In recent years, progress has been made in both anaesthetic techniques and surgery, using minimally invasive techniques. In addition, the introduction of multimodal rehabilitation programmes (MRP) has been particularly important. They are intended for patients undergoing surgical procedures and their purpose is to identify the individual needs of patients, decrease the stress secondary to surgical interventions, reduce the occurrence of complications and thus optimise the peri-operative care; while decreasing hospital stay and healthcare costs at the same time (1-3).

Surgical patients usually show alterations in their nutritional status as a result of the underlying pathology which caused their hospital admission, the fasting period required by the surgical procedure and postoperative complications (4). The PREDyCES study determined that prevalence of malnutrition in surgical services in Spain at the time of admission was around 17% and it increased slightly up to 19.1% at the time of discharge (5). In this context, pre-operative malnutrition is associated with worse peri-operative results, thus increasing morbidity and mortality rates and hospital stay (6).

That is why, it is essential to establish an adequate nutritional support at an early stage, during the pre-operative phase, including nutritional status screening and assessment in order to properly identify the patients at risk of malnutrition or who are already malnourished. Nutritional support during the pre-operative phase has the objective of maintaining or improving the patient’s nutritional status before the surgical intervention, thus decreasing post-operative complications and hospital stay. Available scientific evidence shows that pre-operative nutritional support significantly improves post-operative clinical results in patients with severe malnutrition, especially if administered during 7 – 10 days. In addition, in connection with MRP, avoiding overnight fasting is recommended by supplying carbohydrate-containing drinks. During post-operative care, MRP include the early reintroduction of oral feeding. In those cases where oral intake does not cover 60% of the nutritional requirements during the first days of the post-operative period, the use of nutritional supplements should be considered. High-calorie, high-protein formulas should be the ones chosen for that purpose. Artificial nutrition is also suitable for surgical patients who must fast for a period longer than 7 days (or for more than 5 days if malnourished) or, if there are postoperative complications limiting the patient’s ability to eat orally (7).

Persan Farma offers enteral nutrition formulas adapted to the nutritional needs of surgical patients with the purpose of maintaining or improving their nutritional status, avoiding malnutrition-associated surgical complications.

Bibliography

1. Carli F, Scheede-Bergdahl C. Prehabilitation to Enhance Perioperative Care. Anesthesiol Clin [Internet]. 2015;33(1):17–33. Available from: http://dx.doi.org/10.1016/j.anclin.2014.11.002
2. Dong Q, Zhang K, Cao S, Cui J. Fast-track surgery versus conventional perioperative management of lung cancer-associated pneumonectomy: A randomized controlled clinical trial. World J Surg Oncol [Internet]. 2017;15(1):1–7. Available from: http://dx.doi.org/10.1186/s12957-016-1072-5
3. Muller S, Zalunardo M, Hubner M. A fast-track program reduces complications and lenght of hospital stay after open colonic surgery. Gastroenterology. 2009;136:842–7.
4. Mohamed AA-I, Álvarez J. Guía de actuación: Soporte Nutricional en el Paciente Quirúrgico. 1-222 p.
5. Álvarez-Hernández J, Planas Vila M, León-Sanz M, García de Lorenzo A, Celaya-Pérez S, García-Lorda P, et al. Prevalencia y costes de la malnutriciónn en pacientes hospitalizados; estudio PREDyCES. Nutr Hosp. 2012;27(4):1049–59.
6. Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann A, Bozzetti F. ESPEN Guidelines on Parenteral Nutrition: Surgery. Clin Nutr [Internet]. 2009 Aug;28:378–86. Available from: http://dx.doi.org/10.1016/j.clnu.2009.04.002
7. Ocón M, Ramírez J, Gimeno J. Nutrición en el paciente quirúrgico. In: Gil A, director. Tratado de Nutrición Nutrición y enfermedad. Tomo V, 3ª Edición. Madrid: Editorial Medica Panamericana; 2017. p. 645–57.

In pathologies affecting the digestive system is not uncommon to experience nutritional deficits, especially in inflammatory bowel disease which comprises Crohn’s disease and ulcerative colitis. Both pathologies are of unknown aetiology and usually lead to inflammation and ulceration of the intestinal mucosa, with different distribution and severity of the illness ⁽¹⁾.

