Nutritional status of Kamar tribal children in Chhattisgarh

OBJECTIVE

Assessment of the nutritional status among 309 Kamar children (161 boys and 148 girls) aged 4-12 years.

METHODS

In this cross-sectional study, 24-hours dietary recall method was used to assess dietary intakes of children. Height and weight were recorded and children were classified by WHO criterion (Z-score) using nutritional indices i.e. weight for age, height for age and weight for height. NCHS data were used as reference. Mean energy and protein intake per day were measured and compared with Recommended Dietary Allowances (RDA) of Indian standards.

RESULTS

More than 90 percent of children (both boys and girls) in the age group of 4-6 years suffered by underweight (<-2 SD weight for age), which was comparatively lower in 7-9 and 10-12 years age group children. 84.51 percent of boys suffered by stunting (<-2 SD height for age), which was much higher than girls (47.54%) in 4-6 years age group. Similarly, 80 percent of 4-6 years age group children were affected by wasting (<-2 SD weight for height). The consumption of energy and protein were also much lower among Kamar children than the RDA of India throughout the ages.

CONCLUSION

Undernutrition in the form of underweight, stunting and wasting and low consumption of dietary intake (energy and protein) was found to be widely prevalent among Kamar tribal children. Therefore, an urgent dietary intervention programme is necessary. Further studies are required to investigate into problem and to supplement the key nutrients which are required to ensure a good nutritional status in children.

Risk factors for protein-energy malnutrition in children under 5 years: study from Luangprabang province, Laos

BACKGROUND

Laos is one of the poorest countries in which chronic malnutrition is highest. The aim of the present study was to determine the prevalence of and to identify risk factors associated with protein-energy malnutrition (PEM) in children under 5 years of age in Luangprabang province, Laos.

METHODS

This cross-sectional study was undertaken from March to May 2004. Anthropometric measurements of 798 children were done and data were transformed into height-for-age, weight-for-age and weight-for-height ratios. Mothers were also interviewed with a semi-structured questionnaire. Anthropometric data were entered into Nutstat in Epi-Info 2000 and transferred to SPSS for analysis.

RESULTS

There was a high prevalence of stunting, underweight and wasting, that is, 54.6%, 35%, and 6% respectively. It was also noted that children aged 12-23 months and Khmu ethnic children had a higher prevalence of stunting (65% and 66%) and underweight (45% and 40%), respectively. However, it was also found that boys were more prone to be stunted and underweight. Furthermore, restricted intake of meats, vegetables during illness, and low maternal education were main risk factors for child malnutrition in the study area.

CONCLUSION

Socioeconomic-demographic factors, low maternal education, poor nutrition knowledge for mother and feeding practices for sick children are affecting children's health regarding stunting and underweight. It is recommended that an improvement in societal infrastructure, better maternal education and nutrition are needed to address the child malnutrition issue.

Studies on the nutritional status of children aged 0-5 years in a drought-affected desert area of western Rajasthan, India

OBJECTIVE

The present study was undertaken to assess the impact of drought on the nutritional status of pre-school children aged 0-5 years from a rural population in a desert area facing drought conditions very frequently.

DESIGN

The sampling design for assessment was the three-stage sampling technique.

SETTING

The study was carried out in 24 villages belonging to six tehsils (sub-units of district) of Jodhpur District, a drought-affected desert district of western Rajasthan, during a drought in 2003.

SUBJECTS

A total of 914 children were examined at household level, with nutritional status assessed by anthropometry, dietary intake and clinical signs of nutritional deficiency.

RESULTS

The results revealed growth retardation. Stunting (malnutrition of long duration) was observed in 53% of children and underweight in 60%. Wasting, an indicator of short-duration malnutrition, was present in 28% of children. The extent of malnutrition was significantly higher in girls than boys (P<0.05). Vitamin A and B complex deficiencies were found in 0.7 and 3.0% of children, respectively. Prevalence of marasmus (protein-energy malnutrition, PEM) was 1.7% (2.3% in boys and 1.1% in girls). Overall deficits in mean energy and protein intakes were very high (76 and 54%, respectively). Comparison of the present drought results with earlier studies in desert normal and desert drought conditions showed higher prevalence of PEM and higher dietary energy and protein deficiencies.

CONCLUSIONS

The prevalence of wasting was high, greater than the cut-off point of 15% stated by the World Health Organization to indicate that the severity of malnutrition is critical. PEM, vitamin A and B complex deficiencies and anaemia, along with dietary deficits of energy and protein, were observed to be higher than in non-desert areas. This may be due to the harsh environmental conditions in desert areas where drought occurs quite frequently and adversely affects the economy, largely by eroding the coping capacity and economic potential of the people as a result of heavy livestock losses and reduced harvests, leading to increased poverty and poor food intake of the inhabitants. Due to inadequate consumption of daily food the children were suffering from wasting and PEM. Efforts should be made to incorporate measures, such as ensuring the supply of adequate energy and protein to all age groups and especially pre-school children, into ongoing nutrition programmes in order to improve the food security of local inhabitants in this area.

Oral candidiasis and nutritional deficiencies in elderly hospitalised patients

The prevalence of oral candidiasis and its association with malnutrition in terms of protein–energy malnutrition and mineral and vitamin depletion were evaluated in ninety-seven hospitalised older adults aged 82·1 (SD 8·6) years. Patients underwent a complete oral examination with microbiological investigation on admission to our geriatric rehabilitation unit. Patients were assessed nutritionally by evaluation of dietary intake and measurement of anthropometric variables, serum nutritional proteins, ferritin, Zn, folate, vitamins B12 and C. The prevalence of oral candidiasis was 37% (n 36); the proportion of patients with BMI <20 kg/m2 was 32% (n 31). The nutritional status of the population was studied by comparing two groups defined according to the absence (group I; n 61) or presence (group II; n 36) of oral candidiasis. The two groups did not differ on the basis of BMI and mid-arm circumference. However, group II had a smaller leg circumference, lower daily energy and protein intakes, lower albumin and transthyretin levels. Patients successfully treated with fluconazole increased their intake on day 30. The proportion of patients with hypozincaemia (<12·5 μmol/l) and vitamin C deficiency (<0·7 mg/l) was higher in group II. Treatment with antibiotics, poor oral hygiene, denture wearing, and vitamin C deficiency appeared as the most significant independent risk factors associated with oral candidiasis. The present findings show that oral candidiasis appears to be related to malnutrition and results in mucosal lesions that have a negative impact on energy intake, which may subsequently worsen nutritional status.

Association of resident, facility, and geographic characteristics with chronic undernutrition in a nationally represented sample of older residents in U.S. nursing homes

BACKGROUND

Undernutrition (also known as protein-calorie malnutrition or energy-deficiency) is associated with exacerbation of health conditions, increased frailty, and decline in physical, cognitive, and affective function. This is a critical problem for older adults who reside in nursing homes and have many limitations that contribute to reduced food intake.

OBJECTIVE

To determine the relationship of chronic undernutrition [body mass index (BMI) < 18.5 kg/m2] to resident, facility, and geographical characteristics in a national sample of nursing home residents aged 60 y or older in the U.S.

DESIGN

A cross-sectional, secondary analysis of a 10% nationally representative random sample of annual assessments of nursing home residents in the U.S. (n = 128,514), using the Minimum Data Set (MDS). Data included measured weight and height, resident characteristics, facility characteristics, and geographic location.

RESULTS

More than 12% (n = 15,566) were chronically undernourished (energy-deficient), with more than 27% of those being severely undernourished (BMI < 16). Independent correlates of chronic undernutrition (multivariate analysis) included resident characteristics (ADL, having chewing or swallowing problems, or leaving at least 25% of the meal uneaten), facility characteristics (% Medicare and for-profit status), and geographic characteristics (living in nursing home in urban or large towns).

CONCLUSION

This study found a high percentage of chronic undernutrition in this nationally representative sample of U.S. nursing home residents. Furthermore, resident, facility, and geographic characteristics were associated with chronic undernutrition. Strategies need to be developed and documented that ensure nutritional health to residents with a variety of health problems.

Nutritional status of children under five in three state foster care institutions in Sri Lanka

This study evaluated the prevalence of protein energy malnutrition (PEM) in children under five years (n = 52), in three randomly selected, State operated foster care institutions in Sri Lanka. The prevalence of PEM, was (51.9%), underweight (63.5%) and wasting (25.0%) was found to be considerably higher than the national prevalence (13.5%, 29.4%, 14.0%, respectively). Based on this preliminary evidence, it is recommended that a study representative of all institutionalised children in both State and private facilities be conducted to identify deficiencies and recommend improvements to institutional care in Sri Lanka.

Could nutritional rehabilitation at home complement or replace centre-based therapeutic feeding programmes for severe malnutrition?

