Nutrition in Clinical Practice

The purpose of this article is to present the application of patient-centered care and clinical ethics into nutrition practice, illustrate the process in a case study, and promote change in the current healthcare clinical ethics model. Nutrition support clinicians have an opportunity to add another dimension to their practice with the incorporation of patient-centered care and clinical ethics. This represents a culture change for healthcare professionals, including nutrition support clinicians, patients and their family. All of these individuals are stakeholders in the process and have the ability to modify the current healthcare system to improve communication and facilitate a change by humanizing nutrition support practice. Nutrition support is a medical, life-sustaining treatment, and the use of this therapy requires knowledge by the nutrition support clinician of patient-centered care concepts, preventive clinical ethics, religion/spirituality and cultural diversity, palliative care team role, and advance care planning. Integrating these into the practice of nutrition support is an innovative approach and results in new knowledge that requires a change in the culture of care and engagement and empowerment of the patient and their family in the process. This is more than a healthcare issue; it involves a social/family conversation movement that will be enhanced by the nutrition support clinician’s participation.

Traditionally, registered dietitians (RD) have not had order writing privileges in most patient-care facilities and rely on physicians to implement their recommendations. Research has demonstrated that this model results in a high percentage of RD recommendations not being ordered. Timely nutrition interventions are important due to the prevalence of malnutrition in the hospital setting and when RD recommendations are implemented, important outcomes are improved. In addition, several studies have demonstrated that when RDs have order writing privileges, which allows more assurance that an intervention will occur and timely interventions, improved outcomes, such as improved nutrition status, better management of electrolytes and glycemic control, reaching goal calories sooner, reduction in inappropriate parenteral nutrition use, cost savings, and less error with electronic order entry. The process for implementation and outcomes of an RD order writing program at 1 large, urban, tertiary medical center is described. The program has been successful, but the implementation process required multiple years and ongoing monitoring through data collection to ensure success. RDs interested in order writing privileges must consider federal and state regulations, their individual scope of practice (relevant training and competency assessment), and how to obtain approval from the appropriate hospital governing committees. RDs who obtain order writing privileges must understand “with privilege comes responsibility” and should plan to conduct outcomes research to promote the value and acceptance of RD order writing by regulatory agencies at all levels and hospital leaders, for instance physicians and administrators.

Reimbursement for home parenteral nutrition (HPN) is important for nutrition support clinicians to understand. This intent of this review is to provide nutrition support clinicians knowledge on navigating through the structured requirements of diagnosis driven billing to receive reimbursement for services related to HPN, provide information on coding, provide practical tips for surviving a Medicare billing audit, and discuss challenges of Medicare guidelines seen in clinical practice.

There may be a correlation in critically ill children between the accuracy of estimated energy requirement and infection, mortality, and length of stay. Historically, energy needs were estimated using predictive equations with stress factor adjustments. The purpose of this review is to evaluate the evidence for indirect calorimetry, predictive equations, and other clinical indicators (ie, patient outcomes) to estimate energy requirements of the postoperative, critically ill, cardiac infant. Consistent with current guidelines, indirect calorimetry provides the best estimate of energy requirements for critically ill children. Predictive equations are unreliable, either over- or underestimate energy requirements, and do not take into account the metabolic changes that occur in the postoperative cardiac infant. To address the changing metabolic state throughout the course of illness, clinicians need to individualize recommendations by implementing frequent indirect calorimetry measurements at bedside. Actual energy delivery to the postoperative cardiac surgery child in the pediatric intensive care unit (PICU) can be further hindered by many procedural and patient barriers. The provision of appropriate caloric requirements may help clinicians correct the metabolic state and promote recovery and anabolism. Therefore, optimizing nutrition intake of the postoperative, cardiac surgical child requires a paradigm shift toward individualized nutrition prescription, in the context of a PICU-specific feeding algorithm.

