American Society of Parenteral and Enteral Nutrition Presidential Address: Food for Thought: It's More Than NutritionFrom the Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island; and University of Medicine and Dentistry of New Jersey Correspondence: Marion F. Winkler, MS, RD, CNSD, Rhode Island Hospital, Dept of Surgery/Nutrition Support, 593 Eddy Street, NAB 218, Providence, RI 02903. Electronic mail may be sent to: mwinkler{at}lifespan.org. Three issues were highlighted in the 30th Presidential Address to the society: (1) A.S.P.E.N.'s unique interdisciplinary structure; (2) support of the A.S.P.E.N. Rhoads Research Foundation; and (3) the meaning of food from the perspective of the patient who is receiving life-sustaining home enteral or parenteral nutrition. A.S.P.E.N., founded as a multidisciplinary society in the 1970s has evolved into an interdisciplinary society with an expanded and diverse membership of health care professionals and scientists with overlapping interests in clinical nutrition and metabolism. A.S.P.E.N. envisions an environment in which every patient receives safe, efficacious, and high quality patient care. The society is committed to advancing the science and practice of nutrition support therapy. In support of this direction, the A.S.P.E.N. Rhoads Research Foundation exists to fund research grants, promote evidence-based practice, and foster training and mentorship in nutrition and metabolic research. The scientific advances and technologic innovations that have enabled our profession to provide enteral and parenteral nutrition to patients has caused practitioners to forget that the meaning of food extends beyond nutrient value. Some individuals receiving long term enteral nutrition or home parenteral nutrition have expressed feelings of anger, anxiety, and depression resulting from the inability to eat normally, from losses of independence, and control of body functions. The ritual of eating may be altered when the enteral or intravenous feedings provide nourishment and, for some, the loss of the eating function is a distressing experience, especially given the cultural focus on social gatherings and meals. The emotional meaning attributed to food, and changes in food preferences and eating behaviors, may become a source of conflict for individuals who have substantial dietary restrictions, or for those individuals dependent on enteral or parenteral nutrition therapy. The value of food intake on social patterns, self-esteem, pleasure, and enjoyment, may impact quality of life. While nutrition support can provide the basic need for nutrients, its impact on human needs associated with food requires further investigation. Today is a historical day. Today we celebrate the American Society of Parenteral and Enteral Nutrition's (A.S.P.E.N.'s) 31st annual meeting, the 30th formal presidential address, and the occasion of the first registered dietitian standing before you as president of an organization that has grown into an open and interdisciplinary society. The presidency is a challenging and exciting experience with awesome responsibility. What I bring to the Board of Directors and what I bring to this presidency is an extensive history of leadership in the society; nutrition knowledge; a passion for bridging the gap between research, education, and practice; and the perspective of a clinician providing nutrition support to patients at the bedside, every single day. It is an honor and privilege to represent our society. Today I'd like to highlight 3 important issues for our society. The first is our interdisciplinary structure, that which makes our society unique within the scientific and healthcare community. As I read each of the former presidential addresses, I was inspired by the words used by our past presidents to set the course for our interdisciplinary evolution. The second is exposure and support of our foundation—the A.S.P.E.N. Rhoads Research Foundation—for which we need continued and sustained support if we are to achieve our society's mission. The third important area is patient advocacy, and today I would like to share with you the voice of our patients. Have you ever imagined what it is like to be living with a condition that does not require food for sustenance? The excitement surrounding our scientific and technologic ability to infuse parenteral and enteral nutrition to sustain life has caused us to forget the meaning of food! Today I would like to reexamine why our society exists—who we are, what our purpose is—and remind us that the meaning of food extends well beyond its nutrient value. The wisdom and foresight of our founders in creating A.S.P.E.N. in the 1970s has enabled us to evolve into an interdisciplinary society today. Founded as a multidisciplinary society out of necessity to bring to the forefront the scientific and technologic inventions of Dr Stanley Dudrick and colleagues—the safe delivery of parenteral and enteral nutrition to the bedside—members of 4 traditional disciplines (physicians, nurses, dietitians, and pharmacists) gathered together "to provide optimal nutrition to all people under all conditions at all times" (Dr Stanley J. Dudrick, Presidential Address, 1978). Our society's membership has since expanded and today is truly diverse. We are interdisciplinary. Our membership consists of professionals in