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Taha M, Nael Maslamani A, Atef Abdelsattar Ibrahim H. The Predictive and Prognostic Value of Percentage Change in Calf Circumference in Infants and Children During the First Week of Admission in the Pediatric Intensive Care Unit: A Prospective Cohort Study. Clin Pediatr (Phila) 2024:99228241238631. [PMID: 38511639 DOI: 10.1177/00099228241238631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
Calf circumference (CC) is an easy measure of muscle loss; yet, there are limited studies in children. We aimed to assess the viability of the first-week percent change in CC as a prognostic nutritional marker. Two MUAC (mid-upper arm circumference), CC, and weight measurements were carried out: one on the first day of admission and another on the seventh day. The differences and correlations between their percent changes were examined. The possible association between CC percent change and prolonged length of hospital stay (PLOS) and in-hospital mortality was assessed. Seventy participants were enrolled with a median age of 19.5 months. The median (interquartile range [IQR]) of CC percent change was 0.54 (5.5) with significant correlations between it and each of MUAC and weight percent change (ρ = 0.928, P = .001), (ρ = 0.902, P = .001), respectively. Calf circumference percent changes were significantly more negative in children with PLOS; (P = .004). These changes seem to be viable measures of nutritional status.
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Affiliation(s)
- Marwa Taha
- Department of Pediatrics, Mataria Teaching Hospital, General Organization for Teaching Hospitals and Institutes (GOTHI), Cairo, Egypt
| | | | - Hoda Atef Abdelsattar Ibrahim
- Pediatric Clinical Nutrition Division, Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
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Yilmaz F, Aras MR, Ozturk H, Sahin HN, Gunes AK, Albayrak M. Are the GLIM Criteria Guiding in the Course of Hematological Malignancies? Niger J Clin Pract 2024; 27:338-344. [PMID: 38528354 DOI: 10.4103/njcp.njcp_572_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/21/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Different degrees of malnutrition are seen in patients with hematological malignancies. None of the approaches used to determine malnutrition risk have general acceptance. The use of the GLIM criteria developed by the Global Leadership Initiative on Malnutrition has promising results. MATERIALS AND METHODS A total of 67 patients with leukemia, lymphoma, and multiple myeloma were included in the study. NRS-2002 (Nutritional Risk Screening-2002) was used to screen the nutritional status of the patients, and malnutrition was diagnosed and graded using the GLIM criteria in patients who were found to be at risk of malnutrition in this test. The parameters followed in the groups with and without malnutrition were compared. The Kolmogorov-Smirnov, Mann-Whitney U, and Chi-square test were used for statistical analysis. RESULTS Patients were analyzed by dividing them into two groups as those with and without malnutrition. The presence of infection, duration of fever, antibiotic, and antifungal use were significantly higher in malnourished than in nonmalnourished patients. Platelet counts and sodium levels were significantly lower in the malnourished arm. CONCLUSION Early nutritional support can increase the immunological status of patients with malignant disorders as well as their tolerability to treatment. Minimizing the risk of malnutrition and providing timely calorie and vitamin support are factors that may directly affect febrile neutropenia, duration of fever, and antifungal use, which will consequently lead to a decrease in the length of hospitalization.
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Affiliation(s)
- F Yilmaz
- Department of Hematology, Etlik City Hospital, Ankara, Turkey
| | - M R Aras
- Department of Hematology, Etlik City Hospital, Ankara, Turkey
| | - Hba Ozturk
- Department of Hematology, Etlik City Hospital, Ankara, Turkey
| | - H N Sahin
- Department of İnternal Medicine, Etlik City Hospital, Ankara, Turkey
| | - A K Gunes
- Department of Hematology, Etlik City Hospital, Ankara, Turkey
| | - M Albayrak
- Department of Hematology, Etlik City Hospital, Ankara, Turkey
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Nunes G, Guimarães M, Coelho H, Carregosa R, Oliveira C, Pereira SS, Alves de Matos A, Fonseca J. Prolonged Fasting Induces Histological and Ultrastructural Changes in the Intestinal Mucosa That May Reduce Absorption and Revert after Enteral Refeeding. Nutrients 2023; 16:128. [PMID: 38201958 PMCID: PMC10780540 DOI: 10.3390/nu16010128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/23/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
Background: Malnutrition is usual in patients referred for endoscopic gastrostomy (PEG). Refeeding syndrome is rarely observed in PEG-fed patients, which could possibly be associated with reduced absorption induced by prolonged starvation. Objective: In patients submitted to PEG after a significant period of fasting, the present study aims to: 1. evaluate the histological/ultrastructural initial changes in the intestinal mucosa, potentially associated with reduced absorption, and 2. assess if these changes could reverse with enteral refeeding. Methods: The present study is an observational, prospective, controlled study. Adult patients with ingestion below 50% of daily needs for at least one month and/or diagnosis of malnutrition were enrolled. Duodenal biopsies were taken at baseline and after 3-6 months of PEG feeding, which then underwent histological/ultrastructural analysis. Random healthy individuals were used as controls. Results: A total of 30 patients (16 men/14 women) aged 67.1 ± 13.5 years were included. Malnutrition was found in 40% of patients. Approximately 14 patients completed follow-up during both periods (46.7%). At baseline: duodenal mucosal atrophy was evident in three patients (10%); the median villi length (MVL) was 0.4 mm (0.25-0.6 mm), with it being shorter than the controls, which was 0.6 mm (0.4-0.7 mm) (p = 0.006); ultrastructural changes included focal shortening, bending, and disruption of enterocyte microvilli, the presence of citoplasmatic autophagic vacuoles, dilation and vesiculation of the smooth endoplasmic reticulum, and the presence of dilated intercellular spaces with basement membrane detachment. After refeeding, most patients displayed normal histology (92.9%) and increase MVL (p < 0.001), ultrastructural changes disappeared, and enterocytes resumed a normal appearance, although retaining scarce, small, dense bodies in apical regions from the evolution of previous autophagy. Conclusions: Prolonged fasting induces histological and ultrastructural changes in the intestinal mucosa that may reflect impaired absorption in the early post-PEG period. These changes were reverted after refeeding with enteral nutrition.
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Affiliation(s)
- Gonçalo Nunes
- Gastroenterology Department, GENE—Artificial Feeding Team, Hospital Garcia de Orta, 2805-267 Almada, Portugal
- ICBAS-UP—Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, 4050-313 Porto, Portugal
- PaMNEC—Grupo de Patologia Médica, Nutrição e Estudos Clínicos, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health and Science, 2829-511 Almada, Portugal
| | - Marta Guimarães
- UMIB—Unit for Multidisciplinary Research in Biomedicine, ICBAS—School of Medicine and Biomedical Sciences, Universidade do Porto, Rua Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
- ITR—Laboratory of Integrative and Translocation Research in Population Health, Rua das Taipas 135, 4050-600 Porto, Portugal
| | - Hélder Coelho
- Pathology Department, Hospital Garcia de Orta, 2805-267 Almada, Portugal
| | - Ricardo Carregosa
- Cmicros—Centro de Microscopia Eletrónica e Histopatologia, CiiEM—Centro de Investigação Interdisciplinar Egas Moniz, 2829-511 Almada, Portugal
| | - Cátia Oliveira
- Gastroenterology Department, GENE—Artificial Feeding Team, Hospital Garcia de Orta, 2805-267 Almada, Portugal
| | - Sofia S. Pereira
- UMIB—Unit for Multidisciplinary Research in Biomedicine, ICBAS—School of Medicine and Biomedical Sciences, Universidade do Porto, Rua Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
- ITR—Laboratory of Integrative and Translocation Research in Population Health, Rua das Taipas 135, 4050-600 Porto, Portugal
| | - António Alves de Matos
- Cmicros—Centro de Microscopia Eletrónica e Histopatologia, CiiEM—Centro de Investigação Interdisciplinar Egas Moniz, 2829-511 Almada, Portugal
| | - Jorge Fonseca
- Gastroenterology Department, GENE—Artificial Feeding Team, Hospital Garcia de Orta, 2805-267 Almada, Portugal
- ICBAS-UP—Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, 4050-313 Porto, Portugal
- PaMNEC—Grupo de Patologia Médica, Nutrição e Estudos Clínicos, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health and Science, 2829-511 Almada, Portugal
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Zügül Y, van Rossum C, Visser M. Prevalence of Undernutrition in Community-Dwelling Older Adults in The Netherlands: Application of the SNAQ 65+ Screening Tool and GLIM Consensus Criteria. Nutrients 2023; 15:3917. [PMID: 37764702 PMCID: PMC10537760 DOI: 10.3390/nu15183917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
The aim of this study was to provide recent data on the prevalence of undernutrition based on screening and diagnosis in Dutch community-dwelling older adults. The data from the 2021 to 2022 examination wave from the Longitudinal Aging Study Amsterdam (n = 1138) and the Dutch National Food Consumption Survey 2019-2021 (n = 607) on community-dwelling men and women aged 65 years and older were used. The prevalence of undernutrition was based on a positive score on the Short Nutritional Assessment Questionnaire 65+ (SNAQ65+) screening tool, a positive diagnosis using the Global Leadership Initiative on Malnutrition (GLIM) criteria and their combination. Of the combined sample (n = 1745), the mean age was 74 (SD 6) years, where 16.7% were aged 80 years or older, 50.5% was female, 56.9% had a high education level, and 30.3% lived alone. The prevalence of undernutrition based on the SNAQ65+ screening in the combined sample was 8.5% (95% CI 7.3-9.9%). In the subgroup of LASA participants with complete data on all GLIM criteria (n = 700), the prevalence of undernutrition was 5.4% based on SNAQ65+ and 7.1% based on GLIM. A positive SNAQ65+ screening followed by a positive GLIM diagnosis resulted in a lower prevalence (3.1%). Being female, older, living alone, receiving formal home care, and having poor self-rated health, poor appetite, or mobility limitations, they were all associated with a higher prevalence, with more than two-fold higher prevalence rates in some subgroups. The results show that currently one out of twelve community-dwelling adults aged 65 years and older is undernourished based on the SNAQ65+ screening, and one out of fourteen is undernourished based on the GLIM diagnosis criteria. Awareness is needed to increase early recognition and treatment in community and primary care, especially among the more vulnerable groups.
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Affiliation(s)
- Yaren Zügül
- Department of Health Sciences, Faculty of Science, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Caroline van Rossum
- National Institute for Public Health and the Environment (RIVM), 3721 BA Bilthoven, The Netherlands;
| | - Marjolein Visser
- Department of Health Sciences, Faculty of Science, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
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Sousa-Catita D, Mascarenhas P, Oliveira C, Grunho M, Santos CA, Fonseca J. Nutrition and Outcome of 100 Endoscopic Gastrostomy-Fed Citizens with Severe Dementia. Nutrients 2023; 15:2753. [PMID: 37375659 DOI: 10.3390/nu15122753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Dementia is a rising public health concern. Feeding and nutritional problems increase as the disease progresses, affecting the clinical course and caregiver burden. While some guidelines advise against percutaneous endoscopic gastrostomy (PEG) and tube feeding in advanced dementia, conflicting evidence exists. This study aims to evaluate the nutritional status and influence of PEG feeding on the outcome and evolution of nutritional/prognosis markers of patients with severe dementia (PWSD) who underwent gastrostomy for nutritional support. We conducted a 16-year retrospective study on 100 PEG-fed PWSD with strong familial support. We evaluated the survival PEG-feeding period, safety, and objective nutritional/prognosis data on the gastrostomy day and after 3 months: Body Mass Index (BMI), Mid Upper Arm Circumference, Tricipital Skinfold, Mid-Arm Muscle Circumference, albumin, transferrin, total cholesterol, and hemoglobin. Most patients presented low values in these nutritional/prognosis parameters. No major life-threatening PEG complications were reported. The mean survival time after gastrostomy was 27.9 months (median of 17 months). Female sex, BMI recovery at 3 months, and higher baseline hemoglobin levels were associated with a reduced risk of death and increased survival time. The study concluded that, in carefully selected PWSD with strong familial support, PEG feeding can improve nutritional status and have a positive impact on survival.
