Energy balance in elderly patients after surgery for a femoral neck fracture

Protein Supplement and Enhanced Recovery After Posterior Spine Fusion Surgery: A Randomized, Double-blind, Placebo-controlled Trial

STUDY DESIGN

This was a randomized, double-blind clinical trial study.

OBJECTIVE

The objective of this study was to evaluate the effect of protein supplementation on vertebral fusion and enhanced recovery after posterior spine fusion (PSF) surgery.

SUMMARY OF BACKGROUND DATA

Nonfusion is one of the most common complications of lumbar spine surgery. It has been shown that protein plays an important role in bone repair; however, its correlation to vertebral fusion following PSF surgery is unknown.

PATIENTS AND METHODS

In this randomized, double-blind clinical trial study, the intervention group received a diet with 1.2 g of protein plus high-protein supplement (36 g whey protein), and the control group received a similar diet, except for starch as a placebo from 48 hours before to 1 month after surgery.

RESULTS

The intervention group showed a significantly higher rate of vertebral fusion compared with the control group (P=0.019). Surgical site infection and pain were significantly lower in the intervention group. A significant difference was found in the wound healing rate in favor of the intervention group. The rates of decrease in serum high-sensitivity C-reactive protein levels and increase in serum levels of insulin-like growth factor 1, albumin, total protein, and alkaline phosphatase were greater in the intervention group than in the control group (P<0.001).

CONCLUSIONS

Increased protein intake improves vertebral fusion and enhances recovery in patients undergoing PSF. This was the first study to investigate the effect of protein on fusion and healing factors; as a result, further clinical trials are needed to confirm the current results.

Perioperative nutritional supplementation and skeletal muscle mass in older hip-fracture patients

Older people with hip fractures are often malnourished at the time of fracture, which can have substantial influence on mortality and clinical outcomes, as well as functional outcome and quality of life. A close relationship between protein intake and muscle maintenance has been demonstrated. Skeletal muscle weakness is an independent risk factor for falls and fall-related injuries in the elderly and is an independent marker of prognosis. However, the effect of perioperative nutritional interventions on outcomes in elderly hip-fracture patients remains controversial. In this narrative review, an overview is presented of the existing literature on nutritional status and sarcopenia in elderly hip-fracture patients, clinical outcomes, and the effects of nutritional intervention on outcome and rehabilitation in this patient group.

Energy Expenditure in Older People Hospitalized for an Acute Episode

Weight loss and worsening of nutritional state is a frequent downfall of acute hospitalization in older people. It is usually accepted that acute inflammation is responsible for hypercatabolism. However, several studies suggest, on the contrary, a reduction in resting energy expenditure (REE). This study aimed to obtain a reliable measure of REE and total energy expenditure (TEE) in older patients hospitalized for an acute episode in order to better assess patients’ energy requirements and help understand the mechanisms of weight loss in this situation. Nineteen hospitalized older patients (mean age 83 years) with C-reactive protein (CRP) level >20mg/L were recruited. REE and TEE were measured using gold standard methods of indirect calorimetry and doubly labeled water (DLW), respectively. REE was then compared to data from a previous study on aged volunteers from nursing homes who were free of an acute stressor event. Energy requirements measured by DLW were confirmed at 1.3 × REE. Energy intake covered the needs but did not prevent weight loss in these patients. TEE was not increased in hospitalized patients and was not influenced by inflammation, while the relationship between REE and inflammation was uncertain. Our results suggest that lean mass remains the major determinant of REE in hospitalized older people and that weight loss may not be explained solely by a state of hypercatabolism.

Assessment of Nutrition and Supplementation in Patients With Hip Fractures

Introduction:

Malnutrition is common in older people, is known to interact with frailty, and is a risk factor for wound complications and poor functional outcomes postoperatively. Sustaining a hip fracture is a significant life event, often resulting in a decline in mobility and functional ability. A poor nutritional state may further impede recovery and rehabilitation, so strategies to improve perioperative nutrition are of considerable importance. We provide a review of nutritional supplement practices in this vulnerable and growing population.

Method:

Systematic review of preoperative oral nutritional supplementation (ONS) in hip fracture patients.

Results:

We identified 12 articles pertaining to this important area of perioperative care. The findings suggest postoperative ONS can improve postoperative outcomes in hip fracture patients, especially in terms of increasing total serum protein, improving nutritional status to near-optimum levels, and decreasing postoperative complications.

Discussion:

There is an absence of evidence specific to preoperative ONS in patients admitted following hip fracture. Literature relating to other populations is encouraging but is yet to be robustly studied. It is unclear whether these results are generalizable to the frailer hip fracture population. There is a need for studies clearly defining outcome measurement and complication assessment pertaining to preoperative ONS. The potential benefit is considerable, and this review will provide a means to inform the construction of meaningful trials in preoperative ONS of patients sustaining hip fracture.

Conclusion:

Oral nutritional supplementation in hip fracture patients may decrease postoperative complications while increasing elderly patient’s nutritional state to a near-optimum level. This is extrapolated from postoperative literature, however with a clear gap in research pertaining specifically to preoperative care. The need for well-constructed studies focused on the impact and assessment of early ONS in this population is transparent.

Nutritional supplementation for hip fracture aftercare in older people

BACKGROUND

Older people with hip fractures are often malnourished at the time of fracture, and subsequently have poor food intake. This is an update of a Cochrane review first published in 2000, and previously updated in 2010.

OBJECTIVES

To review the effects (benefits and harms) of nutritional interventions in older people recovering from hip fracture.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, Embase, CAB Abstracts, CINAHL, trial registers and reference lists. The search was last run in November 2015.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture where the interventions were started within the first month after hip fracture.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data and assessed risk of bias. Where possible, we pooled data for primary outcomes which were: all cause mortality; morbidity; postoperative complications (e.g. wound infections, pressure sores, deep venous thromboses, respiratory and urinary infections, cardiovascular events); and 'unfavourable outcome' defined as the number of trial participants who died plus the number of survivors with complications. We also pooled data for adverse events such as diarrhoea.

MAIN RESULTS

We included 41 trials involving 3881 participants. Outcome data were limited and risk of bias assessment showed that trials were often methodologically flawed, with less than half of trials at low risk of bias for allocation concealment, incomplete outcome data, or selective reporting of outcomes. The available evidence was judged of either low or very low quality indicating that we were uncertain or very uncertain about the estimates.Eighteen trials evaluated oral multinutrient feeds that provided non-protein energy, protein, vitamins and minerals. There was low-quality evidence that oral feeds had little effect on mortality (24/486 versus 31/481; risk ratio (RR) 0.81 favouring supplementation, 95% confidence interval (CI) 0.49 to 1.32; 15 trials). Thirteen trials evaluated the effect of oral multinutrient feeds on complications (e.g. pressure sore, infection, venous thrombosis, pulmonary embolism, confusion). There was low-quality evidence that the number of participants with complications may be reduced with oral multinutrient feeds (123/370 versus 157/367; RR 0.71, 95% CI 0.59 to 0.86; 11 trials). Based on very low-quality evidence from six studies (334 participants), oral supplements may result in lower numbers with 'unfavourable outcome' (death or complications): RR 0.67, 95% CI 0.51 to 0.89. There was very low-quality evidence for six studies (442 participants) that oral supplementation did not result in an increased incidence of vomiting and diarrhoea (RR 0.99, 95% CI 0.47 to 2.05).Only very low-quality evidence was available from the four trials examining nasogastric multinutrient feeding. Pooled data from three heterogeneous trials showed no evidence of an effect of supplementation on mortality (14/142 versus 14/138; RR 0.99, 95% CI 0.50 to 1.97). One trial (18 participants) found no difference in complications. None reported on unfavourable outcome. Nasogastric feeding was poorly tolerated. One study reported no cases of aspiration pneumonia.There is very low-quality evidence from one trial (57 participants, mainly men) of no evidence for an effect of tube feeding followed by oral supplementation on mortality or complications. Tube feeding, however, was poorly tolerated.There is very low-quality evidence from one trial (80 participants) that a combination of intravenous feeding and oral supplements may not affect mortality but could reduce complications. However, this expensive intervention is usually reserved for people with non-functioning gastrointestinal tracts, which is unlikely in this trial.Four trials tested increasing protein intake in an oral feed. These provided low-quality evidence for no clear effect of increased protein intake on mortality (30/181 versus 21/180; RR 1.42, 95% CI 0.85 to 2.37; 4 trials) or number of participants with complications but very low-quality and contradictory evidence of a reduction in unfavourable outcomes (66/113 versus 82/110; RR 0.78, 95% CI 0.65 to 0.95; 2 trials). There was no evidence of an effect on adverse events such as diarrhoea.Trials testing intravenous vitamin B1 and other water soluble vitamins, oral 1-alpha-hydroxycholecalciferol (vitamin D), high dose bolus vitamin D, different oral doses or sources of vitamin D, intravenous or oral iron, ornithine alpha-ketoglutarate versus an isonitrogenous peptide supplement, taurine versus placebo, and a supplement with vitamins, minerals and amino acids, provided low- or very low-quality evidence of no clear effect on mortality or complications, where reported.Based on low-quality evidence, one trial evaluating the use of dietetic assistants to help with feeding indicated that this intervention may reduce mortality (19/145 versus 36/157; RR 0.57, 95% CI 0.34 to 0.95) but not the number of participants with complications (79/130 versus 84/125).

