This is the tenth issue of TOP NUTRITION NEWSLETTER in 1998.In this issue, diet, nutrients and gastrointestinal cancers, overfeeding in ICU patients, dietary treatment for obesity and 1998 ADA clinical practice recommendations are updated for your interest.

Cancer remains the third leading cause of death after heart disease and accidents. Deaths of malignant neoplasms in Thailand increased from 26.1 in 1982 to 50.9 in 1995 per 100,000 population. It was estimated that gastrointestinal cancers, including oral, esophageal, stomach, small and large intestine, accounted for 24% of all cancer deaths in 1995. Colorectal cancer is the most common type of gastrointestinal cancer and is the top ten leading cause of deaths. It was estimated in 1981 that nutritional factors may be involved in approximately 35% of all cancers.Diet, Nutrients and Gastrointestinal cancer (Gastroenterology Clinics of North America 1998;27(2):325346) is worth looking the relationships of GI cancers and nutrients and how to prevent by adjusting nutrients intake and supplementation.

Metabolic complications from overfeeding critically ill patients are serious and sometimes fatal. Nutrition care is best provided through repeated evaluation of patients’ responses to feeding. Nutrition support may need to be modified over time to maintain metabolic stability and promote recovery. This article describes the etiology of 10 metabolic complications of overfeeding. Guidelines for recommending macronutrients are discussed, as are factors that could increase the risk of overfeeding. Patients who are very small, very large, or very old are particularly vulnerable to overfeeding. This review article in July 1998 issue of JADA entitled " Overfeeding macronutrients to critically ill adults:Metabolic complications" elaborated how the dietitians can prevent or curtail the metabolic complications of overfeeding by identifying patients at risk, providing adequate assessment, coordinating interdisciplinary care plans, and delivering timely and appropriate monitoring and intervention.

DIETITIANS AND DIETARY TREATMENTS FOR OBESITY: A MOVE TOWARDS EVIDENCE-BASED PRACTICE was the report on joint ASO/BDA meeting.This meeting was the first of its kind; the aims being to assess the evidence on efficacy of dietary treatments and to discuss how the management of obesity could be improved in a variety of healthcare settings. Several experts's recommendations are worth to be applied in this country.

Medical nutrition therapy (MNT) is integral to total diabetes care and management. Although adherence to nutrition and meal planning principles is one of the most challenging aspects of diabetes care, nutrition therapy is an essential component of successful diabetes management.This paper "Nutrition Recommendations and Principles for People With Diabetes Mellitus" reflects current scientific nutrition and diabetes knowledge. However, there are limited published data for some recommendations and, under these circumstances, recommendations are based on clinical experiences and consensus. As the recommendations are updated according to the current knowledge and reviews, we should update our treatment strategies for diabetic patients.

Cancer	Common Places	Causes	Prevention
Oral	France,USSR,(SEA)South EastAsia,India	pan chewing, tobacco, alcohol	fruits, vegetables, vitamin A & C
Esophageal	Asia,China	tobacco, alcohol	fruits, vegetables,
Gastric	Japan,China,parts of South America	salt,nitrates,Helicobacter pylori, cigarette smoking,	Vitamin C, carotenoids, fruits, vegetables
Colorectal	USA,Australia,Western Europe	high fat, red meat, n-6 PUFA	dietary fiber,fish, seafood,

The above table summarizes the GI cancers and the causative factors and preventive nutrients.Curently, large multicenter, randomized dietary modification trials are in progress and theresults will be known in next decade.Many studies have focused on individual micronutrients (e.g., beta-carotene). It is not suprising that the protective effect of fruits and vegetables as a group is stronger and more consistent than those of individual micronutrients.These foods contain an abundant array of recognized nutrients and phytochemicals - compounds found in plants that do not have established nutrient effects but nonetheless could decrease the risk of cancer through a variety of mechanisms. Evidence has accumulated, primarily from in vitro studies, that chemicals contained in plants have anticancer effects. Other examples of phytochemicals that may have anticancer properties, and their food sources, are listed here.

Phytochemical

Source

Allyl sulfides

Capsaicin

Ellagic acid

Ferulic acid

Genistein

Indoles

Isoflavones

Isothiocyanates

Limonene

Lycopene

Protease inhibitors

Saponins

Garlic and onions

Chili peppers

Fruits

Soybeans

Cruciferous vegetables

Beans

Cruciferous vegetables

Citrus fruits

Tomatoes, fruits

Beans

According to the local cancer specialists, the incidence of colorectal cancer is increasing and this may be partly due to high fat, red med and n-6 PUFA over consumption. The same causative factors are accumulating to support the high incidences of breast cancer also. Until more evidences on the long term studies are published, we should take more dietary fiber and balanced n6:n3 ratio of PUFA.

Metabolic complications from overfeeding critically ill patients are serious and sometimes fatal. Nutrition care is best provided through repeated evaluation of patients’ responses to feeding. Nutrition support may need to be modified over time to maintain metabolic stability and promote recovery. This article describes the etiology of 10 metabolic complications of overfeeding. Guidelines for recommending macronutrients are discussed, as are factors that could increase the risk of overfeeding. Patients who are very small, very large, or very old are particularly vulnerable to overfeeding. Overfeeding protein has led to azotemia, hypertonic dehydration, and metabolic acidosis. Excessive carbohydrate infusion has resulted in hyperglycemia, hypertriglyceridemia, and hepatic steatosis. High-fat infusions have caused hypertriglyceridemia and fat-overload syndrome. Hypercapnia and refeeding syndrome have also been caused by aggressive overfeeding. Dietitians can prevent or curtail the metabolic complications of overfeeding by identifying patients at risk, providing adequate assessment, coordinating interdisciplinary care plans, and delivering timely and appropriate monitoring and intervention. Dietitians need to document complications, interventions, and the outcomes of their clinical care to evaluate the appropriateness of existing nutrition guidelines.

