Purpose of review: Gastrointestinal (GI) dysfunction is common among critically ill patients and is associated with poor outcomes. In particular, nutrient delivery can be impaired in patients with GI dysfunction and pose a significant challenge to clinicians in daily clinical practice. This review aims to summarize the impact of GI dysfunction on nutrition therapy during critical illness and provide an update on recent advances in nutritional strategies during gastrointestinal dysfunction.

Recent findings: Although prognostic gastrointestinal dysfunction scoring systems exist, a lack of clear, uniform definitions of GI dysfunction limits diagnosis and subsequent adequate treatment. Recent studies have further investigated separate components of GI dysfunction in ICU patients, including the role of altered GI motility, nutrient digestion and absorption and the metabolic consequences of gut dysfunction. Various strategies to improve nutrient delivery are discussed. However, the evidence supporting their routine use is sometimes lacking.

Summary: GI dysfunction frequently occurs during critical illness and negatively affects nutrition therapy. Strategies to improve nutrient delivery during GI dysfunction are available, though more research into the diagnosis and pathophysiology of GI dysfunction will likely further improve patient outcomes.

Purpose of review: Numerous micronutrients are involved in antioxidant and immune defence, while their blood concentrations are frequently low in critically ill patients: this has fuelled many supplementation trials. Numerous observational, randomized studies have been published, which are presented herein.

Recent findings: Micronutrient concentrations must be analysed considering the context of the inflammatory response in critical illness. Low levels do not always indicate a deficiency without objective micronutrients losses with biological fluids. Nevertheless, higher needs and deficiencies are frequent for some micronutrients, such as thiamine, vitamins C and D, selenium, zinc and iron, and have been acknowledged with identifying patients at risk, such as those requiring continuous renal replacement therapy (CRRT). The most important trials and progress in understanding have occurred with vitamin D (25(OH)D), iron and carnitine. Vitamin D blood levels less than 12 ng/ml are associated with poor clinical outcomes: supplementation in deficient ICU patients generates favourable metabolic changes and decreases mortality. Single high-dose 25(OH)D should not be delivered anymore, as boluses induce a negative feedback mechanism causing inhibition of this vitamin. Iron-deficient anaemia is frequent and can be treated safely with high-dose intravenous iron under the guidance of hepcidin to confirm deficiency diagnosis.

Summary: The needs in critical illness are higher than those of healthy individuals and must be covered to support immunity. Monitoring selected micronutrients is justified in patients requiring more prolonged ICU therapy. Actual results point towards combinations of essential micronutrients at doses below upper tolerable levels. Finally, the time of high-dose micronutrient monotherapy is probably over.

organ failure. Autophagy can remove damaged molecules and organelles but appears insufficiently activated during critical illness. This review discusses insight into the role of autophagy in critical illness and the involvement of artificial feeding in insufficient autophagy activation in critical illness.

Recent findings: Animal studies manipulating autophagy have shown its protective effects against kidney, lung, liver, and intestinal injury after several critical insults. Autophagy activation also protected peripheral, respiratory, and cardiac muscle function, despite aggravated muscle atrophy. Its role in acute brain injury is more equivocal. Animal and patient studies showed that artificial feeding suppressed autophagy activation in critical illness, particularly with high protein/amino acid doses. Feeding-suppressed autophagy may explain short and long-term harm by early enhanced calorie/protein feeding in large randomized controlled trials.

Summary: Insufficient autophagy during critical illness is at least partly explained by feeding-induced suppression. This may explain why early enhanced nutrition failed to benefit critically ill patients or even induced harm. Safe, specific activation of autophagy avoiding prolonged starvation opens perspectives for improving outcomes of critical illness.

Purpose of review: Critically ill patients usually develop insulin resistance and hyperglycemia, which is aggravated by early parenteral nutrition. In observational studies, the lowest mortality risk associates with glucose concentrations close to the antecedent average glucose level. This review summarizes the most recent evidence regarding glucose control in critical illness.

Recent findings: Although pioneer randomized controlled trials showed morbidity and mortality benefit by normalizing blood glucose in intensive care, the largest multicenter randomized controlled trial found increased mortality. Differences in glucose targets, the accuracy of the glucose control protocol, and differences in feeding strategy may explain these differences.

Recent randomized controlled trials investigating the impact of individualized glucose control did not show benefits of targeting individualized or looser glucose values in critically ill patients with poorly controlled diabetes.