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Affiliation(s)
- Diogo Sousa-Catita
- Grupo de Patologia Médica, Nutrição e Estudos Clínicos (PaMNEC) of Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, Caparica, 2829-511 Almada, Portugal
- GENE-Artificial Feeding Team, Gastroenterology Department, Hospital Garcia de Orta, 2805-267 Almada, Portugal
- Residências Montepio-Serviços de Saúde, SA-Rua Julieta Ferrão N° 10-5°, 1600-131 Lisboa, Portugal
| | - Paulo Mascarenhas
- Grupo de Patologia Médica, Nutrição e Estudos Clínicos (PaMNEC) of Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, Caparica, 2829-511 Almada, Portugal
| | - Cátia Oliveira
- GENE-Artificial Feeding Team, Gastroenterology Department, Hospital Garcia de Orta, 2805-267 Almada, Portugal
| | - Miguel Grunho
- Grupo de Patologia Médica, Nutrição e Estudos Clínicos (PaMNEC) of Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, Caparica, 2829-511 Almada, Portugal
- Neurology Department, Hospital Garcia de Orta, 2805-267 Almada, Portugal
| | - Carla Adriana Santos
- GENE-Artificial Feeding Team, Gastroenterology Department, Hospital Garcia de Orta, 2805-267 Almada, Portugal
| | - Jorge Fonseca
- Grupo de Patologia Médica, Nutrição e Estudos Clínicos (PaMNEC) of Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, Caparica, 2829-511 Almada, Portugal
- GENE-Artificial Feeding Team, Gastroenterology Department, Hospital Garcia de Orta, 2805-267 Almada, Portugal
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Malnutrition, Cancer Stage and Gastrostomy Timing as Markers of Poor Outcomes in Gastrostomy-Fed Head and Neck Cancer Patients. Nutrients 2023; 15:nu15030662. [PMID: 36771369 PMCID: PMC9919312 DOI: 10.3390/nu15030662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/21/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
For percutaneous endoscopic gastrostomy (PEG)-fed head and neck cancer (HNC) patients, risk markers of poor outcomes may identify those needing more intensive support. This retrospective study aimed to evaluate markers of poor outcomes using TNM-defined stages, initial anthropometry [body mass index (BMI), mid-upper arm circumference (MUAC), tricipital skinfold (TSF), mid-arm muscle circumference (MAMC)] and laboratory data (albumin, transferrin, cholesterol), with 138 patients, 42-94 years old, enrolled. The patients had cancer, most frequently in the larynx (n = 52), predominantly stage IV (n = 109). Stage IVc presented a four times greater death risk than stage I (OR 3.998). Most patients presented low parameters: low BMI (n = 76), MUAC (n = 114), TSF (n = 58), MAMC (n = 81), albumin (n = 47), transferrin (n = 93), and cholesterol (n = 53). In stages I, III, IVa, and IVb, MAMC and PEG-timing were major survival determinants. Each MAMC unit increase resulted in 16% death risk decrease. Additional 10 PEG-feeding days resulted in 1% mortality decrease. Comparing IVa/IVb vs. IVc, albumin and transferrin presented significant differences (p = 0.042; p = 0.008). All parameters decreased as severity of stages increased. HNC patients were malnourished before PEG, with advanced cancer stages, and poor outcomes. Initial MAMC, reflecting lean tissue, significantly increases survival time, highlighting the importance of preserving muscle mass. PEG duration correlated positively with increased survival, lowering death risk by 1% for every additional 10 PEG-feeding days, signaling the need for early gastrostomy.
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Aydın K, Dalgıç B, Kansu A, Özen H, Selimoğlu MA, Tekgül H, Ünay B, Yüce A. The significance of MUAC z-scores in diagnosing pediatric malnutrition: A scoping review with special emphasis on neurologically disabled children. Front Pediatr 2023; 11:1081139. [PMID: 36950173 PMCID: PMC10025394 DOI: 10.3389/fped.2023.1081139] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 02/16/2023] [Indexed: 03/24/2023] Open
Abstract
This review by a panel of pediatric gastroenterology-hepatology-nutrition and pediatric neurology experts aimed to address the significance of mid-upper arm circumference (MUAC) assessment in diagnosis of pediatric malnutrition. Specifically, the potential utility of recently developed MUAC z-score tape in clinical practice for larger patient populations was addressed including the neurologically disabled children. In accordance with the evidence-based data, four statements were identified by the participating experts on the utility of MUAC z-score tape, including (1) MUAC z-scores correlate with body mass index (BMI) and weight for height/length (WFH/l) z-scores in diagnosing malnutrition; (2) MUAC z-score tape offers a higher sensitivity to diagnose the mild and moderate malnutrition and better ability to track the changes in nutritional status over time than the other single datapoint measurements; (3) Using single-step MUAC z-score tape in children with cerebral palsy (CP) seems to provide more reliable data on anthropometry; and (4) The clinical value of the tool in classifying secondary malnutrition in CP should be investigated in large-scale populations. In conclusion, enabling single-step estimation of nutritional status in a large-scale pediatric population regardless of age and within a wide range of weight, without formal training or the need for ancillary reference charts and calculators, MUAC z-tape offers a favorable tool for easier and earlier diagnosis of pediatric malnutrition. Nonetheless, further implementation of MUAC z-score screening in larger-scale and/or special populations is necessary to justify its utility in relation to other primary anthropometric indicators in diagnosis of malnutrition as well as in treatment monitoring in the community and hospital setting.
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Affiliation(s)
- Kürşad Aydın
- Department of Pediatric Neurology, Medipol University Faculty of Medicine, Istanbul, Türkiye
| | - Buket Dalgıç
- Department of Pediatric Gastroenterology, Gazi University Faculty of Medicine, Ankara, Türkiye
| | - Aydan Kansu
- Department of Pediatric Gastroenterology, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Hasan Özen
- Department of Pediatric Gastroenterology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
- Correspondence: Hasan Özen
| | - Mukadder Ayşe Selimoğlu
- Department of Pediatric Gastroenterology, Memorial Atasehir and Bahcelievler Hospitals, Istanbul, Türkiye
| | - Hasan Tekgül
- Department of Pediatric Neurology, Ege University Faculty of Medicine, Izmir, Türkiye
| | - Bülent Ünay
- Department of Pediatric Neurology, Gulhane Faculty of Medicine, Ankara, Türkiye
| | - Aysel Yüce
- Department of Pediatric Gastroenterology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
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Musa IR, Omar SM, Adam I. Mid-upper arm circumference as a substitute for body mass index in the assessment of nutritional status among adults in eastern Sudan. BMC Public Health 2022; 22:2056. [PMID: 36357916 PMCID: PMC9650816 DOI: 10.1186/s12889-022-14536-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022] Open
Abstract
Background Body mass index (BMI) remains the most used indicator of nutritional status despite the presence of a potentially credible alternative. Mid-upper arm circumference (MUAC) is an anthropometric measure that requires simple equipment and minimal training. The aim of this study was to compare MUAC with BMI and propose a MUAC cut-off point corresponding to a BMI of < 18.5 kg/m2 (underweight) and ≥ 30.0 kg/m2 (obesity) among Sudanese adults. Methods A cross-sectional study using multistage cluster sampling was conducted in New-Halfa, eastern Sudan. Participants’ age and sex were recorded and their MUAC, weight and height were measured using the standard procedures. The MUAC (cm) cut-offs corresponding to < 18.5 kg/m2 and ≥ 30.0 kg/m2 were calculated and determined using receiver operating characteristic (ROC) curve analysis Results Five hundreds and fifty-two adults were enrolled in the study. The median (interquartile range, IQR) of the participants age was 31.0 (24.0 – 40.0) years and 331 (60.0%) of them were females. The medians (IQR) of BMI and MUAC were 22.4 (19.1 – 26.3) kg/m2 and 25.0 (23.0 – 28.0) cm, respectively. There was a significant positive correlation between MUAC and BMI (r = 0.673, p < 0.001). Of the 552 enrolled participants, 104 (18.8%), 282 (51.1%), 89 (16.1%) and 77 (13.9%) were normal weight, underweight, overweight and obese, respectively. Best statistically derived MUAC cut-off corresponding to a BMI < 18.5 kg/m2 (underweight) was ≤ 25.5 cm in both males and females (Youden’s Index, YI = 0.51; sensitivity = 96.0%; specificity = 54.0%), with a good predictive value (AUROCC = 0.82). Best statistically derived MUAC cut-off corresponding to a BMI ≥ 30.0 kg/m2 (obesity) was ≥ 29.5 cm in both males and females (YI = 0.62, sensitivity = 70.3%, specificity = 92.0%), with a good predictive value (AUROCC = 0.86, 95.0% CI = 0.76 – 0.95). Conclusion The results suggest that the cut-offs based on MUAC can be used for community-based screening of underweight and obesity
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Dereje R, Girma A, Molla A, Simieneh A. Mid upper arm circumference as screening tool of overweight or obesity among adult employees of Mizan Tepi University, Southwest Ethiopia. Heliyon 2022; 8:e10793. [PMID: 36211995 PMCID: PMC9535271 DOI: 10.1016/j.heliyon.2022.e10793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 01/14/2022] [Accepted: 09/21/2022] [Indexed: 12/04/2022] Open
Abstract
Background Overweight or obesity is an excessive fat accumulation that impairs the health and wellbeing of the adult population throughout the world. Recently Mid upper arm circumference (MUAC) was suggested as a screening index for overweight or obesity among adolescents, but its utilization for the assessment of overweight or obesity in the adult population is not clear yet. In addition, little is known about the screening ability of MUAC for overweight or obesity in the adult population of Ethiopia. Therefore, this study aimed to evaluate the utility of MUAC for screening overweight or obesity among adult employees of Mizan Tepi University, Southwest Ethiopia. Method A Facility -based cross-sectional study was carried out from February 21 to March 20, 2020, at Mizan Tepi University. About 585 study participants were selected by gender-based stratified sampling technique. Anthropometric data like weight, height, and MUAC were collected. Pearson's correlation between MUAC, body mass index (BMI), and age was calculated to see a relationship between them. The Receiver operating characteristics (ROC) curve was calculated to identify the screening ability of MUAC for overweight or obesity. The appropriate MUAC cutoff point for both men and women established using the Youden index. Additionally, sensitivity, specificity, positive, and negative predictive values were calculated. Result The prevalence of overweight and obesity among the study participants was 18.1% and 4.8%, respectively. MUAC had a strong positive correlation with BMI, r = 0.65 (95% CI; 0.56–0.69). According to ROC analysis, MUAC is an excellent screening tool for male and female employees with excellent accuracy (AUC = 0.9 with 91.4% sensitivity and 76.4% specificity) and good accuracy (AUC = 0.83 with 67.2% sensitivity and 83.5% specificity), respectively. Based on the youden index, the cutoff point of MUAC to screen overweight or obesity among male and female employees was 26.91cm. Conclusion Mid-upper arm circumference (MUAC) has an equal ability with BMI to screen overweight or obesity among adults. Therefore, MUAC can be utilized as an alternative index to screen overweight and obesity in resource-limited setups.
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Sousa-Catita D, Godinho C, Mascarenhas P, Quaresma F, Fonseca J. The Effects of an Intensive Rehabilitation Program on the Nutritional and Functional Status of Post-COVID-19 Pneumonia Patients. Nutrients 2022; 14:nu14122501. [PMID: 35745230 PMCID: PMC9230983 DOI: 10.3390/nu14122501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/10/2022] [Accepted: 06/14/2022] [Indexed: 11/27/2022] Open
Abstract
Most hospitalized COVID-19 pneumonia patients are older adults and/or have nutrition-related issues. Many are bedridden in intensive care units (ICU), a well-documented cause of malnutrition, muscle wasting, and functional impairment. Objectives: To assess the effectiveness of an intensive rehabilitation program over the nutritional/functional status of patients recovering from COVID-19 pneumonia. Post-COVID-19 pneumonia patients underwent a 30-day intensive interdisciplinary rehabilitation program including a personalized nutritional intervention designed to achieve a minimum intake of 30 kcal/kg/day and 1 g protein/kg/day. The nutritional and functional status was assessed in each patient at three different moments. Each assessment included Body Mass Index (BMI), Mid Upper Arm Circumference (MUAC), Mid Arm Muscle Circumference (MAMC), Tricipital Skinfold (TSF), Hand Grip Strength (HGS), and Mini Nutritional Assessment (MNA®). The study included 118 patients, with ages in the range 41−90 years old. BMI increased linearly over time (0.642 units, F-test = 26.458, p < 0.001). MUAC (0.322 units, F-test = 0.515, p = 0.474) and MAMC status (F-test = 1.089, p = 0.299) improved slightly, whereas TSF decreased (F-test = 1.885, p = 0.172), but all these arm anthropometry trends did not show significant variations, while HGS (4.131 units, F-test = 82.540, p < 0.001) and MNA® (1.483 units, F-test = 217.726, p < 0.001) reported a meaningful improvement. Post-COVID-19 pneumonia patients presented malnutrition and functional impairment. An interdisciplinary rehabilitation program, including personalized nutritional intervention, was effective for post-hospital COVID-19 pneumonia nutritional/functional rehabilitation.
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Affiliation(s)
- Diogo Sousa-Catita
- Grupo de Patologia Médica, Nutrição e Exercício Clínico (PaMNEC) do Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), 2829-511 Almada, Portugal; (C.G.); (P.M.); (J.F.)
