BackgroundCritically ill patients are subject to severe skeletal muscle wasting during intensive care unit (ICU) stay, resulting in impaired short- and long-term functional outcomes and health-related quality of life. Increased protein provision may improve functional outcomes in ICU patients by attenuating skeletal muscle breakdown. Supporting evidence is limited however and results in great variety in recommended protein targets.MethodsThe PRECISe trial is an investigator-initiated, bi-national, multi-center, quadruple-blinded randomized controlled trial with a parallel group design. In 935 patients, we will compare provision of isocaloric enteral nutrition with either a standard or high protein content, providing 1.3 or 2.0 g of protein/kg/day, respectively, when fed on target. All unplanned ICU admissions with initiation of invasive mechanical ventilation within 24 h of admission and an expected stay on ventilator support of at least 3 days are eligible. The study is designed to assess the effect of the intervention on functional recovery at 1, 3, and 6 months following ICU admission, including health-related quality of life, measures of muscle strength, physical function, and mental health. The primary endpoint of the trial is health-related quality of life as measured by the Euro-QoL-5D-5-level questionnaire Health Utility Score. Overall between-group differences will be assessed over the three time points using linear mixed-effects models.DiscussionThe PRECISe trial will evaluate the effect of protein on functional recovery including both patient-centered and muscle-related outcomes.Trial registrationClinicalTrials.gov Identifier: NCT04633421. Registered on November 18, 2020. First patient in (FPI) on November 19, 2020. Expected last patient last visit (LPLV) in October 2023.
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Background & aims: High protein delivery during early critical illness is associated with lower mortality, while energy overfeeding is associated with higher mortality. Protein-to-energy ratios of traditional enteral formulae are sometimes too low to reach protein targets without energy overfeeding. This prospective feasibility study aimed to evaluate the ability of a new enteral formula with a high protein-to-energy ratio to achieve the desired protein target while avoiding energy overfeeding.Methods: Mechanically ventilated non-septic patients received the high protein-to-energy ratio nutrition during the first 4 days of ICU stay (n = 20). Nutritional prescription was 90% of measured energy expenditure. Primary endpoint was the percentage of patients reaching a protein target of ≥1.2 g/kg ideal body weight on day 4. Other endpoints included a comparison of nutritional intake to matched historic controls and the response of plasma amino acid concentrations. Safety endpoints were gastro-intestinal tolerance and plasma urea concentrations. Results: Nineteen (95%) patients reached the protein intake target of ≥1.2 g/kg ideal body weight on day 4, compared to 65% in historic controls (p = 0.024). Mean plasma concentrations of all essential amino acids increased significantly from baseline to day 4. Predefined gastro-intestinal tolerance was good, but unexplained foul smelling diarrhoea occurred in two patients. In one patient plasma urea increased unrelated to acute kidney injury. Conclusions: In selected non-septic patients tolerating enteral nutrition, recommended protein targets can be achieved without energy overfeeding using a new high protein-to-energy ratio enteral nutrition.
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ObjectiveTo identify malnutrition assessment methods in cancer patients and assess their content validity based on internationally accepted definitions for malnutrition.Study Design and SettingSystematic review of studies in cancer patients that operationalized malnutrition as a variable, published since 1998. Eleven key concepts, within the three domains reflected by the malnutrition definitions acknowledged by European Society for Clinical Nutrition and Metabolism (ESPEN) and the American Society for Parenteral and Enteral Nutrition (ASPEN): A: nutrient balance; B: changes in body shape, body area and body composition; and C: function, were used to classify content validity of methods to assess malnutrition. Content validity indices (M-CVIA–C) were calculated per assessment method. Acceptable content validity was defined as M-CVIA–C ≥ 0.80.
