Incidence and recognition of malnutrition in hospital

OBJECTIVES: To determine incidence of malnutrition among patients on admission to hospital, to monitor their changes in nutritional status during stay, and to determine awareness of nutrition in different clinical units. DESIGN: Prospective study of consecutive admissions. SETTING: Acute teaching hospital. SUBJECTS: 500 patients admitted to hospital: 100 each from general surgery, general medicine, respiratory medicine, orthopaedic surgery, and medicine for the elderly. MAIN OUTCOME MEASURES: Nutritional status of patients on admission and reassessment on discharge, review of case notes for information about nutritional status. RESULTS: On admission, 200 of the 500 patients were undernourished (body mass index less than 20) and 34% were overweight (body mass index > 25). The 112 patients reassessed on discharge had mean weight loss of 5.4%, with greatest weight loss in those initially most undernourished. But the 10 patients referred for nutritional support showed mean weight gain of 7.9%. Review of case notes revealed that, of the 200 undernourished patients, only 96 had any nutritional information documented. CONCLUSION: Malnutrition remains a largely unrecognised problem in hospital and highlights the need for education on clinical nutrition.     

Nutritional status indicators in population studies

The access to information is crucial to plan, define and evaluate nutritional interventions. Analyzing the main nutritional indices proposed by international fora for food and nutrition surveillance, the usefulness of anthropometry is underscored due to its simplicity and low cost. The height/age index has advantages and limitations, considering that height may be influenced by genetic factors. The joint analysis of different indicators allows a correct individual or population nutritional assessment. It is concluded that height continues to be a good index of nutritional status and of standard of living in countries where nutritional problems are relevant.     

Nutritional assessments, food security and famine

The widely held view that malnutrition is a late indicator of famine is challenged on the basis of evidence that people often deliberately reduce their food intake as an early response to inadequate food security. This broadens the possible interventions in response to high malnutrition rates to include measures to support livelihoods under threat of collapse. In the late stages of famine, social disruption and distress migration often result in a degraded health environment which may raise the threshold of nutritional status associated with an increased mortality risk. It is important to assess the underlying causes of malnutrition and the associated health risks. At present, the main objective of nutrition surveys is usually to obtain a reliable estimate of the prevalence of malnutrition among children under five years of age, with little analysis of the underlying causes of malnutrition. Experience from the 1984-85 famine in Darfur led to the development of an alternative approach to nutritional assessment which could be applicable elsewhere in Africa. The combination of quantitative and qualitative methods was particularly valuable as a means of gaining a wider and deeper understanding of the nature of the nutritional situation.     

One stage reconstruction of extensive abdominal wall defect with bilateral tensor fascia lata (TFL) flaps

Results of a small nutrition survey carried out in an urban settlement in Port Moresby are presented. Anthropometric, dietary and socioeconomic data were collected on 90 children under five years old and 78 adults. 30% of the children under five years old were below 80% weight for age. Of the 31% of adults found to be undernourished, the majority were females aged less than 30 years. With respect to dietary information, most families appear to eat a variety of foods though no attempt was made to measure quantity of foods consumed. Rice is the single most popular food, with 69% of adults having consumed it the previous day. Despite the high reliance on purchased foods, income appears to be low with the majority of people relying on money from relatives and the sale of home produce. The recommendations made for appropriate health and nutrition education may be applicable for other growing settlement populations in and around Port Moresby and other urban centres of Papua New Guinea.     

A nutritional assessment of homebound elderly in a physician-monitored population

Nutritional information and support for the elderly are available from many sources. Yet many older adults still remain at risk for malnutrition. This study examined the nutritional status of homebound elderly in a physician-monitored population, with access to health and social services. Older adult patients from the Home Visit Program of the Department of Family Medicine were visited, and an assessment was administered. All patients had primary care physicians who visited patients in their homes, on average, every 3 months. For this survey, the Nutritional Risk Index, the Nutritional Screening Initiative Checklist, an ADL (Activities of Daily Living) assessment, and general history questions were asked. In order to evaluate content of diet, food frequency and a 24-hour diet history were used. Questions on basic nutritional knowledge were asked, and a kitchen survey was used to examine purchasing behavior. Most patients were found to be at high nutritional risk with an average Nutritional Screening Initiative Risk score of 7, but for reasons that varied among patients. Most patients claimed to have a good appetite and enough money for food. The 24-hour diet analysis showed that many individuals did not meet 70% of RDA for major energy sources and fiber. Patient knowledge of the four basic food groups was poor. Since none of the patients shopped for themselves and many did not cook, the nutritional knowledge and food preparation behaviors of caregivers may be important for the nutritional well-being of the patient. An educational program for this population should include the caregiver as well as the patient.     