different fields of medicine and science, with overlapping interests in clinical nutrition and metabolism. Our strength lies in the creative way our society brings each discipline "to work together and cross-fertilize one another with new ideas for the collective improvement of patient care" (Dr John R. Wesley, Presidential Address, 1994). Where else can professionals interested in nutrition gather to present scientific data, to promote guidelines for evidence-based practice, to link researchers with clinicians, and to demonstrate how best to translate nutrition science into effective clinical care? Our society is "an intellectual melting pot that pools talents of individuals with diverse professional backgrounds and from different nations and cultures together to produce novel and important solutions to our most pressing scientific problems" (Dr Steven B. Heymsfield, Presidential Address, 1997). From neonatologists to gerontologists; from the intensive care unit to home and to the community; nurses, dietitians, and pharmacists; gastroenterologists, surgeons, pediatricians, intensivists, hospitalists; professionals from industry and researchers from the laboratory; professionals from all over the world, working along side each other, functioning independently but with the common goal to improve patient care by advancing the science and practice of nutrition support therapy (A.S.P.E.N. mission, 2007). Our ability as a society to recognize a common body of knowledge with a set of core competencies while preserving our unique professional differences has made A.S.P.E.N.'s programs, publications, and Clinical Nutrition Week extremely successful and has provided direction for the first interdisciplinary certification examination and credential to be offered by the National Board of Nutrition Support Certification in 2008. One of the realizations that stemmed from our society's implementation of the strategic plan in the 1990s, was that our product is nutrition information, and this information itself is transdisciplinary: it crosses the boundaries of all disciplines. Our interdisciplinary structure today sets aside discipline as the primary focus and emphasizes the interrelatedness and interconnectedness of our members. Our insightful former presidents all recognized this strength within A.S.P.E.N. In A.S.P.E.N.'s 10th anniversary Presidential Address in 1986, Dr John Daly remarked that the society's "multidisciplinary characteristics are increasingly reflected at the highest levels of the organization," and Dr Kenneth Kudsk, A.S.P.E.N.'s 22nd president in 1998, noted that A.S.P.E.N. "opened it ranks not based on discipline but whether an individual has done good work and will continue to do good work in our field." The leadership philosophy of the Board of Directors today is to put the right person on the bus, to bring expertise and skill to the table and to use these competencies as the criteria for appointment rather than discipline-specific representation, longevity, or rank. Today's leadership is truly interdisciplinary; each director has a portfolio of skills and competencies that helps to advance A.S.P.E.N.'s strategic direction and move us to closer to realizing our vision: "A.S.P.E.N. envisions an environment in which every patient receives safe, efficacious, and high quality patient care" (Board of Directors, 2007). A.S.P.E.N. today is uniquely positioned to partner researchers with clinicians to solve unanswered practice-based questions in the field of clinical nutrition and metabolism. "As practitioners of parenteral and enteral nutrition, we are the implementers of basic sciences and the conductors of the necessary experimentation to support our current technology and procedures" (Dr George Blackburn, Presidential Address, 1979). Let me again echo the words of Dr John Daly in his presidential address of 1986, who said, "We must recognize that clinical practice and clinical research are not divergent goals." A.S.P.E.N. today remains committed to science and to the recognition that science drives clinical practice. Our society continues to promote and provide a forum for presenting basic, translational, and outcomes research in clinical nutrition and metabolism. A.S.P.E.N.'s unique niche in the medical and nutrition community is to advance the science and practice of nutrition support therapy. What our society provides is interdisciplinary networking, professional collegiality, and community. As a society, A.S.P.E.N. shares this commitment through support of the A.S.P.E.N. Rhoads Research Foundation. Our Foundation exists to fund research grants, to support evidence-based practice that results in safe and efficacious care and positive outcomes, to foster training and mentorship in nutrition and metabolic research, and to support the development of the next generation of nutrition support professionals. Since 1994, the Foundation has awarded $558,000 to investigators for promising new research in nutrition and metabolic support. More than 40 young investigators, clinicians, trainees, and graduate students have received grant support from our Foundation. These individuals represent the diversity of our membership, having come from nursing, pharmacy, dietetics, medicine, and the research laboratory. They are the future of our field. They are the leaders of our