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Providing in-between meals during dialysis treatment contributes to an adequate protein and energy intake in hemodialysis patients

Inauguration Robert Baars

Powerpoint presentation used by Robert Baars at his inauguration on September 24, 2021 as lecturer 'Climate Smart Dairy Value Chains' at Van Hall Larenstein University of Applied Sciences.

Calculation of protein requirements

Background & aims: In dietary practice, it is common to estimate protein requirements on actual bodyweight, but corrected bodyweight (in cases with BMI <20 kg/m2 and BMI ≥30 kg/m2) and fat free mass (FFM) are also used. Large differences on individual level are noticed in protein requirements using these different approaches. To continue this discussion, the answer is sought in a large population to the following question: Will choosing actual bodyweight, corrected bodyweight or FFM to calculate protein requirements result in clinically relevant differences? Methods: This retrospective database study, used data from healthy persons ≥55 years of age and in- and outpatients ≥18 years of age. FFM was measured by air displacement plethysmography technology or bioelectrical impedance analysis. Protein requirements were calculated as 1) 1.2 g (g) per kilogram (kg) actual bodyweight or 2) corrected bodyweight or 3) 1.5 g per kg FFM. To compare these three approaches, the approach in which protein requirement is based on FFM, was used as reference method. Bland–Altman plots with limits of agreement were used to determine differences, analyses were performed for both populations separately and stratified by BMI category and gender. Results: In total 2291 subjects were included. In the population with relatively healthy persons (n = 506, ≥55 years of age) mean weight is 86.5 ± 18.2 kg, FFM is 51 ± 12 kg and in the population with adult in- and outpatients (n = 1785, ≥18 years of age) mean weight is 72.5 ± 18.4 kg, FFM is 51 ± 11 kg. Clinically relevant differences were found in protein requirement between actual bodyweight and FFM in most of the participants with overweight, obesity or severe obesity (78–100%). Using corrected bodyweight, an overestimation in 48–92% of the participants with underweight, healthy weight and overweight is found. Only in the Amsterdam UMC population, protein requirement is underestimated when using the approach of corrected bodyweight in participants with severe obesity. Conclusion: The three approaches in estimation of protein requirement show large differences. In the majority of the population protein requirement based on FFM is lower compared to actual or corrected bodyweight. Correction of bodyweight reduces the differences, but remain unacceptably large. It is yet unknown which method is the best for estimation of protein requirement. Since differences vary by gender due to differences in body composition, it seems more accurate to estimate protein requirement based on FFM. Therefore, we would like to advocate for more frequent measurement of FFM to determine protein requirements, especially when a deviating body composition is to be expected, for instance in elderly and persons with overweight, obesity or severe obesity.

Outline of a Degrowth Business Model Framework

For future generations to meet their needs, and to close the global inequality gap, we need to degrow. That is we need to reduce resource and energy consumption to bring the economy back into balance with the living world in a way that reduces inequality and improves human well-being (Hickel, 2020a,b). This transition has consequences for business, because instead of boosting sales companies need to encourage consumers to make do with less, avoiding build in obsolescence, extending product lives to slow disposal and replacement, focusing on satisfying ‘needs’ rather than ‘wants’ and reducing overall resource consumption through conscious changes in sales and marketing techniques, new revenue models and innovative technology solutions (Bocken & Short, 2016). Overall, we can say that companies have to rethink their business models, therefore I specifically aim to answer the following research question: what could a degrowth business model framework look like? Degrowth business models (DGMs) are supposed to serve the dual aim of (1) obeying planetary boundaries whilst simultaneously (2) contributing to reducing inequality and increasing well-being. That is companies need to develop value propositions that, on the one hand contribute to absolutely reducing resource and energy consumption, and on the other are aimed at production of protected needs (Di Giulio & Defila, 2021). Since degrowth is considered an authentic and legitimate interpretation of sustainable development, SDGs 12-16 can serve as proxies for obeying planetary boundaries, whilst the remaining SDGs (minus SDG8.1 -economic growth) can be regarded as proxies for well-being and reducing inequality.

Productivity and topsoil quality of young and old permanent grassland

Renewing agricultural grasslands for improved yields and forage quality generally involves eliminating standing vegetation with herbicides, ploughing and reseeding. However, grassland renewal may negatively affect soil quality and related ecosystem services. On clay soil in the north of the Netherlands, we measured grass productivity and soil chemical parameters of ‘young’ (5–15 years since last grassland renewal) and ‘old’ (>20 years since last grassland renewal) permanent grasslands, located as pairs at 10 different dairy farms. We found no significant difference with old permanent grassland in herbage dry matter yield and fertilizer nitrogen (N) response, whereas herbage N yield was lower in young permanent grassland. Moreover, the young grassland soil contained less soil organic matter (SOM), soil organic carbon (C) and soil organic N compared to the old grassland soil. Grass productivity was positively correlated with SOM and related parameters such as soil organic C, soil organic N and potentially mineralizable N. We conclude that on clay soils with 70% desirable grasses (i.e., Lolium perenne and Phleum pratense) or more, the presumed yield benefit of grassland renewal is offset by a loss of soil quality (SOM and N-total). The current practice of renewing grassland after 10 years without considering the botanical composition, is counter-productive and not sustainable.

High protein provision of more than 1.2 g/kg improves muscle mass preservation and mortality in ICU patients

BackgroundICU patients lose muscle mass rapidly and maintenance of muscle mass may contribute to improved survival rates and quality of life. Protein provision may be beneficial for preservation of muscle mass and other clinical outcomes, including survival. Current protein recommendations are expert-based and range from 1.2 to 2.0 g/kg. Thus, we performed a systematic review and meta-analysis on protein provision and all clinically relevant outcomes recorded in the available literature.MethodsWe conducted a systematic review and meta-analyses, including studies of all designs except case control and case studies, with patients aged ≥18 years with an ICU stay of ≥2 days and a mean protein provision group of ≥1.2 g/kg as compared to <1.2 g/kg with a difference of ≥0.2 g/kg between protein provision groups. All clinically relevant outcomes were studied. Meta-analyses were performed for all clinically relevant outcomes that were recorded in ≥3 included studies.ResultsA total of 29 studies published between 2012 and 2022 were included. Outcomes reported in the included studies were ICU, hospital, 28-day, 30-day, 42-day, 60-day, 90-day and 6-month mortality, ICU and hospital length of stay, duration of mechanical ventilation, vomiting, diarrhea, gastric residual volume, pneumonia, overall infections, nitrogen balance, changes in muscle mass, destination at hospital discharge, physical performance and psychological status. Meta-analyses showed differences between groups in favour of high protein provision for 60-day mortality, nitrogen balance and changes in muscle mass.ConclusionHigh protein provision of more than 1.2 g/kg in critically ill patients seemed to improve nitrogen balance and changes in muscle mass on the short-term and likely 60-day mortality. Data on long-term effects on quality of life are urgently needed.