Malnutrition risk, outcomes, and costs among older adults undergoing elective surgical procedures: A retrospective cohort study.

BACKGROUND: We examine here the association between malnutrition risk and adverse health outcomes among older adult patients undergoing elective surgical procedures. METHODS: We conducted a retrospective study using linked clinical and administrative databases. Malnutrition risk was assessed prior to surgery, defined by unintentional weight loss and decreased food intake. We performed a logistic regression analysis of the primary outcome, a composite adverse outcome measure, including death, bleeding, pneumonia, and other surgical complications. We conducted Fine-Gray proportional hazard regression analysis of hospital length of stay (LOS). We performed a generalized linear regression analysis of in-hospital cost data. All regression analyses controlled for frailty, age, sex, surgical category, and comorbidities. RESULTS: Of a total of 3457 older adult elective surgical patients (65-102 years), 310 (9.0%) screened positive for malnutrition risk. In multivariable regression analyses, malnutrition risk was associated with an increased risk of the composite adverse outcome (odds ratio [OR] = 1.74; 95% CI = 1.25-2.39), higher hospitalization costs (relative cost = 1.84; 95% CI = 1.59-2.13), and a decreased risk of discharge from the hospital (hazard ratio = 0.67; 95% CI = 0.59-0.77) compared with those who screened negative. CONCLUSION: Older adult patients with malnutrition risk were at an increased risk of adverse surgical outcomes, had longer LOS in the hospital, and incurred higher costs of care. It is important to screen for malnutrition risk and refer older adults for dietetic consults prior to elective surgery.

Nutrition implications of intrinsic restrictive lung disease.

Restrictive lung disease is defined as a reduction in lung volume that may be due to intraparenchymal or extraparenchymal causes. Intraparenchymal causes falls under the umbrella term of interstitial lung disease (ILD) and includes idiopathic pulmonary fibrosis. This manuscript provides an overview of ILD and can be beneficial for all clinicians working with patients with ILD. Although not well documented, the prevalence of malnutrition in patients with ILD has been reported to be between ~9% and 55%. Body mass index has been shown to predict survival; but more recently, research has suggested that fat-free mass has a larger influence on survival. There is insufficient evidence to support the use of antioxidant or vitamin supplementation to help diminish the chronic inflammatory process that is seen in this patient population. There are data from studies examining the vitamin D status in this patient population, but research on vitamin D supplementation appears to be lacking. Registered dietitian nutritionists should continue to advocate and play a more prominent role in the nutrition management of patients with ILD as part of standard of care.

Understanding the Need for Tools and Resources to Manage Enteral Nutrition Intolerance: An On-line Survey.

Purpose: Enteral nutrition intolerance (ENI) is a common complication among tube-fed patients, associated with reduced volumes of nutrition delivered, and may contribute to malnutrition risk. This research aimed to obtain insights about dietitians' needs and preferences related to tools and resources to help identify and manage ENI.Methods: An online survey was administered to registered dietitians (RD) engaged in enteral nutrition (EN) management, recruited from a list of attendees at a national webinar. The 16-question survey asked about participant's experience with ENI and interest in resources to manage ENI.Results: Of the 219 surveys completed (25% response rate), 86% identified ENI as an issue/concern that interferes with adequate nutrition or hydration for their patients. Ninety-seven percent reported being interested in having tools/resources to manage ENI. The symptoms identified as most pressing to manage were diarrhea (73%), bloating/abdominal discomfort (42%), and nausea (32%). Preferred types of tools were hard-copy resources (70%), algorithms (67%), and web-based instruments (62%).Conclusions: ENI remains an issue for clinicians working with tube-fed patients and RDs are interested in management tools. These results have implications for the development of evidence-based resources to help improve EN delivery and ultimately may contribute to clinician's efforts at reducing malnutrition.

Exercise capacity and its relationship with body composition and nutrition status in patients with interstitial lung disease.

