Following the new ESPEN Standard Operating Procedures, the previous 2019 guideline to provide best medical nutritional therapy to critically ill patients has been shortened and partially revised. Following this update, we propose this publication as a practical guideline based on the published scientific guideline, but shortened and illustrated by flow charts. The main goal of this practical guideline is to increase understanding and allow the practitioner to implement the Nutrition in the ICU guidelines. All the items discussed in the previous guidelines are included as well as special conditions.

Offspring health outcomes are often linked with epigenetic alterations triggered by maternal nutrition and intrauterine environment. Strong experimental data also link paternal preconception nutrition with pathophysiology in the offspring, but the mechanism(s) routing effects of paternal exposures remain elusive. Animal experimental models have highlighted small non-coding RNAs (sncRNAs) as potential regulators of paternal effects. Here, we characterised the baseline sncRNA landscape of human sperm and the effect of a 6-week dietary intervention on their expression profile. This study involves sncRNAseq profiling, that was performed on a subset (n = 17) of the participants enrolled in the PREPARE trial: 9 from the control group and 8 from the intervention group. 5’tRFs, miRNAs and piRNAs were the most abundant sncRNA subtypes identified; their expression was associated with age, BMI, and sperm quality. Nutritional intervention with olive oil, vitamin D and omega-3 fatty acids altered expression of 3 tRFs, 15 miRNAs and 112 piRNAs, targeting genes involved in fatty acid metabolism and transposable elements in the sperm genome. PREPARE Trial registration number: ISRCTN50956936, Trial registration date: 10/02/2014.

BACKGROUND:n-6 (ω-6) Polyunsaturated fatty acids may exert divergent biological effects, but limited knowledge exists about their associations with mortality. OBJECTIVES:To investigate the associations between adipose tissue content of individual n-6 polyunsaturated fatty acids - a long-term marker of endogenous exposure to these fatty acids - and all-cause mortality. METHODS:We used a prospective cohort study design. We followed a random sample of 4663 participants from the Danish diet, cancer, and health cohort, which was established between 1993 and 1997. Information on all-cause mortality was retrieved from the nationwide Danish civil registration system. An adipose tissue biopsy was collected from the buttock at recruitment and analyzed for fatty acid composition using gas chromatography. Hazard ratios were obtained using Cox proportional hazard regression. RESULTS:During a median of 21 y of follow-up, 1160 participants died. The median adipose tissue contents of linoleic acid and arachidonic acid were 10.60% and 0.36%, respectively. In multivariable continuous analyses, we observed a statistically significant inverse association between adipose tissue content of linoleic acid and all-cause mortality (P < 0.001). In contrast, a statistically nonsignificant positive association was found in continuous analyses of adipose tissue content of arachidonic acid and all-cause mortality (P = 0.078). Comparing the highest with the lowest quartile, the hazard ratio for mortality was 0.76 (95% confidence interval [CI]: 0.64, 0.90) for linoleic acid and 1.28 (95% CI: 1.07, 1.53) for arachidonic acid in adipose tissue, respectively. CONCLUSIONS:Adipose tissue content of linoleic acid was inversely associated with all-cause mortality, whereas adipose tissue content of arachidonic acid was associated with a higher all-cause mortality.

BACKGROUND:We assessed the cost-effectiveness of personalised nutrition in adults with overweight/obesity in Poland and the United Kingdom (UK) using the results of two randomised controlled trials (RCTs). METHODS:The 4-month RCTs compared three interventions: personalised plan (PP) plus behavioural change (PP+B), PP only, and a control. Outcomes included body mass index (BMI), health-related quality of life (EQ-5D-5L), quality-adjusted life years (QALYs), and costs (2020 British pounds). A Markov model estimated lifetime cost-effectiveness. Different sensitivity analyses were performed. RESULTS:Participants were randomised to PP+B, PP, and control groups in Poland (n = 89, n = 88, n = 88) and the UK (n = 20, n = 19, n = 15). Comparing BMI reductions of PP+B and PP with control in both countries showed no significant differences, but wide confidence intervals (CIs) were observed (e.g., PP+B vs. control-Poland: -0.20, 95% CI: -0.86, 0.45 kg/m2; UK: -0.80, 95% CI: -1.60, 0.00 kg/m2). Lifetime analysis suggested potential cost-effectiveness for PP+B in Poland (£20,404 per QALY gain), and for PP+B (£13,006 per QALY) and PP (£12,222 per QALY) in the UK, since these figures were lower than the willingness-to-pay thresholds (£34,000 in Poland and £20,000 in the UK). PP in Poland was dominated by control, but sensitivity analyses suggested potential cost-effectiveness. CONCLUSIONS:The PREVENTOMICS interventions may offer a cost-effective approach to reduce weight and avoid its related complications in both countries. Future studies should be larger and/or longer to reduce uncertainty about effectiveness. CLINICAL TRIAL REGISTRATION NUMBERS:Poland ISRCTN51509551 and the UK ISRCTN46063864.