profession. A.S.P.E.N. also continues to increase resources for research activities through the establishment of promising investigator travel awards for individuals in the early stages of their career or those still in training by recognizing scientific abstracts and posters of distinction, and by conducting the annual Research Workshop in conjunction with the National Institutes of Health. Can we do more? Yes. Our goal is to increase our endowment to expand funding for research, to support quality work, and to foster translation of research to clinical practice. The Foundation Board of Directors plans to award larger grants and to fund even more investigators. Today I am proud to announce that 100% of the members of the Board of Directors of both A.S.P.E.N. and the Foundation have pledged their support. I hope all of you will join us in advancing the science and practice of nutrition support therapy with your own contribution to the A.S.P.E.N. Rhoads Research Foundation. (If you would like to support the A.S.P.E.N. Rhoads Research Foundation, please contact Kandra Strauss-Riggs at 301-920-9145 or kandras{at}aspen.nutr.org. Your contribution will help the Foundation continue advancing the fields of nutrition, metabolic support, and related areas of clinical nutrition through research grants.) What brought us together as a society in the 1970s and what continues to nurture our growth and development today, in the words of Dr Dudrick himself, is "a genuine and collective humanism and not merely an interest and talent in the nutritional arts and sciences" (Presidential Address, 1978). It is the human and social value of what we do that leads me to advocate for our patients, to explore what contributes to quality of life and what food means to our patients. Today I'd like to share with you some of the qualitative work that is being conducted in our field. In the weeks leading up to my mother's death from advanced colon cancer, she had many requests for what I believed at the time were food cravings. We ran out for every item, whether pizza from a famous restaurant in New Haven, Connecticut, orange soda, or birthday cake, anything, because we felt, of course, that she should get nutrition; she should eat. It took me years to understand, but in the end it was never about the food. It was always about the nostalgic stories that surrounded the food, the memories, the social aspects, and the companionship of the sharing of meals. It was food being used to express love and to provide comfort and hope by conjuring up images of a familiar and soothing way of life.1 Rituals, both social and practical, transform mere food into a meal. "A meal is not about food; it is about the human interchanges and interactions that go on around food."2 Think back to when you first became interested in nutrition. Spencer and Compher3 asked Dr Jonathan Rhoads this same question. Looking his interviewers straight in the eye, Dr Rhoads responded, "a very long time ago." Food beliefs and eating behaviors stem from our childhood and are closely tied to family and culture.4 There is a strong relationship between memory and the emotional dimension of food, as taste, smell, and texture trigger memories of earlier events and activities in our lives.4 Food is the centerpiece of family gatherings, but the ritual of sitting down to eat a meal at the dinner table is often more important than the food itself.4 Food may signify prosperity, good health, strength, or love. Meals also add security, order, and structure to our day,5 so the social loss of being unable to participate in mealtimes and other celebrations involving food has a profound impact and can leave people feeling isolated from the world and disconnected from those they love.6 The lack of social interactions with family and friends because of illness or life consequences may lead to depression and further loss of appetite.7 The World Health Organization defines quality of life as an individual's perception of their position in life in the context of the culture and value system in which they live and in relation to their goals, expectations, standards, and concerns.8 Given this definition, the enjoyment of food, along with its social and nurturing aspects, is an important component of quality of life.9 Any eating problems, unpleasant experiences, or decreased autonomy during mealtimes could have a significant impact on quality of life.10 As nutrition professionals, we see eating from a medical perspective.11 We are primarily interested in physical function, the state of health, the caloric and nutrient content of food, and the adequacy of intake. We focus more on the health-related aspects of eating and eating behavior rather than on the social and emotional aspects of food. The nutrition profession has shied away from talking about food intertwined with nurturance because of the "scientification" of food as nutrients and marketable products.12 We need to increase our understanding of the significance of food, not purely in relation to nutrition value, but as an important quality of life issue.13 Let me expand on Dr Timothy Lipman's JPEN editorial from a few years ago in which he described the "chicken soup paradigm, namely, healing through the provision of nutrients."14 While the emphasis of Dr Lipman's thought-provoking narrative was on rethinking the terminology