Advances in medical nutrition: strategies and innovations in dietetics, obesity management, and nutritional support

This dissertation examines and adds to strategies and innovations in medical nutrition, covering more specifically the areas of dietetics, obesity management, and nutritional support. Medical nutrition encompasses all nutritional interventions under medical or nursing supervision as well as the structure, conception, and scientific derivation of these interventions. Medical nutrition overlaps with clinical nutrition but extends to nutritional care for selected healthy individuals.
1. Dietetics
Dietetics includes nutritional assessment and dietary advice with and without nutrition therapy to modify normal nutrition in cases of food allergies, intolerance, and disease, as well as secondary prevention and treatment of specific nutrient deficiencies. Within dietetics, we explored dietary fiber deficiency and its prevalence and found that 87% of the general Swiss population do not achieve the recommended intake of 30 g/day. Dietary fiber intake and ultra-processed food consumption exhibited an inverse dose-dependent association. Moreover, we examined the effects of potentially anti-inflammatory diets (Mediterranean, vegetarian, vegan, and ketogenic) on rheumatoid arthritis through a meta-analysis. These diets led to significant improvements in pain, health assessment questionnaire scores, and swollen joint counts, although the inflammatory markers did not improve.
2. Obesity Management
The clinical nutrition area of obesity management covers the prevention and treatment of obesity and related disorders, including bariatric surgery, and complements public health interventions. Post-bariatric hypoglycemia (PBH) is a frequent complication of bariatric surgery, particularly Roux-en-Y gastric bypass. This condition manifests as recurrent postprandial hypoglycemic events with potentially critical outcomes, such as loss of consciousness, and diminished quality of life (QOL). The PBH Forecast project aimed to prevent hypoglycemic events in patients with PBH and to establish a sustainable strategy for hypoglycemia correction. Hence, we collected data on continuous blood glucose levels, meal intake, symptoms, heart rate, and physical activity during a 50-day observational phase (n = 50). Concurrently, we conducted a randomized crossover clinical trial (n = 8) to investigate different nutritional strategies (15 g glucose vs. 5 g glucose vs. a combination of 10 g protein and 5 g carbohydrate) to correct mixed meal induced hypoglycemia. Our results suggested that diabetes-inspired guidelines for correcting hypoglycemia with 15 g are not suitable for PBH and that an excessive glucose load may induce rebound hypoglycemia. While none of the tested strategies was unequivocally superior, a lower dose appears to adequately elevate glucose levels outside the critical range, and supplementary nutrients such as proteins may offer glycemia-stabilizing benefits. At present, a randomized controlled trial is testing an intervention for hypoglycemia prevention that combines a hypoglycemia prediction model developed using data from the above-mentioned observational phase with a preventive nutritional intervention, i.e. administering 10 g of glucose before reaching hypoglycemia at a time point dictated by the prediction model.
3. Nutritional Support
Nutritional support involves the provision of food or nutrients through conventional nutrition, special diets, food fortification, and medical nutrition therapy (oral nutritional supplements, enteral nutrition, and parenteral nutrition [PN]), as well as concurrent therapies to promote food intake, to prevent or treat malnutrition and improve clinical outcomes and QOL. If medical nutrition therapy is required over a long period, it can be administered outside the hospital, such as home PN (HPN). This requires specialized care and patient monitoring to prevent potentially life-threatening complications.
3.a) Improvements of Outcomes with eHealth
We explored the potential of eHealth to support and improve the QOL and quality of care of patients with HPN by distant monitoring and counseling. To this end, we conducted a multicenter survey on the attitudes and expectations of patients with HPN towards eHealth and substantiated the need for digital support in this population. Subsequently, we developed a smartphone application for patients and a web-based dashboard for health care professionals (HCPs), centered around a patient journal and videoconference consultations. This provides the data for remote monitoring and enables counseling through timely short consultations and interventions as needed despite physical distance, replacing the traditional model of infrequent lengthy consultations. This eHealth platform is currently undergoing evaluation in a nationwide multicenter project.
3.b) Risk Assessment of Toxic Aluminum Exposure Through Parenteral Nutrition
The long-term administration of PN increases the relevance of chronic exposure to potentially toxic contaminating components like aluminum. Currently, a new chapter of the European Pharmacopoeia (Ph. Eur.) is under development to limit the risk of exposure to toxic levels of aluminum through PN. We developed an innovative and highly sensitive analytical method using inductively coupled plasma mass spectrometry to quantitatively measure aluminum and other elements in very low concentrations in commercial products used for all-in-one PN admixtures. Our findings reveal that commercial products can contain critical aluminum concentrations, emphasizing the necessity for regulatory measures to guarantee quality.
In summary, the evolving landscape of medical nutrition is placing an increasing emphasis on patient-reported outcomes and QOL to be supported by preventive actions. Customized digital solutions and eHealth have the potential to enhance patient-reported outcomes, patient safety, and the quality of care while demanding interprofessional collaboration and research among HCPs, scientists, engineers, legal experts, and end users. Such cooperation is required to produce a clinically useful tool that adheres to data security and privacy regulations as well as medical device regulations. These innovations have the potential to advance medical nutrition and to improve nutrition therapy and support. The thesis substantiated advances in medical nutrition in several projects in different populations as well as scientific lab investigations.