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Nutrition training in UK medical undergraduate programmes – Has the situation improved?
Abstracts / Clinical Nutrition ESPEN 22 (2017) 116e147
OC7 A SYSTEMATIC REVIEW ON THE EFFECT OF FERMENTABLE OLIGOSACCHARIDE, DISACCHARIDE, MONOSACCHARIDE AND POLYOL MANIPULATION ON BIFIDOBACTERIA ABUNDANCE AND GASTROINTESTINAL SYMPTOMS. IMPLICATIONS WHEN FOLLOWING A LOW FODMAP DIET M.A. Summers. London Metropolitan University, 166-220 Holloway Rd, Holloway, London N7 8DB, UK The low fermentable oligosaccharide, disaccharide, monosaccharide and polyol (FODMAP) diet is gaining attention, proving effective in the management of irritable bowel syndrome (IBS) [1]. FODMAPs can act as prebiotics, stimulating the growth of beneficial Bifidobacterium spp.[2], raising concerns that a low FODMAP diet negatively impacts on colonic health. This systematic review examined the relationship between FODMAPs, bifidobacteria and gastrointestinal (GI) symptoms, thus exploring the effect of FODMAP restriction, not only on IBS symptom management, but also on colonic health. PUBMED, EMBASE, COCHRANE, WEB OF SCIENCE core collection and TRIP databases were searched from March 2006 to 2016, using pre-determined inclusion criteria and a pre-defined search strategy. Key search terms included “oligosaccharide”, “lactose”, “fructose”, “polyol”, “microbiota”, “bifidobacteria” and “irritable bowel syndrome”. Critical appraisal was conducted using critical appraisal skills programme (CASP) tools. Included papers investigated outcomes of individual and collective FODMAP supplementation and restriction on bifidobacteria abundance and GI symptoms in healthy adults and adults with IBS. From 552 located records, six papers spanning five randomised controlled trials were included in narrative synthesis e 3/5 studies were in healthy populations [3e5], 1/5 in IBS only [6], and 1/5 in healthy and IBS populations [7,8]. All studies were carried out in industrialised countries, 3/5 in the UK [4e6]. Oligosaccharide (inulin) supplementation in healthy adults (3/5 studies) significantly increased faecal bifidobacteria abundance [3e5], with levels returning to baseline within two to three weeks of supplementation withdrawal [4,5]. Trials assessing FODMAP restriction (2/5 studies) found a low FODMAP diet significantly reduced bifidobacteria [6,7], and reduced abdominal pain and bloating in IBS populations only [6,8]. The effect of inulin supplementation on GI symptoms in healthy adults produced mixed results [3e5]. No association was found between bifidobacteria abundance and GI symptoms, though only one study measured this outcome [7]. A low FODMAP diet improves common IBS symptoms of abdominal pain and bloating [1,6,8], however faecal bifidobacteria abundance is adversely affected [6,7], suggesting a negative impact on colonic health [2]. While an association between inulin and bifidobacteria abundance is clear [3e5], the effect of lactose, fructose, polyols, and oligosaccharides other than inulin, could not been established by this systematic review. Further research is therefore recommended to enhance understanding, and optimise FODMAP intake for colonic health in those following a low FODMAP diet. References [1] Marsh A, Eslick EM, Eslick GD. Does a diet low in FODMAPs reduce symptoms associated with functional gastrointestinal disorders? A comprehensive systematic review and meta-analysis. Eur J Nutr 2015;55(3):897e906. [2] Roberfroid M, Gibson GR, Hoyles L, et al. Prebiotic effects: metabolic and health benefits. Br J Nutr 2010;104(Suppl. S2):S1eS63. [3] Kleessen B, Schwarz S, Boehm A et al. Jerusalem artichoke and chicory inulin in bakery products affect faecal microbiota of healthy volunteers. Br J Nutr 2007;98(3):540e9. [4] Ramnani P, Costabile A, Bustillo AG, et al. A randomised, double- blind, cross-over study investigating the prebiotic effect of agave fructans in healthy human subjects. J Nutr Sci 2015: published online March 13. http:// dx.doi.org/10.1017/jns.2014.68. [5] Ramnani P, Gaudier E, Bingham M, et al. Prebiotic effect of fruit and vegetable shots containing Jerusalem artichoke inulin: a human intervention study. Br J Nutr 2010;104(2):233e40. [6] Staudacher HM, Lomer MCE, Anderson JL, et al. Fermentable carbohydrate restriction reduces luminal bifidobacteria and gastrointestinal symptoms in patients with irritable bowel syndrome. J Nutr 2012;142(8):1510e8. [7] Halmos EP, Christophersen CT, Bird AR, et al. Diets that differ in their FODMAP content alter the colonic luminal microenvironment. Gut 2015;64(1):93e100.
