Annals of Clinical Nutrition and Metabolism

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Volume 16 (3); December 2024

Guideline

Nutritional support for critically ill patients by the Korean Society for Parenteral and Enteral Nutrition — part I: a clinical practice guideline: Seung Hwan Lee, Jae Gil Lee, Min Kwan Kwon, Jiyeon Kim, Mina Kim, Jeongyun Park, Jee Young Lee, Ye Won Sung, Bomi Kim, Seong Eun Kim, Ji Yoon Cho, A Young Lim, In Gyu Kwon, Miyoung Choi, KSPEN Guideline Committee; Ann Clin Nutr Metab 2024;16(3):89-111. Published online December 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.3.89

Abstract PDF Supplementary Material: Purpose: Nutritional support for adult critically ill patients is essential due to the high risk of malnutrition, which can lead to severe complications. This paper aims to develop evidence-based guidelines to optimize nutritional support in intensive care units (ICUs).
Methods: The Grading Recommendations, Assessment, Development and Evaluation process was used to develop and summarize the evidence on which the recommendations were based. Clinical outcomes were assessed for seven key questions.
Results: We recommend the following: (1) initiate enteral nutrition (EN) within 48 hours after treatment as it is associated with improved outcomes, including reduced infection rates and shorter ICU stays; (2) early EN is preferred over early parenteral nutrition due to better clinical outcomes; (3) the use of supplementary parenteral nutrition to meet energy targets during the first week of ICU admission in patients receiving early EN is conditionally recommended based on patient-specific needs; (4) limited caloric support should be supplied to prevent overfeeding and related complications, particularly in the early phase of critical illness; (5) higher protein intake is suggested to improve clinical outcomes, such as muscle preservation and overall recovery; (6) additional enteral or parenteral glutamine is conditionally recommended against due to the lack of significant benefit and potential harm; and (7) fish oil-containing lipid emulsions is conditionally recommended due to their potential to enhance clinical outcomes, including reduced infection rates and shorter ICU stays.
Conclusion: These evidence-based recommendations can improve clinical outcomes and support healthcare providers in making informed decisions about nutritional interventions in the ICU.

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Reviews

Mental health and micronutrients: a narrative review: Hyun Wook Baik; Ann Clin Nutr Metab 2024;16(3):112-119. Published online December 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.3.112

Abstract PDF: Purpose: It aims to summarizes the evidence for the association between specific individual nutrients and mental disorders, focusing on vitamin B12 and related B vitamins, vitamin D, probiotics, and zinc.
Current concept: Vitamin D deficiency is linked to depression, anxiety, and cognitive decline. Vitamin D enhances serotonin synthesis, has anti-inflammatory and neuroprotective effects, and regulates the hypothalamic-pituitary-adrenal axis and circadian rhythms. Vitamin B12 deficiency causes neurological dysfunction, mood disorders, cognitive decline, and psychotic symptoms, especially in the elderly. Vitamin B12 is involved in myelin formation, neurotransmitter synthesis, and preventing homocysteine-related neurodegeneration. Zinc deficiency affects neurotransmitters, neurogenesis, and antioxidant function, contributing to depression, anxiety, and cognitive impairment. Zinc supplementation improves symptoms and increases brain-derived neurotrophic factor levels. The gut-brain axis involves bidirectional communication between the gut microbiome and the central nervous system via the vagus nerve, enteric nervous system, immune system, and neuroendocrine pathways. Probiotics can modulate the gut microbiome to improve depression, anxiety, stress response, and cognitive function by influencing neurotransmitter production, reducing inflammation, and supporting the gut-brain connection.
Conclusion: Nutritional interventions, including vitamin D, B12, zinc, and probiotics, show promise as adjunctive therapies or preventive strategies for mental disorders. These nutrients have specific mechanisms of action on brain function and the gut-brain axis. Further research is needed to establish optimal dosage, timing, and administration methods for these nutritional approaches in supporting mental health.

