Short-term protein and energy supplementation activates nitrogen kinetics and accretion in poorly nourished elderly subjects

Association of Non-Invasive Positive Pressure Ventilation with Short-Term Clinical Outcomes in Patients Hospitalized for Acute Decompensated Heart Failure

The real-world evidence has been sparse on the impact of non-invasive positive pressure ventilation (NPPV) on the outcomes in acute decompensated heart failure (ADHF) patients. We aim to explore this issue in the prospective multicenter WET-HF registry. Among 3927 patients (77 (67–84) years, male 60%), the NPPV was used in 775 patients (19.7%). The association of NPPV use with in-hospital outcome and length of hospital stay (LOS) was examined by two methods, propensity score (PS) matching and multivariable analysis with adjustment for PS. In these analyses the NPPV group exhibited a lower endotracheal intubation (ETI) rate and a comparable in-hospital mortality, but longer LOS compared to the non-NPPV group. In the stratified analysis, the NPPV group exhibited a significantly lower ETI rate in patients with ischemic etiology, systolic blood pressure (sBP) > 140 mmHg and the Controlling Nutritional Status (CONUT) score ≤ 3, indicating better nutritional status. On the contrary, NPPV use was associated with longer LOS in patients with non-ischemic etiology, sBP < 100 mmHg and CONUT score > 3. In conclusion, NPPV use was associated with a lower incidence of ETI. Particularly, patients with ischemic etiology, high sBP, and better nutritional status might benefit from NPPV use.

Assessing calorie and protein recommendations for survivors of critical illness weaning from prolonged mechanical ventilation - can we find a proper balance?

Background & aims:

Survivors of critical illness requiring prolonged mechanical ventilation (PMV) are predisposed to malnutrition, muscle wasting, and weakness. There is a lack of data regarding nutrition adequacy among these patients, and although nitrogen balance has been studied as a marker of adequate protein intake in healthy individuals and acutely critically ill patients, it has not been well studied in critically ill patients with PMV. The purpose of this study was to determine if patients requiring PMV admitted to a long-term acute care hospital (LTACH) achieved registered dietitian (RD) recommended goals for energy and protein intake and if the recommendations were adequate to avoid negative nitrogen balance.

Methods:

Using a retrospective, cohort study design, patients requiring PMV who had orders for 24-h urine collections for urea nitrogen (24hrUUN) were included. Energy and protein intake was calculated from chart documentation of dietary intake for the 24-h period during which patients underwent a 24hrUUN. Nitrogen intake was estimated from protein intake. Dietary intake was compared to RD-recommendations to determine the percentage of RD-recommendations achieved. Nitrogen balance was calculated as nitrogen intake minus nitrogen loss, with negative balance categorized as less than −1.

Results:

Subjects (n = 16) were 38% male and 75% African American (mean age 61.5 ± 3.2 years; mean BMI 27.5 ± 2.5 kg/m²). Duration of LTACH hospitalization was 26.5 (6–221) days. Mean energy and protein intake was 21.7 ± 2.9 kcal/kg/d and 1.1 ± 0.1 g/kg/d, respectively, which corresponded to 86% of both RD energy and protein recommendations. Ten patients achieved a positive nitrogen balance (mean 0.9 ± 1.1 g). In addition, there was a positive linear relationship between protein intake and nitrogen balance (r = 0.59, p = 0.016).

Conclusion:

Survivors of critical illness requiring PMV achieved a high percentage of RD-recommended protein and calories, and prevented a negative nitrogen balance in a majority of patients. Increasing protein intake can prevent a negative nitrogen balance. Future studies should evaluate whether these patients are able to maintain a steady state of nitrogen intake and excretion over time and how this affects time to and/or success of weaning.

Factors influencing the efficacy of nutritional interventions on muscle mass in older adults: a systematic review and meta-analysis

Context

Nutritional interventions stimulate muscle protein synthesis in older adults. To optimize muscle mass preservation and gains, several factors, including type, dose, frequency, timing, duration, and adherence have to be considered.

Objective

This systematic review and meta-analysis aimed to summarize these factors influencing the efficacy of nutritional interventions on muscle mass in older adults.

Data Sources

A systematic search was performed using the electronic databases MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and SPORTDiscus from inception date to November 22, 2017, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria included randomized controlled trials, mean or median age ≥65 years, and reporting muscle mass at baseline and postintervention. Exclusion criteria included genetically inherited diseases, anabolic drugs or hormone therapies, neuromuscular electrical stimulation, chronic kidney disease, kidney failure, neuromuscular disorders, and cancer.

Data Extraction

Extracted data included study characteristics (ie, population, sample size, age, sex), muscle mass measurements (ie, method, measure, unit), effect of the intervention vs the control group, and nutritional intervention factors (ie, type, composition, dose, duration, frequency, timing, and adherence).

Data Analysis

Standardized mean differences and 95%CIs were calculated from baseline to postintervention. A meta-analysis was performed using a random-effects model and grouped by the type of intervention.

Conclusions

Twenty-nine studies were included, encompassing 2255 participants (mean age, 78.1 years; SD, 2.22). Amino acids, creatine, β-hydroxy-β-methylbutyrate, and protein with amino acids supplementation significantly improved muscle mass. No effect was found for protein supplementation alone, protein and other components, and polyunsaturated fatty acids. High interstudy variability was observed regarding the dose, duration, and frequency, coupled with inconsistency in reporting timing and adherence. Overall, several nutritional interventions could be effective to improve muscle mass measures in older adults. Because of the substantial variability of the intervention factors among studies, the optimum profile is yet to be established.

Systematic Review Registration

PROSPERO registration no. CRD42018111306.

Prognostic value of Mini Nutritional Assessment-Short Form with aortic valve stenosis following transcatheter aortic valve implantation

Aims

Older adults at risk for malnutrition are known to have a high mortality rate. This study aimed to investigate whether the Mini Nutritional Assessment—Short Form (MNA‐SF) could predict midterm mortality in patients undergoing transcatheter aortic valve implantation (TAVI).