119
8. Halmos EP, Power VA, Shepherd SJ, et al. A Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome. Gastroenterology 2014;146(1):67e75.e5. OC8 MEDICAL STUDENTS PERCEPTION OF NUTRITION TRAINING AT AN UNDERGRADUATE LEVEL AND THE ROLE OF THE CLINICIANS THEY SHADOW W. Long, P. Neild. St. George's University of London, Cranmer Terrace, London SW17 ORE, UK Medical schools have neglected nutrition training in undergraduate courses, resulting in medical students being unsure of its importance [1], and doctor's graduating from medical school not confident in managing nutrition related problems [2]. The aim of this study was to explore medical students' views and experiences of nutrition education at different stages of their training, and to evaluate the impact of the views of the clinicians they shadowed. A cross-sectional email survey of all medical students in the transitional(T) and final(F) years of the MBBS4 and MBBS5 courses at St. George's University of London was conducted. Clinicians at St. George's hospital were also surveyed with a ten-item questionnaire. The data generated was analysed using SPSS version 21.0 and the significance was determined using a two tailed Fischer's exact test. The overall response rate was 106/549 (19.3%) among the students, with no significant differences between the two year groups. 86 of approx. 500 clinicians responded. 75% of students agreed with the statement “having a strong understanding of nutrition is an important aspect of a doctor's job”. Of those that disagreed, 57% cited the reason that other members of the healthcare team deal with nutrition problems. 71% of students agreed with the statement “nutrition should be included in the undergraduate medical curriculum”. F years were more likely to disagree than T years (12% vs 0%, p¼0.016). Of those that disagreed, 36% cited the reason that “their medical school timetable is too full”. Only 11% of students had had the importance of nutrition highlighted to them by a senior clinician ‘regularly’. Those students were more likely to ‘strongly agree’ with the statements above than those who had not (24% vs 3%, p¼0.02 and 21% vs 6%, p¼0.039). However, only 17% of clinicians frequently emphasised the importance of nutrition problems and only 7% frequently emphasised the importance of nutrition screening tools to students. The most commonly cited reason for not doing so (49% and 51% respectively) was “it does not occur to me to emphasise this”. Only 50% of clinicians reported that they were confident managing nutrition related problems and for the majority (63.4%) of confident clinicians, it took greater than one year as a doctor to achieve this confidence. In conclusion, it appears that whilst senior clinicians do have an impact on how students perceive the importance of nutrition, they do not emphasise it enough and this may be due to themselves viewing it as a low priority or lacking confidence. The greater likelihood of F year students disagreeing with nutrition's inclusion in the curriculum may result from increased time spent on clinical placements compared to T year students, allowing their perception of nutrition to be negatively influenced by the clinicians they shadowed. References [1] Tripisciano F, et al. Medical students$perception of nutrition education at an undergraduate level: an experience of two medical school courses. Proc Nutr Soc 2010, 69(0CE2). [2] Nightingale J, et al. Knowledge about the assessment and management of undernutrition: a pilot questionnaire in a UK teaching hospital. Clin Nutr 1999;18(1):23e7. OC9 NUTRITION TRAINING IN UK MEDICAL UNDERGRADUATE PROGRAMMES e HAS THE SITUATION IMPROVED? W. Long, P. Neild. St. George's University of London, Cranmer Terrace, London SW17 ORE, UK Nutrition-related diseases are an increasing burden that doctors must be trained to manage. Nutrition training has classically been neglected and found to be inadequate. Educational programmes designed to improve nutrition training have reported increased student knowledge [2].