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Changes in perceptions of taste after bariatric surgery: a narrative review: Young Suk Park; Ann Clin Nutr Metab 2024;16(3):120-124. Published online December 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.3.120

Abstract PDF: Purpose: Bariatric surgery effectively treats severe obesity, leading to significant weight loss and improved comorbidities. However, many patients experience postoperative alterations in taste perception, affecting food selection and eating behavior. This narrative review examines the current understanding of taste perception changes following bariatric surgery, including patterns, potential mechanisms, impact on weight loss outcomes, and implications for patient care.
Current concept: Changes in taste perception are frequently reported after bariatric procedures, with prevalence rates from 36% to 72%. Common alterations involve decreased preference and increased sensitivity to sweet and fatty tastes, potentially leading to reduced calorie intake and healthier food choices. Persistence of these changes varies and may depend on surgery type, with Roux-en-Y gastric bypass patients often experiencing more substantial effects than sleeve gastrectomy patients. Potential mechanisms include alterations in gut hormone secretion (e.g., GLP-1, peptide YY, ghrelin), modifications in neural pathways (e.g., vagus nerve), and shifts in the gut microbiome. These factors may collectively influence taste sensitivity and preferences, contributing to weight loss outcomes. Altered reward processing may reduce the appeal of high-calorie foods.
Conclusion: Alterations in taste perception are common after bariatric surgery and may significantly impact dietary behaviors, weight loss, and quality of life. While exact mechanisms are not fully understood, changes in gut hormones, neural pathways, and microbiota are likely involved. Patient counseling and postoperative management of bariatric surgery patients should address potential changes in taste. Further research is needed to elucidate the long-term impacts of taste alterations on weight-loss maintenance and nutritional status.

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Original Articles

Incidence and risk factors of nonalcoholic fatty liver disease after pancreaticoduodenectomy in Korea: a multicenter retrospective cohort study: Chang-Sup Lim, Hongbeom Kim, In Woong Han, Won-Gun Yun, Eunchae Go, Jaewon Lee, Kyung Chul Yoon, So Jeong Yoon, Sang Hyun Shin, Jin Seok Heo, Yong Chan Shin, Woohyun Jung; Ann Clin Nutr Metab 2024;16(3):125-133. Published online December 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.3.125

Abstract PDF: Purpose: This study aimed to investigate the incidence, risk factors, and clinical course of nonalcoholic fatty liver disease (NAFLD) following pancreaticoduodenectomy, focusing on the role of adjuvant chemotherapy and other metabolic changes.
Methods: A retrospective analysis was conducted on 189 patients who underwent pancreaticoduodenectomy between 2013 and 2016. NAFLD was diagnosed using computed tomography (CT) imaging, defined as a liver-to-spleen attenuation ratio <0.9. Sarcopenia and sarcopenic obesity were assessed using preoperative CT scans. Logistic regression analysis was performed to identify risk factors for NAFLD development.
Results: The cumulative incidence of NAFLD increased over time, with rates of 15.9% at one year, 20.4% at three years, and 35.2% at five years post-pancreaticoduodenectomy. Adjuvant chemotherapy was identified as the only significant independent predictor of NAFLD development (odds ratio, 2.74; 95% confidence interval, 1.16-6.70; P=0.023). No significant associations were found between NAFLD and pancreatic enzyme replacement therapy (PERT), sarcopenia, or sarcopenic obesity. Serial analysis of NAFLD status in long-term survivors revealed dynamic changes, with some patients experiencing spontaneous remission or recurrence.
Conclusion: NAFLD is a common, progressive complication following pancreaticoduodenectomy, particularly in patients receiving adjuvant chemotherapy. Although no significant associations with PERT or sarcopenia were observed, these areas warrant further investigation. Long-term monitoring and targeted management strategies are recommended to address NAFLD in this population. Future prospective studies are needed to elucidate the natural history and contributing factors of NAFLD after pancreaticoduodenectomy.

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Perioperative nutritional practice of surgeons in Korea: a survey study: Ji-Hyeon Park, Mi Ran Jung, Sang Hyun Kim, Hongbeom Kim, Gyeongsil Lee, Jae-Seok Min, Heung-Kwon Oh, Jung Hoon Bae, Yoona Chung, Dong-Seok Han, Seung Wan Ryu, The External Relation Committee of the Korean Society of Surgical Metabolism and Nutrition; Ann Clin Nutr Metab 2024;16(3):134-148. Published online December 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.3.134

