PEN eNews 12(10) October 2022 - Do you want to help shape new and updated PEN content on COVID-19 an

What is the Latest on Dietary Strategies and Chronic Pancreatitis?

What are the recommended dietary strategies to manage symptoms and complications of chronic pancreatitis in adults?

Recommendation

Limited evidence suggests that individuals with chronic pancreatitis who are well nourished should eat a well-balanced diet, avoid alcohol and a very high fibre intake but not restrict fat intake unless symptoms of steatorrhea are uncontrolled.

Evidence Summary

The 2020 European Society for Parenteral and Enteral Nutrition (ESPEN) guidelines indicate that individuals with chronic pancreatitis who are not malnourished should follow general healthy eating patterns. All individuals with chronic pancreatitis should avoid alcohol and very high fibre diets and should not restrict fat intake unless symptoms of steatorrhea cannot be controlled. 

Grade of Evidence C

Recommendation

Limited evidence supports supplementation of vitamin D to address deficiency in individuals with chronic pancreatitis and adequate intake of vitamin D and calcium to help mitigate the risk of osteoporosis. Evidence for antioxidant use to treat pain is mixed and any benefit is likely to be limited. Evidence does not support supplementation of synbiotics or other vitamins and minerals in individuals with chronic pancreatitis.

Evidence Summary

Calcium and Vitamin D

A 2020 systematic review and meta-analysis identified three RCTs that found that vitamin D supplementation (either orally or via intramuscular injection) increased serum 25-hydroxyvitamin D levels and therefore can be used to treat vitamin D deficiency in individuals with chronic pancreatitis. 

The 2020 ESPEN guidelines recommend that individuals with chronic pancreatitis consume adequate amounts of calcium and vitamin D because they are at risk of osteoporosis. This recommendation is based on expert consensus. 

Other Vitamins and Minerals

The 2020 ESPEN guidelines recommend monitoring levels of all fat-soluble vitamins (i.e. vitamins A, D, E, K), certain water-soluble vitamins (i.e. vitamin B12, folic acid, thiamine) and some minerals (i.e. magnesium, iron, selenium, zinc) and supplementing if concentrations are low or if there are signs of deficiency. ESPEN guidelines do not recommend general supplementation of vitamins A, E and K in individuals with chronic pancreatitis, because evidence demonstrating the benefits of supplementation is lacking. These recommendations are based on expert consensus.

Antioxidants

A 2020 systematic review and meta-analysis showed that antioxidant supplements (e.g. either a combination of selenium, b-carotene, a-tocopherol, ascorbic acid and methionine or curcumin) do not have an impact on pain, exocrine and endocrine pancreatic function or nutritional status in individuals with chronic pancreatitis. Results were limited by the high heterogeneity between RCTs.

The 2020 American College of Gastroenterology (ACG) guidelines suggest considering using antioxidants to treat pain, although they note that the benefit is likely limited. This was a conditional recommendation based on moderate quality evidence; however, evidence is limited given the inconsistent effects and heterogeneity in type and dosage of antioxidants used in the studies. 

Synbiotics

A 2020 systematic review and meta-analysis identified one RCT that showed unclear benefits of synbiotic supplementation on nutritional status in individuals with chronic pancreatitis, although it did reduce daily bowel frequency, improve blood parameters (e.g. hemoglobin, serum magnesium, albumin) and lower cholesterol. Synbiotic supplementation is an emerging treatment for chronic pancreatitis and more research is needed. 

Recommendation

Limited evidence suggests that individuals with chronic pancreatitis should be screened for malnutrition once every 12 months and individuals who are malnourished should eat small, frequent meals comprised of high protein, energy-dense foods. Oral nutrition supplements should only be used when an individual cannot meet their energy and protein needs through oral intake alone. Enteral nutrition should be considered when oral intake is ineffective and parenteral nutrition can be offered if individuals do not tolerate enteral nutrition or if other complicating conditions exist (e.g.  gastric outlet obstruction or complex fistulating disease).

Evidence Summary

The 2020 ESPEN guidelines suggest that individuals with chronic pancreatitis should be screened for malnutrition at least once every 12 months. Individuals who are malnourished should eat small, frequent meals comprised of high protein, energy-dense foods and should only be prescribed oral nutrition supplements if they cannot reach their energy and protein goals through oral intake alone. Enteral nutrition should be considered when oral nutrition support is ineffective. Semi-elemental formulas with medium-chain triglycerides (MCTs) can be offered if individuals do not tolerate standard formulas. Parenteral nutrition should be initiated if patients do not tolerate enteral nutrition or if they have complicating conditions (e.g.  gastric outlet obstruction or complex fistulating disease).

A 2020 systematic review and meta-analysis found that oral nutrition supplements enriched with MCTs were as effective as dietary counselling on nutritional status, quality of life and pain of individuals with chronic pancreatitis.

Grade of Evidence C

To see the full practice question, including the Evidence Statements, Remarks, Comments and References, click here. 

