アメリカ栄養士会：臨床栄養管理のレベル別能力

アメリカ栄養士会による臨床栄養管理領域における管理栄養士のレベル別能力を解説している論文を紹介します。

Clark KM, Moore C, Trombley L, Skates J, Rogalski MJ, Schofield M, Welch J; Academy of Nutrition and Dietetics. Academy of Nutrition and Dietetics: Standards of professional performance for registered dietitians (competent, proficient, expert) in clinical nutrition management. J Acad Nutr Diet. 2012;112(10):1662-9, 1669.e1-17. doi: 10.1016/j.jand.2012.07.030. PubMed PMID: 23017575.

抄録はありません。管理栄養士の能力をcompetent, proficient, expertの3段階に分類しています。3段階のレベルはそれぞれ以下のように解説されています。

competentのレベルに達するだけでも正直、簡単ではない印象です。個々の患者への臨床栄養管理よりも、組織のマネジメントに関する記載が多いのも特徴かと感じます。expertレベルの管理栄養士が日本にもより増えると嬉しいですね。

Competent Practitioner

In dietetics, a competent practitioner is an RD who is starting practice after having obtained RD registration by the Commission on Dietetic Registration or an experienced RD who has recently assumed responsibility to provide nutrition care in a new focus area. A focus area is defined as an area of dietetics practice that requires focused knowledge, skills, and experience. A competent practitioner who has obtained RD status acquires on-the-job skills and engages in tailored continuing education to enhance knowledge and skills.

A competent level of professional performance in CNM is a level that is typically seen in those with little or no prior experience in a management position, although this level can be demonstrated by more tenured managers or clinicians new to the management role. The focus of a manager at this level is very task oriented. Process must be thoroughly considered, and the manager can benefit from guidance and step-by-step instructions. A manager at this level performs best in a controlled environment with close monitoring to execute tasks, prioritize, and troubleshoot problems. As the competent manager progresses, tasks are put into perspective, context is added to the rules, decision-making skills are refined, and related skills and situations are coordinated.

Proficient Practitioner

A proficient practitioner is an RD who has obtained operational job performance skills and is successful in his or her chosen focus area of practice. A proficient level of professional performance in CNM correlates with mid-level skills and abilities. The manager has developed a systematic approach to skill execution. Managers at this level have mastered the skills integral to the role and understand how these skills fit into a larger context; they have developed approaches to suit different situations. Managers at this level may or may not possess a specialist credential or certification. Compared with competent practitioners, proficient practitioners function at a higher level of management practice by developing long-term plans and goals, leading initiatives to expand current practice as well as managing human and financial resources with finesse and role comprehension. These managers function effectively within their organizations to institute change, secure needed resources, and advance the practice of medical nutrition therapy. As these managers advance their proficiency, they develop an intuitive understanding of the role, which enables them to focus on the critical issues that matter and the implications of information and actions. Their skills are embedded with other related skills, allowing them to form a wider framework of perspective and priorities. They often learn from experience and guidelines developed by others.

Expert Practitioner

An expert practitioner is an RD who is recognized within the profession and has mastered the highest degree of skill in or knowledge of a certain focus or generalized area of dietetics through additional knowledge, experience, and/or training. An expert practitioner has a high degree of professional autonomy and responsibility, exhibits a set of characteristics that include leadership and vision, and demonstrates effectiveness in planning, achieving, evaluating, and communicating targeted outcomes. The expert level of professional performance in CNM correlates with the acquisition of a sound knowledge base and complex decision-making skills that enable the manager to rapidly and accurately grasp the impact of a situation and seamlessly move to resolve it. These managers serve as a primary source of knowledge and information. Expert practitioners may or may not possess additional certification or credentialing. Expert practitioners possess an in-depth understanding of role requirements and a keen ability to envision service expansion and interface influentially with subordinates and peers to make a shared vision a reality. An expert level of practice may accompany tenure in a management position, which cultivates maturation in approaching and guiding others. These managers demonstrate mastery in professional practice, working relationships, leadership, mentorship, and staff/team development. Expert managers address complex cases without referring to management guidelines. Because they already have a mastery of the content, these guidelines are automatically applied without the need to refer to them. Conscious thought is spent more on exceptions, innovations, and challenges faced by others.

