Nutritional status and associated factors among the elderly in Guinea: a first national cross-sectional study

Aging of the Guinean population is a public health concern for the coming years, and the nutritional status of older people is virtually unknown. We also know that this population is growing and that undernutrition and obesity can affect the health of older adults. This study aimed to assess the nutritional status of older people in the general population of Guinea and its associated factors. A representative cross-sectional survey was conducted using sociodemographic, clinical, and anthropometric data (weight and height). Oral status was assessed by using the University of Nebraska Oral Status Scale. Visual acuity was assessed using the Monoyer scale. The standardized prevalence ratio (SPR) of the nutritional status was calculated for each region. The sample included 1698 subjects with a mean BMI of 22.6 ± 4.3 kg/m2. A total of 50.3% had impaired oral status and 20.3% had moderately to severely impaired visual acuity. The prevalence of undernutrition was 14.4% and of obesity 5.7%. Differences in the prevalence of nutritional status were found between regions, with an SPR > 1 for undernutrition in the Labé region (SPR 1.9, 95% CI = 1.5-2.5) and for obesity in the Conakry and Kindia regions (SPR of 2.90, 95% CI = 2.0-4.05 and 2.32, 95% CI = 1.5-3.3, respectively). In Guinea, The prevalence of nutritional disorders was approximately 20%. Screening and management of the health and nutritional status of older adults should be a national priority, and management should be adapted to each region of the country.

Nutritional status and associated factors among community-dwelling elderly

BACKGROUND AND AIMS

Although the ageing of the Cameroonian population is a public health issue in the coming years, the nutritional status of the elderly is unknown. The aim of the study was to assess the nutritional status, health status and associated socio-demographic factors among elderly in Cameroon.

METHODS

A cross-sectional study of 599 elderly (aged ≥ 60) was conducted in urban and rural areas. Several socio-demographic, sanitary, and anthropometric (weight, height, body mass index (BMI), Waist Circumference (WC), Mid-Upper Arm Circumference (MUAC)) data were collected. Nutritional status was defined according to WHO. Multinomial analysis was performed to identify factors associated with nutritional status. The threshold of statistical significance was 5%.

RESULTS

The population, representative of the elderly, was aged 68.9 ± 7.2 years, with sex ratio M/F = 0.93, weight 68.5 ± 14.7 kg, BMI 24.7 ± 5.3, WC 90.1 ± 12.8 cm and MUAC 28.2 ± 5.0 cm. According to BMI, undernutrition was 19.7%, normal status 37.9%, overweight 24.9%, obesity 17.5%. The concordance for undernutrition between BMI and MUAC was weak (kappa = 0.3). In multinomial analysis, only no medication was negatively associated with undernutrition (OR = 0.3). Obesity was positively associated with the urban environment (OR = 4.8) and inactivity (OR = 2.9) and negatively associated with male gender (OR = 0.4), widowed (OR = 0.2), head of household (OR = 0.4), no income (OR = 0.3), one pathology (OR = 0.4), no medication (OR = 0.2), having normal diastolic pressure (OR = 0.2).

CONCLUSIONS

Undernutrition and obesity (more frequent in women, and in urban area) affect 37.2% of the elderly. These nutritional disorders are a public health problem that cannot be ignored.

Associations between dental problems and underweight status among rural women in Burkina Faso: results from the first WHO Stepwise Approach to Surveillance (STEPS) survey

OBJECTIVE

To explore the relationships between dental problems and underweight status among rural women in Burkina Faso by using nationally representative data.

DESIGN

This was a cross-sectional secondary study of primary data obtained by the 2013 WHO Stepwise Approach to Surveillance survey conducted in Burkina Faso. Descriptive and analytical analyses were performed using Student's t test, ANOVA, the χ2 test, Fisher's exact test and logistic regression.

SETTING

All thirteen Burkinabè regions were categorised using quartiles of urbanisation rates.

PARTICIPANTS

The participants were 1730 rural women aged 25-64 years.

RESULTS

The prevalence of underweight was 16·0 %, and 24·1 % of participants experienced dental problems during the 12-month period. The women with dental problems were more frequently underweight (19·9 % and 14·7 %; P < 0·05) and had a lower mean BMI (21·1 ± 3·2 and 21·6 ± 3·7 kg/m2, P < 0·01) than those without dental problems. More risk factors for underweight were observed in less urbanised regions among elderly individuals (> 49 years old) and smokeless tobacco users. Age > 49 years, professions with inconsistent income, a lack of education, smokeless tobacco use and low BMI were factors that were significantly associated with dental problems, while residency in a low-urbanisation area was a protective factor.