Summary: It remains unclear whether tight glucose control in critical illness is beneficial or not in the absence of early parenteral nutrition, which is currently being studied in the multicenter TGC-fast randomized controlled trial. Without new evidence, it seems prudent to avoid severe hyperglycemia and hypoglycemia in all patients.

OBJECTIVES: Evidence supporting glutamine supplementation in severe adult burn patients has created a state of uncertainty due to the variability in the treatment effect reported across small and large randomized controlled trials (RCTs). We aimed to systematically review the effect of glutamine supplementation on mortality in severe adult burn patients.

DATA SOURCES: MEDLINE, Embase, CINAHL, and Cochrane Central were searched from inception to February 10, 2023.

STUDY SELECTION: RCTs evaluating the effect of enteral or IV glutamine supplementation alone in severe adult burn patients were included.

DATA EXTRACTION: Two reviewers independently extracted data on study characteristics, burn injury characteristics, description of the intervention between groups, adverse events, and clinical outcomes.

DATA SYNTHESIS: Random effects meta-analyses were performed to estimate the pooled risk ratio (RR). Trial sequential analyses (TSA) for mortality and infectious complications were performed. Ten RCTs (1,577 patients) were included. We observed no significant effect of glutamine supplementation on overall mortality (RR, 0.65, 95% CI, 0.33-1.28; p = 0.21), infectious complications (RR, 0.83; 95% CI, 0.63-1.09; p = 0.18), or other secondary outcomes. In subgroup analyses, we observed no significant effects based on administration route or burn severity. We did observe a significant subgroup effect between single and multicenter RCTs in which glutamine significantly reduced mortality and infectious complications in singe-center RCTs but not in multicenter RCTs. However, TSA showed that the pooled results of single-center RCTs were type 1 errors and further trials would be futile.

CONCLUSIONS: Glutamine supplementation, regardless of administration, does not appear to improve clinical outcomes in severely adult burned patients.

Background
older adults in aged care account for 30% of the population burden of hip fractures. Nutritional interventions to correct under nutrition reduce these debilitating fractures, perhaps partly by reducing falls and slowing deterioration in bone morphology.

Objective
to determine whether a nutritional approach to fracture risk reduction in aged care homes is cost-effective.

Design
cost-effectiveness was estimated based on results from a prospective 2-year cluster-randomised controlled trial and secondary data. Intervention residents consumed a total of 3.5 daily servings of milk, yoghurt and/or cheese, resulting in 1,142 mg of calcium and 69 g of protein compared with the daily intakes of 700 mg of calcium and 58 g of protein consumed by the control group.

Setting
fifty-six aged care homes.

Participants
residents for 27 intervention (n = 3,313) and 29 control (n = 3,911) homes.

Methods
ambulance, hospital, rehabilitation and residential care costs incurred by fracture were estimated. The incremental cost-effectiveness ratios per fracture averted within a 2-year time horizon were estimated from the Australian healthcare perspective applying a 5% discount rate on costs after the first year.

Results
intervention providing high-protein and high-calcium foods reduced fractures at a daily cost of AU$0.66 per resident. The base-case results showed that the intervention was cost-saving per fracture averted, with robust results in a variety of sensitivity and scenario analyses. Scaling the benefits of intervention equates to a saving of AU$66,780,000 annually in Australia and remained cost-saving up to a daily food expenditure of AU$1.07 per resident.

Conclusions
averting hip and other non-vertebral fractures in aged care residents by restoring nutritional inadequacy of protein and calcium is cost-saving.

Spinal sarcopenia is a multifactorial disorder associated with atrophy and fatty changes in paraspinal muscles. Interventional studies for spinal sarcopenia are limited. We aimed to evaluate the effectiveness of a combined exercise and nutrition intervention for the treatment of spinal sarcopenia. 35 community-dwelling older women diagnosed with spinal sarcopenia in a previous cohort study were included. The 12-week combined intervention consisted of back extensor strengthening exercises and protein supplementation. The following outcomes were measured at baseline (week 0), after the intervention (week 12), and follow-up (week 24): conventional variables of sarcopenia (appendicular skeletal muscle mass, handgrip strength, 6-meter gait speed, and short physical performance battery); lumbar extensor muscle mass; lumbar extensor muscle volume and signal intensity; back extensor isokinetic strength; and back performance scale. We used the intention-to-treat analysis method, and repeated measures analysis of variance was used to analyze the data. Of the total 35 potential participants, 26 older women participated in the study (mean age 72.5 ± 4.0 years old). After 12 weeks of combined exercise and nutrition intervention, there were no changes in the appendicular skeletal muscle mass, lumbar extensor muscle mass, volume, or signal intensity. Handgrip strength and back extensor isokinetic strength did not change significantly. Short physical performance battery significantly increased (P = 0.042) from 11.46 ± 0.86 to 11.77 ± 0.53 at week 12 and 11.82 ± 0.40 at week 24. The back performance scale sum score also significantly improved (P = 0.034) from 2.68 ± 1.81 to 1.95 ± 1.21 at week 12 and 2.09 ± 1.34 at week 24. The combined exercise and nutrition intervention for community-dwelling older women with spinal sarcopenia could be feasible and helpful in improving the physical performance as well as back performance.