we use to describe artificial nutrition and arguing that the physical, and that the biologic properties of parenteral and enteral solutions are not the same as food on the table, what captured my attention was a statement in which he remarked "eating is associated with a host of pleasurable phenomena, including taste, smell, and socialization."14 Perhaps we associate chicken soup not with healing but instead with comfort and memories. Have you ever had this experience? "On a cold and rainy afternoon, you decide that a bowl of chicken soup would hit the spot. While eating, you smile as you recall a rainy day long ago when your mother made you the same kind of soup."15 If you've had this experience, according to researchers formerly with the Food and Brand Lab at the University of Illinois15 then "you're someone who has a comfort food, a specific food consumed under a specific situation to obtain psychological comfort." Everyone seems to yearn for the gastronomic equivalent of a warm sweater, a kiss on the forehead, or a favorite blanket when we are sick, or tired, or far from home.16 Food is critical to our physiologic well-being, and eating and the sharing of meals contribute to our social, cultural, and psychological quality of life.17 Food is identified as a basic human need in Maslow's18 hierarchy. Food is consumed to achieve a sense of security and physical comfort and may instill belonging in the sense of family, social events, and rituals.19 Food is more than nourishment for the body; it is a "symbolic object used to alleviate depression and provide comfort; it also nourishes the mind and soul."1 There are several powerful examples of this. In the book In Memory's Kitchen, a vivid recollection of dream recipes set down by malnourished and starving women who were detained in the concentration camps during the Holocaust, author Cara De Silva20 recalled that the women would talk about who they were and who they had been in terms of the foods that they cooked. "They would exchange recipes. They would talk about food, their homes and the dinners they made."20 Initially, the thought of women doing this was very shocking to her because, she said, "you just think of people who were starving to death as sort of resigning from the fleshly pleasures, but instead it helped them to live, even though the food was imaginary because food nourishes not just the body, but the spirit."20 Let me share another interesting perspective from James Haller, a master chef, who provides comfort and cooking to hospice patients. In his book What to Eat When You Don't Feel Like Eating, he writes, "I knew instinctively, from the encounter with my first cancer patient that there was a need to feed sick people differently. The proper kind of food could either enhance the possibility of recovery, or, if terminal, make that time as pleasant as humanly possible to the very end."21 Chef Haller recommends preparing foods rich in color and texture and embraces the color theory, suggesting that orange is the color of autumn and change and the color of vitamin A–containing vegetables and fruit; green is the color of growth and the color of vegetables rich in vitamins A, C, and potassium; and purple is the color of spirituality and healing.21 When we counsel our patients on what to eat, perhaps we should emphasize colorful foods that are orange, green, and purple rather than focusing on the vitamin, mineral, and antioxidant content. Chef Haller also emphatically states, "Food has to taste incredible. Not just good, but food has to be delicious and has to taste like it is doing something wonderful for you, because that's the essence of nurturing."21 The meaning of food is temporal in nature; it is highly symbolic, and it is a way to describe one's life story. Cheryl Ann Monturo,22 in her doctoral work with aging veterans on the meaning of food and beliefs regarding artificial nutrition at end of life, proposed a cultural model of self in which she delineated 2 branches: eating to live, in which food was necessary and used to be a source of pleasure, and living to eat, in which food was seen as a way to tie people together and as a form of sharing and caring. Understanding the social meaning food has for our patients can help in behavior modification and in preparing our patients for the loss and altered identity that accompanies the absence of food, the inability to eat, or the dependency on nutrition support. Most of the work in this area has focused on dietary change for disease management and weight control, with investigators studying how changing dietary behavior affects one's definition of self.23–26 We do know that when dietary restrictions are stressful, quality of life is impaired. Food provides a source of physical and social comfort and is often used to help people cope with illness and disease.27 Patients who are no longer able to dine in a social setting experience a loss of affinity and social deprivation that leads to a loss of personal identity.28 Even when we do not feel like eating, food still has great importance in terms of community and in the sense of sharing a meal with family and friends. In the hospital setting, we focus a lot of attention at the bedside, encouraging our patients to eat instead of stepping back and listening to how they feel. Here is what a few cancer patients have said.