CONCLUSION

The prevalence of underweight in rural Burkinabè women is among the highest in sub-Saharan Africa, and women with dental problems are more frequently affected than those without dental problems. Public health measures for the prevention of these disorders should specifically target women aged over 49 years and smokeless tobacco users.

Nutritional status, dementia, and mobility among nursing home's residents: First exhaustive cross-sectional study in Limousin territory (France)

BACKGROUND

Aging is accompanied by a drop in the level of health and autonomy, within Western countries more and more people being cared for in nursing homes (NH). The nutritional data in NH in France remain poor, not exhaustive and not representative. The objective of the study was to assess the nutritional status, dementia and mobility patterns among residents of NH in the Limousin territory of France.

METHODS

The study was cross-sectional, descriptive and exhaustive, conducted with the residents of 13 voluntary NH. Undernutrition was identified using French High Authority for Health criteria, and obesity if Body Mass Index >30, in the absence undernutrition criterion. The Mini Mental State examination scores was used for dementia assessment at the threshold of 24. The Mini Nutritional AssessmentTM was used for mobilitity assessment. The statistics were significant at the 5% threshold.

RESULTS

866 residents (70.6% women) included with an average age of 85.3 ± 9.3 years. Undernutrition was 27.5%, obesity 22.9%, dementia 45.7% and very low mobility 68.9%. Women were older than men, more often undernourished, more often demented and more often had very low mobility (p<0.01). Undernutrition (p<0.0001) and low mobility (p<0.0001) were significantly higher among those with dementia versus those without dementia. Very low mobility was higher among undernourished (p<0.05).

CONCLUSIONS

Undernutrition and obesity are important problems in NH in France. Being a woman, having dementia and having a very low mobility may induce undernutrition.

Hypermetabolism is a reality in amyotrophic lateral sclerosis compared to healthy subjects

RATIONALE

Hypermetabolism (HM) in Amyotrophic lateral sclerosis (ALS) is the reflection of a high energy metabolic level, but this alteration seems controversial. The main objective of the study was to confirm the existence of HM during ALS compared to healthy subjects.

METHODS

A cohort of ALS patients was compared to a control group without metabolic disorder. The assessment included anthropometric criteria measurements, body composition by bioelectric impedance analysis and resting energy expenditure (REE) by indirect calorimetry. HM was defined as a variation > +10% between measured and calculated REE. Statistical analysis used Mann-Withney and Chi2 tests. Multivariate analysis included logistic regression.

RESULTS

287 patients and 75 controls were included. The metabolic level was higher in ALS patients (1500 kcal/24 h [1290-1693] vs. 1230 kcal/24 h [1000-1455], p < 0.0001) as well as the REE/fat free mass ratio (33.5 kcal/kg/24 h [30.4-37.8] vs. 28.3 kcal/kg/24 h [26.1-33.6], p < 0.0001). 55.0% of ALS patients had HM vs. 13.3% of controls (p < 0.0001). HM was strongly and positively associated with ALS (OR = 9.50 [4.49-20.10], p < 0.0001).

CONCLUSIONS

HM in ALS is a reality, which affects more than half of the patients and is associated with ALS. This work confirms a very frequent metabolic deterioration during ALS. The identification of HM can allow a better adaptation of the patients' nutritional intake.

Predictive formulas for estimation of height in sub-Saharan African older people: A new formula (EPIDEMCA study)

OBJECTIVES

Chumlea's formulas are a way of predicting height from knee height (KHt), including among individuals >60 y of age who cannot stand upright. However, the formulas were developed with white and African American people and have not yet been validated in native Africans >60 y of age. The aims of the study were to assess Chumlea's formulas in older people in central Africa and to propose a new validated formula for the same population.

METHODS

Height (MHt) and KHt were measured in a population of individuals >65 y of age from the Republic of Congo and the central African Republic. Predicted height (PHt) was calculated using Chumlea's formulas for the American black population (CBP) and for whites (CC). The percentages of accurate predictions (±5 cm) were compared between MHt and PHt. A new formula was estimated after randomization in a derivation sample (n = 877) and assessed for accuracy in a validation sample (n = 877).

RESULTS

The study included 1754 individuals. Prediction was accurate (±5 cm) in 66.8% and 63.2% of CBP and CC, respectively. Overestimation was as high as 24.1% and 29%, respectively. Because an overestimation is unacceptable in clinical practice and population surveys, a new formula was proposed: height (cm) = 72.75 + (1.86 × KHt [cm]) - (0.13 × age [y]) + 3.41 × sex (0: women; 1: men). This new formula significantly increases accuracy (71.3%) and decreases overestimation (14.7%). The nutritional status based on body mass index did not differ with the MHt and the PHt by the new formula.

