Annals of Clinical Nutrition and Metabolism

Letter from Editor: Hyuk-Joon Lee; J Clin Nutr 2013;5(1):1-1. Published online April 1, 2013

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Nutrition Screening and Assessment of Patients for Malnutrition: Hoon Hur; J Clin Nutr 2013;5(1):2-9. Published online April 1, 2013; DOI: https://doi.org/10.15747/jcn.2013.5.1.2

Abstract PDF: A large part of patients admitted to hospital are undernourished and managed without nutritional support because of physician's failure to assess the nutritional state of patients. Therefore, nutritional screening and assessment of patients for malnutrition could be key to improving the treatment outcomes. It is the aim of this paper to inform the concept of nutritional screening and assessment, and introduce tools for general use. Several tools such as nutritional risk screening 2002, nutritional risk classification and others are available for nutritional screening. A recent change of weight, diet history, and the level of serum albumin are mainly included in these assessment tools. After an evaluation using screening tools, physicians can decide whether to start nutritional support or perform nutritional assessment in addition. Subjective global assessment (SGA), developed in 1987, has been mainly used for nutritional assessment. This tool takes into account the past history about the diet, weight variation, the degree of individual activity and fever. Several clinical studies have supported the efficacy of SGA to predict nutritional outcomes. Physicians should devise a plan for nutritional support based on the results of nutritional assessment. In conclusion, nutritional screening and assessment is essential for the evaluation of the patients who require medical or surgical intervention, because the patient's nutritional state can affect treatment outcomes. Therefore, physicians must take care to assess the nutritional state of patients before treatment using appropriate tools. Moreover, the most appropriate tool for nutritional assessment of Korean patients should be suggested through clinical studies. (JKSPEN 2013;5(1):2-9)

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Immunonutrition in Surgical Patients: Hye Seong Ahn, Seung Chul Heo; J Clin Nutr 2013;5(1):10-14. Published online April 1, 2013; DOI: https://doi.org/10.15747/jcn.2013.5.1.10

Abstract PDF: Patients undergoing major surgery are at increased risk of developing post-operative complications. In the last years, several clinical studies and meta-analyses focused on the potential clinical benefits of perioperative immunonutrition in surgical patients and showed contradictory results with regard to complications. The aim of this study is to summarize the concept of immunonutrition and the results of those clinical trials and to draw recommendations about the current indications of immunonutrition in surgery. A range of nutrients, including several amino acids, antioxidant vitamins and minerals, long-chain n-3 fatty acids, and nucleotides have been shown to upregulate the host immune function, modulate inflammatory response, and improve gut barrier function after surgery. Several experimental studies have been carried out that support potential benefits of these nutrients in the surgical patients. The majority of the randomized trials found that perioperative immunonutrition improved short-term outcomes in patients who underwent elective major gastrointestinal (GI) surgery. Five meta-analyses including a large number of randomized clinical trials showed that perioperative immunonutrition is associated with a reduction in both the infection rate and the length of hospital stay. These results have been demonstrated in all patients undergoing both the upper and lower GI surgery, regardless of their baseline nutritional status. Promising results have been obtained also in head and neck surgery. Considering these findings, perioperative immunonutrition should be implemented in patients undergoing elective major GI surgery. The use of perioperative immunonutrition could reduce both postoperative morbidity and costs for healthcare systems. However, large- scale trials are required before recommending the routine use of immunonutrition in head and neck surgery. (JKSPEN 2013; 5(1):10-14)

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Nutritional Support in Critically Ill Surgical Patients: Chi-Min Park; J Clin Nutr 2013;5(1):15-19. Published online April 1, 2013; DOI: https://doi.org/10.15747/jcn.2013.5.1.15