120
Abstracts / Clinical Nutrition ESPEN 22 (2017) 116e147
The aim of this study was to survey the nutrition training provided by UK medical schools and assess the importance of nutrition leads. A fourteen-item questionnaire was sent to academics representing all UK medical schools. The data generated was analysed using SPSS version 21.0 and significance was determined using a two-tailed Fischer's exact test. The response rate was 34% (11/32). Nutrition was given a high priority by two respondents, intermediate by eight and low by one. Students' knowledge was assessed in 8/11(73%) of responding medical schools. The mean total time devoted to nutrition throughout the courses was 8.4 hrs (range of 4 to 40+ hrs). Seven of 10 responded that they taught all four core nutrition topics as part of their undergraduate curriculum. Three of 9 responded that there was a nutrition thread throughout their curriculum. Five of 10 responded that there was a named nutrition lead. Three of 9 responded that their training was adequate. Of those who reported adequate training, all cited ‘increased formal teaching time devoted to nutrition’ and ‘better organisation of the nutrition teaching’ as improvements that facilitated adequate training. Of those who reported inadequate training, 83% cited ‘lack of prioritisation’ and 67% cited ‘being unable to devote more teaching time to nutrition’ and ‘difficulty organising topics and teaching sessions’ as hindrances towards improving training. The presence of a nutrition lead was associated with a trend to greater mean total time allocated to structured teaching (25.4 vs 16.2 hours), and greater likelihood of teaching all four core areas (5 of 5 vs 2 of 5, p¼0.08), but an equal likelihood of formally assessing nutrition knowledge (4 of 5 v. 4 of 5). In conclusion, indicators of good training appear to be more common in courses placing a higher priority on nutrition. Despite a decrease in the percentage of respondents reporting adequate training compared to a previous study in 2009 [1] (33% vs 50%), indicators of good training appear to have increased. This may reflect medical schools becoming more aware of the standards required as a result of the development of a standardised national nutrition curriculum [4]. A named nutrition lead may have a positive impact on nutrition training. References [1] Johnston R, et al. Nutrition training in UK medical undergraduate programme. Proc Nutr Soc 2009, 68(0CE1). [2] Maher B, et al. Evaluation of a novel nutrition education intervention for medical students. Proc Nutr Soc 2013, (OCE3). [3] Taren D. Effect of an integrated nutrition curriculum on medical education, student clinical performance and student perception of medicalnutrition training. Am J Clin Nutr 2001;73:1107e12. [4] GMC. Tomorrow's Doctors. London 2009. http:ttwww.gmc-uk.org/ staticdocuments/content/TomorrowsDoctors.2009.pdf.
compared with estimated requirements. Adequate feeding was defined as 80e110% of estimated requirements. Of the 189 patient records identified from the database, 160 met inclusion criteria. The median duration of vv-ECMO was 10.0 (IQR, 7.0e17.8) days. Whilst on vv-ECMO, the median energy intake was 89.5% (IQR, 80.5e95.9%) and the median protein intake was 85.0% (IQR, 75.0e98.0%) of estimated requirements. Whilst on vv-ECMO, inadequate energy (<80% requirements) was delivered on 23.1% days and inadequate protein was delivered on 25.6% days. The gastric route was the most common main route of delivery (93 patients, 58.1%). There was no association in overall energy (p¼0.464) and protein (p¼0.572) intake between gastric, jejunal and parenteral routes. Higher SOFA (Sepsis-related Organ Failure Assessment) score on the first day on vv-ECMO was associated with underfeeding of energy (p¼0.019). The most common reason for interrupted feeding was procedures (36.1%), followed by GI intolerances (23.8%). Stool output of >500 ml/d was more frequent in patients who received adequate energy (p¼<0.001) or protein (p¼0.010) compared to patients who were underfed energy and protein. To our knowledge, this is the largest study ever taken to investigate nutrition support in adult patients receiving vv-ECMO. We showed that, during vv-ECMO, adequate energy and protein intakes are possible regardless of feeding route. However, underfeeding can still occur, especially in those with more severe organ dysfunction. GI intolerances are common. Further research is needed to gain a better understanding of the nutritional needs of patients receiving vv-ECMO and the impact of underfeeding on outcomes in vv-ECMO. References [1] Heyland DK, Dhaliwal R, Wang M, et al. The prevalence of iatrogenic underfeeding in the nutritionally ‘at-risk’ critically ill patient: Results of an international, multicenter, prospective study. Clin Nutr 2015;34(4):659e66. [2] Villet S, Chiolero R L, Bollmann M D, et al. Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr 2005;24(4):502e9. [3] Faisy C, Lerolle N, Dachraoui F, et al. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation. Br J Nutr 2009; 101(7):1079e87. [4] Lukas G, Davies AR, Hilton AK, et al. Nutritional support in adult patients receiving extracorporeal membrane oxygenation. Crit Care Resusc 2010;12(4);230e4.