Unhealthy dietary patterns are a major modifiable risk factor for atherosclerotic cardiovascular disease (ASCVD). International guidelines recommend reducing saturated fatty acid intake while increasing polyunsaturated and monounsaturated fatty acids (MUFAs) to mitigate cardiovascular risk. However, evidence regarding MUFAs and risk of ASCVD remains conflicting, with recent studies raising concern about a potential higher risk associated with MUFA intake. The aim of this narrative review is to provide an overview of current knowledge and gaps in the literature regarding MUFAs and the risk of ASCVD with a focus on intake, individual types, and content in adipose tissue as a biomarker of endogenous exposure. Main findings reveal that most studies have inappropriately combined all MUFAs together, despite individual MUFA types having different biological effects and showing varying correlations between dietary intake and adipose tissue content. Adipose tissue composition may serve as a biomarker of long-term MUFA exposure, reflecting cumulative intake over one to two years while minimizing biases inherent in dietary assessments. However, tissue levels reflect both dietary intake and endogenous synthesis, complicating interpretation. Importantly, the source of MUFAs appears critical, with plant-derived MUFAs potentially offering advantages over animal-derived sources. In conclusion, we suggest that future research should focus on individual MUFA types rather than treating them as a homogeneous group, investigate their specific dietary sources and associations with ASCVD risk, and use adipose tissue biomarkers to improve exposure assessment and clarify causal relationships while considering overall dietary patterns.

The relationship between the intestinal microbiota and human health during ageing is an area of increasing interest due to increasing health challenges experienced by ageing populations. This paper develops a mathematical model describing the age-related biological changes associated with alterations to the microbiota, vitamin D levels, immunosenescence and inflammageing to determine the likely impact of manipulating the intestinal microbiota with dietary components. Age-dependent parameters are incorporated into a previously developed model to determine the evolution of intestinal bacterial populations, vitamin D receptor:1,25 dihydroxyvitamin D levels, epithelial barrier integrity and immune response with increasing age. Results suggest an age-related decline in both innate and adaptive immunity, weakening of the intestinal barrier, elevation in systemic inflammation and reduced serum vitamin D, resulting in individuals over 60 years old becoming vitamin D deficient (<50 nmol/L). Numerical simulations indicate that administration of probiotics and/or vitamin D supplements upregulates the VDR complex at all ages, which helps restore epithelial barrier function, particularly in older adults in whom the intestinal barrier has been compromised. The greatest benefit is derived from co-supplementation with probiotics and age-dependent doses of vitamin D. Finally, the value of gathering additional experimental data motivated by the modelling insights is discussed.

n-3 PUFA delivered by fish oil supplements alter the number and functions of circulating extracellular vesicles (EV), but consumption of oily fish does not reproduce this effect. In order to assess the effects of fish oil supplements and oily fish, at a level achievable in the diet, on EV numbers, composition and procoagulant activity in healthy human volunteers, forty-two healthy subjects were assigned to one of three treatment groups: (i) fish oil supplements plus white fish meals, (ii) control supplements plus oily fish meals or (iii) control supplements plus white fish meals for 12 weeks in a randomised, double-blind, placebo-controlled, parallel trial; circulating EV were enumerated and their procoagulant activity assessed using thrombin generation and fibrinolysis assays. Our results showed that fish oil supplements decreased circulating EV numbers and reduced EV-stimulated thrombin generation, but the consumption of oily fish at half the dose of EPA had no effect on either EV number or thrombogenic capacity. Consumption of both oily fish and fish oil supplements increased the EPA and DHA contents of EV, and the proportion of EPA in circulating EV was strongly associated with EV-stimulated thrombin generation. This study revealed that the additional 1 g/d EPA delivered in the fish oil supplements is required to decrease the numbers and thrombogenic capacity of EV, since oily fish at a level achievable in the diet had no effect. Increasing EPA intake beyond current guidelines for oily fish consumption may therefore be required for cardiovascular benefits relating to EV.