- GENE—Artificial Feeding Team, Gastroenterology Department, Hospital Garcia de Orta, 2805-267 Almada, Portugal
- Residências Montepio—Serviços de Saúde, SA, 1600-131 Lisboa, Portugal;
- Correspondence:
| | - Catarina Godinho
- Grupo de Patologia Médica, Nutrição e Exercício Clínico (PaMNEC) do Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), 2829-511 Almada, Portugal; (C.G.); (P.M.); (J.F.)
| | - Paulo Mascarenhas
- Grupo de Patologia Médica, Nutrição e Exercício Clínico (PaMNEC) do Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), 2829-511 Almada, Portugal; (C.G.); (P.M.); (J.F.)
| | - Filipa Quaresma
- Residências Montepio—Serviços de Saúde, SA, 1600-131 Lisboa, Portugal;
| | - Jorge Fonseca
- Grupo de Patologia Médica, Nutrição e Exercício Clínico (PaMNEC) do Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), 2829-511 Almada, Portugal; (C.G.); (P.M.); (J.F.)
- GENE—Artificial Feeding Team, Gastroenterology Department, Hospital Garcia de Orta, 2805-267 Almada, Portugal
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Northuis CA, Murray TA, Lutsey PL, Butler KR, Nguyen S, Palta P, Lakshminarayan K. Body mass index prediction rule for mid-upper arm circumference: the atherosclerosis risk in communities study. Blood Press Monit 2022; 27:50-54. [PMID: 34534134 PMCID: PMC8734618 DOI: 10.1097/mbp.0000000000000567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/10/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Electronic health records (EHR) are a convenient data source for clinical trial recruitment and allow for inexpensive participant screening. However, EHR may lack pertinent screening variables. One strategy is to identify surrogate EHR variables which can predict the screening variable of interest. In this article, we use BMI to develop a prediction rule for arm circumference using data from the Atherosclerosis Risk in Communities (ARIC) Study. This work applies to EHR patient screening for clinical trials of hypertension. METHODS We included 11 585 participants aged 52-75 years with BMI and arm circumference measured at ARIC follow-up visit 4 (1996-1998). We selected the following arm circumference cutpoints based on the American Heart Association recommendations for blood pressure (BP) cuffs: small adult (≤26 cm), adult (≤34 cm) and large adult (≤44 cm). We calculated the sensitivity and specificity of BMI values for predicting arm circumference using receiver operating characteristic curves. We report the BMI threshold that maximized Youden's Index for each arm circumference upper limit of a BP cuff. RESULTS Participants' mean BMI and arm circumference were 28.8 ± 5.6 kg/m2 and 33.4 ± 4.3 cm, respectively. The BMI-arm circumference Pearson's correlation coefficient was 0.86. The BMI threshold for arm circumference≤26 cm was 23.0 kg/m2, arm circumference≤34 cm was 29.2 kg/m2 and arm circumference≤44 cm was 37.4 kg/m2. Only the BMI threshold for arm circumference≤34 cm varied significantly by sex. CONCLUSIONS BMI predicts arm circumference with high sensitivity and specificity and can be an accurate surrogate variable for arm circumference. These findings are useful for participant screening for hypertension trials. Providers can use this information to counsel patients on appropriate cuff size for BP self-monitoring.
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Affiliation(s)
- Carin A. Northuis
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota
| | - Thomas A. Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Pamela L. Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota
| | - Kenneth R. Butler
- Department of Medicine, University of Mississippi Medical Center, University of Mississippi, Jackson, Mississippi
| | - Steve Nguyen
- Division of Epidemiology, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, California
| | - Priya Palta
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, Columbia University, New York, USA
| | - Kamakshi Lakshminarayan
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota
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12
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The Cutoff Point of Mid–Upper Arm Circumference in the Supine Position to Detect Malnutrition in Patients with Cancer. TOP CLIN NUTR 2022. [DOI: 10.1097/tin.0000000000000271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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13
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Risk factors for malnutrition among hospitalized gastroenterological patients. VOJNOSANIT PREGL 2022. [DOI: 10.2298/vsp200605085r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background/Aim. Risk factors for malnutrition of patients during hospitalization have not been precisely deter-mined. The aim of the study was to determine these factors in hospitalized gastroenterological patients. Methods. Nutritional status (NS) of 650 gastroenterological patients was assessed at the hospital admission and at discharge by the six parameters: unintentional weight loss, lymphocyte count, serum albumin concentration, body mass index, triceps skinfold thickness, and mid-upper arm muscle circumference. The influence on NS at discharge was tested for ten factors: gender, age, affected organ, the nature, severity, and complications of the disease, the length of hospitalization, mobility worsening during hospitalization, Karnofsky score, and NS on admission. Primary and secondary risk factors were defined among the factors significantly influencing malnutrition. Results. Seven factors were found to be the independent predictors for malnutrition in hospitalized gastroenterological patients. NS at admission was considered as a primary risk factor (Forward: Wald multivariate logistic regression analysis, p < 0.001 for five applied assessment parameters). The other six factors, obtained in the evaluation according to 1-3 assessment parameters, were considered as secondary risk factors: severe disease activity, malignancy, the existence of complications, male gender, hospitalization > 14 days, and mobility worsening during the hospitalization (Forward: Wald multivariate logistic regression analysis, p from 0.001 to 0.027). Conclusion. There are seven risk factors for malnutrition among gastroenterological patients during hospitalization. Timely nutritional support in these patients can prevent the development of intrahospital malnutrition and its negative influence on the clinical outcome.
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Abstract
Introduction Introduction: persistent dysphagia affects 15 % of stroke patients and contributes to malnutrition, aspiration, and death. This study aimed to characterize patients with post-stroke dysphagia who underwent percutaneous endoscopic gastrostomy (PEG), and to assess the impact of PEG feeding on nutritional status and outcome. Methods: an observational and retrospective study using records from patients with post-stroke dysphagia who underwent PEG. Body mass index (BMI), serum albumin, transferrin, and cholesterol were recorded at the time of PEG insertion (T0) and 3 months later (T3). The evolution of these parameters was analyzed and compared to survival. Results: we obtained data from 158 patients (53.2 % males) with a median age of 75 years. Most strokes were ischemic (n = 135, 85.4 %). Median time between stroke and PEG was 2 months. Median survival after gastrostomy was 16 months. At admission, 41.6 % of patients had low BMI, 62.3 % low albumin, 68.6 % low transferrin, and 59.6 % low cholesterol levels. The prevalence of low albumin and low transferrin was higher in the patients who underwent PEG more than 2 months after stroke. A significant increase in albumin and transferrin, and a normalization of cholesterol levels was observed after 3 months of PEG feeding. Mortality was 12.9 %, 27.7 %, and 40 % at 1, 3, and 12 months, respectively. Survival was lower in patients with low albumin, transferrin or total cholesterol at admission. Conclusions: the prevalence of malnutrition is high among patients with post-stroke dysphagia. PEG feeding improves albumin, transferrin, and cholesterol levels. Early post-PEG mortality is high and must be considered on an individual basis.
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Association of Household Food Insecurity with Nutritional Status and Mental Health of Pregnant Women in Rural Bangladesh. Nutrients 2021; 13:nu13124303. [PMID: 34959855 PMCID: PMC8708397 DOI: 10.3390/nu13124303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/24/2021] [Accepted: 11/24/2021] [Indexed: 11/30/2022] Open
Abstract
Food insecurity may affect women’s health; however, pertinent research is scant among pregnant women. This study investigated the association of household food insecurity (HFI) with the nutritional status and mental health of 672 early-gestation (5–16 weeks) pregnant women with a singleton fetus, who participated in the screening activity of a community-based trial (NCT04868669) in Matlab, Bangladesh. Height (cm), weight (kg), body mass index (kg/m2), mid-upper arm circumference (MUAC) (cm), depression, anxiety, and stress were the outcomes studied. HFI was assessed using the Household Food Insecurity Access Scale. Women’s depression, anxiety, and stress were assessed using the Depression, Anxiety, and Stress Scales-21. Propensity score matching based weighted multivariable linear and logistic regression were used to evaluate the independent association of HFI with the outcomes. In adjusted models, pregnant women from food-insecure households in rural Matlab were on average 2.0 cm shorter (β = −2.0, 95% CI: −3.3, −0.7), 2.0 kg lighter (β = −2.0, 95% CI: −3.4, −0.7), and had 0.6 cm lower MUAC (β = −0.6, 95% CI: −1.1, −0.1) than their food-secure counterparts. HFI was associated with higher odds of depression (OR = 3.3, 95% CI: 1.8, 5.9), anxiety (OR = 6.1, 95% CI: 3.7, 10.0), and stress (OR = 4.8, 95% CI: 1.6, 14.2) among the women. Public health measures should focus on ensuring proper nutrition during the critical growth periods of life, pregnancy, and external environmental shocks, to mitigate the adverse effects of HFI on women’s health.
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16
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Graeb F, Wolke R. Malnutrition and Inadequate Eating Behaviour during Hospital Stay in Geriatrics-An Explorative Analyses of NutritionDay Data in Two Hospitals. NURSING REPORTS 2021; 11:929-941. [PMID: 34968279 PMCID: PMC8715451 DOI: 10.3390/nursrep11040085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/12/2021] [Accepted: 11/12/2021] [Indexed: 12/16/2022] Open
Abstract
(1) Background: Malnutrition in hospitalized patients is prevalent worldwide, but the severity of the issue is often underestimated by practitioners. The purpose of this study is to investigate the prevalence of malnutrition and inadequate eating behaviour in a geriatric sample. (2) Methods: Two hospitals participated with six wards on nutritionDay in 2017, 2018 and 2019. Nutritional status, food intake, and nutritional interventions were analyzed for all patients ≥ 65 years (n = 156), using the official nutritionDay questionnaires. Malnutrition risk is identified by Malnutrition Universal Screening Tool (MUST), malnutrition by the ESPEN criteria (European Society of Clinical Nutrition and Metabolism). (3) Results: According to MUST (n = 136) 16.9% (n = 23) were at medium risk of malnutrition, 33.8% (n = 46) at high risk of malnutrition, 28.1% (n = 38) were malnourished. Overall, 62.8% (n = 98) showed an inadequate eating behaviour during hospital stay. Moreover, patients with inadequate nutrition had significantly worse self-reported health statuses (p = 0.001; r = -0.276), were less able to walk on nutritionDay (p = 0.002; r = -0.255), had eaten little in the week before admission to hospital (p < 0.001; r = -0.313), and had an increased length of stay (p = 0.036; r = -0.174). (4) Conclusion: To identify malnourished patients is a significant barrier for practitioners seeking to administer specific, tailored interventions. Malnutrition screening protocols must be improved, just as nutrition monitoring in general.
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Does sarcopenia affect outcomes in pediatric surgical patients? A scoping review. J Pediatr Surg 2021; 56:2099-2106. [PMID: 33500162 DOI: 10.1016/j.jpedsurg.2021.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/06/2020] [Accepted: 01/08/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Adults with sarcopenia have a greater risk of postoperative complications, a higher rate of ICU admission, and an increased length of hospital stay. Few studies have explored the prevalence or importance of sarcopenia in the pediatric population. This study reviews the published literature on sarcopenia in the pediatric population, including pediatric surgery. METHODS Original studies related to sarcopenia in children were identified using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines and the PubMed database. RESULTS A total of 390 articles were screened, with 28 meeting inclusion criteria. Twenty (71%) studies provided a means to define abnormal and 18 studies (64%) showed that a specific disease process could impact lean muscle mass in children. Only 4 (14%) studies associated the change in muscle mass with an outcome. Two studies investigated sarcopenia and outcomes in the pediatric surgical patient and demonstrated associations with worse outcomes. CONCLUSION Despite studies showing an association between sarcopenia and negative outcomes in the adult surgical population, there remains a paucity of evidence regarding the impact of sarcopenia on the pediatric population. Future studies are needed to ascertain the relationship between muscle mass and outcomes in pediatric surgical patients.
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18
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Vieira RR, de Campos MMS, Zamberlan P, Viani K. Can calf circumference be a viable option for nutritional assessment in the PICU? Clin Nutr ESPEN 2021; 45:356-362. [PMID: 34620340 DOI: 10.1016/j.clnesp.2021.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/21/2021] [Accepted: 07/23/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Children admitted to paediatric intensive care units (PICUs) often need specialised nutritional intervention. Nutritional assessments provide specific data to support such interventions. Body composition measures, such as mid-upper arm circumference (MUAC), can complement nutritional assessment. However, MUAC has limitations. Calf circumference (CC) is an easy and common measure of muscle loss in the elderly; however, there are still very few studies on CC in children. AIMS To evaluate the viability of using CC for nutritional monitoring of children under intensive care, compared with MUAC and weight. METHODS Patients aged 2-10 years admitted to the PICU between December 2018 and August 2019 were included in the study. Two MUAC, CC, and weight measurements were performed: one in the first 24 h after PICU admission and another after 7 days. As there are no reference values for CC in children, this measure was used solely to observe the patient's individual progress. The nutritional status, both according to body mass index and MUAC, was used to characterise samples. Percentage changes in these measures were compared using the Wilcoxon signed-rank test for comparison between medians and Spearman's correlation test. Information from medical records regarding hospitalisation was also collected and analysed. RESULTS Thirty patients were included in the study. During hospitalisation week 1, CC decreased significantly (p = 0.001), whereas MUAC (p = 0.427) and weight (p = 0.315) did not change significantly. Percentage changes in CC and MUAC were statistically different (p = 0.0449), with a positive correlation between the changes in both measures (p = 0.0333; r = 0.3896); conversely, although the percentage changes in CC and weight significantly differed (p = 0.0066), no correlation was found between them (p = 0.9382; r = 0.0148). The percentage changes in MUAC and weight were not different (p = 0.1880) or correlated (p = 0.1691; r = 0.2577). No statistically significant relationship was found between percentage changes in CC and clinical outcomes (length of stay, fasting time, and mechanical ventilation time). CONCLUSIONS CC appears to be a viable measure for use in PICUs. Although positively correlated with MUAC, a measure proven useful in critically ill children, CC decreased significantly in the first week of intensive care, whereas MUAC remained unchanged, indicating that CC may show signs of depletion earlier than MUAC in these patients. Our study reinforces the importance of alternative measures for anthropometric assessment of critically ill children.