AUTHORS' CONCLUSIONS

There is low-quality evidence that oral multinutrient supplements started before or soon after surgery may prevent complications within the first 12 months after hip fracture, but that they have no clear effect on mortality. There is very low-quality evidence that oral supplements may reduce 'unfavourable outcome' (death or complications) and that they do not result in an increased incidence of vomiting and diarrhoea. Adequately sized randomised trials with robust methodology are required. In particular, the role of dietetic assistants, and peripheral venous feeding or nasogastric feeding in very malnourished people require further evaluation.

Pioglitazone improves fat distribution, the adipokine profile and hepatic insulin sensitivity in non-diabetic end-stage renal disease subjects on maintenance dialysis: a randomized cross-over pilot study

Background

Fat redistribution, increased inflammation and insulin resistance are prevalent in non-diabetic subjects treated with maintenance dialysis. The aim of this study was to test whether pioglitazone, a powerful insulin sensitizer, alters body fat distribution and adipokine secretion in these subjects and whether it is associated with improved insulin sensitivity.

Trial Design

This was a double blind cross-over study with 16 weeks of pioglitazone 45 mg vs placebo involving 12 subjects.

Methods

At the end of each phase, body composition (anthropometric measurements, dual energy X-ray absorptometry (DEXA), abdominal CT), hepatic and muscle insulin sensitivity (2-step hyperinsulinemic euglycemic clamp with 2H2-glucose) were measured and fasting blood adipokines and cardiometabolic risk markers were monitored.

Results

Four months treatment with pioglitazone had no effect on total body weight or total fat but decreased the visceral/sub-cutaneous adipose tissue ratio by 16% and decreased the leptin/adiponectin (L/A) ratio from 3.63×10⁻³ to 0.76×10⁻³. This was associated with a 20% increase in hepatic insulin sensitivity without changes in muscle insulin sensitivity, a 12% increase in HDL cholesterol and a 50% decrease in CRP.

Conclusions/Limitations

Pioglitazone significantly changes the visceral-subcutaneous fat distribution and plasma L/A ratio in non diabetic subjects on maintenance dialysis. This was associated with improved hepatic insulin sensitivity and a reduction of cardio-metabolic risk markers. Whether these effects may improve the outcome of non diabetic end-stage renal disease subjects on maintenance dialysis still needs further evaluation.

Trial Registration

ClinicalTrial.gov NCT01253928

The importance of dietary protein for muscle health in inactive, hospitalized older adults

Dietary protein and amino acids are necessary for overall human health. Insufficient protein intake induces a negative protein balance with adverse outcomes such as muscle atrophy and functional decline--outcomes that are worsened in older adults. Furthermore, during inactivity, such as bed rest/hospitalization, skeletal muscle protein synthesis is reduced, protein balance is negative, and older adults lose significant amounts of muscle. Dietary protein and amino acid supplementation (∼ 30 g protein and ∼ 3 g leucine) stimulate skeletal muscle protein anabolism in healthy, community-dwelling older adults and may be considered as possible nutritional interventions to improve the muscle protein balance and potentially support skeletal muscle maintenance in hospitalized older adults. The following is a timely review of metabolic and dietary challenges faced by hospitalized older adults and potential dietary protein and amino acids solutions for maintaining skeletal muscle health during hospitalization-induced inactivity in this population.

Cost-effectiveness of nutritional intervention in elderly subjects after hip fracture. A randomized controlled trial

Hip fracture patients can benefit from nutritional supplementation during their recovery. Up to now, cost-effectiveness evaluation of nutritional intervention in these patients has not been performed. Costs of nutritional intervention are relatively low as compared with medical costs. Cost-effectiveness evaluation shows that nutritional intervention is likely to be cost-effective.

INTRODUCTION

Previous research on the effect of nutritional intervention on clinical outcome in hip fracture patients yielded contradictory results. Cost-effectiveness of nutritional intervention in these patients remains unknown. The aim of this study was to evaluate cost-effectiveness of nutritional intervention in elderly subjects after hip fracture from a societal perspective.

METHODS

Open-label, multi-centre randomized controlled trial investigating cost-effectiveness of intensive nutritional intervention comprising regular dietetic counseling and oral nutritional supplementation for 3 months postoperatively. Patients allocated to the control group received care as usual. Costs, weight and quality of life were measured at baseline and at 3 and 6 months postoperatively. Incremental cost-effectiveness ratios (ICERs) were calculated for weight at 3 months and quality adjusted life years (QALYs) at 6 months postoperatively.

RESULTS

Of 152 patients enrolled, 73 were randomized to the intervention group and 79 to the control group. Mean costs of the nutritional intervention was 613 Euro. Total costs and subcategories of costs were not significantly different between both groups. Based on bootstrapping of ICERs, the nutritional intervention was likely to be cost-effective for weight as outcome over the 3-month intervention period, regardless of nutritional status at baseline. With QALYs as outcome, the probability for the nutritional intervention being cost-effective was relatively low, except in subjects aged below 75 years.

CONCLUSION

Intensive nutritional intervention in elderly hip fracture patients is likely to be cost-effective for weight but not for QALYs. Future cost-effectiveness studies should incorporate outcome measures appropriate for elderly patients, such as functional limitations and other relevant outcome parameters for elderly.

Clinical benefits of oral nutritional supplementation for elderly hip fracture patients: a single blind randomised controlled trial

BACKGROUND

malnutrition is an important risk factor for poor outcome in patients recovering after hip fracture surgery. This study aimed to investigate the clinical, nutritional and rehabilitation effects of an oral nutritional supplementation (ONS) in an inpatient rehabilitation setting.

METHODS

this was an observer-blinded randomised controlled trial of elderly post-surgical proximal femoral fracture patients. A ready-to-use oral liquid nutritional supplementation (18-24 g protein and 500 kcal per day) in addition to hospital diet was compared with hospital diet only. Both groups received usual rehabilitation therapy and oral calcium and vitamin D supplements. Outcomes were compared at discharge from rehabilitation and after 4 weeks of discharge. The primary outcome parameters were the serum albumin level, the body mass index (BMI), the functional independence measure (FIM) and the elderly mobility scale (EMS). Secondary outcome parameters were frequency of complications, inpatient length of stay, mortality and acute hospital use within 6 months after discharge.

RESULTS

a total of 126 patients were recruited, 65 in the supplementation arm and 61 in the control arm. There was a significant difference in change in BMI with a decrease of 0.25 and 0.03 kg/m(2) in the ONS group and 0.72 and 0.49 kg/m(2) in the control group at hospital discharge and follow-up, respectively (P = 0.012). The length of stay in rehabilitation ward was shortened by 3.80 (SE = 1.81, P = 0.04) days favouring the ONS group. The total number of infection episodes was also reduced significantly. No difference was observed in the rate of change of the serum albumin level, the FIM and the EMS.

CONCLUSION

clinical and nutritional benefits were seen in this trial but rehabilitation benefits could not be demonstrated.

Effects of dietary supplement on functional condition and clinical outcome measured with a modified Norton scale

Elderly long-term care patients (n = 501) were randomly allocated to receive dietary supplementation (400 kcal/day) in addition to a normal hospital diet, or normal hospital diet only, for 26 weeks. The patients' functional condition was assessed by a modified Norton scale comprising mental condition, activity, mobility, food intake, fluid intake, incontinence and general physical state. Nutritional status was assessed by anthropometry, serum protein analysis and delayed hypersensitivity skin tests. Improvements during the first 8 weeks were seen in activity and general physical condition in the supplemented group, and in mobility and general physical condition in the control group. After 8 weeks the supplemented group showed a significantly higher level of activity (p < 0.05) compared to the control group. We conclude that in long-term geriatric care nutritional supplements help to maintain and improve the patients function.

