Reimagining Nutrition Care and Mealtimes in Long-Term Care

Poor food and fluid intake and subsequent malnutrition and dehydration of residents are common, longstanding challenges in long-term care (LTC; eg, nursing homes, care homes, skilled nursing facilities). Institutional factors like inadequate nutrition care processes, food quality, eating assistance, and mealtime experiences, such as staff and resident interactions (ie, relationship-centered care) are partially responsible and are all modifiable. Evidence-based guidelines on nutrition and hydration for older adults, including those living with dementia, outline best practices. However, these guidelines are not sector-specific, and implementation in LTC requires consideration of feasibility in this setting, including the impact of government, LTC home characteristics, and other systems and structures that affect how care is delivered. It is increasingly acknowledged that interconnected relationships among residents, family members, and staff influence care activities and can offer opportunities for improving resident nutrition. In this special article, we reimagine LTC nutrition by reframing the evidence-based recommendations into relationship-centered care practices for nutrition care processes, food and menus, eating assistance, and mealtime experience. We then expand this evidence into actions for implementation, rating these on their feasibility and identifying the entities that are accountable. A few of the recommended activities were rated as highly feasible (6 of 27), whereas almost half were rated moderate (12/27) and the remainder low (9/27) owing to the need for additional staff and/or expert staff (including funding), or infrastructure or material (eg, food ingredients) investment. Government funding, policy, and standards are needed to improve nutrition care. LTC home leadership needs to designate roles, initiate training, and support best practices. Accountability will result from enforcement of policies through auditing of practice. Further evidence on these desirable nutrition care and mealtime actions and their benefit to residents’ nutrition and well-being is required.     

胰十二指肠切除术后患者临床营养的护理

目的总结胰十二指肠切除术后患者肠外营养（PN）和肠内营养（EN）的护理体会。方法回顾性分析了57例接受胰十二指肠切除术患者的临床资料，所有患者均于术前接受中心静脉置管，术中行空肠造瘘，术后给予PN和EN支持。结果PN中位时间为8天（5～24天），EN中位时间为21天（5～69天），平均术后肛门排气时间（72．5±19．8）小时，术后住院的中位时间为24天（17～74天）。57例患者中，1例于围手术期死亡，2例因严重腹胀、腹泻中止EN；41例出现腹胀，17例发生腹泻；中心静脉导管脱出和堵塞各2例，空肠造瘘未出现导管并发症；29例出现糖代谢严重异常，2例伤口裂开，19例次发生术后感染。结论胰十二指肠切除术后需要联合PN和EN，治疗中应坚持无菌配液、严格管路护理、注意血糖变化和加强心理治疗。     

Randomized Trials in Critical Care Nutrition

Background: The purpose of this methodological review is to quantify and qualify critical care nutrition randomized controlled trials (RCTs) that inform our practice, to evaluate their strengths and limitations, and to recommend strategies for improving the design of future trials in this area. Methods: The literature was systematically reviewed to find all RCTs published between 1980 and December 2008 that evaluated nutrition interventions in critical care. Data were abstracted on the nature and quality of included RCTs. Results: A total of 207 RCTs met the inclusion criteria. Of these, 170 (82.1%) were single‐center, and 37 (17.9%) were multicenter. The largest number of trials evaluated intensive insulin therapy (n = 25), arginine‐supplemented diets (n = 22), and supplemental parenteral glutamine (n = 17). The first RCTs were published in 1983 (n = 2), and the mean sample size was 39.0. In 2008, there were 26 RCTs, each enrolling an average of 237.1 patients. Excluding 2 cluster RCTs, 62 of 205 (30.2%) trials had concealed randomization, 125 of 205 (61.0%) reported on intention‐to‐treat analyses, and 69 of 205 (33.7%) had a double‐blinded intervention; 18 of 205 (8.8%) studies reported on all 3 design characteristics. Currently, 60 critical care nutrition RCTs (18 multicenter trials) are registered on clinical trials registries. Conclusions: The future of clinical critical care nutrition research is promising, with more trials of increasing sample size being conducted. Robust trial methodology, transparent reporting, and the development of research networks will help to further advance this important field.     