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Affiliation(s)
- Rafaela Rodrigues Vieira
- Instituto da Criança do Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil.
| | | | - Patrícia Zamberlan
- Instituto da Criança do Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil.
| | - Karina Viani
- ITACI - Haematology-Oncology Department of Instituto da Criança do Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil.
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19
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Hiruy AF, Opoku S, Xiong Q, Jin Q, Zhao J, Lin X, He S, Zuo X, Ying C. Nutritional predictors associated with malnutrition in continuous ambulatory peritoneal dialysis patients. Clin Nutr ESPEN 2021; 45:454-461. [PMID: 34620355 DOI: 10.1016/j.clnesp.2021.06.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/15/2021] [Accepted: 06/26/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Currently in China, out of the total dialysis population, approximately 20% represents continuous ambulatory peritoneal dialysis (CAPD) and almost half of CAPD patients was affected by malnutrition. This study aimed to investigate the association between nutritional predictors and malnutrition with 5.1 years of dialysis according to the subjective global assessment (SGA) in continuous ambulatory peritoneal dialysis (CAPD) patients. METHODS A cross-sectional study was conducted from April 2013 to May 2018 and included 70 CAPD patients. The relationship between anthropometric and biochemical parameters with malnutrition was assessed by multiple logistic regression analysis. RESULTS The prevalence of malnutrition in CAPD patients was 52.9%. Our result revealed a 7.05-fold increased odds of malnutrition for patients with protein equivalent of total nitrogen appearance normalized to body weight (nPNA) < 1.0 g/kg per day (d) versus patients with normal nPNA (confidence interval (CI) 1.33-37.34; p < 0.05). Patients whose normalized protein catabolic rate (nPCR) was <1.2 g/(kg/d) had a significant positive association with malnutrition versus patients with normal nPCR (adjusted odds ratio (OR) 7.99; p < 0.05). Patients with dietary protein intake (DPI) < 1.0 g/(kg/d) had a higher likelihood of malnutrition than those with normal DPI (OR 12.73; p < 0.05). CAPD patients with upper arm circumference (UAC) < 23.2 cm had a high risk of malnutrition versus patients with normal UAC (OR 12.99; p < 0.05). CONCLUSIONS Our study suggested a close association between nPNA, DPI, nPCR, and UAC and malnutrition in CAPD patients. Further studies can be warranted the use of these variables as predictors and a malnutrition consequence among Chinese CAPD patients.
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Affiliation(s)
- Aschalew Fikru Hiruy
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan, 430030, Hubei, China.
| | - Sampson Opoku
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan, 430030, Hubei, China.
| | - Qianqian Xiong
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan, 430030, Hubei, China.
| | - Qiman Jin
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan, 430030, Hubei, China.
| | - Jing Zhao
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan, 430030, Hubei, China.
| | - Xuechun Lin
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan, 430030, Hubei, China.
| | - Shuiqing He
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan, 430030, Hubei, China.
| | - Xuezhi Zuo
- Department of Clinical Nutrition, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
| | - Chenjiang Ying
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan, 430030, Hubei, China; Ministry of Education Key Lab of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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20
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Dos Santos Rd CO, Burgel CF, Chites Rd VS, Lima Rd J, Silva PhD FM. Low-cost and fast-performing indicators of muscle mass loss are good predictors of clinical outcomes in hospitalized patients: A longitudinal observational study. JPEN J Parenter Enteral Nutr 2021; 46:887-895. [PMID: 34599842 DOI: 10.1002/jpen.2268] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND "Gold standard" methods for muscle mass (MM) assessment are expensive and difficult to use in clinical practice. The present study aimed to evaluate the association between easy-to-apply and low-cost indicators of MM and clinical outcomes in hospitalized patients. METHODS In this cohort study, calf circumference [CC], adductor pollicis muscle thickness [APMT], midarm muscle circumference [MAMC], and arm muscle area [AMA] were measured within 48 h of admission to detect MM loss, and it was also evaluated by physical examination. Patients were followed up until discharge for collection of in-hospital death and length of hospital stay (LOS) data, and they were contacted by phone to assess hospital readmission and mortality at 6 months after discharge. RESULTS We evaluated 601 patients (55.8 ± 14.8 years). Moderate/severe loss of MM (hazard ratio [HR], 4.12; 95% CI, 1.26-13.49), low CC (HR, 3.67; 95% CI: 1.07-12.55), low MAMC (HR, 5.20; 95% CI, 1.48-18.35), and low AMA (HR, 14.28; 95% CI, 1.80-113.14) were predictors of in-hospital mortality. Moderate/severe loss of MM was a predictor of prolonged LOS (odds ratio [OR], 2.27; 95% CI, 1.53-3.36), hospital readmission (OR, 4.14; 95% CI, 1.26-13.55), and mortality at 6 months (OR, 3.20; 95% CI, 1.71-6.01). Low CC (OR, 2.49; 95% CI, 1.27-4.85) and low APMT (OR, 3.22; 95% CI, 1.56-6.66) were associated with death 6 months after discharge. CONCLUSION Easy-to-apply and low-cost indicators of MM were associated with negative clinical outcomes and should be part of nutrition assessment in hospitals.
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Affiliation(s)
| | | | - Victoria Silva Chites Rd
- Endocrinology Postgraduation Program, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Júlia Lima Rd
- Porto Alegre Federal University of Health Sciences, Porto Alegre, Brazil
| | - Flávia Moraes Silva PhD
- Department of Nutrition, Porto Alegre Federal University of Health Sciences, Porto Alegre, Brazil.,Postgraduation Program in Nutrition Science, Porto Alegre Federal University of Health Sciences, Porto Alegre, Brazil
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21
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Validating mid-upper arm circumference (MUAC) cut off points as an indicator of nutritional status among nine tribal populations of India. ANTHROPOLOGICAL REVIEW 2021. [DOI: 10.2478/anre-2021-0018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Mid-upper arm circumference (MUAC) is an alternative anthropometric measurement to assess undernutrition but a universally accepted cut-off is yet to be established. The objectives of the present study are to determine whether the proposed sex-specific global cut-offs are suitable across several tribes in India. This cross-sectional study was conducted among nine tribal populations in India (1046 males, 1087 females). Weight, height and MUAC values were obtained, and body mass index (BMI) was calculated. The BMI cut-off (<18.5 kg/m2) was used to determine chronic energy deficiency (CED). The ROC Curve analyses of binomial logistic regression for MUAC versus CED revealed optimal cut-off point of MUAC as 23.8 cm (in males) and 21.8 cm (in females). MUAC cut-offs were similar in females, relative to males, in all tribes. Males with MUAC<24cm and females with MUAC<22 encompassed significantly higher numbers of CED than those with MUAC≥24 and ≥22 cm, respectively (χ2-value males: 254.9, p<0.001; females: 493.60, p<0.01). A single cut off point of MUAC may not be universally applicable for diverse populations and both sexes as well. It seemed that there is no alternative than to undertake further validation studies in various populations before using the MUAC cut off to identify undernourished or CED condition.
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Philpott DCE, Belchior-Bellino V, Ververs M. Use of mid-upper arm circumference to screen for thinness among sub-Saharan African male detainees. Public Health Nutr 2021; 24:4777-4785. [PMID: 34247695 PMCID: PMC11082798 DOI: 10.1017/s1368980021002913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 05/24/2021] [Accepted: 07/07/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE BMI is a time-intensive measurement to assess nutritional status. Mid-upper arm circumference (MUAC) has been studied as a proxy for BMI in adults, but there is no consensus on its optimal use. DESIGN We calculated sensitivity, specificity and area under receiver operating characteristic curve (AUROCC) of MUAC for BMI < 18·5, <17 and <16 kg/m2. We designed a system using two MUAC cut-offs, with a healthy (non-thin) 'green' group, a 'yellow' group requiring BMI measurement and a 'red' group who could proceed directly to treatment for thinness. SETTING We retrospectively analysed monitoring data collected by the International Committee of the Red Cross in places of detention. PARTICIPANTS 11 917 male detainees in eight African countries. RESULTS MUAC had excellent discriminatory ability with AUROCC: 0·87, 0·90 and 0·92 for BMI < 18·5, BMI < 17 and BMI < 16 kg/m2, respectively. An upper cut-off of MUAC 25·5 cm to exclude healthy detainees would result in 64 % fewer detainees requiring BMI screening and had sensitivity 77 % (95 % CI 69·4, 84·7) and specificity 79·6 % (95 % CI 72·6, 86·5) for BMI < 18·5 kg/m2. A lower cut-off of MUAC < 21·0 cm had sensitivity 25·4 % (95 % CI 11·7, 39·1) and specificity 99·0 % (95 % CI 97·9, 100·0) for BMI < 16 kg/m2. An additional 50 kg weight requirement improved specificity to 99·6 % (95 % CI 99·0, 100·0) with similar sensitivity. CONCLUSIONS A MUAC cut-off of 25·5 cm, above which detainees are classified as healthy and below receive further screening, would result in significant time savings. A cut-off of <21·0 cm and weight <50 kg can identify some detainees with BMI < 16 kg/m2 who require immediate treatment.
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Affiliation(s)
- David CE Philpott
- Johns Hopkins Children’s Center, 1800
Orleans Street, Room 8453, Baltimore, MD21287, USA
| | | | - Mija Ververs
- Centers for Disease Control and Prevention, Center for Global
Health, Division of Global Health Protection, Emergency Response and Recovery
Branch, Atlanta, USA
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Russell LA, Balart MT, Serrano P, Armstrong D, Pinto-Sanchez MI. The complexities of approaching nutrition in inflammatory bowel disease: current recommendations and future directions. Nutr Rev 2021; 80:215-229. [PMID: 34131736 DOI: 10.1093/nutrit/nuab015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 02/03/2021] [Accepted: 02/23/2021] [Indexed: 12/18/2022] Open
Abstract
Inflammatory bowel diseases (IBDs), including Crohn's disease and ulcerative colitis predispose patients to malnutrition due to a combination of increased basal metabolic rate, decreased oral intake, and increased nutritional losses and malabsorption. Malnutrition is common, affecting up to 75% of patients with Crohn's disease and 62% of patients with ulcerative colitis, and is associated with worse disease prognosis, higher complication rates, decreased quality of life, and increased mortality risk. It is imperative to screen patients with IBD for malnutrition to assess those at increased risk and treat accordingly to prevent progression and complications. This literature review provides an overall approach to optimizing nutrition in IBD, focusing on the assessment for the diagnosis of malnutrition, management of macro- and micronutrient deficiencies, and identification of areas for future study.