Abstract PDF Supplementary Material: Purpose: Enhanced recovery after surgery (ERAS) protocols advocate reduced fasting and early nutrition to improve recovery in surgical patients. However, data on ERAS implementation among Korean surgeons performing major abdominal surgeries remain sparse.
Methods: A survey conducted by the External Relation Committee of the Korean Society of Surgical Metabolism and Nutrition assessed perioperative nutritional practices among 389 Korean general surgeons from February to September 2023. The survey covered preoperative fasting, carbohydrate drinks, nasogastric tube use, postoperative dietary progression, parenteral nutrition (PN), and oral supplements, yielding 551 responses stratified by specialty.
Results: More than 80% of respondents practiced “midnight NPO (Nil Per Os)” fasting, often at the anesthesiology department’s request, while 70%–80% reported no use of preoperative carbohydrate drinks. Most surgeons began dietary progression with water on postoperative day one, advancing to a liquid or soft diet by day two. PN was routinely prescribed by 49% of respondents, with a common dosage of 1,000–1,500 kcal/d. Oral supplements were selectively provided, with 21% of surgeons prescribing them universally.
Conclusion: The results reveal significant variability in perioperative nutrition practices across Korean surgical specialties, with many adhering to traditional practices despite ERAS guidelines. These findings highlight a need for standardized guidelines in Korea to optimize perioperative nutritional support and improve patient recovery outcomes following major abdominal surgeries.

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The impact of nutritional intervention by a nutrition support team on extrauterine growth restriction in very low birth weight infants in Korea: a retrospective cohort study: Seung Yun Lee, Hye Su Hwang, Waonsun Im, Hyojoung Kim, Mi Lim Chung; Ann Clin Nutr Metab 2024;16(3):149-157. Published online December 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.3.149

Abstract PDF: Purpose: Achieving proper weight gain through adequate nutrition is critically important in very low birth weight (VLBW) infants. Despite recent active nutritional interventions, growth restriction is still common in VLBW infants. We aimed to determine whether nutritional intervention by a nutrition support team (NST) mitigated extrauterine growth restriction (EUGR) in VLBW infants.
Methods: We retrospectively reviewed the medical records of VLBW infants admitted to Haeundae Paik Hospital between March 2010 and February 2024. EUGR was defined as a decrease in the weight-for-age-z-score>1.2 from birth to the postconceptional age of 36 weeks, using Fenton growth charts.
Results: Among the 603 enrolled VLBW infants, 434 (72.0%) were diagnosed with EUGR. When comparing the control and nutritional intervention groups, the incidence of EUGR was significantly lower in infants in the intervention group (80.6% vs. 62.8%, P<0.00). Intervention group infants started enteral feeding earlier and reached half and full enteral feeding earlier (P<0.05). In addition, intravenous protein and lipid supply started sooner, increased at a faster rate, and reached peak concentrations sooner in the intervention group (P<0.05).
Conclusion: Nutritional intervention by an NST resulted in a significant decrease in the development of EUGR in VLBW infants.

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Micronutrient deficiencies in copper, zinc, and vitamin D as predictors of clinical outcomes in critically ill surgical patients in Korea: a retrospective cohort study: Jiae Kim, Yanghee Jun, Ye Rim Chang, Jong-Kwan Baek, Hak-Jae Lee, Hyewon Han, Suk-Kyung Hong; Ann Clin Nutr Metab 2024;16(3):158-167. Published online December 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.3.158

Abstract PDF: Purpose: To investigate the prevalence of copper, zinc, and vitamin D deficiencies in surgical intensive care unit (SICU) patients and the associations between those deficiencies and clinical outcomes.
Methods: We conducted a retrospective study of 210 patients admitted to the SICU of Asan Medical Center between June 2020 and June 2022. Micronutrient levels were measured within 7 days of SICU admission. Primary outcomes were the mortality rate, length of SICU stay, hospital stay duration, and mechanical ventilation duration.
Results: Copper deficiency was found in 35% (68/193), zinc deficiency in 52% (100/193), and severe vitamin D deficiency in 46% (82/179) of patients. Copper-deficient patients showed a significantly higher mortality rate (25.0% vs. 12.8%, P=0.044), longer hospital stays (57.8±47.0 vs. 45.2±36.6 days, P=0.041), and extended mechanical ventilation duration (26.9±23.3 vs. 18.8±15.7 days, P=0.012). Zinc deficiency was associated with higher C-reactive protein levels (16.2±9.5 vs. 11.5±8.8 mg/dL, P=0.001) and lower prealbumin levels (6.5±2.8 vs. 9.9±5.6 mg/dL, P<0.001). Severe vitamin D deficiency (<10 ng/mL) was not significantly associated with mortality or other clinical outcomes (mortality: <10 ng/mL vs. ≥10 ng/mL, 13% vs. 18%, P=0.583).
Conclusion: Micronutrient deficiencies are prevalent in SICU patients. Copper deficiency significantly correlated with poor clinical outcomes, and zinc deficiency showed a strong association with inflammatory markers. Early assessment and supplementation of micronutrients could be beneficial for critically ill surgical patients.

