Nutrition management guideline for very-long chain acyl-CoA dehydrogenase deficiency (VLCAD): An evidence- and consensus-based approach.

The nutrition management guideline for very-long chain acyl-CoA dehydrogenase deficiency (VLCAD) is the fourth in a series of web-based guidelines focusing on the diet treatment for inherited metabolic disorders and follows previous publication of guidelines for maple syrup urine disease (2014), phenylketonuria (2016) and propionic acidemia (2019). The purpose of this guideline is to establish harmonization in the treatment and monitoring of individuals with VLCAD of all ages in order to improve clinical outcomes. Six research questions were identified to support guideline development on: nutrition recommendations for the healthy individual, illness management, supplementation, monitoring, physical activity and management during pregnancy. This report describes the methodology used in its development including review, critical appraisal and abstraction of peer-reviewed studies and unpublished practice literature; expert input through two Delphi surveys and a nominal group process; and external review from metabolic physicians and dietitians. It includes the summary statements of the nutrition management recommendations for each research question, followed by a standardized rating based on the strength of the evidence. Online, open access of the full published guideline allows utilization by health care providers, researchers and collaborators who advise, advocate and care for individuals with VLCAD and their families and can be accessed from the Genetic Metabolic Dietitians International (https://GMDI.org) and Southeast Regional Genetics Network (https://southeastgenetics.org/ngp) websites.

Using risk of bias domains to identify opportunities for improvement in food- and nutrition-related research: An evaluation of research type and design, year of publication, and source of funding.

PURPOSE: This retrospective cross-sectional study aimed to identify opportunities for improvement in food and nutrition research by examining risk of bias (ROB) domains. METHODS: Ratings were extracted from critical appraisal records for 5675 studies used in systematic reviews conducted by three organizations. Variables were as follows: ROB domains defined by the Cochrane Collaboration (Selection, Performance, Detection, Attrition, and Reporting), publication year, research type (intervention or observation) and specific design, funder, and overall quality rating (positive, neutral, or negative). Appraisal instrument questions were mapped to ROB domains. The kappa statistic was used to determine consistency when multiple ROB ratings were available. Binary logistic regression and multinomial logistic regression were used to predict overall quality and ROB domains. FINDINGS: Studies represented a wide variety of research topics (clinical nutrition, food safety, dietary patterns, and dietary supplements) among 15 different research designs with a balance of intervention (49%) and observation (51%) types, published between 1930 and 2015 (64% between 2000-2009). Duplicate ratings (10%) were consistent (κ = 0.86-0.94). Selection and Performance domain criteria were least likely to be met (57.9% to 60.1%). Selection, Detection, and Performance ROB ratings predicted neutral or negative quality compared to positive quality (p<0.001). Funder, year, and research design were significant predictors of ROB. Some sources of funding predicted increased ROB (p<0.001) for Selection (interventional: industry only and none/not reported; observational: other only and none/not reported) and Reporting (observational: university only and other only). Reduced ROB was predicted by combined and other-only funding for intervention research (p<0.005). Performance ROB domain ratings started significantly improving in 2000; others improved after 1990 (p<0.001). Research designs with higher ROB were nonrandomized intervention and time series designs compared to RCT and prospective cohort designs respectively (p<0.001). CONCLUSIONS: Opportunities for improvement in food and nutrition research are in the Selection, Performance, and Detection ROB domains.

Nutrition Practice Guidelines for Type 1 Diabetes Mellitus positively affect dietitian practices and patient outcomes. The Diabetes Care and Education Dietetic Practice Group.