The effect of a supplement which is nutrient dense compared to standard concentration on the total nutritional intake of anorectic patients

A randomised, double-blind trial was conducted to compare the intake of a standard (4.2kJ/ml) and a nutrient dense (6.3kJ/ml) commericial liquid supplement, and to assess their effect on total nutrient intake. Both products were offered as a supplement to the regular hospital diet to 34 elderly in-patients with poor appetite and intake. Only 24 of these patients completed the entire supplementation period of 10 days. Median (interquartile range) volumes of intake were 300 (200-400) ml of the standard product and 400 (250-500) ml of the nutrient dense product (NS). Neither product decreased energy intake from the hospital diet. In fact, patients on the standard product increased slightly their intake from the hospital diet. This was enough to outweigh the increased contribution to total energy intake provided by the nutrient dense product. Both products received high palatability ratings, but high ratings did not imply high volume intake or good compliance.

Effects of endotoxin on lactate metabolism in humans

Introduction

Hyperlactatemia represents one prominent component of the metabolic response to sepsis. In critically ill patients, hyperlactatemia is related to the severity of the underlying condition. Both an increased production and a decreased utilization and clearance might be involved in this process, but their relative contribution remains unknown. The present study aimed at assessing systemic and muscle lactate production and systemic lactate clearance in healthy human volunteers, using intravenous endotoxin (LPS) challenge.

Methods

Fourteen healthy male volunteers were enrolled in 2 consecutive studies (n = 6 in trial 1 and n = 8 in trial 2). Each subject took part in one of two investigation days (LPS-day with endotoxin injection and placebo-day with saline injection) separated by one week at least and in a random order. In trial 1, their muscle lactate metabolism was monitored using microdialysis. In trial 2, their systemic lactate metabolism was monitored by means of a constant infusion of exogenous lactate. Energy metabolism was monitored by indirect calorimetry and glucose kinetics was measured with 6,6-H₂ glucose.

Results

In both trials, LPS increased energy expenditure (p = 0.011), lipid oxidation (p<0.0001), and plasma lactate concentration (p = 0.016). In trial 1, lactate concentration in the muscle microdialysate was higher than in blood, indicating lactate production by muscles. This was, however, similar with and without LPS. In trial 2, calculated systemic lactate production increased after LPS (p = 0.031), while lactate clearance remained unchanged.

Conclusions

LPS administration increases lactatemia by increasing lactate production rather than by decreasing lactate clearance. Muscle is, however, unlikely to be a major contributor to this increase in lactate production.

Trial registration

ClinicalTrials.gov NCT01647997

A trial assessing N-3 as treatment for injury-induced cachexia (ATLANTIC trial): does a moderate dose fish oil intervention improve outcomes in older adults recovering from hip fracture?

BACKGROUND

Proximal femoral fractures are associated with increased morbidity and mortality. Pre-existing malnutrition and weight loss amongst this patient group is of primary concern, with conventional nutrition support being largely ineffective. The inflammatory response post proximal femoral fracture surgery and the subsequent risk of cachexia may explain the inability of conventional high energy high protein management to produce an anabolic response amongst these patients. Omega-3 fatty acids derived from fish oils have been extensively studied for their anti-inflammatory benefits. Due to their anti-inflammatory properties, the benefit of fish oil combined with individualized nutrition support amongst proximal femoral fracture patients post surgery is an attractive potential therapeutic strategy. The aim of the ATLANTIC trial is to assess the potential benefits of an anti-inflammatory dose of fish oil within the context of a 12 week individualised nutrition program, commencing seven days post proximal femoral fracture surgery.

METHODS/DESIGN

This randomized controlled, double blinded trial, will recruit 150 community dwelling elderly patients aged ≥65 years, within seven days of surgery for proximal femoral fracture. Participants will be randomly allocated to receive either a 12 week individualized nutrition support program complemented with 20 ml/day anti-inflammatory dose fish oil (~3.6 g eicosapentaenoic acid, ~2.4 g docosahexanoic acid; intervention), or, a 12 week individualized nutrition support program complemented with 20 ml/day low dose fish oil (~0.36 g eicosapentaenoic acid, ~0.24 g docosahexanoic acid; control).

DISCUSSION

The ATLANTIC trial is the first of its kind to provide fish oil combined with individualized nutrition therapy as an intervention to address the inflammatory response experienced post proximal femoral fracture surgery amongst elderly patients. The final outcomes of this trial will assist clinicians in the development of effective and alternative treatment methods post proximal femoral fracture surgery which may ultimately result in a reduction in systemic inflammation, loss of weight and lean muscle and improvements in nutritional status, mobility, independence and quality of life among elderly patients.

TRIAL REGISTRATION

ACTRN12609000241235.

Efficacy and cost-effectiveness of nutritional intervention in elderly after hip fracture: design of a randomized controlled trial

Background

Hip fracture patients often have an impaired nutritional status at the time of fracture, which can result in a higher complication rate, prolonged rehabilitation time and increased mortality. A study was designed to evaluate the effect of nutritional intervention on nutritional status, functional status, total length of stay, postoperative complications and cost-effectiveness.

Methods

Open-labelled, multi-centre, randomized controlled trial in hip fracture patients aged 55 years and above. The intervention group receives dietetic counselling (by regular home visits and telephone calls) and oral nutritional supplementation for three months after surgery. The control group receives usual dietetic care as provided by the hospital. Outcome assessment is performed at three and six months after hip fracture.

Discussion

Patient recruitment has started in July 2007 and has ended in December 2009. First results are expected in 2011.

Trial registration

ClinicalTrials.gov NCT00523575

Nutritional supplementation for hip fracture aftercare in older people

BACKGROUND

Older people with hip fractures are often malnourished at the time of fracture, and have poor food intake subsequently.

OBJECTIVES

To review the effects of nutritional interventions in older people recovering from hip fracture.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 3), MEDLINE and other major databases (to July 2008).

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture.

DATA COLLECTION AND ANALYSIS

Both authors independently selected trials, extracted data and assessed trial quality. We pooled data for primary outcomes.

MAIN RESULTS

Twenty-four randomised trials involving 1940 participants were included. Outcome data were limited and many trials were methodologically flawed. Results from 23 trials are presented here.Ten trials evaluated oral multinutrient feeds: providing non-protein energy, protein, some vitamins and minerals. Oral feeds had no statistically significant effect on mortality (16/244 versus 21/226; risk ratio (RR) 0.76, 95% confidence interval (CI) 0.42 to 1.37) or 'unfavourable outcome' (combined outcome of mortality and survivors with medical complications) (46/126 versus 41/103; RR 0.76, 95% CI 0.55 to 1.04).Four heterogenous trials examining nasogastric multinutrient feeding showed no evidence of an effect on mortality (RR 0.99, 95% CI 0.50 to 1.97). Nasogastric feeding was poorly tolerated.One trial examining nasogastric tube feeding followed by oral feeds found no evidence for an effect on mortality or complications.One trial of multinutrient intravenous feeding followed by oral supplements found a reduction in participants with complications (RR 0.21, 95% CI 0.10 to 0.46), but not in mortality (RR 0.11, 95% CI 0.01 to 2.00).Four trials testing increasing protein intake in an oral feed found no evidence for an effect on mortality (RR 1.42, 95% CI 0.85 to 2.37). Protein supplementation may have reduced the number of long term medical complications.Two trials, testing intravenous vitamin B1 and other water soluble vitamins, or oral 1-alpha-hydroxycholecalciferol (vitamin D) respectively, produced no evidence of effect.One trial, evaluating dietetic assistants to help with feeding, showed no statistically significant effect on mortality (RR 0.57, 99% CI 0.29 to 1.11).

AUTHORS' CONCLUSIONS

Weak evidence exists for the effectiveness of protein and energy feeds. Adequately sized randomised trials with robust methodology are required. In particular, the role of dietetic assistants, and peripheral venous feeding require further evaluation.

Fructose overconsumption causes dyslipidemia and ectopic lipid deposition in healthy subjects with and without a family history of type 2 diabetes

BACKGROUND

Both nutritional and genetic factors are involved in the pathogenesis of nonalcoholic fatty liver disease and insulin resistance.

OBJECTIVE

The aim was to assess the effects of fructose, a potent stimulator of hepatic de novo lipogenesis, on intrahepatocellular lipids (IHCLs) and insulin sensitivity in healthy offspring of patients with type 2 diabetes (OffT2D)--a subgroup of individuals prone to metabolic disorders.

DESIGN

Sixteen male OffT2D and 8 control subjects were studied in a crossover design after either a 7-d isocaloric diet or a hypercaloric high-fructose diet (3.5 g x kg FFM(-1) x d(-1), +35% energy intake). Hepatic and whole-body insulin sensitivity were assessed with a 2-step hyperinsulinemic euglycemic clamp (0.3 and 1.0 mU x kg(-1) x min(-1)), together with 6,6-[2H2]glucose. IHCLs and intramyocellular lipids (IMCLs) were measured by 1H-magnetic resonance spectroscopy.

RESULTS

The OffT2D group had significantly (P < 0.05) higher IHCLs (+94%), total triacylglycerols (+35%), and lower whole-body insulin sensitivity (-27%) than did the control group. The high-fructose diet significantly increased IHCLs (control: +76%; OffT2D: +79%), IMCLs (control: +47%; OffT2D: +24%), VLDL-triacylglycerols (control: +51%; OffT2D: +110%), and fasting hepatic glucose output (control: +4%; OffT2D: +5%). Furthermore, the effects of fructose on VLDL-triacylglycerols were higher in the OffT2D group (group x diet interaction: P < 0.05).

CONCLUSIONS

A 7-d high-fructose diet increased ectopic lipid deposition in liver and muscle and fasting VLDL-triacylglycerols and decreased hepatic insulin sensitivity. Fructose-induced alterations in VLDL-triacylglycerols appeared to be of greater magnitude in the OffT2D group, which suggests that these individuals may be more prone to developing dyslipidemia when challenged by high fructose intakes. This trial was registered at clinicaltrials.gov as NCT00523562.

Nutritional status and energy expenditure in elderly patients with recent hip fracture during a 2-month follow-up

A 2-month follow-up of nutritional status was performed in forty elderly patients with recent hip fracture. Patients were nutritionally assessed on admission to our rehabilitation unit (day 0), then monthly (day 30, day 60) by measurement of resting energy expenditure (REE), anthropometric, impedance and biological variables. Patients were defined as undernourished (n 13) or normally nourished (n 27) on the basis of mid-arm circumference (MAC) and triceps skinfold thickness (TST) measurements. Seven patients recovered a walking autonomy and were discharged from the hospital before day 30 (group I) whereas thirteen patients were discharged after day 30 (group II); twenty patients remained in the study at day 60 (group III). MAC and TST decreased in normally nourished patients from group III throughout the study whereas they did not change in group II or in undernourished patients from group III. REE values in relation to fat-free mass were increased compared with normal values and were similar in the three groups on day 0; they did not change during the study. Daily energy intake in relation to body weight was higher in group I and increased in group II and in undernourished patients from group III throughout the study. In contrast, it was below the recommended value at day 0 and it did not significantly improve in normally nourished patients from group III. Serum albumin, transthyretin and transferrin levels on day 0 were below reference intervals in the three groups. Albumin levels increased in group III throughout the study. Inflammatory proteins decreased in groups II and III, with C-reactive protein levels returning to normal values in group II by day 30 and in group III at day 60, while orosomucoid levels did not become completely normal over this period. Our findings indicate no improvement in nutritional status in undernourished patients after surgery for recent hip fracture, despite an adequate energy intake. An insufficient spontaneous energy intake for normally nourished patients was associated with a delayed favourable outcome resulting in a prolonged duration of hospitalization. A hypermetabolic state persisted during the 3 months after surgery.

Resting energy expenditure measured longitudinally following hip fracture compared to predictive equations: is an injury adjustment required?

The present study measuring resting energy expenditure (REE; kJ/d) longitudinally using indirect calorimetry in six elderly women aged ≥70 years following surgery for hip fracture, describes changes over time (days 10, 42 and 84 post-injury) and compares measured values to those calculated from routinely applied predictive equations. REE was compared to REE predicted using the Harris Benedict and Schofield equations, with and without accounting for the theoretical increase in energy expenditure of 35 % secondary to physiological stress of injury and surgery. Mean (95 % CI) measured REE (kJ/d) was 4704 (4354, 5054), 4090 (3719, 4461) and 4145 (3908, 4382) for days 10, 42 and 84, respectively. A time effect was observed for measured REE,P=0·003. Without adjusting for stress the mean difference and 95 % limits of agreement for measured and predicted REE (kJ/kg per d) for the Harris Benedict equation were 1 (−9, 12), 10 (2, 18) and 9 (1, 17) for days 10, 42 and 84, respectively. The mean difference and 95 % limits of agreement for measured and predicted REE (kJ/kg per d) for the Schofield equation without adjusting for stress were 8 (−3, 19), 16 (6, 26) and 16 (10, 22) for days 10, 42 and 84, respectively. After adjusting for stress, REE predicted from the Harris Benedict or Schofield equations overestimated measured REE by between 38 and 69 %. Energy expenditure following fracture is poorly understood. Our data suggest REE was relatively elevated early in recovery but declined during the first 6 weeks. Using the Harris Benedict or Schofield equations adjusted for stress may lead to overestimation of REE in the clinical setting. Further work is required to evaluate total energy expenditure before recommendations can be made to alter current practice for calculating theoretical total energy requirements of hip fracture patients.

Energy requirements in frail elderly people: A review of the literature

This review collates studies of healthy, sick, underweight (BMI < or = 21 kg/m2) and very elderly people (> or = 90 yr), in whom resting energy expenditure (REE) was measured using indirect calorimetry. We have observed the following: (1) REE, when adjusted for differences in both body weight and fat-free mass (FFM), is similar in healthy and in sick elderly people being 20 and 28 kcal/kg of FFM per day, respectively, (2) their nutritional status influences their energy requirements given that weight-adjusted REE increases in line with a decrease in BMI, (3) total energy expenditure is lower in sick elderly people given that their physical activity level, i.e. the ratio of total energy expenditure to REE, is reduced during disease averaging at 1.36, (4) energy intake (EI) being only 1.23 x REE is insufficient to cover energy requirements in sick elderly patients, whereas the EI of healthy elderly people appears sufficient to cover requirements, and finally, (5) gender ceases to be a determinant of REE in people aged 60 yr or over, with the Harris & Benedict equation capable of accurately predicting mean REE in this population, whether healthy or sick.

A 4-wk high-fructose diet alters lipid metabolism without affecting insulin sensitivity or ectopic lipids in healthy humans

BACKGROUND

High fructose consumption is suspected to be causally linked to the epidemics of obesity and metabolic disorders. In rodents, fructose leads to insulin resistance and ectopic lipid deposition. In humans, the effects of fructose on insulin sensitivity remain debated, whereas its effect on ectopic lipids has never been investigated.

OBJECTIVE

We assessed the effect of moderate fructose supplementation on insulin sensitivity (IS) and ectopic lipids in healthy male volunteers (n = 7).

DESIGN

IS, intrahepatocellular lipids (IHCL), and intramyocellular lipids (IMCL) were measured before and after 1 and 4 wk of a high-fructose diet containing 1.5 g fructose . kg body wt(-1) . d(-1). Adipose tissue IS was evaluated from nonesterified fatty acid suppression, hepatic IS from suppression of hepatic glucose output (6,6-2H2-glucose), and muscle IS from the whole-body glucose disposal rate during a 2-step hyperinsulinemic euglycemic clamp. IHCL and IMCL were measured by 1H magnetic resonance spectroscopy.

RESULTS

Fructose caused significant (P < 0.05) increases in fasting plasma concentrations of triacylglycerol (36%), VLDL-triacylglycerol (72%), lactate (49%), glucose (5.5%), and leptin (48%) without any significant changes in body weight, IHCL, IMCL, or IS. IHCL were negatively correlated with triacylglycerol after 4 wk of the high-fructose diet (r = -0.78, P < 0.05).

CONCLUSION

Moderate fructose supplementation over 4 wk increases plasma triacylglycerol and glucose concentrations without causing ectopic lipid deposition or insulin resistance in healthy humans.

Nutritional supplementation for hip fracture aftercare in older people

BACKGROUND

Older people with hip fractures are often malnourished at the time of fracture, and have poor food intake subsequently.

OBJECTIVES

To review the effects of nutritional interventions in older people recovering from hip fracture.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 1), MEDLINE, six other databases and reference lists. We contacted investigators and handsearched journals.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture.

DATA COLLECTION AND ANALYSIS

Both authors independently selected trials, extracted data and assessed trial quality. We sought additional information from trialists, and pooled data for primary outcomes.

MAIN RESULTS

Twenty-one randomised trials involving 1727 participants were included. Overall trial quality was poor, specifically regarding allocation concealment, assessor blinding and intention-to-treat analysis, and limited availability of outcome data. Eight trials evaluated oral multinutrient feeds: providing non-protein energy, protein, some vitamins and minerals. Oral feeds had no statistically significant effect on mortality (15/161 versus 17/176; relative risk (RR) 0.89, 95% confidence interval (CI) 0.47 to 1.68) but may reduce 'unfavourable outcome' (combined outcome of mortality and survivors with medical complications) (14/66 versus 26/73; RR 0.52, 95% CI 0.32 to 0.84). Four trials examining nasogastric multinutrient feeding showed no evidence of an effect on mortality (RR 0.99, 95% CI 0.50 to 1.97) but the studies were heterogeneous regarding case mix. Nasogastric feeding was poorly tolerated. There was insufficient information for other outcomes. Increasing protein intake in an oral feed was tested in four trials. There was no evidence for an effect on mortality (RR 1.42, 95% CI 0.85 to 2.37). Protein supplementation may have reduced the number of long term medical complications. Two trials, testing intravenous vitamin B1 and other water soluble vitamins, or 1-alpha-hydroxycholecalciferol (an active form of vitamin D) respectively, produced no evidence of effect for either supplement. One trial, evaluating dietetic assistants to help with feeding, showed a trend for a reduction in mortality (RR 0.57, 99% CI 0.29 to 1.11).

AUTHORS' CONCLUSIONS

Some evidence exists for the effectiveness of oral protein and energy feeds, but overall the evidence for the effectiveness of nutritional supplementation remains weak. Adequately sized trials are required which overcome the methodological defects of the reviewed studies. In particular, the role of dietetic assistants requires further evaluation.

Nutritional supplementation decreases hip fracture-related complications

Protein energy malnutrition is an important determinant of clinical outcome in older patients after hip fracture, but the effectiveness of nutritional support programs in routine clinical practice is controversial. We performed a prospective, randomized, controlled clinical trial to determine if nutritional supplementation decreased fracture-related complications in a selection of otherwise healthy patients with hip fractures. Patients were randomized to intervention or control groups. The control group (n = 40) was given ordinary hospital food and beverage. The intervention group (n = 40) also was administered a 1000 kcal daily intravenous supplement for 3 days, followed by a 400 kcal oral nutritional supplement for 7 days. We recorded daily fluid and energy intake during the first 10 days of hospitalization and fracture-related complications up to 4 months. The total fluid and energy intake in the intervention group neared optimal levels. The control group received 54% and 64% of optimal energy and fluid intake, respectively. The risk of fracture- related complications was greater in the control group (70%) than in the intervention group (15%). Four patients in the control group died within 120 days postoperatively. The comprehensive balanced nutrition supplement resulted in lower complication rates and mortality at 120 days postoperatively.

Prise en charge et prévention de la dénutrition dans les établissements hospitaliers et institutions d′hébergement

INTRODUCTION

The elderly, especially the institutionalized elderly, are at risk of undernutrition, which institutions do not appear to identify or treat adequately.

OBJECTIVE

To identify activities undertaken to manage and prevent undernutrition in the elderly in institutions in Haute-Normandy (France).

METHODS

In February 2003, all institutions in Haute-Normandy likely to house the elderly received questionnaires for this cross-sectional study: public hospitals (PH) responded, private hospitals (PRH), and retirement homes, classified into two groups according to the medical services provided (RH, retirement homes, NH, nursing homes).

RESULTS

Slightly more than half the institutions responded: 34/36 PH, 20/28 PRH, and 62/161 RH and NH. Half Only 22% reported specific protocols for undernutrition; this figure ranged from 30.3% for PH to 13.6% for RH (p=0.22). Patients' food intake was tracked at 67% of the institutions - from 81.8% of the PH to 45.5% of the retirement homes (p=0.10). Meal choices were offered at 54% of the institutions: 85.0% of PRH hospitals offered a choice, but only 45.4% of the PH and of the RH (p=0.01). Overall, 51% asked about eating habits and preferences at admission. Nurses' aides provided help during meals in 46.9% of institutions, and 49% considered they had sufficient staff to help patients during meals: 95.5% in RH, but only 20.7% in PH (p<0.001).

DISCUSSION

Institutions for the elderly are well aware of the problems of undernutrition, but not enough of them appear to have a specific protocol to deal with it. Earlier screening for undernourishment would be useful. The study also shows the important role of nurses' aides in this area.

CONCLUSION

Institutions in Haute-Normandy agree about the need to screen for and treat undernutrition, but their interventions are not effective. Better organization and special training of health workers could improve this screening and treatment.

Lower limb fracture, cognitive impairment and risk of subsequent malnutrition: a prospective evaluation of dietary energy and protein intake on an orthopaedic ward

OBJECTIVE

To report the dietary energy and protein intake of undernourished older adults (with and without cognitive impairment) admitted to hospital following a lower limb fracture and to determine whether dietary intakes met estimated requirements.

DESIGN

An observational study of a sequential sample.

SETTING

The orthopaedic ward of a South Australian metropolitan teaching hospital.

SUBJECTS

Sixty-eight patients aged > or =70 years screened as undernourished and admitted to hospital following lower limb fracture (50% cognitively impaired) provided 3 to 5 days of dietary data. MAJOR OUTCOME METHODS: Dietary energy and protein intake.

METHODS

Dietary assessment using plate waste methodology and snack record charts commenced within 6 days postinjury and continued for up to five consecutive days or until discharge. Estimated resting energy requirements were calculated and adjusted for activity equivalent to bed rest and physiological stress. Protein requirements were calculated as 1 g/kg/day. Cognition was assessed using the Short Portable Mental Status Questionnaire.

RESULTS

Cognitively impaired participants and those without cognitive impairment consumed, mean (95% CI) respectively, 3661 kJ/day (3201, 4121) versus 4208 kJ/day (3798, 4619) and 38 g (33, 44) versus 47 g (41, 52) protein/day. Cognitively impaired participants consumed mean (95% CI) 48% (43, 53) of estimated total energy expenditure and 78% (69, 87) of estimated protein requirements.

CONCLUSIONS

Orthopaedic fracture patients at greatest nutritional risk, including those with cognitive impairment, do not achieve estimated energy or protein requirements from diet alone. Effective methods of achieving requirements in this vulnerable group are needed before improvements in outcomes will be observed.

Lack of meal intake compensation following nutritional supplements in hospitalised elderly women

Undernutrition contributes to poor clinical outcomes in hospitalised elderly patients but the potential impact of oral nutritional supplements may be reduced by suppressing subsequent food intake. We investigated this possibility in elderly female patients recovering mainly from hip fracture by studying the effect of oral supplements on subsequent food intake during an ad libitum buffet luncheon meal. We tested the effect in seven women by giving the supplement 90 min before the meal and compared energy and macronutrient intake with a control water pre-load condition. A similar study was carried out in another seven women with the supplement or water drink given 30 min beforehand. Both self-rated appetite and energy intake were low in these women. The nutritional supplement did not alter ratings of hunger, fullness or prospective consumption or subsequent energy and macronutrient consumption whether given 90 or 30 min before the meal. There were significant independent correlations between the lack of adequate compensation of energy intake at meals and chronic undernutrition (as assessed by skinfold thickness) and energy intake during the control meal. We conclude that elderly women during the recovery phase after major fractures have low appetites and energy intakes and markedly impaired adjustment of energy intake following liquid oral nutritional supplements. The reasons for this are unknown but are related to anorexia and undernutrition. The consumption of liquid oral supplements given up to 30 min before a meal does not suppress subsequent energy intake from meals.

Effect of fructose overfeeding and fish oil administration on hepatic de novo lipogenesis and insulin sensitivity in healthy men

High-fructose diet stimulates hepatic de novo lipogenesis (DNL) and causes hypertriglyceridemia and insulin resistance in rodents. Fructose-induced insulin resistance may be secondary to alterations of lipid metabolism. In contrast, fish oil supplementation decreases triglycerides and may improve insulin resistance. Therefore, we studied the effect of high-fructose diet and fish oil on DNL and VLDL triglycerides and their impact on insulin resistance. Seven normal men were studied on four occasions: after fish oil (7.2 g/day) for 28 days; a 6-day high-fructose diet (corresponding to an extra 25% of total calories); fish oil plus high-fructose diet; and control conditions. Following each condition, fasting fractional DNL and endogenous glucose production (EGP) were evaluated using [1-13C]sodium acetate and 6,6-2H2 glucose and a two-step hyperinsulinemic-euglycemic clamp was performed to assess insulin sensitivity. High-fructose diet significantly increased fasting glycemia (7 +/- 2%), triglycerides (79 +/- 22%), fractional DNL (sixfold), and EGP (14 +/- 3%, all P < 0.05). It also impaired insulin-induced suppression of adipose tissue lipolysis and EGP (P < 0.05) but had no effect on whole- body insulin-mediated glucose disposal. Fish oil significantly decreased triglycerides (37%, P < 0.05) after high-fructose diet compared with high-fructose diet without fish oil and tended to reduce DNL but had no other significant effect. In conclusion, high-fructose diet induced dyslipidemia and hepatic and adipose tissue insulin resistance. Fish oil reversed dyslipidemia but not insulin resistance.

Nutritional supplementation for hip fracture aftercare in older people

BACKGROUND

Fractures of the hip are an important cause of later ill health and mortality in older people. People with hip fractures are often malnourished at the time of fracture, and have poor food intake in hospital.

OBJECTIVES

This review assesses the effects of nutritional interventions in older people recovering from hip fracture.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 3, 2004), MEDLINE (1966 to October week 1 2004), Nutrition Abstracts and Reviews, EMBASE, BIOSIS, CINAHL, HEALTHSTAR, the National Research Register and reference lists. We contacted investigators and handsearched four nutrition journals.

SELECTION CRITERIA

Randomised and quasi-randomised trials of nutritional interventions for mainly older people (aged over 65 years) with hip fracture.

DATA COLLECTION AND ANALYSIS

Both authors independently selected trials, extracted data and assessed trial quality. We sought additional information from all trialists, and pooled data for primary outcomes.

MAIN RESULTS

Eighteen randomised trials involving 1306 participants were included. Overall trial quality was poor; specifically in terms of allocation concealment, assessor blinding and intention-to-treat analysis. This, and the limited availability of outcome data, mean that the following results must be interpreted with caution. Eight trials evaluated oral multinutrient feeds: these provided non-protein energy, protein, some vitamins and minerals. Oral feeds had no statistically significant effect on mortality (15/161 versus 17/176; relative risk (RR) 0.89, 95% confidence interval (CI) 0.47 to 1.68) but may reduce 'unfavourable outcome' (combined outcome of mortality and survivors with complications) (14/66 versus 26/73; RR 0.52, 95% CI 0.32 to 0.84). Four trials examining nasogastric multinutrient feeding showed no evidence of an effect on mortality (RR 0.99, 95% CI 0.50 to 1.97), but the studies were heterogeneous regarding case mix. There was insufficient information for other outcomes. The specific effect of protein given in an oral feed was tested in three trials. There was no evidence for an effect on mortality (RR 1.38, 95% CI 0.82 to 2.34). Protein supplementation may have reduced the number of long term complications and days spent in rehabilitation wards. Two trials, testing intravenous thiamin (vitamin B1) and other water soluble vitamins, or 1-alpha-hydroxycholecalciferol (an active form of vitamin D) respectively, produced no evidence of effect for either vitamin supplement.

AUTHORS' CONCLUSIONS

While some evidence exists for the effectiveness of oral protein and energy feeds, overall the evidence for the effectiveness of nutritional supplementation remains weak. Future trials are required which overcome the defects of the reviewed studies, particularly inadequate size, methodology and outcome assessment.

Nutritional care: the effectiveness of actively involving older patients

AIMS AND OBJECTIVES

The purpose of the study was to test the effectiveness of nursing care based on active involvement of patients in their nutritional care. It was hypothesized that this type of care could improve energy and protein intake in elder orthopaedic patients.

BACKGROUND

Protein and energy malnutrition and deterioration in nutritional status is a common but neglected problem in hospital patients.

METHODS

The design was quasi-experimental with an intervention and control group. The study included 253 patients aged 65 and above admitted for hip fracture, hip or knee replacement. Food intake was recorded on a daily basis during the hospital stay.

RESULTS

The daily intake of energy increased with 23% (P = 0.001) and of protein with 45% (P = 0.001). The intake increased from the very first day after the operation. The intake of energy and protein was not correlated with the patient's age, body mass index or type of surgery.

CONCLUSIONS

The care based on patients' active involvement in their own nutritional care and was found to be an effective method to raise the intake of energy and protein among elder orthopaedic patients.

RELEVANCE TO CLINICAL PRACTICE

This way of organizing the care identifies patients who do not consume enough energy and protein according to their current requirements and to take appropriate actions to prevent further malnutrition.

Nightly Enteral Nutrition Support of Elderly Hip Fracture Patients: A Pilot Study

OBJECTIVES

Assess whether postoperative nightly enteral nutrition support improves outcomes of elderly patients with an acute hip fracture

DESIGN

Randomized controlled trial.

SETTING

A University and a Department of Veteran's Affairs Hospital

SUBJECTS

Adults >64 years of age who underwent surgical repair of an acute hip fracture.

INTERVENTIONS

Subjects randomized to the control (Ctrl) group received standard care while the treatment (Tx) group received standard care plus up to 1,375 Kcal [5,755 kJ/d] of nasoenteral tube feedings each night. When tube feedings had to be discontinued, Tx subjects were asked to drink an equivalent amount of the nutritional supplement each night.

MEASURES OF OUTCOME

Rate of postoperative complications and 6-month postoperative survival.

RESULTS

Fifty-seven patients were randomized to the Tx (n = 27, mean age 75.9 +/- 7.4 yrs) or Ctrl groups (age 81.7 +/- 7.7 yrs). All subjects had reduced volitional nutrient intakes after surgery. During the first week subsequent to surgery, there was no difference between the treatment and control groups in the amount of nutrients that they volitionally consumed during the day. However, the treatment subjects had a greater total daily nutrient intake (Median 5,866 (IQR 5,024 to 7,335) kJ/d vs. 3,965 (IQR 2,968 to 4,664) kJ/d, p < 0.001). However, by the second postoperative week this difference was no longer statistically significant. Intolerance to the tube feedings developed commonly. There was no difference between the groups in the rate of postoperative life-threatening complications or mortality within six months subsequent to surgery.

CONCLUSIONS

This study failed to confirm findings from a prior study of improved postoperative survival with nutrition support. However, it was conducted on multiple hospital wards which may have contributed to the higher rate of tube-related problems and less nutrient delivery signifying the need for further study.

Provision of high-protein supplement for patients recovering from hip fracture

OBJECTIVE

We compared clinical outcomes with a standard (Ensure) or a high-protein (Boost HP) liquid nutritional supplement for older adults recovering from hip fracture surgery in a rehabilitation hospital.

METHODS

This randomized, double-blind, parallel-group study compared the clinical effectiveness of a standard (Ensure) with a high-protein (Boost HP) liquid nutritional supplement among patients (n = 46) 60 y or older who recently underwent surgical repair of a hip fracture. Patients were encouraged to drink at least two 8-oz cans (17.8 g/d protein for Ensure versus 30 g/d protein for Boost HP) per day for 28 d. Study measurements included change in Functional Independence Measure between rehabilitation admission and discharge, length of rehabilitation stay, laboratory measures (i.e., serum albumin, prealbumin, and C-reactive protein), physical activity energy expenditure by 7-d triaxial accelerometry, and dietary intake by three random, telephonic, 24-h dietary recalls.

RESULTS

There were no significant group differences with respect to age, sex, acute hospital days, hip fracture assessment parameters, or surgical treatment. Consumption of supplement (260 oz/28 d of Ensure versus 239 oz/28 d of Boost HP) was comparable. There were no differences in complication or adverse event rates during the study. The Boost HP group consumed more protein than the Ensure group (63 versus 50 g, P < 0.048) and had a greater improvement in serum albumin over the 28-d supplementation period (+0.7 versus +0.2 g/dL, P < 0.019). The Boost HP group also consumed more fiber (12 versus 8 g), calcium (821 versus 639 mg), vitamin K (66 versus 45 microg), and phosphorus (1035 versus 833 mg) than did the Ensure group. Rehabilitation length of stay was shorter in the Boost HP than in the Ensure group, although this trend did not reach statistical significance (23 versus 28 d, P = 0.27). Outcome differences were not detected in the Functional Independence Measure.