According to the latest ESPEN (European Society for Clinical Nutrition and Metabolism) guidelines on clinical nutrition in inflammatory bowel disease, “in both ulcerative colitis and Crohn’s Disease, malnutrition can be the result of reduced oral intake, increased nutrient requirements, increased gastrointestinal losses of nutrients, and from drug interactions” ⁽²⁾.  When conventional oral diet is not enough to meet the nutritional requirements of these patients, enteral nutrition is a good alternative.

The benefits of enteral nutrition are:

• To prevent and improve nutritional status.
• To treat malnutrition.
• It has been recommended by ESPEN ⁽²⁾ (GR(B), C 92%) as the first line of treatment to induce remission in children and adolescents with Crohn’s disease.

Our policy here at Persan Farma is to offer a wide range of products that meet the nutritional requirements of this type of patients in order to avoid the consequences of malnutrition and to improve their quality of life.

Bibliography

1. Cabré Gelada E, Martín de Carpí J. Nutrición en la enfermedad inflamatoria intestinal. En: Gil Hernández Á, director. Tratado de nutrición, tomo V; 3ª Edición. Madrid: Panamericana; 2017. p. 769-809.
2. Forbes A, Escher J, Hébuterne X et al. ESPEN guideline: Clinical nutrition in inflamatory bowel disease. Clin Nutr 2017; 36: 321-347.

Elderly population is very vulnerable from a nutritional point of view. According to Ruiz López et al. the prevalence of calorie and protein malnutrition affects around 3-5% of older adults who are living at home and about 40-60% of the elderly living in nursing homes or who are in hospital ⁽¹⁾.

Special mention should be made of elderly individuals who are in a dependent situation, such as geriatric elderly and frail elderly people, as they could develop geriatric syndromes. These syndromes are:  immobility, instability, incontinence, intellectual impairment, infections, malnutrition, iatrogenesis, vision and hearing disturbances, etc.

In short, these are symptoms and signs which could be attributed to multiple causes which lead to disability and negatively interfere with the life of elderly people ⁽²⁾.

There are many factors which interfere with nutritional status in old age such as longevity, physical and cognitive deterioration, frailty, excessive use of medication to treat the different pathologies, constipation, dysphagia, loss of appetite for food, missing teeth ⁽¹⁾ and the development of geriatric syndromes.

As the Spanish Society of Geriatrics and Gerontology Nutrition Work Group points out, the consequences of malnutrition in elderly people are very serious as it causes a decrease in quality of life, affects the immune system, increases the risk of developing pressure ulcers and increases hospital stay which leads to an increase in morbidity and mortality and this results in higher healthcare expenditures ⁽³⁾.

Based on scientific evidence, ESPEN (European Society for Clinical Nutrition and Metabolism) guidelines on enteral nutrition in geriatrics, point out that “with a grade of recommendation A, the use of oral nutritional supplements is recommended in patients who are malnourished or are at risk of malnutrition to increase energy, protein and micronutrient intake, to maintain or improve nutritional status and survival” ⁽⁴⁾.

At Persa Farma we are committed to offering a wide range of products that meet the nutritional requirements of this type of patients in order to avoid the consequences of malnutrition and to improve their quality of life.

Bibliography

1. Ruiz López M.D, Artacho Martín-Lagos R, Quiles Morales J.L. Nutrición del adulto mayor. En: Gil Hernández Á, director. Tratado de nutrición, tomo IV; 3ª Edición. Madrid: Panamericana; 2017. p. 433-463.
2. Robles Raya Mª.J et al. Definición y objetivos de la especialidad de geriatría. Tipología de ancianos y población diana. Tratado de geriatría para residentes. Madrid: International Marketing & Communication, S.A; 2006. p. 25-32.
3. Valoración del estado nutricional en geriatría: declaración de consenso del Grupo de Nutrición de la Sociedad Española de Geriatría y Gerontología. Rev Esp Geriatr Gerontol. 2016; 51 (1): 52-57.
4. Volkert D, Berner Y N, Berry E, et al. ESPEN Guidelines on Enteral Nutrition: Geriatrics. Clin Nutr 2006; 25: 330-360.

Neurological diseases are a heterogeneous group of pathologies which affect the Central Nervous System (CNS) and the Peripheral Nervous System (PNS). Some of them are: multiple sclerosis, Parkinson’s disease, Alzheimer’s disease and other dementias, and cerebrovascular diseases such as strokes ⁽¹⁾.

