Annals of Clinical Nutrition and Metabolism

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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The 2024 Korean Enhanced Recovery After Surgery guidelines for colorectal cancer: Kil-yong Lee, Soo Young Lee, Miyoung Choi, Moonjin Kim, Ji Hong Kim, Ju Myung Song, Seung Yoon Yang, In Jun Yang, Moon Suk Choi, Seung Rim Han, Eon Chul Han, Sang Hyun Hong, Do Joong Park, Sang-Jae Park, The Korean Enhanced Recovery After Surgery (ERAS) Committee within the Korean Society of Surgical Metabolism and Nutrition; Ann Clin Nutr Metab 2024;16(2):22-42. Published online August 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.2.22

Abstract PDF Supplementary Material: The Korean Enhanced Recovery After Surgery (ERAS) Committee within the Korean Society of Surgical Metabolism and Nutrition was established to develop ERAS guidelines tailored to the Korean context. This guideline focuses on creating the most current evidence-based practice guidelines for ERAS based on systematic reviews. All key questions targeted randomized controlled trials (RCTs) exclusively. If fewer than two RCTs were available, studies using propensity score matching were also included. Recommendations for each key question were marked with strength of recommendation and level of evidence following internal and external review processes by the committee.

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Early nutritional support for inpatients reduces admission rates to intensive care units in Korea: a single-center case-control study: Hyun Suk Kim, Jae Do Yang, Se Wung Han, Mi Rin Lee, Da-Sol Kim, Sejin Lee, Seon-Hyeong Kim, Chan-Young Kim; Ann Clin Nutr Metab 2024;16(2):57-65. Published online August 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.2.57

Abstract PDF Supplementary Material ePub: Purpose: Early nutritional support (ENS) for critically ill patients is promoted by many studies. However, there is a lack of data evaluating its necessity in general wards. This study aims to determine the impact of ENS on patients in general wards.
Methods: Patients aged 18 and above, admitted to the Jeonbuk National University Hospital in Jeonju from January 2020 to December 2020, who were eligible for nutritional support and hospitalized for at least 7 days were included in the study. We divided the patients into two groups: the ENS group, who received nutritional support within 48 hours of admission, and the control group, who received it after 48 hours.
Results: Among 1,077 patients, 146 met the inclusion criteria. The ENS group (n=38) and the control group (n=108) were compared retrospectively. There was a significant age difference between the two groups (P=0.028). The admission ratio to the intensive care unit (ICU) in the ENS group was significantly lower than that in the control group (10.2% vs. 26.3%, P=0.019). The calorie support rate (%) and protein support rate (%) in the ENS group were significantly higher than in the control group (50.12%±23.30% vs. 38.56%±18.02%, P=0.006; 44.61%±25.07% vs. 32.07%±22.76%, P=0.002, respectively). After propensity score matching, the ENS was significantly associated with ICU low admissions (odds ratio 0.08, 95% confidence interval 0.01–0.69, P=0.022).
Conclusion: A future multi-center study considering underlying diseases is needed to provide additional scientific evidence to support the effects of ENS.

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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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Prognostic significance of serum creatinine and sarcopenia for 5-year overall survival in patients with colorectal cancer in Korea: a comparative study: Jiahn Choi, Hye Sun Lee, Jeonghyun Kang; Ann Clin Nutr Metab 2024;16(2):66-77. Published online August 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.2.66