To measure the success rate of three different strategies used in Médecins Sans Frontières large-scale therapeutic nutritional rehabilitation programme in Niger, we analysed three cohorts of severely malnourished patients in terms of daily weight gain, length of stay, recovery, case fatality and defaulting. A total of 1937 children aged 6-59 months were followed prospectively from 15 August 2002 to 21 October 2003. For the three cohorts, 660 children were maintained in the therapeutic feeding centre (TFC) during the entire treatment, 937 children were initially treated at the TFC and completed treatment at home and 340 children were exclusively treated at home. For all cohorts, average time in the programme and average weight gain met the international standards (30-40 days, >8 g/kg/day). Default rates were 28.1, 16.8 and 5.6% for TFC only, TFC plus home-based and home-based alone strategies, respectively. The overall case fatality rate for the entire programme was 6.8%. Case fatality rates were 18.9% for TFC only and 1.7% for home-based alone. No deaths were recorded in children transferred to rehabilitation at home. This study suggests that satisfactory results for the treatment of severe malnutrition can be achieved using a combination of home and hospital-based strategies.

Hypovitaminosis D in internal medicine inpatients

Some studies have suggested that hypovitaminosis D may be a consequence of protein-calorie malnutrition. This study assessed both the relationship between vitamin D status, malnutrition, calcium and phosphorus metabolism indices and the importance attached by internists to these alterations. There were 239 patients admitted to an internal medicine division who underwent examinations to assess nutritional state, liver and renal function, and bone metabolism. At the end of the study, the clinical data included in the discharge letter, the treatment prescribed, and the diagnosis assigned to patients on their hospital discharge form were collected. Hypovitaminosis D was found in 72% and hypoalbuminemia in 34.3% of patients. Subjects with hypovitaminosis were generally older and had lower albumin levels than those with mild or no hypovitaminosis. 25-Hydroxyvitamin D was inversely related with parathyroid hormone and directly related with albumin. Alterations of calcium and phosphorus metabolism were present in 55.6% and recorded by the division's physicians for only 13.53% of patients, of whom 72.37% were not specifically treated. There is a direct correlation between 25-hydroxyvitamin D and albumin levels. The high incidence and the metabolic consequence of hypovitaminosis D and of protein-calorie malnutrition is significantly underestimated and undertreated by physicians.

Malnutrition, inflammation, atherosclerosis in hemodialysis patients

Protein-energy malnutrition with muscle wasting occurs in a large proportion of patients with chronic renal failure and is, in addition to atherosclerosis, a strong risk factor for cardiovascular mortality in dialysis patients. There is evidence that a chronic inflammation with activation of C-reactive protein and proinfalammatory cytokines is associated with increased oxidative stress and endothelial dysfunction. Strong relations between malnutrition, inflammation and atherosclerosis in dialysis patients suggest the presence of a MIA (malnutrition, inflammation and atherosclerosis) syndrome, which is associated with high mortality rate. Thus, it could be speculated that suppression of the vicious cycle of malnutrition, inflammation and atherosclerosis would improve survival in dialysis patients.

Serum iron status in Orang Asli children living in endemic areas of soil-transmitted helminths

We conducted a cross sectional study to examine the association of intestinal parasitic infections and protein energy malnutrition (PEM) with iron-status indicators and anaemia among Orang Asli children in Selangor, Malaysia. A total of 281 children aged 2 - 15 years were studied. The data were collected using structured questionnaires, anthropometric measurements and laboratory analysis for blood and faecal samples. All children were infected either by A. lumbricoides, T. trichiura or hookworm and almost 19%, 26% and 3% of the children had severe infection of ascariasis, trichuriasis and hookworm infection respectively. The prevalence of giardiasis among them was 24.9%. Overall, 41.5% of the children were anaemic (haemoglobin < 11.0 g/dL). Of these 61.0% of the children had iron deficiency and 36.5% had iron deficiency anaemia (IDA), which accounted for 88.0% of anaemia in this population. Severe trichuriasis had the most significant correlation with anaemia and iron deficiency in this population. It contributed to low concentrations of haemoglobin, serum iron and serum ferritin and high total iron binding capacity (TIBC). Significant underweight and stunting were associated with low concentrations of haemoglobin and serum iron while significant wasting was significantly associated with low concentration of serum ferritin. Logistic regression analysis confirmed that severe trichuriasis was a strong predictor of IDA. It also confirmed that children who were significantly underweight and whose mother was working were independent predictors of IDA in this population.

Reduction in childhood malnutrition in Vietnam from 1990 to 2004

Reduction in childhood malnutrition in Vietnam between 1990 and 2004 was assessed using data from 5 national surveys. The prevalence of malnutrition, including stunting, declined significantly for underweight from 45% in 1990 to 26.6% in 2004. While the average reduction was 1.3% per year in the period from 1990 to 2000, it was 1.8% per year in the period from 2000 to 2004. The prevalence of stunting declined from 56.5% in 1990 to 30.7% in 2004, with an average reduction of 2% per year in the period from 1990 to 2000 and 1.5% per year in the period from 2000 to 2004. There were clear differences in the decrease in malnutrition prevalence between urban, rural and mountainous areas, the reduction being highest in the urban regions and lowest in the mountainous areas. Regression analysis showed that the nutrition status of the child is positively related to better household living conditions and to the educational level of the father, but not the mother. Stunting is higher in children whose parents are farmers and higher in households with more children. Stunting prevalence is lower in households with safe water access and hygienic toilets. In future , the dramatic reduction is childhood malnutrition as seen in the period 1990 to 2004 might not continue. More comprehensive apptoaches will be needed to lower childhood malnutrition in Vietnam further.

Improved nutritional status in elderly patients 6 months after stroke

INTRODUCTION

Nutritional status among stroke patients has received limited attention despite the fact, that it may have an influence on clinical outcome. Previous studies have estimated that 15-20 % of patients suffer from malnutrition in the acute phase of stroke, but so far no studies have focused on the late rehabilitation phase after stroke in the patients own home, where the attention on nutrition may be reduced.

AIMS

To determine the prevalence of malnutrition during 6 months of stroke rehabilitation, and to investigate the association between nutritional status, functional recovery, length of stay in hospital and infectious complications.

SUBJECTS AND METHODS

89 patients with ischemic stroke consecutively admitted to a geriatric stroke rehabilitation unit had their nutritional status evaluated in the hospital at 1 week and 5 weeks after stroke, and in their own home at 3 months and 6 months. Nutritional status was evaluated by body weight, body mass index (BMI), mid upper arm circumference (MAC), triceps skinfold thickness (TSF) and serum concentrations of albumin and transferrin. Malnutrition was defined if the patients had 2 or more abnormal nutritional variables.

RESULTS

We found a significant increase in albumin from 1 week to 6 months (P < 0.0001), and a significant increase in transferrin form 5 weeks to 6 months (P < 0.05). There was no significant change in weight or BMI from 1 week to 6 months. The number of patients with 2 or more abnormal nutritional variables was 31 (35 %) at 1 week and was reduced to 20 (22 %) at 6 months.

CONCLUSION

35 % of elderly patients with ischemic stroke admitted to a geriatric rehabilitation unit were malnourished 1 week after stroke. Particularly serum proteins and body fat were affected. Follow-up of nutritional variables showed improvement for serum proteins, and 22 % of the patients were malnourished 6 months after stroke.

Nutritional status, body composition and health conditions of the Karen hill tribe children aged 1-6 years in Northern Thailand

INTRODUCTION

In Thailand, according to the national nutrition survey of the Thai population who live in the cities by the Ministry of Public Health, about 12% of preschool children aged 1-6 years were malnourished. The rate of malnutrition is much higher among mountain minority ('hill tribe') children than city children. This paper reports a study of malnutrition, body composition and health conditions of Karen hill tribe children aged 1-6 years in Thailand.

METHODS

All children aged 1-6 years (N = 158; 83 boys, 75 girls) from the three Karen villages (Mae Hae Tai, Mae Yot, Mae Raek) of Mae Chaem district in the north of Thailand were studied. Anthropometric measurements of all children were obtained and body composition data were derived. All children were examined by a qualified medical doctor. A stool sample and blood smear for malaria from all children were examined by a well qualified medical technologist.

RESULTS

All families of the study boys and girls had incomes lower than the Thailand poverty line (US $ 1,000/year). There were no significant differences in weight, height or body mass index of boys and girls from each of the three villages. Malnutrition in children were found 85.5% by using weight-for-age, 73% by height-for-age (stunting) and 48.4% by weight-for-height (wasting). Boys had more total body fat mass than girls. However, all of them had low lean body mass and fat mass. Nearly all children (98%) suffered from either upper respiratory tract infection, skin infection, scabies and/or diarrhoea. Also, nearly all of them (97%) had scaly and dry skin over their chest walls and legs. About 10% of children had either angular stomatitis (5%) or bleeding per gums (3%) or bow legs (1%) or frontal bossing (1%) with their implications for micronutrient deficiency. None of the children from the three villages were infested with the malarial parasite. On average, 54% of children from Mae Hae Tai village and 85% of children from Mae Yot village but only 4% of the children from Mae Raek village were infested with parasites. Ascaris lumbricoides was the most common infestation in all children from three villages.

