Screening for protein energy wasting in children with chronic kidney disease using dual energy x-ray absorptiometry as an additional tool

BACKGROUND

The current diagnosis of protein energy wasting (PEW) is based on scoring systems that lack precision in measuring muscle deficits. We undertook this cross-sectional study to determine the prevalence of PEW in children with chronic kidney disease (CKD) using a scoring system that included dual energy x-ray absorptiometry (DEXA) for measuring lean body mass (LBM) and to determine the prevalence of selected markers in PEW.

METHODS

Thirty CKD and 20 healthy children (1-18 years) were evaluated for (1) reduced dietary protein intake (DPI); (2) BMI < fifth centile for height age (BMI/HA); (3) serum albumin < 3.8 g/dl, cholesterol < 100 mg/dl, or CRP > 3 mg/L; (4) LBM < fifth centile for height age [LBMr] on DEXA. PEW was scored as minimal-one parameter positive in 2/4 categories; standard-one parameter positive in 3/4 categories; or modified-standard plus height < 2 SD.

RESULTS

Twenty children with CKD (66.7%) had PEW, (5/9) 55% in CKD 3, and (15/21) 71% in advanced CKD; minimal 12, standard 1, and modified 7. LBMr was seen in 20 (100%), reduced DPI in 16 (80%), and BMI/HA in 6 (30%) children with PEW. LBMr had 100% sensitivity and BMI/HA 100% specificity. LBMr was seen in 8 who had no other criteria for PEW. None of the parameters were positive in controls (p < 0.01).

CONCLUSIONS

PEW prevalence in CKD was high. Both prevalence and severity were higher in advanced CKD. LBMr was a highly sensitive marker to detect PEW. LBMr seen in some children with CKD who were negative for other markers could represent subclinical PEW.

Association of Frailty With Nutritional Status in Patients With Chronic Kidney Disease

OBJECTIVES

Frailty is commonly observed in patients with chronic kidney disease (CKD) and is associated with adverse outcomes. Protein-energy wasting (PEW), a state of decreased body stores of protein and energy fuels, may be associated with frailty. However, few data are available on the possible association between frailty and PEW in CKD.

METHODS

We examined the association between frailty and nutritional status assessed using anthropometric and body composition measurements, serum albumin, handgrip strength, the Malnutrition Inflammation Score (MIS), and dietary protein and calorie intake in a cross-sectional analysis of nondialysis patients with CKD stages 3-5. Body composition was assessed using multifrequency bioelectrical impedance. Frailty was defined as a Clinical Frailty Scale ≥4. We performed logistic regression with different nutrition assessment tools as the main predictors and age, sex, comorbidity, estimated glomerular filtration rate (eGFR), and hemoglobin as covariates.

RESULTS

A total of 157 patients (93 men and 64 women; mean age 64 years; diabetes prevalence 38.9%) with CKD (eGFR 24.4 ± 13.4 mL/min/1.73 m2) were included. Overall, 29.3% of patients were frail. Patients with frailty were older and had a significantly higher fat tissue index and MIS but a significantly lower lean tissue index, eGFR, hemoglobin value, serum albumin value, handgrip strength value, and dietary protein intake. In multivariate logistic regression analyses, a higher body mass index category (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.03-2.31), higher fat tissue index (OR, 1.15; 95% CI, 1.03-1.28), larger waist circumference (OR, 1.05; 95% CI, 1.01-1.09), reduced handgrip strength (OR, 2.70; 95% CI, 1.17-6.21), PEW defined by MIS ≥5 (OR, 3.49; 95% CI, 1.35-9.01), and dietary protein intake ≤0.8 g/kg/day (OR, 2.70; 95% CI, 1.18-6.19) were associated with higher odds of frailty.

CONCLUSION

Frailty is associated with nutritional status in patients with CKD. A comprehensive nutrition assessment may allow the implementation of strategies to prevent or reduce frailty.

Health inequalities of global protein-energy malnutrition from 1990 to 2019 and forecast prevalence for 2044: data from the Global Burden of Disease Study 2019

OBJECTIVES

Protein-energy malnutrition poses a serious medical problem worldwide. This study aims to describe the global burden, trends, and health inequalities of protein-energy malnutrition and forecasts for future prevalence.

STUDY DESIGN

This was a comprehensive analysis based on data provided by the Global Burden of Disease Study 2019.

METHODS

Data were obtained from the Global Health Data Exchange query tool, including prevalence, deaths, disability-adjusted life years (DALYs) and sociodemographic index (SDI). The estimated annual percentage changes were calculated to evaluate temporal trends. We quantified cross-country inequalities in protein-energy malnutrition burden and predicted the prevalence number and rate to 2044.

RESULTS

Globally, there were 147,672,757 (130,405,923 to 167,471,359) cases of protein-energy malnutrition in 2019, with 212,242 (185,403 to 246,217) deaths. Eastern Sub-Saharan Africa had the highest age-standardised death and DALY rates in 2019. From 1990 to 2019, the global age-standardised prevalence rate of protein-energy malnutrition showed an upward trend, while the age-standardised death rate showed a downward trend. A significant decline occurred in SDI-related health inequality, from 2126.1 DALYs per 100,000 persons between the poorest and richest countries in 1990 to 357.9 DALYs per 100,000 persons in 2019. There was a trend of decreasing age-standardised death and DALY rates along with increases in the SDI. Frontier analyses showed that there is much room for improving the current situation of protein-energy malnutrition in some countries. In the next 35 years, the prevalence of protein-energy malnutrition will continue to increase.

CONCLUSION

Although the disease burden of protein-energy malnutrition has greatly decreased since 1990 and health inequalities between countries are shrinking, the prevalence in Asian and African countries may continue to increase. Focussing on regional differences and strengthening the nutritional intake of people in underdeveloped areas are necessary to reduce future burdens.

[Risk factors analysis of protein energy wasting in children with chronic kidney disease]

Objective: To analyze the clinical characteristics and risk factors of protein energy wasting (PEW) in children with chronic kidney disease (CKD). Methods: Clinical data of 231 children with chronic kidney disease hospitalized in Beijing Children's Hospital affiliated to Capital Medical University from January 2018 to January 2023 were retrospectively analyzed to explore the incidence of PEW. According to the diagnostic criteria of CKDPEW, they were divided into a CKDPEW group and a non PEW group. The comparison between the groups was performed by independent-sample t test and Chi-squared test, and the risk factors were analyzed by multivariate Logistic regression. Results: Among the 231 children, there were 138 males and 93 females, with a visiting age of 9.9 (7.9, 16.0) years; 6 cases were in stage 1, 14 cases in stage 2, 51 cases in stage 3, 36 cases in stage 4, and 124 cases in stage 5. A total of 30 children (13.0%) with CKD PEW were diagnosed at the age of 7. 1 (3.8, 13.2) years, including 1 case in stage 1, 1 case in stage 2, 5 cases in stage 3, 5 cases in stage 4, and 18 cases in stage 5. There were a total of 201 cases (87.0%) in the non PEW group, diagnosed at the age of 11.8 (8.5, 12.2) years, including 5 cases in stage 1, 13 cases in stage 2, 46 cases in stage 3, 31 cases in stage 4, and 106 cases in stage 5. The Chi-squared test and t test showed that the systolic blood pressure, diastolic blood pressure, birth weight and carbon dioxide binding capacity of the CKD PEW group were lower than those of the non PEW group ((109±22) vs. (120±20) mmHg (1 mmHg=0.133 kPa), (72±19) vs. (79±16) mmHg, (2.9±0.5) vs. (3.2±0.6) kg, (17±4) vs. (19±4) mmol/L,t=2.85, 2.14, 0.67, 2.63, all P<0.05). Multivariate logistic regression analysis showed that carbon dioxide binding capacity and birth weight were independent protective factors of CKDPEW in children (OR=0.81 and 0.36, 95%CI=0.73-0.90 and 0.17-0.77, respectively; both P<0.01); the risk of PEW in CKD children decreased by 0.187 times for every 1 mmol/L increment in carbon dioxide binding capacity, and 0.638 times for every 1 kg increment in birth weight. Conclusions: The incidence of protein energy expenditure in children with chronic kidney disease is lower than that in the previous researches. PEW can appear in CKD 1-2 stage, and attention should be paid to it in the early stage of CKD in clinical practice. Low birth weight CKD children are susceptible to PEW, and actively correcting metabolic acidosis can reduce the risk of CKDPEW.

Double burden of malnutrition in Nepal: A trend analysis of protein-energy malnutrition and High Body Mass Index using the data from Global Burden of Disease 2010–2019

Background

The co-existence of undernutrition and overnutrition is a global public health threat. We aim to report the burden of both nutritional deficiency (Protein-Energy Malnutrition) and overweight (high Body Mass Index) in Nepal over a decade (2010–2019) and observe the changes through trend charts.