Methods and results

We applied the MNA‐SF in 288 patients who had undergone TAVI from January 2016 to June 2019 at the St. Marianna University School of Medicine hospital. Using the MNA‐SF cut‐off value to indicate the risk of malnutrition, patients were divided into two groups, namely, those with an MNA‐SF score ≤11 (impaired MNA‐SF group) and those with an MNA‐SF score ≥12 (maintained MNA‐SF group). We used this value to investigate the association between the MNA‐SF and all‐cause mortality. Overall, 188 (65%) and 100 (35%) patients comprised the impaired MNA‐SF and maintained MNA‐SF groups, respectively, and 41 patients died after TAVI (mean follow‐up duration, 458 ± 315 days). Kaplan–Meier analyses showed that patients in the impaired MNA‐SF group had a significantly higher incidence of all‐cause mortality (hazard ratio 2.67; 95% confidence interval 1.29–6.21; P = 0.01). Multivariate Cox regression analyses showed that the MNA‐SF score was an independent predictor of all‐cause mortality after adjusting for the Society of Thoracic Surgeons risk score, Katz Index, and brain natriuretic peptide test results (hazard ratio 1.14; 95% confidence interval 1.01–1.28; P = 0.04).

Conclusions

The MNA‐SF was useful to screen for the risk of malnutrition in patients with TAVI and in predicting midterm prognoses in patients undergoing TAVI and could predict patient mortality after the procedure.

The Association of Food Intake and Physical Activity with Body Composition, Muscle Strength, and Muscle Function in Postmenopausal Women

Sarcopenia is defined as an age-related reduction in muscle mass and performance. Some of the most important risk factors include advanced age, malnutrition, and sedentary lifestyle. The aim of this study was to investigate the association of food intake and physical activity with body composition, muscle strength, and muscle function in a cross-sectional study of postmenopausal women. This analysis gave a positive association between physical activity and handgrip strength, calorie intake and muscle function, protein intake and fat-free mass percentage, and total fat intake and fat mass percentage. In addition, there were negative associations found between carbohydrate intake and muscle function, as well as total fat intake and fat-free mass percentage. This chapter presents a protocol for the study setup along with measurements of physical activity, handgrip strength, nutrient intake, and fat-free mass percentage.

Dietary protein intake in older adults undergoing cardiac surgery

BACKGROUND

Older adults undergoing major surgery have increased protein requirements in the postoperative period, but there are limited data describing actual protein intake following cardiac surgery.

METHODS AND RESULTS

We performed a prospective sub-study within a registry of older adults ≥60 years of age undergoing cardiac surgery at a tertiary care centre. A dietician administered a food frequency questionnaire before surgery and 1-4 months after surgery. In-hospital food intake was recorded by direct observation for 3 days in the early postoperative period. Food intake was analyzed to calculate the protein intake per kilogram of body weight per day (g/kg/d) during the three phases of care, compared to the dietary reference intake. Frailty was measured by a questionnaire and physical performance tests before surgery. There were 22 patients (8 females, 14 males; 59% frail) enrolled in the study with a mean age of 72.0 ± 7.8 years. The mean protein intake was 1.3 ± 0.5 g/kg/d, 0.7 ± 0.3 g/kg/d, and 1.3 ± 0.6 g/kg/d in the preoperative, early postoperative, and postdischarge periods, respectively (P < 0.0001 for early postoperative compared to other periods). Compared to the targeted dietary reference intake of 1.5 g/kg/d, there was a mean protein deficit of 0.8 g/kg/d in the early postoperative period. Only one patient (5%) met the protein dietary reference intake in the early postoperative period.

CONCLUSION

In older adults undergoing cardiac surgery, dietary protein intake was substantially lower than the recommended target in the early postoperative period. Strategies to improve protein intake, particularly in frail older patients, may be considered as a therapeutic target.

Are the therapeutic strategies in anorexia of ageing effective on nutritional status? A systematic review with meta-analysis

BACKGROUND

Anorexia of ageing (AA) may be considered as a risk factor for frailty and has an important impact on quality of life, morbidity and mortality.

METHODS

A systematic review and a meta-analysis were performed to summarise the results from several trials on the effectiveness of treatments in AA, as associated with depression, sensory impairment of taste and smell, decreased appetite or early satiety, and disability. Eligible studies were required to report baseline and follow-up values, the mean change (∆-change) from baseline, and/or the mean difference among intervention groups versus control group, concerning food intake (kcal/daily) and/or nutritional outcomes, such as body weight, body mass index, albumin and Mini Nutritional Assessment.

RESULTS

The systematic review included 20 papers based on different therapeutic approaches concerning food intake and/or nutritional outcomes. The results of the meta-analysis indicate that the interventions for AA have an important impact on body weight [+1.59 kg; 95% confidence interval (CI) = 1.48-+1.71 kg; P < 0.001) and on energy intake (+56.09 kcal; 95% CI = -54.05 to +166.25 kcal; P = 0.32). Regarding secondary outcomes, it was not possible to meta-analyse the limited amount of data availab le.

CONCLUSIONS

The different variants of AA need to be defined because diverse therapeutic approaches are available. A more precise definition of the functional impairments associated with AA may allow a more correct decision about the most appropriate therapy to be prescribed. Moreover, this may allow for a more effective performance of the different therapeutic approaches once they are better targeted to the different scenarios of AA.

Nutrition support in hospitalised adults at nutritional risk

BACKGROUND

The prevalence of disease-related malnutrition in Western European hospitals is estimated to be about 30%. There is no consensus whether poor nutritional status causes poorer clinical outcome or if it is merely associated with it. The intention with all forms of nutrition support is to increase uptake of essential nutrients and improve clinical outcome. Previous reviews have shown conflicting results with regard to the effects of nutrition support.