Outcome Indicators for Home Parenteral Nutrition Care

Background and Aims: Patients receiving home parenteral nutrition (HPN) deserve a high‐quality and patient‐centered care. Patient‐centered care can be delivered only if the patient's priorities and concerns are known. Therefore, the aim is to identify the top 3 most important outcome indicators according to patients' perspectives and the differences between several centers, HPN regimen, and HPN experience. Methods: A questionnaire, based on previously developed outcome indicators, was translated into the mother tongue using forward‐backward translation and distributed to adult HPN patients with benign disease in March 2013. To identify differences, a Kruskal‐Wallis or Mann‐Whitney test was performed with GraphPad Prism (significance level <.05) when applicable. Results: Nine centers over 8 countries (300 patients) participated. The top 3 outcome indicators for patients were (1) incidence of catheter‐related infection (CRI), (2) survival, and (3) quality of life (QoL). Between the participating centers, significant differences on rating were found for 5 outcome indicators (catheter obstruction, .015; weight, .002; energy, .010; fear, <.001; and independence, .010). The independence outcome indicator (.050) was considered less important for experienced (>2 years HPN) vs less experienced patients. For this outcome indicator, patients' view also differed significantly based on number of HPN days per week (.0103). Conclusion: A cohort of HPN patients identified incidence of CRI, survival, and QoL as the most important outcome indicators for their care; however, there were significant differences between the participating centers. For one outcome indicator (independence), there were significant differences based on experience and regimen.     

Nutrition Rehabilitation in the Intensive Care Unit

The maintenance of homeostasis after severe injury requires the restoration of the physiological regulation of food intake. A wide array of functional alterations can hinder the intake of adequate amounts of nutrients to support the recovery from critical illness. These alterations encompass changes in the preprandial phase, reflected by a loss of appetite; changes in the prandial phase, yielding swallowing disorders; and changes in the postprandial phase, including impairments of gastric emptying, gut motility, and satiety. This tutorial aims to review these often overlooked features and to suggest recommendations for the nutrition rehabilitation of the critically ill.     

Nutrition Measures for Managed Care Report Cards

Health plan “report cards,” that is, published summaries of health plan performance, are a new way to help consumers select a health plan on the basis of cost and quality. The Health Plan Employer Data and Information Set (HEDIS) includes a set of health plan performance measures, standardized definitions, and methods for data collection. HEDIS is used as the basis for many report card initiatives and is the preferred tool of the managed care industry for measuring health plan performance. Nevertheless, the current list of HEDIS performance measures omits many health services, including medical nutrition therapy. Nutrition measures have the potential for wide appeal among health care stakeholders (ie, payers, consumers, and providers). Four measures related to medical nutrition therapy are proposed for managed care report cards: staffing for nutrition services and medical nutrition therapy for high cholesterol level, gestational diabetes, and cardiovascular disease. Barriers to adopting medical nutrition therapy measures in HEDIS include the need to address technical issues before considering new measures and competition from other potential measures. Steps to create support for medical nutrition therapy measures in HEDIS should focus on influencing representatives of health plans and employers to include these measures. The involvement of registered dietitians in the dynamic process of health plan evaluation is an important extension of ongoing efforts for strategic positioning in the managed care market. J Am Diet Assoc. 1996; 96:374-380.     

Use of the Nutrition Care Process and Nutrition Care Process Terminology in an International Cohort Reported by an Online Survey Tool

Background

Dietitians in countries across the world have been implementing the Nutrition Care Process (NCP) and Terminology (NCPT) during the past decade. The implementation process has been evaluated in specific countries and in smaller international studies; however, no large international study comparing implementation between countries has been completed.