Methods

We did a secondary data analysis using the Institute for Health Metrics and Evaluation (IHME)’s Global Burden of Disease (GBD) database to download age-standardized data on Protein Energy Malnutrition (PEM) and high Body Mass Index (BMI). We presented the trend of death, Disability Adjusted Life Years (DALYs), Years of Life Lost (YLL), and Years Lost due to Disability (YLD) of PEM and high BMI in Nepal from 2010 to 2019 and also compared data for 2019 among South Asian countries.

Results

Between 2010 and 2019, in Nepal, the Disability Adjusted Life Years (DALYs) due to PEM were declining while high BMI was in increasing trend. Sex-specific trends revealed that females had higher DALYs for PEM than males. In contrast, males had higher DALYs for high BMI than females. In 2019, Nepal had the highest death rate for PEM (5.22 per 100,000 populations) than any other South Asian country. The burden of PEM in terms of DALY was higher in under-five children (912 per 100,000 populations) and elderly above 80 years old (808.9 per 100,000 populations), while the population aged 65–69 years had the highest burden of high BMI (5893 per 100,000 populations). In the last decade, the DALYs for risk factors contributing to PEM such as child growth failure (stunting and wasting), unsafe water, sanitation and handwashing, and sub-optimal breastfeeding have declined in Nepal. On the contrary, the DALYs for risk factors contributing to high BMI, such as a diet high in sugar-sweetened beverages, a diet high in trans fatty acid, and low physical activity, have increased. This could be a possible explanation for the increasing trend of high BMI and decreasing trend of PEM.

Conclusion

Rapidly growing prevalence of high BMI and the persistent existence of undernutrition indicate the double burden of malnutrition in Nepal. Public health initiatives should be planned to address this problem.

Burden of Nutritional Deficiencies in China: Findings from the Global Burden of Disease Study 2019

From 1990 to 2019, the age-standardized incidence rate of nutritional deficiencies in China remained stable. However, the age-standardized disability-adjusted life-years (DALY) rate of nutritional deficiencies decreased from 1990 to 2019. Data were extracted from the GBD 2019 datasets. Estimated annual percentage changes (EAPCs) were calculated to assess the incidence rate, and DALY trends of nutritional deficiencies. Measures were stratified by subtypes, regions, and age groups. In 2019, the age-standardized DALY rates of dietary iron deficiency and protein-energy malnutrition reached their highest levels. The main population groups with protein-energy malnutrition and dietary iron deficiency were adults over the age of 70 and children under the age of five. The latter group also had a greater burden of vitamin A deficiency. Zhejiang, Beijing, and Guangdong reported the highest age-standardized incidence rates of nutritional deficiencies, which mainly pertained to protein-energy malnutrition and vitamin A deficiency. Tibet, Xinjiang, and Hainan had the highest age-standardized DALY rates of nutritional deficiencies, which mainly pertained to dietary iron deficiency and protein-energy malnutrition.

Thymic Dysfunction and Atrophy in COVID-19 Disease Complicated by Inflammation, Malnutrition and Cachexia

Background: The current COVID-19 pandemic has put millions of people, especially children at risk of protein-energy malnutrition (PEM) by pushing them into poverty and disrupting the global food supply chain. The thymus is severely affected by nutritional deficiencies and is known as a barometer of malnutrition. Aim: The present commentary provides a novel perspective on the role of malnutrition-induced thymic dysfunction, involution and atrophy on the risk and severity of disease in children during the COVID-19 pandemic. Methods: A review of pertinent indexed literature including studies examining the effects of malnutrition on the thymus and immune dysfunction in COVID-19. Results: Protein-energy malnutrition and micronutrient deficiencies of zinc, iron and vitamin A are known to promote thymic dysfunction and thymocyte loss in children. Malnutrition- and infection-induced thymic atrophy and immune dysfunction may increase the risk of first, progression of COVID-19 disease to more severe forms including development of multisystem inflammatory syndrome in children (MIS-C); second, slow the recovery from COVID-19 disease; and third, increase the risk of other infections. Furthermore, malnourished children may be at increased risk of contracting SARS-CoV-2 infection due to socioeconomic conditions that promote viral transmission amongst contacts and create barriers to vaccination. Conclusion: National governments and international organizations including WHO, World Food Program, and UNICEF should institute measures to ensure provision of food and micronutrients for children at risk in order to limit the health impact of the ongoing COVID-19 pandemic.

Protein Intake among Community-Dwelling Older Adults: The Influence of (Pre-) Motivational Determinants

An adequate protein intake is important for healthy ageing, yet nearly 50% of Dutch community-dwelling older adults do not meet protein recommendations. This study explores protein intake in relation to eight behavioral determinants (I-Change model) among Dutch community-dwelling older adults. Data were collected through an online questionnaire from October 2019–October 2020. Protein intake was assessed by the Protein Screener 55+, indicating a high/low chance of a low protein intake (<1.0 g/kg body weight/day). The behavioral determinants of cognizance, knowledge, risk perception, perceived cues, attitude, social support, self-efficacy and intention were assessed by evaluating statements on a 7-point Likert scale. A total of 824 Dutch community-dwelling older adults were included, recruited via online newsletters, newspapers and by personal approach. Poisson regression was performed to calculate quartile-based prevalence ratios (PRs). Almost 40% of 824 respondents had a high chance of a low protein intake. Univariate analyses indicated that lower scores for all different behavioral determinants were associated with a higher chance of a low protein intake. Independent associations were observed for knowledge (Q4 OR = 0.71) and social support (Q4 OR = 0.71). Results of this study can be used in future interventions aiming to increase protein intake in which focus should lie on increasing knowledge and social support.

The Role of Nutrition in COVID-19 Susceptibility and Severity of Disease: A Systematic Review

BACKGROUND

Many nutrients have powerful immunomodulatory actions with the potential to alter susceptibility to coronavirus disease 2019 (COVID-19) infection, progression to symptoms, likelihood of severe disease, and survival.

OBJECTIVE

The aim was to review the latest evidence on how malnutrition across all its forms (under- and overnutrition and micronutrient status) may influence both susceptibility to, and progression of, COVID-19.

METHODS

We synthesized information on 13 nutrition-related components and their potential interactions with COVID-19: overweight, obesity, and diabetes; protein-energy malnutrition; anemia; vitamins A, C, D, and E; PUFAs; iron; selenium; zinc; antioxidants; and nutritional support. For each section we provide: 1) a landscape review of pertinent material; 2) a systematic search of the literature in PubMed and EMBASE databases, including a wide range of preprint servers; and 3) a screen of 6 clinical trial registries. All original research was considered, without restriction to study design, and included if it covered: 1) severe acute respiratory syndrome coronavirus (CoV) 2 (SARS-CoV-2), Middle East respiratory syndrome CoV (MERS-CoV), or SARS-CoV viruses and 2) disease susceptibility or 3) disease progression, and 4) the nutritional component of interest. Searches took place between 16 May and 11 August 2020.

RESULTS

Across the 13 searches, 2732 articles from PubMed and EMBASE, 4164 articles from the preprint servers, and 433 trials were returned. In the final narrative synthesis, we include 22 published articles, 38 preprint articles, and 79 trials.

CONCLUSIONS

Currently there is limited evidence that high-dose supplements of micronutrients will either prevent severe disease or speed up recovery. However, results of clinical trials are eagerly awaited. Given the known impacts of all forms of malnutrition on the immune system, public health strategies to reduce micronutrient deficiencies and undernutrition remain of critical importance. Furthermore, there is strong evidence that prevention of obesity and type 2 diabetes will reduce the risk of serious COVID-19 outcomes. This review is registered at PROSPERO as CRD42020186194.

Protein-energy malnutrition in older Australians: A narrative review of the prevalence, causes and consequences of malnutrition, and strategies for prevention

ISSUE ADDRESSED

Protein-energy malnutrition (PEM) is a condition of involuntary weight and muscle loss caused by inadequate nutritional intake. In Australia, it is predominantly associated with chronic diseases, as are common in the older population. Given the ageing population of Australia, and the poor outcomes associated with PEM, there is a need to identify the contributing factors, and to explore strategies to prevent PEM.

METHODS

Two databases were searched for pertinent keywords, including malnutrition, Australia and elderly, with relevant articles selected for inclusion. The citations and references of these articles were also searched for further articles.

RESULTS

PEM is associated with increasing age and institutionalisation. The contributing factors are multifactorial, and include physiological, pathophysiological and structural causes. PEM is a significant public health issue for Australia, in terms of its consequences on both quality of life for older adults, and the burden on the healthcare system. However, there are strategies that can be implemented at the community, organisation and policy level to prevent PEM.