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Affiliation(s)
- Lindsey A Russell
- L.A. Russell, M.T. Balart, D. Armstrong, and M.I. Pinto-Sanchez are with Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada; L.A. Russell, M.T. Balart, P. Serrano, D. Armstrong, and M.I. Pinto-Sanchez are with McMaster University, Hamilton, Ontario, Canada
| | - Maria Teresa Balart
- L.A. Russell, M.T. Balart, D. Armstrong, and M.I. Pinto-Sanchez are with Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada; L.A. Russell, M.T. Balart, P. Serrano, D. Armstrong, and M.I. Pinto-Sanchez are with McMaster University, Hamilton, Ontario, Canada
| | - Pablo Serrano
- L.A. Russell, M.T. Balart, D. Armstrong, and M.I. Pinto-Sanchez are with Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada; L.A. Russell, M.T. Balart, P. Serrano, D. Armstrong, and M.I. Pinto-Sanchez are with McMaster University, Hamilton, Ontario, Canada
| | - David Armstrong
- L.A. Russell, M.T. Balart, D. Armstrong, and M.I. Pinto-Sanchez are with Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada; L.A. Russell, M.T. Balart, P. Serrano, D. Armstrong, and M.I. Pinto-Sanchez are with McMaster University, Hamilton, Ontario, Canada
| | - Maria Ines Pinto-Sanchez
- L.A. Russell, M.T. Balart, D. Armstrong, and M.I. Pinto-Sanchez are with Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada; L.A. Russell, M.T. Balart, P. Serrano, D. Armstrong, and M.I. Pinto-Sanchez are with McMaster University, Hamilton, Ontario, Canada
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Pace A, Zobel A, Gearman L, Seitzer D, Larson-Nath C, Somani A. Improving the rate of anthropometric measurements in the pediatric intensive care unit. Nutr Clin Pract 2021; 36:1276-1283. [PMID: 33930222 DOI: 10.1002/ncp.10659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malnutrition occurs in approximately 25% of pediatric intensive care patients and correlates with increased length of stay, prolonged ventilation, and mortality. Anthropometric measurements should be obtained at admission and throughout hospitalization to evaluate nutrition status. We aimed to increase documentation, reporting, and discussion of anthropometric measurements, including height/length, weight, and occipital frontal circumference (OFC) within 24 hours of admission and weekly. METHODS A multifaceted process improvement model was implemented over 1 month. Interventions included education, recruiting nurse champions, process mapping, new equipment, and formal discussion of nutrition status during rounds. A proportions hypothesis test compared frequency of anthropometric measures obtained during each study phase: preintervention, postintervention, and sustainment. RESULTS In terms of admission metrics over respective study phases, the PICU had fluctuation in weights (91%, 98%, and 97%) and height (49%, 73%, and 71%) and increased rates in OFC (36%, 61%, and 65%). The cardiovascular intensive care unit (CVICU) had stable weights (100%, 100%, and 100%) and increased rates in height (87%, 94%, and 95%) and OFC (28%, 64%, and 86%), respectively. In terms of weekly metrics over study phases, the PICU had fluctuation in weights (91%, 89%, and 93%) and increased rates in heights (38%, 69%, and 76%) and OFC (45%, 76%, and 100%). The CVICU had increased rates in weights (98%, 100%, and 100%) and fluctuations in heights (50%, 83%, and 75%), and OFC (48%, 84%, and 75%). CONCLUSIONS Interventions increased rates of measurements. During the sustainment phase, there was regression in rates, although these remained above baseline. Additional interventions may increase compliance and foster change in unit culture.
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Affiliation(s)
- Autumn Pace
- University of Minnesota Medical School-Twin Cities, Minneapolis, Minnesota, USA
| | - Amanda Zobel
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Laura Gearman
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Dale Seitzer
- Fairview Health Services, Minneapolis, Minnesota, USA
| | | | - Arif Somani
- University of Minnesota Medical School-Twin Cities, Minneapolis, Minnesota, USA
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Setyopranoto I, Lestari LA, Wijayanti PM, Rochmah MA. The Effects of Local Food-Based Enteral Nutrition to Improve Nutritional Status of Post-Stroke Patients. J Neurosci Rural Pract 2021; 12:204-209. [PMID: 33531785 PMCID: PMC7846313 DOI: 10.1055/s-0040-1721202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective
We used local-based enteral formula for post-stroke patients to see its effects on the nutritional status.
Materials and Methods
This is an experimental research with a pre- and post-test study design in post-stroke patients. Participants underwent clinical and laboratory examinations to assess their nutritional status before and after the enteral nutrition supplementation. The enteral formula preparation, containing arrowroot powder, cork fish, tempeh (fermented soybeans), nondairy creamer, and pumpkin, was performed in a nationally standardized Food Processing Technology Laboratory in Yogyakarta, Indonesia. The enteral formula was given twice a day for 3 consecutive weeks in addition to the patients’ daily meal.
Statistical Analysis
Nutritional indices before and after enteral nutrition supplementation were analyzed using
t-test
. All statistical analyses were at 5% significance level.
Results
Of the 22 post-stroke patients, we used the cutoff point of National Institutes of Health Stroke Scale ≥3 and Barthel Index <90 to represent dependency. Our findings showed significantly reduced mid-upper arm circumference and increased body mass index in independent post-stroke patients after the enteral nutrition supplementation. The tendency of increasing total cholesterol level should be carefully watched in dependent post-stroke patients.
Conclusion
Local food-based enteral nutrition supplementation for 3 consecutive weeks in post-stroke patients may improve their nutritional status.
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Affiliation(s)
- Ismail Setyopranoto
- Department of Neurology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | | | - Lily Arsanti Lestari
- Department of Nutrition and Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | | | - Punik Mumpuni Wijayanti
- Department of Public Health, Faculty of Medicine, Islamic University of Indonesia, Yogyakarta, Indonesia
| | - Mawaddah Ar Rochmah
- Department of Neurology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
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Anemia and Hematopoietic Factor Deficiencies in Patients after Endoscopic Gastrostomy: A Nine-Year and 472-Patient Study. Nutrients 2020; 12:nu12123637. [PMID: 33256142 PMCID: PMC7760764 DOI: 10.3390/nu12123637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 11/18/2020] [Accepted: 11/23/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction and aims: Patients undergoing percutaneous endoscopic gastrostomy (PEG) may present protein-energy malnutrition, anemia and deficiencies of hematopoietic factors, e.g., iron, folate and vitamin B12. There are no comprehensive studies on anemia or other hematological changes in PEG-patients. Our aim was to evaluate the hematological status of dysphagic patients that had undergone PEG and its association with clinical outcome. Methods: This research comprises a retrospective study of patients followed by our Artificial Feeding Team, submitted to PEG from 2010 to 2018. Patients were divided into two etiological groups: neurological dysphagia (ND) and head/neck or esophageal disorders (HNE). Laboratory data included serum albumin, hemoglobin, mean corpuscular volume, ferritin, transferrin, iron, vitamin B12 and folate. Survival after PEG was recorded in months, until death or December 2018. Results: We evaluated 472 patients; 250 (53%) presented anemia at the moment of gastrostomy, mostly normocytic (n = 219), with laboratory data suggestive of anemia of chronic disease (ACD). Six patients (1.3%) presented vitamin B12 deficiency and 57 (12.1%) presented folate deficit. No statistically significant difference in hemoglobin was found between the etiological groups (p = 0.230). Folate and vitamin B12 levels were lower in the HNE group (p < 0.01). A positive correlation between hemoglobin and survival was present (p < 0.01, r = 0.289), and hemoglobin levels were lower in the deceased population (p < 0.01). Conclusion: Anemia is frequent in PEG-patients, mostly with the features of ACD or multifactorial. It is associated with significant decrease in survival and may be viewed as a marker of severe metabolic distress, signaling poor outcome.
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Feasibility, safety and outcome of endoscopic gastrostomy in patients with esophageal cancer. NUTR HOSP 2020; 37:660-666. [PMID: 32686454 DOI: 10.20960/nh.03024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction Background and aims: esophageal cancer (EC) is an important health problem worldwide with high morbidity and mortality. EC patients are likely to develop malnutrition. The aim of this study was to assess the feasibility and safety of endoscopic gastrostomy (PEG) feeding in EC cancer, and to identify risk factors associated with poor prognosis. Methods: a retrospective observational study was performed using records from EC patients referred for PEG. Age, gender, cancer histologic subtype, indication for gastrostomy, and mortality data were recorded. NRS 2002, body mass index (BMI), hemoglobin, serum albumin, transferrin and total cholesterol were collected at the day of PEG. An association between anthropometric, clinical and laboratorial data with patient survival was assessed. Results: data were obtained for forty-one EC patients (36 men and 5 women) aged 39-88 years (mean, 62 years). Gastrostomy was possible in all patients referred to PEG (27 patients selected for curative treatment and 14 patients for palliative nutrition). No major complications occurred. Mean survival after PEG was 18.1 months, and mortality rate at 3 months was 31.7 %. Most patients (34; 82.9 %) died under PEG feeding. Mean BMI was 21.3 kg/m2 and 14 patients (34.1 %) patients had low BMI. Serum albumin, transferrin and total cholesterol were low in 10 (24.4 %), 20 (48.8 %) and 18 (43.9 %) patients, respectively. Higher BMI (R = 0.30), serum albumin (R = 0.41) and transferrin (R = 0.47) tended to be positively correlated with survival (p < 0.005). Conclusions: PEG is a feasible and safe technique for enteral feeding in EC patients. Higher BMI, serum albumin and transferrin levels at admission predict a better outcome. Enteral feeding through PEG should be considered early in EC patients due to their higher risk of malnutrition, which is associated with shorter survival.
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Trüb FP, Wells JC, Rühli FJ, Staub K, Floris J. Filling the weight gap: Estimating body weight and BMI using height, chest and upper arm circumference of Swiss conscripts in the first half of the 20th century. ECONOMICS AND HUMAN BIOLOGY 2020; 38:100891. [PMID: 32502961 DOI: 10.1016/j.ehb.2020.100891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 04/17/2020] [Accepted: 05/04/2020] [Indexed: 06/11/2023]
Abstract
We estimate weight and BMI values based on height, chest circumference, and mid upper arm circumference measures of Swiss conscripts in the city of Zurich for each year between 1904 and 1932. Height, chest circumference, and mid upper arm circumference were measured each year from 1904 to 1951. Body weight is available from 1933 to 1951. We used prediction equations from the literature, and also developed our own equations, which we tested and validated on the dataset from 1933 to 1951. We used a representative sample of usually 19-year-old Swiss males (N = 88,792, coverage > 88 %). There was an increase in average height and chest circumference between 1904 and 1951. During both world wars, chest circumference, mid upper arm circumference, weight, and BMI decreased, while height stagnated. Overall mean weight and BMI increased from 1904 to 1951, but decreased during the Great Depression. After World War II, weight quickly returned to the pre-war and pre-Great Depression level, while BMI had not reached the 1933 level by 1951. Average weights of the lower and middle socioeconomic groups were catching up with average weight of the upper socioeconomic group from 1904 to 1951. The convergence in height is less pronounced. Finally, we show that it is possible to accurately predict mean weight and BMI from other anthropometric measurements. We suggest that our estimation approach could be replicated for other historical populations to obtain more information on how nutritional status changed over time.
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Affiliation(s)
| | - Jonathan Ck Wells
- Childhood Nutrition Research Centre, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Frank J Rühli
- Institute of Evolutionary Medicine, University of Zurich, Switzerland
| | - Kaspar Staub
- Institute of Evolutionary Medicine, University of Zurich, Switzerland; Zurich Center for Integrative Human Physiology (ZIHP), University of Zurich, Switzerland
| | - Joël Floris
- Institute of Evolutionary Medicine, University of Zurich, Switzerland; Department of History, University of Zurich, Switzerland.
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Association Between Anthropometric Indicators of Nutrition Status and Length of Hospital Stay in Hospitalized Patients. JPEN J Parenter Enteral Nutr 2020; 45:381-393. [DOI: 10.1002/jpen.1844] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 03/30/2020] [Indexed: 11/07/2022]
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Judd S, Khedr M, Milan AM, Davison AS, Hughes AT, Needham A, Psarelli EE, Shenkin A, Ranganath LR. The nutritional status of people with alkaptonuria: An exploratory analysis suggests a protein/energy dilemma. JIMD Rep 2020; 53:45-60. [PMID: 32395409 PMCID: PMC7203650 DOI: 10.1002/jmd2.12084] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 10/16/2019] [Accepted: 10/29/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Alkaptonuria (AKU) is a disorder of tyrosine/protein metabolism leading to accumulation of homogentisic acid. Clinical management historically recommended reducing dietary protein intake, especially in childhood, which has since been discredited in the literature. For the first time, analysis of baseline cross-sectional nutritional surveillance data from a large cohort of AKU patients is presented, which has clinical implications in all aspects of treatment planning. METHOD Seventy-four patients (mean 55 years) admitted to the National Alkaptonuria Centre (NAC), underwent a global nutritional assessment, which included objective anthropometry, bioimpedance measures, habitual nutritional intake using a 7-day food diary and key nutritional biomarkers, including 24 hours urinary nitrogen, serum albumin, total protein and total 25-hydroxy vitamin D. All data was compared with cohort norms or recommended nutrient intakes for health (RNI). The potential beneficial impact of protein and anti-inflammatory nutrients such as vitamin C, selenium, and zinc were statistically interrogated against the AKU severity score index (AKUSSI)-a validated measure of disease progression stratified by age. RESULTS Fifty percent of AKU patients reported some level of protein restriction at some point in their lives. In comparison with national data sets, AKU patients present with significantly lower than predicted mid-upper arm circumference, grip strength, BMI, total energy and protein intake, and higher than predicted percentage body fat. They therefore meet the ESPEN criteria as "clinically undernourished." Severity fluctuates over the life course. No statistical association is identified between protein intake, expressed as %RNI or g/kg, or anti-inflammatory nutrients, including vitamin C as a high dose supplement on the severity of the disease, when correlated against the validated AKUSSI score. CONCLUSION AKU patients are at risk of protein depletion associated with a "perfect storm" of risk factors: historical, poorly evidenced recommendations to reduce total protein intake; limited mobility as the condition progresses, compromising muscle integrity; frequent hospital admissions for major surgery associated with multiple joint replacements, creating pinch points of high metabolic demand and the potential impact of the disease itself. As this is the first time this risk has been identified, the authors consider the dietetic implications of nitisinone treatment, which requires dietary protein control to manage the acquired tyrosinaemia. The lack of statistically significant evidence to support dietary manipulation of any kind to impede disease progression in AKU is demonstrated.