CONCLUSION

Chumlea's formulas provided a poor estimate of height in this population sample. The proposed formula more accurately estimates height in older native Africans. This formula should be tested in other sub-Saharan African countries to extend its use in clinical practice and in future studies.

Predictive factors for gastrostomy at time of diagnosis and impact on survival in patients with amyotrophic lateral sclerosis

BACKGROUND

Gastrostomy is recommended in patients with Amyotrophic Lateral Sclerosis (ALS) in the presence of weight loss over 10% as compared to usual weight, repeated aspirations or meal time duration longer than 45 min. Currently, the impact of gastrostomy on survival of ALS patients is not clear.

AIMS

i) to describe diagnosis factors associated with the indication for gastrostomy ii) to evaluate survival of ALS patients with gastrostomy indication according to their acceptance of feeding tube placement.

METHODS

Patients with ALS were included and followed in the ALS referral centre of Limoges's teaching hospital between 2006 and 2017. Neurological, nutritional and respiratory status was assessed prospectively from diagnosis to death. Statistical analysis was performed using Mann-Whitney test, Chi² tests, Cox model and multivariate logistic regression.

RESULTS

Two hundred and eighty-five patients were included. Among the 182 for whom gastrostomy was indicated, 63.7% accepted the placement. The median time was 7.3 months [IQR: 3.2-15.0] and 2.7 months [IQR: 0.9-5.8] respectively from diagnosis to indication and from indication to placement. Weight loss >5% significantly increased the risk of death by 17% (p < 0.0001). At time of diagnosis, bulbar onset, a loss of one point in the body mass index or on the bulbar functional scale were all positively associated with indication for gastrostomy (aOR = 10.0 [95%CI: 1.96-25.0]; p = 0.002, aOR = 1.17 [95%CI: 1.02-1.36]; p = 0.025 and aOR = 1.19 [95%CI: 1.06-1.32]; p = 0.002, respectively). However, gastrostomy placement did not have any impact on survival (aHR = 1.25 [95%CI: 0.88-1.79]; p = 0.22).

CONCLUSION

Both neurological and nutritional criteria were associated with an indication for gastrostomy at diagnosis. Gastrostomy placement had no impact on survival. The study of earlier gastrostomy placement might be of interest in further prospective studies.

[Food and malnutrition in the elderly]

Food and malnutrition in the elderly. Malnutrition affects 4-10% of elderly at home, but 15-40% of them in institutions. Its consequences are multiple and sometimes severe. Knowing the risk factors often helps to prevent the onset of malnutrition. The simplest and most readily usable criteria are the body mass index (BMI) inferior 21 and weight loss (at least 5% in one month or 10% in six months). The treatment is primarily through enriched intakes by mouth and/or oral nutritional supplements, but in case of severe malnutrition with very limited intakes by mouth, enteral nutrition must be offered at the outset, if the digestive tract is usable. Parenteral nutrition is the last resort because of its dangerousness.

Changes in nutritional state and dysphagia in stroke patients monitored during a 14-d period in a Burkina Faso hospital setting

INTRODUCTION

Dysphagia and undernourishment are common in cerebrovascular accident (stroke) patients in developed countries. Despite the dietary transition, there is little information available in Africa on this topic. This study aims to assess the prevalence of undernourishment and dysphagia in stroke patients in two Burkina Faso teaching hospitals at a starting point (D0), on the eighth day, and on the 14th (D14) and to specify factors related to undernourishment at day 14.

METHODOLOGY

The nutritional state of the patients was assessed using body mass index, triceps skinfold thickness, and mid-upper arm circumference. Dysphagia was identified using the Practical Aspiration Screening Schema.

RESULTS

A total of 222 patients were included in the study. From D0 to D14, the prevalence of undernourishment increased from 25.2% to 31.0% and the prevalence of dysphagia decreased from 37.4% to 15.8%. All nutritional criteria worsened. In a multivariate analysis, undernourishment was more present at D14 for women (odds ratio [OR] = 7.01; 95% confidence interval [CI]: 1.51-32.56, P = 0.01) and was less present if weight (OR = 0.69; 95% CI: 0.60-0.79, P = 0.0001) or triceps skinfold thickness (OR = 0.85; 95% CI: 0.74-0.99, P = 0.03) were high at D0.

CONCLUSION

The prevalence of undernourishment was high at D0 and increased during the monitoring period. It would be advisable to monitor patients' weight and triceps skinfold thickness, to optimize care for women and patients with low weight or triceps skinfold thickness at D0, to monitor dysphagia, and to inform patients, families, and relevant staff of nutritional concerns after a cerebrovascular accident.