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Triglyceride-glucose index predicts future metabolic syndrome in an adult population, Korea: a prospective cohort study: Min-Su Park; Ann Clin Nutr Metab 2024;16(3):168-172. Published online December 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.3.168

Abstract PDF: Purpose: The triglyceride-glucose (TyG) index has been proposed as a reliable surrogate marker for insulin resistance. This study aimed to assess the utility of the TyG index in predicting the future presence of metabolic syndrome (MetS) in an adult population.
Methods: A total of 3,241 adults aged 40–70 years were included in this cross-sectional study. MetS was diagnosed based on the modified National Cholesterol Education Program Adult Treatment Panel III criteria, which requires the presence of at least three of the following components: abdominal obesity, elevated blood pressure, dysglycemia, hypertriglyceridemia, and low high-density lipoprotein cholesterol.
Results: In comparison to the homeostasis model assessment of insulin resistance (HOMA-IR), the TyG index exhibited superior diagnostic performance, with a higher area under the receiver operating characteristic curve of 0.854 vs. 0.702 for HOMA-IR. The 95% confidence interval for the TyG index was narrower, reflecting a more consistent predictive ability. Sensitivity for the TyG index was 79.7%, while specificity was 79.3%, compared to HOMA-IR, which showed a sensitivity of 52.7% and specificity of 78.3%.
Conclusion: The TyG index is a highly effective and robust tool for identifying individuals at risk for MetS, demonstrating superior sensitivity and predictive accuracy over HOMA-IR. This index could be a valuable clinical marker for early detection of MetS, aiding in the prevention and management of associated metabolic disorders.

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Special Article

Kumamoto Earthquake NST activity report: food problems in evacuation shelters in comparison with convalescent facilities: Joji Kotani, Isamu Yamada, Takahiro Ueda; Ann Clin Nutr Metab 2024;16(3):173-180. Published online December 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.3.173

Abstract PDF: Purpose: It aims to investigate the contents of food supplies, gastrointestinal symptoms, and stated preferences of evacuees during the first two weeks after the earthquake.
Methods: Thirty-four evacuees from evacuation shelters and 12 evacuees from geriatric care facilities were surveyed. Subjective and comprehensive nutritional assessment questionnaires were administered to the evacuees, and their dissatisfaction and preferences were also recorded in an open-ended format.
Results: Weight decreased, remained unchanged, increased, or was unknown for 4, 24, 6, and 0 evacuees from the shelters and in 0, 8, 1, and 3 evacuees from the facilities. The number of respondents who reported a decrease, change, or decrease in food intake was 4, 22, and 1 from the evacuation centers and 1, 10, and 1 from the facilities, indicating a large number of changes in the evacuation centers. Reasons for weight gain included “feeling that they should not leave food behind,” “eating a lot of high-calorie food,” and “eating sweets and cup noodles.” Constipation was the most common gastrointestinal symptom (n=5) in the evacuation centers, while diverse symptoms were reported from the facilities. Constipation in the facilities was thought to be related to the high carbohydrate content of the food. Only two respondents were satisfied with the shelter, and the majority complained of dissatisfaction. The most common complaints were “I don’t like bread in the morning (I prefer rice);” “Too sweet;” and “Onigiri (rice ball) is too big,” but there were also complaints about the eating environment on the floor, such as “I lose [my] appetite when eating on the floor due to abdominal pressure” (I prefer to eat on a chair at a table). The majority of the respondents in the facilities did not have any complaints. All of the respondents in the shelters expressed a wide variety of food preferences, including vegetables, rice in the morning, meat, fruit, and foods that were not available due to lack of refrigeration, such as carbonated beverages and ice cream. Some respondents expressed that they were tired of being given food unilaterally and having no choice, such as “I want to choose my own food” and “I want a vending machine [to choose my own food].” There were almost no requests for food at the facilities, and the majority of the respondents were satisfied with their situation. The food was supplied by volunteers and the Self-Defense Forces, which were out of sync with the needs of the evacuees at the evacuation center. However, at the facilities, food was sent to a geriatric care facility in a remote area that accounted for the needs of the victims.
Conclusion: Evacuees were grateful for the food supplies immediately after the disaster, but gradually became dissatisfied. Meals are one of the pleasures in evacuation centers and are important for reducing mental stress. Evacuation centers should consider the needs of evacuees when providing food to evacuees.

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