OC10 OPTIMUM NUTRITIONAL SUPPORT IN ADULTS RECEIVING VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION IS POSSIBLE BUT UNDERFEEDING IS COMMON, ESPECIALLY IN THOSE WITH MORE SEVERE ORGAN DYSFUNCTION
C.M. Fry, S. Ramet, G.P. Hubbard, R.J. Stratton. Medical Affairs, Nutricia Advanced Medical Nutrition, Wiltshire, BA14 0XQ, UK
L. Kaakinen a, E. Smith b, C. Elliott Hammond b, B. Sanderson b, D. Ong b, K. Daly b, N. Barrett b, K. Whelan a, D. Bear b. a King's College London, Diabetes and Nutritional Sciences Division, Stamford Street, London SE1 9NH, United Kingdom; b Guy's & St Thomas' NHS Foundation Trust, Departments of Critical Care and Nutrition and Dietetics, Westminster Bridge Road, London SE1 7EH, United Kingdom Veno-venous extracorporeal membrane oxygenation (vv-ECMO) is increasingly used in adults with severe respiratory failure. However, data on nutritional requirements for these patients are lacking. Patients on the Intensive Care Unit (ICU) are commonly underfed, receiving around 60% of their energy and protein requirements [1]. This underfeeding is associated with increased morbidity [3] and mortality [4]. Studies investigating nutritional support during vv-ECMO reveal underfeeding and gastointestinal (GI) intolerance is common. Our aim was to describe nutritional practices in a single-centre providing vv-ECMO to adult patients. We conducted a retrospective case review of patients receiving vv-ECMO on the ICU at St. Thomas’ Hospital, London. Adult patients admitted to the ICU with severe respiratory failure between December 2010 and March 2015 were included. Patients on vv-ECMO were provided nutrition support according to the same protocol as non-ECMO patients. Data were collected from electronic medical records. Daily energy and protein delivery were
OC11 GP PATIENT DATABASES SHOW THAT MALNUTRITION IS UNDERREPORTED AND UNDER-TREATED IN PATIENTS WITH CHRONIC DISEASE
Disease-related malnutrition is a significant, common and costly problem [1,2], with the majority of those affected living in the community (93%) [1] and under the care of their GP. Patients with chronic disease are particularly vulnerable to the effects of malnutrition and it is recommended that they are routinely screened, and if found to be at risk of malnutrition, appropriately managed (including the use of nutrition support [3]). There is limited recent data available in the literature on the prevalence of malnutrition in patients with chronic diseases and the extent to which the identification and management of malnutrition is undertaken and documented by GPs in such patients. The appropriate use of nutrition support in malnourished patients is also unclear. This study aimed to investigate the recorded prevalence of malnutrition and the use of nutrition support (oral nutritional supplements (ONS) and tube feeds) in community-based malnourished adults with chronic diseases (cancer, COPD, dementia/Alzheimer's and stroke) in the UK. Data was collected from GP databases within the period April 2014eMarch 2015 using electronic longitudinal patient data (IMS Information Solutions UK Ltd), from 1,150,744 adults aged 19+ years (76% 19e65 years, 24% 65+ years) registered with UK GP practices. Patients with a read code for stroke, COPD, dementia/Alzheimer's or cancer, were identified as malnourished if they had a BMI of <18.5 kg/m2 and/or a read code for malnutrition recorded in the GP database. Prescriptions of nutrition support (all available ONS and tube feeds) were also assessed. Overall, 43.5% (501,098) of patients had a BMI recorded, 2.9% (33,877) were identified as malnourished and 0.9% (10,507) were receiving nutrition