[Crossed perceptions about malnutrition in patients and their doctors in oncology]

Malnutrition is common in oncology. However, it is often detected too late and nutritional support is sub-optimal. The patient's opinion, although often sought in therapeutic decisions in oncology, does not appear to be frequently taken into account in dietetic management. In NutriCancer2012 study, we interviewed patients, relatives and doctors about their perceptions of the impact of malnutrition and its quality of care. Of the 2209 patients questioned, majority said they were concerned about nutrition with 75% considering it essential to take appropriate nutritional care but only 19% self-reported link between malnutrition and fatigue. Physicians underestimated impact of malnutrition on patient's "quality of life". Doctors referred to the lack of human resources and knowledge in nutrition, and more than 80% wished the creation of nutrition teams. Sensitization of the general public and patients (and relatives) as soon as the cancer diagnosis could lead to better malnutrition's screening. Better nutrition training for physicians and creation of nutrition team could optimize management and improve efficacy during cancer treatments.

Knowledge and practice concerning swallowing disorders in hemiplegic patients among nurses of Bobo-Dioulasso urban primary health care centers in Burkina Faso

Introduction

The quality of management of swallowing disorders (SD) from admission onwards influences the patients' nutritional status and their prognosis. Neurological diseases are the main causes of SD, affecting one in three patients with hemiplegia (Hp). In Burkina Faso (BF), primary health care center (PHCC) nurses are the first to manage these patients, but there are no data related to their management of SD. The study aimed to assess knowledge and practices regarding SD in Hp among PHCC nurses in Bobo–Dioulasso, a main center for care of Hp in BF.

Methods

This cross-sectional study was performed August 1–September 15 2014. Subjects underwent a standardized survey to determine their knowledge and practices concerning SD in Hp.

Results

Of 125 nurses surveyed (83.3% of the targeted workers), 82.4% had experience of caring for Hp. The role of the central nervous system in cases of Hp and SD was recognized by 56.8% of nurses; 42.3% knew that SD can cause aspiration, and 36.0% were aware of rescue techniques to use when aspiration occurs; 39.2% correctly assessed the impact on nutritional status of SD. Knowledge in this area was better among respondents who recently completed training school. 65.6% and 1.6% respectively knew about the impact of posture and the texture of food on the ability to swallow. Among the 103 nurses with experience of treating Hp, 68.0% considered clinical interview the best way to detect SD, and 30.1% did not give the patient advice in this area. In multivariate analysis, detection of SD was associated with good knowledge of the value of voice disorders (OR = 3.5, 95% CI = 1.4–8.1; p = 0.005).

Conclusion

Few nurses had been warned of the connection between Hp and SD, which are classic issues and potential complications. Practices varied, but most were not in accord with what are recognized as good strategies for SD screening and management. In order to improve care of Hp, neurological and nutritional training should be accompanied by specific training in SD, emphasizing screening and simple management.

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US means “United States of America” (USA) has been clarified.

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Details about western countries and developed countries, with two new references: reference number five and number six.

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We have given more explanations about the background to justify why our study targeted only the nurses, with more data concerning the physicians, nurses, and others practitioners per inhabitants in Burkina Faso.

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We have precised that the type of data collection is face-to-face interview.

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The statistical paragraph has been re-written and enriched.

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We replaced the lack of the study in the discussion section firstly.

Evaluation of iodine intake and status using inductively coupled plasma mass spectrometry in urban and rural areas in Benin, West Africa

OBJECTIVE

Iodine deficiency has severe pathological repercussions. The aim of this study was to evaluate iodine intake and status in adults in Benin, West Africa.

METHODS

We randomly selected 420 participants ages 25 to 64 y and free of visible goiter from urban and rural settings of South Benin. The participants had a diet based on carbohydrates and fish. Urine was collected over a 24-h period and samples were assayed for iodine analysis using inductively coupled plasma mass spectrometry.

RESULTS

We studied 401 urinary iodine samples. The overall median urinary iodine concentration (UIC) in 24-h urine was 62.9 μg/L (interquartile range: 40-96.2 μg/L). UIC was significantly lower in women than men (56.5 versus 78.6 μg/L; P < 0.001) and in rural versus urban areas (54.7 versus 77.8 μg/L; P < 0.001). In multivariate analysis, low UIC (<100 μg/L) was positively associated with women (odds ratio, 2.48; 95% confidence interval, 1.44-4.26; P = 0.001) and body mass index <25 kg/m(2) (odds ratio, 2.06; 95% confidence interval, 1.20-3.54; P = 0.008).

CONCLUSION

Iodine intake appeared to be fairly low in the Beninese population, according to World Health Organization criteria, and factors associated with low iodine intake were identified. Public health interventions to increase iodine intake, such as iodization of commercial salt and/or fortification of selected nutrients, should be strengthened at the national level.

