[Presence and adequacy of the nutritional and eating disorders terminology in the Spanish and English editions of the Wikipedia]

OBJECTIVE

To determine the presence and to assess the adequacy of the nutritional and eating disorders descriptors in the English and Spanish Wikipedia.

METHOD

The terms were obtained from the thesaurus: Medical Subject Headings (MeSH) and APA-Terms. The existence of the terms was confirmed accessing to the Spanish and English editions of Wikipedia via the Internet (http://es.wikipedia.org/). The last date for consultation and calculations was June 8, 2012.

RESULTS

A total of 89 descriptors were identified, being 56 (62.92%) of them as terms in the Wikipedia: 42 (47.19%) in the Spanish edition and 56 (62.92%) in English. Significant differences between the two editions were assessed (chi-square = 9.41, df = 1, P <0.001). At the same time, differences between both editions according to the number of references in each term were observed (t-Student = -2,43; gl = 84,87; p = 0,017). However, there were not differences in the status of information being update/obsolete, neither in the number of queries.

CONCLUSIONS

The entries related to nutritional and eating disorders terms have not yet reached an optimum level. Differences between english and spanish Wikipedia editions are more related to criteria of content principles (term existence) than adequacy of information. The English edition of Wikipedia has a more scientific endorsement, through the references cited, than the Spanish edition.

[New classification of causes of mortality of nutritional origin by means of the Delphi method]

The causes of mortality of nutritional origin (MNO) are not classified in the consecutive reviews of the international disease classification (IDC) and there is no agreement for their most proper classification. The objective of this study is to elaborate, using the last ICD as a guide, a list of causes of mortality of nutritional origin which will be used as a reference in future studies. A two round Delphi method was organized with an expert's consenssus in clinical nutrition. The experts were asked to classify a list of causes of MNO in 4 groups; 1) group A: congenital errors related to nutrition, 2) group B: Causes associated with other pathologies, 3) group 3: Excess and defect nutrition disorders, and 4) excluded. In total, 86 causes of MNO were taken under the consensus of experts, and 79 (91.9%) came to an agreement. 14 (17.7%) causes were classified in group A, 5 (6.3%) causes in group B, 37 (46.8%) causes in group C and 23 (29.1%) were excluded. This is a first approach to the classification of mortality causes of nutritional origin, probably due to the ambiguity and disparity of opinions between experts with respect to these causes. This new classification will be very useful due to the fact that it will enable homogenization of the studies and that way we will have comparable studies, using it as a clarifier annex for the ICD of the moment.

Application of subjective global assessment as a screening tool for malnutrition in surgical patients in Vietnam

BACKGROUND AND AIMS

In most hospitals in Vietnam, clinical assessment of nutritional status has yet to become part of the routine clinical history taking and physical examination. It is the aim of this study to apply subjective global assessment (SGA) of nutritional status in surgical patients in the Mekong Delta, Vietnam, to determine the incidence of malnutrition according to SGA and to know whether there was an association between SGA class and infectious complications.

METHODS

A prospective, cross-sectional study design was used. SGA of nutritional status was applied. Patients were rated as well nourished (A), moderately malnourished (B) or severely malnourished (C). Infectious complications (wound infection, intra-abdominal abscesses, anastomotic leakage) were recorded.

RESULTS

Of the 438 patients assessed, 194 (44.3%) were classified as A, 126 patients (28.8%) were classified as B and 118 patients (26.9%) were classified as C. Of the 274 patients who underwent major abdominal surgery assessed, 61 patients (22.3%) were classified as A, 97 patients (35.4%) were classified as B and 116 patients (42.3%) were classified as C. Weight loss and percent weight loss, muscle wasting, loss of subcutaneous fat, functional capacity and significant gastrointestinal symptoms correlate significantly with the severity of SGA class (P<0.001). The rate of postoperative infectious complications was higher in patients classified as SGA class C (33.6%) than as class A (6%) and B (11%).

CONCLUSIONS

A high rate of malnutrition was found, applying SGA of nutritional state in surgical patients in Vietnam. Malnutrition was associated with an increase in infectious complications. Special attention should be paid to weight loss, muscle wasting, loss of subcutaneous fat, functional capacity and gastrointestinal symptoms.

Anthropometric indicators of nutritional status: implications for fitness, activity, and health in school-age children and adolescents from Maputo, Mozambique

BACKGROUND

Studies are needed to test the relevance of the anthropometric criteria for health and well-being, particularly in developing countries.

OBJECTIVE

The objective of the study was to identify the relevance of anthropometric indexes as indicators of nutritional status.

