Recommended Read (December 2013)

  The Education Committee is very happy to present another edition of recommended read to our members. Eating plenty of food (nutritious or not) is an important part of this festive period and naturally this edition is focussing on nutrition.

  It is not surprising that there are many difficulties in achieving full enteral caloric intake in critically ill patients in intensive care units (ICU). Vomiting, increased gastric residual volume, abdominal distension and diarrhoea all could contribute to limiting enteral feeds in these patients. However should the nutritional advice for these patients be different in Europe and America? The American Society of Parenteral and Enteral Nutrition (ASPEN) and Society of Critical Care Medicine (SCCM) guidelines ( Crit Care Med 2009; 37: 1757-61) recommend that parenteral nutrition be initiated after 1 week, unless the patient is severely malnourished. By contrast, the European Society of Enteral and Parenteral Nutrition (ESPEN) guidelines (http://espen.info/documents/0909/Intensive%20Care.pdf) recommend consideration of a combination of enteral and parenteral nutrition after only 2-3 days in ICU if enteral nutrition alone is insufficient at that time. Heidegger et al has published the results of their supplemental parenteral nutrition (SPN) study in Lancet (Lancet 2013 May 18; 381(9879):1716-7). 305 patients (12% of ICU admissions) who were randomly assigned to receive SPN starting from day 4 after ICU admission, calculated to match the caloric needs determined by indirect calorimetry had fewer infections (Hazard ratio 0.65) and a shorter time on mechanical ventilation than patients who did not receive SPN. However this study does not appear to be the final word on this continuing debate. Heidegger’s study results contrast with those from the large prospective controlled Impact of Early Parenteral Nutrition Completing Enteral Nutrition in Adult Critically Ill Patients (EPaNIC) study (NEJM. 2011 Aug 11; 365(6):506-17) . 4640 patients (53% of ICU admissions) were randomly allocated to start parenteral nutrition early (on day 2), according to ESPEN guidelines or late (day 8), as recommended by ASPEN/SCCM guidelines. Overall, there were fewer complications and earlier discharge from the ICU in the late than in early parenteral nutrition group. Taken together, the data from these two studies suggest that there is no urgency to start parenteral nutrition. Early parenteral nutrition could be started for patients with malnutrition. Both these studies have not addressed the important question of optimum protein intake, which might play a more important role in outcomes than the amount of calories.

  Last month we have talked about increased prevalence of coeliac disease in South Wales. However this phenomenon does not appear to be restricted to Wales. In their paper published in Pediatrics Lois E. White, Victoria M. Merrick, Elaine Bannerman, Richard K. Russell, Dharam Basude, Paul Henderson, David C. Wilson and Peter M. Gillett (Pediatrics Vol. 132 No. 4 October 1, 2013 pp. e924 -e931) describes their experience of increasing incidence of coeliac disease in south east  Scotland. They have noted that the incidence of paediatric coeliac disease has increased 6.4 fold in the last 20 years. The incidence of classic case of coeliac disease has gone up from 1.51/100,000 in 1990 - 1994 to 5.22/ 100,000 in 2005-2009. The authors consider many possible causes for this increase in classic cases of coeliac disease including rise in immune mediated conditions like T1DM, asthma and IBD, reduction in the rate of breast feeding etc. However they believe that some unexplained factor is behind this rise, it could be that young scots are forsaking their breakfast porridge by caving into the pressures brought on by the glitzy advertisements of gluten rich cereals.

  It could be frustrating at sometimes to acknowledge that we do not have an effective remedy for patients with irritable bowel syndrome (IBS). Many dietary approaches have been tried and the latest trend in adult practice is to start on FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet). The hypothesis that reducing intake of FODMAPs can improve gastrointestinal symptoms stems from the clinical observation that a proportion of patients with IBS tolerate intake of certain short-chain carbohydrates poorly. The article by Halmos et al published in Gastroenterology (Gastroenterology. 2014; 146:67–75) provides some evidence of this approach. In a randomized, controlled trial, the authors demonstrate that reducing the intake of poorly absorbed short-chain carbohydrates, or fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) substantially improves the severity of the key symptoms of IBS.  There are some limitations with the study. A relatively limited number of patients (n = 30) were included, which limits the possibility of finding predictors for a favourable response, which is a clinically important question, as not all patients respond favourably to this treatment alternative. Further, a relatively short treatment period (3 weeks) was used and currently no scientific guidance exists on how this diet works in the long run or if gradual reintroduction of excluded food items can be done without worsening of symptoms. Moreover, so far no study has demonstrated that this diet therapy is superior to the dietetic practice that has been used for patients with IBS before a low-FODMAP diet was suggested as a treatment alternative for IBS, that is, to encourage a regular meal pattern and a “healthy eating,” to avoid large meals, reduce intake of fat, discourage excessive fibre intake (especially soluble fibres), reduce caffeine, and avoid gas-producing foods, such as beans, cabbage, and onions. We would need some evidence in children before we adopt this dietary intervention as a treatment of IBS in children. I hope many of our enthusiastic dieticians in the society will take the lead in setting up a clinical trial to try out this hypothesis behind the FODMAP diet.

  Weaning children from tube feeding is not always as easy as it sounds. Wilken et al had published their experience in Germany of a rapid home based weaning of small children with feeding tube dependency (Arch Dis Child 2013; 98:11 856-861). The weaning programme achieved establishment of oral feeding in 89.7% of children (total of 39 children). Professor Wright has written an editorial in the same journal (Arch Dis Child 2013; 98:11 838-840) giving out key practical tips in weaning these children from tube feeds. These tips include making the children hungrier by reducing the energy intake by 20% , developing children’s feeding skills when they are young, anticipate weight loss in the early stages of weaning, assessment of nutrition by measuring skin fold thickness rather than relying only on conventional parameters like weight and height. Children with neurodevelopmental problems and older children could take a longer time to achieve the oro-motor skills compared to younger infants without neurologic problems. Professor Wright appears to be concerned about the prospect of children and families needing to travel abroad and pay a private psychologist to achieve tube feed weaning and urge us to develop multi-disciplinary tube weaning clinics in the UK health service.

  The education committee is very fond of breakfast.  Hence I was disappointed to see that many socioeconomically disadvantaged women in Australia do not eat breakfast (J.Nutr.  2013 143: 1774-1784). The authors thought naturally that this must be bad for these women and they found that breakfast skipping is associated with a lack of nutritional knowledge in general. All of our members would have noticed that many supermarkets claim that weekly shop from them would be cheaper compared to their competitors, if not they would be happy to ‘price match’ to keep your customs. When finances are squeezed many families would naturally like to keep their weekly shopping bills reduced. Could this strategy affect our nutritional status? A study published in Nutrition Journal (2013; 12:117, doi: 10.1186/1475-2891-12-117) finds that supermarkets in Vancouver with lower prices per average food basket are frequented by people with higher body mass index (BMI). Authors suggest that ‘’ careful manipulation of food prices may be used as an intervention for decreasing BMI. ’’ If our society members have not finalised their New Year resolution, it would be good to consider ‘eating a more expensive breakfast every day.’

  As usual most of these articles can be obtained by your Athens account and I would encourage our trainee members to read these articles in full. Please feedback by emailing myself or Carla.

  We wish you all a Merry Christmas and a very Happy New Year.

Rafeeq
Chair of Education committee
December 2013