Branched-chain amino acids (BCAAs) constituting of valine, leucine, and isoleucine act as both substrates of proteins and as key regulators for various nutrient metabolisms. Patients with liver cirrhosis frequently lack sufficient BCAAs and therefore suffer from various metabolic disorders. Hepatic encephalopathy (HE) is a severe metabolic disorder with neurologic manifestations such as flapping tremors and coma in patients with liver cirrhosis. In addition, a mild form of HE known as minimal HE (MHE) is an important social issue because it occurs in up to 80% of patients with chronic liver disease and affects prognosis and activities of daily living, possibly resulting in falls and motor vehicle accidents. Although HE/MHE can be caused by various pathological conditions, including in an accumulation of mercaptans, short-chain fatty acids, and alterations in the gut flora, hyperammonemia has also been implicated in an important pathogenesis of HE/MHE. Besides urea cycle of liver, ammonia can be detoxified in the skeletal muscles by the amidation process for glutamine synthesis using BCAAs. Thus, BCAA supplementation may enhance detoxification of ammonia in skeletal muscle and may be a possible therapeutic strategy for HE/MHE. In this review, we summarize the clinical impacts of BCAA supplementation on HE/MHE and discuss possible mechanisms for a BCAA-induced improvement of HE/MHE. Furthermore, we present some modifications of oral BCAA therapy for improvement of efficacy in HE treatment. We also briefly describe pleiotropic benefits of BCAAs on life-threatening events and overall prognosis in patients with liver cirrhosis.

In recent years, fecal microbiota transplantation (aka fecal transplantation, fecal bacteriotherapy, FMT) has become increasing utilized to treat recurrent and refractory Clostridium difficile infection (CDI). Almost 600,000 cases of CDI occur each year in the United States. Of these, an estimated 15,000 patients have a recurrence. The management of recurrent disease has been challenging for patients and clinicians. Increasingly, FMT has been recognized as an effective option for these patients. This article explores why FMT has reemerged as a practical therapeutic modality. In the process, the logistics by which the procedure is performed and the factors that may affect quality, safety, and patient outcomes will be described.

Background: The purpose of this study was to compare 2 methods (syringe and spoon methods) of removing the fat from the low-fat milk portion and compare 3 methods (refrigerated centrifuge, nonrefrigerated centrifuge, and refrigeration method) of separating breast milk into the fat and low-fat milk components. Methods: Human milk was divided into 24 aliquots using the 3 separating methods, and 2 methods (syringe, spoon) were compared to extract the low-fat milk. Thirty-one human milk samples were separated into fatty and low-fat milk layers using 3 methods: 24-hour refrigerator storage (2°C), centrifuged at 3000 rpm for 15 minutes at room temperature, and spun in the refrigerated-centrifuge at 3000 rpm for 15 minutes at 2°C. After 24 hours of refrigeration, a syringe was used to remove the low-fat milk. Triglycerides were analyzed before and after separation and removal methods. Results: For fat removal, the syringe method (1.2 g/dl, 95% confidence interval [CI], 1.1-1.4, fat content) left 34% less residual fat compared to the spoon method (1.9 g/dl, 95% CI, 1.5-2.3); this difference did not reach statistical significance (P = .065). For fat separation, the centrifuge methods (mean: 1.0 g/dl, 95% CI, 0.8-1.1) left significantly less residual fat than the refrigerator method (3.4 g/dl, 95% CI, 3.0-3.7; P < .0001). Conclusion: Using the syringe vs a spoon at removing the milk from the fat, although not statistically significant, was likely of clinical importance. A centrifuge was more effective at separating the fat in human milk.