OC7 A SYSTEMATIC REVIEW ON THE EFFECT OF FERMENTABLE OLIGOSACCHARIDE, DISACCHARIDE, MONOSACCHARIDE AND POLYOL MANIPULATION ON BIFIDOBACTERIA ABUNDANCE AND GASTROINTESTINAL SYMPTOMS. IMPLICATIONS WHEN FOLLOWING A LOW FODMAP DIET M.A. Summers. London Metropolitan University, 166-220 Holloway Rd, Holloway, London N7 8DB, UK The low fermentable oligosaccharide, disaccharide, monosaccharide and polyol (FODMAP) diet is gaining attention, proving effective in the management of irritable bowel syndrome (IBS) [1]. FODMAPs can act as prebiotics, stimulating the growth of beneficial Bifidobacterium spp.[2], raising concerns that a low FODMAP diet negatively impacts on colonic health. This systematic review examined the relationship between FODMAPs, bifidobacteria and gastrointestinal (GI) symptoms, thus exploring the effect of FODMAP restriction, not only on IBS symptom management, but also on colonic health. PUBMED, EMBASE, COCHRANE, WEB OF SCIENCE core collection and TRIP databases were searched from March 2006 to 2016, using pre-determined inclusion criteria and a pre-defined search strategy. Key search terms included “oligosaccharide”, “lactose”, “fructose”, “polyol”, “microbiota”, “bifidobacteria” and “irritable bowel syndrome”. Critical appraisal was conducted using critical appraisal skills programme (CASP) tools. Included papers investigated outcomes of individual and collective FODMAP supplementation and restriction on bifidobacteria abundance and GI symptoms in healthy adults and adults with IBS. From 552 located records, six papers spanning five randomised controlled trials were included in narrative synthesis e 3/5 studies were in healthy populations [3e5], 1/5 in IBS only [6], and 1/5 in healthy and IBS populations [7,8]. All studies were carried out in industrialised countries, 3/5 in the UK [4e6]. Oligosaccharide (inulin) supplementation in healthy adults (3/5 studies) significantly increased faecal bifidobacteria abundance [3e5], with levels returning to baseline within two to three weeks of supplementation withdrawal [4,5]. Trials assessing FODMAP restriction (2/5 studies) found a low FODMAP diet significantly reduced bifidobacteria [6,7], and reduced abdominal pain and bloating in IBS populations only [6,8]. The effect of inulin supplementation on GI symptoms in healthy adults produced mixed results [3e5]. No association was found between bifidobacteria abundance and GI symptoms, though only one study measured this outcome [7]. A low FODMAP diet improves common IBS symptoms of abdominal pain and bloating [1,6,8], however faecal bifidobacteria abundance is adversely affected [6,7], suggesting a negative impact on colonic health [2]. While an association between inulin and bifidobacteria abundance is clear [3e5], the effect of lactose, fructose, polyols, and oligosaccharides other than inulin, could not been established by this systematic review. Further research is therefore recommended to enhance understanding, and optimise FODMAP intake for colonic health in those following a low FODMAP diet. References [1] Marsh A, Eslick EM, Eslick GD. Does a diet low in FODMAPs reduce symptoms associated with functional gastrointestinal disorders? A comprehensive systematic review and meta-analysis. Eur J Nutr 2015;55(3):897e906. [2] Roberfroid M, Gibson GR, Hoyles L, et al. Prebiotic effects: metabolic and health benefits. Br J Nutr 2010;104(Suppl. S2):S1eS63. [3] Kleessen B, Schwarz S, Boehm A et al. Jerusalem artichoke and chicory inulin in bakery products affect faecal microbiota of healthy volunteers. Br J Nutr 2007;98(3):540e9. [4] Ramnani P, Costabile A, Bustillo AG, et al. A randomised, double- blind, cross-over study investigating the prebiotic effect of agave fructans in healthy human subjects. J Nutr Sci 2015: published online March 13. http:// dx.doi.org/10.1017/jns.2014.68. [5] Ramnani P, Gaudier E, Bingham M, et al. Prebiotic effect of fruit and vegetable shots containing Jerusalem artichoke inulin: a human intervention study. Br J Nutr 2010;104(2):233e40. [6] Staudacher HM, Lomer MCE, Anderson JL, et al. Fermentable carbohydrate restriction reduces luminal bifidobacteria and gastrointestinal symptoms in patients with irritable bowel syndrome. J Nutr 2012;142(8):1510e8. [7] Halmos EP, Christophersen CT, Bird AR, et al. Diets that differ in their FODMAP content alter the colonic luminal microenvironment. Gut 2015;64(1):93e100.