The nutritional status of older people with and without dementia living in an urban setting in Central Africa: the EDAC study

OBJECTIVES

To determine the nutritional status of elderly African people and to investigate the association between undernutrition and dementia.

DESIGN

Door-to-door cross-sectional surveys in the general population.

SETTING

Representative districts of Bangui (Central African Republic) and Brazzaville (Republic of Congo).

PARTICIPANTS

Population aged over 65 years.

MEASUREMENT

Undernutrition was defined as a body mass index <18.5. Anthropometric parameters (arm circumference, waist circumference and triceps skinfold thickness) were measured, and information was gathered on nutritional habits. PARTICIPANTS underwent cognitive screening using the Community Screening Interview for Dementia (CSI-D) and the Five-Word Test. After further neuropsychological testing and neurological examination, the diagnosis of dementia was confirmed according to DSM-IV criteria. Multivariate logistic regression models were applied in order to identify factors associated with undernutrition in populations with or without dementia.

RESULTS

1016 people were included. In the general population, the prevalence of undernutrition was 19.2%. Dementia was found in 7.4% of elderly people. Compared with healthy people, patients with dementia had an increased prevalence of undernutrition (32.0% vs. 17.7%; p = 0.002), lower weight (49.3 ± 10.5 kg vs. 58.4 ± 13.5 kg ; p < 0.001), and lower BMI (20.8 ± 4.1 vs. 22.9 ± 4.8 ; p < 0.001); they were less likely to eat their fill (38.9% vs. 45.9% ; p = 0.001), had more dietary restrictions (36.1% vs. 24.3% ; p = 0.03) and ate less often with their family (66.7% vs. 90.6% ; p < 0.0001). Eating only one meal per day was the sole factor associated with undernutrition in dementia (OR: 7.23 [CI: 1.65-31.7]; p = 0.03).

CONCLUSION

The prevalence of undernutrition is high in the older population. The nutritional status of patients with dementia is more impaired than that of healthy patients. However, they are less often malnourished than in French home care settings. This study is the first to look at the nutritional status of at-home patients with dementia in Africa. These comparative data will eventually be used in the development of new nutritional intervention strategies.

Epidemiology of dementia in Central Africa (EPIDEMCA): protocol for a multicentre population-based study in rural and urban areas of the Central African Republic and the Republic of Congo

Background

The worldwide population is ageing and the proportion of elderly aged 60 and over is expected to dramatically rise in Low and Middle Income Countries (LMIC). The epidemic of dementia will not spare those countries, where the largest increases in numbers of people affected are estimated. Besides, dementia is still understudied in sub-Saharan Africa (SSA) compared to other regions. This paper describes the protocol for the ‘Epidemiology of Dementia in Central Africa’ population-based study, which aims at estimating the prevalence of dementia in two countries of Central Africa and investigating possible risk factors.

Methods/Design

A multicenter population-based study was carried out in Central African Republic and Republic of Congo between 2011 and 2012 including both urban and rural sites in each country. Around 2000 participants aged ≥65 years old were interviewed in total using the Community Screening Interview for Dementia (CSI-D), the GMS-AGECAT and the CERAD’s 10-word list. Elderly with low performance to the cognitive part of the CSI-D (COGSCORE ≤ 24.5) were then clinically assessed by neurologists and underwent further psychometrical tests. DSM-IV and NINCDS-ADRDA criteria were required for dementia and Alzheimer’s disease (AD) diagnoses respectively. The algorithmic 10/66 dementia diagnosis was also determined. Petersen’s criteria were required for the diagnosis of Mild Cognitive Impairment. Sociodemographic, and environmental factors including vascular, nutritional, biological, psychosocial and lifestyle factors were collected in each setting in order to investigate factors associated with dementia. Blood sampling was realized to investigate genetic variations that could modify the risk of dementia.

Discussion

For now, no large epidemiological study has been undertaken to compare the prevalence of dementia in both rural and urban areas within SSA countries. This programme will provide further evidence regarding the prevalence of dementia in SSA, and also the possible rural/urban disparities existing with associated factors. Furthermore, the genetics of AD in those populations will be addressed.

Nutritional assessment and follow-up of residents with and without dementia in nursing homes in the Limousin region of France: a health network initiative

INTRODUCTION

Limousin in France has the second oldest regional population in Europe, with people over 65-years-old who have Alzheimer's disease accounting for more than 9%. In France as a whole, a large number of residents in nursing homes (NH) have dementia, leading to many nutritional problems. LINUT is a health network that assesses the nutritional status of elderly NH residents and provides support where necessary. Aims of the present study were to use this network to evaluate the nutritional status of NH residents with and without dementia and to review changes after 4 months of intervention.