CONCLUSION

The prevalence of malnutrition was high among the Karen hill tribe children aged 1-6 years, Thailand. Most of the children suffered from upper respiratory tract infection, skin infection, scabiasis and/or diarrhrea. Nearly all of them had scaly and dry skin over their chest walls and legs which indicated essential fatty acid deficiencies. However, only 10% of them had vitamin deficiencies such as B2, C, and D.

Body mass index in Central India: inter district variation

Basic causes of poor state of nutrition and infections in developing countries are poverty, low level of hygienic conditions and little access to preventive and health care. Central India is known for its high rate of population growth and mortality, which persisted over time along with a low level of social, economic and infrastructure development. In the present study the body mass index (BMI) of 31 populations residing in 38 districts of Central India (comprising the States of Madhya Pradesh and Chhattisgarh) is assessed. Anthropometric data collected by the Anthropological Survey of India were utilized in this context. The mean body mass index values of the populations of total backward and non-backward districts are found to be lower than that of well-to-do individuals of India (Bharati 1989, Khongsdier 1997, Reddy 1998), but it is not as low as that found among the South Indian populations (Ferro-Luzzi et al. 1992). In the present investigation, it is also found that the majority of the backward districts fall in the category of different grade of chronic energy deficiency (CED), while in the non-backward districts a considerably less number of districts follows this trend. A better level of the nutritional status among the populations of the non-backward districts corroborates the findings of the Ministry of Health and Family Welfare (NFHS 1992). It reveals that the apparently healthy individuals with CED grade I in the present study may be thin but physically active and healthy. The present study, however, narrates further intensive investigations in these populations, because the BMI as a measure of the CED should incorporate the aspects like morbidity and health status of a population.

Nutritional implications of patient–provider interactions in hospital settings: evidence from a within-subject assessment of mealtime exchanges and food intake in elderly patients

OBJECTIVE

To examine the nutritional implications of the interactions taking place between patients and care providers during mealtimes in hospital settings. Specifically, we tested research propositions that the amount and nature of interpersonal behaviours exchanged between patients and providers impact patients' food intake. These propositions were derived from prior evidence of social influences on eating behaviour and a well-established framework that identifies two fundamental modalities of human interaction: striving for mastery and power (agency) and efforts to promote union with others (communion).

DESIGN

In a within-subject naturalistic study, participants were observed on multiple meals (n=1477, 46.2 meals/participant on average), during which participants' and providers' agency- and communion-related behaviours and patients' protein and energy intake were recorded. Meal-level frequency and complementarity of patients' and providers' behaviours were computed to test research propositions.

SETTING

Dining room of a geriatric rehabilitation unit.

SUBJECTS

Thirty-two elderly patients (21 females, mean age:78.8, 95% CI: 76.4, 81.1).

RESULTS

Meal-level frequency of patient-provider exchanges (P=0.016) and patients' agency-related behaviours (P=0.029), as well as mutual reciprocation of patients' and providers' communion-related behaviours (P=0.015) on a given meal were positively linked to protein intake. Higher energy intake was found during meals where patients expressed more agency-related behaviours (P=0.029).

CONCLUSION

Results present evidence that the amount and nature of patient-provider interpersonal exchanges on a given meal influence the nutritional quality of food intake in hospitalized elderly. They provide insights into how to improve the design and delivery of routine care to this malnutrition-prone population.

SPONSORSHIP

This study was supported by the Canadian Institutes of Health Research (Operating grant to Laurette Dubé, Doctoral Fellowship to Catherine Paquet) the Fonds de la Recherche en santé du Québec and by the Danone Institute (Doctoral fellowship to Danielle St-Arnaud McKenzie).

The Mini Nutritional Assessment (MNA) review of the literature--What does it tell us?

To review the literature on the MNA to Spring 2006, we searched MEDLINE, Web of Science and Scopus, and did a manual search in J Nutr Health Aging, Clin Nutr, Eur J Clin Nutr and free online available publications.

VALIDATION AND VALIDITY

The MNA was validated against two principal criteria, clinical status and comprehensive nutrition assessment using principal component and discriminant analysis. The MNA shortform (MNA-SF) was developed and validated to allow a 2-step screening process. The MNA and MNA-SF are sensitive, specific, and accurate in identifying nutrition risk.

NUTRITIONAL SCREENING

The prevalence of malnutrition in community-dwelling elderly (21 studies, n = 14149 elderly) is 2 +/- 0.1% (mean +/- SE, range 0- 8%) and risk of malnutrition is 24 +/- 0.4% (range 8-76%). A similar pattern is seen in out-patient and home care elderly (25 studies, n = 3119 elderly) with prevalence of undernutrition 9 +/- 0.5% (mean +/- SE, range 0-30%) and risk of malnutrition 45 +/- 0.9% (range 8-65%). A high prevalence of undernutrition has been reported in hospitalized and institutionalized elderly patients: prevalence of malnutrition is 23 +/- 0.5% (mean +/- SE, range 1- 74%) in hospitals (35 studies, n = 8596) and 21 +/- 0.5% (mean +/- SE, range 5-71%) in institutions (32 studies, n = 6821 elderly). An even higher prevalence of risk of malnutrition was observed in the same populations, with 46 +/- 0.5% (range 8-63%) and 51 +/- 0.6% (range 27-70%), respectively. In cognitively impaired elderly subjects (10 studies, n = 2051 elderly subjects), detection using the MNA, prevalence of malnutrition was 15 +/- 0.8% (mean +/- SE, range 0-62%), and 44 +/- 1.1% (range 19-87%) of risk of malnutrition.

CHARACTERISTICS

The large variability is due to differences in level of dependence and health status among the elderly. In hospital settings, a low MNA score is associated with an increase in mortality, prolonged length of stay and greater likelihood of discharge to nursing homes. Malnutrition is associated with functional and cognitive impairment and difficulties eating. The MNA(R) detects risk of malnutrition before severe change in weight or serum proteins occurs.

NUTRITIONAL INTERVENTION

Intervention studies demonstrate that timely intervention can stop weight loss in elderly at risk of malnutrition or undernourished and is associated with improvements in MNA scores. The MNA can also be used as a follow up assessment tool.

CONCLUSION

The MNA is a screening and assessment tool with a reliable scale and clearly defined thresholds, usable by health care professionals. It should be included in the geriatric assessment and is proposed in the minimum data set for nutritional interventions.

Training nurses to save lives of malnourished children

A qualitative study with a pre- and post-intervention component was undertaken among 66 professional nurses at 11 hospitals in the Eastern Cape to assess their perceptions and attitudes towards severely malnourished children and their mothers/ caregivers. Nurses’ attitudes were compared before and after attending a 5-day training course to improve the management of malnutrition along with implementing World Health Organization (WHO) guidelines. Severe malnutrition is a major cause of death among paediatric patients in many hospitals in South Africa. A qualitative study with a pre- and post-intervention component was undertaken among 66 professional nurses at 11 hospitals in the Eastern Cape to assess their perceptions and attitudes towards severely malnourished children and their mothers/caregivers. Nurses’ attitudes were compared before and after attending a 5-day training course to improve the management of severe malnutrition through implementing the World Health Organisation (WHO) guidelines. Focus group discussions were conducted in isiXhosa following a semi-structured discussion guide. Three themes emerged from these discussions, i.e. nurses placed blame on the mothers for not giving adequate care at home; nurses valued malnourished children less than those with other conditions; and nurses felt resentment towards caregivers. Underlying reasons for the negative attitudes towards severely malnourished children and their caregivers were misunderstandings of the causes of malnutrition, misinterpretation of clinical signs, especially poor appetite, and high mortality during treatment. However, the training course and successful application of the treatment guidelines altered these perceptions and helped nurses to have a better understanding of the causes of the presenting clinical signs. These nurses have begun advocating for raised awareness of the physiological differences that occur in malnutrition and the need to include the WHO Ten Steps of treatment in the nursing curricula and inservice training. A cadre of volunteer nurse-trainers has been formed in Eastern Cape. Experience in this province has shown that in-service training changes attitudes to malnutrition and treatment practices, as well as saving lives.