119
8. Halmos EP, Power VA, Shepherd SJ, et al. A Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome. Gastroenterology 2014;146(1):67e75.e5. OC8 MEDICAL STUDENTS PERCEPTION OF NUTRITION TRAINING AT AN UNDERGRADUATE LEVEL AND THE ROLE OF THE CLINICIANS THEY SHADOW W. Long, P. Neild. St. George's University of London, Cranmer Terrace, London SW17 ORE, UK Medical schools have neglected nutrition training in undergraduate courses, resulting in medical students being unsure of its importance [1], and doctor's graduating from medical school not confident in managing nutrition related problems [2]. The aim of this study was to explore medical students' views and experiences of nutrition education at different stages of their training, and to evaluate the impact of the views of the clinicians they shadowed. A cross-sectional email survey of all medical students in the transitional(T) and final(F) years of the MBBS4 and MBBS5 courses at St. George's University of London was conducted. Clinicians at St. George's hospital were also surveyed with a ten-item questionnaire. The data generated was analysed using SPSS version 21.0 and the significance was determined using a two tailed Fischer's exact test. The overall response rate was 106/549 (19.3%) among the students, with no significant differences between the two year groups. 86 of approx. 500 clinicians responded. 75% of students agreed with the statement “having a strong understanding of nutrition is an important aspect of a doctor's job”. Of those that disagreed, 57% cited the reason that other members of the healthcare team deal with nutrition problems. 71% of students agreed with the statement “nutrition should be included in the undergraduate medical curriculum”. F years were more likely to disagree than T years (12% vs 0%, p¼0.016). Of those that disagreed, 36% cited the reason that “their medical school timetable is too full”. Only 11% of students had had the importance of nutrition highlighted to them by a senior clinician ‘regularly’. Those students were more likely to ‘strongly agree’ with the statements above than those who had not (24% vs 3%, p¼0.02 and 21% vs 6%, p¼0.039). However, only 17% of clinicians frequently emphasised the importance of nutrition problems and only 7% frequently emphasised the importance of nutrition screening tools to students. The most commonly cited reason for not doing so (49% and 51% respectively) was “it does not occur to me to emphasise this”. Only 50% of clinicians reported that they were confident managing nutrition related problems and for the majority (63.4%) of confident clinicians, it took greater than one year as a doctor to achieve this confidence. In conclusion, it appears that whilst senior clinicians do have an impact on how students perceive the importance of nutrition, they do not emphasise it enough and this may be due to themselves viewing it as a low priority or lacking confidence. The greater likelihood of F year students disagreeing with nutrition's inclusion in the curriculum may result from increased time spent on clinical placements compared to T year students, allowing their perception of nutrition to be negatively influenced by the clinicians they shadowed. References [1] Tripisciano F, et al. Medical students$perception of nutrition education at an undergraduate level: an experience of two medical school courses. Proc Nutr Soc 2010, 69(0CE2). [2] Nightingale J, et al. Knowledge about the assessment and management of undernutrition: a pilot questionnaire in a UK teaching hospital. Clin Nutr 1999;18(1):23e7. OC9 NUTRITION TRAINING IN UK MEDICAL UNDERGRADUATE PROGRAMMES e HAS THE SITUATION IMPROVED? W. Long, P. Neild. St. George's University of London, Cranmer Terrace, London SW17 ORE, UK Nutrition-related diseases are an increasing burden that doctors must be trained to manage. Nutrition training has classically been neglected and found to be inadequate. Educational programmes designed to improve nutrition training have reported increased student knowledge [2].
120
Abstracts / Clinical Nutrition ESPEN 22 (2017) 116e147
The aim of this study was to survey the nutrition training provided by UK medical schools and assess the importance of nutrition leads. A fourteen-item questionnaire was sent to academics representing all UK medical schools. The data generated was analysed using SPSS version 21.0 and significance was determined using a two-tailed Fischer's exact test. The response rate was 34% (11/32). Nutrition was given a high priority by two respondents, intermediate by eight and low by one. Students' knowledge was assessed in 8/11(73%) of responding medical schools. The mean total time devoted to nutrition throughout the courses was 8.4 hrs (range of 4 to 40+ hrs). Seven of 10 responded that they taught all four core nutrition topics as part of their undergraduate curriculum. Three of 9 responded that there was a nutrition thread throughout their curriculum. Five of 10 responded that there was a named nutrition lead. Three of 9 responded that their training was adequate. Of those who reported adequate training, all cited ‘increased formal teaching time devoted to nutrition’ and ‘better organisation of the nutrition teaching’ as improvements that facilitated adequate training. Of those who reported inadequate training, 83% cited ‘lack of prioritisation’ and 67% cited ‘being unable to devote more teaching time to nutrition’ and ‘difficulty organising topics and teaching sessions’ as hindrances towards improving training. The presence of a nutrition lead was associated with a trend to greater mean total time allocated to structured teaching (25.4 vs 16.2 hours), and greater likelihood of teaching all four core areas (5 of 5 vs 2 of 5, p¼0.08), but an equal likelihood of formally assessing nutrition knowledge (4 of 5 v. 4 of 5). In conclusion, indicators of good training appear to be more common in courses placing a higher priority on nutrition. Despite a decrease in the percentage of respondents reporting adequate training compared to a previous study in 2009 [1] (33% vs 50%), indicators of good training appear to have increased. This may reflect medical schools becoming more aware of the standards required as a result of the development of a standardised national nutrition curriculum [4]. A named nutrition lead may have a positive impact on nutrition training. References [1] Johnston R, et al. Nutrition training in UK medical undergraduate programme. Proc Nutr Soc 2009, 68(0CE1). [2] Maher B, et al. Evaluation of a novel nutrition education intervention for medical students. Proc Nutr Soc 2013, (OCE3). [3] Taren D. Effect of an integrated nutrition curriculum on medical education, student clinical performance and student perception of medicalnutrition training. Am J Clin Nutr 2001;73:1107e12. [4] GMC. Tomorrow's Doctors. London 2009. http:ttwww.gmc-uk.org/ staticdocuments/content/TomorrowsDoctors.2009.pdf.
compared with estimated requirements. Adequate feeding was defined as 80e110% of estimated requirements. Of the 189 patient records identified from the database, 160 met inclusion criteria. The median duration of vv-ECMO was 10.0 (IQR, 7.0e17.8) days. Whilst on vv-ECMO, the median energy intake was 89.5% (IQR, 80.5e95.9%) and the median protein intake was 85.0% (IQR, 75.0e98.0%) of estimated requirements. Whilst on vv-ECMO, inadequate energy (<80% requirements) was delivered on 23.1% days and inadequate protein was delivered on 25.6% days. The gastric route was the most common main route of delivery (93 patients, 58.1%). There was no association in overall energy (p¼0.464) and protein (p¼0.572) intake between gastric, jejunal and parenteral routes. Higher SOFA (Sepsis-related Organ Failure Assessment) score on the first day on vv-ECMO was associated with underfeeding of energy (p¼0.019). The most common reason for interrupted feeding was procedures (36.1%), followed by GI intolerances (23.8%). Stool output of >500 ml/d was more frequent in patients who received adequate energy (p¼<0.001) or protein (p¼0.010) compared to patients who were underfed energy and protein. To our knowledge, this is the largest study ever taken to investigate nutrition support in adult patients receiving vv-ECMO. We showed that, during vv-ECMO, adequate energy and protein intakes are possible regardless of feeding route. However, underfeeding can still occur, especially in those with more severe organ dysfunction. GI intolerances are common. Further research is needed to gain a better understanding of the nutritional needs of patients receiving vv-ECMO and the impact of underfeeding on outcomes in vv-ECMO. References [1] Heyland DK, Dhaliwal R, Wang M, et al. The prevalence of iatrogenic underfeeding in the nutritionally ‘at-risk’ critically ill patient: Results of an international, multicenter, prospective study. Clin Nutr 2015;34(4):659e66. [2] Villet S, Chiolero R L, Bollmann M D, et al. Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr 2005;24(4):502e9. [3] Faisy C, Lerolle N, Dachraoui F, et al. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation. Br J Nutr 2009; 101(7):1079e87. [4] Lukas G, Davies AR, Hilton AK, et al. Nutritional support in adult patients receiving extracorporeal membrane oxygenation. Crit Care Resusc 2010;12(4);230e4.