METHODS

A cross-sectional survey was conducted by a doctor and a dietician at baseline (T0) and 4 months (T4) among residents at the 26 NH in Limousin that agreed to take part. The evaluation criteria included presence of dementia, depression and autonomy, weight, height, body mass index, Mini Nutritional Assessement (MNA™), and a 3-day survey of food intake.

RESULTS

The 346 residents assessed at T0 were aged 87.9±6.9 years, 83.4% were women, 66.8% had dementia, 53.3% were malnourished and 27.4% obese. Autonomy was not affected by obesity. Residents with dementia had a lower Activities of Daily Living score and a lower weight than non-demented individuals (2.2±1.2 vs. 2.7±1.7 p=0.03 and 60.1±16.3 vs. 64.7±20.0 kg p=0.03, respectively), were more often malnourished (56.1% vs. 46.4% p=0.004) and less often obese (22.0% vs. 39.1% p=0.004) but consumed more protein (62.6±17.8 vs. 58.2±16.9 g/d p=0.04, 1.1±0.4 vs. 1.0±0.4 g/kg/d p=0.005). Energy intake was at the lower limit of French recommendations (26.4±8.8 vs. >25.0 kcal/kg/d). Assessment of all residents at T4 showed improved MNA™ (+0.4 points/month p=0.02), protein intake (+3.3 g/d p=0.0007), and energy intake (+41.4 kcal/d p=0.01 and 0.1 kcal/kg/d p=0.03). Variations in prevalences of malnutrition and obesity were not statistically significant. MNA™ increased in the dementia group (+0.29±0.8 points/month p=0.003). All other changes were comparable, and nutritional status did not differ more between the two groups at T4 than at T0.

CONCLUSION

The prevalence of dementia was high in the population studied. Malnutrition was the main problem, particularly if residents had dementia. Protein intake was satisfactory, but energy intake often insufficient. The nutritional status of dementia patients improved after 4 months of follow-up, suggesting that effective action to support such services would be worthwhile.

Alteration of nutritional status at diagnosis is a prognostic factor for survival of amyotrophic lateral sclerosis patients

OBJECTIVES

The aims were to analyse changes in nutritional parameters from diagnosis of amyotrophic lateral sclerosis (ALS) to death and to assess their relationships with survival at the time of diagnosis and during follow-up.

METHODS

92 ALS patients were included and clinically assessed every 3 months (ALS functional rating scale, manual muscular testing, forced vital capacity, weight, BMI, percentage weight loss). Bioimpedance was performed to evaluate body composition (fat-free mass, fat mass and hydration status) and phase angle. Survival analyses were performed from diagnosis to death or censoring date using a Cox model.

RESULTS

The evolution of nutritional parameters in ALS patients was marked by significant decreases in weight, BMI, fat-free mass and phase angle, and increased fat mass. The authors identified an adjusted 30% increased risk of death for a 5% decrease from usual weight at time of diagnosis (RR 1.30; 95% CI 1.08 to 1.56). During follow-up, the authors identified adjusted 34% (95% CI 18% to 51%) and 24% (95% CI 13% to 36%) increased risks of death associated with each 5% decrease in usual weight and each unit decrease in usual BMI, respectively (p<0.0001). Malnutrition during the course was related to a shorter survival (p=0.01), and fat mass level was associated with a better outcome (RR 0.90 for each 2.5 kg fat mass increment).

CONCLUSIONS

Nutritional parameters of ALS patients worsened during evolution of the disease, and worse nutritional status (at time of diagnosis or during the course) was associated with a higher mortality. This study offers some justification for studying the use of therapeutic nutritional intervention to modify the survival of ALS patients.

Analysis of the food consumption of 87 elderly nursing home residents, depending on food texture

OBJECTIVES

Texture-modified food (chopped, mashed, or mixed) is often used for patients, and particularly for dependent elderly people facing swallowing disorders or dental problems. Food must be energy and protein enriched, because dilution is needed for preparation, and several meals like bread can be removed. The aim of the study was to assess the food consumption of residents in four French nursing homes depending on diet texture. DESIGN/PARTICIPANTS/MEASUREMENTS: The food consumption of 87 elderly people followed by a nutrition network, randomly taken and living in nursing homes in which texture-modified food enrichment was practiced was evaluated according to the type of texture used.

RESULTS

13.8% of residents had chopped texture and 29.9% mixed texture. There was no relationship between used food textures and nutritional status residents. Calorie consumption was below the recommended intakes for elderly nursing home residents in France, whatever the type of texture. The mixed texture had more protein than the normal one and was better balanced regarding fat intake. Protein consumption was at the lower limit of the recommended intakes. Residents in overweight were those whose food consumption relative to their weight was the lowest.