PROTEIN

FAT

CARBOHYDRATE

azotemia

hypertonic dehydration

metabolic acidosis

Fat overload syndrome

hypertriglyceridemia

hepatic steatosis

hypercapnia

hyperglycemia

hyperglycemic hyperosmolar nonketotic syndrome

Overfeeding macronutrients to ICU patients has not been paid attention much and thus overzealous administration can negatively affect organ function, particularly in lungs, liver, and kidneys. This review paper described the common comp[lications with case examples and valuable to those ICU specialists who have to take responsibility of the outcome of these patients.Health care teams should be educated about the indicators of metabolic complications of overfeeding, which patients are at risk, and strategies for monitoring and intervention.What we should know is to identify (1) Who is at risk of metabolic complications from being overfed? (2) How much is too much and (3) Usefulness of measurable indicators of overfeeding on the quality of critical care and patient outcome.

REPORT ON JOINT ASO/BDA MEETING: DIETITIANS AND DIETARY TREATMENTS FOR OBESITY: A MOVE TOWARDS EVIDENCE-BASED PRACTICE.

This meeting was the first of its kind; the aims being to assess the evidence on efficacy of dietary treatments and to discuss how the management of obesity could be improved in a variety of healthcare settings.

The Journal begins with an Introduction by the Honorary Chair of The British Dietetic Association (BDA), Alison Dobson, entitled ‘Moving towards evidence-based practice.’ She explained how evidence based practice is now, more than ever, a key priority for the BDA as part of its long term Strategic Plan. She also welcomed a multidisciplinary approach to weight management, based on evidence of effectiveness. Gill Cowburn and Carolyn Summerbell presented a paper entitled, ‘A survey of dietetic practice in obesity management’. It reports on a questionnaire sent to BDA Members asking them about current practice in the management of obesity. From evidence based practice it seems that Dietitians should be moving towards longer-term treatment using group therapy rather than traditional approaches for the treatment of obesity.

Grace, C. Summerbell and P. Kopelman reported on the results of an audit performed in a specialist obesity clinic for patients resistant to conventional treatment. The paper, entitled, ‘An audit of dietary treatment modalities and weight loss outcomes in a specialist obesity clinic’, showed that different treatment methods suit different individuals, and that dietary advice should be tailored to the individual patient. Systemic review of the effectiveness of interventions used in the management of obesity was the title of a paper by S. O’Meara, A. M. Glenny, T. Sheldon, A. Melville and C. Wilson. It highlights the growing problem of obesity as public health problem. The review included ninety-nine studies which identified some potentially effective interventions for the management of obesity. The authors, however, stressed that the results should be interpreted with caution due to the poor methodology of many of the studies.

The Journal includes an Abstract by R. Jung entitled, ‘An evolution for obesity - The Scottish Intercollegiate Guideline Network (SIGN) guideline’. This guideline, developed in 1996, is a blueprint for the development of a coherent plan for the prevention and management of obesity in Scotland, and hopefully the UK. Its implication is that the nation’s target for weight will not be reached unless there is some substantive financial expenditure, which would hopefully be counterbalanced by the ultimate financial gain from having a thinner nation.

C.D. Summerbell, L.V. Jones and P. Glasziou presented, ‘The long-term effect of advice on low-fat diets in terms of weight loss: an interim meta-analysis.’ It reports on the results from a meta-analysis on the effectiveness of low-fat diets as a mean of achieving sustained weight loss. An interim analysis of the data suggests that low-fat diets are as efficacious as other types of low-energy diets in promoting weight loss in the overweight and obese.

Very low-energy diets (VLEDs) were put in the spotlight in a paper by S A Jebb and G R. Goldberg, entitled, ‘Efficacy of very low-energy diets and meal replacements in the treatment of obesity’. They concluded that there is evidence to suggest that VLEDs can be successful in achieving weight loss but they raise concerns regarding the composition of tissue loss and the long-term maintenance of weight loss.

Rapoport reported on ‘Integrating cognitive behavioural therapy into dietetic practice: a challenge for dietitians’. She claims that cognitive behavioural therapy is state of the art in the treatment of obesity and that dietitians should receive further training in key behaviour change theory and skills.

Thorogood believes that increased physical activity has a key role to play in both the prevention and treatment of obesity and presented evidence for this in her paper entitled, ‘Combining diet with physical activity in the treatment of obesity.’

E.L. Harvey, A.M. Glenny, S.F.L. Kirk and C.D. Summerbell presented a protocol for a review of strategies which are effective in improving health professionals’ management of obesity or the delivery of health care services for overweight and obese people. The paper is entitled, ‘Effective professional practice: protocol for a systematic review of health professionals’ management of obesity.’ The aim of the study, by J. Ogden and R. Hope, entitled, ‘Changing practice nurses’ management of obesity’ was to assess ways of improving practice nurses’ management of obesity. The results showed that patient-centred perspective does not always achieve the desired outcome and that the approach to weight loss should involve an assessment of whether this approach is best suited to each individual patient.

Although the overall goal of MNT is to assist individuals with diabetes in making changes in nutrition and exercise habits leading to improved metabolic control, there are additional specific goals: