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clinical nutrition research through the years claire james rd head of nutrition and regulatory affairs aymes international ltd emily wong msc rnutr medical reimbursement manager nutricia on behalf of bsna ...

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                 Clinical Nutrition Research 
                 Through the Years
                                               Claire James, RD, Head of Nutrition and Regulatory Affairs, 
                                               AYMES International Ltd & Emily Wong MSc RNutr, 
                                               Medical Reimbursement Manager, Nutricia, on behalf of BSNA
                         Despite Hippocrates acknowledging the connection between nutrition and health in his 
                         famous quote, ‘let food be thy medicine and medicine by thy food’, research into the           
                         role of nutrition as treatment only really started growing from the mid-20th century.                   
                         This growing body of research underpins current dietetic practice and formed the 
                         foundation of the medical nutrition industry. Investing in future research is vital to truly 
                         unlock the power of nutrition as treatment and ensure innovation is kept at the heart of       
                         the medical nutrition industry. Together we explore the history of clinical nutrition research, 
                         key milestones and discoveries, and brave new frontiers looking to the future. 
                  Laying the foundations                                                   practices to eliminate common deficiencies, such as 
                  In the 20th century, some key nutritional science                        mandatory fortification of margarine with vitamins A and D 
                                                                                                    2
                  discoveries were made that paved the way for the                         in 1942.  
                                                                                               Alongside the identification of vitamins, essential 
                  beginnings of clinical nutrition. The early part of the               
                  20th century was an era of vitamin discoveries, with                     amino acids were also discovered through both animal       
                                                         1                                 and human studies in the late 1930s, paving the way                     
                  thiamin being the first in 1926. In 1932, vitamin C was 
                                                                                           for further research into the role of amino acids in the 
                  isolated and definitively documented for the first time                 
                                                                                           human diet. 
                  to protect against scurvy. By the mid-20th century, all             
                  the major vitamins had been isolated and synthesised.                        A further key milestone in the UK was the publication 
                  Their identification and use in studies led to the adoption              of  The Composition of Foods by Dr Elsie Widdowson             
                                                                                                                                           3
                  of dietary strategies to tackle overt vitamin deficiencies,              and Professor Robert McCance in 1940.  This publication    
                  such as beriberi (vitamin B1), scurvy (vitamin C), rickets               is still regarded as the foremost nutrition publication                 
                                                                                           and the basis of most nutritional databases around                     
                  (vitamin D) and other deficiency conditions. However,             
                  the chemical synthesis of vitamins also allowed for vitamin              the world. Shortly after this, the Recommended Dietary 
                  supplementation to be an effective treatment strategy for                Allowance (RDA) was introduced in 1941 to guide planning 
                                                                                                                                    4
                  deficiency conditions which is still widely used in clinical             of adequate nutrition for civilians.  The RDA was defined 
                  nutrition today.                                                         as: ‘an average amount of the nutrient, which should                     
                      The identification of single nutrient deficiencies and               be provided per head of a group of people if the needs       
                                                                                                                                                            
                  synthesis of vitamins also led to national food fortification            of practically all members of the group are to be met’.
                                                                                                                                         CN Vol.22 € No.2 € April 2022  |  51
        BSNA  |  Clinical Nutrition Research Through the Years
        “Much of the early                                         These key developments, from the                               With an ageing population, research on 
                                                                   identification and synthesis of vitamins     pr ot  ein turned t                 owards the maintenance           
        research from late 20th                                    to the development of RDAs, lay the  of a healthy elderly population. Disease-
        century on nutrition                                       foundations for the application of  related malnutrition and frailty are common 
                                                                   nutritional science to the treatment of                    issues among the aging, and research has 
        support in critical illness                                disease, developing into what we now     highlight                    ed the importance of nutrition in 
        was focused on energy                                      know as clinical nutrition.                                maintaining health, lean body mass and 
                                                                   Clinical nutrition                                         functionality alongside physical exercise. 
        intake and balance, and                                                                                               Protein requirements in the older 
        only in the 21st century                                   underpinning dietetic                                      population are higher due to age-related 
                                                                   practice                                                   changes in metabolism, and especially in 
        did the attention of                                       It's easy to see the rise in clinical nutrition            illness due to inflammatory and catabolic 
                                                                                                                                           7
        clinical research shift                                    research, as a simple PubMed search using                  responses.  Based on a review of the global 
                                                                   the term ‘clinical nutrition’ shows an                     evidence and expert consensus, ESPEN 
        to the importance                                                                                                     guidelines recommend increased protein 
                                                                   exponential rise in publications beginning         
        of protein intakes in                                      in the 1980s. See Figure 1.                                intake (minimum 1.0 g/kg/d) in older 
                                                                       In this time, our understanding of                     persons depending on their nutritional 
        illness”                                                                                                              status, physical activity level, disease         
                                                                   nutrition and its role in clinical medicine         
                                                                                                                                                        8
                                                                   has grown significantly. From early research               status and tolerance.  