DESIGN

The sample consisted of 2316 subjects (n = 1094 males, 1222 females) aged 6-18 y from Mozambique. Anthropometric variables, maturity stage, physical fitness, physical activity, and metabolic fitness were measured. Samples of blood, urine, and feces were obtained. Subjects were classified in 5 nutritional groups labeled normal, low height-for-age (stunted), low weight-for-height (wasted), low height-for-age and low weight-for-height (stunted and wasted), and overweight, according to cutoffs set by a World Health Organization expert committee. Socioeconomic status was classified according to region of residence.

RESULTS

Prevalence rates for males and females, respectively, in the nutritional groups were 3.0% and 2.3% (stunted group), 21.9% and 10.0% (wasted group), 3.0% and 0.8% (stunted and wasted group), and 4.8% and 7.7% (overweight group). With control for age, socioeconomic status, and maturity stage, the overweight group performed significantly worse than did the other groups on most of the fitness tests. Compared with the normal group, the 3 undernourished groups performed significantly worse in absolute strength tasks, better in endurance tasks, and equally in flexibility and agility. Very few differences were found in physical activity scores. The 3 undernourished groups had scores for the biochemical indicators that were similar to those of the normal group and had more favorable profiles for blood pressure and cholesterol.

CONCLUSIONS

In this population, the cutoffs used to classify overweight status appear to appropriately identify potential health problems. No relevance to health was found for the lower cutoffs identifying undernourished children.

Anthropometric assessment of nutritional status in adolescent populations in humanitarian emergencies

OBJECTIVE

To outline the difficulties and suggest potential solutions in anthropometric assessment of adolescents during humanitarian emergencies.

DESIGN

Literature review.

SETTING

Multiple settings in which the nutritional status of adolescents has been assessed using anthropometric measurements.

SUBJECTS

Adolescents in multiple populations.

INTERVENTIONS

None.

RESULTS

The use of anthropometry may be more difficult in adolescents than in other age groups because anthropometric indices in normally nourished adolescents change with age and sexual development. Moreover, survey and reference populations may differ in the age at which certain pubertal landmarks are attained, requiring adjustment for differences between survey and reference populations. Adolescent populations may also differ by ethnicity in various body proportions that affect anthropometric indices. Adjustment may be required when the body proportions of adolescents in the reference population differ from those in the population assessed.

CONCLUSIONS

Although no definitive recommendation can be made regarding which anthropometric indices are the most appropriate for adolescents, some revisions may improve current practices. Weight-for-height could be used for prepubertal adolescents and body mass index could be used for postpubertal adolescents. Because cut-off points are age-specific, age should be collected as accurately as possible for all adolescents measured during screening or survey activities. The WHO-recommended reference population of US adolescents is inappropriate in most populations of adolescents. Adolescents should never undergo nutritional assessment in isolation; other population subgroups should be included, and other health, nutrition and food data should be collected at the same time.

SPONSORSHIP

The United Nations Administrative Committee on Coordination/Sub-Committee on Nutrition.

A new approach to classifying malnutrition in the hemodialysis patient

BACKGROUND

Novel classification nomenclature defining the type of malnutrition by the root cause of the hypoalbuminenia has been developing in the literature since 1999. As the classification of malnutrition became more definite in the literature, the need to assess the type of malnutrition, thereby the root cause(s) and initiate appropriate intervention(s), has become apparent.

METHODS

In September 1999, San Diego Dialysis began a continuous quality improvement (CQI) project to assess the root causes of hypoalbuminemia for patients with serum albumin level <3.5 g/dL. An extensive review of the literature was conducted on the subject of malnutrition, inflammation, and the acute-phase reaction.

FINDINGS

Two major groups of patients emerged: those consuming adequate protein and calories, yet presenting with hypoalbuminemia, and those suffering from a protein calorie deficit. Observation of the second group showed that although the monthly percentage of patients with hypoalbuminemia remained fairly constant, the names on the list changed from month to month.

CONCLUSIONS

The CQI team developed a protocol and a unique nomenclature to classify the types of malnutrition, type I, type IIa, type IIb, or mixed, by adapting the definitions in the literature through clinical practice. Interventions were developed to address each classification of malnutrition.

Definition and measurement of child malnutrition

Child Malnutrition has been defined or described in many ways. To summarize the common points, child malnutrition may be defined as a pathological state resulting from inadequate nutrition, including undernutrition (protein-energy malnutrition) due to insufficient intake of energy and other nutrients; overnutrition (overweight and obesity) due to excessive consumption of energy and other nutrients; deficiency diseases due to insufficient intake of one or more specific nutrients such as vitamins or minerals. In the assessment of child malnutrition, a large number of measures are available. Among these measuring methods, Z-score, growth charts, weight-for-length index (WLI), height standard weight, body mass index, skin fold thickness and clinical grading diagnosis standard for child malnutrition are selected for discussion. The same set of anthropometry data of a group of preschool children was analyzed by using different methods. The results showed that it was very difficult to determine the nutritional state of children using a single index. For a given group of children, Z-score method is recommended to observe their height, weight and weight for height at the same time in order to have a comprehensive understanding.

