIVES: This study aims to describe a) standard nutrition care received by recently discharged older medical patients, b) change in nutritional and functional status at six weeks post-discharge and c) clinical outcomes at twelve weeks post discharge. DESIGN: Prospective cohort study. SETTING: Two metropolitan teaching hospitals in Brisbane, Australia. PARTICIPANTS: Medical patients aged ≥65 years at risk of malnutrition (Malnutrition Screening Score ≥2) and discharged to independent living in the community. MEASUREMENT: Nutritional status (Mini Nutritional Assessment (MNA), weight, lean body mass), functional status (grip strength, walk speed, activities of daily living) and health-related quality of life assessed on discharge and six weeks post-discharge. Inpatient and post-discharge nutrition intervention was recorded. Death and unplanned admissions were measured at 12 weeks. RESULTS: Of the 42 consented participants, only 14% (n=6) received post-discharge dietitian review and 19% (n=8) received practical nutrition supports at home (meal delivery, shopping assistance) as part of standard care. While there was a small improvement in MNA (18.4±4.0 to 20.1±4.2, p=0.004) and walk speed (0.7±0.3 m/s to 0.9±0.3, p=0.004) at six weeks, there was no difference in mean weight, lean body mass, grip strength or activities of daily living. Five (15%) participants lost ≥5% body weight. By twelve weeks, 17 participants (46%) had at least one unplanned hospital admission and four (10%) had died. CONCLUSIONS: Few patients at nutrition risk received nutrition-focussed care in the post-hospital period, and most did not improve nutritional or functional status at 6 weeks.

Emergency department malnutrition screening and support model improves outcomes in a pilot randomised controlled trial.

OBJECTIVE: To trial malnutrition screening in older adults presenting to an emergency department (ED) and compare two service delivery models of nutritional support on nutritional status, quality of life, falls and unplanned hospital admissions. DESIGN: Participants (>60 years) presenting to ED screened at malnutrition risk were randomly allocated to either the control group (receiving regular treatment from community hospital interface programme nursing staff) or intervention group (receiving dietetic assessment, nutrition intervention and follow-up in addition to regular community hospital interface programme support). Outcome measures including body weight, quality of life, depression, falls history and days of hospital admissions were collected at baseline and 12 weeks. RESULTS: Of 703 patients screened, 84 (12%) were identified at malnutrition risk. 24 consented to the intervention study, with 88% (21/24) confirmed to be malnourished. Clinically important but not statistically significant differences were found over the 12-week trial; the intervention group (n=9) gained 0.8 kg (±3.7) while the control group (n=10) lost -1.1 kg (±4.6). The intervention group also had better quality of life, less depression and shorter hospital admissions. CONCLUSIONS: Malnutrition screening appears feasible in ED. This pilot suggests a model of care providing nutrition support to older adults identified at nutritional risk may lead to improved patient outcomes but further research in a larger sample is required to confirm these findings.

Dosimetric factors associated with weight loss during (chemo)radiotherapy treatment for lung cancer.

BACKGROUND/OBJECTIVES: Thoracic radiotherapy (RT) is associated with acute toxicities, including oesophagitis, which can have an impact on nutritional intake and subsequently lead to malnutrition. This study aimed to identify RT dosimetric factors associated with ⩾5% weight loss in patients receiving treatment for non-small-cell lung cancer (NSCLC). METHODS: Radiation dose data to the oesophagus (including mean, maximum dose and oesophageal length) were retrospectively analysed for a cohort of 54 NSCLC patients treated with concurrent chemoradiotherapy between 2004 and 2006. Weight change was calculated using the lowest weight during the 90 days from RT commencement compared with the start of RT. RESULTS: Four patients for whom weight was not available at the start or end of treatment were excluded, leaving 50 patients for analysis. The prevalence of significant weight loss during the 90 days from RT commencement was 22% (median weight loss=9.1%, range=5.9-22.1). Dosimetric factors significantly associated with ⩾5% weight loss were maximum dose to the oesophagus (P=0.046), absolute oesophageal length receiving 40 Gy (odds ratio (OR)=1.18, P=0.04), 50 Gy (OR=1.20, P=0.02) and 60 Gy (OR=1.32, P=0.005) to the partial circumference, relative oesophageal length receiving 50 Gy (OR=1.03, P=0.03) and 60 Gy (OR=1.07, P=0.005) to the partial circumference. CONCLUSIONS: Multiple dosimetric factors were associated with significant weight loss. Of these factors, absolute and relative length of the oesophagus receiving 60 Gy to the partial circumference were more strongly related. Understanding the dosimetric factors associated with weight loss may aid early identification and intervention in patients at nutritional risk.

Telephone-delivered nutrition and exercise counselling after auto-SCT: a pilot, randomised controlled trial.