Nutritional study of the 1-4 year old population of the Lower Jimi Valley, Western Highlands Province, Papua New Guinea

Malnutrition is a significant problem in parts of Papua New Guinea, including the Lower Jimi Valley. There is evidence of specific nutritional deficiencies, such as endemic cretinism, but this study focused on protein-energy malnutrition. It found that, in the 1-4 year old population of three remote villages in the Jimi, only 26% were nutritionally normal, 65% were stunted, 7% were wasted and 2% were stunted and wasted. With respect to weight for age, 16% were 80-100% weight for age, 77% were 60-80% and 7% were < 60%. These figures are considerably higher than those of the National Nutrition Survey of 1982-1983; although the Survey data originated from the entire Jimi District rather than only the villages in this study, these findings suggest that malnutrition is a significant and worsening problem in the Lower Jimi Valley.

Nutritional disorders in the elderly

Undernutrition is common in older people and has serious adverse effects. Weight loss and low body weight are key markers. Correctable causes, such as depression, are common and should be sought. Structured efforts to encourage food intake, together with nutritional supplements, often are of benefit. It is hoped that a better understanding of the underlying mechanisms will lead to targeted treatments. Overweight and obesity also are common in older people, and are associated with morbidity and impaired function. It is probably appropriate to recommend weight loss to obese older people who have associated comorbidities, particularly reduced mobility, but seldom, if ever, for increased weight alone.

Somatic growth after ventricular septal defect in malnourished infants

OBJECTIVE

To assess somatic growth after ventricular septal defect (VSD) repair in severely malnourished infants.

STUDY DESIGN

Ninety consecutive infants (age at surgery: 7.2 +/- 3.2 months) were followed after VSD closure at a referral center in southern India to evaluate somatic growth.

RESULTS

At surgery, 44% and 30% of patients had weight and height Z score <-3, respectively. On follow-up (age 5.4 +/- 0.8 years), despite a significant improvement from baseline (Z score -1.8 +/- 1.2 vs -2.8 +/- 1.3, P <.001), weight was significantly lower compared with healthy Indian children, particularly for boys. Height Z score improved significantly only in girls (-0.8 +/- 1.3 vs -1.8+/-2.1, P = .01). Weight, height, and combined weight and height Z scores (failure to thrive) of <-2 were observed in 42%, 27%, and 18 % of patients, respectively. On multivariate analysis, weight Z score <-2 on follow-up was predicted by weight Z score at surgery and male sex, height Z score <-2 by maternal height and male sex, and failure to thrive by maternal height and caloric intake.

CONCLUSIONS

There is suboptimal recovery of somatic growth after repair of VSD in severely malnourished infants. Preoperative malnutrition affected only weight on follow-up, whereas height recovery and failure to thrive were influenced by constitutional factors.

[Nutritional status of peritoneal dialysis patients and parameters of dialysis adequacy]

The aim of our study was to evaluate relations between peritoneal dialysis (PD) adequacy and nutritional parameters of PD patients. Patients (n = 124), who finished PD treatment, were separated on 2 groups according to the mean total Kt/V for the entire PD course being below 2.0 (group I) or over 2.0 (group II). Adequacy parameters, daily intake of food products and nutritional indices were evaluated in each patient every 3-6 months during the entire PD course. Mean values of examined parameters were used for comparison of differences observed between both groups. Group I included 63 men, 16 women, age 50.3 +/- 13.8 years, PD duration 13.2 +/- 10.1 months. Group II consisted of 12 men, 33 women, age 49.1 +/- 14.9 years, PD duration 8.8 +/- 6.0 months. Due to a significant difference in sex distribution, dialysis duration and ideal body mass (IBM) between groups, statistical analysis was performed with adjustment of results to these parameters. Absolute amounts of daily intake of food components were higher in group I for animal protein, sodium, retinol, niacin, saturated and polyunsaturated fatty acids and cholesterol. When daily food intake was normalized to IBM, group II showed higher both protein nitrogen appearance (I - 0.92 +/- 0.25, II - 1.12 +/- 0.45 g/kg IBM, p = 0.005) and intake of vegetable protein (I - 0.29 +/- 0.10, II - 0.34 +/- 0.09 g/kg IBM, p = 0.040), carbohydrates (I - 3.30 +/- 1.08, II - 3.80 +/- 1.34 g/kg IBM, p = 0.029), potassium (I - 33.2+/-10.6, II - 38.3 +/- 13.2 mg/kg IBM, p = 0.034), calcium (I - 5.81 +/- 2.46, II - 7.20 +/- 3.54 mg/kg IBM, p = 0.028), magnesium (I - 2.86 +/- 0.86, II - 3.41 +/- 1.36 mg/kg IBM, p = 0.004), beta-carotene (I 22.4 +/- 15.8, II - 34.9 +/- 29.1 mg/kg IBM, p = 0.002) as well as calorie delivered from protein (I - 0.22 +/- 0.04, II - 0.26 +/- 0.07%, p = 0.001) and carbohydrates (I - 0.79 +/- 0.15, II - 0.94 +/- 0.21, p = 0.000) in relation to total amount of ingested calorie. Group I showed significantly lower serum levels of albumin (I - 2.45, 1-3, II - 2.83, 1-3 scores, p = 0.023) and cholesterol (I - 5.54 +/- 1.06, II - 6.35 +/- 1.63 mmol/l, p = 0.009), but higher serum iron (I - 16.7 +/- 4.4, II - 15.8 +/- 5.2 micromol/l, p = 0.042) and ferritin (I - 615, 28-5113, II - 377, 24-3376 ng/ml, p = 0.021) concentrations as well as transferrin saturation (I - 31.1 +/- 9.2, II - 28.5 +/- 9.2%, p = 0.032). We conclude that PD patients with Kt/V over 2.0 as compared to those with Kt/V below 2.0 show tendency for better nutritional indices excluding serum iron parameters.

Nutritional support in patients with chronic liver disease

Malnutrition is highly prevalent among patients with chronic liver disease and is nearly universal among patients awaiting liver transplantation. Malnutrition in patients with cirrhosis leads to increased morbidity and mortality rates. Furthermore, patients who are severely malnourished before transplant surgery have a higher rate of complications and a decreased overall survival rate after liver transplantation. In light of the high incidence of malnutrition among patients with chronic liver disease and the complications that result from malnutrition in these patients, it is essential to assess the nutritional status of all patients with liver disease, and to initiate treatment as indicated. This review addresses the etiologies of malnutrition, methods used to assess nutritional status, and appropriate treatment strategies.

Promotion of the Feeding Minds and Fighting Hunger Initiative in Selected Rural Schools in Andhra Pradesh, India

Background

Schoolchildren are good agents of change and need to be educated and sensitized to specific issues of hunger and malnutrition through a question-and-answer process. Feeding Minds and Fighting Hunger (FMFH), a global project initiated by the Food and Agriculture Organization and partner organizations, attempts to help schoolchildren learn about these issues by introducing concepts in the prevention of hunger and malnutrition to teachers, and by facilitating transfer of knowledge to the children through a set of model lessons.

Objective

To test the feasibility of the FMFH approach to improve the nutrition knowledge of rural schoolchildren in three rural schools in Medak District of the South Indian state of Andhra Pradesh.

Methods

Participatory workshops for teachers were conducted to facilitate knowledge transfer to the children through interactive classroom teaching and other activities. The change in knowledge and thinking of children in the seventh and eighth grades was assessed by a questionnaire administered before and after the intervention. The questionnaire also assessed, in part, the status of local food security based on the sources of different food items in the households.

Results

The responses to the questionnaire suggested that the children's knowledge of nutrients and their functions was not good initially but improved after the intervention. However, their understanding of the social factors responsible for hunger and malnutrition was fairly good prior to the intervention. Improvement in responses to the question of what should be done to combat malnutrition also occurred after intervention. The community had village-level food security for rice and maize but depended partially or fully on outside sources for pulses, fruits and vegetables, and animal products.

Conclusions

The FMFH approach can be applied in rural schools where “the poorest of the poor” children can improve their understanding of balanced diets, better nutrition, the causes of malnutrition, and approaches to combat malnutrition.

[Heart failure, malnutrition and inflammation. Prevalence and relevant aspects in its assessment]

Heart failure is associated to alterations in the nutritional status that contributes to a worse prognosis of the disease.

OBJECTIVE

To study protein-calorie malnutrition (PEM) prevalence, micronutrient deficits and increase of inflammatory parameters in patients with cardiac failure (CF).

MATERIAL AND METHODS

Cross-sectional, observational study in 98 heart failure patients of Internal Medicine Service have been evaluated. We have analyzed biomedical, anthropometric variables (weight, size, BMI, tricipital fold), search of treatments, echocardiogram valuation and determination of albumin, pre-albumin, A and E group vitamins, ESR and C-reactive protein. We have defined protein malnutrition (PN) as albumin values

RESULTS

Average age was 76.6 +/- 7.5. A total of 77.7% showed a functional class II-III/IV. Prevalence of PEM was 40%. Low albumin and prealbumin was found in 12.8% and 38.3% respectively (p < 0.05). Using BMI, 5.3% of patients had malnutrition. Nevertheless, if tricipital fold is used, EM was found in the 25.3% of the cases (p < 0.05). Iron iron, vitamin A and C-reactive protein levels were different in heart failure patients with PM (p < 0.05). The percentage of protein malnutrition in patients with LVEF < 45% was 16.4% versus 5.5% in diastolic dysfunction (p = 0.01). Treatment with ACE-inhibitors was 42.2%; in this group the malnutrition for any criterion was 13% vs 26% in the group of patients without ACE-inhibitors (p = 0.08).