Background
The aim of this review is to evaluate the relationship between weight status and taste perception and preference of sweet, salt, fat, bitter, and sour through reviewing observational and interventional studies with objective methods.

Methods
A comprehensive literature search was performed in 6 online databases of PubMed, Scopus, Web of Science, Cochrane, Embase, and Google Scholar up to October 2021. The following keywords were used in the search strategy: (Taste OR "Taste Perception" OR "Taste Threshold" OR "Taste preference" OR "Taste sensitivity" OR "Taste changes") AND (weight OR "Weight gain" OR "weight loss" OR "weight change").

Results
Most observational studies indicate that four taste sensitivities or perceptions (especially sweet and salt taste perception) are lower in subjects with overweight and obesity. The longitudinal studies reported that sweet and fat preference is increased along with weight gain in adults. It is concluded that taste perceptions are decreased in individuals with overweight and obesity, especially in men. Also, taste perception and preference change after weight loss but not significantly.

Conclusion
It is suggested that the results of the interventional studies are not conclusive and need further studies with the same and standard design adjusting cofounding variables including genetic, gender, age and food condition of subjects.

Purpose of review: To discuss recent evidence on the influence of complementary feeding (CF) timing, content and feeding methods on childhood obesity risk.

Recent findings: The evidence-base is limited by heterogeneity, risk of bias and the predominance of observational studies. The content of the diet and feeding practices are more influential than timing for obesity risk. There is limited evidence that CF introduction before 4 months may be associated with increased risk. Intake of animal protein, particularly dairy protein, may contribute to rapid weight gain; protein from infant/follow-on formula shows the most robust association with later obesity risk. Evidence linking sugar intake to obesity risk is limited, but intake should be as low as possible given there is no nutritional requirement. Responsive feeding (RF) practices may promote appropriate infant growth and reduce risk. The effect of baby-led weaning (BLW) is inconclusive.

Summary: Recent evidence supports current recommendations to avoid high protein intakes, especially from infant/follow-on formula, for infants in high income countries; and to promote RF practices for all infants. Studies in low- and middle-income countries are required to define optimal CF practices given increasing rates of child obesity alongside double-burden malnutrition.

Purpose of review: Muscle wasting is an important health problem in chronic kidney disease (CKD) patients. Protein restriction in the diet can be one of the main causes of muscle wasting in this population. In this review, we aimed to investigate the relationship between dietary protein intake and muscle wasting in CKD patients according to recent literature.

Recent findings: The one of the main mechanisms responsible for the muscle wasting is the disturbances in skeletal muscle protein turnover. Muscle wasting primarily occurs when the rates of muscle protein breakdown exceed the muscle protein synthesis. Dietary protein intake represents an important role by causing a potent anabolic stimulus resulting a positive muscle protein balance. Compared to studies made in healthy populations, there are very limited studies in the literature about the relationship between dietary protein intake and muscle wasting in the CKD population. Majority of the studies showed that a more liberal protein intake is beneficial for muscle wasting in especially advanced CKD and hemodialysis population

Summary: Although evaluating muscle wasting in CKD patients, the amount of protein in the diet of patients should also be reviewed. Although excessive protein intake has some negative consequences on this patient group, a more liberated dietary protein intake should be taken into account in this patient group with muscle wasting and especially in dialysis patients.

Background
Reducing portion sizes of commercially available foods could be an effective public health strategy to reduce population energy intake, but recent research suggests that the effect portion size has on energy intake may differ based on socioeconomic position (SEP).

Objective
We tested whether the effect of reducing food portion sizes on daily energy intake differed based on SEP.