食道がん化学療法中のグレリン投与

食道がん化学療法中のグレリン投与の効果をみたPhase2のランダム化比較試験を紹介します。

Hiura Y, Takiguchi S, Yamamoto K, Takahashi T, Kurokawa Y, Yamasaki M, Nakajima K, Miyata H, Fujiwara Y, Mori M, Kangawa K, Doki Y. Effects of ghrelin administration during chemotherapy with advanced esophageal cancer patients: a prospective, randomized, placebo-controlled phase 2 study. Cancer. 2012 Oct 1;118(19):4785-94. doi: 10.1002/cncr.27430.

リサーチクエスチョンは以下の通りです。

P：食道がんでシスプラチンの化学療法を行っている患者に
I：合成ヒトグレリン(3μg/kg)を1日2回1週間、静脈投与すると
C：プラセボと比較して
O：経口摂取エネルギー量が増加する
D：ランダム化比較試験

結果ですが、グレリン投与群で経口摂取エネルギー量は有意に増加しました(18.2kcal/kg/day vs 12.7kcal/kg/day）。食欲のVASスコアもグレリン投与群で有意に高かったです。化学療法中の副作用、QOL低下、吐気・嘔吐、全般的健康状態悪化は、グレリン投与群のほうが少なかったです。

グレリン投与を中止したのは21人中、大量発汗を認めた患者1人のみです。以上より、食道がんでシスプラチンの化学療法を行っている患者への短期のグレリン投与は、経口摂取エネルギー量を増加させ副作用を少なくするという結論です。

1週間のみの使用ですので、体組成の変化や筋力の変化は評価していません。経口摂取エネルギー量の増加は意味がありますが、静脈栄養とリハを適切に併用で体重変化に差は出ないかもしれません。サルコペニアや悪液質の改善に化学療法中（～後）のグレリンが有効か知りたいですね。

Abstract

BACKGROUND:

Cisplatin reduces plasma ghrelin levels through the 5-hydroxytryptamine (5-HT) receptor. This may cause cisplatin-induced gastrointestinal disorders and hinders the continuation of chemotherapy. The authors of this report conducted a prospective, randomized phase 2 trial to evaluate the effects of exogenous ghrelin during cisplatin-based chemotherapy.

METHODS:

Forty-two patients with esophageal cancer who were receiving cisplatin-based neoadjuvant chemotherapy were assigned to either a ghrelin group (n = 21) or a placebo group (n = 21). They received either intravenous infusions of synthetic human ghrelin (3 μg/kg) or saline twice daily for 1 week with cisplatin administration. The primary endpoint was changes in oral calorie intake, and the secondary endpoints were chemotherapy-related adverse events; appetite visual analog scale (VAS) scores; changes in gastrointestinal hormones and nutritional status, including rapid turnover proteins, and quality of life (QoL) estimated with the European Organization for Research and Treatment of Cancer QoL core questionnaire (QLQ-C30).

RESULTS:

Two patients were excluded from the final analysis: One patient suspended ghrelin administration because of excessive diaphoresis, and another patient in the placebo group failed to monitor the self-questionnaire. Food intake and appetite VAS scores were significantly higher in the ghrelin group than in the placebo group (18.2 ± 5.2 kcal/kg/day vs 12.7 ± 3.4 kcal/kg/day [P = .001] and 6.2 ± 0.9 vs 4.1 ± 0.9 [P < .0001], respectively). Patients in the ghrelin group had fewer adverse events during chemotherapy related to anorexia and nausea than patients in the control group. Significant deterioration was noted after chemotherapy in the placebo group in QoL scores, appetite, nausea and vomiting, and global health status.

CONCLUSIONS:

Short-term administration of exogenous ghrelin at the start of cisplatin-based chemotherapy stimulated food intake and minimized adverse events.

