Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. EDITORIAL Nutritional care: from the dark ages to the renaissance, to the age of enlightenment Michael M. Meguid a , Alessandro Laviano b and Claude Pichard c a Department of Surgery, Upstate Medical University, University Hospital, Syracuse, New York, USA, b Department of Clinical Medicine, Sapienza University of Rome, Italy and c Head, Clinical Nutrition, Geneva University Hospital, Geneva, Switzerland Correspondence to Michael M. Meguid, MD, PhD, Department of Surgery, Upstate Medical University, University Hospital, 750 E. Adams Street, Syracuse, NY 13210, USA Tel: +1 315 491 2863; fax: +1 315 464 6237; e-mail: meguidm@upstate.edu Current Opinion in Clinical Nutrition and Metabolic Care 2009, 12:364–365 One of the most extraordinary epidemiological human events occurred in Europe between the mid-19th and mid-20th centuries. In a few decades, life expectancies for all social classes increased significantly, which was paralleled by an increase of the average intelligent quo- tient. If one were to poll a hundred doctors as to the factors they consider best to explain this astonishing change in human biology, it is likely that the majority would attribute this progress to the scientific and medical advances of that era. Actually, the factor that best explains the increased life expectancy and the enhanced intelligent quotient is improved nutrition [1–3]. Indeed, medical progress had an effect on life expectancy, but its impact occurred when a trend toward improved survival was already evident. These developments provide strong evidence for the crucial role that nutrition plays in our welfare. The converse argument is provided by data from countless human famines [4] and hunger strike studies [5] that documented malnutrition to poor outcome. Adequacy of nutrition is of primacy to the survival of our species. Similarly, an intuitive understanding exists between seriously sick patients who are or became malnourished consequent to their illness and the need to nourish them to enhance their survival. Early examples underscore this point. In 1932, Warren [6] documented that cancer cachexia was a common cause of death in patients with cancer. Similarly, in 1936, Studley [7] made the crucial observation in his gastrectomized patients that the greater the preoperative weight loss in his patients, the higher the complication and mortality rate. These two seminal observations clearly linked nutritional status during illness to outcome. Whether the type of disease and its therapy also plays a role is best illustrated in patients with upper gastrointestinal tumors. They have among the highest incidence of malnutrition that corre- lates positively with high postoperative complication rates, including death [8]. The complications contribut- ing to their poor outcome are similar to those described by Studley [7] 70 years ago: wound dehiscence, ileus, sepsis, pneumonia, prolonged hospital stay, poor quality of life and death. In the intervening years, numerous studies examined the effects of nutrition therapy, either parenteral or enteral, to decrease disease-related complications. Most com- monly, high-risk elective surgical cancer patients were studied. Initially, these studies focused on providing supraphysiological concentrations of different substrates to induce postoperative positive nitrogen balance. The observed reversal of weight loss was due to an increase in fat mass and in total body water. Throughout this time, our concepts in nutrition therapy evolved to include the understanding that specific nutri- ents had immunological effects, particularly when given in pharmacological amounts. Thus began the era of ‘trial and error’ of immune-enhancing nutrition, not only in cancer patients and high-risk elective surgical patients but also in critically ill postoperative patients. On the basis of our understanding, omega-3 fatty acids exert anti-inflamma- tory effects and reduce costs when their use is integrated into surgical care [9]. Glutamine influences the expression of many genes, and its clinical benefits remain to be completely elucidated [10]. By further understanding the specific molecular effects of each nutrient, it will be possible to combine nutrients in correct proportion to tailor the therapeutic needs of managing critically ill patients. The ‘immune enhancing nutritional mixtures’ that in the past were added to conventional substrates known to improve metabolic processes included arginine, gluta- mine, nucleotides, antioxidants and omega-3 fatty acids often in different permutations. It required a meta- analysis of many studies to conclude that immune-enhan- cing nutrition improved clinical outcomes. In retrospect, it may seem curious that for almost 20 years, studies were done in which different experimental compounds were administered simultaneously in an effort to determine the nebulous postoperative beneficial metabolic effects. But at the time, such was our knowledge base, the sense of frustration and urgency that underpinned the need to address ongoing critical issues as to which ‘immune compounds’ and in what amounts were needed to reverse the processes of cancer cachexia. 1363-1950 ß 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/MCO.0b013e32832cdc98