Adverse changes in nutrition-related outcomes including quality of life (QoL) occur after PBSC transplantation. This randomised controlled trial aims to evaluate the impact of nutrition and exercise counselling provided at hospital discharge on nutritional status, body composition and QoL post transplantation. Usual care (UC) (n=19) received no intervention after discharge; extended care (EC) (n=18) received fortnightly telephone counselling from a dietitian and exercise physiologist up to 100 days post transplantation. Nutritional status (patient-generated subjective global assessment, and diet history), QoL (EORTC QLQ-C30 version 3) and body composition (air displacement plethysmography) were assessed at pre-admission, discharge and 100 days post transplantation. Intervention groups were compared using two-sample t-tests of changes in the outcomes; results were adjusted using analysis of covariance. EC exhibited clinically important but not statistically significant increases in protein intake (14.7 g; confidence interval (CI) 95% -6.5, 35.9, P=0.165), cognitive functioning (7.2; CI 95% -7.9, 22.2, P=0.337) and social functioning (16.5; CI 95% -7.3, 40.3, P=0.165) compared with UC. Relative to pre-admission, EC experienced less weight loss than UC (-3.3 kg; CI 95% -6.7, 0.2, P=0.062). Physical activity was not significantly different between the groups. Ongoing nutrition and exercise counselling may prevent further weight loss and improve dietary intake and certain QoL components in autologous PBSC transplantation patients following hospitalisation.

A novel, automated nutrition screening system as a predictor of nutritional risk in an oncology day treatment unit (ODTU).

PURPOSE: Paper-based nutrition screening tools can be challenging to implement in the ambulatory oncology setting. The aim of this study was to determine the validity of the Malnutrition Screening Tool (MST) and a novel, automated nutrition screening system compared to a 'gold standard' full nutrition assessment using the Patient-Generated Subjective Global Assessment (PG-SGA). METHODS: An observational, cross-sectional study was conducted in an outpatient oncology day treatment unit (ODTU) within an Australian tertiary health service. Eligibility criteria were as follows: ≥ 18 years, receiving outpatient anticancer treatment and English literate. Patients self-administered the MST. A dietitian assessed nutritional status using the PG-SGA, blinded to the MST score. Automated screening system data were extracted from an electronic oncology prescribing system. This system used weight loss over 3 to 6 weeks prior to the most recent weight record or age-categorised body mass index (BMI) to identify nutritional risk. Sensitivity and specificity against PG-SGA (malnutrition) were calculated using contingency tables and receiver operating curves. RESULTS: There were a total of 300 oncology outpatients (51.7% male, 58.6 ± 13.3 years). The area under the curve (AUC) for weight loss alone was 0.69 with a cut-off value of ≥ 1% weight loss yielding 63% sensitivity and 76.7% specificity. MST (score ≥ 2) resulted in 70.6% sensitivity and 69.5% specificity, AUC 0.77. CONCLUSIONS: Both the MST and the automated method fell short of the accepted professional standard for sensitivity (~≥ 80%) derived from the PG-SGA. Further investigation into other automated nutrition screening options and the most appropriate parameters available electronically is warranted to support targeted service provision.

Exposure to solar ultraviolet radiation is associated with a decreased folate status in women of childbearing age.

In vitro studies indicate that folate in collected human blood is vulnerable to degradation after exposure to ultraviolet (UV) radiation. This has raised concerns about folate depletion in individuals with high sun exposure. Here, we investigate the association between personal solar UV radiation exposure and serum folate concentration, using a three-week prospective study that was undertaken in females aged 18-47years in Brisbane, Australia (153 E, 27 S). Following two weeks of supplementation with 500µg of folic acid daily, the change in serum folate status was assessed over a 7-day period of measured personal sun exposure. Compared to participants with personal UV exposures of <200 Joules per day, participants with personal UV exposures of 200-599 and >600 Joules per day had significantly higher depletion of serum folate (p=0.015). Multivariable analysis revealed personal UV exposure as the strongest predictor accounting for 20% of the overall change in serum folate (Standardised B=-0.49; t=-3.75; p=<0.01). These data show that increasing solar UV radiation exposures reduces the effectiveness of folic acid supplementation. The consequences of this association may be most pronounced for vulnerable individuals, such as women who are pregnant or of childbearing age with high sun exposures.

Patient satisfaction with nutrition services amongst cancer patients treated with autologous stem cell transplantation: a comparison of usual and extended care.

BACKGROUND: This study aimed to determine patient satisfaction with clinical nutrition services delivered by an accredited practicing dietitian amongst cancer patients treated with autologous stem cell transplantation that was provided with usual and extended care at 100 days post-transplantation. METHODS: Patients were randomised to receive usual nutrition care or extended nutrition care during the course of their stem cell transplantation. After hospital discharge, usual care patients received no further nutrition support, whereas extended care patients received telephone dietary counselling from the same dietitian for up to 100 days post-transplantation. The patient satisfaction with clinical nutrition service questionnaire was completed anonymously at 100 days post-transplantation. Group comparisons were made using independent t-tests. RESULTS: Thirty-seven patients consented to participate in the study (54% male; mean age 58.7 ± 9.5 years; median body mass index 26.8 kg m(-2) , range 16.4-47.6 kg m(-2) ); 33 patients completed the study and 28 patients returned the questionnaire (response rate = 85%). All components of the questionnaire were rated highly by both groups; there was no significant difference between the groups (P > 0.05). Although not statistically significant, extended care patients who received at least three telephone calls rated a higher overall satisfaction compared to those who received less calls; this difference was clinically important (score difference = 0.56). CONCLUSIONS: Cancer patients treated with autologous stem cell transplantation were satisfied with usual and extended nutrition care. Extended care patients who received at least three telephone calls after hospital discharge were more satisfied than those with less frequent intervention. Further exploration regarding the frequency and intensity of nutrition service is required.