aLaboratory of Nutrition and Metabolic Surgery, Department of Gastroenterology, Faculty of Medicine, University of Sao Paulo, São Paulo, Brazil bSchool of Human Development and Health, Faculty of Medicine, University of Southampton cNIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK Correspondence to Philip C. Calder, School of Human Development and Health, Faculty of Medicine, University of Southampton, IDS Building, MP887 Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK. E-mail: [email protected]

Lipids are integral to parenteral nutrition (PN) in all settings where PN is required, serving as a source of energy and essential fatty acids. In addition, lipids modulate a variety of biological functions, including inflammatory and immune responses. Moreover, fish oil (FO), which contains omega-3 fatty acids, has become an important component of modern lipid emulsions. The Lipids in PN Summit involved a panel of international experts with extensive clinical experience in PN use. They assessed the current state of knowledge and developed expert consensus statements regarding the use of lipid emulsions in patients requiring PN. This summit built upon outcomes from an earlier summit, and focused on adult patients in three distinct clinical settings: intensive care units, hospital wards, and the home environment/long-term PN. The summit workflow included identification and appraisal of scientific and clinical literature, the exchange of practical clinical experience, and the formulation of consensus statements. The latter aim to assist healthcare professionals in their decision-making processes in daily practice by providing practical guidance related to providing lipid emulsions as part of PN. This article briefly summarizes the biological effects of lipids used in PN, and then focuses on the rationale for their use in three distinct adult PN settings. Expert consensus statements are also provided, helping to bridge gaps between evidence and clinical practice, and thus complementing formal PN guideline recommendations. There is accumulating evidence suggesting that PN including FO confers clinically meaningful advantages compared with PN without FO, and has a favorable risk–benefit ratio.

Cardiovascular disease remains a major global health concern. The combination of the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) has been shown to beneficially modify a range of cardiovascular risk factors. However, whether EPA and DHA have differential effects or potencies is currently unclear. A systematic review of randomized controlled trials (RCTs) that compared ≥2 g/day of near pure EPA and DHA was conducted. A total of 24 publications from nine unique RCTs were included. EPA and DHA both lower triglyceride levels, with DHA most likely having a slightly greater effect. Furthermore, both EPA and DHA increase high density lipoprotein (HDL) 2 cholesterol, which is cardioprotective, with the increase being greater with DHA. DHA appears to increase low density lipoprotein (LDL) cholesterol; however, DHA also increases LDL particle size, which would render LDL less atherogenic. DHA seems more effective than EPA in decreasing heart rate and blood pressure. Both EPA and DHA alter platelet function decreasing thrombogenicity, although they may have different actions on platelets. Both EPA and DHA decrease F2-isoprostanes, interpreted as a reduction in oxidative stress. They both decrease inflammatory gene expression and promote an anti-inflammatory oxylipin profile. These are all favorable effects with regard to cardiovascular disease risk. Effects of EPA and DHA on blood glucose are inconsistent. This review is constrained by the small number of high quality RCTs that directly compare EPA to DHA and report on outcomes other than blood lipids. There is a need for additional high-quality research to assess the independent effects of EPA and DHA on cardiovascular risk factors (e.g., inflammation, blood pressure, vascular function, platelet function) in larger and more diverse study populations.