CONCLUSIONS

Supplementation was well tolerated in this population and contributed significantly to total dietary intake. Consumption of a high-protein liquid nutritional supplement may offer some benefits by improving visceral protein status.

Evaluation of hepatic and whole body glycogen metabolism in humans during repeated administrations of small loads of 13C glucose

BACKGROUND

Postprandial suppression of endogenous glucose production and regulation of glucose homeostasis involve alterations of whole body and hepatic glycogenolysis and glycogen breakdown. These parameters can be estimated by the simultaneous measurement of net total and exogenous, (13)C-labeled, glucose oxidation.

METHODS

Eight subjects were studied on 3 occasions, while receiving oral loads of 60 mg, 120 or 180 mg (13)C glucose/kg every hour for 4 consecutive hours. Net glucose oxidation was calculated from indirect calorimetry, and exogenous glucose oxidation from (13)CO(2) production. These parameters were evaluated during the hour following the fourth glucose load. Whole body endogenous glycogen breakdown was calculated as (net glucose oxidation) - (exogenous glucose oxidation). Total glycogen synthesis was calculated as (glucose load) - (exogenous glucose oxidation). Whole body glucose turnover was measured with 6.6 (2)H(2) glucose. The systemic appearance of oral, (13)C labeled glucose was monitored, and the suppression of endogenous glucose production was calculated.

RESULTS

Plasma glucose tracers had reached near steady state during the hour following the fourth glucose load. Glucose ingestion dose-dependently suppressed endogenous glycogen breakdown and stimulated total glycogen synthesis. Endogenous glycogen breakdown was completely inhibited with 180 mg oral glucose/kg. Endogenous glucose production was suppressed in a dose-dependent way, but remained positive with all 3 doses. The first pass splanchnic glucose uptake averaged 25-35%.

CONCLUSION

Repeated administration of small doses of (13)C labeled glucose allow to reach near steady state conditions after four hours, and to non-invasively evaluate whole body glycogen turnover and hepatic glucose metabolism.

Assessment of adipose tissue metabolism by means of subcutaneous microdialysis in patients with sepsis or circulatory failure

To evaluate the role of adipose tissue in the metabolic stress response of critically ill patients, the release of glycerol and lactate by subcutaneous adipose tissue was assessed by means of microdialysis in patients with sepsis or circulatory failure and in healthy subjects. Patients with sepsis had lower plasma free fatty acid concentrations and non-significant elevations of plasma glycerol concentrations, but higher adipose-systemic glycerol concentrations gradients than healthy subjects or patients with circulatory failure, indicating a stimulation of subcutaneous adipose lipolysis. They also had a higher lipid oxidation. Lipid metabolism (adipose-systemic glycerol gradients, lipid oxidation) was not altered in patients with circulatory failure. These observations highlight major differences in lipolysis and lipid utilization between patients with sepsis and circulatory failure. Hyperlactataemia was present in both groups of patients, but the adipose-systemic lactate concentration gradient was not increased, indicating that lactate production by adipose tissue was not involved. This speaks against a role of adipose tissue in the development of hyperlactataemia in critically ill patients.

A systematic review of protein and energy supplementation for hip fracture aftercare in older people

OBJECTIVES

To evaluate whether protein and energy supplementation influences recovery after hip fracture.

DESIGN

Systematic review of randomised and quasi-randomised trials in people aged 65 y and over.

DATA SOURCES

We searched seven electronic databases from 1966 to April 2002, four journals and reference lists of relevant articles. We contacted trial investigators and experts for details of other trials.

MAIN OUTCOME MEASURES

Mortality, complications and unfavourable outcome (mortality or survivors with complications) were the primary outcomes. We also sought data on length of hospital stay, functional status after hip fracture, quality of life and compliance with supplementation.

RESULTS

In total, 12 randomised trials involving 898 participants were included. Nine trials evaluated protein and energy supplementation (five oral and four nasogastric feeding), and a further three trials tested oral protein supplementation. Potential biases resulting from inadequate allocation concealment and lack of assessor blinding and intention-to-treat analysis, as well as the limited outcome data, mean that the results must be interpreted with caution. Pooled data from eight of the nine trials evaluating protein and energy supplements showed no evidence for an effect on mortality (relative risk 0.92, 95% CI 0.56-1.50). Limited data from only three trials showed that oral protein and energy supplements may reduce unfavourable outcome (relative risk 0.52, 95% CI 0.32-0.84).

CONCLUSION

Based on limited evidence, oral protein and energy supplementation after hip fracture may reduce unfavourable outcome. Further evidence from good-quality randomised trials is required to inform clinical practice.

Fish oil prevents the adrenal activation elicited by mental stress in healthy men

OBJECTIVES

A diet rich in n-3 fatty acids (fish oils) is associated with reduced risks of cardiovascular and metabolic diseases, but the mechanisms remain incompletely understood. Sympathoadrenal activation is postulated to be involved in the pathogenesis of these diseases, and may be inhibited by n-3 fatty acids. We therefore evaluated the effects of a diet supplemented with n-3 fatty acids on the stimulation of the sympathetic nervous system and of stress hormones elicited by a mental stress.

METHODS

Seven human volunteers were studied on two occasions, before and after 3 weeks of supplementation with 7.2 g/day fish oil. On each occasion, the concentrations of plasma cortisol, and catecholamines, energy expenditure (indirect calorimetry), and adipose tissue lipolysis (plasma non esterified fatty acid concentrations) were monitored in basal conditions followed by a 30 min mental stress (mental arithmetics and Stroop's test) and a 30 min recovery period.

RESULTS

In control conditions, mental stress significantly increased heart rate, mean blood pressure, and energy expenditure. It increased plasma epinephrine from 60.9 +/- 6.2 to 89.3 +/- 16.1 pg/ml (p<0.05), plasma cortisol from 291 +/- 32 to 372 +/- 37 micromol/l (p<0.05) and plasma non esterified fatty acids from 409 +/- 113 to 544 +/- 89 micromol/l (p<0.05). After 3 weeks of a diet supplemented with n-3 fatty acids, the stimulation by mental stress of plasma epinephrine, cortisol, energy expenditure, and plasma non esterified fatty acids concentrations, were all significantly blunted.

CONCLUSION

Supplementation with n-3 fatty acids inhibits the adrenal activation elicited by a mental stress, presumably through effects exerted at the level of the central nervous system.

Metabolic adaptations to dexamethasone-induced insulin resistance in healthy volunteers

OBJECTIVE

Insulin resistance is observed in individuals with normal glucose tolerance. This indicates that increased insulin secretion can compensate for insulin resistance and that additional defects are involved in impaired glucose tolerance or type 2 diabetes. The objective of this study was to evaluate a procedure aimed at assessing the compensatory mechanisms to insulin resistance.

RESEARCH METHODS AND PROCEDURES

Eight healthy nonobese female patients were studied on two occasions, before and after administration of 2 mg/d dexamethasone for 2 days during a two-step hyperglycemic clamp. Insulin secretion was assessed from plasma insulin concentrations. Insulin sensitivity was assessed from the ratio of whole-body glucose use (6,6 (2)H(2) glucose) to plasma insulin concentrations. This procedure is known to induce a reversible impairment of glucose tolerance and insulin resistance.

RESULTS

In all subjects, dexamethasone induced a decrease in insulin sensitivity and a proportionate increase in first-phase insulin secretion and in insulin concentrations at both steps of glycemia. The resulting hyperinsulinemia allowed the restoration of normal whole-body glucose uptake and the suppression of plasma free fatty acids and triglycerides. In contrast, the suppression of endogenous glucose production was impaired after dexamethasone (p < 0.01).

DISCUSSION

Increased insulin secretion fully compensates dexamethasone-induced insulin resistance in skeletal muscle and adipose tissue but not in the liver. This suggests that failure to overcome hepatic insulin resistance can impair glucose tolerance. The compensatory insulin secretion in response to insulin resistance can be assessed by means of a hyperglycemic clamp after a dexamethasone challenge.