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Affiliation(s)
- Shirley Judd
- Department of Nutrition and DieteticsRoyal Liverpool University HospitalLiverpoolUK
| | - Milad Khedr
- Department of Clinical Biochemistry and Metabolic MedicineLiverpool Clinical Laboratories, Royal Liverpool University HospitalLiverpoolUK
| | - Anna M. Milan
- Department of Clinical Biochemistry and Metabolic MedicineLiverpool Clinical Laboratories, Royal Liverpool University HospitalLiverpoolUK
| | - Andrew S. Davison
- Department of Clinical Biochemistry and Metabolic MedicineLiverpool Clinical Laboratories, Royal Liverpool University HospitalLiverpoolUK
| | - Andrew T. Hughes
- Department of Clinical Biochemistry and Metabolic MedicineLiverpool Clinical Laboratories, Royal Liverpool University HospitalLiverpoolUK
| | - Alexander Needham
- Liverpool Cancer Trials UnitUniversity of Liverpool, Block C, Waterhouse BuildingLiverpoolUK
| | - Eftychia E. Psarelli
- Liverpool Cancer Trials UnitUniversity of Liverpool, Block C, Waterhouse BuildingLiverpoolUK
| | - Alan Shenkin
- Department of Clinical Biochemistry and Metabolic MedicineLiverpool Clinical Laboratories, Royal Liverpool University HospitalLiverpoolUK
| | - Lakshiminaryan R. Ranganath
- Department of Clinical Biochemistry and Metabolic MedicineLiverpool Clinical Laboratories, Royal Liverpool University HospitalLiverpoolUK
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The effect of malnutrition on mortality in hospitalized patients with hematologic malignancy. Support Care Cancer 2019; 28:1441-1448. [PMID: 31273503 DOI: 10.1007/s00520-019-04952-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 06/18/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The aim of this study was to assess the association between malnutrition status with the (Global Leadership Initiative on Malnutrition) GLIM criteria and 1-year mortality in hospitalized patients with hematologic malignancy. METHODS This study included 120 hospitalized patients with hematologic malignancy. Patients who were at risk of malnutrition with NRS2002 were reevaluated with the GLIM criteria for defined malnutrition. Also, the mid-upper arm circumference (MUAC), calf circumference (CC), and handgrip (HG) were measured, and albumin, C reactive protein (CRP), and total protein were recorded to assess malnutrition-related factors. RESULTS A total of 120 patients are with lymphoma, leukemia, and myeloma having a rate of 34.2%, 34.2%, and 31.6%, respectively, and risk of malnutrition with NRS2002 was established in 82% of patients. Malnutrition with GLIM criteria was seen in 25.8% of patients. The 1-year mortality rate was 41.7% (n = 50). Malnutrition was associated with higher mortality risk independently with age and duration of diagnosis (HR 3.55 (1.99-6.34), p = 0.001). Low HG (HR 0.51 (0.26-0.99), p = 0.03), low albumin (HR 0.39 (0.2-0.6), p = 0.001), and high CRP (HR 2.39 (1.36-4.20), p = 0.002) were significantly associated with increased mortality risk. In contrast, BMI, MUAC, FFMI, and CC were not associated with higher mortality. CONCLUSION Malnutrition is high with the GLIM criteria. Hospitalized patients with hematologic malignancy with malnutrition have a higher 1-year mortality risk.
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Nutrition indicators as potential predictors of AIDS-defining illnesses among ARV-naïve HIV-positive adults in Kapiri Mposhi, Zambia 2008-2009. PLoS One 2019; 14:e0219111. [PMID: 31265479 PMCID: PMC6605674 DOI: 10.1371/journal.pone.0219111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 06/17/2019] [Indexed: 11/19/2022] Open
Abstract
Early changes in nutritional status may be predictive of subsequent HIV disease progression in people living with HIV (PLHIV). In addition to conventional anthropometric assessment using body mass index (BMI) and mid-upper arm circumferences (MUAC), measures of strength and fatigability may detect earlier changes in nutrition status which predict HIV disease progression. This study aims to examine the association between various nutritional metrics relevant in resource-scarce setting and HIV disease progression. The HIV disease progression outcome was defined as any occurrence of an incident AIDS-defining illnesses (ADI) among antiretroviral treatment (ART)-naïve PLHIV. From 2008–2009, HIV+ Zambian adult men and non-pregnant women were followed for 9 months at a Doctors without Borders (Medecins Sans Frontiers, MSF) HIV clinic in Kapiri Mposhi, Zambia. Since the study was conducted in the time period when former WHO recommendations on ART (i.e., ≤200 CD4 cell count as opposed to treating all individuals regardless of CD4 cell count or disease stage) were followed, caution should be applied when considering the implications from this study’s results to improve HIV case management under current clinical guidelines, or when comparing findings from this study with studies conducted in recent years. Bivariable and multivariable logistic regression was used to assess the associations between baseline nutritional measurements and the outcome of incident ADI. Self-reported loss of appetite study (AOR 1.90, 95% CI 1.04, 3.45, P = 0.036) and moderate wasting based on MUAC classification (AOR 2.40, 95% CI 1.13, 5.10, P = 0.022) were independently associated with increased odds of developing incident ADI within 9 months, while continuous increments (in psi) of median handgrip strength (AOR 0.74, 95%CI 0.60, 0.91, P = 0.004) was independently associated with decreased odds of incident ADI only among women. The association between low BMI and the short-term outcome of ADI was attenuated after controlling for these nutritional indicators. These findings warrant further research to validate the consistency of these observed associations among larger ART-naïve HIV-infected populations, as well as to develop nutritional assessment tools for identifying disease progression risk among ART-naïve PLHIV.
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Lee N, White LV, Marin FP, Saludar NR, Solante MB, Tactacan-Abrenica RJC, Calapis RW, Suzuki M, Saito N, Ariyoshi K, Parry CM, Edwards T, Cox SE. Mid-upper arm circumference predicts death in adult patients admitted to a TB ward in the Philippines: A prospective cohort study. PLoS One 2019; 14:e0218193. [PMID: 31246958 PMCID: PMC6597043 DOI: 10.1371/journal.pone.0218193] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 05/28/2019] [Indexed: 11/18/2022] Open
Abstract
Background The Philippines is ranked 3rd globally for tuberculosis incidence (554/100,000 population). The tuberculosis ward at San Lazaro Hospital, Manila receives 1,800–2,000 admissions of acutely unwell patients per year with high mortality. Objectives of this prospective cohort study were to quantify the association of under-nutrition (primary) and diabetes (secondary) with inpatient mortality occurring between 3–28 days of hospital admission in patients with suspected or previously diagnosed TB. Methods and results We enrolled 360 adults (≥18 years); 348 were eligible for the primary analysis (alive on day 3). Clinical, laboratory, anthropometric and enhanced tuberculosis diagnostic data were collected at admission with telephone tracing for mortality up to 6 months post-discharge. In the primary analysis population (mean age 45 years, SD = 15.0 years, 70% male), 58 (16.7%) deaths occurred between day 3–28 of admission; 70 (20.1%) between day 3 and discharge and documented total post-day 3 mortality including follow-up was 96 (27.6%). In those in whom it could be assessed, body mass index (BMI) ranged from 11.2–30.6 kg/m2 and 141/303 (46.5%) had moderate/severe undernutrition (BMI<17 kg/m2). A sex-specific cut-off for mid-upper arm circumference predictive of BMI<17 kg/m2 was associated with inpatient Day 3–28 mortality in males (AOR = 5.04, 95% CI: 1.50–16.86; p = 0.009; p = 0.032 for interaction by sex). The inability to stand for weight/height for BMI assessment was also associated with mortality (AOR = 5.59; 95% CI 2.25–13.89; p<0.001) as was severe compared to normal/mild anaemia (AOR = 9.67; 95% CI 2.48–37.76; p<0.001). No TB specific variables were associated with Day 3–28 mortality, nor was diabetes (HbA1c ≥6.5% or diabetes treatment). Similar effects were observed when the same multivariable model was applied to confirmed TB patients only and to the outcome of all post-day 3 in-patient mortality. Conclusion This research supports the use of mid-upper arm circumference for triaging acutely unwell patients and the design and testing of nutrition-based interventions to improve patient outcomes.
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Affiliation(s)
- Nathaniel Lee
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Royal Free Hospital, London, United Kingdom
| | - Laura V. White
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | | | | | - Marietta B. Solante
- San Lazaro Hospital, Manila, the Philippines
- The Lung Center, Manila, the Philippines
| | | | | | - Motoi Suzuki
- Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan
| | - Nobuo Saito
- Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan
| | - Koya Ariyoshi
- Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan
| | - Christopher M. Parry
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Tansy Edwards
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sharon E. Cox
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Faculty of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
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White LV, Lee N, Marin FP, Saludar NR, Edwards T, Cox SE. Performance of alternative measures to body mass index in the assessment of moderate and severe under-nutrition among acutely unwell patients hospitalized in a TB ward in the Philippines: A cross-sectional study. PLoS One 2019; 14:e0215968. [PMID: 31095582 PMCID: PMC6522031 DOI: 10.1371/journal.pone.0215968] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 04/11/2019] [Indexed: 02/04/2023] Open
Abstract
Body mass index (BMI) kg/m2 is a key screening tool for under-nutrition in adults, but difficult to obtain in immobile or unwell patients, particuarly in low resource settings, due to inability to accurately measure both weight and height. Mid-upper arm circumference (MUAC) is used to assess under-nutrition in children under 5 years but no standardised cut-off values exist for adults. In a cohort of adult Filipino patients admitted to a tuberculosis ward we assessed (i) cut-offs for MUAC to predict moderate under-nutrition (BMI <17kg/m2), (ii) the performance of limb lengths to predict height and; (iii) associations of body fat percentage from skinfolds and hand grip-strength with BMI. In 303 patients with MUAC and BMI at admission, aged 18-80 years (mean = 45.5, SD:14.8), BMI ranged from 11.2-30.6 kg/m2 and 141 (46.5%) had BMI <17.0 kg/m2. Using receiver operator curves, MUAC cut-offs were identified as <20.5cm for males (sensitivity: 89%, specificity: 84%) and <18.5cm for females (sensitivity: 91%, specificity: 89%), for BMI<17.0 kg/m2. Using published equations, knee height had the lowest mean difference between predicted and measured heights compared to ulnar or demi-span: (-0.98 cm, 95% CI: -1.51/-0.44). Both grip-strength and body fat percentage were positively associated with BMI, in separate linear regression models with exposure-age-sex interactions (adjusted-R-squared values: 0.15, 0.66, respectively). MUAC can predict moderate acute under-nutrition with high positive predictive value. Further research is required to determine the performance of alternative measures to BMI to predict mortality or adverse outcomes in acutely unwell patients.
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Affiliation(s)
- Laura V. White
- Nagasaki University, School of Tropical Medicine and Global Health, Nagasaki, Japan
| | - Nathaniel Lee
- Nagasaki University, School of Tropical Medicine and Global Health, Nagasaki, Japan
- Royal Free Hospital, London, United Kingdom
| | | | | | - Tansy Edwards
- Nagasaki University, School of Tropical Medicine and Global Health, Nagasaki, Japan
- Tropical Epidemiology Group, Faculty of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sharon E. Cox
- Nagasaki University, School of Tropical Medicine and Global Health, Nagasaki, Japan
- Faculty of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Borkent JW, Naumann E, Vasse E, van der Heijden E, de van der Schueren MAE. Prevalence and Determinants of Undernutrition in A Sample of Dutch Community-Dwelling Older Adults: Results from Two Online Screening Tools. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16091562. [PMID: 31060212 PMCID: PMC6539798 DOI: 10.3390/ijerph16091562] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 04/18/2019] [Accepted: 05/01/2019] [Indexed: 12/20/2022]
Abstract
To stimulate undernutrition screening among Dutch community-dwelling adults, a website was developed with general information on healthy eating for healthy aging and self-tests. Based on cross-sectional data obtained from the self-tests, we studied nutritional risk factors (early determinants) as well as risk of undernutrition (late symptoms). SCREEN II (n = 2470) was used to asses nutritional risk factors. This tool consists of 16 items regarding nutritional intake, perception of body weight, appetite, oral health and meal preparation. An adjusted SNAQ65+ (n = 687) was used to assess risk of undernutrition. This four-item tool contains questions on weight loss, appetite, walking stairs and body mass index. Differences between age-groups (65-74, 75-84, ≥85) were tested by logistic regression. Overall prevalence of nutritional risk factors was 84.1%, and increased risk of undernutrition was 56.8%. Participants aged ≥85 scored worst on almost all items of the SCREEN II and the SNAQ65+. In conclusion: A large proportion of older adults reported early determinants for increased nutrition risk, while a smaller, yet remarkable proportion scored positive on undernutrition risk. Internet screening may be a useful, contemporary, and easy, accessible way to reach older adults who are at nutritional risk and may thus contribute to early identification and prevention of undernutrition.
