Carlo Pedrolli

Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomized controlled trial.

OBJECTIVES: To investigate whether a disease‐specific nutritional approach is more beneficial than a standard dietary approach to the healing of pressure ulcers (PUs) in institutionalized elderly patients.

Diabetes and Risk of Parkinson’s Disease A systematic review and meta-analysis

OBJECTIVE Diabetes has been associated with chronic neurodegeneration. We performed a systematic review and meta-analysis to assess the relationship between pre-existing diabetes and Parkinson’s disease (PD). RESEARCH DESIGN AND METHODS Original articles in English published up to 10 May 2011 were searched for in electronic databases (PubMed, Embase, and Scopus) and by reviewing references of eligible articles. Prospective cohort and case-control studies providing risk and precision estimates relating to pre-existing diabetes and PD were considered eligible. RESULTS Nine studies/1,947 citations (cohort, N = 4; case-control, N = 5) fulfilled inclusion criteria for meta-analysis. In prospective studies, the onset of diabetes before onset of PD was found to be a risk factor for future PD (relative risk [RR] = 1.37 [95%CI 1.21–1.55]; P < 0.0001). This association was confirmed by secondary analyses based on estimates derived after the exclusion of participants who had vascular disease at baseline and/or who developed vascular disease during follow-up (RR = 1.34 [1.14–1.58]; P < 0.001) and by sensitivity analyses addressing the association with diabetes at baseline or during follow-up. However, the association found for case-control studies was not significant (odds ratio [OR] 0.75 [95%CI 0.50–1.11]; P = 0.835). Sensitivity analysis based on estimates adjusted for BMI confirmed the lack of a relationship between PD and diabetes (OR 0.56 [0.28–1.15]; P = 0.089). CONCLUSIONS Although data from cohort studies suggest that diabetes is a risk factor for PD, there is no conclusive evidence on this association. Further prospective studies focused on putative pathogenic pathways and taking a broad range of confounders into account is required to clarify this relationship.

Mini nutritional assessment is a good predictor of functional status in institutionalised elderly at risk of malnutrition.

BACKGROUND & AIMS To possibly validate the use of Mini Nutritional Assessment (MNA) with respect to functional status in institutionalised elderly. METHODS One hundred twenty-three long-term care resident elderly (85.3+/-8.4 years) were recruited. Nutritional and functional states were assessed by MNA and Barthel Index (BI), respectively. Main inclusion criterion was a MNA<23.5. Anthropometric, biochemical data and oral intake (percentage of food consumed to that delivered) were evaluated. RESULTS MNA significantly correlated with BI (r=0.55; p<0.0001). Malnutrition (MNA<17) was characterized by lower BMI, muscle mass, poor nutritional habits and higher weight loss and disability. Similarly, poorer functional status was associated with low BMI, sarcopenia and reduced oral intake. The interrelationship between MNA and BI were investigated by multiple regression models with progressive inclusion of variables (one/analysis). The initial association between MNA and BI (p<0.0001) was masked by weight loss (p<0.02), muscle mass (p<0.03) and oral intake (p<0.05). However, when BI was included as dependent variable the association with MNA depended on sarcopenia (p<0.05) and reduced food consumption (p<0.001). CONCLUSIONS MNA reliably identifies at-risk institutionalised elderly needing higher standards of care, particularly related to eating. Routine documentation of oral intakes and feeding assistance might be useful to prevent weight loss, sarcopenia and functional status deterioration.

The geriatric nutritional risk index

Purpose of reviewA new nutrition-related risk assessment tool, the Geriatric Nutritional Risk Index (GNRI), has been recently proposed. The aim of this review is to summarize current evidences on the use of this tool with particular focus on the rationales of its application in elderly healthcare. Recent findingsStructured as a dichotomous index, based on serum albumin values and the discrepancy between real and ideal weight, the GNRI seems to account for both acute and chronic reasons of nutrition-related complications. It allows us to face the frequent difficulties in obtaining a profitable participation of the old patient to nutritional assessment. Its application appears feasible in all healthcare settings in which it shows adequacy to discriminate different profiles of nutritional risk. A GNRI less than 92 might be suggested as clinical trigger for routine nutritional support. SummaryIn maths of nutrition ‘recognize and treat’ has become a clinical imperative. Actually, clinical judgement by an expert is still considered the reference standard to diagnose malnutrition but the use of simplified tools profitably assists in nutritional risk screening process. The GNRI is easy to use and preliminary results show that it is promising. Its routine application, next to the other validated tools already available, might be enforced in the assessment of the old patient.