CONCLUSION

PEM is a common problem for older Australians, and this has important physiological and public health consequences, especially in the context of the ageing Australian population. However, there is significant scope for preventing PEM. SO WHAT?: Readers can be advised that PEM is a significant public health issue that will increase in importance as the population continues to age. It is important that communities, organisations and governments develop strategies to prevent PEM.

Understanding the Mothers of Children with Spina Bifida and Hydrocephalus in Tanzania

OBJECTIVE

To identify if there are cultural, medical, educational, economic, nutritional and geographic barriers to the prevention and treatment of spina bifida and hydrocephalus.

METHODS

The mothers of infants with spina bifida and hydrocephalus admitted to Muhimbilli Orthopaedic Institute, Dar Es Salaam, Tanzania, between 2013 and 2014 were asked to complete a questionnaire. A total of 299 infants were identified: 65 with myelomeningoceles, 19 with encephaloceles, and 215 with isolated hydrocephalus. The questionnaire was completed by 294 of the mothers.

RESULTS

There was a high variation in the geographic origin of the mothers. Approximately 85% traveled from outside of Dar Es Salaam. The mean age was 29 (15-45) years old with a parity of 3 (1-10). The rates of consanguinity, obesity, antiepileptic medication, HIV seropositivity, and family history were 2%, 13%, 0%, 2%, and 2%, respectively. A maize-based diet was found in 84%, and only 3% of woman took folic acid supplementation, despite 61% of mothers stating that they wished to conceive another baby. Unemployment was high (77%), a low level of education was common (76% not attended any school or obtaining a primary level only), and 20% were single mothers. Hospital only was the preferred method of treatment for 94% of the mothers, and 85% of the babies were born in a hospital.

CONCLUSIONS

Our study highlights some of the cultural, educational, geographic, nutritional, and economic difficulties in the prevention and management of spina bifida and hydrocephalus in Tanzania.

Impact of Elderly Masticatory Performance on Nutritional Status: An Observational Study

Background and Objectives: Masticatory limitations on the dietary habits of edentulous subjects restrict their access to adequate nutrition, exposing them to a greater risk of protein energy malnutrition. The aim of this study is to verify the existence of an association between Masticatory Performance (MP) and nutritional changes in the elderly. Materials and Methods: 76 participants were enrolled. MP testing was performed using the two-color chewing gum mixing test. The system used reveals the extent to which the two differently colored chewing gums mix, and allows discrimination between different MPs. The assessment of the participants' nutritional statuses was carried out through a food interview. Anthropometric parameters were collected, and bioimpedance analysis was performed. Results: Mean MP was 0.448 ± 0.188. No statistically significant differences were detected between male and female subjects (p > 0.05). According to the Body Mass Index (BMI), obese patients had a lower MP than overweight and normal weight subjects (0.408 ± 0.225, 0.453 ± 0.169 and 0.486 ± 0.181, respectively). MP values were lower both in male and female subjects with a waist circumference above the threshold than those below it (0.455 ± 0.205 vs. 0.476 ± 0.110, respectively, in males and 0.447 ± 0.171 vs. 0.501 ± 0.138, respectively, in females). No relationship was noticed between MP and bioimpedance parameters (p > 0.05). Conclusions: A statistically significant relation was observed between MP and the number of missing teeth. A reduced MP could worsen nutritional parameters. A reduced MP did not seem to negatively affect bioimpedance parameters.

Childhood Disability and Nutrition: Findings from a Population-Based Case Control Study in Rural Bangladesh

Background: Evidence regarding the complex relationship between childhood disability and malnutrition is limited in low and middle income countries. We aimed to measure the association between childhood disability and malnutrition in rural Bangladesh. Method: We conducted a population-based case control study among children aged <18 years in a rural sub-district (i.e., Shahjadpur) in Bangladesh. Children with permanent disability (i.e., Cases) and their age/sex-matched peers (i.e., Controls) were identified from the local community utilizing the key informant method. Socioeconomic, anthropometric, and educational information was collected using a pre-tested questionnaire. Only Cases underwent detailed medical assessment for clinical and rehabilitation information. Descriptive and bivariate analyses were performed. Results: Between October 2017 and February 2018, 1274 Cases and 1303 Controls were assessed. Cases had 6.6 times and 11.8 times higher odds of being severely underweight and severely stunted respectively than Controls. Although epileptic children had the highest overall prevalence of malnutrition, the age/sex-adjusted odds of malnutrition were significantly higher among children with physical impairments. Underweight and/or stunting among children with disability was significantly associated with parental educational qualification, socioeconomic status and mainstream school attendance. Conclusion: The significantly high proportion of severe malnutrition among children with disability calls for urgent action and implementation of inclusive nutrition intervention programs in rural Bangladesh.

Appetite and Protein Intake Strata of Older Adults in the European Union: Socio-Demographic and Health Characteristics, Diet-Related and Physical Activity Behaviours

Considerable efforts have been directed towards stimulating healthy ageing regarding protein intake and malnutrition, yet large-scale consumer studies are scarce and fragmented. This study aims to profile older adults in the European Union (EU) according to appetite (poor/good) and protein intake (lower/higher) strata, and to identify dietary and physical activity behaviours. A survey with older (aged 65 years or above) adults (n = 1825) in five EU countries (Netherlands, United Kingdom, Finland, Spain and Poland) was conducted in June 2017. Four appetite and protein intake strata were identified based on simplified nutritional appetite questionnaire (SNAQ) scores (≤14 versus >14) and the probability of a protein intake below 1.0 g/kg adjusted BW/day (≥0.3 versus <0.3) based on the 14-item Pro55+ screener: "appi"-Poor appetite and lower level of protein intake (12.2%); "APpi"-Good appetite but lower level of protein intake (25.5%); "apPI"-Poor appetite but higher level of protein intake (14.8%); and "APPI"-Good appetite and higher level of protein intake (47.5%). The stratum of older adults with a poor appetite and lower level of protein intake (12.2%) is characterized by a larger share of people aged 70 years or above, living in the UK or Finland, having an education below tertiary level, who reported some or severe financial difficulties, having less knowledge about dietary protein and being fussier about food. This stratum also tends to have a higher risk of malnutrition in general, oral-health related problems, experience more difficulties in mobility and meal preparation, lower confidence in their ability to engage in physical activities in difficult situations, and a lower readiness to follow dietary advice. Two multivariate linear regression models were used to identify the behavioural determinants that might explain the probability of lower protein intake, stratified by appetite status. This study provides an overview and highlights the similarities and differences in the strata profiles. Recommendations for optimal dietary and physical activity strategies to prevent protein malnutrition were derived, discussed and tailored according to older adults' profiles.

Prevalence of malnutrition for elderly hemodialysis patients

INTRODUCTION

The prevalence of the terminal chronic renal failure treated by hemodialysis is rising steadily especially for the elderly. Its evolution is fraught with complications including protein-energy malnutrition. The aim of this study was to evaluate the predominance of protein-energy malnutrition among elderly hemodialysis patients.

METHODS

This cross-sectional descriptive study included 40 elderly hemodialysis patients recruited at the M8 nephrology department of Charles Nicolle Hospital in Tunis. All patients went through a clinical examination, a biological assessment, a dietary survey based on food registration for 3 consecutive days and the calculation of nutritional risk scores (MNA and GNRI).

RESULTS

The Average  of hemodialysis was of 7 ± 3.8 years. The average energy intake of the patients was 25.3 ± 12.3 kcal / kg of ideal weight per day. The weight evolution during the last 6 months preceding the study was marked by a weight loss exceeding the 10 % in 12 % of the cases. A BMI less than 21 kg / m² was noted in 73.7 % of the women and 47.6 % of the men. The brachial circumference was less than 22 cm in 36.8 % of the women and 23.6 % of the men. One-third (32.5 %) of the study population had a calf circumference that is less than 31 cm. Most patients (67.5 %) had hypoalbuminaemia. The predominance of malnutrition according to the 2007 HAS criteria was 71% among hemodialysis patients. The majority of women (78.9 %) and 57.1 % of men had GNRI less than or equal to 98.

CONCLUSION

Protein-energy malnutrition is a common and serious pathological situation in elderly hemodialysis patients which can be life-threatening.

Protein-Energy Malnutrition and Outcomes of Hospitalizations for Heart Failure in the USA

Chronically elevated cytokines from un-abating low-grade inflammation in heart failure (HF) results in Protein-Energy Malnutrition (PEM). However, the impact of PEM on clinical outcomes of admissions for HF exacerbations has not been evaluated in a national data. From the 2012 to 2014 Nationwide Inpatient Sample (NIS) patient's discharge records for primary HF admissions, we identified patients with concomitant PEM, and their demographic and comorbid factors. We propensity-matched PEM cohorts (32,771) to no-PEM controls (1:1) using a greedy algorithm-based methodology and estimated the effect of different clinical outcomes (SAS 9.4). There were 32,771 (∼163,885) cases of PEM among the 541,679 (∼2,708,395) primary admissions for HF between 2012 and 2014 in the US. PEM cases were older (PEM:76 vs no-PEM:72 years), Whites (70.75% vs 67.30%), and had higher comorbid burden, with Deyo-comorbidity index >3 (31.61% vs 26.30%). However, PEM cases had lower rates of obesity, hyperlipidemia and diabetes. After propensity-matching, PEM was associated with higher mortality (AOR:2.48 [2.31 to 2.66]), cardiogenic shock (3.11[2.79 to 3.46]), cardiac arrest (2.30[1.96 to 2.70]), acute kidney failure (1.49[1.44 to 1.54]), acute respiratory failure (1.57[1.51 to 1.64]), mechanical ventilation (2.72[2.50 to 2.97]). PEM also resulted in higher non-routine discharges (2.24[2.17 to 2.31]), hospital cost ($80,534[78,496 to 82,625] vs $43,226[42,376 to 44,093]) and longer duration of admission (8.6[8.5 to 8.7] vs 5.3[5.2 to 5.3] days). In conclusion, PEM is a prevailing comorbidity among hospitalized HF subjects, and results in devastating health outcomes. Early identification and prevention of PEM in HF subjects during clinic visits and prompt treatment of PEM both in the clinic and during hospitalization are essential to decrease the excess burden of PEM.

Assessment of Myocardial Function in Kenyan Children With Severe, Acute Malnutrition: The Cardiac Physiology in Malnutrition (CAPMAL) Study

Importance

Mortality among African children hospitalized with severe malnutrition remains high, with sudden, unexpected deaths leading to speculation about potential cardiac causes. Malnutrition is considered high risk for cardiac failure, but evidence is limited.

Objective

To investigate the role of cardiovascular dysfunction in African children with severe, acute malnutrition (SAM).

Design, Setting, and Participants

A prospective, matched case-control study, the Cardiac Physiology in Malnutrition (CAPMAL) study, of 88 children with SAM (exposed) vs 22 severity-matched patients without SAM (unexposed) was conducted between March 7, 2011, and February 20, 2012; data analysis was performed from October 1, 2012, to March 1, 2016.

Exposures

Echocardiographic and electrocardiographic (ECG) recordings (including 7-day Holter monitoring) at admission, day 7, and day 28.

Main Outcomes and Measures

Findings in children with (cases) and without (controls) SAM and in marasmus and kwashiorkor phenotypes were compared.

Results

Eighty-eight children (52 with marasmus and 36 with kwashiorkor) of the 418 admitted with SAM and 22 severity-matched controls were studied. A total of 63 children (57%) were boys; median age at admission was 19 months (range, 12-39 months). On admission, abnormalities more common in cases vs controls included severe hypokalemia (potassium <2.5 mEq/L) (18 of 81 [22%] vs 0%), hypoalbuminemia (albumin level <3.4 g/dL) (66 of 88 [75%] vs 4 of 22 [18%]), and hypothyroidism (free thyroxine level <0.70 ng/dL or thyrotropin level >4.2 mU/L) (18 of 74 [24%] vs 1 of 21 [5%]) and were associated with typical electrocardiographic changes (T-wave inversion: odds ratio, 7.3; 95% CI, 1.9-28.0; P = .001), which corrected as potassium levels improved. Fourteen children with SAM (16%) but no controls died. Myocardial mass was lower in cases on admission but not by day 7. Results of the Tei Index, a measure of global cardiac function, were within the reference range and similar in cases (median, 0.37; interquartile range [IQR], 0.26-0.45) and controls (median, 0.36; IQR, 0.28-0.42). Echocardiography detected no evidence of cardiac failure among children with SAM, including those receiving intravenous fluids to correct hypovolemia. Cardiac dysfunction was generally associated with comorbidity and typical of hypovolemia, with low cardiac index (median, 4.9 L/min/m2; IQR, 3.9-6.1 L/min/m2), high systemic vascular resistance index (median, 1333 dyne seconds/cm5/m2; IQR, 1133-1752 dyne seconds/cm5/m2), and with few differences between the marasmus and kwashiorkor manifestations of malnutrition. Seven-day continuous ECG Holter monitoring during the high-risk initial refeeding period demonstrated self-limiting significant ventricular arrhythmias in 33 of 55 cases (60%) and 6 of 18 controls (33%) (P = .049); none were temporally related to adverse events, including fatalities.

Conclusions and Relevance

There is little evidence that African children with SAM are at greater risk of cardiac dysfunction or clinically significant arrhythmias than those without SAM or that marasmus and kwashiorkor differed in cardiovascular profile. These findings should prompt a review of current guidelines.

Prevalence of Protein-Energy Wasting and Its Association With Cardiovascular Disease Risk Factors in Iranian Peritoneal Dialysis Patients

INTRODUCTION

Protein-energy wasting (PEW) is prevalent in dialysis patients, and cardiovascular disease (CVD) is the leading cause of mortality in these patients. This study aimed to determine the prevalence of PEW and its relationship with CVD risk factors in peritoneal dialysis (PD) patients in Tehran, Iran.

MATERIALS AND METHODS

All eligible PD patients in Tehran peritoneal dialysis centers were included in this cross-sectional study. The diagnosis of PEW was done based on the criteria of the International Society of Renal Nutrition and Metabolism. Serum high-sensitivity C-reactive protein, soluble intercellular adhesion molecule type 1, malondialdehyde, and lipid profile were measured.

RESULTS

The prevalence of PEW was 29% in the PD patients. Significant associations were found between the prevalence of PEW in PD patients and sex (P = .01), age (P = .03), type of PD dialysis solution (P = .04), and microinflammation (P = .03). Serum C-reactive protein (P = .02), soluble intercellular adhesion molecule type 1 (P = .001), and triglyceride (P = .03) were significantly higher in the PD patients without PEW as compared to those with PEW, whereas high-density lipoprotein cholesterol level was significantly lower in the PD patients without PEW as compared to those with PEW (P = .003).

CONCLUSIONS

Our study shows that PEW is prevalent in Iranian PD patients. In addition, serum concentrations of CVD risk factors are dependent on the amount of glucose absorbed from PD solutions and are more impaired in PD patients without PEW as compared to those with PEW.

A village-matched evaluation of providing a local supplemental food during pregnancy in rural Bangladesh: a preliminary study

BACKGROUND

Prenatal balanced protein energy supplementation consumed by undernourished women improves mid-upper arm circumference in early infancy. This study aimed to identify whether locally produced maternal food-based supplementation improved anthropometric measures at birth and early infancy.

METHODS

A village-matched evaluation, applying principles of a cluster randomised controlled trial, of a locally produced supplemental food to 87 undernourished pregnant women. 12 villages (intervention: n = 8; control: n = 4) in Pirganj sub-district, Rangpur District, northern Bangladesh. Daily supplements were provided.

RESULTS

Anthropometric data at birth were available for 77 mother-infant dyads and longer-term infant growth data for 75 infants. Mid-upper arm circumference (MUAC) was significantly larger in infants of mothers in the intervention group compared with the control group at 6 months (p < 0.05). The mean birth weight in babies of supplemented mothers (mean: 2·91 kg; SD: 0·19) was higher than in babies of mothers in the control group (mean: 2·72 kg; SD: 0·13), and these changes persisted until 6 months. Also, the proportion of low birth weight babies in the intervention group was much lower (event rate = 0.04) than in the control group (event rate = 0.16). However, none of these differences were statistically significant (p > 0·05; most likely due to small sample size). The intervention reduced the risk of wasting at 6 months by 63.38% (RRR = 0.6338), and of low birth weight by 88·58% (RRR = 0.8858), with NNT of 2.22 and 6.32, respectively. Only three pregnant women require this intervention in order to prevent wasting at 6 months in one child, and seven need the intervention to prevent low birth weight of one child.

CONCLUSIONS

Locally produced food-based balanced protein energy supplementation in undernourished pregnant women in northern Bangladesh resulted in larger MUAC in infants at 6 months. Further research, with larger sample sizes, is required to confirm the role of locally produced supplementation for undernourished pregnant women on weight and linear growth in newborns and infants.

TRIAL REGISTRATION

This research was registered with the ISRCTN registry (ISRCTN97447076). This project had human research ethical approval from the James Cook University (Australia) Ethics committee (H4498) and the Bangladesh Medical Research Council (BMRC/NREC/2010-2013/58).