高齢者の脂肪・筋肉量・筋力と機能低下：メタ解析

高齢者の脂肪・筋肉量・筋力と機能低下の関係のメタ解析を紹介します。

Laura A. Schaap, Annemarie Koster and, Marjolein Visser. Adiposity, Muscle Mass, and Muscle Strength in Relation to Functional Decline in Older Persons. Epidemiol Rev (2012) doi: 10.1093/epirev/mxs006

メタ解析の結果ですが、BMI30以上と筋力低下は、機能低下と有意な関連を認めました。オッズ比はBMI30以上より筋力低下のほうが高いです。一方、筋肉量低下は機能低下と統計学的に有意な関連を認めませんでした（オッズ比1.19、95％信頼区間0.98～1.45ですので無関係とは言えませんが）。

筋肉量低下よりもBMI30以上の肥満や筋力低下のほうが、高齢者への機能低下の影響が大きいとは言えます。サルコペニア肥満対策としても、筋肉量が増加するにこしたことはありませんが、むしろBMI30未満（日本人なら25未満かもしれません）への減量や筋力増強のほうが重要だと思われます。

Abstract

Aging is associated with changes in body composition and muscle strength. This review aimed to determine the relation between different body composition measures and muscle strength measures and functional decline in older men and women. By use of relevant databases (PubMed, Embase, and CINAHL) and keywords in a search from 1976 to April 2012, 50 articles were reviewed that met the inclusion criteria (written in English, a prospective, longitudinal design, involving older persons aged 65 years or more, and at least one of the measures that follow: body mass index (BMI), waist circumference, waist/hip ratio, midarm circumference, fat mass, muscle fat infiltration, muscle mass, or strength as independent variables and a measure of functional decline as outcome measure). Meta-analyses were performed and revealed that BMI ≥30 and low muscle strength were associated with functional decline (pooled odds ratio (OR) = 1.60, 95% confidence interval (CI): 1.43, 1.80, for BMI ≥30 and OR = 1.86, 95% CI: 1.32, 2.64, for muscle strength). Low muscle mass was not significantly associated with functional decline (pooled OR = 1.19, 95% CI: 0.98, 1.45). Future intervention research should focus on positive changes in body composition to prevent onset or worsening of functional decline in old age. 

高齢者の性ホルモンとサルコペニア

高齢者の性ホルモンとサルコペニアのレビュー論文を紹介します。

Maggio, Marcello; Lauretani, Fulvio; Ceda, Gian Paolo. Sex hormones and sarcopenia in older persons. Current Opinion in Clinical Nutrition & Metabolic Care: January 2013 - Volume 16 - Issue 1 - p 3–13

性ホルモンの中でもテストステロンとデヒドロエピアンドロステロン（DHEAS）について、サルコペニア治療として投与した場合のレビュー論文です。テストステロンとDHEASの投与で筋肉量は増加しますが、筋力や身体機能の改善は明らかではありません。さらなる研究が必要という結論です。

テストステロンでは高齢男性で筋力増強も得られるというメタ解析がありますが、副作用の問題が大きく日常診療でルーチンに使用するものではないと考えます。特にサルコペニアが顕著な場合には、リハ・筋トレと併用して副作用をモニタリングしながら、同化ホルモンを使用してもよいとは思いますが。

Abstract

Purpose of review: Sarcopenia is a geriatric syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength with a risk of adverse outcomes such as physical disability, poor quality of life, and death. Sarcopenia is a multifactorial process involving the decline of androgens, including dehydroepiandrosterone sulphate (DHEAS) and testosterone. The aim of this review is to highlight the effects of DHEAS and testosterone treatment to counteract sarcopenia, especially in older men.

Recent findings: DHEAS and, more importantly, testosterone treatment are associated with increased muscle mass, whereas the effects on muscle function and physical performance are less clear. The results of recent randomized placebo controlled trials with DHEAS in older men and women and testosterone in men with mobility limitation are discussed. The novel current and future scenarios to attenuate the detrimental effects and to optimize the efficacy of sex hormone treatment are also addressed.