The social aspects of meals and mealtimes are frequently addressed in the geriatric setting and gerontology literature. Happy hours or planned gatherings have been used as an opportunity for socialization, as well as a strategy to encourage fluids outside of scheduled mealtimes. Wood and Vogen29 were able to increase fluid and nutrient intake in elderly patients by using a happy-hour teacart with beverages not appearing regularly on the menu and by serving calorie-dense and visually appealing drinks in party cups, with party napkins. We all would probably agree that the atmosphere, ambiance, and company with whom we are eating contribute greatly to our overall dining experience. Research supports this. Evans and Crogan30 reported a 50% increase in food intake of 15 elderly nursing home residents by playing music and using aromatherapy. We may be able to enhance the eating experiences for our patients by serving small, healthy, and colorful foods; pouring everything from a can into a crystal goblet or nice glass; creating ambiance with beautiful, soothing, and relaxing music; bringing in sunlight or candles instead of keeping the room dark; and incorporating laughter, comedy, or massage into the dining experience. For the elderly, particularly when a patient has dementia, assisted oral feeding allows the patient to enjoy the gratification of eating and socialization that accompanies mealtimes.31 Finucane and colleagues32 suggest that careful hand feeding, although it is labor intensive, can be socially and nutritionally beneficial for patients with very severe cognitive deficits. "Like all animals, we eat to survive. But as humans, we transform simple feeding into the ritual art of dining, creating customs and rites that turn out to be as crucial to our well-being as are proteins and carbohydrates. This is because everything about eating—including what we consume, how we acquire it, who prepares it, and who's at the table—is a form of communication rich with meaning. Our attitudes, practices, and rituals around food are a window onto our most basic beliefs about our world and ourselves."2 What about our patients with feeding tubes? How do they feel? Ashby Walker, a researcher at Emory University, addressed the social and symbolic meaning of food and explored what happens when patients with percutaneous endoscopic gastrostomy (PEG) tubes lose the ability to eat.33 "For PEG tube recipients the loss of the ability to eat is experienced as a social loss and as an event that results in an undesirable change in their identity."33 Loss of the ability to eat was viewed as social bereavement. There was a common experience of isolation because of diminished social interactions. Being unable to eat was socially uncomfortable for the patient and everyone eating around them. Patients with gastrostomy feeding tubes, in other published reports, have described overwhelming grief over the loss of the ability to eat and drink, fantasies about food, and a longing for the need for the feeding tube to go away.34 Feeding tubes are a constant reminder of the disease and are associated with embarrassment, concerns about appearance, and lack of enjoyment of the social aspects of eating.35 Although some patients who have PEG tubes describe their quality of life as acceptable, some see meal times as boring because of the loss of enjoyment of food.36 A colleague of mine recently told me that one of her patients fills his feeding bag with coffee because he misses the caffeine and the ritual of starting his day with a cup of coffee. Not surprisingly, caregivers also describe feeling very uncomfortable eating and drinking in front of loved ones who cannot eat food. "I only cooked dishes that I knew he didn't like. I couldn't sit and eat his favorite meal while he cannot have even one mouthful."36 Withdrawing from the social situations that involve food and eating is a very common coping mechanism. The functional role of being nourished is met, but the social role of food disappears.37 Technically, even though patients are receiving nourishment, tube feedings are not able to substitute for the symbolic nature of food or the cultural event of eating.33 The Oley Foundation (www.oley.org) is a wonderful organization whose members provide peer support to others receiving enteral and parenteral nutrition (PN). A recommendation to join the Oley Foundation is a good first step in helping our patients cope. Do individuals receiving PN have the same experience? The literature suggests that although home PN (HPN) provides life-sustaining therapy, the technology does not replace the enjoyment or socialization that we obtain from food and mealtimes.38–43 Preliminary results from my own research support this concept.44 My doctoral dissertation is an exploration of the quality of life and the meaning of food in adults living with HPN. To date, I have interviewed 20 adults throughout the United States who are receiving HPN. These individuals on average have been receiving HPN for 9.3 ± 8.5 years (4 months–28 years). They range in age from 28 to 68 years old; 75% are women and 25% are men. Eighty percent have short bowel syndrome due to Crohn's disease, multiple small bowel resection, or ischemia; 15% have radiation enteritis, and 5% have pseudoobstruction. Although I am still in the midst of analyzing the narratives, a few themes related to food and eating have emerged. HPN was viewed as a nutrition safety net; in other words, these individuals were relieved that they were getting the proper nutrition. Food was viewed as enjoyable but not necessary to survive. Here are a few examples of what I heard:
Another emerging theme illustrates the importance of the social situation surrounding food and mealtimes.
Some of the individuals described sorrow and dissatisfaction over not being able to eat like they used to.
And clearly others are still dealing with diarrhea and symptoms related to the underlying medical condition.