Knowledge Pathway Alert: Allergic Disease - High Risk Infant

The Allergic Disease - High Risk Infant Knowledge Pathway has been updated. Check out these updated practice questions:

Does a history of maternal atopy predict a higher risk for the development of allergy in infants and children as compared to a paternal history of atopy?

Do infants with a parental history of allergy have a reduced incidence of allergy if their mothers avoid common allergenic foods during pregnancy as compared to infants of mothers who do not restrict their diets during pregnancy?

Among term infants and children with a parental history of allergy, does breastfeeding reduce the incidence of allergy?

Do infants and children with a parental history of allergy who are exclusively breastfed and whose mothers avoid common allergenic foods during breastfeeding have a reduced incidence of allergy as compared to infants whose mothers do not restrict their diets?

Among infants with parental history of allergy, does delaying the introduction of common allergenic foods until after four months of age decrease the incidence of allergy?

What infant feeding formulas contribute to risk reduction for allergic diseases, including food allergy and eczema, among infants at high risk for allergy?

Among infants with parental history of allergy, does a combination of maternal avoidance of common allergenic foods during breastfeeding, infant feeding with hydrolyzed formula, delayed introduction of common allergenic foods and a house dust mite reduction program decrease the incidence of allergy as compared to infant-mother pairs who do not adhere to these interventions?

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Do you want to help shape new and updated PEN content on COVID-19 and nutrition, gallbladder disease and GERD/GORD?

We want to share a fantastic opportunity to help shape PEN content to ensure it is relevant to dietitians in everyday food and nutrition practice.

The following PEN Knowledge Pathways are being updated:

• COVID-19 and Nutrition (NEW Knowledge Pathway)
• Gastrointestinal Disease - Gallbladder disease
• Gastrointestinal System - Gastroesophageal/Gastro-oesophageal Reflux Disease (GERD/GORD

Contact the PEN Content Manager (coordinator@pennutrition.com) to learn how you can contribute.

When developing new or updating existing PEN content, we look for input on practice questions that make up a knowledge pathway. Specifically, this will look like:

• providing input on the existing practice questions that reflect the everyday practice situations faced by dietitians in the specific topic area
• providing direction on any practice guidelines, national policy documents or reports that would be important for authors to include in their work
• recommending reviewers for content review once it's been written.

This is a 1:1 request. Meaning it's a one-time request that requires about one hour of your time (meaning you are not committing to writing or reviewing content). 

With your permission, you will be acknowledged for your role as a Topic Advisor. Once the content is published, you can also download a letter of contribution signed by PEN's Director of Knowledge Translation acknowledging your contributions to the PEN System.

Are you interested? That’s great! Reach out to our PEN Content Manager (elizabeth.manafo@dietitians.ca) by October 31, 2022. Your input will be required by mid-November.

Do You Love PEN Handouts? Reviewers Are Needed!

• Low Tyramine Diet
• Osteoporosis 
• Fibromyalgia  
• Inflammatory bowel disease.

In April 2013, the PEN^® Team introduced the Practice Guidance Toolkits. These toolkits make the access to essential information on nutrition assessment, diagnosis, intervention, monitoring, associated tools and education materials based on nutrition-related conditions/diseases more 'up-front' and easier to retrieve. The toolkits present information in a format consistent with Nutrition Care Process Terminology (NCPT) with direct access to succinct information that dietitians use in their practice. The toolkits are a stand-alone tool used primarily for clinical knowledge pathways and also include the associated Summary of Recommendations and Evidence.  

To find them on the PEN home page, click on the Toolkits icon, which leads to all available toolkits. 

They can also be found on the Knowledge Pathways Table of Contents page. Click on any of the icons under the Practice Guidance Toolkit column. Alternatively, within a knowledge pathway, click on the “Toolkit “ tab on the right-hand side of the page. The Toolkit tab will only display as an option if the knowledge pathway has a toolkit.

Helpful Features in the Toolkits  

• Click on any of the items on the Table of Contents of the right-hand side of a toolkit to get quick, direct access to any section within the toolkit.  
• Flags! Where information is specific to a particular country, you have the option of seeing only your country’s information or viewing other’s information as well.  Simply click the box at the top of the page for the country information that you would like to view, and it will be displayed (or alternatively unclick the box to hide it).

Below is a list of toolkits that have recently been added or updated: 

• Nephrology - Chronic Kidney Disease (Pediatric/Paediatric) Practice Guidance Toolkit
• Weight/Obesity - Adult Practice Guidance Toolkit
• Diabetes - Continuous Subcutaneous Insulin Infusion Practice Guidance Toolkit.

Adapted from an April 2013 PEN eNews article.

thank you to our PEN^® volunteers

Canada

Paisley Steele
Laura Bjorklund
Paula Brauer
Nicole Byrom
Isabella Carneiro
Amy Chow
Denise K. Daley
Karen Davis
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Kristen MacEachern
Debbie MacLellan
Genevieve Mailhot
Sabrina Morris
Sarah O'Hara
Veronica Rouse
Monica Storey
Sandra Tsui
Savannah VanHerwynen
Julia Yeh