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De ontwikkeling van de Verpleegkundige Revalidatierichtlijn Beroerte heeft geresulteerd in uitwerking van elf themas met in totaal 210 aanbevelingen die verpleegkundigen kunnen gebruiken in de dagelijkse zorg van patiënten met een beroerte. Met een groot deel van deze aanbevelingen kunnen verpleegkundigen meteen aan de slag in de praktijk, maar voor een aantal aanbevelingen zou een verdere vertaalslag moeten plaatsvinden naar de praktijk. In totaal 71 aanbevelingen zijn van redelijk hoog niveau (A of B). Meer dan de helft van de aanbevelingen (138) is van lagere niveaus. Uiteraard is er behoefte aan verdere ontwikkeling van verschillende interventies en is verder onderzoek nodig naar effecten van deze interventies. Door middel van de Verpleegkundige Revalidatierichtlijn Beroerte kunnen verpleegkundigen effectiever en efficiënter handelen. Op deze wijze zet deze richtlijn een nieuwe standaard voor verpleegkundigen en mogelijkerwijze andere professionals die dagelijks zorgen voor patiënten met een beroerte.
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Background: Parents influence their children’s nutrition behavior. The relationship between parental influences and children’s nutrition behavior is often studied with a focus on the dyadic interaction between the parent and the child. However, parents and children are part of a broader system: the family. We investigated the relationship between the family nutrition climate (FNC), a family-level concept, and children’s nutrition behavior. Methods: Parents of primary school-aged children (N = 229) filled in the validated family nutrition climate (FNC) scale. This scale measures the families’ view on the consumption of healthy nutrition, consisting of four di erent concepts: value, communication, cohesion, and consensus. Parents also reported their children’s nutrition behavior (i.e., fruit, vegetable, water, candy, savory snack, and soda consumption). Multivariate linear regression analyses, correcting for potential confounders, were used to assess the relationship between the FNC scale (FNC-Total; model 1) and the di erent FNC subscales (model 2) and the child’s nutrition behavior. Results: FNC-Total was positively related to fruit and vegetable intake and negatively related to soda consumption. FNC-value was a significant predictor of vegetable (positive) and candy intake (negative), and FNC-communication was a significant predictor of soda consumption (negative). FNC-communication, FNC-cohesion, and FNC-consensus were significant predictors (positive, positive, and negative, respectively) of water consumption. Conclusions: The FNC is related to children’s nutrition behavior and especially to the consumption of healthy nutrition. These results imply the importance of taking the family-level influence into account when studying the influence of parents on children’s nutrition behavior. Trial registration: Dutch Trial Register NTR6716 (registration date 27 June 2017, retrospectively registered), METC163027, NL58554.068.16, Fonds NutsOhra project number 101.253.
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Under- and overfeeding in Intensive Care Units (ICUs) are linked to prolonged hospitalisation, increased morbidity, and elevated mortality. This study investigates whether ICU patients were optimally nourished according to the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines. Methods: A cohort of 158 COVID-19 patients requiring intensive care for severe respiratory failure, necessitating a nuanced approach to nutritional support, was analysed. Nutritional status was determined regarding kilocalories and protein using the Energy Expenditure derived from ventilator-measured VCO2 and the adjusted Weir equation, and data on intake through enteral feeding was used. The study included ventilated patients hospitalised for over five days without Extra Corporeal Life Support (ECLS) and receiving enteral nutrition. Associations between mortality and (i) calorie intake and (ii) protein intake were examined using Chi-Square statistics. Results: Conforming to the ESPEN guidelines, 45% of patients were malnourished, and 21% were over-nourished in kilocalories. Additionally, 61% were malnourished, and 16% were over-nourished in protein. The distribution between the groups of survivors and deceased relative to each of the groups well nourished, malnourished, and over-nourished was not statistically different (p = 0.21). The protein distribution among survivors and deceased groups was not statistically different (p = 0.67) regarding correct, insufficient, or excessive protein intake. Conclusions: Based on ESPEN guidelines, most ICU patients were inadequately nourished in kilocalories and protein. However, no significant survival differences were observed across groups with varying nutritional adequacy. Further research is recommended to explore the implications of nutritional interventions in critically ill patients.