Restrictive lung disorder is common in patients with kidney failure and associates with protein-energy wasting, inflammation and cardiovascular disease

BACKGROUND

Cardiovascular disease (CVD), protein-energy wasting (PEW), and inflammation are common interrelated features of chronic kidney disease (CKD). Less is known about lung dysfunction in CKD and its possible role in this context. We evaluated lung function and its association with estimated glomerular filtration rate (GFR), CVD, PEW, and inflammation in individuals with normal to severely reduced GFR.

METHODS

In 404 individuals with GFR category G1 (n = 31; GFR >90mL/min/1.73 m2), G2 (n = 46), G3 (n = 33), G4 (n = 49) and G5 (n = 245; GFR<15mL/min/1.73 m2), pulmonary function was assessed by spirometry. Obstructive (OLD) and restrictive (RLD) lung dysfunction was defined based on forced vital capacity (FVC), forced expiratory volume in the first second (FEV1) and peak expiratory flow (PEF), expressed as percentages of predicted values (%FEV1, %FVC and %PEF, respectively). PEW was evaluated by subjective global assessment, handgrip strength (HGS) and lean body mass index (LBMI), and inflammation by interleukin-6 and high sensitivity C-reactive protein.

RESULTS

RLD (defined as FEV1/FVC ≥ 0.70 and %FVC<80) associated with GFR and was present in 36% of G5 and 14% of G1-4 individuals. OLD (FEV1/FVC<0.70) was less common with similar prevalence among G1-4 (9%) and G5 (11%) individuals. Notably, 64% of those with concomitant presence of PEW, inflammation and clinical signs of CVD had RLD while 79% of those lacking these complications had normal lung function. In multivariate logistic regression analysis, RLD associated with CVD, PEW and inflammation, after adjusting for Framingham's CVD risk score, serum albumin, and GFR category.

CONCLUSIONS

RLD is a common complication in patients with advanced CKD, especially in those with concomitant presence of CVD, inflammation and PEW. RLD appears to be an integral albeit scarcely explored consequence of pulmonary-renal interactions in CKD patients.

Prospective associations of poor diet quality with long-term incidence of protein-energy malnutrition in community-dwelling older adults: the Health, Aging, and Body Composition (Health ABC) Study

Background

Protein-energy malnutrition (PEM) is a major problem in older adults. Whether poor diet quality is an indicator for the long-term development of PEM is unknown.

Objective

The aim was to determine whether poor diet quality is associated with the incidence of PEM in community-dwelling older adults.

Design

We used data on 2234 US community-dwelling older adults aged 70-79 y of the Health, Aging, and Body Composition (Health ABC) Study. In 1998-1999, dietary intake over the preceding year was measured by using a Block food-frequency questionnaire. Indicators of diet quality include the Healthy Eating Index (HEI), energy intake, and protein intake. Outcomes were determined annually by using measured weight and height and included the following: 1) incident PEM [body mass index (in kg/m2) <20, involuntary weight loss of ≥5% in the preceding year at any follow-up examination, or both] and 2) incident persistent PEM (having PEM at 2 consecutive follow-up examinations). Associations of indicators of diet quality with 4-y and 3-y incidence of PEM and persistent PEM, respectively, were examined by multivariable Cox regression analyses.

Results

The quality of the diet, as assessed with the HEI, was rated as "poor" for 6.4% and as "needs improvement" for 73.0% of the participants. During follow-up, 24.9% of the participants developed PEM and 8.5% developed persistent PEM. A poor HEI score was not associated with incident PEM or persistent PEM. Lower baseline energy intake was associated with a lower incidence of PEM (HR per 100-kcal/d lower intake: 0.98; 95% CI: 0.97, 0.99) and persistent PEM (HR: 0.97; 95% CI: 0.95, 0.99), although lower baseline protein intake was observed to be associated with a higher incidence of persistent PEM (HR per 10-g/d lower intake: 1.15; 95% CI: 1.03, 1.29).

Conclusions

These findings do not indicate that a poor diet quality is a risk factor for the long-term development of PEM in community-dwelling older adults, although there is an indication that lower protein intake is associated with higher PEM risk.

Dietary Protein Intake in Young Children in Selected Low-Income Countries Is Generally Adequate in Relation to Estimated Requirements for Healthy Children, Except When Complementary Food Intake Is Low

Background: Previous research indicates that young children in low-income countries (LICs) generally consume greater amounts of protein than published estimates of protein requirements, but this research did not account for protein quality based on the mix of amino acids and the digestibility of ingested protein.Objective: Our objective was to estimate the prevalence of inadequate protein and amino acid intake by young children in LICs, accounting for protein quality.Methods: Seven data sets with information on dietary intake for children (6-35 mo of age) from 6 LICs (Peru, Guatemala, Ecuador, Bangladesh, Uganda, and Zambia) were reanalyzed to estimate protein and amino acid intake and assess adequacy. The protein digestibility-corrected amino acid score of each child's diet was calculated and multiplied by the original (crude) protein intake to obtain an estimate of available protein intake. Distributions of usual intake were obtained to estimate the prevalence of inadequate protein and amino acid intake for each cohort according to Estimated Average Requirements.Results: The prevalence of inadequate protein intake was highest in breastfeeding children aged 6-8 mo: 24% of Bangladeshi and 16% of Peruvian children. With the exception of Bangladesh, the prevalence of inadequate available protein intake decreased by age 9-12 mo and was very low in all sites (0-2%) after 12 mo of age. Inadequate protein intake in children <12 mo of age was due primarily to low energy intake from complementary foods, not inadequate protein density.Conclusions: Overall, most children consumed protein amounts greater than requirements, except for the younger breastfeeding children, who were consuming low amounts of complementary foods. These findings reinforce previous evidence that dietary protein is not generally limiting for children in LICs compared with estimated requirements for healthy children, even after accounting for protein quality. However, unmeasured effects of infection and intestinal dysfunction on the children's protein requirements could modify this conclusion.

Protein Nutrition and Malnutrition in CKD and ESRD

Elevated protein catabolism and protein malnutrition are common in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). The underlying etiology includes, but is not limited to, metabolic acidosis intestinal dysbiosis; systemic inflammation with activation of complements, endothelin-1 and renin-angiotensin-aldosterone (RAAS) axis; anabolic hormone resistance; energy expenditure elevation; and uremic toxin accumulation. All of these derangements can further worsen kidney function, leading to poor patient outcomes. Many of these CKD-related derangements can be prevented and substantially reversed, representing an area of great potential to improve CKD and ESRD care. This review integrates known information and recent advances in the area of protein nutrition and malnutrition in CKD and ESRD. Management recommendations are summarized. Thorough understanding the pathogenesis and etiology of protein malnutrition in CKD and ESRD patients will undoubtedly facilitate the design and development of more effective strategies to optimize protein nutrition and improve outcomes.

The Rise and Fall of Protein Malnutrition in Global Health

BACKGROUND

From the 1950s to the mid-1970s, United Nations (UN) agencies were focused on protein malnutrition as the major worldwide nutritional problem. The goal of this review is to examine this era of protein malnutrition, the reasons for its demise, and the aftermath.

SUMMARY

The UN Protein Advisory Group was established in 1955. International conferences were largely concerned about protein malnutrition in children. By the early 1970s, UN agencies were ringing the alarm about a 'protein gap'. In The Lancet in 1974, Donald McLaren branded these efforts as 'The Great Protein Fiasco', declaring that the 'protein gap' was a fallacy. The following year, John Waterlow, the scientist who led most of the efforts on protein malnutrition, admitted that a 'protein gap' did not exist and that young children in developing countries only needed sufficient energy intake. The emphasis on protein malnutrition waned. It is recently apparent that quality protein and essential amino acids are missing in the diet and may have adverse consequences for child growth and the reduction of child stunting. Key Messages: It may be time to re-include protein and return protein malnutrition in the global health agenda using a balanced approach that includes all protective nutrients.

Convergence of a diabetes mellitus, protein energy malnutrition, and TB epidemic: the neglected elderly population

BACKGROUND

On a global scale, nearly two billion persons are infected with Mycobacterium tuberculosis. From this vast reservoir of latent tuberculosis (TB) infection, a substantial number will develop active TB during their lifetime, with some being able to transmit TB or Multi-drug- resistant (MDR) TB to others. There is clinical evidence pointing to a higher prevalence of infectious diseases including TB among individuals with Diabetes Mellitus (DM). Furthermore, ageing and diabetes mellitus may further aggravate protein-energy malnutrition (PEM), which in turn impairs T-lymphocyte mediated immunologic defenses, thereby increasing the risk of developing active TB and compromising TB treatment. This article aims to a) highlight synergistic mechanisms associated with immunosenescence, DM and PEM in relation to the development of active TB and b) identify nutritional, clinical and epidemiological research gaps.

METHODS

To explore the synergistic relationship between ageing, DM, tuberculosis and PEM, a comprehensive review was undertaken. The MEDLINE and the Google Scholar databases were searched for articles published from 1990 to March 2015, using different MESH keywords in various combinations.

