PEN eNews 11(9) September 2021

PEN eNews is a monthly e-newsletter shared with the global PEN Community and created to help dietitians position themselves as leaders in evidence-based nutrition practice. In addition, users of the PEN System will find articles on the new evidence, resources and features available and how to maximize one's use of PEN.

September 2021 · Volume 11, Issue 9

Preschool and Nutrition Interventions – What Works?

The Question

What is known about the effectiveness of nutrition interventions to improve dietary intake of the preschool population?

The Recommendation

Multicomponent nutrition interventions (e.g. teacher and parent education, preschool policy changes) aimed at improving healthy eating behaviours in children aged two to five years may be mildly successful. Most of the successful interventions that have been studied were implemented in preschools and encouraged parents to extend the intervention to the home.

Characteristics of successful interventions include:

frequent, short sessions to accommodate children’s attention spans
duration of at least one year
educators who are trained to ensure that the intervention is implemented as designed
parental engagement (ideally face-to-face)
interactive, age-appropriate activities that are aligned with the intervention objectives and expected behaviours
supportive intervention environment (e.g. making water, fruit and vegetables easily available)
intervention targets should be specific. Measurable targets may include:
- intervention environment (e.g. home, preschool)
- educator and/or parent behaviours
- child knowledge, preferences or behaviours.

For more detailed information, see the table in the Evidence Statements section.

Repeated taste exposure shows promise as a successful strategy in both home and child care settings for increasing vegetable intake and is especially effective when applied to plain vegetables and vegetables that the child initially dislikes.

At a planning level, interventions may be successful if they are grounded in behaviour change theory, evaluated by an advisory group and if they consider economic challenges.

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

Want to know what else is new and updated? Bookmark these pages:
New Knowledge Pathway Content  (Knowledge Pathways, Practice Questions, Summary of Recommendations and Evidence, Practice Guidance Toolkits, Backgrounds)
Tools and Resources.

Pediatric Health Nutrition

Heart Failure and Omega-3s: To Take or Not to Take?

The Heart Failure KP has been updated and one of the five new GRADE practice questions is on omega-3 fatty acids. Here is a quick look at the practice question.

The Question

Should omega-3 fatty acid supplements be recommended for individuals with heart failure?

The Recommendation

For individuals with a diagnosis of heart failure (HF), members of the PEN Collaborative Partnership (Dietitians of Canada, the British Dietetic Association and Dietitians Australia) suggest daily omega-3 fatty acid supplementation (1 g/day), depending on resources available and users' values and preferences.

Conditional recommendation | Moderate quality evidence ⊕⊕⊕о

The Evidence

The conditional recommendation for omega-3 supplementation puts a high value on the moderate clinical benefit achieved for some outcomes (i.e. reduced overall mortality, cardiovascular mortality and hospital admissions) and the few harms associated with supplementation, and a lower value on the costs for the individual in purchasing supplements. Resource requirements and patient values/preferences related to this intervention were not examined and this should be discussed with individuals on a case-by-case basis. The evidence was obtained from one multicentre trial in predominantly men diagnosed with HF (left ventricular ejection fraction <40%, NYHA class II), using a dose of 1 g/day for a median of 3.9 years. Additional research is needed investigating supplementation of various doses of omega-3 fatty acid supplements in addition to effects on individuals with preserved or mid-range ejection fraction. The decision to recommend omega-3 fatty acids for an individual should be discussed with the physician with consideration given to other medical factors. Individuals taking omega-3 fatty acids should have their lipid profile assessed and should be monitored for potential adverse effects (e.g. gastrointestinal).

To see the full practice question, including references, click here.

Looking for more content on cardiovascular disease? The PEN^® System has lots of content on CVD including:

5 Knowledge Pathways
172 Practice Questions
197 Professional Resources
70 Client Handouts

Enter “cardiovascular disease” in the PEN search and see all the results!