Abstract PDF Supplementary Material: Purpose: Previous studies have demonstrated that the serum creatinine level and skeletal muscle index (SMI) (correlated with the overall survival [OS] of patients with colorectal cancer [CRC]). However, the combined significance of these 2 factors is not fully understood. The goal of this study was to investigate the prognostic potential of the combination of these two factors in patients with CRC.
Methods: The patients were categorized into subgroups based on preoperative serum creatinine level, with a cut-off value of 1.01 mg/dL for males and 0.80 mg/dL for females. The patients were further categorized into 4 groups based on SMI. Data were analyzed using the Cox proportional hazards model and Harrell’s concordance index (C-index).
Results: Poor 5-year OS was observed in patients with high SMI and high serum creatinine levels (hazard ratio [HR]=1.676, 95% confidence interval [CI]=1.110–2.529, P=0.013), low SMI and low serum creatinine levels (HR=1.916, 95% CI=1.249–2.938, P=0.002), and low SMI and high serum creatinine levels (HR=2.172, 95% CI=1.279–3.687, P=0.004) compared to those of patients with high SMI and low serum creatinine levels. Grouping patients based on both SMI and serum creatinine levels led to improved prognostic stratification (C-index, 0.626; 95% CI=0.587–0.666) compared to grouping based on SMI (CI difference=0.062, 95% CI=0.031–0.103, P=0.0011) or serum creatinine (CI difference=0.043, 95% CI=0.017–0.081, P=0.0072) alone.
Conclusion: Incorporating both SMI and serum creatinine levels enhances the prognostic stratification for 5-year OS in patients with CRC, surpassing the prognostic power of grouping solely based on SMI or creatinine.

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Liver Cirrhosis and Sarcopenia: Hye Yeon Chon, Tae Hee Lee; Ann Clin Nutr Metab 2022;14(1):2-9. Published online June 1, 2022; DOI: https://doi.org/10.15747/ACNM.2022.14.1.2

Abstract PDF: Malnutrition is one of the most common complications in patients with liver cirrhosis. In previous studies, cirrhotic patients with severe malnutrition have been associated with higher morbidity and mortality rates before and after liver transplantation. Frailty and sarcopenia are phenotypes of severe malnutrition that have been associated with complications requiring hospitalization or mortality during the wait for transplantation in patients with cirrhosis. Tools for evaluating frailty include the Activities of Daily Living scale, the Karnofsky Performance Status scale, and the Liver Frailty Index. Diagnosed by using computed tomography, sarcopenia is measured with the skeletal muscle index at L3 and is normalized by height. Nutritional status should be evaluated within the first 24~48 hours of hospitalization in every patient with cirrhosis. Among the various available screening tools, the Royal Free Hospital-Nutritional Prioritizing Tool proposed in the UK is recommended. Nutritional counseling with a multidisciplinary team is recommended to improve long-term survival in patients with cirrhosis. Multidisciplinary nutrition management should include evaluating nutritional status and providing guidance for achieving nutritional goals. Most guidelines suggest a calorie intake of 25~35 kcal/kg/day, and the recommended protein intake is 1.2~1.5 g/kg/day. One beneficial technique for patients is to divide the total recommended intake across four to five daily meals, including a nighttime snack. The principles of nutritional intervention in cirrhotic patients are not different from those in noncirrhotic patients. For improvement of sarcopenia, a strategic approach including physical activity and exercise, hormone replacement therapy, ammonia-lowering agents, and treatment of underlying liver disease is required.

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Nutritional therapy for critically ill children: Eunju Ha; Ann Clin Nutr Metab 2024;16(2):21-21. Published online August 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.2.21

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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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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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Impact of immune-supplementation on muscle health and inflammation status of South Indian patients who have undergone gastrointestinal resection: a pilot randomized-controlled study: Nivedita Pavithran, Catherine Bompart, Alisa Alili, Sudheer Othiyil Vayoth; Ann Clin Nutr Metab 2024;16(2):78-86. Published online August 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.2.78

Abstract PDF: Purpose: Gastrointestinal (GI) resection significantly impacts nutritional and physical health, causing stress and inflammation that increase energy needs. Post-operative caloric intake often falls short, disrupting protein homeostasis and compromising muscle health. Nutritional supplementation is crucial to reduce inflammation and maintain muscle health. This study aimed to evaluate the impact of a three-week oral nutritional immuno-supplement (IMM) intervention compared to a control (CTL) on post-operative inflammatory status and muscle health in patients receiving limb and chest physiotherapy from June to August 2023.
Methods: A randomized, controlled, blinded cohort of 20 patients (ages 30–75) undergoing GI surgery was established. Participants were recruited on the day of surgery and assigned to either the CTL, which received standard protein supplementation, or the IMM group, which received protein immune-enriched supplementation for three weeks. All participants also received chest and limb physiotherapy. Follow-up and data collection were conducted at three post-surgery time points: 3 days, 7 days, and 3 weeks. Assessments included body composition, handgrip strength, basal metabolic rate, 24-hour dietary intake, and C-reactive protein (CRP) levels.
Results: Fifteen patients completed the study (IMM=9, CTL=6). After three weeks of supplementation, the IMM group showed a significant increase in lean mass percentage and handgrip strength, along with a significant decrease in CRP levels, compared to the CTL.
Conclusion: A 3-week oral immuno-supplement provided to patients post-GI resection, in conjunction with limb and chest physiotherapy, is more effective in reducing inflammation and preserving muscle health compared to standard protein supplementation.