RESULTS

Ageing and DM act synergistically to reduce levels of interferon gamma (IFN- γ), thereby increasing susceptibility to TB, for which cell mediated immunity (CMI) plays an instrumental role. These processes can set in motion a vicious nutritional cycle which can predispose to PEM, further impairing the CMI and consequently limiting host defenses. This ultimately transforms the latent TB infection into active disease. A clinical diagnostic algorithm and clinical guidelines need to be established for this population.

CONCLUSION

Given the increase in ageing population with DM and PEM, especially in resource-poor settings, these synergistic tripartite interactions must be examined if a burgeoning TB epidemic is to be averted. Implementation of a comprehensive, all-encompassing approach to curb transmission is clearly indicated. To this end, clinical, nutritional and epidemiological research gaps must be addressed without a delay.

Biomarkers of Cardiovascular Disease and Mortality Risk in Patients with Advanced CKD

BACKGROUND AND OBJECTIVES

The high risk of cardiovascular disease (CVD) and premature death in patients with CKD associates with a plethora of elevated circulating biomarkers that may reflect distinct signaling pathways or simply, are epiphenomena of CKD. We compared the predictive strength of 12 biomarkers analyzed concomitantly in patients with stage 5 CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

From 1994 to 2014, 543 patients with stage 5 CKD (median age =56 years old; 63% men; 199 patients had CVD) took part in our study on malnutrition, inflammation, and CVD in incident dialysis patients. Circulating levels of albumin, ferritin, high-sensitivity C-reactive protein (hsCRP), IGF-1, IL-6, orosomucoid, troponin T (TnT), TNF, soluble intracellular adhesion molecule, soluble vascular cellular adhesion molecule 1 (sVCAM-1), and platelet and white blood cell (WBC) counts were analyzed as predictors of the presence of clinically overt CVD at baseline, protein-energy wasting (PEW), and subsequent all-cause mortality. During follow-up for a median of 28 months, there were 149 deaths, 81 of which were caused by CVD.

RESULTS

Most biomarkers were elevated compared with reference values and--except for albumin, ferritin, and IGF-1-higher in patients with CVD. In receiver operating characteristic analysis, age, IL-6, TnT, hsCRP, and IGF-1 were classifiers of baseline CVD and predictors of all-cause mortality. In addition to age, diabetes mellitus, smoking (for CVD), and PEW, only IL-6, relative risk (RR) 1.10 and 95% confidence interval ([95% CI], 1.02 to 1.19), sVCAM-1 RR 1.09 (95% CI, 1.01 to 1.17), and serum albumin RR 0.89 (95% CI, 0.83 to 0.95) associated with baseline CVD, and only WBC, hazard ratio (HR) 1.94 (95% CI, 1.34 to 2.82), IL-6 HR 1.79 (95% CI, 1.20 to 2.67), and TNF HR 0.65 (95% CI, 0.44 to 0.97) predicted all-cause mortality.

CONCLUSIONS

In addition to age and comorbidities, only IL-6, sVCAM-1, and albumin could-independently of other biomarkers-classify clinical CVD, and only IL-6, WBC, and TNF could-independently of other biomarkers-predict all-cause mortality risk. These data underscore the robustness of IL-6 as a classifier of clinically overt CVD and predictor of all-cause mortality in patients with stage 5 CKD.

Association of anemia with functional and nutritional status in the German multicenter study "GeriAnaemie2013"

OBJECTIVES

Anemia and malnutrition are risk factors for frailty in older people but data from multicenter studies among German geriatric inpatients are lacking. This analysis evaluated data from the multicenter study "GerAnaemie2013" commissioned by the German Geriatric Society.

PATIENTS AND METHODS

The study involved an analysis of the 579 geriatric inpatients recruited in the context of the German multicenter study "GeriAnaemie2013". Study parameters: Barthel index (BI), handgrip strength, nutritional data (e.g. loss of appetite, loss of weight and decreased food intake).

INCLUSION CRITERIA

in-patient age ≥70 years, exclusion criteria: current cancer disease or cancer-associated treatment. Anemia was defined according to the World Health Organization (WHO) criteria.

RESULTS

The mean age of patients was 81.9 years, overall prevalence of anemia 55.1 %, mean hemoglobin (Hb) level 11.9 g/dl, average BI 50.8 points and 30.3 % of all patients were at risk of malnutrition. While univariate analysis revealed a significantly lower BI in anemic patients, this association was no longer seen in multivariate analysis. Regression analysis revealed that a drug intake of > 5 drugs/day doubles the chance of suffering from anemia with an adjusted odds ratio (OR) of 2.17 (confidence interval (CI) 1.28-3.68, p = 0.004) as well as a serum albumin level below 3.5 g/dl with an adjusted OR of 2.11 (range 1.40-3.19, p < 0.001).

CONCLUSION

Polymedication and low serum albumin were independent risk factors for anemia in geriatric patients, probably reflecting disease severity.

Protein energy malnutrition associates with different types of hearing impairments in toddlers: Anemia increases cochlear dysfunction

OBJECTIVES

This work aimed to highlight a challenging asymptomatic problem which is early detection of hearing impairment in toddlers with protein energy malnutrition (PEM) as a neuro-cognitive effect of PEM on developing brain in relation to hemoglobin level.

METHODS

100 toddlers, aged 6-24 months, fifty with moderate/severe PEM and fifty healthy children, were included in study. Both TEOAEs and ABR testing were used to assess auditory function.

RESULTS

Study reported an association between malnutrition and hearing impairment, 26% of cases had conductive deafness secondary to otitis media with effusion using tympanometry; 84.6% showed type B and 15.4% type C which may suggest developing or resolving otitis media. Their ABR showed 46% mild and 53% moderate impairment. 32% of PEM cases had sensory neural hearing loss and with type (A) tympanometry. Those were assessed using ABR; 58% had mild, 34% moderate and 8% profound impairment. 10% of PEM cases had mixed hearing loss with 50% type B and 50% type C tympanometry and their ABR showed moderate to profound impairment. TEOAEs latencies at different frequencies correlate negatively with hemoglobin level.

CONCLUSIONS

Toddlers with moderate/severe PEM had hearing impairments of different types and degrees. Neuro-physiological methods could be early and safe detectors of auditory disorders especially in high-risk toddlers. Anemia increases risk for auditory dysfunction.

Nutritional Status of Maintenance Dialysis Patients: Low Lean Body Mass Index and Obesity Are Common, Protein-Energy Wasting Is Uncommon

BACKGROUND AND AIMS

Maintenance dialysis patients are at increased risk of abnormal nutritional status due to numerous causative factors, both nutritional and non-nutritional. The present study assessed the current prevalence of protein-energy wasting, low lean body mass index and obesity in maintenance dialysis patients, and compared different methods of nutritional assessment.

METHODS

In a cross-sectional study conducted in 2014 at Roskilde Hospital, Denmark, we performed anthropometry (body weight, skinfolds, mid-arm, waist, and hip circumferences), and determined plasma albumin and normalized protein catabolic rate in order to assess the prevalence of protein-energy wasting, low lean body mass index and obesity in these patients.

RESULTS

Seventy-nine eligible maintenance dialysis patients participated. The prevalence of protein-energy wasted patients was 4% (95% CI: 2-12) as assessed by the coexistence of low lean body mass index and low fat mass index. Low lean body mass index was seen in 32% (95% CI: 22-44). Obesity prevalence as assessed from fat mass index was 43% (95% CI: 32-55). Coexistence of low lean body mass index and obesity was seen in 10% (95% CI: 5-19). The prevalence of protein-energy wasting and obesity varied considerably, depending on nutritional assessment methodology.

CONCLUSIONS

Our data indicate that protein-energy wasting is uncommon, whereas low lean body mass index and obesity are frequent conditions among patients in maintenance dialysis. A focus on how to increase and preserve lean body mass in dialysis patients is suggested in the future. In order to clearly distinguish between shortage, sufficiency and abundance of protein and/or fat deposits in maintenance dialysis patients, we suggest the simple measurements of lean body mass index and fat mass index.