BACKGROUND: Patients with interstitial lung disease (ILD) are known to have diminished exercise ability. This study aimed to explore the relationship between nutrition status and body composition parameters with exercise capacity in ILD patients. A second aim focused on assessing the appropriateness of surrogate markers of nutrition status in ILD patients. METHODS: Disease severity was determined by the percentage of predicted forced vital capacity. Exercise capacity was determined using 6-minute walk distance. Nutrition status was assessed using the subjective global assessment (SGA), standardized phase angle (SPhA), and impedance ratio z-score (z-IR). Bioelectrical impedance analysis estimated body composition parameters. RESULTS: 45 of 79 participants (57%) were malnourished according to the SGA. FFM index z-score (z-FFMI) (r = 0.42, P = .02) and SGA (r = 0.49, P < .01) were significant predictors of exercise capacity independent of disease severity. Age (odds ratio [OR] = 1.1; 95% CI, 1.01-1.25; P = .04), low body mass index (OR = 0.73; 95% CI, 0.57-0.92; P = .01), z-FFMI (OR = 0.34; 95% CI, 0.17-0.68; P < .01), and body fat mass index z-score (OR = 0.39; 95% CI, 0.17-0.91; P = .03) were significantly associated with severe malnutrition. There was no significant difference in SPhA across SGA groups; however, a higher z-IR (poorer cell health) significantly increased the odds of severe malnutrition (OR = 2.75; 95% CI, 1.27-6.03; P = .02). CONCLUSION: In ILD patients, malnutrition and loss of FFM negatively impact the ability to perform activities of daily living.

Fat-Free Mass Index Controlled for Age and Sex and Malnutrition Are Predictors of Survival in Interstitial Lung Disease.

BACKGROUND: Literature focusing on nutritional variables and survival in interstitial lung disease (ILD) is limited by its focus on weight and BMI and has not considered body composition. OBJECTIVES: The primary objective of this study was to examine whether body composition measures, specifically fat-free mass index z-score (z-FFMI) and body fat mass index z-score (z-BFMI), were predictors of survival in fibrotic ILD patients. The second objective was to examine if nutrition status was a predictor of survival. METHOD: Seventy-eight outpatients diagnosed with fibrotic ILD were recruited in this cross-sectional study. Body composition data using dual frequency bioelectrical impedance analysis (BodyStat 1500MD; UK) and nutrition status using the subjective global assessment (SGA) were determined. To control for age and sex, z-FFMI and z-BFMI were calculated using population means. Participant charts were reviewed for diagnosis, age, disease severity, and exercise capacity. RESULTS: Age (HR 1.08, 95% CI [1.03-1.13], p < 0.01), BMI (HR 0.90, 95% CI [0.84-0.97], p < 0.01]), z-FFMI (HR 0.70, 95% CI [0.56-0.87], p = 0.02), z-BFMI (HR 0.74, 95% CI [0.57-0.96], p < 0.01), 6-min walk distance (6MWD) (HR 0.99, 95% CI [0.99-1.00], p < 0.01), percent predicted diffusing capacity for carbon monoxide (%DLco) (HR 0.93, 95% CI [0.89-0.97], p < 0.01), and severe malnutrition (SGA-C) (HR 6.98, 95% CI [2.00-24.27], p < 0.01) were significant predictors of survival. When controlled for exercise capacity and disease severity, z-FFMI and severe malnutrition were significant predictors of survival independent of %DLco. CONCLUSION: z-FFMI and severe malnutrition were significant predictors of survival in fibrotic ILD patients independent of disease severity.

Exploring Attitudes, Subjective Norms and Perceived Behavioural Control in a Genetic-Based and a Population-Based Weight Management Intervention: A One-Year Randomized Controlled Trial.