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Preoperative consumption of a carbohydrate drink before laparoscopic cholecystectomy is safe and beneficial in Korea: a non-randomized controlled study: Yoo Jin Choi, Yoonhyeong Byun, Seong Mi Yang, Ho-Jin Lee, Hongbeom Kim; Ann Clin Nutr Metab 2023;15(1):15-21. Published online April 1, 2023; DOI: https://doi.org/10.15747/ACNM.2023.15.1.15

Abstract PDF Supplementary Material: Purpose: Overnight fasting prior to elective surgery is the traditional way of avoiding the risk of aspiration during anesthesia induction. However, it causes mental and metabolic stress to patients. Therefore, we investigated the safety and potential benefits of the preoperative consumption of a carbohydrate drink.
Methods: This was a single-center prospective, nonrandomized study with questionnaire. Patients scheduled for elective laparoscopic cholecystectomy were included. There was no restriction on age, underlying diseases, and biliary drainage prior to surgery. They were preoperatively given either a carbohydrate drink or were instructed to fast from midnight before surgery. Perioperative emotional status was measured using the visual analog scale.
Results: The 132 patients completed the questionnaire, with 68 receiving the carbohydrate drink and 64 following nil per oral after-midnight instruction. There were no postoperative complications related to preoperative drink consumption or the cholecystectomy procedure itself in both groups. There were no significant differences in all the assessed feelings postoperatively except that preoperative discomforts, such as hunger and thirst, were significantly more alleviated in the group of preoperative consumption of a carbohydrate drink.
Conclusion: Preoperative consumption of a carbohydrate drink was found to be safe and effective in alleviating preoperative discomfort in elective surgery patients, including older patients and those with underlying comorbidities, who were at greater risk for aspiration. Therefore, we recommend considering preoperative drink consumption as an alternative to traditional overnight fasting in elective surgery patients.

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Letter from the Editor: Chi-Min Park; Ann Clin Nutr Metab 2022;14(1):1-1. Published online June 1, 2022; DOI: https://doi.org/10.15747/ACNM.2022.14.1.1

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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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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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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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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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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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Pneumothorax due to malpositioned nasogastric enteral feeding tube: Hyebeen Kim, Suk-Kyung Hong; Ann Clin Nutr Metab 2024;16(2):87-88. Published online August 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.2.87

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Definition, assessments, and current research on sarcopenia in children: a narrative review: Min-Jung Bang; Ann Clin Nutr Metab 2024;16(2):49-56. Published online August 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.2.49

Abstract PDF: Purpose: Sarcopenia is a well-established prognostic factor for the clinical outcomes of adult patients with cancer and chronic diseases and correlates with increased intensive care unit admissions and prolonged hospital stays. However, research on sarcopenia in children is limited due to its undefined criteria and a lack of studies exploring its impact on clinical outcomes.
Current concept: The challenges in pediatric sarcopenia research include the absence of standardized body composition methods to quantify muscle mass and muscular function, as well as inconsistencies in definitions. Additionally, there is a lack of age- and gender-specific normative data, particularly for young children and infants. Most studies also lack assessments of muscle function, which can lead to bias and misclassification of sarcopenia. The field is further hindered by poor study quality, limited outcome-focused research, and a dearth of longitudinal data. While some studies suggest that various diseases can affect children’s lean muscle mass, few have linked changes in muscle mass to clinical outcomes.
Conclusion: The existing literature on pediatric sarcopenia and its relationship with medical and surgical outcomes is sparse and indicates poorer outcomes associated with sarcopenia. Although extensive research has established a link between sarcopenia and adverse outcomes in adults, information on its impact in pediatric populations remains scarce. Further studies are needed to elucidate the association between muscle mass and outcomes in pediatric surgical patients.