OC10 OPTIMUM NUTRITIONAL SUPPORT IN ADULTS RECEIVING VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION IS POSSIBLE BUT UNDERFEEDING IS COMMON, ESPECIALLY IN THOSE WITH MORE SEVERE ORGAN DYSFUNCTION
C.M. Fry, S. Ramet, G.P. Hubbard, R.J. Stratton. Medical Affairs, Nutricia Advanced Medical Nutrition, Wiltshire, BA14 0XQ, UK
L. Kaakinen a, E. Smith b, C. Elliott Hammond b, B. Sanderson b, D. Ong b, K. Daly b, N. Barrett b, K. Whelan a, D. Bear b. a King's College London, Diabetes and Nutritional Sciences Division, Stamford Street, London SE1 9NH, United Kingdom; b Guy's & St Thomas' NHS Foundation Trust, Departments of Critical Care and Nutrition and Dietetics, Westminster Bridge Road, London SE1 7EH, United Kingdom Veno-venous extracorporeal membrane oxygenation (vv-ECMO) is increasingly used in adults with severe respiratory failure. However, data on nutritional requirements for these patients are lacking. Patients on the Intensive Care Unit (ICU) are commonly underfed, receiving around 60% of their energy and protein requirements [1]. This underfeeding is associated with increased morbidity [3] and mortality [4]. Studies investigating nutritional support during vv-ECMO reveal underfeeding and gastointestinal (GI) intolerance is common. Our aim was to describe nutritional practices in a single-centre providing vv-ECMO to adult patients. We conducted a retrospective case review of patients receiving vv-ECMO on the ICU at St. Thomas’ Hospital, London. Adult patients admitted to the ICU with severe respiratory failure between December 2010 and March 2015 were included. Patients on vv-ECMO were provided nutrition support according to the same protocol as non-ECMO patients. Data were collected from electronic medical records. Daily energy and protein delivery were
OC11 GP PATIENT DATABASES SHOW THAT MALNUTRITION IS UNDERREPORTED AND UNDER-TREATED IN PATIENTS WITH CHRONIC DISEASE
Disease-related malnutrition is a significant, common and costly problem [1,2], with the majority of those affected living in the community (93%) [1] and under the care of their GP. Patients with chronic disease are particularly vulnerable to the effects of malnutrition and it is recommended that they are routinely screened, and if found to be at risk of malnutrition, appropriately managed (including the use of nutrition support [3]). There is limited recent data available in the literature on the prevalence of malnutrition in patients with chronic diseases and the extent to which the identification and management of malnutrition is undertaken and documented by GPs in such patients. The appropriate use of nutrition support in malnourished patients is also unclear. This study aimed to investigate the recorded prevalence of malnutrition and the use of nutrition support (oral nutritional supplements (ONS) and tube feeds) in community-based malnourished adults with chronic diseases (cancer, COPD, dementia/Alzheimer's and stroke) in the UK. Data was collected from GP databases within the period April 2014eMarch 2015 using electronic longitudinal patient data (IMS Information Solutions UK Ltd), from 1,150,744 adults aged 19+ years (76% 19e65 years, 24% 65+ years) registered with UK GP practices. Patients with a read code for stroke, COPD, dementia/Alzheimer's or cancer, were identified as malnourished if they had a BMI of <18.5 kg/m2 and/or a read code for malnutrition recorded in the GP database. Prescriptions of nutrition support (all available ONS and tube feeds) were also assessed. Overall, 43.5% (501,098) of patients had a BMI recorded, 2.9% (33,877) were identified as malnourished and 0.9% (10,507) were receiving nutrition