OBJECTIVES

To assess the benefits and harms of nutrition support versus no intervention, treatment as usual, or placebo in hospitalised adults at nutritional risk.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid SP), Embase (Ovid SP), LILACS (BIREME), and Science Citation Index Expanded (Web of Science). We also searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp); ClinicalTrials.gov; Turning Research Into Practice (TRIP); Google Scholar; and BIOSIS, as well as relevant bibliographies of review articles and personal files. All searches are current to February 2016.

SELECTION CRITERIA

We include randomised clinical trials, irrespective of publication type, publication date, and language, comparing nutrition support versus control in hospitalised adults at nutritional risk. We exclude trials assessing non-standard nutrition support.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane and the Cochrane Hepato-Biliary Group. We used trial domains to assess the risks of systematic error (bias). We conducted Trial Sequential Analyses to control for the risks of random errors. We considered a P value of 0.025 or less as statistically significant. We used GRADE methodology. Our primary outcomes were all-cause mortality, serious adverse events, and health-related quality of life.

MAIN RESULTS

We included 244 randomised clinical trials with 28,619 participants that met our inclusion criteria. We considered all trials to be at high risk of bias. Two trials accounted for one-third of all included participants. The included participants were heterogenous with regard to disease (20 different medical specialties). The experimental interventions were parenteral nutrition (86 trials); enteral nutrition (tube-feeding) (80 trials); oral nutrition support (55 trials); mixed experimental intervention (12 trials); general nutrition support (9 trials); and fortified food (2 trials). The control interventions were treatment as usual (122 trials); no intervention (107 trials); and placebo (15 trials). In 204/244 trials, the intervention lasted three days or more.We found no evidence of a difference between nutrition support and control for short-term mortality (end of intervention). The absolute risk was 8.3% across the control groups compared with 7.8% (7.1% to 8.5%) in the intervention groups, based on the risk ratio (RR) of 0.94 (95% confidence interval (CI) 0.86 to 1.03, P = 0.16, 21,758 participants, 114 trials, low quality of evidence). We found no evidence of a difference between nutrition support and control for long-term mortality (maximum follow-up). The absolute risk was 13.2% in the control group compared with 12.2% (11.6% to 13%) following nutritional interventions based on a RR of 0.93 (95% CI 0.88 to 0.99, P = 0.03, 23,170 participants, 127 trials, low quality of evidence). Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.We found no evidence of a difference between nutrition support and control for short-term serious adverse events. The absolute risk was 9.9% in the control groups versus 9.2% (8.5% to 10%), with nutrition based on the RR of 0.93 (95% CI 0.86 to 1.01, P = 0.07, 22,087 participants, 123 trials, low quality of evidence). At long-term follow-up, the reduction in the risk of serious adverse events was 1.5%, from 15.2% in control groups to 13.8% (12.9% to 14.7%) following nutritional support (RR 0.91, 95% CI 0.85 to 0.97, P = 0.004, 23,413 participants, 137 trials, low quality of evidence). However, the Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.Trial Sequential Analysis of enteral nutrition alone showed that enteral nutrition might reduce serious adverse events at maximum follow-up in people with different diseases. We could find no beneficial effect of oral nutrition support or parenteral nutrition support on all-cause mortality and serious adverse events in any subgroup.Only 16 trials assessed health-related quality of life. We performed a meta-analysis of two trials reporting EuroQoL utility score at long-term follow-up and found very low quality of evidence for effects of nutritional support on quality of life (mean difference (MD) -0.01, 95% CI -0.03 to 0.01; 3961 participants, two trials). Trial Sequential Analyses showed that we did not have enough information to confirm or reject clinically relevant intervention effects on quality of life.Nutrition support may increase weight at short-term follow-up (MD 1.32 kg, 95% CI 0.65 to 2.00, 5445 participants, 68 trials, very low quality of evidence).

AUTHORS' CONCLUSIONS

There is low-quality evidence for the effects of nutrition support on mortality and serious adverse events. Based on the results of our review, it does not appear to lead to a risk ratio reduction of approximately 10% or more in either all-cause mortality or serious adverse events at short-term and long-term follow-up.There is very low-quality evidence for an increase in weight with nutrition support at the end of treatment in hospitalised adults determined to be at nutritional risk. The effects of nutrition support on all remaining outcomes are unclear.Despite the clinically heterogenous population and the high risk of bias of all included trials, our analyses showed limited signs of statistical heterogeneity. Further trials may be warranted, assessing enteral nutrition (tube-feeding) for different patient groups. Future trials ought to be conducted with low risks of systematic errors and low risks of random errors, and they also ought to assess health-related quality of life.

The Association between Total Protein and Vegetable Protein Intake and Low Muscle Mass among the Community-Dwelling Elderly Population in Northern Taiwan

Sarcopenia, highly linked with fall, frailty, and disease burden, is an emerging problem in aging society. Higher protein intake has been suggested to maintain nitrogen balance. Our objective was to investigate whether pre-sarcopenia status was associated with lower protein intake. A total of 327 community-dwelling elderly people were recruited for a cross-sectional study. We adopted the multivariate nutrient density model to identify associations between low muscle mass and dietary protein intake. The general linear regression models were applied to estimate skeletal muscle mass index across the quartiles of total protein and vegetable protein density. Participants with diets in the lowest quartile of total protein density (<13.2%) were at a higher risk for low muscle mass (odds ratio (OR) 3.03, 95% confidence interval (CI) 1.37–6.72) than those with diets in the highest quartile (≥17.2%). Similarly, participants with diets in the lowest quartile of vegetable protein density (<5.8%) were at a higher risk for low muscle mass (OR 2.34, 95% CI 1.14–4.83) than those with diets in the highest quartile (≥9.4%). Furthermore, the estimated skeletal muscle mass index increased significantly across the quartiles of total protein density (p = 0.023) and vegetable protein density (p = 0.025). Increasing daily intakes of total protein and vegetable protein densities appears to confer protection against pre-sarcopenia status.