Summary: DHEAS and testosterone are important options in the armamentarium of sarcopenia treatment in older men. Future studies are needed to address new approaches by using selective compounds, targeting the correct form and dosage, tailoring the correct patient to treat, and taking into account the multifactorial origin and the new definition of sarcopenia.

筋トレ＋魚油で筋力と身体機能改善

筋トレに魚油摂取を併用すると高齢女性では筋力と身体機能がより改善するというRCTを紹介します。

Rodacki CL, Rodacki AL, Pereira G, Naliwaiko K, Coelho I, Pequito D, Fernandes LC. Fish-oil supplementation enhances the effects of strength training in elderly women. Am J Clin Nutr. 2012 Feb;95(2):428-36.

リサーチクエスチョンは以下の通りです。

P：高齢女性（平均年齢64歳）が
I：筋トレに魚油1日2g摂取を3ヶ月間、併用すると
C：筋トレのみの場合と比較して
O：筋力と身体機能が改善する
D：ランダム化比較試験

抄録しか読めていないので、筋トレの頻度・強度は不明です。魚油摂取群は、90日間摂取群と150日間摂取群（筋トレ60日前から開始）にさらに分かれています。結果ですが、3群とも筋トレ前後で筋力は増加しました。しかし、魚油摂取群でより筋力と身体機能が向上しました。

筋肉量を評価していないので、サルコペニアが魚油摂取で改善したかどうかは不明です。また栄養状態がどうなのかもわかりません（おそらく明らかな低栄養やサルコペニアは認めない方たちが対象だと思いますが）。

しかし、筋力と身体機能がより増加するというのは意味あると思います。魚油摂取単独で筋力と身体機能が改善するとは考えにくいですが、筋トレに魚油摂取を併用するのは高齢女性ではよいかもしれません。サルコペニアの方でも男性を含めて同様な結果が得られるかを知りたいですね。

Abstract

BACKGROUND:

Muscle force and functional capacity generally decrease with aging in the older population, although this effect can be reversed, attenuated, or both through strength training. Fish oil (FO), which is rich in n-3 (omega-3) PUFAs, has been shown to play a role in the plasma membrane and cell function of muscles, which may enhance the benefits of training. The effect of strength training and FO supplementation on the neuromuscular system of the elderly has not been investigated.

OBJECTIVE:

The objective was to investigate the chronic effect of FO supplementation and strength training on the neuromuscular system (muscle strength and functional capacity) of older women.

DESIGN:

Forty-five women (aged 64 ± 1.4 y) were randomly assigned to 3 groups. One group performed strength training only (ST group) for 90 d, whereas the others performed the same strength-training program and received FO supplementation (2 g/d) for 90 d (ST90 group) or for 150 d (ST150 group; supplemented 60 d before training). Muscle strength and functional capacity were assessed before and after the training period.

RESULTS:

No differences in the pretraining period were found between groups for any of the variables. The peak torque and rate of torque development for all muscles (knee flexor and extensor, plantar and dorsiflexor) increased from pre- to posttraining in all groups. However, the effect was greater in the ST90 and ST150 groups than in the ST group. The activation level and electromechanical delay of the muscles changed from pre- to posttraining only for the ST90 and ST150 groups. Chair-rising performance in the FO groups was higher than in the ST group.

CONCLUSIONS:

Strength training increased muscle strength in elderly women. The inclusion of FO supplementation caused greater improvements in muscle strength and functional capacity.