The consequences of malnutrition following discharge from rehabilitation to the community: a systematic review of current evidence in older adults.

BACKGROUND: The prevalence of malnutrition in the rehabilitation setting is estimated to be 30-50%, with older adults at higher nutritional risk. Malnutrition also exists in the community setting, where 10-30% of adults are malnourished; however, the relationship between the two settings has been little explored. The present study aimed to determine the association between malnutrition in older adults admitted for rehabilitation and nutrition status, functional status, quality of life, institutionalisation, acute care admissions and mortality once discharged to the community. METHODS: Six electronic databases were searched for relevant publications (1990-2013) using controlled vocabulary. Longitudinal papers were included in which older adults (≥65 years) were admitted for rehabilitation if nutrition assessment was performed during admission with relevant outcomes measured following discharge to the community. RESULTS: Five observational studies were eligible for review which had similar populations. The five reviews comprised 1020 participants in total and, once discharged, follow-up ranged from immediate to 26 months. Malnutrition during rehabilitation was negatively associated with physical function and quality of life, and positively associated with risk of institutionalisation, hospitalisation and mortality. Although these studies were of high quality and strength, the overall contribution to the evidence is limited as a result of the small number of heterogenic studies. No intervention studies were identified. CONCLUSIONS: Malnutrition in older adults admitted for rehabilitation has a negative effect on functional recovery and quality of life following discharge to the community. This review highlights an evidence gap along the continuum of care for malnourished older adults, where further observational and intervention research is needed following discharge from rehabilitation to the community.

An exploratory study to evaluate whether medical nutrition therapy can improve dietary intake in hospital patients who eat poorly.

BACKGROUND: The Australasian Nutrition Care Day Survey (ANCDS) reported that two-fifths of patients consume ≤50% of the offered food in Australian and New Zealand hospitals. After controlling for confounders (nutritional status, age, disease type and severity), the ANCDS also established an independent association between poor food intake and increased in-hospital mortality. The present study aimed to evaluate whether medical nutrition therapy (MNT) could improve dietary intake in hospital patients eating poorly. METHODS: An exploratory pilot study was conducted in the respiratory, neurology and orthopaedic wards of an Australian hospital. At baseline, percentage food intake (0%, 25%, 50%, 75% and 100%) was evaluated for each main meal and snack for a 24-h period in patients hospitalised for ≥2 days and not under dietetic review. Patients consuming ≤50% of offered meals as a result of nutrition-impact symptoms were referred to ward dietitians for MNT. Food intake was re-evaluated on the seventh day after recruitment (post-MNT). RESULTS: One hundred and eighty-four patients were observed over 4 weeks; 32 patients were referred for MNT. Although baseline and post-MNT data for 20 participants [mean (SD) age 68 (17) years, 65% females] indicated a significant increase in median energy and protein intake post-MNT (3600 kJ day(-1) ; 40 g day(-1) ) versus baseline (2250 kJ day(-1) ; 25 g day(-1) ) (P < 0.05), the increased intake met only 50% of dietary requirements. Persistent nutrition impact symptoms affected intake. CONCLUSIONS: In the present pilot study, although dietary intake improved, it remained inadequate to meet participants' estimated requirements as a result of ongoing nutrition-impact symptoms. Appropriate medical management and early enteral feeding could be a possible solution for such patients.

Are informal carers and community care workers effective in managing malnutrition in the older adult community? A systematic review of current evidence.

BACKGROUND: Enhancing the effectiveness of the community and aged care workforce to prevent malnutrition and functional decline is important in reducing hospital and aged care facility demand. OBJECTIVE: To investigate the impact of nutrition-related interventions delivered to or by informal carers and non-clinical community care workers on malnutrition-related health outcomes of community-dwelling older adults (≥65 years). METHODS: Intervention studies were searched for using six electronic databases for English-language publications from January 1980 to 30 May 2012. RESULTS: Nine studies were eligible for inclusion. The strength and quality of the evidence was moderate (six studies with level II intervention evidence, five with positive quality). Types of interventions used were highly varied. The majority of interventions were delivered to informal carers (6 studies), with three of these studies also involving older adult care recipients. Five interventions were targeted at identifying, preventing and/or treating malnutrition specifically (two positive quality, three neutral quality, n=2368). As a result of these interventions, nutritional status improved or stabilized (two positive quality, two neutral quality, n=2333). No study reported an improvement in functional status but two successfully prevented further decline in their participants (two neutral quality, n=1097). CONCLUSION: Interventions targeted at identifying, preventing and/or treating malnutrition were able to improve or prevent decline in nutritional and functional status, without increasing informal carer burden. The findings of this review support the involvement of non-clinical community care workers and informal carers as part of the nutritional care team for community-dwelling older adults.