CONCLUSION

It seems important to check the mode of preparation of texture-modified food in nursing homes and to assess the real energy and protein consumptions of residents receiving this food.

High metabolic level in patients with familial amyotrophic lateral sclerosis

An abnormally elevated level of resting energy expenditure (REE, measured by indirect calorimetry) has been reported in a subset of patients with sporadic amyotrophic lateral sclerosis (SALS). Hypermetabolism (measured REE/calculated REE (cREE)> or =1.1, or 110%) has also been observed in transgenic mice harbouring ALS-causing mutations in the SOD1 gene. By contrast, the REE of patients with familial amyotrophic lateral sclerosis (FALS) has never been assessed. Our objective was to evaluate the metabolic and nutritional parameters of FALS patients and to compare them with those of SALS patients, and search for correlations with clinical parameters. Eleven patients with FALS (from 10 different families, none carrying a SOD1 mutation) were evaluated by indirect calorimetry in our centre. As a control group, we used a sample of 33 patients with SALS, matched for age and sex with the FALS patients. 11/11 (100%) patients with FALS were hypermetabolic, compared to 17/33 (52%) patients with SALS (p=0.009). Measured REE (mREE) and mREE/cREE (metabolic level) were significantly higher in FALS patients than in SALS patients (p=0.03 and p=0.0008, respectively). No correlation was found between metabolic measures and neurological or respiratory parameters. In conclusion, hypermetabolism appears to be a common feature of subjects with FALS, suggesting that this impairment of energy homeostasis may be genetically driven. The high metabolic level of FALS patients should be taken into account for their nutritional management (need for a high-energy diet to prevent malnutrition).

Disease progression and survival in ALS: first multi-state model approach

Although several prognostic factors have been identified in ALS, there remains some discordance concerning the prognostic significance of the age and clinical form at onset. In order to clarify these findings, we have analysed already known prognostic factors using a multi-state model. Two hundred and twenty-two sporadic ALS patients were followed. A simple unidirectional three-states model was used to summarize clinical course of ALS. States 1 and 2 reflected the progression of neurological impairment and state 3 represented the end of follow-up (tracheotomy or death). Gender, diagnostic delay, body mass index (BMI) and slow vital capacity (SVC) were also recorded. A time-inhomogeneous Markov model with piecewise constant transition intensities was used to estimate the effect of the covariates in each transition. The bulbar form at onset was only correlated with a more rapid clinical progression between state 1 and state 2. In contrast, an advanced age at diagnosis affected only survival from state 2. This methodological approach suggests that these two factors have a different prognostic significance: age at onset is related to patient's survival and the clinical form at onset predicts the progression of motoneuronal impairment in different regions.

Link between Epilepsy and Malnutrition in a Rural Area of Benin

PURPOSE

Epilepsy and malnutrition are both important public health problems in sub-Saharan Africa. A relationship between epilepsy and malnutrition has been suspected for many years. Our objective was to investigate the association between epilepsy and malnutrition in Djidja, Benin.

METHODS

A matched population-based cross-sectional case-control survey was performed: cases (patients with epilepsy) were matched to controls according to sex, age +/- 5 years, and village of residence. The World Health Organization's criteria for malnutrition was used. Anthropometric measurements (weight, height, mid arm upper circumference, triceps skinfold thickness) were taken. Bioelectrical impedance analysis, a standardized food and social questionnaire and a clinical examination were done. Statistical analysis (conditional logistic regression) was performed using SAS 8.0.

RESULTS

A total of 131 cases and 262 controls were included. The prevalence of malnutrition was higher in cases than in controls (22.1% vs. 9.2%, p = 0.0006). Social factors were significantly different between cases and controls. Feeding difficulties were more frequent and health status was worse in cases. Seven variables were associated with epilepsy: (i) nutritional factors: mid arm upper circumference (prevalence odds ratio (pOR) = 0.7, CI: 0.6-0.9), cereal consumption <3 times during the 3 days before the study (pOR = 4.2, CI: 1.8-10.0), <3 meals/day (pOR = 4.2, CI: 1.6-10.9), tooth decay (pOR = 2.9, CI: 1.1-7.4), food taboos (pOR = 25.0, CI: 8.3-100.0), (ii) social factors: surrogate respondent (pOR = 16.8, CI: 3.1-90.3) and no second job (pOR = 7.1, CI: 2.3-22.3).

CONCLUSION

Epilepsy and nutritional status are linked in sub-Saharan Africa. Programs to improve the nutritional status of people with epilepsy are needed.