CONCLUSIONS

There is a high prevalence of nutritional and inflammatory disturbances (low in diastolic dysfunction) in patients with moderate status of heart failure. Treatment with an ACE-inhibitor improves the nutritional parameters.

Nutritional status in elderly people admitted to community residential homes: comparisons between two cohorts

The aim was to describe nutritional status and socio-demographic and medical data in people who were newly admitted to community residential homes (cohort 2), and to compare the results with a previous study performed in the same municipality four years earlier (cohort 1). One hundred and twenty-seven people, 65 years of age, or older, newly admitted to residential homes in a municipality in the southern part of Sweden, were consecutively included. Nutritional status was assessed, using a combination of anthropometry and serum protein measurements and by Mini Nutritional Assessment (MNA). The results showed that 32% of the residents in cohort 2 were assessed as protein-energy malnourished (PEM), compared with 38% in cohort 1. Body mass index, psychological stress or acute disease, and reduced fluid intake were items in MNA which had power to predict PEM. Residents in cohort 2, diagnosed as having severe medical diseases, increased as well as residents with neuropsychological problems. Simultaneously, the number living in residential homes decreased, as compared to cohort 1. These differences indicate that the admission criteria have changed between cohorts 1 and 2.

Repeated assessment of energy and nutrient intake in 52 nursing home residents

Studies in Swedish nursing-home patients have shown a high prevalence of protein-energy malnutrition. One potential cause for this may be low food intake.

OBJECTIVE

To examine the intake of energy and nutrients in the residents of a nursing home; to investigate changes in dietary intake and body-weight over time and to analyze two-year-mortality.

DESIGN

Explorative study. Five-day weighed assessment of food intake repeated three times during 1.5 years. Analysis of body composition at baseline and recording of body weight every third month. Analysis of two-year mortality.

RESULTS

Fifty-two residents had three complete dietary assessments. Mean age 84 +/- 7 years, 79% were female. Mean body weight was stable at 61 kg. Mean energy intake at baseline was 1501 kcal/d (25 kcal/kg/d) and mean protein intake was 53 g/d (0.9 g/kg/d). Mean intake of vitamin D, vitamin E, folic acid, selenium and dietary fibre was less than 60% of recommended. At the second assessment intake of energy and many nutrients was higher than at baseline, but at the third assessment intake had decreased. There was no correlation between energy intake and body weight over time. Two-year mortality was 52%. Male gender and low body-weight constituted an increased risk of mortality. Comparing survivors and non-survivors showed that the mean body weight was 9 kg higher in the survivors throughout the study (p=0.02). This group had a relatively lower fat free mass and higher fat mass than the non-survivors. The difference in body composition was only seen in females, possibly due to the low number of males. The survivors had higher intakes of most nutrients but this reached significance only for a few of them. The non-survivors had significantly higher intakes of sucrose.

CONCLUSION

Intake of energy and many nutrients was low in these nursing-home patients, and decreased further after one year, without any change in body weight. The significant positive relation between energy intake and body weight at group level disappeared when analyzing data at an individual level. Male gender and low body weight were associated with increased risk of mortality.

Increased food intake after the addition of amylase-rich flour to supplementary food for malnourished children in rural communities of Bangladesh

BACKGROUND

In Bangladesh, as in other developing countries, protein-energy malnutrition is mostprevalent among children during weaning. After weaning, children are often fed cereal-based diluted low-calorie porridge, resulting in growth-faltering.

OBJECTIVE

To assess the effect on food intake of adding amylase-rich flour (ARF) from germinated wheat to supplementary food among children in nine rural Community Nutrition Centers under the Bangladesh Integrated Nutrition Project (BINP).

METHODS

A total of 166 malnourished children of either sex, aged 6 to 24 months, received one of three diets randomly allocated to the Community Nutrition Centers. The composition of the diets was the same; however, the consistency and calorie density were altered by adding either ARF or water. Thirty-five children received the standard supplementary food of the BINP (S-SF), 65 received supplementaryfood with added ARF (ARF-SF), and 66 received supplementary food with added water (W-SF). The children were studied for six weeks. Results. The mean +/- SD intake of supplementaryfood from a single meal by children completing six weeks on the diets was higher for children receiving ARF-SF (33.91 +/- 8.25 g) than for those receiving S-SF (25.66 +/- 6.73 g) or W-SF (30.26 +/- 8.39g) (p < .05 for both comparisons). The weight of vomited food was significantly higher for children receiving W-SF than for children in the other two groups. Weight gain and increments in length and weight-for-height were higher for children who received ARF-SF than for children in the other two groups, but the differences were not statistically significant. The acceptability ofARF-SF was higher than that of the two other diets. The additional cost of adding 2 g of ARF to the diet was about Taka 0.25 (U.S. dollar 1 = Taka 48).

CONCLUSIONS

Addition of ARF to existing standard supplementary food, as used under the BINP program, is a simple and effective means to increase the intake of food by changing its consistency, thus making it easier for malnourished children to ingest.

The quality of the diet in Malawian children with kwashiorkor and marasmus

Nutritionists have suggested that kwashiorkor is related to low dietary protein and/or antioxidant intake. This study explored the hypothesis that among Malawian children with severe malnutrition, those with kwashiorkor consume a diet with less micronutrient- and antioxidant-rich foods, such as fish, eggs, tomatoes and orange fruits (mango, pumpkin and papaya), than those with marasmus. A case-control method with a food frequency questionnaire was used to assess the habitual diet. Children with severe childhood malnutrition presenting to the central hospital in Blantyre, Malawi during a 3-month period in 2001 were eligible to participate. The food frequency questionnaire collected data about foods consumed by siblings <60 months of age in the home. It was assumed that the habitual diet of all siblings 1-5 years old in the same home was similar. Dietary diversity was assessed using a validated method, with scores that ranged from 0 to 7. Regression modelling was used to control for demographic and disease covariates. A total of 145 children with kwashiorkor and 46 with marasmus were enrolled. Children with kwashiorkor consumed less egg and tomato than those with marasmus: 17 (15) vs. 24 (31) servings per month for egg, mean (SD), P < 0.01 and 27 (17) vs. 32 (19) servings per month for tomato, P < 0.05. Children with kwashiorkor had a similar dietary diversity score as those with marasmus, 5.06 (0.99) vs. 5.02 (1.10), mean (SD). Further research is needed to determine what role consumption of egg and tomato may play in the development of kwashiorkor.

Childhood illnesses and malnutrition in under five children in drought affected desert area of western Rajasthan, India

The study was undertaken to asses the impact of drought on childhood illnesses and nutrition in under five children of rural population using three stage sampling design. The study has been carried out in 24 villages belonging to 6 tehsils of Jodhpur district which was a drought affected desert district of Western Rajasthan in 2003. A total of 914 under five children (0-5 years) could be examined for their childhood illnesses, malnutrition, dietary intake and clinical signs of nutritional deficiency. Childhood illnesses observed at the time of drought were respiratory (7.5 %), gastroentrological (7.5%), and 5.6% fever (viral, malaria and jaundice), higher in males than females. Children suffered from recent and long term malnutrition were 39% and 26% respectively as per National Centre for Health Statistics (NCHS) standards. The extent of malnutrition was significantly higher in females than in males (p<0.01). Vitamin A & B complex deficiencies were 0.7% and 3/% respectively. The protein energy malnutrition (PEM) was observed in 44.4%. Overall mean calorie and protein intake deficit was observed to be very high (76.0 & 54.0 %). The comparison of present drought results with earlier studies in normal and drought conditions showed higher prevalence of PEM and deficiencies of calories & proteins in their diet. Respiratory, gastroentrological and fever were main childhood illnesses observed and were higher in males at the time of drought. PEM, vitamin A & B- complex deficiencies, anemia along with deficit in calories and proteins in their diet was observed higher in present study as compared to non desert areas, which may be due to the harsh environmental conditions in desert areas and paucity in the consumption of daily food intake. Due to inadequate consumption of daily food, the children were suffering from PEM resulting in several childhood illnesses. Effective measures making availability of adequate calories and proteins to all age groups especially to under five children through the ongoing nutrition programs needs to be ensured.

Anemia in kidney transplanted patients

BACKGROUND

Although a known cardiovascular risk factor, anemia in the renal transplant recipients has only recently been receiving an increasing attention.