BACKGROUND: Several studies demonstrate that the provision of personalized lifestyle advice, based on genetics, can help motivate individuals to engage in greater nutrition and physical activity changes compared to the provision of population-based advice. The theoretical mechanism behind this phenomenon is poorly understood. The objective of this study was to determine the impact of providing genetically tailored and population-based lifestyle advice on key constructs of the Theory of Planned Behaviour (TPB). MATERIALS AND METHODS: A pragmatic, cluster randomized controlled trial (n = 140) took place at the East Elgin Family Health Team, in Aylmer, Ontario, Canada. Participants were primarily Caucasian females enrolled in a weight management program (BMI ≥ 25.0 kg/m2). Weight management program groups were randomized (1:1) to receive a population-based lifestyle intervention for weight management (Group Lifestyle Balance™ (GLB)) or a lifestyle genomics (LGx)-based lifestyle intervention for weight management (GLB+LGx). Attitudes, subjective norms and perceived behavioural control were measured at baseline, immediately after receiving a report of population-based or genetic-based recommendations and after 3-, 6- and 12-month follow-ups. Linear mixed models were conducted, controlling for measures of actual behavioural control. All analyses were intention-to-treat by originally assigned groups. RESULTS: Significant changes (p < 0.05) in attitudes, subjective norms, and perceived behavioural control tended to be short-term in the GLB group and long-term for the GLB+LGx group. Short-term and long-term between-group differences in measures of subjective norms were discovered, favouring the GLB+LGx group. CONCLUSIONS: The TPB can help provide a theoretical explanation for studies demonstrating enhanced behaviour change with genetic-based lifestyle interventions. CLINICAL TRIAL REGISTRATION: NCT03015012.

Enhanced long-term dietary change and adherence in a nutrigenomics-guided lifestyle intervention compared to a population-based (GLB/DPP) lifestyle intervention for weight management: results from the NOW randomised controlled trial.

BACKGROUND: Adherence to nutritional guidelines for chronic disease prevention and management remains a challenge in clinical practice. Innovative strategies are needed to help optimise dietary behaviour change. OBJECTIVE: The objective of this study was to determine if a nutrigenomics-guided lifestyle intervention programme could be used to motivate greater dietary adherence and change in dietary intake short-term, moderate-term and long-term compared to the gold-standard population-based weight management intervention (Group Lifestyle Balance (GLB)/Diabetes Prevention Programme (DPP)). DESIGN: The Nutrigenomics, Overweight/Obesity, and Weight Management (NOW) randomised controlled trial is a pragmatic, parallel-group, superiority clinical trial (n=140), which was conducted at the East Elgin Family Health Team (EEFHT). GLB weight management groups were prerandomised 1:1 to receive either the standard GLB programme or a modified GLB+nutrigenomics (GLB+NGx) programme. Three 24-hour recalls were collected at baseline, 3, 6 and 12 months using the validated multiple pass method. Research assistants collecting the three 24-hour recalls were blinded to the participants' group assignments. Statistical analyses included split plot analyses of variance (ANOVAs), two-way ANOVAs, binary logistic regression, χ2 and Fisher's exact tests. Using the Theory of Planned Behaviour as guidance, key confounding factors of behaviour change were considered in the analyses. This study was registered with clinicaltrials.gov (NCT03015012). RESULTS: Only the GLB+NGx group significantly reduced their total fat intake from baseline to 12-month follow-up (from 36.0%±4.8% kcal to 30.2%±8.7% kcal, p=0.02). Long-term dietary adherence to total fat and saturated fat guidelines was also significantly (p<0.05) greater in the GLB+NGx group compared to the standard GLB group. CONCLUSIONS: Weight management interventions guided by nutrigenomics can motivate long-term improvements in dietary fat intake above and beyond gold-standard population-based interventions.

Can a Lifestyle Genomics Intervention Motivate Patients to Engage in Greater Physical Activity than a Population-Based Intervention? Results from the NOW Randomized Controlled Trial.

BACKGROUND: Lifestyle genomics (LGx) is a science that explores interactions between genetic variation, lifestyle components such as physical activity (PA), and subsequent health- and performance-related outcomes. The objective of this study was to determine whether an LGx intervention could motivate enhanced engagement in PA to a greater extent than a population-based intervention. METHODS: In this pragmatic randomized controlled trial, participants received either the standard, population-based Group Lifestyle BalanceTM (GLB) program intervention or the GLB program in addition to the provision of LGx information and advice (GLB + LGx). Participants (n = 140) completed a 7-day PA recall at baseline, 3, 6, and 12 months. Data from the PA recalls were used to calculate metabolic equivalents (METs), a measure of energy expenditure. Statistical analyses included split plot analyses of covariance and binary logistic regression (generalized linear models). Differences in leisure time PA weekly METs, weekly minutes of moderate + high-intensity PA, and adherence to PA guidelines were compared between groups (GLB and GLB + LGx) across the 4 time points. RESULTS: Weekly METs were significantly higher in the GLB + LGx group (1,114.7 ± 141.9; 95% CI 831.5-1,397.8) compared to the standard GLB group (621.6 ± 141.9 MET/week; 95% CI 338.4-904.8) at the 6-month follow-up (p = 0.01). All other results were non-significant. CONCLUSIONS: The provision of an LGx intervention resulted in a greater weekly leisure time PA energy expenditure after the 6-month follow-up. Future research should determine how this could be sustained over the long-term. CLINICAL TRIAL REGISTRATION: NCT03015012.