Cardiovascular Disease

PEN Uses PEN Applied

Lisa Doerr's Surprising Findings - Probiotics and postpartum depression

Although it often seems difficult to make evidence-based decisions during pregnancy without relying on fuzzy evidence, dietitians can be comforted that we can usually provide some clear recommendations (see PEN’s recently updated pregnancy content here). However, what to eat during pregnancy remains a confusing prospect to many people, and even I was surprised to see a meta-analysis that found that probiotic supplementation may decrease symptoms of perinatal anxiety, but not of perinatal depression (1).

Some (2,3), but not all (4), recent meta-analyses have shown that probiotic supplementation can improve depressive symptoms in non-pregnant people, but due to major biological differences, these results cannot be generalized to the pregnant population. Three RCTs examining women who were pregnant or had recently given birth were included in the review, all of which examined different probiotic strains (1). One study compared Lactobacillus rhamnosus GG and Bifidobacterium lactis BB to placebo; one compared Lactobacillus rhamnosus HN001 to placebo; and one compared Lactobacillus acidophilus and Bifidobacterium lactis-fortified yogurt to regular yogurt. Mean depression scores, as well as the proportion of participants scoring above the cutoff for depression on a depression rating scale, were not significantly different between probiotic and control groups. However, mean anxiety scores were significantly lower in probiotic compared to control groups, although the proportion of participants scoring below the cutoff for anxiety was not different between groups.

Overall, the authors concluded that the current base of evidence is not robust enough to guide clinical recommendations. The certainty of evidence was moderate to low for most outcomes, meaning that these results are likely to change as more evidence is gathered. Which, I suppose, is a very unsurprising ending to this surprising finding: the effect of probiotics in pregnancy is just another example of fuzzy evidence.

Lisa Doerr, RD MScFN

PEN Evidence Analyst

References

Desai V, Kozyrskyj AL, Lau S, Sanni O, Dennett L, Walter J, Ospina MB. Effectiveness of Probiotic, Prebiotic, and Synbiotic Supplementation to Improve Perinatal Mental Health in Mothers: A Systematic Review and Meta-Analysis. Front Psychiatry. 2021 Apr 22;12:622181. doi: 10.3389/fpsyt.2021.622181. PMID: 33967849; PMCID: PMC8100186. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/33967849/
Barbosa RSD, Vieira-Coelho MA. Probiotics and prebiotics: focus on psychiatric disorders - a systematic review. Nutr Rev. 2020 Jun 1;78(6):437-450. doi: 10.1093/nutrit/nuz080. PMID: 31769847. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/31769847/
Ansari F, Pourjafar H, Tabrizi A, Homayouni A. The Effects of Probiotics and Prebiotics on Mental Disorders: A Review on Depression, Anxiety, Alzheimer, and Autism Spectrum Disorders. Curr Pharm Biotechnol. 2020;21(7):555-565. doi: 10.2174/1389201021666200107113812. PMID: 31914909. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/31914909/
Ng QX, Peters C, Ho CYX, Lim DY, Yeo WS. A meta-analysis of the use of probiotics to alleviate depressive symptoms. J Affect Disord. 2018 Mar 1;228:13-19. doi: 10.1016/j.jad.2017.11.063. Epub 2017 Nov 16. PMID: 29197739. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/29197739/

Pregnancy Probiotics

PEN Uses COVID-19

Practice Guidance Toolkits - There for you!

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:

Adapted from an April 2013 PEN eNews article.

PEN Features

PEN eNews

September 2021 · Volume 11 (9)

A Publication of the PEN System Global Partners,

a collaborative partnership between International Dietetic Associations.

Learn more about PEN.

PEN eNews 11(9) September 2021

Preschool and Nutrition Interventions – What Works?

The Question

The Recommendation

Heart Failure and Omega-3s: To Take or Not to Take?

The Question

The Recommendation

The Evidence

We Need Your Expertise: PEN® Reviewers Needed

We need reviewers within the next few months for:

Lisa Doerr's Surprising Findings - Probiotics and postpartum depression

Open Access to COVID-19 Content Continues

Practice Guidance Toolkits - There for you!

We Need Your Expertise: PEN^® Reviewers Needed