Abstract PDF: Malnutrition is associated with poor clinical outcomes in critically ill surgical patients and nutritional support has emerged as an important component in the management of these patients. The purpose of this study is to review the general nutritional support in critically ill surgical patients. Enteral nutrition (EN) is found to be the preferred method over parenteral nutrition (PN) for feeding the critically ill patient. EN should be started early within the first 24∼48 hours after admission as soon as the patient is hemodynamically stable and have functioning gastrointestinal tract. PN, if indicated, should also be initiated within 24∼48 hours after intensive care unit admission; however, there is controversy and further investigation is needed regarding the early start of PN. After gastrointestinal surgery, Studies have shown that EN is associated with fewer complications compared with PN and early enteral feeding may be of benefit in the patients following gastrointestinal surgery, even in emergency. During the acute phase, target dose of EN should be 20∼25 kcal/kg/day, whereas during the recovery phase, the dose is increased to 25∼30 total kcal/kg/day. Care must be taken to avoid overfeeding and development of refeeding syndrome in critically ill surgical patients. (JKSPEN 2013; 5(1):15-19)

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Nutrition Support in Liver Transplantation Patients: Mira Moon, Nam-Joon Yi; J Clin Nutr 2013;5(1):20-23. Published online April 1, 2013; DOI: https://doi.org/10.15747/jcn.2013.5.1.20

Abstract PDF: Malnutrition is common in cirrhotic patients undergoing liver transplantation. It has been associated with a high risk of postoperative complications and mortality rates in patients undergoing surgery. Studies have shown that nutrition therapy may improve the clinical outcomes in cirrhotic patients undergoing liver transplantation. This study focuses on the role of nutrition support, including immunonutrition such as branched-chain amino acids and n-3 fatty acid, vitamins and long-term consideration of nutritional status. (JKSPEN 2013;5(1):20-23)

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A Comparison Between Measured and Predicted Resting Energy Expenditure of Pancreaticoduodenectomy Patients: Seon Hyeong Kim, Hee Chul Yu, Baik Hwan Cho, Soo Wan Chae, Mi Jin Jeong, Yeong Ran Choi, Haeng Sun Kim, Ju Sin Kim, Sook Bae Kim; J Clin Nutr 2013;5(1):24-30. Published online April 1, 2013; DOI: https://doi.org/10.15747/jcn.2013.5.1.24

Abstract PDF: Purpose
An accurate determination of energy expenditure is needed to prevent postoperative complications and provide effective medical care for surgical patients. The aim of this study was to compare measured resting energy expenditure (REE) in patients undergoing pancreaticoduodenectomy (PD) using an indirect calorimetry (IC) with the help of five predictive equations. Methods: The subjects chosen for the study were 18 patients (12 males, 6 females) who underwent PD at Chonbuk National University Hospital between March 2010 and October 2011. REE was measured by IC (IC_REE) and calculated with the following five predictive equations - (^eqREE)-Harris-Benedict (HB), Mifflin St. Jeor (MI), American College of Chest Physician (AC), Ireton- Jones (IJ) and Cunningham (CU) equation - on postoperative day 3. Results: The mean measured REE by IC was 1,117.9 ±180.2, whereas the mean predicted REE by HB, MI, AC, IJ and CU equations were 1,241.3±156.1, 1,226±153.0, 1,401.7±188.0, 1,355.1±342.7, and 1,324.8±188.7 kcal/ day, respectively. The mean predicted REE by HB, MI, AC, IJ, and CU were found to be significantly different from the measured IC_REE. The intraclass correlation coefficient (ICC), which describes the degree of agreement with the IC_REE, was significantly highest in CU^eq_REE(r= 0.679). The rate of accuracy of HB^eq_REE, MI^eq_REE, AC^eq_REE, IJ^eq_REE, and CU^eq_REEfor IC_REE was 27.8%, 50.0%, 27.8%, 22.2%, and 23.5%, respectively, in individual subjects. Conclusion: The intraclass correlation coefficient (r= 0.124∼0.679) and accuracy rate (22.2∼50.0%) determined from the results of REE measured by IC and that calculated by five predictive equations were low in overall. The low accuracy rate of energy expenditure by equations, which apply uniform indicators, can be explained by ongoing metabolic changes of the patient. Thus, the use of IC is recommended to assess energy requirements in PD; when this method is not practical in clinical settings, nutrition intervention is needed through regular monitoring because of the low accuracy rate of the predictive methods and IC_REE that can cause inappropriate energy management, leading to metabolic disorders. (JKSPEN 2013;5(1):24-30)