Physical activity and healthy eating are important for physical and mental health, yet long-standing inequalities constrain the ability of ethnic minorities in the United Kingdom (UK) to adopt these behaviours. Programmes aimed to improve these behaviours have also often not been engaged with by these communities. This study therefore aimed to: (1) identify the values underlying the physical activity and healthy eating behaviours of UK ethnic minorities and (2) explore how structural, socio-economic and environmental factors interact with these values to influence their physical activity and healthy eating behaviours. The study adopted a relativist ontological and subjectivist epistemological philosophical assumption. Qualitative interviews were used to address research objectives. A total of 10 group and five individual interviews were conducted with 41 participants. All participants were from an ethnic minority background (Black, Asian or Mixed according to the UK Office for National Statistics classification), recruited purposively and aged between 18 and 86 years and were living in England and Wales. Data were analysed using inductive thematic analysis. Community engagement was embedded throughout the study. We found that culture and family, community and social life, and health are important values underlying the physical activity and healthy eating behaviours of UK ethnic minority communities. External factors, including racism and access (geographical, social and economic), interact with these values to drive health behaviours. Using an illustrative guide, we conclude the paper with policy and practice recommendations on how public health programmes on physical activity and healthy eating can be aligned with these values to ensure relevance for ethnic minority communities.

The optimal feeding strategy for critically ill patients is still debated, but feeding must be adapted to individual patient needs. Critically ill patients are at risk of muscle catabolism, leading to loss of muscle mass and its consequent clinical impacts. Timing of introduction of feeding and protein targets have been explored in recent trials. These suggest that “moderate” protein provision (maximum 1.2 g/kg/day) is best during the initial stages of illness. Unresolved inflammation may be a key factor in driving muscle catabolism. The omega-3 (n-3) fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are substrates for synthesis of mediators termed specialized pro-resolving mediators or SPMs that actively resolve inflammation. There is evidence from other settings that high-dose oral EPA + DHA increases muscle protein synthesis, decreases muscle protein breakdown, and maintains muscle mass. SPMs may be responsible for some of these effects, especially upon muscle protein breakdown. Given these findings, provision of EPA and DHA as part of medical nutritional therapy in critically ill patients at risk of loss of muscle mass seems to be a strategy to prevent the persistence of inflammation and the related anabolic resistance and muscle loss.

This meeting report presents a consensus on the biological aspects of lipid emulsions in parenteral nutrition, emphasizing the unanimous support for the integration of lipid emulsions, particularly those containing fish oil, owing to their many potential benefits beyond caloric provision. Lipid emulsions have evolved from simple energy sources to complex formulations designed to improve safety profiles and offer therapeutic benefits. The consensus highlights the critical role of omega-3 polyunsaturated fatty acids (PUFAs), notably eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), found in fish oil and other marine oils, for their anti-inflammatory properties, muscle mass preservation, and as precursors to the specialized pro-resolving mediators (SPMs). SPMs play a significant role in immune modulation, tissue repair, and the active resolution of inflammation without impairing host defense mechanisms. The panel's agreement underscores the importance of incorporating fish oil within clinical practices to facilitate recovery in conditions like surgery, critical illness, or immobility, while cautioning against therapies that might disrupt natural inflammation resolution processes. This consensus not only reaffirms the role of specific lipid components in enhancing patient outcomes, but also suggests a shift towards nutrition-based therapeutic strategies in clinical settings, advocating for the proactive evidence-based use of lipid emulsions enriched with omega-3 PUFAs. Furthermore, we should seek to apply our knowledge concerning DHA, EPA, and their SPM derivatives, to produce more informative randomized controlled trial protocols, thus allowing more authoritative clinical recommendations.

Epidemiological and clinical trial evidence indicates that n-6 polyunsaturated fatty acid (PUFA) intake is cardioprotective. Nevertheless, claims that n-6 PUFA intake promotes inflammation and oxidative stress prevail. This narrative review aims to provide health professionals with an upto-date evidence overview to provide the requisite background to address patient/client concerns about oils containing predominantly unsaturated fatty acids (UFA), including MUFA and PUFA. Edible plant oils, commonly termed vegetable oils, are derived from vegetables, nuts, seeds, fruits and cereal grains. Substantial variation exists in the fatty acid composition of these oils; however, all are high in UFA, while being relatively low in saturated fatty acids (SFA), except for tropical oils. Epidemiological evidence indicates that higher PUFA intake is associated with lower risk of incident CVD and type 2 diabetes mellitus (T2DM). Additionally, replacement of SFA with PUFA is associated with reduced risk of CVD and T2DM. Clinical trials show higher intake of UFA from plant sources improves major CVD risk factors, including reducing levels of atherogenic lipids and lipoproteins. Importantly, clinical trials show that increased n-6 PUFA (linoleic acid) intake does not increase markers of inflammation or oxidative stress. Evidence-based guidelines from authoritative health and scientific organisations recommend intake of nontropical vegetable oils, which contain MUFA and n-6 PUFA, as part of healthful dietary patterns. Specifically, vegetable oils rich in UFA should be consumed instead of rich sources of SFA, including butter, tallow, lard, palm and coconut oils.