日本人男性の喫煙と筋力

日本人男性で喫煙と筋力の関連を調査した論文を紹介します。

Takeshi Saito, et al. Relationship Between Cigarette Smoking and Muscle Strength in Japanese Men. J Prev Med Public Health. 2012 Nov;45(6):381-386

下記HPで全文見ることができます。
http://synapse.koreamed.org/search.php?where=aview&id=10.3961/jpmph.2012.45.6.381&code=0056JPMPH&vmode=FULL

対象は日本人男性4249人、平均年齢43.3歳で、喫煙はブリンクマン指数、筋力は握力と下肢筋力を評価しています。結果ですが、38.1%が喫煙していて、34.9%が定期的に運動していました。年齢での補正後でもブリンクマン指数400以上の場合、筋力が有意に低かったです。

年齢、身長、体重、運動習慣で調整後も、ブリンクマン指数400以上の喫煙者は握力が有意に低かったです。一方、下肢筋力は統計学的有意差を認めませんでした。以上より、喫煙と筋力（特に握力）は負の相関を認めるかもしれないという結論です。

交絡因子の評価と調整が十分とはいえない気もしますが、喫煙と筋力に負の相関を認めるという結果には意味があると思います。喫煙者にはサルコペニアが多いという報告もありますので、サルコペニア予防には禁煙したほうがよいと考えます。

Abstract

Objectives To investigate the link between cigarette smoking and muscle strength in Japanese men.

Methods We used data on 4249 Japanese men, aged 43.3±13.9 years, in this cross-sectional investigation study. Grip strength and leg strength were measured as indicators of overall muscle strength. Meanwhile, subjects' cigarette smoking habits were recorded by trained medical staff. The effect of cigarette smoking on muscle strength was evaluated.

Results A total of 1618 men (38.1%) were smokers and 1481 men (34.9%) exercised regularly. Significant differences in muscle strength were noted between men with and without a Brinkman index of 400 or greater, after adjusting for age. After adjusting for age, height, body weight and exercise habits, associations between the Brinkman index and leg strength and the ratio of leg strength to body weight were attenuated.

Conclusions Cigarette smoking might be negatively associated with muscle strength, especially grip strength in Japanese men.

がん悪液質のメカニズムと治療

がん悪液質のメカニズムと治療のレビュー論文を紹介します。

Fearon K, Arends J, Baracos V. Understanding the mechanisms and treatment options in cancer cachexia. Nat Rev Clin Oncol. 2012 Dec 4. doi: 10.1038/nrclinonc.2012.209. [Epub ahead of print]

悪液質の早期治療（＝早期診断）の重要性が指摘されています。その上で、食欲不振（痛み、吐気）に対して、栄養サポート、抗炎症作用のある薬物もしくは栄養素、レジスタンス運動を組み合わせた包括的治療に、新たな治療方法を開発・実践することで、QOLやがん治療耐性の改善を期待できます。

エビデンスは十分とはいえませんが、がん悪液質に対して栄養・薬物・運動（レジスタンス運動だけでなく有酸素運動もよいと思います）を組み合わせた包括的治療は、もはや標準的なパッケージとあります。がん以外の慢性臓器不全も含めた悪液質に対するリハ栄養＋薬物療法の重要性を早く広めたいです。

Abstract

Cancer cachexia is a metabolic syndrome that can be present even in the absence of weight loss ('precachexia'). Cachexia is often compounded by pre-existing muscle loss, and is exacerbated by cancer therapy. Furthermore, cachexia is frequently obscured by obesity, leading to under-diagnosis and excess mortality. Muscle wasting (the signal event in cachexia) is associated not only with reduced quality of life, but also markedly increased toxicity from chemotherapy. Many of the primary events driving cachexia are likely mediated via the central nervous system and include inflammation-related anorexia and hypoanabolism or hypercatabolism. Treatment of cachexia should be initiated early. In addition to active management of secondary causes of anorexia (such as pain and nausea), therapy should target reduced food intake (nutritional support), inflammation-related metabolic change (anti-inflammatory drugs or nutrients) and reduced physical activity (resistance exercise). Advances in the understanding of the molecular biology of the brain, immune system and skeletal muscle have provided novel targets for the treatment of cachexia. The combination of therapies into a standard multimodal package coupled with the development of novel therapeutics promises a new era in supportive oncology whereby quality of life and tolerance to cancer therapy could be improved considerably.