Methods
Participants were served either smaller or larger portions of food at lunch and evening meals (N = 50; Study 1) and breakfast, lunch and evening meals (N = 46; Study 2) in the laboratory on two separate days, in repeated-measures designs. The primary outcome was total daily energy intake (kcal). Participant recruitment was stratified by primary indicators of SEP; highest educational qualification (Study 1) and subjective social status (Study 2), and randomisation to the order portion sizes were served was stratified by SEP. Secondary indicators of SEP in both studies included household income, self-reported childhood financial hardship and a measure accounting for total years in education.

Results
In both studies, smaller (vs larger) meal portions led to a reduction in daily energy intake (ps < .02). Smaller portions resulted in a reduction of 235 kcal per day (95% CI: 134, 336) in Study 1 and 143 kcal per day (95% CI: 24, 263) in Study 2. There was no evidence in either study that effects of portion size on energy intake differed by SEP. Results were consistent when examining effects on portion-manipulated meal (as opposed to daily) energy intake.

Conclusions
Reducing meal portion sizes could be an effective way to reduce overall daily energy intake and contrary to other suggestions it may be a socioeconomically equitable approach to improving diet.

Trial registration
These trials were registered at www.clinicaltrials.gov as NCT05173376 and NCT05399836.

Medical nutrition therapy (MNT) represents an essential element in the medical care of critically ill patients admitted to an intensive care unit (ICU). Increasing awareness exists that energy and nutrients not only preserve body structures such as lean body/muscle mass but also represent promising therapeutic elements to target the profound metabolic, inflammatory, endocrinologic, and immunologic alterations occurring during critical illness. However, despite intense research activities for years, diverse aspects of MNT such as the optimal timing, dosing, and composition of energy and macronutrient supply, as well as the role of micronutrients, are still an issue of debate resulting from strong heterogeneity in methods and findings of respective studies. These discrepancies are also reflected in diverging recommendations of international clinical nutrition guidelines for specific topics. In addition, implementing targeted, personalized MNT strategies in routine clinical practice underlies difficulties and challenges resulting from disease-specific issues and/or organizational, structural, and educational aspects. This narrative review aims to summarize the most recent evidence relevant to clinical practice on selected aspects of MNT in adult patients in the ICU and to provide guidance for implementing evidence-based approaches for adequate energy and nutrient supply in the ICU setting.

Food is essential for growth, nutrition, and good health. Yet at times, food proteins have the potential to be allergens, inducing systemic responses by the body. Allergic reactions to food proteins are typically thought of as IgE-mediated type I hypersensitivity reactions that can cause life-threatening anaphylaxis and require emergency medical treatment. However, food protein–induced enterocolitis syndrome (FPIES) is a non–IgE-mediated allergic reaction to food proteins, primarily in infants, that is much less common, although not rare, with an incidence approaching 0.7%. It has a variable clinical presentation, typically characterized by vomiting and diarrhea associated with allergen ingestion. Presentations range from mild-moderate to severe or even chronic forms. It remains a largely clinical diagnosis.

We conducted an umbrella review to summarize the existing evidence on the effect of early enteral nutrition (EEN) compared with other approaches, including delayed enteral nutrition (DEN), parenteral nutrition (PN), and oral feeding (OF) on clinical outcomes in hospitalized patients. We performed a systematic search up to December 2021, in MEDLINE (via PubMed), Scopus, and Institute for Scientific Information Web of Science. We included systematic reviews with meta-analyses (SRMAs) of randomized trials investigating EEN compared with DEN, PN, or OF for any clinical outcomes in hospitalized patients. We used “A Measurement Tool to Assess Systematic Reviews” (AMSTAR2) and the Cochrane risk-of-bias tool for assessing the methodological quality of the systematic reviews and their included trial, respectively. The certainty of the evidence was rated using the “Grading of Recommendations Assessment, Development, and Evaluation” (GRADE) approach. We included 45 eligible SRMAs contributing with a total of 103 randomized controlled trials. The overall meta-analyses showed that patients who received EEN had statistically significant beneficial effects on most outcomes compared with any control (ie, DEN, PN, or OF), including mortality, sepsis, overall complications, infection complications, multiorgan failure, anastomotic leakage, length of hospital stay, time to flatus, and serum albumin levels. No statistically significant beneficial effects were found for risk of pneumonia, noninfectious complications, vomiting, wound infection, as well as number of days of ventilation, intensive care unit days, serum protein, and pre–serum albumin levels. Our results indicate that EEN may be preferred over DEN, PN, and OF because of the beneficial effects on many clinical outcomes.