Factors Associated With Protein-energy Malnutrition in Chronic Liver Disease: Analysis Using Indirect Calorimetry

We aimed to elucidate the incidence of protein-energy malnutrition (PEM) in patients with chronic liver disease and to identify factors linked to the presence of PEM.A total of 432 patients with chronic liver disease were analyzed in the current analysis. We defined patients with serum albumin level of ≤3.5 g/dL and nonprotein respiratory quotient (npRQ) value using indirect calorimetry less than 0.85 as those with PEM. We compared between patients with PEM and those without PEM in baseline characteristics and examined factors linked to the presence of PEM using univariate and multivariate analyses.There are 216 patients with chronic hepatitis, 123 with Child-Pugh A, 80 with Child-Pugh B, and 13 with Child-Pugh C. Six patients (2.8%) had PEM in patients with chronic hepatitis, 17 (13.8%) in patients with Child-Pugh A, 42 (52.5%) in patients with Child-Pugh B, and 10 (76.9%) in patients with Child-Pugh C (P < 0.001). Multivariate analysis revealed that Child-Pugh classification (P < 0.001), age ≥64 years (P = 0.0428), aspartate aminotransferase (AST) ≥40 IU/L (P = 0.0023), and branched-chain amino acid to tyrosine ratio (BTR) ≤5.2 (P = 0.0328) were independent predictors linked to the presence of PEM. On the basis of numbers of above risk factors (age, AST, and BTR), the proportions of patients with PEM were well stratified especially in patients with early chronic hepatitis or Child-Pugh A (n = 339, P < 0.0001), while the proportions of patients with PEM tended to be well stratified in patients with Child-Pugh B or C (n = 93, P = 0.0673).Age, AST, and BTR can be useful markers for identifying PEM especially in patients with early stage of chronic liver disease.

The pleiotropic role of vitamin A in regulating mucosal immunity

The effect of vitamin A on mucosal immunity has never been subjected to extensive studies until recently. We started to work in this area in the early 1970s when we observed that children with protein-calorie malnutrition (PCM) often had defective mucosal immunity, judging from the incidence of respiratory tract infections and diarrhea. We reported that these children had depressed secretory IgA (sIgA) levels in their nasal wash fluids. The IgA level in specimens collected from those superimposed with some degrees of vitamin A deficiency state appeared to be more severely affected. In order to better understand the underlying mechanism associated with this condition, we started to study more detail the deficiency state using experimental vitamin A-deficient rats. From a series of experiments using this animal model, we proposed that vitamin A was needed for transport and/or secretion of sIgA across the mucosa. This conclusion was based on the observation that the secretory component of sIgA synthesized by the epithelial cells of these vitamin A deficient animals was adversely affected as compared to the control animals. From that time onward, much progress has been made by several other groups showing that other mechanisms could also influence the integrity and immune function of the mucosa. For instance, recent studies demonstrated that retinoic acid which is a biologically active form of vitamin A has an essential role in mucosal homeostasis, controlling tolerance and immunity in these non-lymphoid tissues. Such a conclusion was made possible by the availability of sophisticated new molecular biology and genetic engineering techniques together with advances in the field of immunoregulation, e.g., the discovery of dendritic cells (DCs) and T helper cell subsets in 1980s, and the role of Toll-like receptors (TLRs) together with other innate immune regulators in controlling adaptive immune response in the early 1990s. These advances provided considerable new insights into the pleiotropic roles of vitamin A including educating mucosal DCs, differentiation of lymphocyte lineages and imprinting them with mucosal-homing properties as well as in regulating tolerance and immunity. The identification of a novel lymphocyte subpopulation, innate lymphoid cells (ILCs), at the beginning of this century has provided us with an additional insight into a new role of vitamin A in regulating homeostasis at the mucosal surface through influencing ILCs. Another new player that regulates intestinal homeostasis and mucosal immune response is microbiota whose composition is known to vary with vitamin A status. So it appears now that the role of vitamin A on mucosal immunity is far beyond regulating the adaptive Th1-Th2 cell response, but is highly pleiotropic and more complicating, e.g., polarizing the phenotype of mucosal DCs and macrophages, directing gut-homing migration of T and B cells, inducing differentiation of effector T cells and Treg subpopulation, balancing mucosal ILCs subpopulation and influencing the composition of microbiota. In this review, I will attempt to bring together these important advances to provide a comprehensive and contemporary perspective on the role of vitamin A in regulating mucosal immunity.

Context for food-based approaches for improved feeding of infants and children in Ethiopia

BACKGROUND

Regardless of efforts by the health sector and partner organizations, maternal and child malnutrition is still a challenge in Ethiopia.

OBJECTIVE

To describe the context of current infant and child feeding patterns in Ethiopia.

METHODS

Feeding patterns, diet content and quality, and nutritional outcomes and feeding practices of mothers of young children are described from literature review of a number of field studies.

RESULTS

Protein and energy deficiencies and multiple micronutrient deficiencies are common. Breastfeeding is often prolonged until 2 years of age, with introduction of small amounts of poor-quality complementary foods. Vitamin A and iodine deficiencies have also been problems. Focus group discussions showed that mothers did not believe that animal-source foods are needed.by young children or schoolchildren. However, the Health Extension Program led by the Federal Ministry of Health promotes optimal child feeding as one of the health extension packages.

CONCLUSIONS

Continued use of germination and fermentation of cereals should be encouraged to increase bioavailability of trace elements. Use of fat in the diet would increase energy density. To improve the situation, extension education, including nutrition and agricultural expertise delivered in aformat understandable to mothers about appropriate complementary feeding, including animal-source foods, is urgently needed, with expansion of governmental and nongovernmental resources.

Variation de l’albuminémie au cours de la malnutrition protéino-energétique dans une zone urbano-rurale congolaise

Introduction

La malnutrition est à ce jour un problème de santé publique majeur, notamment dans les pays en voie de développement. Le diagnostic est fait cliniquement, mais l'intérêt de certains dosages paracliniques ont leur importance pour en évaluer la gravité ou faciliter un dépistage précoce, notamment de l'albuminémie. Cette étude a eu pour objectif de déterminer la variation de l'albuminémie au cours de la malnutrition protéino-calorique de l'enfant et de déterminer les facteurs associés.

Méthodes

Il s'agit d'une étude descriptive transversale, effectuée prospectivement de juillet 2013 à mars 2014. 154 cas ont été colligés, par échantillonnage de convenance, avec un dépistage actif des enfants malnutris.

Résultats

72,7% d'enfants avaient un taux normal d'albuminémie, ce taux bas étant pour la plupart lié à un état inflammatoire et/ou infectieux au cours de la malnutrition. Le taux d'albuminémie a un lien étroit avec l’état nutritionnel, chez le malnutri chronique, l’émacié et chez ceux présentant un déficit pondéral avec respectivement 18,3%; 24,0% et 30,4% d'enfants qui ont présenté un taux bas en albumine plasmatique. Cette hypo albuminémie a été retrouvé chez les malnutris avec ou sans œdèmes. 30 enfants ont présentés des œdèmes et 63% avaient un taux bas d'albumine sérique; contre 124 enfants qui n'ont pas présentés des œdèmes et 18,3% ont présenté un taux bas en albumine sérique.

Conclusion

La malnutrition est une maladie dont les perturbations impliquent celle de l'albuminémie. Les variations de l'albuminémie sont statistiquement associées au tableau clinique.

[Prevalence of malnutrition in a mid-long term stay unit]

INTRODUCTION

Malnutrition is a common health problem, especially in hospitalized patients, where it's associated with longer hospital stays and higher rates of morbidity and mortality. Furthermore, current scientific advances and life expectancy increase, have produced a progressive increase of mid- to long-term stay units (UMLE).

AIMS

To determinate the prevalence of malnutrition on admission to a mid- to long-term stay unit, using MNA and VGS and to analyze the possible factors/clinical features associated with malnutrition and its consequences.

METHODS

Descriptive and transversal study conducted with 201 patients admitted consecutively for 12 months in an Universitary Hospital mid- to long-term stay unit (Valencia). Clinical, anthropometric, biochemical and nutritional history data were registered, as well as Charlson comorbidity scale, Pfeiffer cognitive scale, Barthel functional scale and presence of edema, ascitis and pressure ulcers. Nutritional status was evaluated in the first 24-72 hours of admission using MNA and VGS. Dysphagia was evaluated using EAT-10 and MECV-V questionnaires.

RESULTS

The overall rate of malnutrition was 76,6%, being severe protein energy malnutrition the most common type (20,4%). Malnourished patients were older (p=0,002), presented greater dependence (p.

Tooth loss strongly associates with malnutrition in chronic kidney disease

BACKGROUND

In chronic kidney disease (CKD), inadequate nutritional intake, inflammation, and increased oxidative stress have been the major contributing factors in malnutrition pathogenesis. However, there is still a paucity of evidence assessing the magnitude of the effect of tooth loss on malnutrition in CKD populations. The authors hypothesize that among patients with CKD, tooth loss may affect nutritional status, using the National Health and Nutrition Examination Survey 1988 to 1994 (NHANES III).

METHODS

Glomerular filtration rate (GFR) was estimated based on cystatin C levels using the relevant equation. Urinary albumin-to-creatinine ratio (albuminuria) was calculated in milligrams per gram with a cutoff point of 30 mg/g. CKD was defined based on estimated GFR <60 mL/minute/1.73m(2) and albuminuria ≥30 mg/g. The cutoff point for serum albumin was set at 3.7 g/dL. Tooth loss categories were based on the number of missing and replaced teeth.