The individualization of activities of blood vessels]

Due to its short half life and high tryptophan content, prealbumin has been considered a sensitive indicator of protein and/or energy deficiency. In addition, prealbumin diminishes during the acute phase response elicited by either infection or tissue injury. Serum levels of prealbumin were determined in undernourished children with or without associated clinical infection and in their infected or non-infected controls matched for age, sex, race and socioeconomical conditions. Serum levels of prealbumin were significantly lower in undernourished than in control children without overt infections. On the other hand, the concentrations of serum prealbumin diminished significantly and to similar levels both in undernourished and control children with associated clinical infection as compared with those observed in non infected children belonging to the similar nutritional status. A positive correlation was found between prealbumin level and the Z-scores of weight-for-age, height-for-age and weight-for height in children without associated infections, which disappeared in clinically infected patients. Thus, prealbumin is a marker of undernutrition in the absence of infection and could be an earlier and more sensitive indicator of actual undernutrition caused by the metabolic effects of acute phase cytokines, than the anthropometrical measurements used here.     

Evaluating and treating nutritional problems in older patients

Up to 65% of elderly hospitalized patients are protein-energy undernourished at admission or acquire nutritional deficits while hospitalized. For the elderly patient who requires nutritional support therapy, a strategy of intervention should be carefully formulated based on the results of a clinical assessment. While receiving nutritional support, the patient should be monitored carefully for complications and changing metabolic requirements. Modifications to the original regimen should be made to meet the patient's needs as necessary.     

Social-cognitive determinants of nutrition behavior among supermarket food shoppers: A structural equation analysis.

A social-cognitive model of nutrition behavior (A. Bandura, 1997) was tested using structural equation modeling of data from 307 food shoppers recruited from 5 supermarkets in Southwest Virginia. The shoppers were participating in the baseline phase of an ongoing nutrition promotion program. As part of the evaluation, data were collected on the self-efficacy and outcome-expectations components of social-cognitive theory as well as on food purchases and intake. The structural analyses presented here support the social-cognitive model. Self-efficacy, physical outcome expectations, age, socioeconomic status, and number of children were important predictors of nutrition behavior among shoppers. Implications for interventions using social-cognitive variables to improve the nutritional content of food purchases and intake are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sinus histiocytosis with massive lymphadenopathy--a disseminated form of the Rosai-Dorfman syndrome]

With the aim of assessing the possible benefits of nutritional therapy, 140 patients were prospectively studied during radiotherapy of the head and neck (81%) and esophageal cancer (19%). Mean age was 56.0 (17-80), with 114 males and 26 females. Duration of both nutrition and radiotherapy was 78.0 +/- 45 days. Tube feeding was the primary modality in 50.7% of the population, and oral regimens in the remaining 49.3%, but associations between the methods were also used. Enteral diets were supplied under the supervision of a specialized tem for home alimentation (PROSNED). Compliance to the program was 100%, and a lymphocyte count diminished along this period (1933 +/- 1033 vs 1265 +/- 688, p. 0.001). A subjective improvement was reported by 84% of the population, and total calorie intake, that was below 60% of estimated needs in 100% of the cases initially, significantly improved to just 40% inadequate at the end of the observations. Radiotherapy was associated with mucositis in 21% of the patients, taste changes in 79%, xerostomy in 81%, anorexia in 66% and odinophagia in 59%. In the individuals selected for enteral feeding, side-effects were represented by technical problems (20%) and gastrointestinal disorders (13%). All patients completed the nutritional support program and there was no mortality in this series. It is concluded that; 1) Early nutritional support during radiotherapy was able to maintain or improve the nutritional status; 2) Tube feeding, alone or in combination with oral diets, was indicated whenever appropriate and contributed to fulfillment of the energy requirements; 3) Reduction of total lymphocytes could not be prevented by the mentioned therapy; 4) Complications of enteral alimentation were mild and affected a small proportion of the population; 5) Troubles induced by radiotherapy were as frequent as expected, and tended to disturb the intake of food; 6) The compliance to the therapeutic plan was excellent and can be attributed to the efforts of the multidisciplinary team as well as to the help of the specialized home alimentation unit (PROSNED): Diet therapy. Cancer. Nutritional assessment. Radiotherapy. Nutritional support.     