A malnutrition-inflammation score is correlated with morbidity and mortality in maintenance hemodialysis patients

Malnutrition inflammation complex syndrome (MICS) occurs commonly in maintenance hemodialysis (MHD) patients and may correlate with increased morbidity and mortality. An optimal, comprehensive, quantitative system that assesses MICS could be a useful measure of clinical status and may be a predictor of outcome in MHD patients. We therefore attempted to develop and validate such an instrument, comparing it with conventional measures of nutrition and inflammation, as well as prospective hospitalization and mortality. Using components of the conventional Subjective Global Assessment (SGA), a semiquantitative scale with three severity levels, the Dialysis Malnutrition Score (DMS), a fully quantitative scoring system consisting of 7 SGA components, with total score ranging between 7 (normal) and 35 (severely malnourished), was recently developed. To improve the DMS, we added three new elements to the 7 DMS components: body mass index, serum albumin level, and total iron-binding capacity to represent serum transferrin level. This new comprehensive Malnutrition-Inflammation Score (MIS) has 10 components, each with four levels of severity, from 0 (normal) to 3 (very severe). The sum of all 10 MIS components ranges from 0 to 30, denoting increasing degree of severity. These scores were compared with anthropometric measurements, near-infrared-measured body fat percentage, laboratory measures that included serum C-reactive protein (CRP), and 12-month prospective hospitalization and mortality rates. Eighty-three outpatients (44 men, 39 women; age, 59 +/- 15 years) on MHD therapy for at least 3 months (43 +/- 33 months) were evaluated at the beginning of this study and followed up for 1 year. The SGA, DMS, and MIS were assessed simultaneously on all patients by a trained physician. Case-mix-adjusted correlation coefficients for the MIS were significant for hospitalization days (r = 0.45; P < 0.001) and frequency of hospitalization (r = 0.46; P < 0.001). Compared with the SGA and DMS, most pertinent correlation coefficients were stronger with the MIS. The MIS, but not the SGA or DMS, correlated significantly with creatinine level, hematocrit, and CRP level. During the 12-month follow-up, 9 patients died and 6 patients left the cohort. The Cox proportional hazard-calculated relative risk for death for each 10-unit increase in the MIS was 10.43 (95% confidence interval, 2.28 to 47.64; P = 0.002). The MIS was superior to its components or different subversions for predicting mortality. The MIS appears to be a comprehensive scoring system with significant associations with prospective hospitalization and mortality, as well as measures of nutrition, inflammation, and anemia in MHD patients. The MIS may be superior to the conventional SGA and the DMS, as well as to individual laboratory values, as a predictor of dialysis outcome and an indicator of MICS.

Nutrition in the elderly

Nutrition is a prime concern for the optimal health of older persons. Nutritional requirements for older persons must take into account the physiologic changes that occur with aging. The gastrointestinal tract is the site of key structural and functional changes that affect nutrient intake and assimilation. A working knowledge of nutritional screening, assessment, and interventions can assist the practitioner in providing quality care for the older patient.

Use of subjective global assessment to identify nutrition-associated complications and death in geriatric long-term care facility residents

OBJECTIVE

The primary objective of this study was to assess the use of Subjective Global Assessment to identify nutrition-associated complications and death in a geriatric population. A secondary objective was to evaluate the ability of Subjective Global Assessment to identify geriatric residents of long-term care facilities who were undernourished or at risk for developing undernutrition.

METHODS

Fifty-three consecutive residents who were > or = 65 years of age and had been residing in a long-term care facility for < 2 weeks were enrolled in the study. The Subjective Global Assessment Classification technique was performed according to the procedure outlined by Detsky and colleagues. Residents were classified as well-nourished (A), mild/moderately undernourished (B) or severely undernourished (C). In addition, a Subjective Global Assessment Composite Score was derived. Subjective Global Assessment measures were compared with two traditional objective measurements of nutritional status: serum albumin and serum total cholesterol. Outcome measurements of nutrition-associated complications were determined over a 3-month period by recording the incidence of major infections, decubitus ulcers, nutrition-related hospital readmissions, and mortality.

RESULTS

Sixteen residents (30.2%) were categorized as Subjective Global Assessment class A, 28 residents (52.8%) were class B, and 9 residents (17%) were class C. A significant association was found between nutritional status as determined by Subjective Global Assessment Composite Score and nutrition-associated complications (p<0.05). Subjective Global Assessment Classification was related to death (p<0.05) with severely undernourished residents having the highest mortality rate. Hypoalbuminemia only demonstrated a significant relationship with nutrition-associated complications (p<0.05), whereas hypocholesterolemia was associated with death (p<0.05).