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Dysphagia and quality of life: a narrative review: Jung Mi Song; Ann Clin Nutr Metab 2024;16(2):43-48. Published online August 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.2.43

Abstract PDF: Purpose: Dysphagia is a chronic health condition that causes impairment of eating and drinking functions. It occurs in various diseases such as stroke, neurodegenerative disease, brain tumor, and head and neck cancer, and can also occur during the normal aging process.
Current concept: As patients experience symptoms of dysphagia, they no longer feel the pleasure of eating, depression and anxiety increase, and self-esteem decreases. Prolonged loss of appetite can lead to malnutrition, which can lead to death due to serious complications such as aspiration pneumonia and airway obstruction. Dysphagia reduces quality of life by affecting basic activities of daily living, limitations in social life, nutritional deficiencies, and mood disorders.
Conclusion: Accordingly, I plan to conduct a literature review on the quality of life of patients with dysphagia. First, to determine the relationship between quality of life and sociodemographic, physical health, and mental health characteristics of patients with dysphagia. I also aim to review quality of life measurement tools and intervention programs for patients with dysphagia.

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Recent advances in refeeding syndrome in critically ill patients: a narrative review: Sang Woo Ha, Suk-Kyung Hong; Ann Clin Nutr Metab 2024;16(1):3-9. Published online April 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.1.3

Abstract PDF: Purpose: The aim of this article is to provide a narrative review of the most recent studies on refeeding syndrome (RS) in critically ill patients and to summarize recent advancements that can be referenced in the treatment of these patients.
Current concept: RS in critically ill patients is a potentially lethal nutrition-related condition leading to sudden death. Initiation of food intake after a period of fasting can trigger rapid electrolyte uptake due to increased insulin release, leading to a decline in serum electrolytes with thiamine. This depletion may cause severe complications, such as cardiac arrhythmias, respiratory failure, seizures, and even death. The incidence of RS varies significantly, ranging from 7.4%–89%. Despite updates in diagnostic criteria over time, there remains a crucial need for criteria applicable to critically ill patients with underlying disorders such as metabolic derangement and organ dysfunction. To prevent RS, it is strongly recommended to start food intake after a fast at 20%–25% of estimated goals, gradually increasing the intake over several days. Close monitoring and electrolyte supplementation—especially of phosphorus, potassium, magnesium, and thiamine—are crucial, especially in critically ill patients. If electrolyte imbalances persist, slowing down or halting the progression of nutrition should be considered.
Conclusion: Clinicians should continue their efforts to promptly identify high-risk patients and to provide prevention and treatment for RS, particularly during the initiation of nutritional therapy in critically ill patients. Developing evidence-based protocols through further well-designed research is essential for effectively managing critically ill patients at risk of RS.

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Efficacy of high-protein diet protocol and education after distal gastrectomy for gastric cancer patients to prevent loss of lean body mass in Korea: a non-randomized controlled study: Hee Kyung Yoon, Sun Ae Kim, Ji Yoon Han, Dong Jin Kim; Ann Clin Nutr Metab 2024;16(1):10-19. Published online April 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.1.10

Abstract PDF Supplementary Material: Purpose: We studied whether active education of patients about the importance of a high-protein diet can prevent lean body mass loss after gastrectomy for gastric cancer.
Methods: In the study group, intensive high protein diet education and monitoring was performed immediate post operative, 1, 3, and 6 months after surgery. Study group patients were compared with data from the control group formed using propensity matching with the study group for age, sex, resection extent, and TNM stage. Clinicopathologic factors were compared between the groups, and changes in quality of life (QOL) and lean body mass between preoperative levels and 6 months after surgery were assessed.
Results: Among the 100 patients, 31 patients from each group were matched with propensity matching. The groups had no significant clinicopathologic differences. Although the changes in QOL scale and body composition did not differ statistically between the groups, a favorable trend was observed in the study group. Six months after surgery, the mean change in the QOL scale, which measured physical, role, emotional, cognitive, and social functioning, decreased less than the control group or even increased in the study group. In the body composition analysis, the study group showed greater reductions in weight, body mass index, fat mass, and body fat percentage than the control group, and their lean body mass and skeletal muscle mass decreased less.
Conclusion: A high-protein diet protocol and education might increase patient QOL and prevent a decrease in lean body weight 6 months after distal gastric resection.