There is a strong connection between neurological disorders and malnutrition. The nutritional risk of patients with both acute and chronic neurological diseases is significantly high due to different factors such as: reduced intake, cognitive impairment, apraxia, dysphagia, changes in energy expenditure and gastrointestinal disorders (nausea, vomiting, constipation) due to secondary effects of the pharmacological treatment of the disease ⁽²⁾.

Malnutrition makes the evolution of these patients complicated, it increases muscular atrophy (affecting the respiratory system and dysphagia), alters immune function, increases the risk of disability, and the chances of developing pressure ulcers and fractures ⁽³⁾.  In short, it increases the risk of morbidity and mortality and significantly worsens the patient’s quality of life.

Because all of this, a correct assessment of the nutritional status of patients with neurological disorders must be part of the diagnostic and therapeutic process of these types of diseases, and the adequate nutritional support should be provided ⁽⁴⁾.  Based on the scientific evidence available, the ESPEN guidelines recommend with a high level of evidence the use of nutritional supplements to improve nutritional status in patients with dementia ⁽⁵⁾.

At Persa Farma we are committed to offering a wide range of products that meet the nutritional requirements of this type of patients in order to avoid the consequences of malnutrition and to improve the patients’ quality of life.

Bibliography

• OMS. ¿Qué son los trastornos neurológicos? [Internet]. 2018 [cited 218 Mar 30]. Available from: http://www.who.int/features/qa/55/es.
• Bretón Lesmes I, Burgos Peláez R. Nutrición en las enfermedades neurológicas. En: Gil Hernández Á, director. Tratado de Nutrición Nutrición y enfermedad. Tomo V; 3ª Edición. Madrid: Editorial Médica Panamericana; 2017. p. 991-1008.
• Planas Vilà M. Aspectos metabólico-nutricionales en las enfermedades neurológicas. Nutr Hosp. 2014; 29 (supl 2): 3-12.
• De Luis D A, Izaola O, de la Fuente B, Muñoz-Calero P, Franco-Lopez A. Enfermedades neurodegenerativas, aspectos nutricionales. Nutr Hosp. 2015; 32(2) 946-951.
• Volkert D, Chourdakis M, Faxen-Irving G et al. ESPEN guidelines on nutrition in dementia. Clin. Nutr 2015: 1-22

To this day, diabetes mellitus represents one of the main health problems in the world. In Spain, the Di@bet.es study revealed that prevalence of diabetes mellitus in adults over 18 is around 13.8% (CI 95 %, 12.8 – 14.7 %) ⁽¹⁾.

Diabetes mellitus is a chronic endocrine/metabolic disorder which causes metabolism alterations, especially in carbohydrates metabolism, but it also affects protein and lipid metabolism. This is caused by a deficit in insulin secretion and/or activity causing persistent hyperglycemia, which in the long term is associated with the occurrence of vascular complications, which determine the high morbidity and mortality rate of this disease. In addition, patients in a situation of metabolic stress with metabolic alterations may develop symptoms similar to those of diabetes mellitus, which is known as stress hyperglycemia ⁽²⁾.

There is a strong correlation between nutritional status and diabetes mellitus. Therefore, being overweight or obese is a risk factor for the development of type 2 diabetes mellitus ⁽³⁾. On the other hand, the results of the sub-analysis of the PREDyCES study in diabetic patients revealed that 29.3% of patients were malnourished at the time of their hospital discharge and compared with normal-nourished patients, their hospital stays were longer (12.3 ± 8.3 vs 8.4 ± 5.5 días; p < 0.001) and their health costs, higher (8911,3 ± 6755 vs 5965,1 ± 4654 €; p = 0,001) ⁽⁴⁾. In this context, it is clear that nutrition plays a key role in disease management, together with drug treatment and the promotion of healthy life habits.

Nutritional intervention in patients with diabetes mellitus has the following goals ⁽²⁾:

• To help towards a good glycaemic control.
• To provide the right calories while at the same time helping maintain a healthy body weight close to the patient’s ideal weight.
• To monitor and control plasma lipid levels and blood pressure.
• To prevent and treat the development of disease-related complications.