CONCLUSIONS

Subjective Global Assessment of nutritional status appears to be a simple, noninvasive and cost-effective tool for assessing nutritional status of geriatric residents in long-term care facilities. This assessment tool is also beneficial for identifying patients with increased risk of nutrition-associated complications as well as death.

Relationships between nutritional markers and the mini-nutritional assessment in 155 older persons

OBJECTIVE

To investigate the relationships between nutritional status measured by a comprehensive nutritional assessment including anthropometric measurements, nutritional biological markers, evaluation of dietary intake, and the Mini-Nutritional Assessment (MNA) nutrition screening tool.

DESIGN

A prospective study.

PARTICIPANTS

One hundred fifty-five older subjects (53 men and 102 women; mean age = 78 years; range = 56-97 years). These participants were hospitalized in a geriatric evaluation unit (n = 105) or free living in the community (n = 50).

MEASUREMENT

Weight, height, knee height, midarm and calf circumferences, triceps and subscapular skinfolds, albumin, transthyretin (prealbumin), transferrin, ceruloplasmin, C-reactive protein, alpha1-acid glycoprotein, cholesterol, vitamins A, D, E, B1, B2, B6, B12, folate, copper, zinc, a 3 day food record combined with a food-frequency questionnaire; the MNA nutritional screening.

RESULTS

The MNA scores have been found to be significantly correlated to nutritional intake (P < .05 for energy, carbohydrates, fiber, calcium, vitamin D, iron, vitamin B6, and vitamin C), anthropometric and biological nutritional parameters (P < .001 for albumin, transthyretin, transferrin, cholesterol, retinol, alpha-tocopherol, 25-OH cholecalciferol zinc). An MNA score between 17 and 23.5 can identify those persons with mild malnutrition in which nutrition intervention may be effective.

CONCLUSIONS

The MNA is a practical, noninvasive, and cost-effective instrument allowing for rapid nutritional evaluation and effective intervention in frail older persons.

The validity and reproducibility of clinical assessment of nutritional status in the elderly

Malnutrition is an important predictor of morbidity and mortality. In the non-elderly, a subjective global assessment (SGA) has been developed. It has a high inter-rater agreement, correlates with other measures of nutritional status, and predicts subsequent morbidity. The purpose of this study was to determine the validity and reproducibility of the SGA in a group of patients older than 70 y of age. Consecutive patients from four geriatric/rehabilitation units were considered for the study. Each patient underwent independent nutritional assessments by a geriatrician and senior medical resident. At the completion of the assessment, skinfold caliper measurements were obtained and the patient reclassified according to the results, which were then compared with objective measures of nutritional status. Six-month follow-up was obtained on all patients. The agreement between the two clinicians was 0.48 +/- 0.17 (unweighted kappa), which represents moderate agreement and is less than the reported agreement in nonelderly subjects. Skin calipers improved the agreement between clinicians but did not improve the correlation with other nutritional markers or prediction of morbidity and mortality. There was a correlation between a patient's severely malnourished state and mortality. In addition, patients with a body mass index (BMI) of <75% or >150% age/sex standardized norms had an increased mortality. The SGA is a reproducible and valid tool for determining nutritional status in the elderly. The reproducibility is less than in the nonelderly, which may relate to changes in body composition or ability to obtain an accurate nutritional history.

The relationship between nutritional status and physical activity, ulcer history and ulcer-related problems in patients with leg and foot ulcers

The nutritional status in patients with leg and foot ulcers is assessed in relation to sociodemographic data, mobility, physical activity, ulcer history, and ulcer-related problems from the patients' point of view. The patients (20 men and 50 women, mean age 79 years) were living in their own homes and treatment was given in primary health care. The Mini Nutritional Assessment (MNA) was used to assess nutritional status. Interviews were conducted to collect data on patients' mobility, physical activity, ulcer history and ulcer-related problems. According to the MNA, 32 patients were classified as being at risk of malnutrition and two were malnourished. Patients classified as at risk of malnutrition or malnourishment were usually living alone and were more dependent on aids for mobility and on home-help services than the well-nourished patients (p < 0.05). There were no significant differences between the well-nourished patients and those classified as at risk of malnutrition or malnourished in the number and the duration of open ulcers. This study shows that risk of malnutrition was common in this elderly population of 70 patients with leg and foot ulcers. Comprehensive patient care should include nutritional assessment and preventive actions to restore the nutritional status before malnutrition is manifest.

[Anthropometric indices used for the diagnosis of malnutrition in adolescents and adults: review of the literature]

The International Dietary Energy Consultative Group, sponsored by the World Health Organization (WHO), has done most of the research conducted in the field of adult malnutrition in the late 1980's. These studies were carried out mainly in populations suffering from chronic malnutrition, and led to the current WHO recommendations for the diagnosis and classification of adult malnutrition. Body Mass Index (BMI) is the gold standard to be used in adults, with the following cut-off points identified: 16.0, 17.0 and 18.5. The good correlation observed between BMI and Middle Upper Arm Circumference (MUAC) led to the determination of corresponding cut-off points. However, the very few field studies available in the literature are in favor of a lowering of the BMI cut-off points during nutritional emergencies. Several questions need to be answered through field research, mainly concerning the type of indicator best predicting the risk of death, and the type of indicator to be used in adolescents, pregnant women and older people.