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A comprehensive overview of enhanced recovery after surgery: Sang Hyun Shin; Ann Clin Nutr Metab 2024;16(1):1-2. Published online April 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.1.1

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Comparative assessment of nutritional characteristics of critically ill patients at admission and discharge from the neurosurgical intensive care unit in Korea: a comparison study: Eunjoo Bae, Jinyoung Jang, Miyeon Kim, Seongsuk Kang, Kumhee Son, Taegon Kim, Hyunjung Lim; Ann Clin Nutr Metab 2023;15(3):97-108. Published online December 1, 2023; DOI: https://doi.org/10.15747/ACNM.2023.15.3.97

Abstract PDF: Purpose: Patients in neurosurgical (NS) intensive care units (ICUs) experience considerable energy and protein deficits associated with adverse outcomes. This study aimed to compare the nutritional status of patients at admission to (baseline) and discharge from the NS ICU.
Methods: This was a single-center, retrospective, before and after study of patients admitted in the NS ICU of the CHA Bundang Medical Center, from January 31, 2019, to February 28, 2020. All anthropometric data, biochemical data, clinical data, and dietary data were collected during the NS ICU stay. Specifically, we investigated the cumulative caloric deficit rate, phase angle and skeletal muscle index as indicators of lean muscle mass, and nitrogen balance according to demographic and clinical characteristics.
Results: A total of 140 NS patients were studied. Calf circumference decreased from 31.4±4.2 cm at baseline to 30.2±4.0 cm at discharge (P<0.001). Energy supply rate increased from 44.4% at baseline to 89.2% at discharge. Phase angle (PhA) patients with an modified Nutrition Risk in the Critically ill (mNUTRIC) score≤5 group had significantly lower PhA values than those with an mNUTRIC score>5 (P=0.005).
Conclusion: Although clinical and dietary parameters of patients in the NS ICU improved from baseline to discharge, anthropometric and biochemical markers of lean muscle mass and nutritional status decreased. PhA and nitrogen balance difference values were significantly different between those with an mNUTRIC score≤5 and those with an mNUTRIC score>5. These data indicate that the nutritional risk of critically ill patients increases during hospitalization in the NS ICU.

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Multi-biomarker approach to metabolic syndrome and associated diseases in Turkey: a cross sectional study: Semra Can Mamur, Omer Colak, Selma Metintas, Inci Arikan, Mehmet Kara; Ann Clin Nutr Metab 2023;15(3):88-96. Published online December 1, 2023; DOI: https://doi.org/10.15747/ACNM.2023.15.3.88

Abstract PDF: Purpose: Biomarker for cardiovascular diseases (CVDs) are important in the clinical monitoring of individuals with metabolic syndrome (MetS). The use of these biomarkers in combination may be predictive of CVDs. This study aimed to demonstrate the ability of multiple biomarkers to predict MetS, diabetes mellitus (DM), and CVDs. The use of multiple biomarkers instead of a single biomarker may be more useful in early diagnosis. We investigated the use of a multi-biomarker approach in MetS and associated diseases.
Methods: The study was performed by selecting control (n=30), MetS (n=30), MetS+DM (n=30), and MetS+CVD (n=30) groups from data of the Eskisehir Healthy Hearts Project conducted from January 2008 to October 2009 in Turkey. We recorded serum level of biomarkers, including lipid profile, liver enzyme, paraoxonase, arylesterase and arginase to find their difference among the groups.
Results: Compared to the control group, gamma-glutamyl transferase (GGT) and arginase levels increased, while paraoxonase and arylesterase activity and high-density lipoprotein–cholesterol levels were low in the patient groups (P<0.001). A negative correlation was observed between paraoxonase and arylesterase activity and MetS.
Conclusion: We believe that the combined use of biomarkers, including GGT, arginase, paraoxonase, and arylesterase, may be useful in predicting diseases such as MetS and CVDs.