METHODS

In a cross-sectional study, data was obtained from 959 patients followed at a single outpatient transplant clinic. Based on the guideline of the American Society of Transplantation, anemia was defined as hemoglobin (Hb) < or =130 g/L in males and < or =120 g/L in females.

RESULTS

About one-third (34%) of the patients were anemic. The prevalence of anemia was comparable in males and females. Serum Hb concentration was significantly correlated with the estimated glomerular filtration rate (eGFR) (abbreviated modification of diet in renal disease formula) (r = 0.266, p < 0.001), serum transferrin (r = 0.268, p < 0.001) and serum albumin (r = 0.196, p < 0.001). None of the immunosuppressive medications or the use of angiotensin converting enzyme inhibitors was associated with a higher likelihood of anemia. In multivariate analysis the eGFR, serum albumin and serum transferrin, potential markers of nutritional status and/or chronic inflammation, and also iron deficiency were independently and significantly associated with anemia. Erythropoietin was administered only to 63 (19%) anemic patients.

CONCLUSIONS

Post-transplant anemia is a prevalent and under-treated condition. Based on our results we suggest that, besides other factors, protein/energy malnutrition and/or chronic inflammation may be independently associated with anemia. Further studies are needed to determine whether the presence of anemia and its treatment will have an impact on long-term outcomes of this population.

Risk factors for malnutrition among rural Nigerian children

Protein Energy Malnutrition (PEM) remains a major public health problem in the developing world. The aim of this study was to determine the current nutritional status and the influence of feeding practices and family characteristics on the nutritional status of under-five rural Nigerian children. It was conducted using a cross sectional, community based survey design. From 344 households, 420 children were studied. Using the modified Wellcome Classification, the prevalence of PEM was 20.5 percent whereas the prevalence of underweight, wasting and stunting using the World Health Organization/ National Centre for Health Statistics (WHO/NCHS) standards were 23.1 percent, 9 percent and 26.7 percent respectively. Young age was significantly associated with a higher prevalence of underweight (P = 0.004). Overcrowding, low maternal income and the use of infant formula feeds in children who have attained the age of 6 months and above were associated with a higher prevalence of wasting (P = 0.029, P = 0.031 and P = 0.005 respectively). Improved living standard of families, empowerment of mothers with the aim of augmenting family income and parental education on appropriate feeding practices may help in reducing the incidence of under-five malnutrition in communities. The low prevalence rate of malnutrition was probably due to activities of the NGO in this community. This method of intervention is similarly achievable in any other community.

A longitudinal study on the nutritional state of elderly women at a nursing home in Japan

OBJECTIVE

Elderly people at nursing homes often suffer from malnutrition, which is characterized by a loss of muscle mass and hypoalbuminemia. This malnourished state is closely associated with an impaired activity of daily living (ADL). We analyzed the nutritional state of such elderly individuals longitudinally over 3 years by anthropometry, serum albumin, and muscle and fat volume as estimated by MRI.

PATIENTS AND METHODS

The subjects consisted of 16 elderly women aged 83 +/- 7 (mean +/- SD) years who resided at a nursing home in an urban area of central Japan. We determined their ADL levels using the Barthel Index (BI) at entry. Seven women belonged to group A (BI; 65-100), thus implying either a mild or no decline in ADL, while the other 9 were in group B (BI; 0-60) and they demonstrated a severe decline in ADL. We measured the following parameters every year from 2000 to 2003; anthropometry including height, body weight, arm circumference (AC), and arm muscle circumference (AMC), thigh muscle and fat volume as estimated by MRI [thigh muscle volume (TMV) and thigh fat volume (TFV)], serum albumin, and plasma amino acid levels by blood biochemistry. The anthropometric values were converted into percentages of the age- and sex-matched reference values for Japanese.

RESULTS

In all subjects, the TMV, %AMC, and serum albumin level decreased significantly during the three-year period (p<0.05, respectively). The change in TMV correlated significantly with those in the %AC and %AMC (p<0.05, respectively). Group B showed significantly larger decreases in the %AMC and serum albumin level than group A.

CONCLUSION

Both the muscular and visceral protein levels were found to decrease with aging in the subjects at the nursing home. This decrease depends partly on the ADL level of each subject.

Assessment of nutritional status of pre-schoolers in slum areas of Udaipur City

The present study was conducted in pre-schoolers (2-6 years) from ten different slums of Udaipur City in Rajasthan with the aim to their nutritional status. From the data collected and observations recorded was observed that majority of the subjects were from nuclear family with monthly family income of less than Rs.1500/-. Developmental pattern of these subjects indicated that the height with age of bothe male and female subjects increased, however, their body weight did not increase. More than 50% of these pre-schoolers showed symptoms of protein energy malnutrition and anaemia, while 22% had pigeon chest deformity due to vitamin D and calcium deficiency. Classification for degree of malnutrition as per IAP showed that majority of these subjects (66%) were under weight (Grade I and II). Waterlow's classification revealed that majority of these pre-schoolers were wasted (30%) or wasted and Stunted (42%). This malnutrition was either of PCM (past chronic) or CLM (current long duration) type as per Seoane and Latham's classification.

Nutritional status of pregnant women in Northeast Thailand

A comparative study on the nutritional status of primiparous and multiparous women in the first trimester of pregnancy was conducted in the northeastern province of Thailand, Khon Kaen, to investigate differences in protein-energy-malnutrition, iron deficiency anaemia, vitamin A deficiency and carotenoid status between both parity groups. 94 subjects were recruited at first attendance of antenatal clinic. Data about weight, height, haemoglobin and haematocrit were obtained from hospital records. Anthropometric measurements of mid-upper arm circumference and triceps skinfold were done on a sub sample. Retinol, carotenoids and alpha-tocopherol were analysed using a reversed-phase high-performance liquid chromatography method. Ferritin, transthyretin and retinol-binding protein were determined by enzyme-linked immunosorbent assay. Primiparous women showed lower body mass index, mid-upper arm circumference, corrected arm muscle area (P<0.001) as well as lower retinol, cholesterol and triceps skinfold (P<0.05). After adjusting for age and socio-economical status the significant difference persisted for all parameters but triceps skinfold. No significant differences of alpha-tocopherol, serum proteins, carotenoids and iron indices could be observed, even though a tendency to higher values for ferritin, haemoglobin and haematocrit was shown in multiparous women. Prevalence of protein-energy-malnutrition (body mass index <18.5 kg/m2) in the primiparous group was significantly higher compared to the multiparous group (P<0.05). Prevalence of protein-energy-malnutrition, iron deficiency anaemia and vitamin A deficiency were 15.1%,6.3% and 3.3%, respectively, in the total study population. No differences between parity groups could be observed for prevalence of iron deficiency anaemia and vitamin A deficiency.

Implementing clinical guidelines for nutrition in a neurosurgical intensive care unit

Patients in neurosurgical intensive care have individual needs concerning nutrition because of their conditions. An important therapeutic goal is to prevent the development of malnutrition as it contributes to an increase in mortality and enhances the risk of complications in these patients. The health-care team has a mutual responsibility for this, although it is a complex task and a correct assessment of patients' nutritional needs is vital. Multidisciplinary clinical guidelines focused on nutrition might help the health-care staff in decision-making and allowing individualized treatment for patients. The aim of this study was to evaluate the implementation and use of such a guideline. The results show that the guideline is used in varying degrees by the health-care team. Areas that focused on more practical aspects of nutritional support seemed to have a unified approach, whereas areas on nutritional assessment and routine nutrition orders demonstrated both a lack of knowledge and unclear role responsibilities. The results reveal how different professional groups in health care perceive the implementation of a clinical guideline. Some areas need further clarification, there needs to be continuing development of nutritional guidelines, and education of staff is needed in order to enhance the nutritional care of patients.

Geographical inequalities in nutrient status and risk of malnutrition among English people aged 65 y and older

OBJECTIVE

Geographical inequalities in health continue to be a problem within developed countries. This study investigated whether there were north-south geographical inequalities among older people living in England with respect to risk of protein-energy malnutrition and status of nutrients, particularly those derived from fruit and vegetables.

METHODS

A secondary analysis of data collected prospectively by the National Diet and Nutrition Survey of people aged 65 y and older was undertaken to assess geographical prevalence of risk of protein-energy malnutrition (1155 subjects) and nutrient status (881 to 1046 subjects).

RESULTS

A north-south gradient was found in risk of protein-energy malnutrition (19.4%, 12.3%, and 11.2% in the northern, central, and southern regions, respectively; P = 0.013, P for trend = 0.002). This was accompanied by a north-south gradient in the status of vitamin C (30, 38, and 46 micromol/L in the respective regions, P < 0.001), which was associated with deficiency (<11 micromol/L) in a third of subjects in the northern region, a range of carotenoids (P = 0.023 to <0.001), vitamin D (P < 0.001), and selenium (P < 0.001). These inequalities were accompanied by gradients in indices of health status and socioeconomic status, which could account only partly for the "geographical" inequalities. Circulating vitamin C and carotenoid concentrations were related to the intake of fruit and vegetables.