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Affiliation(s)
- Jos W Borkent
- Dutch Malnutrition Steering Group, Nicolaas Witsenkade 13hs, 1017 ZR Amsterdam, The Netherlands.
- Faculty of Health and Social Studies, Department of Nutrition and Health, HAN University of Applied Sciences, Kapittelweg 33, 6525 EN Nijmegen, The Netherlands.
| | - Elke Naumann
- Dutch Malnutrition Steering Group, Nicolaas Witsenkade 13hs, 1017 ZR Amsterdam, The Netherlands.
- Faculty of Health and Social Studies, Department of Nutrition and Health, HAN University of Applied Sciences, Kapittelweg 33, 6525 EN Nijmegen, The Netherlands.
| | - Emmelyne Vasse
- Dutch Malnutrition Steering Group, Nicolaas Witsenkade 13hs, 1017 ZR Amsterdam, The Netherlands.
- Department of Dietetics, Hospital Gelderse Vallei, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands.
| | - Ellen van der Heijden
- Dutch Malnutrition Steering Group, Nicolaas Witsenkade 13hs, 1017 ZR Amsterdam, The Netherlands.
| | - Marian A E de van der Schueren
- Dutch Malnutrition Steering Group, Nicolaas Witsenkade 13hs, 1017 ZR Amsterdam, The Netherlands.
- Faculty of Health and Social Studies, Department of Nutrition and Health, HAN University of Applied Sciences, Kapittelweg 33, 6525 EN Nijmegen, The Netherlands.
- Department of Nutrition and Dietetics, Amsterdam UMC, Vrije Universiteit, De Boelelaan 1117; 1081 HV Amsterdam, The Netherlands.
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Dodos J, Altare C, Altmann M. Letter to the editor regarding the comment by Gupta and Goswami about our article "individual and household risk factors of severe acute malnutrition among under-five children in Mao, Chad: a matched case-control study". Arch Public Health 2019; 77:18. [PMID: 30962930 PMCID: PMC6437975 DOI: 10.1186/s13690-019-0344-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 03/04/2019] [Indexed: 11/10/2022] Open
Abstract
We would like to thank the authors Sunanda Gupta and Kiran Goswami for their interest in our article "Individual and household risk factors of severe acute malnutrition among under-five children in Mao, Chad: a matched case-control study". In this response we aim to address their criticisms.
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Affiliation(s)
- Jovana Dodos
- Action contre la Faim, 14/16 Boulevard Douaumont - CS 80060, 75854 Paris, CEDEX 17 France
| | - Chiara Altare
- Action contre la Faim, 14/16 Boulevard Douaumont - CS 80060, 75854 Paris, CEDEX 17 France
| | - Mathias Altmann
- Action contre la Faim, 14/16 Boulevard Douaumont - CS 80060, 75854 Paris, CEDEX 17 France
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Feeding tube transparietal thickness - A promising anthropometric parameter for nutritional assessment of endoscopic gastrostomy fed patients. Clin Nutr ESPEN 2019; 29:224-230. [PMID: 30661691 DOI: 10.1016/j.clnesp.2018.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 10/05/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND & AIMS Malnutrition is common in patients eligible for percutaneous endoscopic gastrostomy (PEG). Feeding tube transparietal thickness (TT) may contribute to assess nutritional status. This study aims to: 1) Characterize TT in PEG patients. 2) Determine the association between TT and the currently used tools 3) Define TT best cut-offs to predict undernutrition 4) Assess the correlation between TT and survival. METHODS Prospective cohort study including patients who underwent PEG. Nutritional assessment was performed using NRS 2002, anthropometry and serum proteins. Anthropometry included body-mass index (BMI), mid upper arm circumference (MUAC), triceps skinfold (TSF) and mid arm muscle circumference (MAMC). TT was measured immediately after PEG and survival was recorded. TT cut-offs were established by comparison with other anthropometric parameters and using the ROC analysis. The correlation between TT and survival was assessed. RESULTS 227 patients (161 men and 66 women) aged 23-96 years. Most presented head or neck cancer (51.1%). Undernutrition was identified in 57.7% according with BMI. Median TT was 25 mm (IQR = 10). TT was correlated with BMI (R = 0.5), MUAC (R = 0.5), TSF (R = 0.5) and MAMC (R = 0.4) (p < 0.01), respectively, being accurate in predicting undernutrition (AUROC 0.71 ± 0.033, p < 0.01). TT <20 mm showed positive predictive value of 81.6% and specificity of 84.4% to detect undernutrition. TT was correlated with survival (R = 0.1) (p = 0.05). Head or neck cancer patients' survival was significantly lower if TT ≤ 25 mm (p = 0.03). CONCLUSIONS TT is variable among PEG patients but values below 20-25 mm are suggestive of undernutrition. TT defined in the day of the gastrostomy procedure is the easiest anthropometric parameter that can be obtained from a PEG patient. Due to its higher positive predictive value and correlation with survival, TT should be viewed as an additional anthropometric tool specific for PEG patients, with diagnostic and prognostic value.
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Barosa R, Roque Ramos L, Santos CA, Pereira M, Fonseca J. Mid upper arm circumference and Powell-Tuck and Hennessy's equation correlate with body mass index and can be used sequentially in gastrostomy fed patients. Clin Nutr 2018; 37:1584-1588. [DOI: 10.1016/j.clnu.2017.08.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 07/20/2017] [Accepted: 08/11/2017] [Indexed: 01/07/2023]
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Van Tonder E, Mace L, Steenkamp L, Tydeman-Edwards R, Gerber K, Friskin D. Mid-upper arm circumference (MUAC) as a feasible tool in detecting adult malnutrition. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2018. [DOI: 10.1080/16070658.2018.1484622] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- E Van Tonder
- Department of Dietetics, Nelson Mandela University, Port Elizabeth, South Africa
| | - L Mace
- Dietetics Department, Department of Health, Tayler Bequest Hospital, Matatiele, South Africa
| | - L Steenkamp
- Dietetics Department, Department of Health, Settlers Hospital, Grahamstown, South Africa
| | - R Tydeman-Edwards
- Dietetics Department, Department of Health, Port Elizabeth Provincial Hospital, Port Elizabeth, South Africa
| | - K Gerber
- Nursing Department, Nelson Mandela University, Port Elizabeth, South Africa
| | - D Friskin
- Department of Statistics, Nelson Mandela University, Port Elizabeth, South Africa
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Mantzorou M, Vadikolias K, Pavlidou E, Serdari A, Vasios G, Tryfonos C, Giaginis C. Nutritional status is associated with the degree of cognitive impairment and depressive symptoms in a Greek elderly population. Nutr Neurosci 2018; 23:201-209. [PMID: 29914306 DOI: 10.1080/1028415x.2018.1486940] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Introduction: Cognitive impairment and malnutrition are two important public health issues in the elderly, which have been associated with their mental health.Aims: This study aims to evaluate the nutritional status of an elderly population in Greece, and its association with the grade of cognitive decline, anthropometric measures and psychological status.Materials and Methods: A total of 2092 elderly men and women were enrolled from seven Greek cities. Mini Nutritional Assessment (MNA), Mini Mental State Examination (MMSE) and Geriatric Depression Scale (GDS) questionnaires were used to assess the impact of nutritional status on cognitive abilities and psychological status of the participants.Results: Of the elderly, 35.0% were at risk of malnutrition and 11.3% were malnourished, while 34.4% of the participants had impaired cognitive function, and 32.3% showed depressive symptoms. Malnutrition was more frequently observed in participants presenting cognitive impairment, and depressive symptoms. In multiple regression analysis, nutritional status was independently associated with cognitive and psychological status.Conclusions: A high prevalence of malnutrition was recorded in this elderly population sample, which was directly associated with cognitive impairment and depression. Diagnostic tools such as MNA, MMSE, and GDS are strongly recommended to be applied as a routine clinical practice in the elderly to timely and effectively address these health problems.
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Affiliation(s)
- Maria Mantzorou
- Department of Food Science and Nutrition, School of Environment, University of Aegean, Myrina, Lemnos, Greece
| | - Konstantinos Vadikolias
- Department of Neurology, School of Medicine, Democritus University of Thrace, Alexandroupoli, Greece
| | - Eleni Pavlidou
- Department of Food Science and Nutrition, School of Environment, University of Aegean, Myrina, Lemnos, Greece
| | - Aspasia Serdari
- Department of Psychiatry and Child Psychiatry, Democritus University of Thrace, University Hospital of Alexandroupolis, Thrace, Greece
| | - Georgios Vasios
- Department of Food Science and Nutrition, School of Environment, University of Aegean, Myrina, Lemnos, Greece
| | - Christina Tryfonos
- Department of Food Science and Nutrition, School of Environment, University of Aegean, Myrina, Lemnos, Greece
| | - Constantinos Giaginis
- Department of Food Science and Nutrition, School of Environment, University of Aegean, Myrina, Lemnos, Greece
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Sanson G, Bertocchi L, Dal Bo E, Di Pasquale CL, Zanetti M. Identifying reliable predictors of protein-energy malnutrition in hospitalized frail older adults: A prospective longitudinal study. Int J Nurs Stud 2018; 82:40-48. [DOI: 10.1016/j.ijnurstu.2018.03.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 03/04/2018] [Accepted: 03/06/2018] [Indexed: 01/10/2023]
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The validity of mid-upper arm circumference as an indicator of low BMI in population screening for undernutrition: a study among adult slum dwellers in eastern India. Public Health Nutr 2018; 21:2575-2583. [PMID: 29843829 DOI: 10.1017/s1368980018001301] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To explore the possibility for a statistically appropriate value of mid-upper arm circumference (MUAC) to identify the state of severe undernutrition, based on very low BMI, among adult Indian slum dwellers. DESIGN Cross-sectional study on adults. Height and MUAC were recorded and BMI was computed. Chronic energy deficiency (CED) was determined using the WHO international guidelines as BMI<18·5 kg/m2 and normal as BMI≥18·5 kg/m2. Besides calculating mean, sd and 25th, 50th and 75th percentile values, multiple linear regression analysis was undertaken to assess the associations between age, MUAC and BMI. Receiver-operating characteristic curve analysis was performed to determine the best MUAC cut-off to identify CED status. The χ 2 test was used to assess significance of the difference in CED prevalence across MUAC categories. SETTING An urban slum in Midnapore town, West Bengal State, India. SUBJECTS Male (n 467) and female (n 488) Indian slum dwellers. RESULTS MUAC of 22·7 and 21·9 cm, respectively, in males and females were the best cut-off points to differentiate CED from non-CED. CONCLUSIONS Results supported the validity of the WHO-recommended MUAC cut-offs for adults. There is still a need to establish statistically appropriate MUAC cut-offs to predict undernutrition and morbidity.
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Weng CH, Tien CP, Li CI, L'Heureux A, Liu CS, Lin CH, Lin CC, Lai SW, Lai MM, Lin WY. Mid-upper arm circumference, calf circumference and mortality in Chinese long-term care facility residents: a prospective cohort study. BMJ Open 2018; 8:e020485. [PMID: 29743327 PMCID: PMC5942455 DOI: 10.1136/bmjopen-2017-020485] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE To investigate the association between mid-upper arm circumference (MUAC), calf circumference (CC) and all-cause mortality in a Chinese population. DESIGN Prospective cohort study. SETTING Eight long-term care facilities in central Taiwan. PARTICIPANTS A total of 329 residents age 60 years and older (median 79.0 years, range 60-101; 139 men, 190 women) were enrolled. METHODS Anthropometrics and metabolic parameters were measured at the time of enrolment to the study. Mean MUAC and CC were 24.2±3.4 cm and 27.5±4.3 cm, respectively. Mortality data were obtained from the Department of Health in Taiwan. MAIN OUTCOME MEASURE To identify the association between all-cause mortality and MUAC or CC. RESULTS There were 255 deaths during the 7-year follow-up period. After adjusting for age, sex, cigarette smoking, betel nut chewing, alcohol use, Karnofsky Performance Status Scale score, serum albumin level, hypertension and diabetes mellitus, subjects in the highest tertile of MUAC (27.8±2.2 cm) and CC (32.1±2.6 cm) had a significantly lower mortality rate than did subjects in the lowest tertile (MUAC 20.6±1.7 cm; CC 22.8±1.9 cm). The adjusted HR for all-cause mortality in the highest versus lowest MUAC tertile was 0.64 (95% CI 0.45 to 0.90). The adjusted HR for all-cause mortality in the highest versus lowest CC tertile was 0.51 (95% CI 0.35 to 0.74). CONCLUSIONS MUAC and CC are negative predictors for all-cause mortality in older Chinese adults living in long-term care facilities. Participants with higher MUAC and CC had lower all-cause mortality.