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Perioperative nutritional practices and attitudes among gastrointestinal oncologic surgeons in Korea: a nation-wide survey study: Dae Hoon Kim, Jeong-Meen Seo, Min-Gew Choi; Ann Clin Nutr Metab 2023;15(3):81-87. Published online December 1, 2023; DOI: https://doi.org/10.15747/ACNM.2023.15.3.81

Abstract PDF Supplementary Material: Purpose: This study aimed to investigate the current perioperative nutritional practices and attitudes among gastrointestinal (GI) oncologic surgeons in Korea. Evidence-based perioperative nutritional practices are not well-established in this field.
Methods: A nationwide survey was conducted with 24 items, targeting GI oncologic surgical faculty members from March 2022 to April 2022 through social networking service messaging and email. Whole target number was 3,421.
Results: Out of responding 161 GI surgeons, 83.9% were male and 16.1% were female, and about 49.7% were in their 40s. When asked about their hospital policies, 67.1% reported the existence of formal nutritional screening programs. However, the execution and analysis of these programs varied considerably. Most surgeons conducted preoperative nutritional screening, with albumin testing the most frequently performed. In addition, nutritional supplementation—primarily protein drinks—was given before surgery. The duration for which these supplements were used varied from ≤3 days to 4–7 days. Most respondents recognized the importance of addressing nutritional deficiencies in patients with GI tumors; however, when asked about immunonutrition, 89.4% of surgeons admitted having limited knowledge.
Conclusion: Although there is recognition of the importance of evidence-based nutrition practices in GI and oncologic surgery programs, this study reveals limited implementation of such practices. This study highlights a considerable opportunity to leverage existing positive surgeon beliefs and published data on the benefits of perioperative nutrition to enhance surgical nutrition practices and to improve patient outcomes in Korea.

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Body composition assessment using bioelectrical impedance analysis and computed tomography in patients who underwent pancreatoduodenectomy in Korea: a before and after study: Juwan Kim, Seung-seob Kim, Ho Kyoung Hwang, Chang Moo Kang, Kyung Sik Kim, Sung Hyun Kim; Ann Clin Nutr Metab 2023;15(3):72-80. Published online December 1, 2023; DOI: https://doi.org/10.15747/ACNM.2023.15.3.72

Abstract PDF Supplementary Material: Purpose: This study focuses on the need for standardized body composition measurements in the hepatobiliary-pancreatic field. It evaluates and compares the effectiveness of bioelectrical impedance analysis (BIA) and computed tomography (CT) scans in assessing body composition of patients undergoing pancreatoduodenectomy (PD), aiming to establish correlations among different body composition indexes.
Methods: Ninety-seven patients who underwent PD between August 2022 and March 2023, were enrolled in this study. Muscular and fatty parameters related to BIA and CT were assessed both preoperatively and on postoperative day 6. The correlation between each parameter related to muscle fat was analyzed according to the measurement modalities.
Results: There was an increase of skeletal muscle area (SMA), total muscle area, and low attenuated muscle area after surgery. Skeletal muscle mass (SMM) measured using BIA exhibited a strong correlation with the SMA and normal attenuated muscle area (NAMA) measured using CT (r=0.86, P<0.001; r=0.76, P<0.001). The trunk muscle measured using BIA demonstrated moderate to strong correlations with SMA and NAMA measured using CT (r=0.84 P<0.001; r=0.73, P<0.001). Body fat measured using BIA and total fat area (TFA) measured using CT showed strong correlations (r=0.74, P<0.001). In the postoperative analysis, a similar trend was observed (SMM vs. SMA: r=0.80, P<0.001; SMM vs. NAMA: r=0.70, P<0.001), (trunk muscle vs. SMA: r=0.79, P<0.001; trunk muscle vs. NAMA: r=0.69, P<0.001), and (body fat vs. TFA: r=0.83, P<0.001).
Conclusion: BIA, akin to CT, serves as a valuable tool for assessing body composition ratios in patients undergoing PD.

