WORKSHOP REPORT Nutrition Vol. 12, No. 3, 1996

Workshop Spreads Nutrition Message Across Europe

JOHN MACFIE, MD, FRCS

Combined Gastroenterology Unit, Scarborough Hospital, Scarborough, N. Yorks, UK

A recent educational media workshop organized by Phar- macia and Upjohn was held in conjunction with the XXVIItb Congress of the European Society of Parenteral and Enteral Nutrition (ESPEN). The workshop was organized to dissemi- nate information about the clinical significance of providing adequate nutrition. Recent studies identified that inadequate education of health care professional and the public is hindering widespread recognition of the role that nutrition can play in influencing clinical outcome and improving quality of life.

Twenty journalists from 10 European countries were invited to attend presentations by recognized experts in the field of nutrition. The workshop addressed several key issues on the importance of nutrition.

The Injluence of Nutrition on Clinical Outcome

The deleterious effects of malnutrition on a wide variety of patients were reviewed by Professor H. Lochs from Germany. Professor Lochs indicated that improved nutrition has been shown to improve liver function and survival in patients with cirrhosis and to prevent or reverse inhibition of growth in chil- dren with Crohn’s disease.

Professor Lochs also focused on the use of glutamine-an essential nutrient during catabolic illness, which, until recently, has not been included in parenteral nutrition solutions because of its instability. He emphasized the success of glutamine in improving gut function, preventing infections, increasing nitro- gen balance and reducing complications and duration of hospi- talization.

Cost-Effectiveness of Nutritional Support

Dr. S. Allison from the United Kingdom reported on an increased incidence of morbidity and mortality resulting from a loss of body weight of more than 10-B%. He explained that malnutrition can impair functional capacity in several ways, through reduced muscle strength, immune function and wound healing as well as inducing apathy and depression.

Nutritional intervention has been shown to produce rapid improvement in function and reduce the number of complica- tions and length of hospital stay. Dr. Allison recommended that nutritional support should be regarded as a system with which to sustain patients with gastrointestinal failure-just as ventila- tion or dialysis has been shown to support patients with lung

or kidney failure. The cost benefit and improved quality per year of life of patients receiving nutritional support is no greater than that of these well-accepted medical technologies.

Just as ventilation and dialysis are best performed by teams of health care providers specializing in these techniques, so nutritional intervention is best carried out by nutrition support teams. Studies have shown that nutrition support teams achieve more appropriate patient selection, reduce complications and improve outcome compared with nonspecialist personnel. As a result, they also obtain significant cost savings. Results from one such study were presented by Dr. M. Sagoo from the United Kingdom at the ESPEN conference. He reported that 52% of the total estimated cost of total parenteral nutrition (TPN) ad- ministration in a large London teaching hospital was wasted due to usage deemed inappropriate or of debatable beneft.

Pyschological, Social and Physical Consequences of Malnutrition

The reality of malnutrition and the requirement of parenteral nutrition from a patient’s perspective was discussed by Ms. Carolyn Wheatley from the United Kingdom, who has been maintained on parenteral nutrition for over 10 years. Ms. Wheatley described how she suffered from undiagnosed health problems for 8 years before her malnutrition was recog- nized and treated. Symptoms included severe pain, vomiting and weight loss. Psychologically, her confidence and self- esteem deteriorated, and her ability to concentrate was greatly reduced. Unable to cope with her underlying disease before administration of TPN, Ms. Wheatley’s quality of life since has significantly improved. She is currently General Secretary of Patients on Intravenous, Nasogastric, and Nutrition Therapy, a patient support group in the United Kingdom that provides patients and caregivers with support and understanding and educates health care professionals on the benefits of home par- enteral nutrition.

The advantages of home TPN usage in patients with short bowel syndrome, intestinal obstruction and other chronic non- malignant gastrointestinal diseases was also stressed in a retro- spective home TPN study. Malnutrition in the Human Immunodejciency Virus (HIV) and AIDS

Progressive weight loss appears to be a major predictor of clinical outcome in patients with HIV or AIDS, according to

Further information on the computer-aided learning program can he obtained from Lilian Bjelron, Pharmacia & UpJohn, S-l 12 87 Stockholm, Sweden, Office Franzengaran 9.

Nutrition 12:227-228, 1996 OElsevier Science Inc. 1996 Printed in the USA. All rights reserved.

0899-9007/96/$15.00 PII: SO899-9007(96)00000-0

228 WORKSHOP REPORT

Professor H. Sauerwein from the Netherlands. He noted that studies have shown that periods of stable weight are inter- spersed with episodes of rapid wasting during active secondary infections. Thus, treatment of infections can help prevent wast- ing. He stated that prevention of wasting could theoretically have a positive influence on the course of the disease. As with other catabolic illnesses such as sepsis or cancer, the cause of the catabolic changes in patients with AIDS is not well under- stood, although cytokines are thought to be involved.

Growing Importance of Nutritional Support in Oncology

Professor K. Lundholm of Sweden reported that the high incidence of malnutrition in cancer patients is due not only to the disease but also results from therapies given during their illness. Because malnutrition can increase the risk of complica- tions and prolong hospital stay, nutritional therapy is particu- larly important in such patients. Using the Pharmacia computer- aided learning program, Professor Lundholm demonstrated the role and influence from provision of adequate nutritional sup- port at each stage in the management of a cancer patient. By educating the user in how to provide the most appropriate level of nutritional support at each stage of illness, the program illus- trated how it was possible to improve the patient’s quality of life sufficiently to allow a return to work and, once the disease had progressed, to allow the patient to die with dignity at home. Widespread use of such an educational program should help in

training physicians, nurses, dietitians and pharmacists in the most appropriate use of nutritional support. Ethics of Nutritional Support

Professor J. MacFie from the United Kingdom addressed the increasing controversy over the ethics of malnutrition and its therapy in many types of patients over the next decade. He noted that as functional metabolic deficits become evident after only 15 days of semistarvation in previously healthy individuals and more rapidly in those compromised by disease. Nutritional support should be considered in all patients with inadequate oral intake lasting 7-10 days. At present, nutritional therapy is underused, and health care professionals have only just started to confront the financial and ethical implications of its use. Professor MacFie noted that health care providers should not control provision of nutritional support on the basis of cost.

ABCs of Parenteral Nutrition: Pharmacia and UpJohn’s Computer-Aided Learning Program

In an effort to educate health care providers, Pharmacia and UpJohn have developed an interactive computer program to help train and update physicians, nurses, dietitians and pharma- cists. The program consists of modulates covering the basics of nutrition, including anatomy, biochemistry and physiology, and the ABCs of parenteral nutrition. The ABCs of parenteral nutrition include a theoretical section covering aspects of paren- teral nutrition and a practical section in which the users test themselves on appropriate nutritional management of patients.