CONCLUSIONS

This study suggests there is a north-south divide in the risk of protein-energy malnutrition and a range of nutrients, which have been implicated in the development of common chronic diseases.

Giardiasis as a predictor of childhood malnutrition in Orang Asli children in Malaysia

A cross-sectional study to examine the association of giardiasis with protein-energy malnutrition, vitamin A deficiency and iron deficiency anaemia was conducted among Orang Asli children in Selangor, Malaysia. A total of 281 children aged 2-15 years were studied. The data were collected using structured questionnaires, anthropometric measurements and laboratory analysis of blood and faecal samples. The results showed that 24.9% of the children were infected with Giardia duodenalis, while 56.5, 61.3 and 15.1% had significant underweight, stunting and wasting, respectively. Giardiasis was statistically identified as a strong predictor of significant wasting in this study population.

The effect of family structure on a sample of malnourished urban Nigerian children

This study focused on the role of family structure in 458 malnourished children under five years of age clinically diagnosed with protein-energy malnutrition (PEM), kwashiorkor, and marasmus. The majority of these children were of higher birth order (3rd child and higher): 63.2% based on the mother's parity and 56.4% based on the father's parity. More than half (54.8%) of the malnourished children's mothers were the first wives of their respective husbands. About 43.9% of the children's fathers were urban danfo (public minibus transport) drivers. Half (51.5%) of the mothers who claimed to be single opted into single status and were mostly from polygamous households, but 87.6% of the children were from polygamous families, of which 18.6% of the mothers had divorced. Only 27.7% of the children lived with both parents; 40.4% lived with their grandparents, and 37.8% were the financial responsibility of their grandparents. We observed an association between children treated for malnutrition and father's occupation, parents' marital status, mothers' seniority among other wives, and source of financial responsibility for the children.

Malaria and nutritional status among pre-school children: results from cross-sectional surveys in western Kenya

Protein-energy malnutrition (PEM) affects millions of children in the developing world. The relationship between malaria and PEM is controversial. The goal of this study was to evaluate whether undernutrition is associated with increased or decreased malaria attributable morbidity. Three cross-sectional surveys were conducted using insecticide-treated bed nets (ITNs) among children aged 0-36 months living in an area with intense malaria transmission. Data were collected on nutritional status, recent history of clinical illness, socioeconomic status, current malaria infection status, and hemoglobin. In multivariate models, stunted children had more malaria parasitemia (odds ratio [OR] 1.98, P < 0.0001), high-density parasitemia (OR 1.84; P < 0.0001), clinical malaria (OR 1.77; P < 0.06), and severe malarial anemia (OR 2.65; P < 0.0001) than nonstunted children. The association was evident in children with mild-to-moderate (-3 < height-for-age Z-score [HAZ] < -2) and severe stunting (HAZ < -3). The cross-sectional nature of the study limits the interpretation of causality, but the data provide further observational support that the presence of undernutrition, in particular chronic undernutrition, places children at higher, not lower risk of malaria-related morbidity.

Comparison of the Mini Nutritional Assessment, Subjective Global Assessment, and Nutritional Risk Screening (NRS 2002) for nutritional screening and assessment in geriatric hospital patients

The Mini Nutritional Assessment (MNA), the Subjective Global Assessment (SGA) and the Nutritional Risk Screening (NRS) are screening and assessment tools aimed at detecting malnourished individuals and those at risk for malnutrition. In our study we tested their applicability in geriatric hospital patients and compared the results of the three tools. We examined prospectively all patients of two acute geriatric wards by the MNA, the SGA and the NRS. 121 patients were included in the study. The MNA could be completed in 66.1% of all patients, the SGA in 99.2% and the NRS in 98.3%. There was a significant association of all three tools with the BMI (p<0.01). With regard to serum albumin and to length of hospital stay (p<0.05), only a significant association could be shown for the MNA (p<0.05). Although the categories of the results were not completely identical for the three tools there were more patients at risk or malnourished according to the MNA (70%) than according to the SGA (45%) or the NRS (40.3%). The direct comparison of the NRS with the MNA and the SGA demonstrated significant differences, especially for the latter (p<0.001). In a relevant percentage of those tested, MNA, SGA, and NRS identify different individuals as malnourished or at risk for malnutrition. Because of its association with relevant prognostic parameters, the MNA is still the first choice for geriatric hospital patients. For those patients to whom the MNA cannot be applied, the NRS is recommended.

[Child malnutrition and maternal overweight in same households in poor urban areas of Benin]

The coexistence of child malnutrition and maternal overweight in the same households typifies rapid nutrition transition in developing countries (DCs). It is reportedly less common in Africa than in Latin America or Asia, but the phenomenon is still little documented. The purpose of our study in poor urban neighbourhoods of the capital city of Benin (West Africa) was to assess the magnitude of the overlap of child protein-energy malnutrition (PEM) and maternal overweight within households, and to compare these households with other nutritional phenotypes in terms of socio-economic circumstances and diet quality. Our hypothesis was that both child PEM and maternal overweight could stem from poor socio-economic conditions, including lack of sanitation, and poor diet quality. Food diversity was used as an index of diet quality, or the qualitative dimension of food security. A random sample of 148 households that included a least the biological mother, one child between 6 and 59 months of age and a second one between 5 and 11 years was selected in two poor neighbourhoods of the capital city of Cotonou to assess the prevalence of "double burden" households and of other nutritional phenotypes of households: with PEM only in at least one child; with maternal overweight only; and without PEM or overweight. Body weights and heights of mothers and of the two targeted children were measured. As long as one child had low weight-for-height or height-for-age (z-score <-2.0), the household came under the "PEM" type. In mothers, overweight was defined as body mass index (BMI) > or = 25, obesity > or = 30 and chronic energy deficiency <18.5. We retained 126 households for interviews with mothers on socio-economic circumstances and food diversity. A socio-economic status (SES) score was constructed on the basis of household amenities and maternal education. Food insecurity was based on reported shortage of food in the last year in the household. Based on the frequency of consumption of 13 different food groups in the previous week, a food diversity score was computed. Overall 35.5% of children were malnourished, and school-age children had a worse nutritional status than under-5 children: 41% and 30% PEM (chronic or acute or both), respectively. The rate of maternal overweight was 39.1% including 15.5% of obesity. Child PEM coexisted with maternal overweight or obesity in 16.2% of the households; 27.7% of households had PEM only, 23% overweight only, 20.3% showed no malnutrition or overweight, and 12.8% had an underweight mother. Maternal BMI status was significantly associated with both children's weight-for-height z-score, particularly the elder one. The rate of child malnutrition, particularly wasting, was significantly higher among underweight mothers and lower in overweight mothers . Underweight mothers were merged with mothers with BMI < or = 25 for the remaining analyses. Households with overweight mothers tended to enjoy relatively better socio-economic conditions--higher SES, higher maternal education, less food insecurity, better household sanitation; they also tended to have a more diversified diet. This is in contrast with PEM households. Dual burden households shared several socio-economic features with the PEM households, except for a higher (not significant) SES score. Dual burden households also had the lowest food diversity score of all household types. Logistical regression models revealed that a relatively higher SES level was associated with a higher likelihood of maternal overweight in PEM households, whereas poor household sanitation increased the odds of PEM among maternal overweight households. Food diversity appeared significantly associated with a lower likelihood of dual burden in all types of households. The study highlights the importance of addressing the double burden of malnutrition and overweight even in poor areas of low income countries of West Africa. It suggests that prevention efforts should be aimed at improving diet quality and sanitation in poor urban households.

[Anemia and deficiency of vitamin A in children evaluated in a nutritional attention center from Caracas]

In order to determine the prevalence of anemia and the deficiency of vitamin A in children under 10 years, the concentration of hemoglobin, transferrin saturation, serum iron and the nutritional state of vitamin A were studied between 1999 and 2000, in 124 children with moderate malnutrition and 98 healthy children who attend triage consultation in the Centro de Atención Nutricional Infantil Antímano (CANIA, Caracas) by means of plasma retinol test (high performance liquid chromatography), relative dose response test (RDR) and conjunctival impression cytology (CIC). The dietary intake was analyzed by 24 hour recall. The Student t and Chi-square test were used for the statistical analysis of the data. The prevalence of vitamin A deficiency was approximately 10% in malnourished and healthy children, the CIC test discriminated a proportion of vitamin A deficient children superior to 25% and RDR test detected a significantly smaller percentage of deficiency in healthy children (p < 0.05). The prevalence of anemia was significantly higher in malnourished (34.2%) than in healthy children (19.2%). In children under 2 years the percentage of anemia reached 75.8% in undernourished children and 50% in healthy children. The consumption of macronutrients and micronutrients was inadequate; more than 40% undernourished children had caloric and macronutrients intake adequacy below 85%, whereas this level of adequacy in healthy children was around 30%. These results indicate there were problems of moderate anemia and moderate vitamin A deficiency in the studied infantile population, without significant differences between moderate undernourished and healthy children.