OBJECTIVES: Assess the acceptance and ease of use of Nutrition Practice Guidelines for Type 1 Diabetes Mellitus by dietitians in a variety of settings; determine if nutrition care activities of dietitians change when practice guidelines are available; measure changes in patient control of blood glucose level, measured as glycated hemoglobin (HbA1c); compare patient satisfaction with care and perceptions about quality of life. DESIGN: Using the approach of outcomes research, volunteer dietitians were recruited and assigned randomly to a usual care group or a practice guidelines group. Patients with type 1 diabetes were enrolled by dietitians and followed up for a 3-month period. Outcome measures included dietitian care activities, changes in patient HbA1c levels, and patient satisfaction and perceptions about quality of life. SUBJECTS/SETTINGS: Dietitians from across the United States who responded to a recruitment notice participated. Their work settings included diabetes referral centers, endocrinology clinics, primary care and community health clinics, hospitals, and a worksite clinic. They recruited patients from their setting for the study. Outcome data were available from dietitians providing care to 24 patients using the new practice guidelines and dietitians providing care to 30 patients using more traditional methods. STATISTICAL ANALYSIS: chi 2 Test, t test, and analysis of covariance. RESULTS: Dietitians in the practice guidelines group spent 63% more time with patients and were more likely to do an assessment and discuss results with patients than dietitians in the usual care group. Practice guidelines dietitians paid greater attention to glycemic control goals. Levels of HbA1c improved at 3 months in 21 (88%) of practice guidelines patients compared with 16 (53%) of usual care patients. Practice guidelines patients achieved greater reductions in HbA1c level than usual care patients (-1.00 vs -0.33). This difference was statistically significant and clinically meaningful. CONCLUSIONS/APPLICATIONS: Dietitians responded positively to practice guidelines for type 1 diabetes. Use of guidelines resulted in changes in dietitian practices and produced greater improvements in patient blood glucose outcomes at 3 months compared with usual care. Practice guidelines did not significantly influence patient satisfaction with care of perceived quality of life.

Economic benefit of breast-feeding infants enrolled in WIC.

OBJECTIVES: To determine whether breast-feeding of infants enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is associated with a reduction in Medicaid expenditures during the first 6 months of life; if so, to determine whether the reduction in Medicaid expenditures represents a positive economic benefit to society when WIC costs for these infants and their mothers are considered. DESIGN: Cohorts of exclusively breast-fed and formula-fed infants were tracked for 6 months to compare WIC costs and Medicaid expenditures. SUBJECTS: The sample consisted of 406 healthy infants who were breast-fed exclusively for at least 3 months and 470 healthy infants who were formula-fed exclusively. The infants, born between August 1, 1993, and December 31, 1993, were enrolled in WIC and Medicaid. COST AND BENEFIT MEASURES: WIC costs included redeemed WIC vouchers for formula and foods for infants and mothers, plus administrative expenses for 6 months, minus manufacturers' rebates for formula. Benefit was determined from Medicaid expenditures for health care initiated in the first 180 days of each infant's life. STATISTICAL AND BENEFIT-COST ANALYSES: Economic benefit was calculated as net benefit and as benefit-cost ratios. Regression techniques were used to estimate Medicaid expenditures associated with breast-feeding, adjusted for demographic and prenatal care variables. RESULTS: Compared with formula-feeding, breast-feeding each infant enrolled in WIC saved $478 in WIC costs and Medicaid expenditures during the first 6 months of the infant's life, or $161 after consideration of the formula manufacturer's rebate. A Medicaid cost saving of $112 per infant was realized by the breast-feeding cohort, and Medicaid pharmacy reimbursement costs for breast-fed infants were significantly lower-half that of formula-fed infants. APPLICATIONS: The promotion of breast-feeding among low-income populations through nutrition programs such as WIC is an effective cost-containment measure.

Cost-effectiveness of medical nutrition therapy provided by dietitians for persons with non-insulin-dependent diabetes mellitus.

