10 myths & facts about nutrition theraphy

Fact:

Malnourished patients represent a significant part of healthcare systems in highly developed countries.^1,2
 

A study of 1886 consecutively admitted patients in 13 German hospitals (n=1073, university hospitals; n=813, community or teaching hospitals) showed that every fourth patient in Germany is malnourished. Malnutrition was associated with an increased length of hospital stay. Higher age, malignant disease and major comorbidity were found to be the main contributors to malnutrition. The largest group reflecting a malnourished state was found in elderly people (52 %), followed by cancer (38 %) or gastroenterological patients (32 %).¹ The results for cancer patients were confirmed in a large study of 154 hospital wards (1,903 patients) in France, which showed that also nearly 40 % of the cancer patients were malnourished.²

In addition to this data, the NutritionDay, a multinational one-day cross-sectional survey with approx. 16,000 patients supported by ESPEN in 25 European countries show that less than 50 % of patients eat their entire meals. This decreased food intake represents an independent risk factor for hospital mortality.³

1. Pirlich M. et al. The German hospital malnutrition study. Clin Nutr. 2006; 25(4): 563-72.

2. Hébuterne X. et al. Prevalence of malnutrition and current use of nutrition support in patients with cancer. JPEN. 2014; 38(2):196-204.

3. Hiesmayr M. et al. Decreased food intake is a risk factor for mortality in hospitalised patients: the NutritionDay survey 2006. 

Clin Nutr. 2009; 28: 484–91.

Fact:

Clinical nutrition is able to fully cover nutritional requirements.^1,2

An enteral formula comprises any food formulas for special medical purposes designed for use in tube feeding or as an Oral Nutritional Supplement (ONS). An enteral formula can be

1. Nutritionally complete, when given in the recommended amount, and therefore, can be used as a sole source of nutrition or as a supplement to the patient’s normal intake.
2. Nutritionally incomplete, and therefore, can be used as a supplement only and not as a sole source of nutrition.¹
    

The same with parenteral nutrition, which can be divided into

1. Total parenteral nutrition – all nutrient needs are provided intravenously without any supplementary oral or enteral intake.²
2. Supplementary parenteral nutrition – a portion of the patient’s nutrient needs is provided via the gastrointestinal tract, and the remainder is infused parenterally in a sufficient amount to meet optimal nutrition.²
    

1. Lochs H. et al. Introductory to the ESPEN Guidelines on Enteral Nutrition: Terminology, Definitions and General Topics. Clin Nutr. 2006; 25: 180–186.
2. Sobotka L. (Editor in Chief). Basics in clinical nutrition. Fourth edition. GALEN, page 401

Fact:

The healthcare system can benefit from guideline-based clinical nutrition implementation.¹

Nutritional support provision should not happen by accident. Clinical dimensions include screening and assessment, the estimation of requirements, the identification of a feeding route and the subsequent need for monitoring.² A nutrition support team (NST) is a multi-disciplinary team of physicians, dietitians, nurses and pharmacists who are to guide patients through nutrition therapy.³ Several studies have shown that a nutrition support team can lead to stabilization in the nutrition status of patients, less complications like infections, better compliance of therapy (e.g. radio chemotherapy), decreased hospital stays (e.g. up to 4.5 days) and therefore less in-patient costs (e.g. 1.26 ± 0.75 thousand US dollars person-times).⁴

There are also advantages regarding clinical nutrition and economy seen in the home care sector. Nowadays, technological advances in the home care setting allow patients to be discharged early from the hospital. The advantages of home enteral nutrition (HEN) and home parenteral nutrition (HPN) relate to improved quality of life (QoL), survival and economic outcomes. Home care services are cost-effective when compared to typical per day charges in a hospital or a skilled nursing facility and reduce re-hospitalizations.¹

1. Winkler M. et al. Home nutrition support. In: The ASPEN Adult Nutrition Support Core Curriculum, 3rd Edition. C.M. Mueller, ed. American Society for Parenteral and Enteral Nutrition: Silver Spring, MD, 2012, page 640
2. Howard P. et al. Managing the patient journey through enteral nutritional care. Clin Nutr. 2006;25: 187-95.
3. Cederholm T. et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr. 2017 Feb 36 (1): 49-64.
4. Cong M.H. et al. An Interdisciplinary Nutrition Support Team Improves Clinical and Hospitalized Outcomes of Esophageal Cancer Patients  with Concurrent Chemoradiotherapy. Chin Med J (Engl). 2015 Nov 20;128 (22): 3003-7.

Fact:

Clinical nutrition is also safe and effective at home if used according to a guideline-based standard operating procedure.^1,2,3

For decades enteral and parenteral nutrition has been able to be administered at home. 