Change in Weight, BMI, and Body Composition in a Population-Based Intervention Versus Genetic-Based Intervention: The NOW Trial.

OBJECTIVE: The aim of this study was to compare changes in body fat percentage (BFP), weight, and BMI between a standard intervention and a nutrigenomics intervention. METHODS: The Nutrigenomics, Overweight/Obesity and Weight Management (NOW) trial is a parallel-group, pragmatic, randomized controlled clinical trial incorporated into the Group Lifestyle BalanceTM (GLB) Program. Statistical analyses included two-way ANOVA and split-plot ANOVA. Inclusion criteria consisted of: BMI ≥ 25.0 kg/m2 , ≥18 years of age, English speaking, willing to undergo genetic testing, having internet access, and not seeing another health care provider for weight-loss advice outside of the study. Pregnancy and lactation were exclusion criteria. GLB groups were randomly assigned 1 to 1 (N = 140) so that participants received either the standard 12-month GLB program or a modified 12-month program (GLB plus nutrigenomics), which included the provision of nutrigenomics information and advice for weight management. The primary outcome was percent change in BFP. Secondary outcomes were change in weight and BMI. RESULTS: The GLB plus nutrigenomics group experienced significantly (P < 0.05) greater reductions in percent and absolute BFP at the 3-month follow-up and percent BFP at the 6-month follow-up compared with the standard GLB group. CONCLUSIONS: The nutrigenomics intervention used in the NOW trial can optimize change in body composition up to 6 months.

Assessing the effectiveness of actionable nutrigenomics and lifestyle genomics interventions for weight management in clinical practice: A critical, scoping review with directions for future research.

BACKGROUND: The use of nutrigenomics and lifestyle genomics in clinical practice has the potential to optimize weight-related outcomes for patients. AIM: A scoping review was conducted to summarize and evaluate the current body of knowledge related to the effectiveness of providing DNA-based lifestyle advice on weight-related outcomes, with the aim of providing direction for future research. METHOD: Primary studies were included if they were written in English, evaluated weight-related and/or body mass index and/or body composition outcomes, and provided participants with an actionable genetic-based lifestyle intervention; interventions that only provided information on genetic risk for diseases/conditions were excluded. Data was extracted from each article meeting inclusion criteria (N=3) and the studies were critically appraised for methodological limitations. RESULTS: Research in this area is promising, but limited. Specific limitations relate to study designs, the nature of the recommendations provided to participants, small (underpowered) sample sizes, the use of self-reported weight/BMI data and lack of consideration of important confounding factors. CONCLUSIONS: Therefore, the effectiveness of nutrigenomics and lifestyle genomics interventions for weight management in clinical practice cannot yet be conclusively determined. Recommendations for future research are detailed in the present manuscript.

Assessing the Validity of the Past-Month, Online Canadian Diet History Questionnaire II Pre and Post Nutrition Intervention.