OBJECTIVE: To conduct a cost analysis and cost-effectiveness study based on a randomized clinical trial of basic nutrition care (BC) and practice guidelines nutrition care (PGC) provided by dietitians in outpatient clinics. DESIGN: Subjects with non-insulin-dependent diabetes mellitus (NIDDM) from three states (Minnesota, Florida, Colorado) were randomly assigned to a group receiving BC or a group receiving PGC for a 6-month clinical trial. Along with data about medical and clinical outcomes, data about cost resources were collected. The cost-effectiveness of PGC compared with BC was calculated using per-patient costs and glycemic outcomes for the 6 months of the study. A net cost-effectiveness ratio comparing BC and PGC, including the cost savings resulting from changes in medical therapy, was also calculated. SUBJECTS: The study reports on a sample of 179 subjects with NIDDM between the ages of 38 and 76 years who completed the clinical trial. RESULTS: Patients in the PGC group experienced a mean 1.1 +/- 2.8 mmol/L decrease in fasting plasma glucose level 6 months after entry to the study, for a total per-patient cost of $112. PGC costs included one glycated hemoglobin assay used by the dietitian to evaluate nutrition outcomes. Patients in the BC group experienced a mean 0.4 +/- 2.7 mmol/L decrease, for a total per-patient cost of $42. In the PGC group, 17 persons had changes in therapy, which yielded an average 12-month cost savings prorated for all patients of $31.49. In contrast, in the BC group, 9 persons had changes in therapy, for an average 12-month prorated cost savings of $3.13. Each unit of change in fasting plasma glucose level from entry to the 6-month follow-up can be achieved with an investment of $5.75 by implementing BC or of $5.84 by implementing PGC. If net costs are considered (per-patient costs--cost savings due to therapy changes), the cost-effectiveness ratios become $5.32 for BC and $4.20 for PGC, assuming the medical changes in therapy were maintained for 12 months. APPLICATIONS: These findings suggest that individualized nutrition interventions can be delivered by experienced dietitians with a reasonable investment of resources. Cost-effectiveness is enhanced when dietitians are engaged in active decision making about intervention alternatives based on the patient's needs.

Nutrition risk factors in a home health population.

This cross-sectional study focused on three related questions: (1) What is the prevalence of nutrition-related risk factors among home health care clients? (2) What is the relationship between nutrition-related risk factors and client demographic characteristics? (3) How does the assessment of nutritional status by home health nurses compare with a standardized screening method? One hundred-twenty completed questionnaires, modified from the Nutrition Screening Initiative's "DETERMINE Your Nutritional Health" assessment form, were administered by home health nurses to their clients during a one-week period. Results indicated a high prevalence of nutritional risk factors including the need for meal preparation assistance (71%), shopping difficulties (66%), special diet (55%), and regular meals alone (39%). The number of medical diagnoses was associated with several risk factors. Nurses, when asked to assess their clients, were able to discern a client's nutritional risk relative to others but tended to underestimate the degree of risk. Routine nutrition screening, further training of home health providers and access to dietitians for consultation could minimize poor nutritional status as a complicating factor in the treatment of home care clients.

Dietitian practices for adult outpatients with hypercholesterolemia referred by physicians. The Minnesota Dietitian Survey.

OBJECTIVE: To characterize the physician-to-dietitian referral process and dietitian practice patterns and opinions related to adult outpatients with hypercholesterolemia. DESIGN: Cross-sectional mail survey. PARTICIPANTS: Minnesota dietitians who treat adult outpatients referred by physicians for hypercholesterolemia. MAIN OUTCOME MEASURES: Proportion of patients for whom background information or specific diet instructions were provided by referring physicians and for whom follow-up was recommended and dietary fat content calculated by the dietitians. RESULTS: Completed questionnaires were returned by 216 of 267 eligible dietitians (81% response rate). Respondents saw, on average, 31 referred patients per month, 31% of whom were referred for hypercholesterolemia, 31% for type II diabetes mellitus, and 24% for obesity. For patients referred for hypercholesterolemia, background information was provided by physicians 37% of the time, and specific diet instructions 15% of the time. One or more follow-up visits by the dietitians were recommended for 42% of patients referred for hypercholesterolemia, compared with 60% and 70% of patients referred for diabetes and obesity, respectively. The average number of additional visits within 6 months of the initial consultation recommended by dietitians was 2.0 for patients referred for hypercholesterolemia, 3.5 for patients referred for diabetes, and 6.7 for patients referred for obesity, and the number of visits that occurred was half or less than that recommended. Dietary fat content was calculated by the dietitians for only 25% of patients referred for hypercholesterolemia. CONCLUSIONS: For adult outpatients referred to dietitians for hypercholesterolemia, relevant patient information is usually not provided by referring physicians, the number of follow-up visits is well below what would reasonably be expected to produce significant and sustained eating behavior change, and calculation of dietary fat content is generally not done. More research is needed to determine appropriate nutrition intervention protocols for these patients.