The advantages of home enteral nutrition are a reduction in complications, hospital admission and healthcare costs.⁴ Therefore, policies developed in combination with the National Institute for Clinical Excellence (NICE) guideline on nutrition support point out the importance of a high-quality nutrition support service.^3,5,6 However, the availability of a dedicated home enteral nutrition (HEN) program consisting of healthcare providers, including nurses, dietitians, physicians, as well as speech and occupational therapists varies between countries and centers.⁶

Home parenteral nutrition (HPN) is a much more complex therapy, as life-threatening complications like bloodstream infections can occur if it is not used properly. Therefore, the ESPEN Guidelines on HPN recommend: "There should be a formal teaching program for the patient and/or caretaker. The teaching program should include catheter care as well as pump use, and the prevention, recognition and management of complications. Experienced nurses are usually best placed to take responsibility for the teaching program.”²

HPN administration with a high quality standard can be safely performed with a relatively low rate of central venous catheter (CVC) complications.² Patients with a benign disease such as chronic intestinal failure (CIF) and concurrent HPN dependency have a high probability of long-term survival (about 80 % in adults and 90 % in children at 5 years).⁷

1. Lochs H. et al. Introductory to the ESPEN Guidelines on Enteral Nutrition: Terminology, Definitions and General Topics. Clin Nutr. 2006; 25: 180–186.
2. Staun M. et al. ESPEN Guidelines on Parenteral Nutrition: Home Parenteral Nutrition (HPN) in adult patients. Clin Nutr. 2009; 28: 467–47
3. Ojo O. Home enteral nutrition NICE guidelines and nutrition support in primary care. Br J Community Nurs. 2010 Mar;15 (3): 116-8, 120.
4. Klek S. et al. Home enteral nutrition reduces complications, length of stay, and health care costs: results from a multicenter study. Am J Clin Nutr. 2014; 100: 609–1.
5. Gramlich L. et al. Home Enteral Nutrition: Towards a Standard of Care. Nutrients. 2018 Aug 4; 10(8):1020. Doi: 10.3390/nu10081020.
6. National Institute for Health and Care Excellence (NICE) Nutrition support in adults. Quality standard Home Enteral Nutrition: Towards a Standard of Care. 2012.
7. Pironi L. et al. Outcome on home parenteral nutrition for benign intestinal failure: a review of the literature and benchmarking with the European prospective survey of ESPEN. Clin Nutr. 2012; 31: 831-45.

Fact:

Starving the patient does not starve the tumor.¹

The myth of “starving the tumor“ often creates fear in the press or in the minds of concerned cancer patients, but starving the patient during the active treatment against cancer means caloric restriction, which leads to a deficiency of macro and micronutrients, resulting in weight loss and malnutrition. These two parameters influence cancer patients negatively.² The results of an analysis of 240 patients showed a statistically significant correlation between "poor" nutritional status (depressed nutritional indexes) and "high" labeling index (increased tumoural growth).¹

1. Bozzetti F. et al. Relationship between nutritional status and tumor growth in humans. Tumori. 1995; 81(1): 1-6.
2. Arends J. et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017; 36(1): 11-48.

Fact:

The healing of wounds requires optimal nutrition. ^1,2

Optimal wound healing requires adequate nutrition with all the needed macro and micronutrients.1 Nutrition deficiencies interfere with the normal processes of wound healing through all the stages.1 Malnutrition has also been related to decreased wound tensile strength and increased infection rates.1

Optimal nutritional care for wound healing includes:¹

• A sufficient energy amount, as energy is necessary for anabolism, protein synthesis, collagen formation, and wound healing.
• The optimal protein content is necessary for the synthesis of the enzymes involved in wound healing, the proliferation of cells and collagen, and the formation of connective tissue. The amino acids arginine and glutamine have been studied extensively in this field.
• Essential fatty acids are essential for wound healing.
• Ensuring adequate water intake is mandatory for perfusion and oxygenation healing as well as for healthy tissues.
• Standard multivitamins with minerals are recommended for patients with wounds and in the event deficiencies are confirmed or suspected. A special role is played by vitamin A, vitamin C and zinc.
   

There is a need to further investigate whether the usage of standard oral nutritional supplements or single use substances like glutamine, zinc or others improves the wound healing process. Optimal nutrition and hydration play not only an important role in wound healing in general but also in preserving skin and in supporting tissue repair for pressure ulcer healing.²

1. Stechmiller J.K. Understanding the Role of Nutrition and Wound Healing. Nutr Clin Pract. 2010; 25: 61-68.
2. Posthauer M.E. et al. The Role of Nutrition for Pressure Ulcer Management: National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance White Paper. Advances in Skin & Wound Care. 2015; 28(4): 175-188.

Fact:

Clinical nutrition therapy only starts from dietary recommendations but comprises many treatment options, which are managed by a multidiciplinary team.1,2

Providing high quality in clinical nutrition care means doing the right thing, at the right time, in the right way for the right person and achieving the best possible results. The systematic approach to providing high-quality nutrition care is the nutrition care process and not “general DIETARY advice”.³

The nutrition care process includes:¹

• Malnutrition risk screening
• Nutritional assessment
• Diagnostic procedure
• Nutritional care plan
• Nutritional care
• Nutrition therapy
• Monitoring and evaluating the effects of nutritional care and therapy
• Documentation
   

The nutrition care plan, including enteral and/or parenteral nutrition, shall be developed with an interdisciplinary approach involving the patient, caregivers and/or family, the patient’s referring physician, healthcare providers, and other healthcare professionals.²