Nitrogen Balance and Protein Requirements for Critically Ill Older Patients

Critically ill older patients with sarcopenia experience greater morbidity and mortality than younger patients. It is anticipated that unabated protein catabolism would be detrimental for the critically ill older patient. Healthy older subjects experience a diminished response to protein supplementation when compared to their younger counterparts, but this anabolic resistance can be overcome by increasing protein intake. Preliminary evidence suggests that older patients may respond differently to protein intake than younger patients during critical illness as well. If sufficient protein intake is given, older patients can achieve a similar nitrogen accretion response as younger patients even during critical illness. However, there is concern among some clinicians that increasing protein intake in older patients during critical illness may lead to azotemia due to decreased renal functional reserve which may augment the propensity towards worsened renal function and worsened clinical outcomes. Current evidence regarding protein requirements, nitrogen balance, ureagenesis, and clinical outcomes during nutritional therapy for critically ill older patients is reviewed.

Need-based nutritional intervention is effective in improving handgrip strength and Barthel Index scores of older people living in a nursing home: a randomized controlled trial

BACKGROUND

Nutritional status is associated with physical functioning in older people. Protein-energy malnutrition can limit functional performance.

OBJECTIVES

This study examined the effectiveness of a "need-based intervention" on improving the physical functioning of older adults living in nursing homes.

DESIGN

A 24-week randomized, double-blind, controlled trial.

SETTINGS

A privately managed geriatric nursing home in Taiwan.

PARTICIPANTS

Ninety-two persons who were ≥65 years old, ≤25 kg/m(2), >1 month residence, non-bed-ridden, without acute infection, and able to self-feed or receive oral feeding.

METHODS

Qualified participants were stratified by gender and then randomly assigned to either the control group (n=45) or the intervention group (n=47). Each participant in the intervention group would receive a 50 g/day soy-protein-based nutritional supplement when he/she was rated as undernourished, defined as Mini Nutritional Assessment score ≤24 and body mass index ≤24 kg/m(2). The supplement contained 9.5 g protein, 250 kcal energy, and all essential micronutrients. The supplementation would be suspended if either one of the two "at risk" conditions was not met at the next measurement (every 4 weeks). Handgrip strength and Barthel Index were measured at baseline, mid-point (week 12), and end-point (week 24) of the trial. Results were analyzed with Student's t-test and by the Generalized Estimating Equations controlled for nutritional status.

RESULTS

The intervention significantly improved (a) handgrip strength of the older adults at weeks 12 and 24, and (b) the overall Barthel Index at week 24 (all p<0.05) according to the Generalized Estimating Equations.

CONCLUSIONS

"Need-based intervention" can be an effective and useful strategy for improving the physical functioning of older adults living in nursing homes, without adverse effects. The results probably are the indirect results of the improved nutritional status. The study highlights the importance of routine screening and timely intervention in geriatric care. The applicability of this need-based strategy to community-living older adults is an important issue and should be evaluated. We can probably reap a greater benefit by eliminating the risk of malnutrition at the emerging stage.

Influence of aging on nitrogen accretion during critical illness

BACKGROUND

Aging adversely affects nitrogen accretion during health, but its effect during critical illness is unknown. Nitrogen balance (NB) response to varying protein intakes was compared between critically ill, older and younger patients.

METHODS

Adult patients admitted to the trauma intensive care unit, given enteral or parenteral nutrition, and who had a NB determination within 5-14 days after injury were evaluated. Patients with renal or hepatic disease were excluded. Patients were categorized as older (≥60 years) or younger (18-59 years of age). Data are given as mean ± SD or median [interquartile range].

RESULTS

Fifty-four older (69 [65, 77] years) and 195 younger (35 [27, 47] years) patients were evaluated. NB was blunted for the older patients with an observed trending improvement in NB from -13.5 ± 5.5 to -5.6 ± 8.8 g/d (P = NS) noted at 1.5-1.99 g/kg/d. NB improved from -22.2 ± 8.2 to -11.8 ± 9.9 g/d (P = .05) at 1-1.49 g/kg/d and modestly thereafter for each 0.5-g/kg/d increase in protein intake for the younger patients. Serum urea nitrogen concentration during the NB was highly variable but overall greater for the older patients (20 [14, 33] vs 15 [10, 20] mg/dL, P = .001).

CONCLUSIONS

Improvement in nitrogen accretion was blunted at lower protein intakes in critically ill, older patients compared with younger patients. Individualization of protein intake is warranted.

Systematic review and meta-analysis of the effects of high protein oral nutritional supplements

Disease-related malnutrition is common, detrimentally affecting the patient and healthcare economy. Although use of high protein oral nutritional supplements (ONS) has been recommended to counteract the catabolic effects of disease and to facilitate recovery from illness, there is a lack of systematically obtained evidence to support these recommendations. This systematic review involving 36 randomised controlled trials (RCT) (n=3790) (mean age 74 years; 83% of trials in patients >65 years) and a series of meta-analyses of high protein ONS (>20% energy from protein) demonstrated a range of effects across settings and patient groups in favour of the high protein ONS group. These included reduced complications (odds ratio (OR) 0.68 (95%CI 0.55-0.83), p<0.001, 10 RCT, n=1830); reduced readmissions to hospital (OR 0.59 (95%CI 0.41-0.84), p=0.004, 2 RCT, n=546); improved grip strength (1.76 kg (95%CI 0.36-3.17), p<0.014, 4 RCT, n=219); increased intake of protein (p<0.001) and energy (p<0.001) with little reduction in normal food intake and improvements in weight (p<0.001). There was inadequate information to compare standard ONS (<20% energy from protein) with high protein ONS (>20% energy from protein). The systematic review and meta-analysis provides evidence that high protein supplements produce clinical benefits, with economic implications.

Nutritional status and associations with falls, balance, mobility and functionality during hospital admission

OBJECTIVES

To explore associations between nutritional status, falls and selected falls risk factors amongst older hospitalized people. Lengths of stay amongst fallers and the malnourished were assessed.

DESIGN

An observational longitudinal cohort study.