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BackgroundIncreased protein provision might ameliorate muscle wasting and improve long-term outcomes in critically ill patients. The aim of the PRECISe trial was to assess whether higher enteral protein provision (ie, 2·0 g/kg per day) would improve health-related quality of life and functional outcomes in critically ill patients who were mechanically ventilated compared with standard enteral protein provision (ie, 1·3 g/kg per day).MethodsThe PRECISe trial was an investigator-initiated, double-blinded, multicentre, parallel-group, randomised controlled trial in five Dutch hospitals and five Belgian hospitals. Inclusion criteria were initiation of invasive mechanical ventilation within 24 h of intensive care unit (ICU) admission and an expected duration of invasive ventilation of 3 days or longer. Exclusion criteria were contraindications for enteral nutrition, moribund condition, BMI less than 18 kg/m2, kidney failure with a no dialysis code, or hepatic encephalopathy. Patients were randomly assigned to one of four randomisation labels, corresponding with two study groups (ie, standard or high protein; two labels per group) in a 1:1:1:1 ratio through an interactive web-response system. Randomisation was done via random permuted-block randomisation in varying block sizes of eight and 12, stratified by centre. Participants, care providers, investigators, outcome assessors, data analysts, and the independent data safety monitoring board were all blinded to group allocation. Patients received isocaloric enteral feeds that contained 1·3 kcal/mL and 0·06 g of protein/mL (ie, standard protein) or 1·3 kcal/mL and 0·10 g of protein/mL (ie, high protein). The study-nutrition intervention was limited to the time period during the patient's ICU stay in which they required enteral feeding, with a maximum of 90 days. The primary outcome was EuroQoL 5-Dimension 5-level (EQ-5D-5L) health utility score at 30 days, 90 days, and 180 days after randomisation, adjusted for baseline EQ-5D-5L health utility score. This trial was registered with ClinicalTrials.gov (NCT04633421) and is closed to new participants.FindingsBetween Nov 19, 2020, and April 14, 2023, 935 patients were randomly assigned. 335 (35·8%) of 935 patients were female and 600 (64·2%) were male. 465 (49·7%) of 935 were assigned to the standard protein group and 470 (50·3%) were assigned to the high protein group. 430 (92·5%) of 465 patients in the standard protein group and 419 (89·1%) of 470 patients in the high protein group were assessed for the primary outcome. The primary outcome, EQ-5D-5L health utility score during 180 days after randomisation (assessed at 30 days, 90 days, and 180 days), was lower in patients allocated to the high protein group than in those allocated to the standard protein group, with a mean difference of –0·05 (95% CI –0·10 to –0·01; p=0·031). Regarding safety outcomes, the probability of mortality during the entire follow-up was 0·38 (SE 0·02) in the standard protein group and 0·42 (0·02) in the high protein group (hazard ratio 1·14, 95% CI 0·92 to 1·40; p=0·22). There was a higher incidence of symptoms of gastrointestinal intolerance in patients in the high protein group (odds ratio 1·76, 95% CI 1·06 to 2·92; p=0·030). Incidence of other adverse events did not differ between groups.InterpretationHigh enteral protein provision compared with standard enteral protein provision resulted in worse health-related quality of life in critically ill patients and did not improve functional outcomes during 180 days after ICU admission.