                                                                   into basal metabolism and energy balance                       As clinical nutrition research developed, 
                                                                   in disease states, to the growing research                 so did the necessity to develop enteral 
                                                                   on nitrogen balance, protein and recovery,                 formulations to administer nutrients in 
                                                                   continued developments in clinical nutrition               appropriate amounts to patients, leading         
                                                                   help improve dietetic support in disease                   to the formation of the medical nutrition 
                                                                   and improve patient outcomes.                              industry. Much progress has been made 
                                                                       Much of the early research from late                   from the early days of hospitals brewing 
                                                                   20th century on nutrition support in critical              their own enteral formulations (feeds made 
                                                                   illness was focused on energy intake and                   up of milk, eggs, meat broth, flour, etc.),             
                                                                                                                              as we now have convenient, ready-to-feed, 
                                                                   balance, and only in the 21st century did       
                                                                                                                              sterile formulations delivering specific levels 
                                                                   the attention of clinical research shift to     
                                                                   the importance of protein intakes in illness.5             of nutrients available. As the importance         
                                                                   Since this discovery, the focus on protein in              of protein intake was investigated, the 
                                                                   maintenance and recovery continues, with                   medical nutrition industry concurrently 
                                                                   studies working to determine the optimal                   reviewed their product formulations to 
                                                                   protein intake in numerous conditions.                     reflect emerging research.  
                                                                   Based on the analysis of extensive studies,                    Technological advances have also 
                                                                   NICE (CG32) in the UK recommend intakes                    allowed the development of high protein 
                                                                   of 0.8-1.5 g protein/kg/day in adults                      feeds in lower volumes for use in critical 
                                                                                                       6
                                                                   requiring nutritional support.                             illness or conditions with fluid restriction. 
                                                                   Figure 1: Rise in publications 1980-2021 based on Pub Med 
                                                                   search term Clinical Nutrition 
                                                                          18000 
                                                                          16000 
                                                                          14000 
                                                                       tions12000 
                                                                          10000 
                                                                           8000 
                                                                           6000 
                                                                       Number of publica
                                                                           4000 
                                                                           2000 
                                                                                0
                                                                                    1975     1980     1985     1990     1995     2000     2005    2010    2015    2020    2025
                                                                                                                                Year
                                                                     (adapted from Pub Med timeline, search using the term ‘Clinical Nutrition’ – February 2022)
        52  |  CN Vol.22 € No.2 € April 2022
                                                                                                                 Clinical Nutrition Research Through the Years  |  BSNA
           Not only is the quantity of protein key,     cons     tant de                   velopments in clinical nutrition, 
           but also the quality of protein. Research     fr om the isolation of nutrients previously 
           into the composition of different protein                      undiscovered to clinical nutrition in new 
           sources, their levels of essential amino     disease ar                      eas, such as COVID-19 in its acute 
           acids and their metabolism led to optimal                      treatment and management of Long COVID.  
           sources of protein being used in enteral                            Exciting research into the gut 
           feeds to deliver complete proteins.   micr   obiota fr       om the ill t                            o the healthy,               
           Other improvements in technical  from infants to elderly, could also influence 
           capabilities to produce energy dense,    clinical nutrition as w                                 e know it today.                           
           or compact, oral nutritional supplements     In r    ecent years, infant feeds containing         
           have been shown to improve patient  pre- and probiotics have been introduced to 
                                                          9
           compliance to prescribed volumes.                              clinical practice, and the long-term impact 
                As the nutritional care of patients                       of this is only just starting to be studied. 
           moved from the acute setting to the                                 With increasing prevalence of cancer 
           community, a need to make nutrition  and improvements in treatment and survival 
           support available on prescription was                          rates, much research is focused on the 
           recognised. The Advisory Committee on                          management of these diseases. Nutrition 
           Borderline Substances (ACBS) was formed                        impacts clinical outcomes throughout the 
           to assess enteral nutrition formulations           
                                                                          cancer treatment process, from baseline 
           and their suitability to be prescribed at             
                                                                          nutritional status, during/post treatment or 
           the NHS’ expense for specific patient                          pre-/post-operatively, to the maintenance 
           groups in the community. Established in                        of nutritional status during recovery, 
           1971, the ACBS remains the body that                           especially in the management of cancer-
           assesses and approves applications                           
                                                                          related malnutrition and cachexia which         
           for borderline substances to be made         
                                                                          are commonly seen.  
           available on prescription in the community                          As the breadth and depth of clinical 
           today. Alongside community prescription,                       nutrition is extensive, there are many         
           homecare services were developed by               
                                                                          topics we have not touched upon here: 
           the medical nutrition industry to deliver                                                                                           References:  1. Mozaffarian D, Rosenberg I, Uauy R. (2018). 
                                                                          research into the expanding use of                                   History of modern nutrition science—implications for current 
           nutritional products and any associated                        ketogenic diets in different therapy areas,                          research, dietary guidelines, and food policy. BMJ. 361:k2392.      
                                                                                                                                               2. Accessed online: https://archive.nutrition.org.uk/nutrition 
           ancillaries directly to patients’ homes,                                                                                            inthenews/wartimefood/warnutrition.html. (Feb. 2022).        