Dietary intake tools are used in epidemiological and interventional studies to estimate nutritional intake. The past-month Canadian Diet History Questionnaire II (CDHQII) has not yet been validated. This study aimed to assess the validity of the CDHQII in adults by comparing dietary results from the CDHQII to the same participants' 24-h recalls consisting of two weekdays and one weekend day. The recalls were collected using the validated multiple-pass method. Participants were asked to complete both tools at baseline, and again at 3-month follow-up. The study further aimed to determine which dietary intake tool was preferred by study participants by comparing completion rates. Data collection occurred at baseline (pre-intervention) and 3-month follow-up (post-intervention). Paired sample t-tests were conducted to compare means for the following nutrients (grams and %kcal): calories, protein, carbohydrates, total fat, saturated fat, unsaturated fat and sodium. Intraclass correlation coefficients of agreement and coefficients of variation were further calculated. Chi-square tests were used to determine the dietary assessment method with the greatest participant completion rate. At baseline (n = 104), there were no significant differences between the results of the CDHQII and three 24-h recalls (averaged), with overall moderate correlation coefficients. At 3-months (n = 53), there were significant differences (p < 0.05) between dietary intake collection methods for all nutrients assessed in this study, except for saturated fat (%kcal), unsaturated fat (%kcal), protein (%kcal) and sodium (mg). Correlation coefficients were moderate. A significantly greater proportion of participants completed the three 24-h recalls compared to the CDHQII after 3 months (completion rates of 67.2% vs. 50.8% of the sample, respectively). The CDHQII provided estimates of mean nutritional intake (calories, macronutrients and sodium) that were comparable to mean intake established from three 24-h recalls, at baseline and was validated in a sample of primarily middle-aged, college-educated, Caucasian female adults with overweight and obesity for mean baseline or cross-sectional measurement only but not for assessing individual/patient dietary intake in clinical practice (r = 0.30-0.68). This tool was not validated at 3-month follow-up. Additionally, participants preferred the three 24-h recalls to the online, past-month CDHQII.

Study protocol of a pragmatic randomized controlled trial incorporated into the Group Lifestyle Balance™ program: the nutrigenomics, overweight/obesity and weight management trial (the NOW trial).

BACKGROUND: The nutrigenomics, overweight/obesity and weight management trial (NOW Trial) is a pragmatic randomized controlled trial of community-dwelling adults recruited from the Group Lifestyle Balance™ (GLB™) Program. The GLB™ Program (formerly referred to as the Diabetes Prevention Program) is an evidence-based, intensive weight management program, which was offered to overweight/obese patients (BMI ≥ 25.0 kg/m2) in a rural Ontario community. METHODS: Patients enrolled in the GLB™ Program were invited to participate in this study. GLB™ groups were randomized 1:1 to receive either the standard GLB™ program + population-based lifestyle advice for weight management, or a modified GLB™ program + personalized, genetic-based lifestyle advice for weight management. The purpose of this study is to determine if the provision of genetic-based lifestyle guidelines is superior to the provision of population-based guidelines in a pragmatic clinical setting to promote changes in: body composition, weight, body mass index, dietary and physical activity habits, as well as attitudes, subjective norms, and behavioural control. The 12-month intervention protocol consists of 23 group-based sessions and 4 one-on-one sessions. Data collection time points include baseline in addition to 3, 6, and 12-month follow up. The comprehensive study design is described in the present manuscript, using both the extended CONSORT checklist for reporting pragmatic trials and the SPIRIT checklist as guidance during manuscript development. DISCUSSION: Overall, this study seeks to pragmatically determine if the provision of DNA-based lifestyle advice leads to improved health and lifestyle outcomes compared to the provision of standard, population-based lifestyle advice. The results of this trial can be used to inform clinical and community nutrition practice guidelines. TRIAL REGISTRATION: This study was registered with clinicaltrials.gov : NCT03015012 on January 9, 2017.

Is phase angle an appropriate indicator of malnutrition in different disease states? A systematic review.

BACKGROUND & AIMS: Subjective Global Assessment (SGA) classifies malnutrition severity via a simple bedside assessment. Phase angle (PhA) is an indicator of cell integrity and has been suggested to be indicator of nutritional status. OBJECTIVE: To explore the relationship between PhA and SGA. METHODS: Relevant studies published through October 31, 2017 were identified using 7 electronic databases. Articles were included for review if they included comparison data between SGA and PhA within adult disease populations. Evidence quality was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines and methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. RESULTS: 33 articles within four disease states (liver, hospitalization, oncology and renal) met inclusion criteria for review. Results were limited by restricting the database search to articles published in English only, and by the inherent difficulty of comparing 2 methods which are both influenced by the operator. CONCLUSION: Based on GRADE guidelines, evidence quality received a grade of Low. Based on QUADAS-2, 61% of studies had high risk of bias in the index test (PhA), while all other domains had low risk. It is not possible to conclude that PhA is an accurate independent indicator of malnutrition. PROSPERO no. CRD42016050876.