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Effects of Fiber in Enteral Formula on Stool Frequency: Miran Cho, Jung Sook Lee, Myungcheon Kim; J Clin Nutr 2013;5(1):31-35. Published online April 1, 2013; DOI: https://doi.org/10.15747/jcn.2013.5.1.31

Abstract PDF: Purpose
Diarrhea is generally recognized as one of the most common complications associated with tube feeding. As a result, various forms of fibers are added to the formula to reduce the incidence of tube-feeding-related diarrhea. The purpose of this study was to compare the frequency of liquid stool in enterally fed patients receiving an insoluble fiber-enriched formula and those fed a mixed fibers diet formula. Methods: We conducted a prospective, double-blind trial to determine the effects of administration of enteral nutrition containing insoluble fiber on the stool frequency. Eight patients were given soluble and insoluble group (SIF group), and 11 patients were given the insoluble fiber formula (IF group) for consecutively 7 days. A number of stool and fecal score were recorded for all 7 days by using the King's stool chart with an absolute daily fecal score of 15. Results: Calorie was started on the first day with 625± 170.6 (150∼1,400) kcal/day for SIF group and 827.3± 140.8 (300∼1,200) kcal/day for IF group. On the seventh day, these values were increased to 74.9±6.6 (44.4∼100)% for SIF group and 87.0±4.6 (66.7∼107.1)% for IF group of nutritional goal. SIF group reported a significantly higher tendency towards the mean number of stools per day (2.8±0.7 [0.7∼6.7]), mean fecal score per day (16.3±3.8 [4.6∼36.0]) and mean number of days with diarrhea per week (3.1±1.0 [0∼7]) than IF groups with corresponding values of (1.8±0.2 [0.6∼2.9], 10.3± 2.0 [2.6∼19.7] and 1.9±0.5 [0∼4]). Conclusion: The results of this study suggest that enteral nutrition with insoluble fiber is beneficial in reducing the incidence of diarrhea in patients. Because gastrointestinal functional status (e.g., delayed gastric emptying) and intestinal environment (e.g., antibiotics) of patients with enteral tube feeding may be different from that of healthy humans, gastrointestinal symptoms (e.g., stool aspects) may vary depending on the fiber in enteral formula. (JKSPEN 2013;5(1):31-35)

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The Development and Evaluation of Nutritional Therapy-Clinical Professional for Nurses Education Program: Jeongyun Park, Youngwoo Park; J Clin Nutr 2013;5(1):36-40. Published online April 1, 2013; DOI: https://doi.org/10.15747/jcn.2013.5.1.36

Abstract PDF: Purpose
Malnutrition is associated with an increased risk of complications, and leads to higher morbidity, rising costs of hospitalization, and reduced quality of life for the patients. Nutrition is attracting interest to address malnutrition, with many hospitals forming nutrition support teams (NST) to provide timely, safe, appropriate, and cost-effective nutrition support therapy. NST consists of a multidisciplinary group of health care professionals including physicians, nurses, pharmacists, and dietitians. The nurse plays a major role in NST and takes responsibility for planning and implementing interventions to prevent malnutrition. The purpose of this study is to develop a nutritional education program for nurses and to analyze the result of the implementation of the program. Methods: Nutritional therapy (NT)-Clinical Professional for Nurses (CPN) education program was developed after analyzing nutrition education program for physicians, pharmacists, or dietitians to provide nutritional nursing care. The program content includes the role and scope of the nutrition support nurse (NSN), nutritional education, and skill. The developed program was administered to 33 nurses. After implementing the program, data were collected from the nurses who attended the program using a questionnaire. Results: The overall average score of satisfaction was 3.61 out of 4 points during evaluation. After the program, the nurses became more aware of their specific role in facilitating the acceleration of nutrition care. They emphasized that the program would improve their knowledge in nutrition and help them to act as role models. Conclusion: NT-CPN education program proved to be a helpful program for nurses. For the NSNs in NST, this program would play a crucial role. (JKSPEN 2013;5(1):36-40)

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