Preterm birth (delivery prior to 37 weeks) appears to be rising globally, increasing the risk of a myriad of down-stream disorders which affect families, their offspring and society, including increased morbidity, mortality and economic costs. Strategies for prevention of preterm birth have therefore become a priority among healthcare providers. One proposed strategy is increased consumption of Omega-3 long-chain polyunsaturated fatty acids (LC-PUFAs), particularly docosahexaenoic acid (DHA) (from food or supplements) in women of childbearing age and during pregnancy. It is hypothesized that Omega-3 LC-PUFAs, through several different actions, reduce the risk of early onset labor or lengthen gestation. An expert group, acting on behalf of several relevant organizations, recently published guidance based on compelling trial evidence for increased Omega-3 LC-PUFA intake to protect women of childbearing age and during pregnancy from preterm birth (PTB) and early preterm birth (ePTB). Here, we consider how this guidance can be achieved in a sustainable manner. We present data on suitable, efficacious alternatives to fish as a source of Omega-3 LC-PUFAs, so that while aiming to protect families and society against PTB and ePTB there is no increased burden on other species on our vulnerable planet. Finally, how the guidance can be implemented in practice is discussed, with consideration for those most at risk and effective ways of communicating this important message.

Managing atherosclerotic cardiovascular disease (ASCVD) often involves a combination of lifestyle modifications and medications aiming to decrease the risk of cardiovascular outcomes, such as myocardial infarction and stroke. The aim of this article is to discuss possible omega-3 (n-3) fatty acid–statin interactions in the prevention and treatment of ASCVD and to provide evidence to consider for clinical practice, highlighting novel insights in this field. Statins and n-3 fatty acids (eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)) are commonly used to control cardiovascular risk factors in order to treat ASCVD. Statins are an important lipid-lowering therapy, primarily targeting low-density lipoprotein cholesterol (LDL-C) levels, while n-3 fatty acids address triglyceride (TG) concentrations. Both statins and n-3 fatty acids have pleiotropic actions which overlap, including improving endothelial function, modulation of inflammation, and stabilizing atherosclerotic plaques. Thus, both statins and n-3 fatty acids potentially mitigate the residual cardiovascular risk that remains beyond lipid lowering, such as persistent inflammation. EPA and DHA are both substrates for the synthesis of so-called specialized pro-resolving mediators (SPMs), a relatively recently recognized feature of their ability to combat inflammation. Interestingly, statins seem to have the ability to promote the production of some SPMs, suggesting a largely unrecognized interaction between statins and n-3 fatty acids with relevance to the control of inflammation. Although n-3 fatty acids are the major substrates for the production of SPMs, these signaling molecules may have additional therapeutic benefits beyond those provided by the precursor n-3 fatty acids themselves. In this article, we discuss the accumulating evidence that supports SPMs as a novel therapeutic tool and the possible statin–n-3 fatty acid interactions relevant to the prevention and treatment of ASCVD.

In critical illness the regulation of inflammation and oxidative stress can improve patient outcomes, and thus omega-3 polyunsaturated fatty acids (PUFAs) have been used as part of parenteral nutrition (PN) owing to their potential anti-inflammatory effects. The international lipids in PN Summit, encompassed discussions and the production of consensus guidelines concerning PN intravenous lipid emulsion (ILE) use in critical care. The Lipid Summit participants agreed that the inclusion of fish oil in ILEs is associated with meaningful clinical benefits without signals of harm, based on a strong biological rationale and current clinical evidence. Decisions concerning ILE choice should be made based on current evidence, thus addressing clinical requirements for guidance, particularly as further definitive evidence seems unlikely to occur. In addition, a future of individualized ICU care is envisioned, yielding better clinical outcomes. This approach will require the greater use of intelligent study designs incorporating the use of biomarkers of omega-3 derivatives, inflammatory-resolving processes, and/or muscle protein breakdown.