Background: Barbiturate coma may have a significant effect on metabolic rate, but the phenomenon is not extensively studied. The primary purpose of the current study was to compare the metabolic rate of general critical care patients with those requiring barbiturate coma. A secondary purpose was to evaluate the accuracy of the Penn State prediction equation between these 2 groups of patients. Materials and Methods: Indirect calorimetry was used to measure the resting metabolic rate of mechanically ventilated, critically ill patients in a barbiturate coma and those of similar height, weight, and age but not in a barbiturate coma. Measurements of resting metabolic rate were compared with predictions using the Penn State equation accounting for body size, body temperature, and minute ventilation. Results: The barbiturate coma group had a lower resting metabolic rate than the control group that remained lower even after adjustment for predicted healthy metabolic rate and maximum body temperature (1859 ± 290 vs 2037 ± 289 kcal/d, P = .020). When minute ventilation was also included in the analysis, the resting metabolic rate between the groups became statistically insignificant (1929 ± 229 vs 2023 ± 226 kcal/d, P = .142). The Penn State equation, which uses these variables, was accurate in 73% of the control patients and also the barbiturate coma patients. Conclusion: Resting metabolic rate is moderately reduced in barbiturate coma, but the decrease is out of proportion with changes in body temperature. However, if both body temperature and minute ventilation are considered, then the change is predictable.

Background: L-carnosine (CAR) is an endogenous dipeptide. We aimed to determine the effects of CAR and its zinc complex polaprezinc (PLZ) on pressure ulcer healing in institutionalized long-term care patients. Methods: This study was a nonrandomized controlled trial with a maximum 4-week follow-up. Forty-two patients with stage II–IV pressure ulcers for 4 or more weeks were allocated to 1 of 3 groups in order of recruitment: the control group (n = 14) was untreated, the PLZ group (n = 10) orally received 150 mg/d PLZ (containing 116 mg CAR and 34 mg zinc), and the CAR group (n = 18) orally received 116 mg/d CAR. Pressure ulcer severity was measured weekly using the Pressure Ulcer Scale for Healing (PUSH) score. Results: At baseline, no significant differences were found among groups in demographic and nutrition parameters and pressure ulcer characteristics (severity, size, and staging). After 4 weeks, the rate of pressure ulcer healing, assessed by the mean weekly improvement in PUSH score, was significantly greater in the CAR (1.6 ± 0.2, P = .02) and PLZ groups (1.8 ± 0.2, P = .009) than in the control group (0.8 ± 0.2). The difference between the CAR and PLZ groups was not significant (P = .73). Actual dietary intakes over this period did not differ significantly among groups. Conclusions: Our results suggest that CAR and PLZ may almost equally accelerate pressure ulcer healing during 4 weeks. The results need confirmation by randomized controlled trials with larger sample sizes.

Background: The Academy of Nutrition and Dietetics recommends the use of indirect calorimetry for calculating caloric targets for weight loss in obese youth. Practitioners typically use predictive equations since indirect calorimetry is often not available. The objective of this study was to compare measured resting energy expenditure (MREE) with that estimated using published predictive equations in obese pediatric patients. Material and Methods: Youth aged 7 to 18 years (n = 80) who were referred to a university-based healthy weight clinic and who were greater than the 95th percentile BMI for age and gender participated. MREE was measured via a portable indirect calorimeter. Predicted energy expenditure (pEE) was estimated using published equations including those commonly used in children. pEE was compared to the MREE for each subject. Absolute mean difference between MREE and pEE, mean percentage accuracy, and mean error were determined. Results: Mean percentage accuracy of pEE compared with MREE varied widely, with the Harris-Benedict, Lazzer, and Molnar equations providing the greatest accuracy (65%, 61%, and 60%, respectively). Mean differences between MREE and equation-estimated caloric targets varied from 197.9 kcal/day to 307.7 kcal/day. Conclusions: The potential to either overestimate or underestimate calorie needs in the clinical setting is significant when comparing EE derived from predictive equations with that measured using portable indirect calorimetry. While our findings suggest that the Harris-Benedict equation has improved accuracy relative to other equations in severely obese youth, the potential for error remains sufficiently great to suggest that indirect calorimetry is preferred.