Nutritional management of enteropathy

The prognosis for nutritional management of enteropathy in children is good when the enteropathy is reversible with the use of a food elimination diet, such as cow's-milk-sensitive enteropathy, but is poor when enteropathy is irreversible, such as microvillous atrophy. However, nutritional management is central to the care of all children with small intestinal enteropathy. Enteral nutrition (provision of liquid formula diets by mouth or by tube) is possible in most cases, but in some children with intractable diarrhea, parenteral nutrition needs to supplement enteral feeding. The choice of enteral feeding ranges from elemental to partial hydrolysate.     

Cigarette smoking is associated with unhealthy patterns of nutrient intake: a meta-analysis

The aim of this investigation was to assess the relationship between smoking status and nutrient intakes using a meta-analysis. Publications in English were sought through a Medline search using the following key words: food habits, eating, feeding behavior, diet, food, nutrition, nutritional status or assessment, tobacco use disorder, tobacco, nicotine and smoking. Scanning relevant reference lists of articles and hand searching completed the data collection. No attempt was made to search for unpublished results. Paper selection was based on nutritional surveys including comparisons of smokers with nonsmokers. Fifty-one published nutritional surveys from 15 different countries with 47,250 nonsmokers and 35,870 smokers were used in the analysis. The estimates of size effects were calculated with the mean and variance values of each nutrient intake and the size of the sample. Smokers declared significantly (all P < 10(-5)) higher intakes of energy (+4.9%), total fat (+3.5%), saturated fat (+8.9%), cholesterol (+10.8%) and alcohol (+77.5%) and lower intakes of polyunsaturated fat (-6.5%), fiber (-12.4%), vitamin C (-16.5%), vitamin E (-10.8%) and beta-carotene (-11.8%) than nonsmokers. Protein and carbohydrate intakes did not differ between smokers and nonsmokers. There was no evidence of heterogeneity among studies. In conclusion, the nutrient intakes of smokers differ substantially from those of nonsmokers. Some of these differences may exacerbate the deleterious effects of smoke components on cancer and coronary heart disease risk.     

Treatment of acute herpes simplex encephalitis

Combined subjective and objective nutritional assessment was performed on admission in 127 patients with oral and maxillofacial malignancies. On the basis of the nutritional assessment result, three typical nutritional parameters-body weight (BW) (X1), mid-upper-arm circumference (MAC) (X2), and hand grip strength (HGS) (X3) were used to establish a new nutritional assessment method that was developed by a computer-based discriminant analysis. The established model was as follows: Y1 = -126 + 1.09X1 + 1.34X2 + 0.23X3; Y2 = -95.63 + 0.96X1 + 1.17X2 + 0.19X3. In the model Y1 was regarded as good nutrition and Y2 as malnutrition. The larger value of Y stood for the patient's nutritional status (i.e. Y1 > Y2, well nourished; Y1 < Y2 malnourished). The new nutritional assessment correlates well with the combined subjective and objective nutritional assessment with a total agreement rate of 88.2%. With its simplicity and accuracy, the new nutritional assessment deserves a wide application in clinical situation.     

Nutritional aspects of wound healing

The nutritional aspects of wound healing include completing a nutritional assessment, estimating a patient's nutrient needs, and evaluating options for medical nutrition therapy. Some key nutrients involved in wound healing are discussed and their food sources described.     

Anthropometric nutritional assessment of critically ill hospitalized children

In a prospective study, the nutritional status was evaluated in 46 consecutive admissions to a Pediatric Intensive Care Unit, using anthropometric parameters. About 65% of the patients presented malnutrition on admission, with predominance of the chronic form. The mortality rate was greater in the malnourished (20 versus 12.5%) and chronic malnutrition was associated with a higher incidence of infection (42%). There was a fall in channel of percentile for weight-for-height in 36% of the patients evaluated at the final follow up. These results suggest that a significant number of patients are at nutritional risk at the time of hospital admission, and there is an association between nutritional status and hospital course. The anthropometric nutritional evaluation is a simple an reproducible method, and a valuable parameter for an objective nutritional assessment of the critically ill child. Therefore, it should be performed on admission and follow up of hospitalized children.     