Position of the Academy of Nutrition and Dietetics: Benchmarks for Nutrition in Child Care

It is the position of the Academy of Nutrition and Dietetics that early care and education (ECE) programs should achieve recommended benchmarks to meet children’s nutrition needs and promote children’s optimal growth in safe and healthy environments. Children’s dietary intake is influenced by a number of factors within ECE, including the nutritional quality of the foods and beverages served, the mealtime environments, and the interactions that take place between children and their care providers. Other important and related health behaviors that may influence the development of obesity include children’s physical activity, sleep, and stress within child care. Recent efforts to promote healthy eating and improve other health behaviors in ECE include national, state, and local policy changes. In addition, a number of interventions have been developed in recent years to encourage healthy eating and help prevent obesity in young children in ECE. Members of the dietetics profession, including registered dietitian nutritionists and nutrition and dietetics technicians, registered, can work in partnership with ECE providers and parents to help promote healthy eating, increase physical activity, and address other important health behaviors of children in care. Providers and parents can serve as role models to support these healthy behaviors. This Position Paper presents current evidence and recommendations for nutrition in ECE and provides guidance for registered dietitian nutritionists; nutrition and dietetics technicians, registered; and other food and nutrition practitioners working with parents and child-care providers. This Position Paper targets children ages 2 to 5 years attending ECE programs and highlights opportunities to improve and enhance children’s healthy eating while in care.     

Nutrition Screening Practices in Adult Day Care Centers

Older adults have been identified as one of the largest groups at risk of malnutrition in America and represent the target population of the Nutrition Screening Initiative. At the University of Delaware Adult Day Care Center, nutrition screening is an integral component of basic services provided to clients and their caregivers. To determine the extent of current nutrition screening practices in other adult day care centers, centers across the United States were surveyed. A total of 160 centers (53%) responded, 101 indicated nutrition screening was an on-going service. A number of differences and similarities in nutrition screening parameters was evident. Most centers responding assessed the following parameters: food intolerance, medical history, weight, height, swallowing difficulties, and bowel habits. Hematological parameters and other anthropometric measurements were evaluated with least frequency. Interest in nutrition screening appeared great. Further research should examine relationships between nutrition screening and other factors such as staffing patterns, center settings, and funding sources.     

Need for Intensive Nutrition Care After Bariatric Surgery

Severe nutrition complications after bariatric surgery remain poorly described. The aim of this case series was to identify specific factors associated with nutrition complications after bariatric surgery and to characterize their nutrition disorders. We retrospectively reviewed all people referred to the clinical nutrition intensive care unit of our university hospital after bariatric surgery from January 2013 to June 2015. Twelve persons who required artificial nutrition supplies (ie, enteral nutrition or parenteral nutrition) were identified. Seven persons underwent a “one‐anastomosis gastric bypass” (OAGB) or “mini gastric bypass,” 2 underwent a Roux‐en‐Y gastric bypass, 2 had a sleeve gastrectomy, and 1 had an adjustable gastric band. This case series suggests that OAGB could overexpose subjects to severe nutrition complications requiring intensive nutrition care and therefore cannot be considered a “mini” bariatric surgery. Even if OAGB is often considered a simplified surgical technique, it obviously requires as the other standard bariatric procedures a close follow‐up by experimented teams aware of its specific complications.     

Food and Nutrition Care in Long-Term Care Facilities: Examining the Perspectives of Frontline Workers

Abstract

Malnutrition in older adults residing in long-term care facilities continues to be a problem in the United States. Existing research has identified a list of possible contributing factors, including staffing problems. Few studies on food and nutrition care have attempted to gain the perspectives of nursing or dietary aides (henceforth, aides), the frontline staff who work most closely with the residents of long-term care facilities. The current study takes a qualitative approach grounded in a theoretical perspective based on Total Quality Management (TQM) to increase understanding of the interpersonal and management practices that affect resident wellbeing, health, and nutrition. Four focus groups (n?=?24) were conducted with aides working in long-term care facilities. Aides expressed emotional closeness with residents and provided detailed knowledge about food and nutrition care. They reported both compassion fatigue and satisfaction. An element of dissatisfaction related to aide relationships with management and other employees who did not actively solicit their perspectives and knowledge on resident feeding. The knowledge and experience of aides could be better utilized by shifting management strategies to focus on employee empowerment and training. Principles of TQM could be applied to improve food and nutrition care in long-term care facilities.