SETTING

Geriatric Assessment and Rehabilitation Unit (GARU) of a tertiary teaching hospital.

PARTICIPANTS

Admissions to the GARU during a six-month period were included.

MEASUREMENTS

Associations between nutritional status and falls during hospitalization, reported preadmission history of falls, functional status, balance and mobility during GARU admission were analysed. Associations between nutritional status or experiencing a hospital fall and length of stay were also examined.

RESULTS

Malnutrition prevalence was 39% (75/194, 95% CI 32-46%) with odds of falling during admission being 1.49 (95%CI: 0.81, 2.75), p< 0.20). Patients assessed as malnourished were older (p<0.001) and more likely to have a poorer score on both the admission (p<0.05) and discharge (p<0.009) timed "Up and Go" test. Malnutrition was associated with reduced mobility (p<0.05). Those who fell during admission had statistically greater lengths of stay compared with non-fallers [median (range): 57.0 (7-127) vs 35.0 (5-227) days; p<0.002].

CONCLUSION

Evidence of reduced mobility was evident during GARU admission amongst older people assessed as malnourished. Considering the results, a larger study concerning nutritional status, functionality and falls in the hospitalized population is warranted. The influence of nutritional status upon a person's physical functioning should be considered more broadly in falls research.

Predicting the value of the Mini Nutritional Assessment (MNA) as an indicator of functional ability in older Iranian adults (Kahrizak elderly study)

OBJECTIVE

We aimed to investigate the appropriateness of the Mini Nutritional Assessment (MNA) in predicting functional ability in older adults.

DESIGN

Cross-sectional study.

SETTING

Participants were recruited from the Kahrizak Charity Foundation (KCF).

MEASUREMENTS

Nutritional and ability status were examined using the MNA and the Barthel Index (BI). Participants were divided according to MNA (≤ 23.5 and > 23.5).

RESULTS

Two hundred and thirty-five ≥ 60-year-old subjects were studied. The MNA and BI were positively correlated (r = 0.199; P = 0.001). The optimal cut-off point for BI with the highest sensitivity and specificity derived from the ROC curve was approximately 91.5 for males and 83.5 for females. The BI was significantly associated with MNA (odds ratio (OR): 1.89; 95% CI: 1.17-3.05, P = 0.009), mobility (OR: 6.39; 95% CI: 3.43-11.89, P < 0.001), consuming ≥ 2 servings of fruit and vegetables (OR: 2.27; 95% CI: 1.09-4.72, P = 0.02) and self-view of nutritional status (OR: 4.15; 95%CI: 1.26-13.63, P = 0.01). The sensitivity (62.9% in males; 68.2% in females) and specificity (51.4% in males and 52.9% in females) of these cut-off points justifies the appropriateness of the MNA for determining functional ability.

CONCLUSION

The MNA is potentially able to verify functional status among the elderly (as BI ≥ 91.5 with those of < 91.5 in males and ≥ 83.5 with those of < 83.5 in females) of KCF. It is suggested that this relationship should be further studied in a larger prospective population-based study.

Short-term protein intake increases fractional synthesis rate of muscle protein in the elderly: meta-analysis

The precise effects of protein intake on fractional synthesis rate (FSR) of muscle protein are still under debate. The sample size of these studies was small and the conclusions in young and elderly subjects were inconsistent. To assess the effect of dietary protein intake on the FSR level, we conducted a meta-analysis of controlled protein intake trials. Random-effects models were used to calculate the weighted mean differences (WMDs). Ten studies were included and effects of short-term protein intake were evaluated. In an overall pooled estimate, protein intake significantly increased the FSR (20 trials, 368 participants; WMD: 0.025%/h; 95%CI: 0.019-0.031; P < 0.0001). Meta-regression analysis suggested that the protein dose was positively related to the effect size (regression coefficient = 0.108%/h; 95%CI: 0.035, 0.182; P = 0.009). A subgroup analysis indicated that protein intake significantly increased FSR when the protein dose was ≤ 0.80 g/kg BW (16 trials, 308 participants; WMD: 0.027%/h; 95%CI: 0.019-0.031; P < 0.0001), but did not affect FSR when the protein dose was > 0.80 g/kg BW (4 trials, 60 participants; WMD: 0.016%/h; 95%CI: 0.004-0.029; P = 0.98). In conclusion, this study is the first integrated results showing that a short-term protein intake is effective at improving the FSR of muscle protein in the healthy elderly as well as young subjects. This beneficial effect seems to be dose-dependent when the dose levels of protein range from 0.08 to 0.80 g/kg BW.

Advantages of dietary, exercise-related, and therapeutic interventions to prevent and treat sarcopenia in adult patients: an update

Sarcopenia is the loss of skeletal muscle mass and function with aging. Although the term sarcopenia was first coined in 1989, its etiology is still poorly understood. Moreover, a consensus for defining sarcopenia continues to elude us. Sarcopenic changes in the muscle include losses in muscle fiber quantity and quality, alpha-motor neurons, protein synthesis rates, and anabolic and sex hormone production. Other factors include basal metabolic rate, increased protein dietary requirements, and chronic inflammation secondary to age-related changes in cytokines and oxidative stress. These changes lead to decreased overall physical functioning, increased frailty, falls risk, and ultimately the loss of independent living. Because the intertwining relationships of these factors are complex, effective treatment options are still under investigation. The published data on sarcopenia are vast, and this review is not intended to be exhaustive. The aim of this review is to provide an update on the current knowledge of the definition, etiology, consequences, and current clinical trials that may help address this pressing public health problem for our aging populations.

Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomized controlled trial

OBJECTIVES

To investigate whether a disease-specific nutritional approach is more beneficial than a standard dietary approach to the healing of pressure ulcers (PUs) in institutionalized elderly patients.

DESIGN

Twelve-week follow-up randomized controlled trial (RCT).

SETTING

Four long-term care facilities in the province of Como, Italy.