ICPC-code approach of nutritional questions in general practice: a look at the future

The Dutch College of General Practitioners is developing a computerised consult supporting system on nutrition that is integrated in the widely used GP Information System. Connected to every ICPC-code (International Code of Primary Care) for diagnosis relevant nutritional information is available. Short items simple sentences with respect to the content-provide the main nutritional information, needed to inform the patient within the limited consultation time. Background information is the second level and is reachable by clicking on the coloured items in the first part. After all the patients' practical advice is the last part of this so-called: 'P-module of nutrition'.

Nutritional status and dietary intake in tribal children of Bihar

OBJECTIVE

To assess the dietary intake and nutritional status in children of the tribal areas of Bihar.

DESIGN

Cross sectional survey with two stage probability proportional to size sampling.

SETTING

Study covered 396 villages from 17 tribal districts of Bihar.

SUBJECTS

1847 preschool children (0-6 Years) were studied.

METHODS

24 hours recall method was used to assess the nutrition intake and anthropometric measurements included height and weight. Nutritional intake was compared with Indian Council of Medical Research recommended dietary allowances (RDA) and nutritional status assessed by SD classification.

RESULTS

The intake of protein was broadly in line with the recommended dietary allowances (RDA) in all age groups among children. However, the average intake of energy and other nutrients was lower in allage groups as compared to RDA. Calorie deficiency was 38% whereas protein deficiency was about 19%. More than half of the children were caloric deficient in Katihar, Bokaro, Godda and Singhbhum (east and west). The overall prevalence of stunting was about 60% and underweight about 55% and was comparable in boys and girls. However, wasting was more frequent in girls (urban - 34.5% vs. 16.3% and rural - 34.9% vs 18%). The level of malnutrition was not very different in rural and urban areas.

CONCLUSION

The nutritional status and dietary intakes of tribal children in Bihar is very poor. Urgent remedial measures are required in this context, particularly on a war footing in especially vulnerable districts identified by this survey.

Growth status in children with cystic fibrosis based on the National Cystic Fibrosis Patient Registry data: evaluation of various criteria used to identify malnutrition

OBJECTIVES

The objectives of this study were to determine growth status and to identify malnutrition with various anthropometric indicators in children with cystic fibrosis (CF) based on cross-sectional analysis of the 1993 National CF Patient Registry data.

METHODS

Heights and weights of 13,116 children with CF were evaluated with percentile, percent of reference median, Z-score, and percent ideal weight-for-height based on National Center for Health Statistics/Centers for Disease Control growth references. Malnutrition was defined by four criteria: (1) height-for-age <5th percentile ("stunting") or weight-for-age <5th percentile ("wasting") (2) height-for-age <90% of reference median or weight-for-age <80% of reference median, (3) height-for-age <5th percentile or percent ideal weight-for-height <85%, and (4) height-for-age <90% of reference median or weight-for-height <85% of reference median.

RESULTS

Mean and median height- and weight-for-age were found to be at the 30th and 20th percentiles in children with CF. Malnutrition (height- or weight-for-age <5th percentile) was particularly pronounced in infants (47%) and adolescents (34%) and patients with newly diagnosed CF (44%). A significant sex difference (p < 0.01) in the occurrence of stunting (height-for-age <5th percentile) was observed during adolescence: boys 11 to 14 years of age showed lower occurrence of stunting (19%) compared with girls (29%), whereas the opposite trend was observed at 15 to 18 years (34% in male patients vs 28% in female patients).

CONCLUSION

Twenty percent of all children in the 1993 National CF Patient Registry were <5th percentile for height- or weight-for-age. A significant discrepancy was found when different criteria were used to distinguish "stunting" versus "wasting" in malnourished children with CF.