A randomized study of radiotherapy alone versus radiotherapy plus 5-fluorouracil and platinum in patients with inoperable, locally advanced squamous cancer of the esophagus

Crohn's disease is frequently complicated by protein-calorie malnutrition. Four common clinical presentations of Crohn's disease include acute exacerbations or flares of disease, intestinal obstruction, fistulizing disease, and perianal disease. In this review, we examine the role of nutritional support in these clinical scenarios. Nutritional support is important for maintaining functional status and preventing loss of lean tissue. Determinants of lean-tissue loss include severity of underlying injury, baseline nutritional status, and duration of inadequate nutrition. One of the clinically useful measures of nutritional status is the nutritional risk index (NRI) defined on the basis of the serum albumin and weight loss. Nutritional support is important in severely malnourished patients (NRI < 83). Enteral nutrition is the route of choice, provided there are no contraindications to using the gastrointestinal tract. In acute exacerbations of Crohn's disease, enteral nutrition also has a role in the primary management of disease although it is not as effective as corticosteroids in inducing remission. The mechanisms are poorly understood and the most effective enteral formulation needs to be determined. Total parenteral nutrition is justified in severely malnourished Crohn's disease patients who are unable to tolerate enteral feeding or in whom enteral feeding is contraindicated. More clinical studies are needed on the assessment of malnutrition in Crohn's disease, the effects of nutritional management on functional status, and the timing of nutritional intervention.     

Diminished levels of insulin-like growth factor-I in lungs in streptozotocin-induced diabetes: relation to nutritional status and growth

It is yet unknown whether the impaired nutritional status of streptozotocin-induced diabetic rats influences changes in levels of insulin-like growth factor-I (IGF-I) in this experimental model of diabetes. To explore this possibility, simultaneous studies were undertaken of rats made diabetic by streptozotocin (75 mg/kg body wt, intraperitoneally) and undernourished control rats with similar somatic growth rate (determined by body weight gain), in comparison with normal controls. Serum IGF-I levels were diminished in the untreated diabetic and undernourished control animals, but more so in the diabetic group. Lung IGF-I levels (per lung and per lung DNA) and DNA contents were diminished to similar degrees in the untreated diabetic animals and the undernourished control group. Lung dry weights of the diabetic rats were greater than those of the undernourished control group, such that lung IGF-I/100 mg tissue dry wt in the former was significantly lower than in the latter group. Insulin treatment of the diabetic rats restored their body weights, serum and lung IGF-I levels, and DNA contents to normal control values. Lung IGF-I levels in the diabetic rats correlated strongly with serum glucose (r = .75) and body weight (r = .79), and moderately with lung weight (r = .43) and lung DNA (r = .58). These findings suggest that the diminished lung IGF-I levels in streptozotocin-induced diabetes may be related to the impaired nutritional status and/or somatic growth of the experimental animals, and that this relationship may be responsible, at least in part, for the diminished lung cellular proliferation observed in experimental diabetic animals.     

Evaluation of school feeding programs: some Jamaican examples

It is hypothesized that giving children a daily breakfast at school may improve their scholastic achievement through several mechanisms: increasing the time spent in school, improving certain cognitive functions and attention to tasks, and, perhaps indirectly, improving nutritional status. Two Jamaican studies showed that providing breakfast to students at school improved some cognitive functions, particularly in undernourished children. However, changes in classroom behavior varied depending on the quality of the school. Children in better-organized schools concentrated on tasks for longer periods and made fewer undesirable movements, whereas in poorly organized schools the children's behavior deteriorated. Studies to date have provided insufficient evidence to determine whether children's long-term scholastic achievement is improved by eating breakfast daily. Well-designed, randomized, controlled, long-term trials are essential for determining public policy on the implementation of school feeding programs.     

Effects of undernutrition and diabetes on serum and liver mRNA expression of IGFs and their binding proteins during rat development