PARTICIPANTS

Twenty-eight elderly subjects with Stage II, III, and IV PUs of recent onset (<1-month history).

INTERVENTION

All 28 patients received 30 kcal/kg per day nutritional support; of these, 15 received standard nutrition (hospital diet or standard enteral formula; 16% calories from protein), whereas 13 were administered a disease-specific nutrition treatment consisting of the standard diet plus a 400-mL oral supplement or specific enteral formula enriched with protein (20% of the total calories), arginine, zinc, and vitamin C (P<.001 for all nutrients vs control).

MEASUREMENTS

Ulcer healing was evaluated using the Pressure Ulcer Scale for Healing (PUSH; 0=complete healing, 17=greatest severity) tool and area measurement (mm(2) and %).

RESULTS

The sampled groups were well matched for age, sex, nutritional status, oral intake, type of feeding, and ulcer severity. After 12 weeks, both groups showed significant improvement (P<.001). The treatment produced a higher rate of healing, the PUSH score revealing a significant difference at Week 12 (-6.1+/-2.7 vs -3.3+/-2.4; P<.05) and the reduction in ulcer surface area significantly higher in the treated patients already by Week 8 (-1,140.9+/-669.2 mm(2) vs -571.7+/-391.3 mm(2); P<.05 and approximately 57% vs approximately 33%; P<.02).

CONCLUSION

The rate of PU healing appears to accelerate when a nutrition formula enriched with protein, arginine, zinc, and vitamin C is administered, making such a formula preferable to a standardized one, but the present data require further confirmation by high-quality RCTs conducted on a larger scale.

Protein and energy supplementation in elderly people at risk from malnutrition

BACKGROUND

Evidence for the effectiveness of nutritional supplements containing protein and energy, often prescribed for older people, is limited. Malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition.

OBJECTIVES

This review examined trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually as commercial 'sip-feeds'.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of oral protein and energy supplementation in older people, with the exception of groups recovering from cancer treatment or in critical care.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary.

MAIN RESULTS

Sixty-two trials with 10,187 randomised participants have been included in the review. Maximum duration of intervention was 18 months. Most included trials had poor study quality. The pooled weighted mean difference (WMD) for percentage weight change showed a benefit of supplementation of 2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42 trials. There was no significant reduction in mortality in the supplemented compared with control groups (relative risk (RR) 0.92, CI 0.81 to 1.04) from 42 trials. Mortality results were statistically significant when limited to trials in which participants (N = 2461) were defined as undernourished (RR 0.79, 95% CI 0.64 to 0.97).The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75 to 0.99). Few trials were able to suggest any functional benefit from supplementation. The WMD for length of stay from 12 trials also showed no statistically significant effect (-0.8 days, 95% CI -2.8 to 1.3). Adverse effects included nausea or diarrhoea.

AUTHORS' CONCLUSIONS

Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.

Timing of creatine or protein supplementation and resistance training in the elderly

Muscle loss with age has a negative effect on strength and functional independence. Age-related loss of muscle is the result of decreased muscle fiber number and size, which are functions of altered hormonal status, physical inactivity, and variations in nutritional intake. Resistance training has a positive effect on muscle mass and strength in the elderly. Studies of protein or creatine supplementation for increasing muscle mass and strength in older individuals are equivocal. The timing of nutritional supplementation may be more important than the absolute daily intake of supplements. Protein or creatine ingestion proximate to resistance-training sessions may be more beneficial for increasing muscle mass and strength than ingestion of protein or creatine at other times of the day, possibly because of increased blood flow and therefore increased transport of amino acids and creatine to skeletal muscle.

Dietary Intake of Elderly Living in Toronto Long-Term Care Facilities: Comparison to the Dietary Reference Intake

OBJECTIVE

To compare the dietary intake of elderly living in 11 long-term care facilities (LTCFs) to the Estimated Average Requirement set as part of the Dietary Reference Intake for older adults.

DESIGN

A cross-sectional assessment of dietary intake using a 3 days food record among 407 elderly with mean age of 85.2 +/- 7.7 years and BMI of 23.8 +/- 5.7 kg/m(2). This population sample was similar to the one living in LTCFs in the province of Ontario.

RESULTS

The daily energy intake was 1513 +/- 363 kcal (6330.4 +/- 1518.8 kJ). Percentage of energy from fat, saturated fat, polyunsaturated fat, protein, and carbohydrate were 30%, 11%, 5.2%, 15%, and 56%, respectively. Although these values were close to the recommendations, 29.5% had protein intake below the recommended 0.8 g/kg; and 38.3% of subjects had cholesterol intake more than the recommended 300 mg/d. More than 50% of the subjects had suboptimal intake of calcium, magnesium, zinc and vitamins E, B(6), and folate. In addition, greater than 15% had suboptimal intakes of other micronutrients such as vitamins A, C, niacin, and copper.

CONCLUSIONS

Elderly subjects living in LTCFs in Toronto despite having a normal body mass index (BMI), do not meet the recommended levels of intake for protein and many of the micronutrients. LTCFs staff should monitor dietary intake. Menu modification and micronutrient supplementation may be required in order to meet the daily requirements of these elderly.

Protein supplementation before and after resistance training in older men

We determined the effects of protein supplementation immediately before (PRO-B) and after (PRO-A) resistance training (RT; 12 weeks) in older men (59-76 years), and whether this reduces deficits in muscle mass and strength compared to younger men (18-40 years). Older men were randomized to PRO-B (0.3 g/kg protein before RT + placebo after RT, n=9), PRO-A (placebo before + protein after RT, n=10), or PLA (placebo before and after RT, n=10). Lean tissue mass, muscle thickness of the elbow, knee, and ankle flexors and extensors, and leg and bench press strength were measured before and after RT and compared to databases of younger subjects (n=22-60). Myofibrillar protein degradation (3-methylhistidine) and bone resorption (cross-linked N-telopeptides) were also measured before and after RT. Lean tissue mass, muscle thickness (except ankle dorsi flexors), and strength increased with training (P<0.05), with little difference between groups. There were no changes in 3-methylhistidine or cross-linked N-telopeptides. Before RT, all measures were lower in the older compared to younger groups (P<0.05), except for elbow extensor muscle thickness. Following training, muscle thickness of the elbow flexors and ankle dorsi flexors and leg press strength were no longer different than the young, and elbow extensor muscle thickness was greater in the old men (P<0.05). Supplementation with protein before or after training has no effect on muscle mass and strength in older men. RT was sufficient to overcome deficits in muscle size of the elbow flexors and ankle dorsi flexors and leg press strength in older compared to younger men.