Basal metabolism of weight-stable chronically undernourished men and women: lack of metabolic adaptation and ethnic differences

The purpose of this study was to investigate whether weight-stable chronically energy-deficient subjects exhibit evidence of metabolic adaptation and to establish whether international predictive equations overestimate the basal metabolic rate (BMR) of tropical populations. BMR, body weight, height, and fat-free mass (FFM) by underwater weighing were measured in healthy, physically active urban dwellers of low socioeconomic status (178 men and women aged 22-38 y) in Bangalore, Southern India. Subjects were selected on the basis of body mass index (BMI; in kg/m2) and classified in three groups: severely undernourished (BMI < 17.0; n = 30 men, n = 25 women), marginally undernourished (BMI = 17.0-18.5; n = 31 men, n = 30 women), and well nourished (BMI > 18.5; n = 27 men, n = 35 women). The BMR of the well-nourished group, expressed in absolute terms (6.20 and 5.18 MJ/d for men and women, respectively), was significantly higher (P < 0.000) than that of the severely undernourished group (5.72 and 4.64 MJ/d for men and women, respectively). Normalizing BMR for either body weight or FFM by analysis of covariance abolished all differences. The mean BMR of the low-BMI study group was substantially higher (11-14%) than reported previously for undernourished Indian adults. The BMR of both men and women, regardless of their nutritional status, was accurately estimated by age- and sex-specific FAO/WHO/UNU equations. These findings suggest the absence of an enhanced metabolic response in weight-stable chronically undernourished adults. This is in contrast with earlier reports, and supports more recent views. The study also provides evidence of the absence of ethnic-specific energy turnover in Indians.

Prevalence of malnutrition in nonsurgical hospitalized patients and its association with disease complications

The prevalence of malnutrition and its predictive value for the incidence of complications were determined in 155 patients hospitalized for internal or gastrointestinal diseases. At admission, 45% of the patients were malnourished according to the Subjective Global Assessment (physical examination plus questionnaire), 57% according to the Nutritional Risk Index [(1.5 x albumin) + (41.7 x present/usual weight)], and 62% according to the Maastricht Index [(20.68 - (0.24 x albumin) - (19.21 x transthyretin (prealbumin) - (1.86 x lymphocytes) - (0 04 x ideal weight)]. Crude odds ratios for the incidence of any complication in malnourished compared with well-nourished patients during hospitalization were 2.7 (95% CI: 1.4, 5.3) for the Subjective Global Assessment, 2.8 (1.5, 5.5) for the Nutritional Risk Index, and 3.1 (1.5, 6.4) for the Maastricht Index. Odds ratios were reduced to 1.7 (0.8, 3.6), 1.6 (0.7, 3.3), and 2.4 (1.1, 5.4), respectively, after a multivariate analysis that included disease category and disease severity. Because the confounding factors adjusted for are not only a measure of the severity of the disease but may also be influenced by malnutrition itself, the actual risk for complications due to malnutrition could be higher than the adjusted odds ratios. In conclusion, malnutrition was frequent in patients with gastrointestinal disease and other internal diseases at the time of admission. The severity of malnutrition in the patients predicted the occurrence of complications during their hospital stay and this association was not completely explained by confounding factors.

Nutritional status and survival of patients with liver cirrhosis: anthropometric evaluation

Malnutrition frequently occurs in patients with liver cirrhosis independently for its aetiology and can modify prognosis of the disease. We have evaluated if malnutrition can affect the survival of 184 patients with liver cirrhosis (124 at stage A according to Child-Pugh criteria, and 50 at stage B-C of the disease). Nutritional status was assessed by anthropometric measurements: body weight (actual and ideal), and biceps, triceps, over-iliac and sub-scapular skinfold thickness. About 8% of Child A patients and 26% of Child B-C were malnourished, and malnutrition affected the mortality of these patients at 1 year, whereas no differences were observed at 2 years. Our data suggest that the evaluation of nutritional status is important in cirrhotic management and malnutrition can be an aggravating factor for the survival of these patients.

Determinants of nutritional status in south-west Uganda

In a cross-sectional survey carried out of 4320 children 0-59 months old in South-west Uganda various socio-economic and environmental factors were related to poor nutritional status. Diarrhoea was strongly associated with all the anthropometric parameters examined, suggesting a bidirectional influence of diarrhoea on malnutrition and of malnutrition on diarrhoea. The other most important variables independently associated with one or more anthropometric parameters were: distance from a health unit, living in a household not able to hire labour, and whose members worked on other people's land, religion, parental education, crowding conditions, sanitation, acreage, ownership of cow, father's occupation, birth order, ethnicity, and prolonged breastfeeding. This data indicates that a range of specific interventions are likely to be necessary for the improvement of nutrition in this community.

Comparison of methods to categorize undernutrition in children

We compared the results of three methods of categorizing undernutrition in a group of 258 children referred for evaluation of "failure to thrive." There was broad variation between the number of children classified as malnourished (75% to 98%) and the degree of undernutrition, depending on the method used. We recommend that categorization systems be used only to define a child as having a risk of possible adverse effects of undernutrition, not as being malnourished.

Malnutrition among the elderly

Nutrition is a significant determinant of health. Undernutrition presenting as malnutrition is a serious health concern for frail elderly people with many health problems. Understanding the risk factors for malnutrition helps physicians assess and manage the condition. Primary care physicians are in an excellent position to screen, educate, and manage their elderly malnourished patients.

Classification of nutritional status as 'Z score' or per cent of reference median--does it alter mortality prediction in malnourished children?