RESULTS

A total of 2,749 patients was included and stratified based on their oral health status. There was a statistically significant correlation between tooth loss and the proportion of patients with low protein and caloric intake (P = 0.02 and 0.01, respectively). Serum albumin reached a frequency peak in the fully edentulous group without dentures (group 4, 19.2%). In the same group, individuals had lower protein (30.1%) and caloric intake (30.2%) (P = 0.01 and 0.02, respectively). Furthermore, logistic regression analysis confirmed the significant role of tooth loss on serum albumin and protein and energy intake in this population even after adjusting for confounding variables.

CONCLUSION

Tooth loss independently predicts low energy and protein intake, as well as serum albumin levels, biomarkers of malnutrition in CKD.

Undernutrition and anaemia among HAART-naïve HIV infected children in Ile-Ife, Nigeria: a case-controlled, hospital based study

INTRODUCTION

Case control studies that assess the burden and factors associated with undernutrition and anaemia among HAART naïve HIV infected children in Nigeria is very sparse. This will help to formulate nutritional programs among these children.

METHODS

Seventy HAART naive HIV infected children aged 18 months and above were as well as seventy age and sex matched HIV negative children were recruited from August 2007 to January 2009 at Paediatric Clinic of Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria. Their bio data, WHO clinical stage, anthropometric measurements, haematocrit, serum albumin and CD4 counts were taken with other parameters according to a study proforma.

RESULTS

The prevalence of stunting, underweight and wasting among the HIV infected subjects were 48. 6%,58. 6% and 31. 4% respectively which as significantly higher than 28. 1%, 7. 1% and 28. 1% among the HIV negative controls. 20. 1% of the HIV infected children were marasmic compared to 2. 3% of the controls. Triple anthropometric failure was found in 7. 1% of the subjects as compared to none among the controls. Anaemia is significantly more prevalent among the subjects than the controls (70. 0% vs 31. 4%; p<0. 001). The prevalence of anaemia was higher in the HIV infected subjects with undernutrition. Low socioeconomic status, hypoalbuminemia and severe immunosuppression are significantly associated with higher undernutrition prevalence.

CONCLUSION

Several years after availability of HAART, undernutrition and anaemia remain widely prevalent among newly presenting HAART naïve HIV infected Nigerian children. Nutritional supplementation and evaluation for anaemia still need close attention in the management of these children.

Initiation of dialysis: a mini-review of a changing paradigm

A paradigm shift is occurring in the way nephrologists evaluate patients with progressive chronic kidney disease for initiation of maintenance renal replacement therapy. Serum creatinine and serum creatinine-based equations used to calculate an estimated glomerular filtration rate (eGFR) are not accurate approximations of renal function at low levels. Further complicating matters is a trend toward early initiation of dialysis, once considered beneficial since patients had better outcomes if they started dialysis before the onset of protein malnutrition. But recent data, including results of a large randomized controlled trial, suggest no benefit and possibly increased risk of death with early initiation of dialysis. This review will examine the data and where the field stands in deciding when to initiate dialysis.

[Prevalence and prevention of common nutritional risks in children after earthquake]

Children have been identified as the most nutritionally vulnerable group when disaster happens. The most common nutritional risks include protein-energy malnutrition, iron-deficiency anemia, and trace element deficiency in children after earthquake. During the disaster relief, effective nutritional interventions should be performed according to the nutritional conditions of children in the affected area, so as to prevent the common nutritional risks. Timely diagnosis and treatment should be provided for children at a high risk of malnutrition.

The occurrence of small for gestational age infants and perinatal and maternal outcomes in normal and poor maternal weight gain singleton pregnancies

OBJECTIVE

To assess the occurrence of small for gestational age (SGA) infants and perinatal and maternal outcomes in singleton pregnancies with normal and poor maternal weight gain.

MATERIAL AND METHOD

Pregnant women with normal pre-pregnancy body mass index (BMI) and attending the antenatal clinic at King Chulalongkorn Memorial Hospital (KCMH) between 2006 and 2010 were eligible for the present study. The Thai population guidelines recommend a total weight gain of 10 to 16 kg or > or = 0.27 kg/week during pregnancy. In contrast, in 2009 the Institute of Medicine (IOM) guidelines recommended a total weight gain of 11.5 to 16 kg or > or = 0.31 kg/week. Our patients were analyzed using both sets of guidelines based on a normal pre-pregnancy BMI (18.5-24.9 kg/m2). SGA infants, perinatal outcomes, and maternal outcomes were compared between women whose weight gain met or exceeded the recommendations (normal weight gain) and women who did not meet these recommendations (poor weight gain).

RESULTS

A case-control of 1,152 singleton pregnancies was used for the analyses. Women with poor weight gain by the recommendation of the Thai population guidelines were significantly associated with SGA infants (1% in normal weight gain group and 2.6% in poor weight gain group adjusted odd ratio (aOR) 2.77, 95% confidence interval (CI) 1.06 to 7.28), preterm births (aOR 2.20, 95% CI 1.43 to 3.38), and low birth weight (LBW) infants (aOR 2.57, 95% CI 1.60 to 4.13). Women with poor weight gain by the recommendation in the 2009 IOM guidelines were significantly associated with preterm births (aOR 2.04, 95% CI 1.31 to 3.17), LBW infants (aOR 2.75, 95% CI 1.66 to 4.55), but not SGA infants (aOR 1.97, 95% CI 0.74 to 5.20). Maternal weight gain < 0.27 kg/week (Thai guidelines) was more likely to associate with SGA infants than maternal weight gain < 0.31 kg/week (2009 IOM guidelines). Women with normal weight gain by both recommendations were more likely to have pregnancy-induced hypertension and less likely to have gestational diabetes compared with women with poor weight gain.

CONCLUSION

Poor maternal weight gain during pregnancy was associated with SGA infants, preterm births, and LBW infants. The Thai guidelines were a better predictor of SGA infants. The 2009 IOM guidelines should be used with caution in Thai patients.

[Functional diseases of the digestive organs in patients with the connective tissue dysplasia]

Research objective was studying of features of functional diseases of digestive organs at patients with a dysplasia of a connecting tissue. In the conditions of the specialized Center of a dysplasia of a connecting tissue the assessment of a functional condition of digestive organs at 121 patients with signs of a dysplasia of a connecting tissue is carried out. High frequency of functional disorders of digestive organs at patients with a dysplasia of a connecting tissue (74-75%) is registered. Overlapping of syndromes of functional diseases (functional dyspepsia and syndrome of the angry intestine) it is registered at 73 +/- 3.9% of patients with DST, in group of comparison - at 9 +/- 2.3% (p &It; 0.001). Syndromes demonstrated against a wide range of changes of the digestive organs associated with a dysplasia of a connecting tissue. Existence of a dysplasia of a connecting tissue defines variety and features of a course of functional diseases of digestive organs, development of a syndrome of a maldigestiya and advance of an protein-energy malnutrition at this category of patients.

[Protein-energy malnutrition in patients with connective tissue dysplasia]

In the conditions of the specialized Center of a dysplasia of a connecting tissue the assessment of an protein--energy malnutrition at 121 patients with signs of a dysplasia of a connecting tissue is carried out. High frequency of an oligotrophy at patients with a dysplasia of a connecting tissue is registered. The I degree of a gipotorofiya is taped at 26.21% of the patients, II degree--at 18.44%, the III degree--at 3.88% of patients.

[Enteral dysfunction as a factor of protein-energy insufficiency development in elderly persons following gastric surgery]

264 patients within the age group of 61-93 were observed both by the gastroenterologist and surgeon for 3-6 years following gastroduodenal ulcer surgical treatment. 31,8% developed protein-energy insufficiency (PEI) in late terms, i.e. 3-12 months after the operation. Comparative analysis with a control group showed that PEI development in elderly patients occurs under conditions of membrane and cytosol enzyme synthesis decrease in small intestine and transport system disturbance in its mucosa in postoperative period. Risk of PEI development is especially high in elderly patients with the accompanying cardiovascular pathology resulting in membrane digestion depression and absorption inhibition. The importance of membrane small intestinal digestion disorders in elderly patients in postoperative period was suggested to play a significant role in prognosis and detection of PEI in early stages.

[Protein-energy malnutrition in clinical practice]

The analysis of the reasons and mechanisms of development of an protein-energy malnutrition, communication of fetal pathology and development of an protein-energy malnutrition at mature age is submitted. Systemic character of a syndrome is marked out. Importance of a problem of an protein-energy malnutrition at patients with a dysplasia of a connecting tissue is bound to high prevalence of a syndrome at this pathology.