The end-product method of measuring whole-body protein turnover: a review of published results and a comparison with those obtained by leucine infusion

The present review summarizes the results of all published papers on whole-body protein turnover in man measured by [15N]glycine and the end-product method using both urea and ammonia. It begins with a short account of the underlying assumptions and the justification for the use of [15N]glycine. The results are then compared with those of a large sample of measurements by the 'gold standard' precursor method with continuous infusion of [13C]leucine. The pros and cons of the two methods are compared and it is suggested that there is a place for further work by the less invasive end-product method, particularly for population studies of the genetic, environmental and functional determinants of whole-body rates of protein synthesis.

Protein and energy supplementation in elderly people at risk from malnutrition

BACKGROUND

Evidence for the effectiveness of nutritional supplements containing protein and energy, which are often prescribed for older people, is limited. Furthermore malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition.

OBJECTIVES

This review examined the evidence from trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually in the form of commercial 'sip-feeds'.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers. Date of most recent search: March 2004.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised controlled trials of oral protein and energy supplementation in older people with the exception of groups recovering from cancer treatment or in critical care.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary.

MAIN RESULTS

Forty-nine trials with 4790 randomised participants have been included in the review. Most included trials had poor study quality. The pooled weighted mean difference [WMD] for percentage weight change showed a benefit of supplementation of 2.3% (95% confidence interval (CI) 1.9 to 2.7) from 34 trials. There was a reduced mortality in the supplemented compared with control groups (relative risk (RR) 0.74, CI 0.59 to 0.92) from 32 trials. The risk of complications from 14 trials showed no significant difference (RR 0.95, 95% CI 0.81 to 1.11). Few trials were able to suggest any functional benefit from supplementation. The pooled weighted mean difference (WMD) for length of stay from 10 trials also showed no statistically significant effect (WMD -1.98 days, 95% CI -5.20 to 1.24).

AUTHORS' CONCLUSIONS

Supplementation produces a small but consistent weight gain in older people. There may also be a beneficial effect on mortality. However, there was no evidence of improvement in clinical outcome, functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.

Nutritional issues in the care of the elderly patient

Aging is associated with a progressive decline in the function of many organs and apparatus. In a medical context, depletion of lean body mass and muscle mass in particular, and alteration of the immune system are of utmost importance. A defective immune response is associated with an increased incidence of inflammatory, infective and neoplastic diseases in the elderly as well as with a slow and sluggish recovery after illness or other injury. Depletion of muscle mass, the so-called sarcopenia, is responsible for the typical frailty of the elderly. Moreover, since muscle represents the protein reserve of the body, its progressive erosion not only results in a poor mobility and disability of these subjects, with associated complications, but with a diminished capacity to meet the extra demand of protein synthesis associated with disease and injury. In cancer patients, as in other elderly patients with different pathologies, it is important to evaluate the nutritional status, since frailty of these individuals recognizes as a relevant etiopathogenetic cofactor, a defective food intake. Nutritional support should aim at meeting the requirements in macronutrients, in water and in micronutrients. Requirements are not so different from those of adult subjects, since the decrease in energy expenditure due to a lower physical activity is compensated by the increase due to the disease. Particular attention must be given to fluid administration, since the elderly tolerate fluid overload less than hypohydration. Elderly patients quite frequently suffer from long-standing undernutrition; this means that nutritional repletion will take more time than is usually expected with use of medication. If a correct feeding program is performed for a few weeks, a benefit can be observed not only on the nutritional status but also in the clinical outcome. In fact nutritional support may have a permissive role in the administration of aggressive (oncologic) treatment than may be otherwise denied to elderly patients.

Frailty amplifies the effects of aging on protein metabolism: role of protein intake

BACKGROUND

We previously showed that muscle contributes less to whole-body protein breakdown with healthy aging.

OBJECTIVE

We hypothesized that frailty further compromises protein metabolism and that short-term protein supplementation improves protein status.

DESIGN

Protein metabolism was studied with the oral, 60-h [(15)N]glycine and N(tau)-methylhistidine methods in 8 frail and 13 healthy elderly women during a 9-d isoenergetic, isonitrogenous formula diet and then after increased protein intakes in the frail women, to match the intakes of healthy subjects, for 12 d.

RESULTS

Compared with healthy women, frail women had higher rates of whole-body protein synthesis and breakdown per kg fat-free mass and lower rates of muscle protein breakdown when expressed as total amounts per day but higher rates when expressed per kg muscle. Because muscle mass was lower in frail women, the contribution of muscle to whole-body protein breakdown was lower and that of nonmuscle lean tissues was higher. The protein-enriched diet had no effect on these variables but resulted in an increase in net endogenous protein balance and a positive nitrogen balance at the end of the diet period.

CONCLUSIONS

Frailty exacerbates age-related changes in protein metabolism by inducing an increase in muscle protein catabolism and a decrease in muscle mass. At low protein intakes, the increase in muscle catabolism may be a form of protection for both nonmuscle lean tissue mass and function at the expense of muscle mass. Frail women maintained the capacity to retain nitrogen after increased protein intakes, which could convey health benefits if sustained over a long enough period to result in lean tissue accretion.