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Affiliation(s)
- Chien-Hsiang Weng
- Department of Family Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
- NH Dartmouth Family Medicine Residency, Concord Hospital, Concord, New Hampshire, USA
- Department of Family Medicine, Providence Community Health Centers, Providence, Rhode Island, USA
| | - Chia-Ping Tien
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Ing Li
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Abby L'Heureux
- Department of Family Medicine, Rural Medical Partners, Grand Forks, North Dakota, USA
| | - Chiu-Shong Liu
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Social Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Chih-Hsueh Lin
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Family Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Cheng-Chieh Lin
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Social Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Shih-Wei Lai
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Family Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Ming-May Lai
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Wen-Yuan Lin
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Social Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, College of Medicine, China Medical University, Taichung, Taiwan
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Vieira J, Nunes G, Santos CA, Fonseca J. SERUM ELECTROLYTES AND OUTCOME IN PATIENTS UNDERGOING ENDOSCOPIC GASTROSTOMY. ARQUIVOS DE GASTROENTEROLOGIA 2018; 55:41-45. [PMID: 29561975 DOI: 10.1590/s0004-2803.201800000-05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Accepted: 10/19/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is a gold standard for long term enteral feeding. Neurologic dysphagia and head/neck cancer are the most common indications for PEG as they can lead to protein-energy malnutrition and serum electrolyte abnormalities, with potential negative impact on metabolic balance. Refeeding syndrome may also be related with severe electrolyte changes in PEG-fed patients and contribute to poor prognosis. OBJECTIVE This study aims to evaluate the changes in serum concentrations of the main electrolytes and its possible association with the outcome. METHODS Retrospective study of patients followed in our Artificial Nutrition Clinic, submitted to PEG from 2010 to 2016, having head/neck cancer or neurologic dysphagia, who died under PEG feeding. Serum electrolytes (sodium, potassium, chlorine, magnesium, calcium and phosphorus) were evaluated immediately before the gastrostomy procedure. Survival after PEG until death was recorded in months. RESULTS We evaluated 101 patients, 59 with electrolyte alterations at the moment of the gastrostomy. Sodium was altered in 32 (31.7%), magnesium in 21 (20.8%), chlorine in 21 (20.8%), potassium in 14 (13.8%), calcium in 11 (10.9 %) and phosphorus in 11 (10.9%). The survival of patients with low sodium (<135 mmol/L) was significantly lower when compared to patients with normal/high values, 2.76 months vs 7.80 months, respectively (P=0.007). CONCLUSION Changes in serum electrolytes of patients undergoing PEG were very common. More than half showed at least one abnormality, at the time of the procedure. The most frequent was hyponatremia, which was associated with significantly shorter survival, probably reflecting severe systemic metabolic distress.
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Affiliation(s)
- Joana Vieira
- Departamento de Gastroenterologia, GENE - Artificial Feeding Team, Hospital Garcia de Orta, Almada, Portugal
| | - Gonçalo Nunes
- Departamento de Gastroenterologia, GENE - Artificial Feeding Team, Hospital Garcia de Orta, Almada, Portugal
| | - Carla Adriana Santos
- Departamento de Gastroenterologia, GENE - Artificial Feeding Team, Hospital Garcia de Orta, Almada, Portugal
| | - Jorge Fonseca
- Departamento de Gastroenterologia, GENE - Artificial Feeding Team, Hospital Garcia de Orta, Almada, Portugal.,CiiEM, Centro de Investigação Interdisciplinar Egas Moniz, Monte da Caparica, Portugal
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Opio MO, Namujwiga T, Nakitende I, Kellett J, Brabrand M. The prediction of in-hospital mortality by mid-upper arm circumference: a prospective observational study of the association between mid-upper arm circumference and the outcome of acutely ill medical patients admitted to a resource-poor hospital in sub-Saharan Africa. Clin Med (Lond) 2018; 18:123-127. [PMID: 29626015 PMCID: PMC6303455 DOI: 10.7861/clinmedicine.18-2-123] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
There are few reports of the association of nutritional status with in-hospital mortality of acutely ill medical patients in sub-Saharan Africa. This is a prospective observational study comparing the predictive value of mid-upper arm circumference (MUAC) of 899 acutely ill medical patients admitted to a resource-poor sub-Saharan hospital with mental alertness, mobility and vital signs. Mid-upper arm circumference ranged from 15 cm to 42 cm, and 12 (24%) of the 50 patients with a MUAC less than 20 cm died (OR 4.84, 95% CI 2.23-10.37). Of the 237 patients with a MUAC more than 28 cm only six (2.5%) died (OR 0.27, 95% CI 0.10-0.67). On logistic regression, the National Early Warning Score (NEWS), alertness, mobility and MUAC were independent predictors of in-hospital mortality. Mid-upper arm circumference is an independent predictor of the in-hospital mortality of acutely ill medical patients in a resource-poor hospital in sub-Saharan Africa.
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Affiliation(s)
| | | | | | | | - Mikkel Brabrand
- Institute of Regional Health Research, University of Southern Denmark, Denmark
| | - on behalf of the Kitovu Hospital Study Group
- Kitovu Hospital, Masaka, Uganda
- Kitovu Hospital, Masaka, Uganda
- Kitovu Hospital, Masaka, Uganda
- University of Southern Denmark, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Denmark
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Stephens K, Escobar A, Jennison EN, Vaughn L, Sullivan R, Abdel-Rahman S. Evaluating Mid-Upper Arm Circumference Z-Score as a Determinant of Nutrition Status. Nutr Clin Pract 2018; 33:124-132. [DOI: 10.1002/ncp.10018] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 06/30/2017] [Indexed: 11/06/2022] Open
Affiliation(s)
- Karen Stephens
- Department of Nutrition Services; Children's Mercy Hospital; Kansas City Missouri USA
| | - April Escobar
- Department of Nutrition Services; Children's Mercy Hospital; Kansas City Missouri USA
| | - Erika Nicole Jennison
- Department of Nutrition Services; Children's Mercy Hospital; Kansas City Missouri USA
| | - Lindsey Vaughn
- Department of Nutrition Services; Children's Mercy Hospital; Kansas City Missouri USA
| | - Rhonda Sullivan
- Department of Nutrition Services; Children's Mercy Hospital; Kansas City Missouri USA
| | - Susan Abdel-Rahman
- Division of Clinical Pharmacology; Medical Toxicology; and Therapeutic Innovation; Children's Mercy Hospital; Kansas City Missouri USA
- Department of Pediatrics; University of Missouri-Kansas City; School of Medicine; Kansas City Missouri USA
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Kumar A, Sharma S, Kar P, Agarwal S, Ramji S, Husain SA, Prasad S, Sharma S. Impact of maternal nutrition in hepatitis E infection in pregnancy. Arch Gynecol Obstet 2017; 296:885-895. [PMID: 28871471 DOI: 10.1007/s00404-017-4501-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 08/23/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIM The basis of host response in hepatitis E virus (HEV)-related liver disease during pregnancy-is still unclear. The study aims to evaluate anthropometric parameters and biochemical nutritional parameters in hepatitis E infection during pregnancy and correlate it with severity of the disease. METHODS A total of consecutive 267 pregnant women with jaundice were recruited. The jaundiced patients were classified as acute viral hepatitis (AVH) or acute liver failure (ALF). The study group included 144 pregnant women with HEV infection and 144 healthy asymptomatic age and gestational age-matched pregnant women as controls. Nutritional factors were evaluated on basis of anthropometric parameters and biochemical factors. Serum prealbumin and folate were assayed by ELISA kit. RESULTS All nutritional parameters were significantly lower in pregnant women with HEV infection as compared with healthy pregnant controls. Some of the nutritional parameters significantly lower in ALF pregnant patients compared to AVH pregnant patients in HEV group. Linear regression analysis of the AVH group showed that serum total protein and mid-upper arm circumference (MUAC) were significant predictors for bilirubin, body mass index (BMI) could significantly predict viral load level, and total protein, prealbumin, folate, and tricep skin fold thickness (TSFT) could significantly predict prothrombin time. In ALF group, serum prealbumin could significantly predict bilirubin levels and MUAC could significantly predict prothrombin time. CONCLUSION Malnutrition might confer a higher predisposition for HEV infection during pregnancy and is associated with increased severity of disease in terms of occurrence of ALF.
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Affiliation(s)
- Ashok Kumar
- Department of Obstetrics and Gynecology, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, 110002, India. .,, 13B, DDA Flats, Ber Sarai, New Delhi, 110016, India.
| | - Sheetal Sharma
- Department of Obstetrics and Gynecology, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, 110002, India
| | - Premashish Kar
- Department of Medicine, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, 110002, India
| | - Sarita Agarwal
- Department of Biochemistry, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, 110002, India
| | - Siddhartha Ramji
- Department of Neonatology, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, 110002, India
| | - Syed Akhtar Husain
- Department of Biosciences, Jamia Millia Islamia, Jamia Nagar, New Delhi, 110025, India
| | - Sudha Prasad
- Department of Obstetrics and Gynecology, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, 110002, India
| | - Shashi Sharma
- National Institute of Cancer Prevention and Research (NICPR) ICMR, Sector-39, Noida, Uttar Pradesh, 201301, India
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Guerra RS, Fonseca I, Sousa AS, Jesus A, Pichel F, Amaral TF. ESPEN diagnostic criteria for malnutrition – A validation study in hospitalized patients. Clin Nutr 2017; 36:1326-1332. [DOI: 10.1016/j.clnu.2016.08.022] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 01/25/2016] [Accepted: 08/24/2016] [Indexed: 01/10/2023]
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Jaroch A, Główczewska-Siedlecka E, Jaroch K, Kędziora-Kornatowska K. Application of Nutritional Risk Score-2002 Questionnaire and Other Nutritional Status Parameters Among Hospitalized Elderly. INT J GERONTOL 2017. [DOI: 10.1016/j.ijge.2016.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Santos CA, Fonseca J, Carolino E, Guerreiro AS. LOW SERUM CHROMIUM IS RARE IN PATIENTS THAT UNDERWENT ENDOSCOPIC GASTROSTOMY FOR LONG TERM ENTERAL FEEDING. ARQUIVOS DE GASTROENTEROLOGIA 2017; 54:211-216. [PMID: 28538943 DOI: 10.1590/s0004-2803.201700000-25] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/09/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients that underwent Percutaneous Endoscopic Gastrostomy (PEG) present with protein-energy malnutrition. Trace elements are required in small quantities and Chromium (Cr) displays a major role in the metabolism. OBJECTIVE This study aims to evaluate Cr levels and its relationship with serum proteins, BMI and underlying diseases during the first 3 months of PEG feeding. METHODS Prospective observational study during 3-months, when PEG was performed (T0), after 4 (T1), and 12 weeks (T3). Initial evaluation included: age, gender, underlying disease, NRS-2002, BMI, serum albumin, transferrin and Cr concentration. At T1 and T3 a blood sample was collected for Cr, albumin and transferrin. A Graphite Furnace Atomic Absorption Spectroscopy was used to assess Cr. According with the underlying disease, patients were divided into two groups: head and neck cancer (HNC) and neurological dysphagia (ND). All patients were fed with homemade meals. RESULTS A one hundred and twenty-nine patients (80 males), 26-95 years old were studied: HNC-52; ND-77. The observed data included low mean values of BMI from 71 patients; low Cr-8, low albumin-70, low transferrin-85 and 57 with both proteins low. Albumin was associated with survival time ( P =0.024) and there was a significant correlation between albumin and Cr (r=0.217, P =0.012). A good evolution of Cr and proteins values was observed, with no low Cr levels at T3. CONCLUSION Low serum Cr is rare in PEG-patients, with no relationship to other studied parameters. For the minority of patients displaying low Cr before gastrostomy, homemade PEG meals seem to be effective.
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Affiliation(s)
| | - Jorge Fonseca
- GENE - Enteral Feeding Team. Hospital Garcia de Orta, Portugal.,Center for Interdisciplinary Research Egas Moniz (CiiEM), Almada, Portugal
| | - Elisabete Carolino
- Departamento das Ciências Naturais e Exatas, Escola Superior de Tecnologias da Saúde de Lisboa, Instituto Politécnico de Lisboa, Portugal
| | - António Sousa Guerreiro
- Centro de Estudos de Doenças Crónicas (CEDOC), NOVA Medical School / Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Portugal.,Serviço de Medicina 4 / Hospital Santa Marta / Centro Hospitalar de Lisboa Central, Portugal
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