The objective of the study was to evaluate, using a prospective cohort study, whether classification of nutritional status by 'Z score' or per cent of reference median alters the prediction of death in malnourished children. The subjects were children with diarrhoea requiring hospitalization due to moderate or severe dehydration and/or associated complications. There were 382 participants under 5 years of age, of whom 37 died (cases), 320 were discharged in a satisfactory condition (controls) and 25 left before diarrhoea was completely cured (lost to follow-up--excluded). Rehydrated weight and recumbent length (under 2 years) or standing height were recorded and the three indices (weight for age, height for age and weight for height) derived as both 'Z scores' and per cents of reference National Centre for Health Statistics (NCHS) medians. Logistic regression, sensitivity specificity curves and Zda test for normalized distances were used to compare the relative utility of these two classification methods in identifying children with a high risk of dying. The per cent of reference median and 'Z scores' were highly correlated (r = 0.9540, 0.9787 and 0.9667, respectively). Both methods yielded virtually identical results in predicting death of malnourished children for all the three indices. It was concluded that 'Z score' and per cent classification of nutrition are equally efficient in predicting death of malnourished children.

Risk indicators of nutritional status of households of a Kenyan semi-arid population

Assessments of nutritional status of semi-arid population in Kiambu District comprising 1042 persons from 260 households showed that 64.2% of the households had at least one malnourished person. The main aim of the study was to establish whether patterns of households malnutrition were distinguishable by specific risk indicators. Fourteen patterns of household malnutrition were established by classifying malnourished people according to age vis-a-vis nutritional status of other members of that household and six risk indicators were found to be related to malnutrition at the household level. Although partial relation was found between patterns and some indicators, no risk was found to be exclusively related to a specific pattern but failure to establish such a relationship was attributed to sample size.

Nutritional disorders in adolescent girls

Four hundred and fifty four adolescent girls (11-18 years) were screened for nutritional disorders by anthropometry (weight, height and triceps skinfold measurements), clinical examination and hemoglobin estimation. Of these, 56% belonged to high socio-economic groups (Group A) and the rest (44%) to lower middle class (Group B). A large number of girls from Group B were undernourished (35.5% had weight/height2 less than the fifth percentile of reference standard) stressing the need for nutritional screening, nutrition and health education. Obesity was prevalent in 3.1% of Group A adolescents. Goitre grade I or more was observed in a high proportion of Group B girls, stressing the need for continued consumption of iodized salt in Delhi. Anemia appears to be a major health problem in adolescent girls in both groups (47, 56% in Groups A and B, respectively) underlying the ned for iron supplementation along with health education.

A simplified approach of assessing adult chronic energy deficiency

Body mass index (BMI) in conjunction with indices of energy turnover, e.g. physical activity levels (PAL), was recently proposed for classifying adult chronic energy deficiency (CED). Three deprived populations in Africa and Asia were chosen to assess the classification system. Repeated monitoring showed that the combined indicator was affected by instability in PALs and produced implausible discontinuities in the prevalence of different grades of CED. The use of BMI alone produced coherent data with changing BMI distributions, and only 5% of the population would have been wrongly classified as being malnourished, because of being thin but active. The risk of misclassification would be even smaller for populations with BMI distribution shifted towards the right. The prevalence of CED was consistently related within each country to indices of socio-economic status. Yet in Zimbabwe 18% of women and 6% of men had Grade I obesity compared with 11% and 14%, respectively, with CED. Less than 1% Indian and Ethiopian adults were obese but 61% of women and 70% of men were classified as CED in India and 57% and 50%, respectively, in Ethiopia. We propose that adult BMI alone is sufficient to provide important new insights into the problems of food availability and its control in less developed countries.

Determining nutritional status of the elderly surgical patient: steps in the assessment process

Many variables contribute to complications of nutritional depletion, and any complication can be caused by nutrient deficiencies alone. A broad knowledge of contributing factors, clinical signs and symptoms, and laboratory test results equips the nurse to quickly and accurately identify a malnourished patient. The perioperative team then can initiate steps to support the patient through the surgical and recovery process.

The effects of malnutrition on the motor, perceptual, and cognitive functions of Filipino children

The motor, perceptual, and cognitive abilities of 99 Filipino children, aged 4-6 years with a documented history of malnutrition from a nutritionally depressed area of Manila were determined using the Revised Manila Motor-Perceptual Screening Test. They were classified into four groups of: (1) normal; (2) acutely malnourished; (3) stunted but not malnourished; and (4) chronically malnourished using the Waterlow classification. Thirty-one normal children of comparable ages and background from a nationwide pool were similarly tested and served as the control group. Motor (p = 0.001) and perceptual skill (p less than 0.03 to less than 0.001) scores were significantly lower than in their normal counterparts, especially in the chronically malnourished children. Cognitive abilities were not evidently affected by malnutrition.