Fact:

Clinical nutrition at home is a live-saving therapy for patients with irreversible intestinal failure. ^1,2

Intestinal failure occurs when the intestines are not able to digest food and absorb macronut-rients, micronutrients and fluids that are essential to live. Intestinal failure is often caused by short bowel syndrome or digestive disorders like Crohn's Disease.¹

For the treatment of chronic intestinal failure (CIF) in patients with a benign disease, the administration of intravenous nutrients and fluids are an option. The relatively low morbidity and mortality associated with home parenteral nutrition (HPN) as a part of clincical nutrition has encouraged its widespread use in western countries for this special patient group.²

A prospective survey from ESPEN about patients with CIF due to a benign disease found out that patients with CIF on HPN have a high probability of long-term survival (about 80 % in adults and 90 % in children at 5 years).³

1. Allan P. and Simon S. Intestinal failure: a review. F1000 Res. 2018; 7: 85.

2. Staun M. et al. ESPEN Guidelines on Parenteral Nutrition: Home Parenteral Nutrition (HPN) in adult patients. Clin Nutr. 2009; 28: 467–479.

3. Pironi L. et al. Outcome on home parenteral nutrition for benign intestinal failure: a review of the literature and benchmarking with the European prospective survey of ESPEN. Clin Nutr. 2012; 31: 831-45.

Fact:

The goal of clinical nutrition at home is not only to save lives by providing adequate nutrients but also to improve quality of life and to allow for socio-professional rehabilitation.^1,2

Clinical nutrition at home can be divided into enteral tube feeding and/or parenteral nutrition at home.

Enteral tube feeding is a life-saving technique for patients with a functioning gut, who are unable to consume sufficient food and fluids via the oral route, e.g. patients who have swallowing difficulties. Data from national registers and retrospective studies show that many people receiving enteral nutrition at home live independently and manage their daily care while achieving normal activity levels.³

Home parenteral nutrition (HPN) provides long-term delivery of intravenous fluids and nutrients to individuals who have maldigestion or malabsorption issues due to gastrointestinal (GI) disease or failure.⁴ The current ESPEN Guidelines on HPN points out that the goal of HPN is not only to save lives in providing adequate nutrients but also to improve the quality of life (QoL) of patients and allow for socio-professional rehabilitation.¹ This is in line with a qualitative analysis (using content and interpretative phenomenological questions). The majority of participants with HPN described their QoL as “good” to “wonderful”⁵, even if their lifestyle was affected by several factors from the underlying disease and respective burden e.g. having an ostomy.²

1. Staun M. et al. ESPEN Guidelines on Parenteral Nutrition: Home Parenteral Nutrition (HPN) in adult patients. Clin Nutr. 2009; 28: 467–479.
2. Winkler M.F. et al. An Exploration of Quality of Life and the Experience of Living With Home Parenteral Nutrition. JPEN. 2010; 34: 395-407.

3. Medical Nutrition International Industry. Better care through better nutrition: Value and effects of Medical Nutrition. 2018. Fourth Version: Page 171. https://european-nutrition.org/wp-content/uploads/2018/03/Better-care-through-better-nutrition.pdf Download on Oct. 2019
4. Pironi L. et al. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr. 2016; 35: 247-307.
5. Orrevall Y. et al. Home parenteral nutrition:  A qualitative interview study of the experiences of advanced cancer patients and their families. Clin Nutr. 2005; 24, 961–970. 

Fact:

Patients with benign disease receiving clinical nutrition at home may enjoy lives spanning many decades.^1,2

Enteral tube feeding is a life-saving technique. Without it, patients with a functioning gut, but who are unable to consume sufficient food and fluids via the oral route to meet their nutritional needs would die due to dehydration and starvation.³ The main indication for enteral tube feeding is dysphagia, and the underlying diseases are a neurological disorder, or head and neck cancer.⁴

Chronic Intestinal Failure (CIF) is the long-lasting reduction of the gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. Home parenteral nutrition (HPN) is the primary treatment for CIF.⁴

The results of a UK national referral center for intestinal failure showed that HPN dependence in survivors with CIF was 83 %, 63 %, 59 % and 53 % at 1, 5, 10 and 15 years.¹

The underlying disease is one of the main factors relating to outcome.⁵

1. Pironi L. et al. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr. 2016; 35: 247-307.
2. Dibb M. et al. Survival and nutritional dependence on home parenteral nutrition: Three decades of experience from a single referral centre. Clin Nutr. 2017; 36: 570-576.
3. Medical Nutrition International Industry. Better care through better nutrition: Value and effects of Medical Nutrition. 2018. Fourth Version: Page 171. https://european-nutrition.org/wp-content/uploads/2018/03/Better-care-through-better-nutrition.pdf Download on Oct. 2019.
4. Gramlich L. et al. Home Enteral Nutrition: Towards a Standard of Care. Nutrients. 2018 Aug 4; 10(8):1020. Doi: 10.3390/nu10081020.
5. Martin K., Gardner G. Home Enteral Nutrition: Updates, Trends, and Challenges. Nutr Clin Pract. 2017 Dec; 32(6): 712-721.