Feeding practices and factors contributing to wasting, stunting, and iron-deficiency anaemia among 3-23-month old children in Kilosa district, rural Tanzania

Infants in Tanzania are particularly vulnerable to under-nutrition during transition from breastmilk (as the only source of nourishment) to solid foods. A cross-sectional study was undertaken in Kilosa district in Tanzania to determine the feeding practices and the extent of wasting, stunting, and iron-deficiency anaemia. The study was done in two stages: in the first stage, a 24-hour dietary assessment was conducted to identify the type of complementary foods given and the eating habits according to age for 378 children aged 3-23 months. In the second stage, a progressive recruitment of 309 infants aged six months was made to measure weight, length, haemoglobin (Hb) concentration, zinc protoporphyrin concentration, and malaria parasitaemia. Birth-weight, the potential contributing factor to under-nutrition and iron-deficiency anaemia, was obtained from the children's clinic cards. The 24-hour dietary assessment revealed that children consumed mainly a thin porridge prepared from maize flour as complementary food. Carbohydrates contributed most energy (on average 69%), followed by fats (18.6%) and protein (on average 12.1%). The complementary food co-vered only 15%, 20%, and 27% of the recommended iron intake for children aged 6-8, 9-11 and 12-23 months respectively. The mean Hb concentration was 9.3 +/- 1.9 g/dL, 68% of the infants were moderately anaemic (7 < or =11 g/dL), and about 11% were severely anaemic with Hb below 7 g/dL, while 21% were non-anaemic Hb (> or =11 g/dL). Equally, the mean zinc protoporphyrin concentration was 10.0 +/- 6.2 microg/g Hb, and 76% of the infants were iron-deficient (>5 microg/g Hb). The prevalence of stunting was 35%, while wasting was only 1.3%. Low birth-weight and low body mass index of mothers were the strong predictors of stunting, whereas low birth-weight and iron-deficiency were the strong predictors of anaemia. The prevalence of malaria parasitaemia was high, affecting 50% of the infants. Having malaria was the only independent predictor associated with stunting, anaemia, and iron-deficiency. There is an urgent need to improve tradi-tional complementary foods in the studied community in terms of energy density, amount of fat in the diet, and bioavailability of macro and micronutrients.

Tuberculosis skin testing, anergy and protein malnutrition in Peru

SETTING

Malnutrition and intestinal parasites cause immunosuppression. This may cause false-negative tuberculin skin tests (TST) and failure to identify tuberculosis (TB) infection.

OBJECTIVE

To assess factors associated with TST positivity and anergy in disadvantaged communities in Peru.

DESIGN

A study of 212 randomly selected adults: 102 in a rural Amazonian village and 110 shanty town residents in urban Lima.

RESULTS

Respectively 52% and 53% of urban and rural jungle populations were TST-positive. Using simultaneous tetanus and candida skin tests, 99% had at least one positive skin test. Generalised anergy was therefore rare, despite frequent intestinal parasitic infection, including 34% helminth infection prevalence in the jungle. TST positivity was associated with age (P = 0.001), known TB contact (P = 0.02) and poor household ventilation (P = 0.007). TST positivity was not significantly associated with crowding, reported past TB, single/multiple BCG vaccination, income, intestinal parasites, dietary factors, body mass index or body fat. Individuals with lower anthropometric body protein, as measured by corrected arm muscle area, were less likely to be TST-positive (P = 0.02), implying that protein malnutrition caused tuberculin-specific anergy.

CONCLUSION

These results identify the importance of household ventilation for community TB transmission and add to the evidence that protein malnutrition suppresses TB immunity, causing false-negative TST results.

Bacterial isolates in severely malnourished children at Kenyatta National Hospital, Nairobi

OBJECTIVES

To identify bacterial isolates and determine antibiotic sensitivity pattern in children with severe Protein Energy Malnutrition (PEM) presenting at the Paediatric Filter Clinic (PFC) of Kenyatta National Hospital (KNH).

DESIGN

Hospital based cross-sectional survey.

SETTING

Paediatric Filter Clinic of Kenyatta National Hospital (KNH), a tertiary level teaching institution for the University of Nairobi, Kenya.

SUBJECTS

Children between two and sixty months presenting at the hospital outpatient filter clinic with severe malnutrition.

RESULTS

Ninety-one children, forty six female and forty five males, were recruited for the study. Of these, sixty had Marasmus, twenty Kwashiorkor and eleven Marasmic-Kwashiorkor. HIV serology was positive in 43% of study subjects. There were 30 bacterial isolates from 26 subjects. Ten bacterial isolates were gram positive and twenty gram negative. Isolation rates did not vary by HIV serological status. Twenty one out of the 30 isolates were from blood culture. About 1/3 of the gram positive isolates were coagulase negative staphylococci, largely resistant to commonly used antibiotics such as Erythromycin, Ampicillin, Cotrimoxazole, Chloramphenicol and even Oxacillin. More than half demonstrated resistance to commonly used oral antibiotics while 80% of all gram positive and negative isolates were sensitive to Ciprofloxacin. Aminoglycosides, Gentamicin and Amikacin, and third generation Cephalosporins, Ceftriaxone and Ceftazidime, were found to be effective against most gram-negative isolates.

CONCLUSION

Nearly a third (28.9%) of children admitted with severe malnutrition at KNH have concomitant severe bacterial infections; primarily manifesting as bacteraemia. Gram-negative agents are responsible for most severe bacterial infections in children admitted at the KNH, regardless of their HIV serological status. Whenever possible, blood culture should be included in the initial septic screening of severely malnourished children at KNH. In the absence of culture and sensitivity information, ciprofloxacin should be considered among the first line options in the empirical treatment of severe bacterial infections among these children. Clinical trials to further evaluate in-vivo effectiveness of various single or combination antibiotics are recommended.

Reverse epidemiology: a spurious hypothesis or a hardcore reality?

In maintenance hemodialysis (MHD) patients, associations between demographic, clinical and laboratory values and mortality, including cardiovascular death, are significantly different and, in some cases, in the opposite direction of those derived from the general population. This phenomenon, termed 'reverse epidemiology', is not limited to MHD patients but is also observed in populations that encompass an estimated 20 million Americans including those with an advanced age, heart failure, malignancies, and AIDS. A significant portion of this reversal may be due to the overwhelming effect of the malnutrition-inflammation complex syndrome (MICS). Since two thirds of MHD patients die within 5 years of initiation of dialysis treatment, traditional cardiovascular risk factors such as obesity, hypercholesterolemia and hypertension cannot exert a long-term deleterious impact, and instead, their short-term beneficial effects on MICS provides a survival advantage. In order to improve survival and quality of life in MHD patients, extrapolated ideal norms derived from the general population should be substituted with novel norms obtained from outcome-oriented epidemiologic analyses while accounting for the differential effect of MICS in different case-mix subgroups.

Comparison between handgrip strength, subjective global assessment, and prognostic nutritional index in assessing malnutrition and predicting clinical outcome in cirrhotic outpatients

OBJECTIVE

This study compared three methods of assessing malnutrition in cirrhotics and correlated nutritional status with clinical outcome.

METHODS

This cross-sectional study evaluated nutritional status by subjective global assessment (SGA), prognostic nutritional index (PNI), and handgrip strength (HG) in outpatients with cirrhosis (n = 50) and two control groups with hypertension (n = 46) and functional gastrointestinal disorders (n = 49). Patients with cirrhosis were followed for 1 y to verify the incidence of major complications, the need for transplantation, and death.

RESULTS

Among patients with cirrhosis, 88% were Child-Pugh A and only 12% were Child-Pugh B. Among these, prevalences of malnutrition were 28% by SGA, 18.7% by PNI, and 63% by HG (P < 0.05). HG, but not SGA or PNI, predicted a poorer clinical outcome in patients with cirrhosis because major complications such as uncontrolled ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, and hepatorenal syndrome developed in 65.5% of malnourished patients versus 11.8% of well-nourished ones (P < 0.05). No significant differences by any method were seen between the two groups regarding liver transplantation or death.

CONCLUSIONS

There was a high prevalence of malnutrition in cirrhotic outpatients, especially when assessed by HG, which was superior to SGA and PNI in this study. HG was the only technique that predicted a significant incidence of major complications in 1 y in undernourished cirrhotic patients.