Hypermetabolism in ALS: correlations with clinical and paraclinical parameters

Despite a reduction in fat-free mass (FFM), a hypermetabolism has been reported with an average of 10% in amyotrophic lateral sclerosis (ALS) patients as compared with a healthy population. The objectives of this study were to confirm the level of hypermetabolism determined by using indirect calorimetry in 168 patients with a probable or a definite ALS and to study correlations with survival. Consecutive evaluations of resting energy expenditure (REE) were performed from diagnosis to the proximity of death in 44 ALS patients. Differences with the calculated value determined a DeltaREE. FFM was given by bioimpedance. At T(1), REE was significantly increased by an average of 14% as compared with the calculated value. 62.3% of ALS patients were considered as hypermetabolic. REE was correlated in univariate analysis with age, sex, clinical form at onset, presence of a denutrition, weight, FFM, phase angle and ALS Functional Rating Scale (ALSFRS). In multivariate analysis, REE was linked to age and FFM. DeltaREE was correlated in univariate analysis with sex, phase angle and manual muscle testing (MMT). In multivariate analysis, age and sex remained significantly correlated. During progression of ALS, REE levels remained higher than calculated values with a trend to decrease at proximity of death, whereas FFM remained stable. From T(1), survival was linked to MMT, ALSFRS, vital capacity, REE and phase angle. We confirmed the existence of a stable hypermetabolic state in ALS which depends mainly on age, sex and FFM. REE is a prognostic factor for survival in univariate analysis.

[Announcement of amyotrophic lateral sclerosis diagnosis]

Breaking the news of amyotrophic lateral sclerosis (ALS) is considered as a daunting task in most cases and is not a standardizable procedure. However, proven techniques exist to reduce the trauma to the patient. Announcing ALS falls upen the neurologist who must respect the ethical principle of the patient's independence. After the diagnosis is firmly established, the patient should be informed that he or she has a progressive disease of the motor nerves, for which no curative therapy is available. The name of the disease must be stated and explained. If the family history is negative, it is reassuring for the patient and family to know that their children are unlikely to be at risk. Positive aspects (no pain, no disturbances in sensation, cognition, memory and continence) should be stressed as well as the availability of efficient palliative measures for practically all symptoms. Current research efforts, and when available, the possibility of taking part in clinical studies of new drugs should be pointed out as a means of hope. The answer to the question of prognosis should include the information that there are no sudden worsenings to be expected, that the course of ALS may vary between months and decades, that making a firm statement on prognosis all but impossible for any single patient and that respiratory function may worsen during the disease course. It is therefore mandatory to inform patients and families about the existence of ALS patients'associations. The way the patient is told the diagnosis is of great importance and is considered as a multiple-step procedure. Discussion should take place in a private and quiet room and respect some fundamental objectives such as finding out what the patient already knows or suspects and how much more the patient wants to know, observing and responding to the patient's reactions, reinforcing the information and planning the future. It is proven that communicating the diagnosis of ALS in an empathetic fashion is an important and sensitive step to disease management.

Complications and survival following radiologically and endoscopically-guided gastrostomy in patients with amyotrophic lateral sclerosis

In the natural progression of amyotrophic lateral sclerosis (ALS), a state of malnutrition often develops, associated with reduced oral intake, caused by difficulties with swallowing, adequate salivation, and/or anorexia. The placement of a feeding tube should be considered at the point where patients demonstrate swallowing difficulty and/or alteration in nutritional status. The goal of this prospective work was to compare, in 50 patients having definite or probable ALS, the complications after endoscopic (PEG), or radiologically-guided gastrostomy (RIG) and to evaluate their effects on survival. RIG was proposed as first-line therapy when patients had a slow vital capacity (SVC) less than 50% of the theoretical value, or in a case where PEG was refused by the patient. Thirty patients underwent PEG procedure, and 20 had RIG. Among the decisional criteria for placing a gastrostomy tube, risk of aspiration demonstrated by using videofluoroscopy was more frequently observed in the RIG group (65%) than in the PEG group (19.2%) (p=0.002). The two patient populations at time of gastrostomy placement were comparable with respect to age, gender ratio, disease duration before gastrostomy, the form and the gravity of neurological involvement as well as for nutritional criteria. The only significant difference observed between the two groups was the level of the SVC, much lower for patients undergoing RIG: 51.6+/-25.0% versus 67.4+/-26.7% than for the PEG group (p=0.03). The frequency of all complications observed at the moment of placement of gastrostomy tube and during the first month of follow-up was not significantly different between the two groups. Kaplan-Meier survival curves from the date of gastrostomy placement were not different in univariate analysis (p=0.85). In multivariate analysis, survival was not different between one group and the other (p=0.28). The major interest of the RIG technique rests on its greater feasibility and on the possibility of utilizing it in ALS patients who have significant ventilatory compromise.