Effect of metformin on insulin sensitivity and insulin secretion in female obese patients with normal glucose tolerance

OBJECTIVES

Metformin is recognized as the treatment of chronic obese, insulin-resistant type 2 diabetic patients. Whether it improves insulin sensitivity in obese patients with normal glucose tolerance remains unknown.

METHODS

Eight obese female patients with normal glucose tolerance were studied during a double blinded, randomized cross-over study including a 2-week administration of metformin and a 2-week administration of placebo. Insulin secretion and insulin sensitivity were assessed after metformin and placebo by means of a 3-hour hyperglycemic clamp.

RESULTS

The plasma insulin and C-peptide concentrations during the hyperglycemic clamp were identical after placebo or metformin (both first and second phases). Insulin-mediated glucose disposal, stimulation of glucose oxidation and suppression of endogenous glucose production were identical after metformin and placebo.

CONCLUSIONS

Metformin does not improve insulin sensitivity nor insulin secretion in obese female patients with normal glucose tolerance.

Metabolic effects of mental stress during over- and underfeeding in healthy women

OBJECTIVE

To assess the short-term consequences of carbohydrate or fat overfeeding or of food restriction on the metabolic effects of mental stress in healthy lean women.

RESEARCH METHODS AND PROCEDURES

The effects of a sympathetic activation elicited by mental stress were evaluated in a group of healthy women after standardized isocaloric feeding (ISO) or after a 3-day overfeeding with 40% excess calories as either carbohydrate overfeeding (CHO OF) or fat overfeeding (FAT OF). Oxygen consumption rate (VO(2)) was measured as an index of energy expenditure, and subcutaneous glycerol concentrations were monitored with microdialysis. The same measurements were performed in another group of healthy women after ISO and after a 3-day period of underfeeding with a protein sparing modified fast (UF).

RESULTS

In all conditions, mental stress significantly increased heart rate, blood pressure, plasma norepinephrine and epinephrine concentrations, and VO(2), and produced a nonsignificant increase in subcutaneous glycerol concentrations. CHO OF and FAT OF did not alter the effects of mental stress on VO(2) and subcutaneous glycerol concentrations. In contrast, UF increased basal VO(2) but significantly reduced its stimulation by mental stress. UF also enhanced the increase in subcutaneous glycerol concentrations during mental stress.

DISCUSSION

UF reduces the stimulation of energy expenditure and enhances lipolysis during sympathetic activation. These adaptations may be involved in mobilization of endogenous fat while limiting weight loss. In contrast, short-term overfeeding fails to alter the sympathetic control of energy expenditure and lipolysis.

Effects of fatty acids on exercise plus insulin-induced glucose utilization in trained and sedentary subjects

Fatty acids are known to decrease insulin-mediated glucose utilization in humans, both at rest and during exercise. To evaluate the effect of endurance training in this process, we infused lipids or saline in groups of sedentary and highly trained subjects. Whole body glucose utilization and substrate oxidation were monitored during a 2.5-h hyperinsulinemic clamp. During the last 30 min, a cycling exercise was superimposed. During hyperinsulinemia at rest, whole body glucose utilization and glucose oxidation were higher in trained subjects than in sedentary subjects. Compared with the control experiments with the antilipolytic agent acipimox, lipid infusion stimulated lipid oxidation to the same extent in trained as in sedentary subjects. It reduced whole body glucose utilization by 37% in trained and by 41% in sedentary subjects. During exercise, lipid infusion increased more lipid oxidation in trained than in sedentary subjects and reduced whole body glucose utilization by 43 +/- 4% in trained and by 22 +/- 4% in sedentary subjects (P < 0.01). The present data indicate that lipid infusion has similar effects on lipid oxidation and whole body glucose utilization during hyperinsulinemia at rest in trained and sedentary subjects. During exercise, however, it increases more lipid oxidation and produces a more important reduction in glucose utilization in trained than in sedentary subjects. These results suggest that endurance training enhances the inhibitory effect of lipids on whole body glucose metabolism during exercise.

[Nutritional status assessment in 57 hospitalized aged patients: impact of the causal disease]

PURPOSE

To study the nutritional status in elderly patients hospitalized for rehabilitation and to compare it among patients with hip fracture and those with medical care.

METHODS

Patients were nutritionally assessed upon admission (d0) to our unit by measurement of anthropometric, biological parameters and dietary intake. Thirty-seven patients were operated for hip fracture (group I) and 21 were hospitalised for medical disease (group II). Nutritional status was compared in the two groups on d0 and was evaluated after one month (d30) in the operated group.

RESULTS

No significant difference could be observed for any anthropometric or biologic (albumin, transthyretin and transferrin) in the two groups. Daily food intake related to body weight was much the same in both groups (31 kcal/kg). C-reactive protein and orosomucoid levels were above the reference range in both groups. Hip fracture operated patients had higher orosomucoid than non-operated ones (1.50 +/- 0.4 versus 1.14 +/- 0.4 g/L; P = 0.002). One-month follow-up of nutritional status performed in 31 operated patients showed a significant decrease in TST and MAC (respectively p = 0.02 and p = 0.007) and in orosomucoid (p = 0.003) although daily food intake increased.

CONCLUSION

Twenty-eight percent of patients were undernourished upon admission in the unit. A moderate inflammatory state still remained in all our patients, particularly in those who had undergone surgery. This inflammatory state persisted two months after surgery.

Effects of mental stress on insulin-mediated glucose metabolism and energy expenditure in lean and obese women

The effects of the sympathetic activation elicited by a mental stress on insulin sensitivity and energy expenditure (VO(2)) were studied in 11 lean and 8 obese women during a hyperinsulinemic-euglycemic clamp. Six lean women were restudied under nonselective beta-adrenergic blockade with propranolol to determine the role of beta-adrenoceptors in the metabolic response to mental stress. In lean women, mental stress increased VO(2) by 20%, whole body glucose utilization ([6,6-(2)H(2)]glucose) by 34%, and cardiac index (thoracic bioimpedance) by 25%, whereas systemic vascular resistance decreased by 24%. In obese women, mental stress increased energy expenditure as in lean subjects, but it neither stimulated glucose uptake nor decreased systemic vascular resistance. In the six lean women who were restudied under propranolol, the rise in VO(2), glucose uptake, and cardiac output and the decrease in systemic vascular resistance during mental stress were all abolished. It is concluded that 1) in lean subjects, mental stress stimulates glucose uptake and energy expenditure and produces vasodilation; activation of beta-adrenoceptors is involved in these responses; and 2) in obese patients, the effects of mental stress on glucose uptake and systemic vascular resistance, but not on energy expenditure, are blunted.

Hepatic nonoxidative disposal of an oral glucose meal in patients with liver cirrhosis

Seven patients with liver cirrhosis and five healthy subjects were studied over 4 hours after ingestion of a glucose meal to determine whether alterations of hepatic nonoxidative glucose disposal participate in the pathogenesis of impaired glucose tolerance. Hepatic uridyl-diphosphoglucose (UDPG) turnover was calculated from the isotopic enrichment of urinary acetaminophen glucuronide during continuous infusion of 13C-galactose and used as an index of hepatic glycogen synthesis. Patients with cirrhosis had postprandial hyperglycemia and decreased glucose clearance, but hepatic UDPG turnover was not altered (1.84 +/- 0.29 mg/kg fat-free mass min v 1.76 +/- 0.15 in controls, nonsignificant). It is concluded that hepatic postprandial glycogen synthesis is unaltered in patients with advanced cirrhosis, demonstrating important hepatic functional reserve.

Effects of sodium lactate on ventilation and acid-base balance in healthy humans

Sodium lactate inhibits ventilation when infused in healthy human subjects. This effect has been attributed to lactate-induced metabolic alkalosis. In order to further delineate the mechanisms responsible for this depression of ventilation, healthy humans were infused with sodium lactate with or without acetazolamide. Sodium lactate increased blood pH from 7.37 +/- 0.02 to 7.47 +/- 0.01 and induced a sustained urinary excretion of bicarbonate. PO2 of arterialized blood decreased by 10.3 +/- 2.1 mmHg, indicating an inhibition of ventilation. Acetazolamide decreased lactate-induced alkalinisation of blood (pH after lactate + acetazolamide 7.42 +/- 0.02), but did not prevent the drop in PO2. Acetazolamide alone tended to stimulate ventilation, as indicated by an increase in PO2. These results indicate that sodium lactate inhibits ventilation independently of changes in systemic blood pH. Alkalinization of the cerebrospinal fluid, or other central effects of lactate, is probably responsible for this ventilatory depression.