Persan Farma offers enteral nutrition formulas to meet the nutritional requirements of diabetic patients with the purpose of maintaining or improving their nutritional status, preventing malnutrition-associated surgical complications and improving their quality of life.

Bibliography

1. Soriguer F, Goday A, Bosch-Comas A, Bordiú E, Calle-Pascual A, Carmena R, et al. Prevalence of diabetes mellitus and impaired glucose regulation in Spain: The Di@bet.es Study. Diabetologia. 2012;55(1):88–93.
2. Valero M, León-Sanz M. Nutrición en la diabetes mellitus. In: Gil A, director. Tratado de Nutrición Nutrición y enfermedad. Tomo V, 3^a Edición. Madrid: Editorial Medica Panamericana; 2017. p. 533–50.
3. National Institute of Diabetes and Digestive and Kidney Diseases. [Internet]. U.S. Department of Health and Human Services. Factores de riesgo para la diabetes tipo 2, 2016 Nov [cited 2018 March 20]. Available on: https://www.niddk.nih.gov/health-information/informacion-de-la-salud/diabetes/informacion-general/factores-riesgo-tipo-2. 2016.
4. León-Sanz M, Álvarez J, Planas M, García A, Araujo K, Celaya-Pérez S. Prevalence of Hospital Malnutrition in SM Journal of Public Health and Patients with Diabetes Mellitus : A Sub- Analysis of the PREDyCES ® Study Epidemiology. SM J Public Heal Epidemiol. 2015;1(4):1–6.

Kidney disease, also known as nephropathy, may appear abruptly and it can be reversible, as with acute kidney disease, or it can be progressive and irreversible, as with chronic kidney disease. In both cases, there is a reduction in the ability of the kidney to perform its main functions ⁽¹⁾.

In patients with kidney disease, the factors that contribute to the deterioration of their nutritional status are many, including: (i) a low intake or anorexia, (ii) intercurrent diseases and (iii) nutrient losses during dialysis. Bearing in mind that the term “kidney disease” includes a wide range of clinical situations, the establishment of common nutritional recommendations is a challenge. In addition, these patients show limitations in terms of macro and micronutrient intake and the volume they can consume ⁽²⁾.

For all this, nutritional intervention in kidney patients should be individualised, according to the aetiology, the stage of the illness and the therapy they are undergoing.

Persan Farma offers enteral nutrition formulas adapted to the nutritional needs of patients with a kidney pathology, with the purpose of maintaining or improving their nutritional status, preventing malnutrition-associated complications and improving their quality of life.

Bibliography

1. ALCER Federación Nacional. ¿Qué es la enfermedad renal? [Internet]. [cited 2018 Mar 21]. Available from: http://alcer.org/federacionalcer/que-es-la-enfermedad-renal/
2. Riobó P, Ortiz A, Barril G. Nutrición en las enfermedades renales. In: Gil A, director. Tratado de Nutrición Nutrición y enfermedad. Tomo V, 3^a Edición. Madrid: Editorial Medica Panamericana; 2017. p. 935–56.

Respiratory diseases are those that affect the airways and other structures of the lung. Among the most frequent ones are asthma, respiratory allergies, pulmonary hypertension, work-related lung diseases, chronic obstructive pulmonary disease (COPD), and cystic fibrosis ⁽¹⁾.

COPD is a disorder that causes obstructed airflow to the lungs. This can be due to the narrowing of the airways, as with chronic bronchitis, or to the loss of elastic tissue and the destruction of alveolar walls in emphysema. As a result, there is limited airflow which, together with the unexpelled trapped air, causes an abnormal inflammatory response ⁽²⁾.

Cystic fibrosis is an inherited genetic disorder characterised by mucus build-up which obstructs different organs, especially involving the lungs and pancreas ⁽³⁾.

Lungs play a key role in digestive, metabolic and endocrine functions of the body, as they are excretory organs, they excrete water and CO2. Therefore, if the respiratory system is affected in any way, either in an acute or chronic form, it can have an impact on the nutritional status of the patient ⁽⁴⁾. Malnutrition associated with advanced lung disease has been termed the “pulmonary cachexia syndrome” and is characterized by loss of fat-free body mass ⁽⁵⁾. This syndrome is associated with an accelerated decline in functional status and can affect patients with any type of advanced lung disease, as with chronic obstructive pulmonary disease (COPD) and cystic fibrosis ^(5-7).