The purpose of the present study was to investigate the influence of nutrients and insulin on IGFs and their binding proteins (IGFBPs) during the fetal and neonatal periods of three rat populations: (a) rats undernourished by a 35% reduction in the diet from day 16 of gestation, (b) streptozotocin-induced diabetic rats from the same day, or 4 days after birth, and (c) control rats. Fetuses from the diabetic population showed a decrease in insulinemia at 19 and 21 days, along with an increase in glycemia at all stages. Neither glycemia nor insulinemia changed in the fetuses of undernourished mothers, but body weight was decreased at birth. Serum IGF-II decreased at 18 and 19 days of gestation in fetuses from undernourished mother, and increased at 18, 19 and 21 days in fetuses from diabetic mothers. Serum IGFBPs of low molecular weight (IGFBP-1 and IGFBP-2) increased in the three fetal populations studied, although no changes in serum IGFBPs were found from the effect of undernutrition or diabetes, but fetal liver IGFBP-1 mRNA expression was found to decreased in undernourished and diabetic animals as compared with controls. In neonatal rats, body weight, insulinemia and serum GH decreased in both undernourished and diabetic rats vs controls, while glycemia decreased in the undernourished and increased in the diabetic group. Serum IGF-II decreased only in diabetic rats and serum IGF-I decreased in both groups. The neonatal serum 30 kDa complex (IGFBP-1 and -2) also increased in undernutrition and diabetes parallel to the expression of mRNA. But, taken together, the changes in IGFBP peptide levels and liver mRNA expression strongly suggest that the 30 kDa complex seems to be composed mostly of IGFBP-1 in the diabetic group and of both IGFBP-1 and -2 in the undernourished animals. The studies of liver mRNA expression of IGFs and IGFBPs confirm the different metabolic control mechanism for the availability of IGFs by the IGFBPs, depending on the animal's maturity. The different adaptation shown by the diabetic neonatal population was confirmed by correlation studies between body weight, glycemia, insulinemia, IGF-I and IGFBPs. The different mechanism of adaptation in diabetic vs undernourished rats seems to be probably due to the decisive role played by hyperglycemia in the diabetic population, and also shows the crucial influence of nutritional status on IGFs and IGFBPs.     

Subtotal colectomy with ceco-rectal anastomosis (Deloyers) for severe idiopathic constipation: an alternative to total colectomy reducing risks of digestive sequelae

The objective of this study was to determine the degree of knowledge on food and nutrition of school-age children's mothers from Chile's Metropolitan Region and to measure the impact of socioeconomic, sociocultural and demographic variables on knowledge. A representative and proportional sample of 4,509 school-age children was chosen from Chile's Metropolitan Region and the degree of knowledge on food and nutrition on mothers of 1,985 of them was determined. The sample was stratified according to grade (I, II, IV, VI, VIII elementary school grades and I and IV high school grades), sex, type of school and geographic area. Socioeconomic status (SES) was determined through Graffar's modified method. The degree of knowledge on food and nutrition was assessed by a test based on the specific objectives pursued by the elementary school curriculum programs of the Ministry of Education and submitted to adequate statistical proofs for its content validity and reliability. Mother's schooling level mean was 9.7 +/- 4.0 y. The field study was carried out on 1986-1987. Statistical procedures included analysis of variance, Student "t" test for comparison of the means, correlation and regression. Results revealed that mothers did not know food and nutrition matters in fundamental aspects related to the observance of a healthy lifestyle, both, for themselves and their family. The degree of knowledge of food and nutrition significantly and positively correlated with SES, mother's schooling and occupation level, housing conditions (quality and sanitation) and age, and significantly and inversely correlated with the number of sons and crowding, besides of being significantly higher in urban than rural mothers. Mother's schooling level and geographic area were the independent variables with the greatest explanatory power in the food and nutrition knowledge variance (r2 = 0.1723), but mother's schooling level explains 93.2% of the explained variance. Results suggest the need to introduce, during school age, nutrition education programs focused on mother and children to improve the population life quality.     

Active and alpha-1 proteinase inhibitor complexed leukocyte elastase levels in crevicular fluid from patients with periodontal diseases

The nutritional habits are changing, and compromising in a lot of cases the health of the population. A preventive measurement is to educate in the eating manners and the hygienic orientation, since both are essential in order to change eating attitudes and habits. The purpose of these guides was to aid in the training of health workers as well as to orient the Mexican population in improving their eating habits and nutrition. These guides were prepared taking into account the social and cultural characteristics of the population and were based on educational methodology of participation, with the intention of adapting them to each population group. Initially a critical analysis of the diverse material and methods used in nutritional education of urban and rural populations, was carried out and a lack of systematized methods and existent content was observed. Thus, the development of a didactic integral proposal of the nutritional education was considered necessary. The guides contain eleven modules with the most excellent information on nutrition during the life's cycle, hygienic handling and conservation of the foods. Each module contains ideas for the instructors and examples of exercises that they could propose to the population. Didactic units or guides with similar structures were designed conformated by introduction, basic concepts, educational content, bibliography, suggestions for further reading and techniques. The guides were included in a practical manual of easy use designed for health care working with public, including the educationally. The material has been used as an aid in diet and nutrition programs in Mexico and in courses proportionated to general public, where the result of the effectiveness learning index was 89%. The results obtained demonstrate the efficacy of these guides and suggest a longer term prospective study to determine real impact of our proposal.