Physicians' expectations for quality nutrition expertise and service in prenatal care.

OBJECTIVES: To identify physicians' needs and expectations related to quality nutrition services in prenatal care; to rank service characteristics by importance in making nutrition referral decisions; and to identify nutrition services physicians would likely add to their practice. DESIGN: We used a market research survey based on the quality service management model. SETTING: We selected prenatal care as the setting because diet plays an important role in the health of the mother and the infant; specific recommendations exist for physicians to provide for nutrition assessment and counseling during pregnancy; and dietitians are not uniformly represented and used in obstetrics practices. SUBJECTS: The survey population consisted of all members of a state obstetrics and gynecology society (N = 352). A return rate of 37% was achieved. ANALYSIS: Data were analyzed using descriptive statistics and qualitative analytic methods. RESULTS: Responses from 130 physicians revealed an expectation that dietitians working in prenatal care must have expertise in prenatal nutrition and skillfully work with patients to achieve compliance with individualized care plans. To be judged excellent, physicians indicated that nutrition care would have to produce desired outcomes in patients. Good communication, documentation, and availability of the dietitian were also important. Financial issues were not of great concern to the respondents. APPLICATION: The findings from this study help pinpoint opportunities for dietitians to develop and strengthen relationships with physician-customers for the provision of quality nutrition service in prenatal care. Important characteristics of quality nutrition service include timely and effective counseling followed by conscientious documentation and feedback to physician.

Prenatal nutrition services: a cost analysis.

The scarcity of information about program costs in relation to quality care prompted a cost analysis of prenatal nutrition services in two urban settings. This study examined prenatal nutrition services in terms of total costs, per client costs, per visit costs, and cost per successful outcome. Standard cost-accounting principles were used. Outcome measures, based on written quality assurance criteria, were audited using standard procedures. In the studied programs, nutrition services were delivered for a per client cost of $72 in a health department setting and $121 in a hospital-based prenatal care program. Further analysis illustrates that total and per client costs can be misleading and that costs related to successful outcomes are much higher. The three levels of cost analysis reported provide baseline data for quantifying the costs of providing prenatal nutrition services to healthy pregnant women. Cost information from these cost analysis procedures can be used to guide adjustments in service delivery to assure successful outcomes of nutrition care. Accurate cost and outcome data are necessary prerequisites to cost-effectiveness and cost-benefit studies.

Prenatal weight gains related to the birth of healthy-sized infants to low-income women.

Prepregnancy weight status and weight gain during pregnancy are major independent variables associated with infant birth weight. This study quantitated the influence of weight gain on birth weight and identified rates and total amounts of weight gain related to the birth of healthy-sized infants to healthy low-income women who entered pregnancy underweight, at normal weight, overweight, or obese. Data used in the study were obtained from randomly sampled prenatal health records from Maternal and Infant Care (MIC) projects in Cleveland and Minneapolis. Subsamples of healthy mothers who delivered healthy-sized infants were identified from each sample, and rates and total amounts of weight gain by prepregnancy weight status group were calculated. There were 384 healthy mother and healthy-sized infant pairs in the Cleveland subsample and 75 such pairs in the Minneapolis sample. Multiple regression analysis revealed that the influence of prenatal weight gain and birth weight varied depending on prepregnancy weight status. Prenatal weight gains related to the birth of healthy-sized infants (newborns with birth weights of 3,000 to 4,500 gm) to healthy mothers in the Cleveland MIC sample averaged 33 lb for underweight, 32 lb for normal weight, 29 lb for overweight, and 19 lb for obese women. Except for obese women, rates and total amount of weight gain associated with the birth of healthy-sized infants were equivalent for the two samples.