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Rationale: Inadequate operationalisation of the multidimensial concept of malnutrition may result in inadequate evaluation of nutritional status. In this review we aimed to assess content validity of methods used to assess malnutrition in cancer patients, according to domains directly derived from European Society for Clinical Nutrition and Metabolism (ESPEN) and American Society for Parenteral and Enteral Nutrition (ASPEN) definitions for malnutrition. Methods: Studies on malnutrition in adult cancer patients published between 1999 and 2013 were considered eligible. Methods to assess malnutrition were classified using 13 indicators within three domains that the malnutrition definitions of ESPEN and ASPEN have in common: A) Nutrient balance; B) Changes in body shape, body area and body composition; and C) Body function.Content validity index per method (M-CVIA-C) was calculated by averaging indicator scores weighted per domain, quantifying to what extent the methods covered the construct of malnutrition. Acceptable content validity was defined as M-CVIA-C ≥0.80.Results: 40 Different methods within 166 articles were identified. Median M-CVIA-C was 0.22 (interquartile range: 0.08-0.53). None of the methods reached M-CVIA-C=0.80. Mini Nutritional Assessment (MNA; M-CVIA-C=0.75), Nutritional Screening Questionnaire (NSQ; M-CVIA-C=0.56) and Scored Patient-Generated Subjective Global Assessment (PG-SGA; M-CVIA-C=0.53) were responsible for the top 25% of M-CVIA-C scores. Conclusion: Content validity of methods that assess malnutrition in cancer patients varies widely and is unacceptable in terms of M-CVIA-C. MNA, NSQ and PG-SGA showed highest scores in terms of content validity. Conflict of interest: None.
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PURPOSE: The objectives of this review are to summarize the current practices and major recent advances in critical care nutrition and metabolism, review common beliefs that have been contradicted by recent trials, highlight key remaining areas of uncertainty, and suggest recommendations for the top 10 studies/trials to be done in the next 10 years.METHODS: Recent literature was reviewed and developments and knowledge gaps were summarized. The panel identified candidate topics for future trials in critical care nutrition and metabolism. Then, members of the panel rated each one of the topics using a grading system (0-4). Potential studies were ranked on the basis of average score.RESULTS: Recent randomized controlled trials (RCTs) have challenged several concepts, including the notion that energy expenditure must be met universally in all critically ill patients during the acute phase of critical illness, the routine monitoring of gastric residual volume, and the value of immune-modulating nutrition. The optimal protein dose combined with standardized active and passive mobilization during the acute phase and post-acute phase of critical illness were the top ranked studies for the next 10 years. Nutritional assessment, nutritional strategies in critically obese patients, and the effects of continuous versus intermittent enteral nutrition were also among the highest-ranking studies.CONCLUSIONS: Priorities for clinical research in the field of nutritional management of critically ill patients were suggested, with the prospect that different nutritional interventions targeted to the appropriate patient population will be examined for their effect on facilitating recovery and improving survival in adequately powered and properly designed studies, probably in conjunction with physical activity.
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Background. One of the stakeholders in tackling the rise and health consequences of overweight and obesity is the general practice physician (GP). GPs are in a good position to inform and give nutrition guidance to overweight patients. Objective. Assessment of working mechanism of determinants of the nutrition guidance practice: noticing patients’ overweight and guidance of treatment by GPs [linear analysis of structural relations (LISREL) path model] in a longitudinal study. Methods. This longitudinal study measured data in 1992, 1997 and 2007. The 1992 LISREL path model (Hiddink GJ, Hautvast J, vanWoerkumCMJ, Fieren CJ, vantHofMA. Nutrition guidance by primary-care physicians: LISREL analysis improves understanding. Prev Med 1997; 26: 29–36.) demonstrated that ‘noticing patients’ overweight and guidance of treatment’ was directly and indirectly influenced by predisposing factors, driving forces and perceived barriers. This article defines and discusses the path analysis of the 2007 data (compared with 1997). Results. This analysis shows both similarity and differences inworking mechanism of determinants of noticing patients’ overweight and guidance of treatment between 1997 and 2007. The backbone of themechanism with four predisposing factors is the similarity. The number of driving forces and of paths through intermediary factors to the dependent variable constitutes the difference. Conclusions. The backbone of the working mechanism of determinants of the nutrition guidance practice: noticing patients’ overweight and guidance of treatment by GPs was similar in 2007 and 1997. The influence of GPs task perception on noticing patients’ overweight and guidance of treatment considerably increased in 2007 compared to 1997. The longitudinal character of this article gives a strong practice-based evidence for weight management by GPs.
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