Because all of this, it is necessary to carry out a nutritional assessment of patients with respiratory disease and thus identify those with higher nutritional risk or those who are already malnourished, so that the proper nutritional strategy can be established in accordance with the patient’s clinical situation.

Persan Farma offers enteral nutrition formulas adapted to the nutritional needs of patients with respiratory pathology, with the purpose of maintaining or improving their nutritional status, preventing malnutrition-associated complications and improving their quality of life.

Bibliography

1. OMS. Acerca de las enfermedades respiratorias crónicas [Internet]. 2018 [cited 2018 Mar 21]. Available from: http://www.who.int/respiratory/about_topic/es/
2. Bordejé-Laguna ML. Nuestros grandes olvidados, los enfermos respiratorios crónicos. Nutr Hosp. 2017;34(1):38–45.
3. National Center for Advancing Translational Sciences. Genetic and Rare Diseases Information Center. Fibrosis quística [Internet]. 2017 [cited 2018 Mar 21]. Available from: https://rarediseases.info.nih.gov/espanol/12467/fibrosis-quistica
4. Bordejé-Laguna ML, Sánchez C, Pérez A. Nutrición en las enfermedades del aparato respiratorio. In: Gil A, director. Tratado de Nutrición Nutrición y enfermedad. Tomo V, 3^a Edición. Madrid: Editorial Medica Panamericana; 2017. p. 689–703.
5. Wagner PD. Possible mechanisms underlying the development of cachexia in COPD. Eur Respir J. 2008;31(3):492–501.
6. Schols AMWJ. Pulmonary cachexia. Int J Cardiol. 2002;85:101–10.
7. King SJ, Nyulasi IB, Strauss BJG, Kotsimbos T, Bailey M, Wilson JW. Fat-free mass depletion in cystic fibrosis: Associated with lung disease severity but poorly detected by body mass index. Nutrition. 2010;26(7–8):753–9.

Dysphagia is a symptom characterised by the difficulty or inability to swallow foods and/or liquids and transfer them from the oral cavity to the stomach. It is noteworthy to mention that this is a geriatric syndrome that has a great impact on the lives of those who suffer it ⁽¹⁾.

There are multiple causes for dysphagia, such as the presence of tumours, lesions, neurological disease and cancer and surgical treatments. Depending on the type of dysphagia the patient has, different clinical effects will appear and specific therapeutical approaches will be selected, as dysphagia can be permanent or temporary ⁽²⁾.

There are multiple classifications of dysphagia, depending on:

• The phase of swallowing affected: oesophageal dysphagia or oropharyngeal dysphagia.
• Cause: mechanical dysphagia or motor dysphagia (neuromuscular).
• Acute or gradual onset.
• Consistency of the substance to be ingested: dysphagia to liquids, to solids or both ⁽²⁾.

Oropharyngeal dysphagia is particularly prevalent in the older population (more than 60% of elderly people in residential care), in people with neurological disorders (more than 30% of patients who have had a stroke develop dysphagia in acute stages) and in people with neurodegenerative diseases (around 35-45% of patients with Parkinson’s disease, 100% of patients with bulbar amyotrophic lateral sclerosis and 84% of patients with Alzheimer’s disease) ⁽³⁾.

The most serious consequences of dysphagia are due to the alterations in the efficacy and safety of deglutition:

• Malnutrition.
• Dehydration.
• Respiratory complications (which may lead to the patient’s death).
• A significant reduction in quality of life ⁽⁴⁾.

Because of all of the above, it is very important to carry out an early diagnosis and establish an adequate treatment according to the degree of dysphagia, with the aim of preventing and reversing the situation. Based on scientific evidence, the ESPEN (European Society for Clinical Nutrition and Metabolism) recommends with a grade of recommendation A, “the use of enteral nutrition in geriatric patients with acute neurological dysphagia to guarantee the supply of energy and nutrients and, thus, maintain or improve nutritional status” ⁽⁵⁾.