                                                                          the dietary management of inherited                                  3. Buttriss J. (2015). Food composition data updated. Nutrition 
           with supporting nursing care.                                  metabolic diseases, the improvements in                              Bulletin. 1-3. 4. Department of Health. (1991). Dietary Reference 
                Standardised medical nutrition                                                                                                 Values for Food Energy and Nutrients for the United Kingdom 
                                                                          technology that have enabled further                                 41. Panel on Dietary Reference Values of the Committee on 
           products have also allowed for further                         research, the list goes on.                                          Medical Aspects of Food Policy. 5. Weijs PJ, et al. (2014). 
           advances in research. With enteral feeds                                                                                            Proteins and amino acids are fundamental to optimal nutrition 
                                                                                                                                               support in critically ill patients. Crit Care.  18(6):591. 6. NICE. 
           delivering specific nutrients, studying the                    Future innovation                                                    (2017). Nutrition support for adults: oral nutrition support, 
                                                                                                                                               enteral tube feeding and parenteral nutrition. Accessed online: 
           impact of standardised formulations on                                                                                              www.nice.org.uk/guidance/cg32/resources/nutrition-support-
                                                                          The UK has been at the forefront of                 
                                                                                                                                               for-adults-oral-nutrition-support-enteral-tube-feeding-and- 
           clinical outcomes became easier for  many of the advances in clinical nutrition                                                     parenteral-nutrition-pdf-975383198917 (March 2021). 7. Bauer J, 
           researchers. Research has shown that                                                                                                et al. (2013). Evidence-Based Recommendations for Optimal 
                                                                          and can continue to do so through further                            Dietary Protein Intake in Older People: A Position Paper From 
           the use of oral nutrition support in the                       investment in research supported by                                  the PROT-AGE Study Group. J Am Med Dir Assoc. 8. Volkert DH, 
                                                                                                                                               et al. (2018). ESPEN guideline on clinical nutrition and hydration 
           community can improve clinical outcomes,                       responsive regulation. A recent report                               in geriatrics. Clinical Nutrition. 9. Hubbard GP, et al. (2012). A 
           quality of life, and reduce number of                                                                                               systematic review of compliance to oral nutritional supplements. 
                                                                                                                                               Clinical Nutrition. 31(3) :293-312. 10. Cawood AL, Elia M, Stratton 
                                                                          highlighted the need for regulatory               
           hospital re-admissions, length of stay,                        reform to put innovation at its heart,                               RJ. (2012). Systematic review and meta-analysis of the effects    
                                                                                                                                               of high protein oral nutritional supplements. Ageing Research 
           ultimately improving patient recovery and                      particularly as the boundaries between                               Reviews. 11:278-96. 11. Stratton R, Hebuterne X, Elia M. (2013). 
                                                            10-13                                                                              Systematic review and meta-analysis of the effects of oral 
           reducing spend in the acute setting.                           food, medicine and technology become                                 nutritional supplements on hospital admissions. Ageing 
                                                                                                                                               Research Reviews. 12(4):884-97. 12. Elia M, Normand C, Norman 
           New frontiers                                                  increasingly blurred.14 With the growing                             K. (2015). A systematic review of the cost and cost effectiveness 
                                                                          body of research, we should continue to                              of using standard oral nutritional supplements in community 
                                                                                                                                               and care home settings. Clinical Nutrition. 13. Parsons EL, et al. 
           of clinical research                                                                                                                (2017). Oral Nutritional Supplements in a randomised trial are 
                                                                          expect that nutritional care will sit at                 
                                                                                                                                               more effective than dietary advice at improving quality of life     
           As we discover more about clinical nutrition,                  the heart of patient care. Hippocrates                               in malnourished care home residents. Clinical Nutrition. 
           we also uncover more questions. There are                      would be pleased.                                                    36(1):134-42. 14. Smith ID, Villiers T, Freeman G. (2021). Taskforce 
                                                                                                                                               on Innovation, Growth and Regulatory Reform. 
                   About the British Specialist Nutrition Association 
                   BSNA is the trade association representing the manufacturers of products designed to meet the           
                   particular nutritional needs of individuals; these include specialist products for infants and young               
                   children (including infant formula, follow-on formula, young child formula and complementary                     
                   weaning foods), medical nutrition products for diseases, disorders and medical conditions, including      
                   oral nutritional supplements, enteral tube feeding and parenteral nutrition, as well as companies who 
                   aseptically compound chemotherapy, parenteral nutrition and CIVAS.
                                                                                                                                                           CN Vol.22 € No.2 € April 2022  |  53
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...Clinical nutrition research through the years claire james rd head of and regulatory affairs aymes international ltd emily wong msc rnutr medical reimbursement manager nutricia on behalf bsna despite hippocrates acknowledging connection between health in his famous quote let food be thy medicine by into role as treatment only really started growing from mid th century this body underpins current dietetic practice formed foundation industry investing future is vital to truly unlock power ensure innovation kept at heart together we explore history key milestones discoveries brave new frontiers looking laying foundations practices eliminate common deficiencies such some nutritional science mandatory fortification margarine with vitamins a d were made that paved way for alongside identification essential beginnings early part was an era vitamin amino acids also discovered both animal human studies late s paving thiamin being first c further isolated definitively documented time diet protec...

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