Comparison of Gomez and Waterlow classifications in a follow-up study among pre-school children

Two classifications, widely used for assessing malnutrition, those of Gomez and Waterlow, were examined for concordance in a follow-up study. Unlike in cross-sectional studies, the classifications should reflect the changes in the nutritional status of individuals over a period of time. A method of cross-classification is illustrated for assessing these changes. Data were collected on 95 children from a village and on 74 children from an urban slum. Children were measured twice for weight and height, at an interval of 17 months in the village and 12 months in the slum. The usual way of comparing estimates of malnutrition in the initial and final rounds of a follow-up study would not reveal the shifts of individuals from one grade to another grade of malnutrition. The method illustrated in this paper, on the contrary, is able to identify individuals who improve, deteriorate or show no change in their nutritional status. It was found in this follow-up study that identical conclusions were reached by both classifications in only about 17 per cent of the children, whereas about 40 per cent showed only partial concordance (ie, between Gomez and either wasting only or stunting only).

Classification of malnutrition by statistical analysis of quantitative two-dimensional gel electrophoresis of plasma proteins

An attempt to use the relative concentrations of major plasma proteins for clinical assessment of severe malnutrition is described. Quantitative two-dimensional gel electrophoresis was used to measure the concentrations of 24 major proteins in small aliquots of plasma obtained from children, aged 0 to 3 years, who were patients and outpatients in Liberian hospitals. Fifteen had a clinical diagnosis of kwashiorkor, 36 were diagnosed with marasmus, and 18 were controls. There were also 5 controls from the United States. The individuals were placed in six groups; kwashiorkor, kwashiorkor who died during treatment, marasmus, marasmus who died, Liberian controls, and U.S. controls. The amount of protein in each spot in the two-dimensional gels was estimated by measuring bound stain using a laser scanner and computerized image analysis. We found very low serum transferrin levels in malnourishment, in agreement with reports from other investigators. All of the data for 24 protein variables were pooled for factor analysis; the mean factor scores for each group differed, with the kwashiorkor groups furthest from the controls. Results of discriminant analysis using the amounts of different numbers of protein variables (3 to 24) were compared for posterior assignment of individuals to groups. The validity of the method was tested by analysis of plasma aliquots obtained from patients following initiation of therapy and which were not a part of the training set. Predictive performance (prognosis of patient survival) depended upon the number of protein variables used. Although artifactual fitting of the data is expected to contribute to performance as the number of variables is increased, use of as many as 7 variables may be justified, even with our small patient groups. Possible use of these results for development of a practical clinical test is discussed.

A rapid appraisal of the nutritional status of Irian Jaya refugees and Papua New Guineans undergoing severe food shortage in the North Fly region

A survey of nutritional status of recent border crossers from Irian Jaya undergoing severe food shortages was carried out. The two camps visited were those considered to have the most serious problems at the height of the crisis. Komopkin Camp had the highest levels of malnutrition in all age groups and in all categories, including 52% of children aged 1 to 5 years with signs of kwashiorkor. No kwashiorkor, however, was found in the other camp. Papua New Guinea villagers living alongside the refugees in Komopkin were also suffering from malnutrition, though of lesser severity and shorter duration.

Hepatic antipyrine metabolism in malnourished patients: influence of the type of malnutrition and course after nutritional rehabilitation

The present study of hepatic mixed function oxidase activity was carried out by determining antipyrine clearance in 49 patients presenting with energy malnutrition (group E, n = 26) or global protein-calorie malnutrition (group P, n = 23). A control group (group C, n = 25) was composed of subjects with good nutritional status. The metabolic clearance rate and weight-corrected clearance in group P were significantly lower than those in groups E and C. The weight clearances in the latter two groups were not significantly different, suggesting that mixed function oxidase activity decreases only in protein-calorie malnutrition. Antipyrine clearance was studied again in 27 patients after nutritional rehabilitation with artificial nutrition for 31 +/- 4 days (means +/- SEM). Concomitant with an improvement in nutritional state, clearances tended towards normal values in group P (n = 17) and were not significantly modified in group E (n = 10). It is thus important to take the type of malnutrition into account in pharmacological studies of malnourished humans in order to correctly adapt therapeutic doses.

Chronic undernutrition and cognitive abilities

This review attempts to summarize recent developments in our understanding of the relationship between childhood malnutrition and cognitive abilities. The first questions briefly discussed relate to methods: the definition of malnutrition and the selection of suitable methods of measuring cognitive abilities. Next are considered the effects on mental development of undernutrition, social background and the behavioural patterns of mothers. The consequences of an episode of severe malnutrition in infancy and of confinement in hospital represent a special but important case. The review ends with a discussion of the factors that influence recovery and of strategies for intervention which might be included in a health care programme.