Chyle leaks of any source or type can cause significant morbidity and mortality. Attention to the anatomy and physiology of the leak, followed by stepwise dietary and pharmacologic management, obviates the need for surgical intervention in a majority of patients. In this article, we review the importance, etiology, anatomy, diagnosis, nutrition and immunologic effects, and options for treatment of chylothorax and chylous ascites based on experience and prior literature. We propose a multidisciplinary approach to optimize these treatments including the primary surgical teams, pharmacists, and dietitians, with reoperation as a last resort to minimize the morbidity of this challenging complication.

Purpose of review: Eating behaviors and dietary patterns begin in early childhood and persist into adolescence and adulthood, affecting lifelong acute and chronic disease risk. Vegetables provide a high density of necessary vitamins, minerals, and fiber. Dietary intake data show that children of all ages consume below the recommended range for vegetables. Pediatric providers are optimally positioned to promote vegetable intake in childhood. This review seeks to summarize lessons learned from behavioral interventions useful in the pediatric primary care setting to improve vegetable intake.

Recent findings: Ten published studies tested behavioral interventions in primary care to increase child vegetable intake. Strategies tested include teaching healthy eating behaviors and role modeling to parents of infants, and motivational interviewing paired with frequent office visits and reminders for families of older children and adolescents. Some strategies suggested positive change, despite study quality being limited by underpowered samples, heterogeneity of outcome measures, and statistical analytic approach.

Summary: Increased vegetable intake was achieved in infants through parental role-modeling when providers emphasized healthy dietary choices in parents. Older children increased their vegetable intake with motivational interviewing and frequent reminders from providers. Despite the high prevalence of inadequate vegetable intake among children, at present, there is only a modest body of literature to help guide pediatric providers in implementing practice-based interventions to improve vegetable intake in childhood, highlighting a need for high-quality research in this area.

Purpose of review: Most young children in the United States spend a significant portion of their time in early care and education (ECE) settings, commonly known as child care. This review highlights recent literature to support a continued focus and increased investment in embedding nutrition and physical activity standards within ECE settings and systems as a critical strategy for child obesity prevention. Pediatricians can support the promotion of these standards by understanding their local child care settings and sharing information with families about the importance of healthy eating and physical activity in early childhood.

Recent findings: The child care sector is fragile and complex, but quality improvement efforts have been successful in improving healthy eating and physical activity. Diverse child care providers, including family child care homes, can effectively embed nutrition and physical activity standards in their environments to promote healthy eating and active play, limit screen time, and support breastfeeding families. A small but growing body of evidence also demonstrates how these standards can be embedded in broader state systems to stimulate change across a state.

Summary: The literature demonstrates progress supporting diverse child care settings to embed high-impact standards into their environments. There is a small but growing body of evidence around systems-change efforts as well. Greater attention is needed on embedding physical activity standards in facilities, especially family child care homes, and state systems.

Background
Endothelial dysfunction serves as an early marker for the risk of cardiovascular disease (CVD); therefore, it is an attractive site of therapeutic interventions to reduce the risk of CVD. This study was conducted to investigate the effect of folic acid supplementation on endothelial function markers in randomized controlled trials (RCTs).

Methods
PubMed, ISI web of science, and Scopus databases were searched up to July 2022 for detecting eligible studies. A random-effects model was used for meta-analysis, and linear Meta-regression and non-linear dose-response analysis were performed to assess whether the effect of folic acid supplementation was affected by the dose and duration of intervention. Cochrane tools were also used to assess the risk of bias in the included studies.

Results
Twenty-one studies, including 2025 participants (1010 cases and 1015 controls), were included in the present meta-analysis. Folic acid supplementation significantly affected the percentage of flow-mediated dilation (FMD%) (WMD: 2.59%; 95% CI: 1.51, 3.67; P < 0.001) and flow-mediated dilation (FMD) (WMD: 24.38 μm; 95% CI: 3.08, 45.68; P = 0.025), but not end-diastolic diameter (EDD) (WMD: 0.21 mm; 95% CI: − 0.09, 0.52; P = 0.176), and intercellular adhesion molecule (ICAM) (WMD: 0.18 ng/ml; 95% CI: − 10.02, 13.81; P = 0.755).

Conclusions
These findings suggest that folic acid supplementation may improve endothelial function by increasing FMD and FMD% levels.

Trial registration
PROSPERO registration cod: CRD42021289744.