Bibliography

1. Barroso J. Disfagia orofaríngea y broncoaspiración. Rev Esp Geriatr Gerontol. 2009; 44(S2): 22-28.
2. Laborda González L, Gómez Enterría P. Tratamiento nutricional de la disfagia orofaríngea. Endocrinol Nutr. 2006; 53(5): 309-14.
3. García-Peris P, Velasco C, Frías Soriano L. Nutr Hosp Suplementos. 2012; 5(1): 33-40.
4. Ashbaugh R.A, Ferrero López I. Nutrición y disfagia. En: Gil Hernández Á, director. Tratado de nutrición, tomo V; 3ª Edición. Madrid: Panamericana; 2017. p. 977-989.
5. Volkert D, Berner Y N, Berry E, et al. ESPEN Guidelines on Enteral Nutrition: Geriatrics. Clin Nutr 2006; 25: 330-360

Palliative care

Patients in palliative care are a heterogeneous group of clinical situations that derive, for the most part, from advanced oncological processes and other chronic pathologies, which have a high prevalence of malnutrition due to the presence of the anorexia-cachexia syndrome. This multifactorial syndrome leads to weight loss, loss of muscle mass and depression of the immune system (1-3).

Malnutrition in these patients is caused by a significant reduction in food intake, due to an alteration in their metabolism and/or absorption of nutrients, and due to an increase in nutritional requirements that these patients are unable to achieve (1). In addition, there is a greater nutritional risk as the palliative care situation progresses. The consequences of malnutrition are directly related to the duration of this inadequate intake and the impact of the underlying chronic disease itself. This leads to an increase in complications and a greater number of hospital admissions, as well as to a reduction in functional capacity (4,5).

Preventing and addressing malnutrition in palliative care patients depends on early identification to correct nutritional deficiencies in order to preserve a good nutritional status and improve quality of life (6), since malnutrition is an independent predictor of mortality in palliative care patients with advanced cancer processes (7).

For all these reasons, it is essential to carry out a nutritional assessment in order to determine an adequate nutritional approach to cover the needs of palliative care patients, and thus reduce the complications that arise directly from being malnourished (2-3). The objective of this procedure is to increase the intake, maintain and/or recover the nutritional status and functional capacity of the patient, as well as to improve their quality of life (2,5,6). To carry out this procedure, the use of oral nutritional supplements or, when necessary, enteral tube nutrition would be recommended (8,9).

Persan Farma offers formulas for both oral supplementation and enteral tube nutrition adapted to the nutritional needs of patients in palliative care situations, with the goal of maintaining or improving the nutritional status, functionality and quality of life of patients.

Bibliography

1. García-Luna PP, Parejo J, Pereira JL. Causas e impacto clínico de la desnutrición y caquexia en el paciente oncológico. Nutr Hosp. 2006; 21(Supl. 3):10-6.
2. Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017; 36(1):11–48.
3. Arends J et al. ESPEN expert group recommendations for action against cancer-related malnutrition. Clin Nutr. 2017; 36:1187-1196.
4. Maltoni M, Caraceni A, Brunelli C, Broeckaert B, Christakis N, Eychmueller S, et al. Prognostic factors in advanced cancer patients: evidence based clinical recommendations – a study by the steering committee of the European association for palliative care. J Clin Oncol. 2005; 23(25):6240-48.
5. Tan CS, Read JA, Phan VH, Beale PJ, Peat JK, Clarke SJ, et al. The relationship between nutritional status, inflammatory markers and survival in patients with advanced cancer: a prospective cohort study. Support Care Cancer 2015; 23:385-91.
6. de Oliveira LC, Abreu GT, Lima LC, Aredes MA, Wiegert EVM. Quality of life and its relation with nutritional status in patients with incurable cancer in palliative care. Support Care Cancer. 2020; Feb 7. doi:10.1007/s00520-020-05339
7. Marcela C. Souza Jr, Emanuelly Varea Maria Wiegert, Larissa Calixto-Lima, Livia C. Oliveira. Relationship of nutritional status and inflammation with survival in patients with advanced cancer in palliative care. Nutrition 2018. doi: 10.1016/j.nut.2017.12.004.
8. Philipson TJ1, Snider JT, Lakdawalla DN, Stryckman B, Goldman DP. Impact of oral nutritional supplementation on hospital outcomes. Am J Manag Care. 2013; 19(2):121-8.
9. Gómez Candela C, Cantón Blanco A, Luengo Pérez LM, Fuster GO. Efficacy, cost-effectiveness, and effects on quality of life of nutritional supplementation. Nutr Hosp. 2010;25(5):781-92.