Martindale, Robert G.

AbstractThe dual burden of undernutrition and overnutrition requires a greater understanding and commitment to physician training and specialization in nutrition support. Despite the significant healthcare need and existence of organizations focused on nutrition support such as the American Society for Parenteral and Enteral Nutrition (ASPEN), physician involvement in the nutrition care of high‐risk patients remains low. In an ASPEN survey of members, inadequate training among physicians was reported along with significant barriers to involvement in nutrition support, such as insufficient protected time, reduced reimbursement and financial support, inadequate support from administrators or supervisors, as well as a nationwide reduction in number of nutrition support teams. These changes in the healthcare landscape prompted the ASPEN Physician Engagement Committee to develop a critical review focused on domains of nutrition risk assessment, enteral and parenteral access and support, scholarly activities, board certification, administrative responsibilities, education and training opportunities, coding, and reimbursement. The aim of this critical review is to capacitate physicians to engage in nutrition support and enhance their acumen in clinical nutrition to improve patient care and enrich personal and professional development.

Purpose of review Once considered to have only local influences on the gut mucosa, short-chain fatty acids (SCFAs) now appear to have a much wider anti-inflammatory, immune-modulating, systemic effect. This article reviews recent evidence to suggest a much wider clinical application of this valued dietary substrate. Recent findings SCFAs act systemically through stimulation of G protein receptors (GPRs) and inhibition of histone deacetylases (HDACs). SCFAs cause appetite suppression, reduce systemic inflammation, improve insulin sensitivity, increase energy expenditure, promote mitochondrial function, stimulate satiety, reduce blood pressure, and improve cognitive function from various neurologic maladies. Summary Dietary strategies should be implemented to provide this beneficial substrate across a wide spectrum of disease conditions. Use of prebiotic fiber or liquid supplements containing high SCFA-producing organisms should be considered as therapeutic targets for multiple metabolic, immunologic, and neurodegenerative diseases.

Purpose of review The intent of this review is to highlight any recent changes in the delivery of parenteral nutrition to the geriatric population. The percentage of patients in the geriatric age group increases clinical awareness of the potential risks and benefits of appropriate parenteral nutrition delivery, which is crucial to well tolerated and optimum outcomes. Recent findings The major recent finding is the increased awareness of risk of parenteral nutrition in the elderly population. Summary The implications of this very brief review expose the need for further focused studies to better clarify the specifics of parenteral nutrition in this vulnerable ageing population. The importance of nutritional risk assessment cannot be overstated. With the rapidly expanding volume of geriatric population, the need for more data to better understand the delicate balance in parenteral nutrition therapy for both the acute care setting and home parenteral population is needed.

Abstract Advances in treatment of malignancy including novel pharmacologic therapies and surgical interventions has led to significant improvement in survival. As cancer becomes a chronic disease, nutrition interventions play an increasingly important role in short‐ and long‐term outcomes. The current manuscript presents a case of a 66‐year‐old male with new diagnosis of pancreatic cancer diagnosed incidentally in the setting of COVID‐19. Expert panelists in the field of nutrition discuss optimal strategies for diagnosis of malnutrition along with preoperative, perioperative, and postoperative optimization of nutrition. This discussion focuses on the use of probiotics, immune‐modulating nutrition, fish oil, specialized proresolving mediators, and use of enteral and parenteral nutrition support.

Abstract Background High–ω‐6 polyunsaturated fatty acids (PUFAs) are noted to contribute to development of intestinal failure–associated liver disease (IFALD) in home parenteral nutrition (HPN). Fish oil (FO) has been added to latest generation of lipid injectable emulsion (ILE) to increase ω‐3:ω‐6 PUFA ratio; however, appropriate dose of FO to treat IFALD is unknown. Methods After approval of exclusive FO ILE in the US for pediatric patients, we noted 2 adult patients with ongoing IFALD despite transition to mixed‐oil (MO) ILE. They were transitioned to off‐label FO ILE after review of literature regarding use of FO ILE in adult HPN patients was conducted to guide management. Results The first case involves a 40‐year‐old female receiving HPN with IFALD refractory to MO ILE. MO ILE (with 15% FO) was provided at 50 g/d for 3 d/wk and combined with FO ILE at 50 g/d for 4 d/wk. This combination resulted in improvement in liver studies and allowed for decrease in dextrose calories. The second case involves a 49‐year‐old male receiving HPN (secondary to complications of necrotizing pancreatitis) who developed IFALD. FO ILE was used as the sole source of lipids and led to improvement in liver function tests. No evidence of essential fatty acid deficiency was found in either case. Conclusions Current case presentations and review of literature support the use of FO ILE to increase ω‐3 PUFAs in patients with IFALD refractory to MO ILE. Additional research is necessary to delineate the dose of FO ILE necessary to achieve benefit.