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Role of nutrition in wound healing and nutritional recommendations for promotion of wound healing: a narrative review: Myoungjean Ju, Yoonhong Kim, Kyung Won Seo; Ann Clin Nutr Metab 2023;15(3):67-71. Published online December 1, 2023; DOI: https://doi.org/10.15747/ACNM.2023.15.3.67

Abstract PDF: Purpose: Addressing both malnutrition and wound healing requires strategic intervention. However, guidelines for adequate nutrition for a variety of wounds are lacking. Based on the latest literature review, we summarize the role of nutrition in each stage of wound healing and nutritional recommendations for wound healing.
Current concept: Wounds undergo three healing phases: inflammatory, proliferative, and remodeling. The inflammatory phase involves clotting and cleaning the wound. The proliferative phase builds the wound bed through tissue growth. In the remodeling phase, collagen strength increases. Proper nutrition is crucial throughout. During inflammation, calcium, vitamin K, A, and E, zinc, and proteins are essential. In proliferation, amino acids, B vitamins, lipids, zinc, and iron play key roles. During remodeling, vitamins C and E, zinc, and water are critical for collagen synthesis and skin cell maturation. Vulnerable groups like the elderly, newborns, and obese patients need proper nutrition for skin maintenance. For pressure ulcers with malnutrition risk, recommendations are 30–35 kcal/kg/day energy, 1.25–1.5 g/kg/day protein, and 30 mL/kg water. Supplements might be added if regular meals don’t meet needs. For diabetic foot ulcers, despite common deficiencies, the 2019 International Working Group on the Diabetic Foot advises against prioritizing nutritional interventions over standard care due to limited high-quality evidence.
Conclusion: Despite limited guidelines, nutrition assessment is vital for wound evaluation. A multidisciplinary approach is key, emphasizing nutrition’s role in wound healing. Implementing nutritional interventions tailored to the wound and the individual’s nutritional status is essential. This comprehensive strategy ensures the best wound care outcomes.

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Association between sarcopenia and prognosis of hepatocellular carcinoma: Hae Il Jung; Ann Clin Nutr Metab 2023;15(3):65-66. Published online December 1, 2023; DOI: https://doi.org/10.15747/ACNM.2023.15.3.65

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Consultation pattern changes of parenteral nutrition with a multidisciplinary nutrition support team in a recently opened hospital in Korea: a retrospective cohort study: Kyoung Won Yoon, Hyo Jin Kim, Yujeong Im, Seul Gi Nam, Joo Yeon Lee, Hyo Gee Lee, Joong-Min Park; Ann Clin Nutr Metab 2023;15(2):57-63. Published online August 1, 2023; DOI: https://doi.org/10.15747/ACNM.2023.15.2.57

Abstract PDF: Purpose: Parenteral nutrition (PN) is essential for the treatment of patients with malnutrition. The provision of central PN should be recommended by a nutrition support team (NST) made up of a team of experts, even in a newly established hospital. This study sought to evaluate the effectiveness of PN delivered by a multidisciplinary NST in a recently opened hospital.
Methods: This was a retrospective study of the effectiveness of a central PN recommendation pop-up message by the electronic medical record (EMR) software to prompt physicians to either calculate the required calorie and protein intake or consult with the NST. The study period was divided into pre-NST and post-NST based on the time of recruitment of NST-dedicated personnel.
Results: Patients in the 12-week pre-NST period (n=50) and 12-week post-NST period (n=74) were compared retrospectively. Baseline characteristics were not significantly different between the two groups, except for the median Acute Physiology and Chronic Health Evaluation II score (pre-NST group, 8 [interquartile range, IQR 5–15.5] vs. post-NST group, 15 [IQR 9–24], P=0.012) of the 45 patients total admitted to the intensive care unit. The percentage of patients for whom physicians requested a consultation with the NST for central PN was significantly higher in the post-NST group (52.0% vs. 75.7%, P=0.011). There was no significant difference in achievement of nutrition targets or mortality.
Conclusion: Building a multidisciplinary NST may increase awareness of nutritional status and affect the behavior of physicians in recently-opened hospitals.

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