title: How close do gastroenterologists follow specific guidelines for nutrition recommendations in liver cirrhosis? A survey of current practice.
abstract: OBJECTIVE
  Malnutrition is a common feature of terminal chronic liver disease. In Great Britain earlier studies revealed a widespread use of inappropriate dietary management for example, protein restriction in patients with liver cirrhosis (LC). Therefore, it was the aim of this study to evaluate the current dietary recommendations for patients with LC, recommended by gastroenterologists in Germany.
  
  
  METHODS
  Anonymous questionnaires were sent to 576 members of the Bavarian Society of Gastroenterology. Information was requested on the dietary management and on the diagnostic assessment of nutritional status of all patients with LC seen in the past 12 months. Further questions were included concerning knowledge of recent guidelines on enteral nutrition (EN) in LC, use of an adequate EN and estimated prevalence of malnutrition.
  
  
  RESULTS
  Forty-four percent of all questionnaires were returned within 4 weeks; of those 94% were fully completed and appropriate for further analysis. Fifty-six percent respondents stated that they were familiar with guidelines concerning EN in patients with LC and 92% believed that evidence-based recommendations are both important and relevant for everyday practice. Only 23% of the respondents gave a correct estimate of the prevalence of protein-calorie malnutrition in patients with chronic liver disease. The majority underestimated the correct amount of energy and protein intake that is recommended by the European Society for Parenteral and Enteral Nutrition guidelines on EN for patients with LC. Only 42% respondents recommended a protein-rich diet whereas most of the respondents under or overestimated the required daily energy (55%) and protein intake (58%). As simple bedside methods such as the subjective global assessment or anthropometry are considered adequate to identify malnutrition in LC, these methods were familiar only to 24 and 55% of the respondents, respectively. Forty-one percent, however, believed that an evaluation of the body mass index represents the best diagnostic tool to detect malnourished patients although body mass index may be misleading in cirrhotics with tense ascites.
  
  
  CONCLUSIONS
  The dietary management of German cirrhotic patients should be improved, especially concerning the required daily energy and protein intake. Simple bedside methods for the diagnosis of malnutrition are widely unknown. In general, malnutrition in LC clearly represents a widely underestimated problem even in a highly specialized sample of medical practitioners in digestive and hepatological diseases. At the same time the number of nutrition support teams in German speaking countries are very low. A higher number of multidisciplinary teams including dietitians, psychologists and physical activity supervisors caring for undernourished patients might be an important step for an improvement towards correct management of malnutrition in LC.
authors.affiliation: Department of Gastroenterology, Hepatology and Gastrointestinal Oncology, Bogenhausen Academic Teaching Hospital, Technical University of Munich, Munich, Germany. Gastroenterologie@kh-bogenhausen.de
authors.forename: Felix
authors.initials: F
authors.lastname: Gundling
authors.forename: Holger
authors.initials: H
authors.lastname: Seidl
authors.forename: Christian
authors.initials: C
authors.lastname: Pehl
authors.forename: Thomas
authors.initials: T
authors.lastname: Schmidt
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Schepp