Albumin has a number of important physiologic functions, which include maintaining oncotic pressure, transporting various agents (fatty acids, bile acids, cholesterol, metal ions, and drugs), scavenging free oxygen radicals, acting as an antioxidant, and exerting an antiplatelet effect. Hypoalbuminemia in adults, defined by an intravascular albumin level of <3.5 g/dL, is associated with poor postoperative outcomes in patients undergoing surgical intervention. Although the relationship of hypoalbuminemia and poor surgical outcome has been known for many years, the pathophysiology behind the relationship is unclear. Three theoretical constructs might explain this relationship. First, albumin might serve as a nutritional marker, such that hypoalbuminemia represents poor nutritional status in patients who go on to experience poor postoperative outcomes. Second, albumin has its own pharmacologic characteristics as an antioxidant or transporter, and therefore, the lack of albumin might result in a deficiency of those functions, resulting in poor postoperative outcomes. Or third, albumin is known to be a negative acute phase protein, and as such hypoalbuminemia might represent an increased inflammatory status of the patient, potentially leading to poor outcomes. A thorough review of the literature reveals the fallacy of these arguments and fails to show a direct cause and effect between low albumin levels per se and adverse outcomes. Interventions designed solely to correct preoperative hypoalbuminemia, in particular intravenous albumin infusion, do little to change the patient's course of hospitalization. While surgeons may use albumin levels on admission for their prognostic value, they should avoid therapeutic strategies whose main endpoint is correction of this abnormality.

Abstract It is estimated that over 25,000 Americans receive home parenteral nutrition (HPN), mostly because of intestinal failure (IF). Although there is significant variability in the fluid and energy needs of patients receiving HPN, intravenous lipid emulsions (ILEs) are an essential part of the macronutrient composition, serving as an excellent source of non‐protein energy, as well as supplying essential fatty acids. However, the long‐term use of ILEs in particular may be associated with some detrimental health effects, such as intestinal failure associated liver disease (IFALD). Although there is lack of unifying diagnosis, IFALD can present as cholestasis, steatosis, or fibrosis, with a prevalence that ranges between 5% and 43%. The development of IFALD tends to be multifactorial. Risk factors of IFALD can include those related to IF, inflammation/infection, and long‐term parenteral nutrition. Some studies have shown a link between development of IFALD and ILE dose, especially if the dose is >1 g/kg/d, with high ω‐6:ω‐3 polyunsaturated fatty acid (PUFA) ratio and phytosterol content being theorized as some contributing factors. Thus, efforts have been made to use alternative oils (olive oil, medium‐chain triglycerides, and fish oil) to reduce the soybean‐oil content of ILE, which tends to be high in ω‐6 PUFA and phytosterols. Although additional long‐term clinical data are emerging, this strategy, as reviewed in the current manuscript, has shown to provide some benefit in both prevention and treatment of IFALD and other sequelae of HPN.

AbstractBackgroundThe 2018 Lipids in Parenteral Nutrition summit involved a panel of experts in clinical nutrition, lipid metabolism, and pharmacology, to assess the current state of knowledge and develop expert consensus statements regarding the use of intravenous lipid emulsions in various patient populations and clinical settings. The main purpose of the consensus statements is to assist healthcare professionals by providing practical guidance on common clinical questions related to the provision of lipid emulsions as part of parenteral nutrition (PN).MethodsThe summit was designed to allow interactive discussion and consensus development. The resulting consensus statements represent the collective opinion of the members of the expert panel, which was informed and supported by scientific evidence and clinical experience.ResultsThe current article summarizes the key discussion topics from the summit and provides a set of consensus statements designed to complement existing evidence‐based guidelines. Lipid emulsions are a major component of PN, serving as a condensed source of energy and essential fatty acids. In addition, lipids modulate a variety of biologic functions, including inflammatory and immune responses, coagulation, and cell signaling. A growing body of evidence suggests that lipid emulsions containing ω‐3 fatty acids from fish oil confer important clinical benefits via suppression of inflammatory mediators and activation of pathways involved in the resolution of inflammation.ConclusionsThis article provides a set of expert consensus statements to complement formal PN guideline recommendations.

AbstractMalnutrition continues to be highly prevalent in hospitalized and critically ill patients and is associated with significant morbidity and mortality. Additionally, survivors of critical illness have an increased risk for sarcopenia, which leads to weakness and physical debilitation that can persist for years. Nutrition risk assessment tools have been developed and validated in critically ill patients but have limitations. Variables such as body weight, body mass index, weight change, or percentage of food intake can be difficult to obtain in critically ill patients and may be misleading given changes in body composition, such as an increase in body water. Assessment of body composition through new techniques provides a unique opportunity to counter some of these limitations and develop improved methods of nutrition risk assessment based on objective data. The present manuscript provides a review of the most commonly available clinical technology for assessment of body composition (bioimpedance, computed tomography, and ultrasound), including data from trials in critically ill patients highlighting the benefits and weaknesses of each modality.