Updates in European Nutritional Guidelines Reflect Advances

Unprecedented progress that poses new challenges, increased attention to the environment in which one eats, and a focus on diseases with a broad impact but where nutrition is still neglected have motivated the updates to nutritional guidelines that were presented in Milan, Italy, during the 46th Congress of the European Society for Clinical Nutrition and Metabolism (ESPEN).

Nutrition in Dementia

Elisabet Rothenberg, a professor of geriatric nutrition at the Department of Health Sciences at Kristianstad University in Kristianstad, Sweden, presented the updates to the ESPEN guidelines on nutrition and hydration in dementia, which were published in June 2024. The updates include 40 recommendations: Seven at an institutional level and 33 at an individual level. Dementia poses numerous obstacles to proper nutrition, including difficulties in preparing meals and using utensils, appetite loss owing to medications, the ease with which patients forget to eat or drink, dysphagia, and refusal to nourish. In addition, factors and comorbidities typical of old age complicate the picture.

The previous guidelines dated back to 2015. Among the many updates is the first-ever recommendation to entrust the patient to qualified personnel — and to provide personalized dietary counseling — as well as to place the patient in a pleasant and stimulating environment during meals to encourage eating. Studies on this topic do not have a strong level of evidence but generally show positive results for interventions such as improving lighting and contrast, providing the most familiar and homey environment possible, and serving meals in common areas in a social context. It is necessary to avoid distractions as much as possible.

The use of fortified foods or modified textures to address poor nutrient intake, dysphagia, or chewing problems is recommended, while other types of supplements or specific diets are not. “It should be emphasized that we do not recommend ketogenic diets, which are currently promoted as a solution for many different pathologies. However, we do not find evidence to support their routine use, nor do we recommend probiotics for the same reason,” said Rothenberg.

Furthermore, there is now a recommendation to use standardized operational practices, including screening and systematic evaluation of patients.

Nutrition for Cystic Fibrosis (CF)

The long-awaited new ESPEN guidelines on nutrition for CF were drawn up in 2016 and updated in February 2024. In his presentation, Michael Wilschanski, head of pediatric gastroenterology at Hadassah University Hospital in Jerusalem, Israel, emphasized how the increased life expectancy and standard of care for patients with CF have created entirely new patient classes to consider.

CF causes nutritional problems, among other things, because of pancreatic insufficiency and an increased energy requirement due to respiratory difficulties. Normally, the main effort is therefore to maintain a normal body mass index (BMI), which requires a recommended daily caloric intake of 120%-200% of the norm and a diet rich in fats (35%-40%), with special attention to fat-soluble vitamins.

But because of the significant progress made for genetic variants of CF that benefit from cystic fibrosis transmembrane conductance regulator channel modulator drugs (which slow or stop functional decline by acting on the cause of the disease rather than the symptom), some patients now face the problem of overweight. Increased life expectancy, which in the best cases is now estimated to be over 80 years, means that there are now women with CF who can sustain a pregnancy, as well as elderly patients. Nutrition guidelines must therefore consider these cases, which once were almost unthinkable but fortunately are becoming more common.

Nutrition and Chronic Obstructive Pulmonary Disease (COPD)

Still on the topic of lung diseases, Peter Collins, senior lecturer in nutrition and dietetics at the Sydney Nursing School at the University of Sydney in Sydney, Australia, reviewed the status of efforts to draw up ESPEN guidelines on COPD.

Collins began by recalling the magnitude of the problem. “It is estimated that up to 390 million people worldwide suffer from COPD, and a recent study in JAMA suggests that this number could exceed 600 million individuals by 2050. Considering the minimum prevalence of malnutrition in COPD patients, which is around 20% (and can reach up to 50% in hospitalized patients), this is a figure that should alarm most healthcare systems worldwide.” Nevertheless, current information on the nutritional management of COPD is scarce and confusing: It is not clear what the optimal BMI is for patients with COPD, what the nutritional goals should be, how much energy and protein should be provided, or how to act during an acute exacerbation of COPD, compared with periods of stability or pulmonary rehabilitation. Guidelines from the United Kingdom, Australia, and the United States are too vague, according to Collins.

“As our knowledge of nutritional support in patients with COPD increases, we are more interested in the mode of nutritional support. Should we use powdered or liquid supplements or ready-to-drink options? Research has been presented evaluating the utility of slightly modified nutritional support for these patients, such as omega-3 fatty acids and different types of protein diets. These are all areas where we are still uncertain and need to further explore the literature,” said Collins.

The guideline working group has identified 14 key questions, ranging from the energy and protein requirements of patients to nutritional assessment or whether nutrition can influence the incidence of COPD. The working group is finishing its literature review. However, the levels of evidence and agreement on future recommendations still need to be understood. The guidelines should be ready for the 47th ESPEN Congress, which is scheduled for September 13-16, 2025, in Prague, said Collins.

This story was translated from Univadis Italy, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.