Approaches to quantifying protein metabolism in response to nutrient ingestion

The investigation of protein metabolism under various nutritional and physiological conditions has been made possible by the use of indirect, principally tracer-based methods. Most studies were conducted at the whole-body level, mainly using steady-state isotopic techniques and equations based on simple two-pool models, in which amino acids are either free or protein bound. Because whole-body methods disregard regional contributions to protein metabolism, some regional approaches have tried to distinguish the distribution of protein kinetics in the different tissues. The organ-balance tracer technique, involving the arteriovenous catheterization of regions or organs with concomitant isotopic tracer infusion, distinguishes between amino acid uptake and release in the net amino acid balance and measures protein synthesis and degradation under steady-state conditions. Last, the importance has become clear of the difference in dietary and endogenous amino acids recycled from proteolysis for anabolic and catabolic pathways. In humans, the dual tracer technique, which consists of the simultaneous oral/enteral administration and intravenous infusion of different tracers of the same amino acid, allows an estimate of the splanchnic uptake of amino acids administered. Furthermore, the whole-body retention of labeled dietary nitrogen after the ingestion of a single protein meal has enabled a clearer understanding of the metabolic fate of dietary amino acids. Based on such data, a newly developed compartmental model provides a simulation of the regional distribution and metabolism of ingested nitrogen in the fed state by determining its dynamic fate through free and protein-bound amino acids in both the splanchnic and peripheral areas in humans.

Treatment of protein-energy malnutrition in chronic nonmalignant disorders

Protein-energy malnutrition (PEM) is common in connection with chronic disease and is associated with increased morbidity and mortality. Because the risk of PEM is related to the degree of illness, the causal connections between malnutrition and a poorer prognosis are complex. It cannot automatically be inferred that nutritional support will improve the clinical course of patients with wasting disorders. We reviewed studies of the treatment of PEM in cases of chronic obstructive pulmonary disease, chronic heart failure, stroke, dementia, rehabilitation after hip fracture, chronic renal failure, rheumatoid arthritis, and multiple disorders in the elderly. Several methodologic problems are associated with nutrition treatment studies in chronically ill patients. These problems include no generally accepted definition of PEM, uncertain patient compliance with supplementation, and a wide range of outcome variables. Avail-able treatment studies indicate that dietary supplements, either alone or in combination with hormonal treatment, may have positive effects when given to patients with manifest PEM or to patients at risk of developing PEM. In chronic obstructive pulmonary disease, nutritional treatment may improve respiratory function. Nutritional therapy of elderly women after hip fractures may speed up the rehabilitation process. When administered to elderly patients with multiple disorders, diet therapy may improve functional capacity. The data regarding nutritional treatment of the conditions mentioned above is still inconclusive. There is still a great need for randomized controlled long-term studies of the effects of defined nutritional intervention programs in chronically ill and frail elderly with a focus on determining clinically relevant outcomes.

Ageing and muscle: the effects of malnutrition, re-nutrition, and physical exercise

Because of the metabolic changes caused by ageing, malnutrition is accompanied by a preferential loss of fat-free mass in the elderly, and it exaggerates the physiological loss of body cell mass, muscle mass and muscle function observed in the aged. Exercise training has positive anabolic effects even in the frail elderly, and may improve the effect of re-nutrition in malnourished elderly patients.

Nutritional status after short-term dietary supplementation in hospitalized malnourished geriatric patients

AIM

To examine the evolution of different parameters of the nutritional status after short-term oral protein-energy supplementation in moderately malnourished geriatric patients.

METHODS

Seventeen hospitalized malnourished elderly patients and 12 healthy adults received dietary supplements for 10 days. A group of six malnourished elderly subjects served as controls. Spontaneous oral intakes, biological and biophysical markers of the nutritional status were measured. Fat-free mass (FFM) was assessed using Dual energy X-ray absorptiometry (DXA), bio-impedance analysis (BIA) and anthropometry.

RESULTS

In elderly subjects, the supplementation significantly increased both dietary intake (energy +32%, protein +65%) and FFM (+1.3 kg, P<0.001) as assessed using DXA. BIA and anthropometric data correlated with DXA measurements in the elderly (BIA: r=0.68--0.80, anthropometry: r=0.80--0.89), but failed to reflect accurately the changes measured in FFM. Supplementation had no notable effect on biological markers in any of the groups. IGF-I and hand-grip strength were not significantly influenced by the supplementation despite trends towards an improvement.

CONCLUSIONS

Monitoring short-term changes in nutritional status in malnourished elderly individuals is a problem in routine clinical management. Our data put in the limelight the changes in IGF-I values related to dietary supplementation, and, chiefly, suggest a prime role for the assessment of dietary intake and FFM, as assessed by DXA, as indicators of short-term efficacy of refeeding. Nevertheless larger studies are necessary to confirm the clinical and prognostic significance of the changes.

Beyond the zone: protein needs of active individuals

There has been debate among athletes and nutritionists regarding dietary protein needs for centuries. Although contrary to traditional belief, recent scientific information collected on physically active individuals tends to indicate that regular exercise increases daily protein requirements; however, the precise details remain to be worked out. Based on laboratory measures, daily protein requirements are increased by perhaps as much as 100% vs. recommendations for sedentary individuals (1.6-1.8 vs. 0.8 g/kg). Yet even these intakes are much less than those reported by most athletes. This may mean that actual requirements are below what is needed to optimize athletic performance, and so the debate continues. Numerous interacting factors including energy intake, carbohydrate availability, exercise intensity, duration and type, dietary protein quality, training history, gender, age, timing of nutrient intake and the like make this topic extremely complex. Many questions remain to be resolved. At the present time, substantial data indicate that the current recommended protein intake should be adjusted upward for those who are physically active, especially in populations whose needs are elevated for other reasons, e.g., growing individuals, dieters, vegetarians, individuals with muscle disease-induced weakness and the elderly. For these latter groups, specific supplementation may be appropriate, but for most North Americans who consume a varied diet, including complete protein foods (meat, eggs, fish and dairy products), and sufficient energy the increased protein needs induced by a regular exercise program can be met in one's diet.