A Systematic Review of Genetic Testing and Lifestyle Behaviour Change: Are We Using High-Quality Genetic Interventions and Considering Behaviour Change Theory?

BACKGROUND: Studying the impact of genetic testing interventions on lifestyle behaviour change has been a priority area of research in recent years. Substantial heterogeneity exists in the results and conclusions of this literature, which has yet to be explained using validated behaviour change theory and an assessment of the quality of genetic interventions. The theory of planned behaviour (TPB) helps to explain key contributors to behaviour change. It has been hypothesized that personalization could be added to this theory to help predict changes in health behaviours. PURPOSE: This systematic review provides a detailed, comprehensive identification, assessment, and summary of primary research articles pertaining to lifestyle behaviour change (nutrition, physical activity, sleep, and smoking) resulting from genetic testing interventions. The present review further aims to provide in-depth analyses of studies conducted to date within the context of the TPB and the quality of genetic interventions provided to participants while aiming to determine whether or not genetic testing facilitates changes in lifestyle habits. This review is timely in light of a recently published "call-to-action" paper, highlighting the need to incorporate the TPB into personalized healthcare behaviour change research. METHODS: Three bibliographic databases, one key website, and article reference lists were searched for relevant primary research articles. The PRISMA Flow Diagram and PRISMA Checklist were used to guide the search strategy and manuscript preparation. Out of 32,783 titles retrieved, 26 studies met the inclusion criteria. Three quality assessments were conducted and included: (1) risk of bias, (2) quality of genetic interventions, and (3) consideration of theoretical underpinnings - primarily the TPB. RESULTS: Risk of bias in studies was overall rated to be "fair." Consideration of the TPB was "poor," with no study making reference to this validated theory. While some studies (n = 11; 42%) made reference to other behaviour change theories, these theories were generally mentioned briefly, and were not thoroughly incorporated into the study design or analyses. The genetic interventions provided to participants were overall of "poor" quality. However, a separate analysis of studies using controlled intervention research methods demonstrated the use of higher-quality genetic interventions (overall rated to be "fair"). The provision of actionable recommendations informed by genetic testing was more likely to facilitate behaviour change than the provision of genetic information without actionable lifestyle recommendations. Several studies of good quality demonstrated changes in lifestyle habits arising from the provision of genetic interventions. The most promising lifestyle changes were changes in nutrition. CONCLUSIONS: It is possible to facilitate behaviour change using genetic testing as the catalyst. Future research should ensure that high-quality genetic interventions are provided to participants, and should consider validated theories such as the TPB in their study design and analyses. Further recommendations for future research are provided.

Incorporating the 'Theory of Planned Behavior' into personalized healthcare behavior change research: a call to action.

The 'Theory of Planned Behavior' (TPB) has been tested and validated in the scientific literature across multiple disciplines and is arguably the most widely accepted theory among behavior change academics. Despite this widespread acceptability, the TPB has yet to be incorporated into personalized healthcare behavior change research. Several prominent personalized healthcare researchers suggest that personalizing healthcare recommendations have a positive impact on changes in lifestyle habits. However, research in this area has demonstrated conflicting findings. We provide a scientific and theoretical basis to support a proposed expansion of the TPB to include personalization, and call to action-personalized healthcare behavior change researchers to test this expansion. Specific recommendations for study design are included.

Sarcopenia in liver transplantation: A review.

BACKGROUND & AIMS: The most recent definition of sarcopenia includes the presence of both low skeletal muscle mass and low skeletal muscle function. As sarcopenia has been associated with numerous poor outcomes in the general surgical population, investigation into its presence in the liver transplantation population is warranted. This review aims to synthesize the available data regarding sarcopenia and liver transplantation. METHODS: Data sourcing was completed by searching the following databases: PubMed, Google Scholar and Cochrane. RESULTS: Perioperative sarcopenia has been associated with poorer survival, increased wait list mortality and increased length of stay. Although the Model for End-Stage Liver Disease score is routinely used to predict post liver transplantation mortality and morbidity, literature suggests it does not reflect sarcopenic status. DISCUSSION: Sarcopenia is associated with poor liver transplantation outcomes. Future research should consider utilizing the recent working definition of sarcopenia and generating diagnostic reference values.