Here's my personal favorite: "What else could be put in that [parenteral nutrition] bag–like could you make a superhuman person? If I could get buffed up, I'd do it voluntarily."44 This gives you a brief look at the preliminary results of my interviews as they pertain to food and eating, but let me conclude by sharing what HPN means to our patients. Almost of all the people I interviewed explained that HPN means:
Eating is a fundamental activity. Eating can be defined as the consumption of food and liquid to sustain life. Eating is an activity we often take for granted. Our role in promoting optimal nutrition care for all patients should include an advocacy role that increases staff resources for assisted hand-feeding, improves the eating environment, and guarantees that food served to our patients not only has nutrition value but is delicious and incredible-tasting too. Our role as health care professionals working with individuals who are receiving enteral nutrition and PN also extends beyond assuring nutrition adequacy. We need to be aware of the social consequences of the loss of ability to eat. We need to recognize when patients' worries about eating cause social isolation and depression, and we need to help our patients develop effective coping strategies. Effective counseling should focus on both the relationship between food and physical health and the relationship between food and psychological well-being.27 Research should focus not only on the health-related dimensions of eating behavior but also on the social and emotional aspects.1 Qualitative research in this arena contributes greatly to our understanding of how patients experience the therapy we provide. I hope by giving voice to individuals who receive parenteral and enteral nutrition, we are better able to understand the meaning of food and nutrition and how our science and technology affects their lives. Perhaps we are realizing the hope expressed by Dr John Rombeau, president of A.S.P.E.N. in 1989, who said, "... when we start the next century I hope we will recognize the need to provide nutrition support science with nutrition support service."45 Let me conclude by saying how honored I am today to have the opportunity to serve as President of A.S.P.E.N. I joined A.S.P.E.N. 28 years ago as a young dietetic student, and since then I was fortunate to train at the Cleveland Clinic Foundation and to round with Dr Ezra Steiger's nutrition support teams before I even understood the importance of nutrition support. I was fortunate to have been assigned to work in the burn unit at my first job at Bridgeport Hospital in Connecticut and to witness the catabolic effects of severe burn injury, the major role nutrition support has in burn recovery, and the essential role of the multidisciplinary team in patient care. I was fortunate to have been hired by Drs Michael Caldwell and Jorge Albina at Rhode Island Hospital and Brown Medical School more than 20 years ago, after seeing a job announcement at A.S.P.E.N.'s freezing-cold Clinical Congress in Miami in 1985. The passion for surgical nutrition and metabolism was instilled in me as they shared their own experiences of being trained under the mentorship of Drs Vars and Rhoads and from my own opportunity to work side by side with Dr Henry Thomas Randall, known by many of us as the Father of Enteral Nutrition. I remain indebted to Dr Jorge Albina, my boss, colleague, and friend, and to Betty Hagan RN, CNSN, my friend and work partner, for their undying support of my professional and leadership activities. I was fortunate to be mentored by faculty and advisors at Case Western Reserve University in Cleveland, Ohio; the University of Connecticut; and the University of Medicine and Dentistry of New Jersey, who value leadership in professional associations and also served as presidents of the American Dietetic Association. I am humbled to be working with talented and dedicated leaders who compose the A.S.P.E.N. Board of Directors, as well as our loyal staff partners, all of whom are committed to advancing the science and practice of nutrition support therapy. I continue to be inspired by many patients whom I've had the opportunity to care for, learn from, listen to, and to understand how thankful they are for the science, technology, and art of providing nutrition support that has allowed them to live a life of quality. And I am fortunate to have an understanding family who continues to support my commitment to career and professionalism, most importantly my daughters, Pam and Rachel, who themselves value leadership and volunteer work; and to my husband, Larry, who understands firsthand how important nutrition support is and who has taught me how valuable these interventions are for quality of life. I want to thank the society for embracing change, for maturing into a truly interdisciplinary organization, for promoting leadership that assures that the necessary skills, expertise, and experience are included at all levels of the organization, and for having the strategic vision to see that the road to assuring optimal nutrition care for all patients depends on a commitment to basic science, translating science into effective clinical care, understanding the meaning of food, and improving quality of life. Thank you. Received for publication March 6, 2007. Accepted for publication March 19, 2007.
Journal of Parenteral and Enteral Nutrition, Vol. 31, No. 4,
334-340 (2007) This article has been cited by other articles:
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