Body Mass Index and Mortality in Institutionalized Elderly

OBJECTIVE Malnutrition and sarcopenia in institutions are very common and significantly affect the prognosis. Aging is characterized by weight and lean body mass losses. Accordingly, in elderly patients, body mass index (BMI) is considered a marker of protein stores rather than of adiposity. Current guidelines suggest a BMI 21 kg/m(2) or lower as major trigger for nutritional support. We evaluated the association between BMI and mortality in institutionalized elderly. METHODS This was a multicentric prospective cohort study involving 519 long-term care resident elderly individuals. Risk for mortality across BMI tertiles was estimated by the Cox hazards regression model adjusted for potential confounders recorded at inclusion and collected during the follow-up. RESULTS During a median follow-up of 5.7 years (25th to 75th percentile, 5.2-8.2], 409 (78.8%) elderly patients died. In primary analyses, based on variables collected at inclusion, patients in the first tertile of BMI (≤ 21 kg/m(2)) were at higher risk for all-cause (hazard ratio [HR] 1.38; 95% confidence interval [CI] 1.04-1.84; P = .025) and cardiovascular mortality (HR = 1.49; 95% CI, 1.00-2.08; P = .045). Increased risk was confirmed even after adjusting for nutritional support during the follow-up (all-cause HR = 1.53; 95% CI, 1.13-2.06; P = .006; cardiovascular HR = 1.62; 95% CI, 1.09-2.40; P = .018), which in turn was associated with a reduced risk (all-cause HR = 0.74; 95% CI, 0.55-0.97; P = .035; cardiovascular HR = 0.62; 95% CI, 0.42-0.91; P = .016). CONCLUSION BMI is significantly associated with all-cause and cardiovascular mortality in institutionalized elderly patients. A value of 21 kg/m(2) or lower can be considered a useful trigger for nutritional support. These results support intending BMI as nutritional reserve in institutionalized elderly patients.

Low-protein and protein-redistribution diets for Parkinson's disease patients with motor fluctuations: A systematic review†‡

The American Academy of Neurology suggests advising the redistribution of daily protein meal content to every Parkinsons disease (PD) patient with motor fluctuations during levodopa treatment. However, no comprehensive evaluation of this complementary therapy has been performed. A systematic review of intervention studies investigating the neurologic outcome of low‐protein (<0.8 g/kg of ideal weight/day) and protein‐redistribution diets in patients with PD experiencing motor fluctuations during levodopa treatment. All studies (uncontrolled or randomized) investigating a low‐protein and/or a protein‐redistribution diet (LPD and PRD) and involving patients with PD with motor fluctuations were included, provided that sufficient information on dietary protein content and neurologic outcome measures was available. We identified 16 eligible studies, but they were markedly heterogeneous. There was not enough evidence to support the use of LPD. Response to PRD seemed very good. Acceptability appeared high upon introduction, but it seemed to progressively decrease over time. On average, PRD resulted in improved motor function, but also complications occurred. At the beginning, drop‐outs were due to levodopa side effects rather than unsatisfactory benefits. Long‐term adherence was more affected by changes in dietary habits than by diet‐related side effects. Efficacy and benefits appeared to be higher when the intervention was proposed to subjects in the early stages of PD. PRD can be safely advised to fluctuating patients with PD, but those in whom benefits override the possible inconveniences still need to be identified. The long‐term effects of PRD on nutritional status should be evaluated and true effectiveness in clinical practice should be reassessed, given the changes in levodopa formulations and the introduction of several adjuvants (levodopa degradation inhibitors and/or dopamine agonists).

Nutritional risk, functional status and mortality in newly institutionalised elderly.

Previous studies have reported a close relationship between nutritional and functional domains, but evidence in long-term care residents is still limited. We evaluated the relationship between nutritional risk and functional status and the association of these two domains with mortality in newly institutionalised elderly. In the present multi-centric prospective cohort study, involving 346 long-term care resident elderly, nutritional risk and functional status were determined upon admission by the Geriatric Nutritional Risk Index (GNRI) and the Barthel Index (BI), respectively. The prevalence of high (GNRI <92) and low (GNRI 92–98) nutritional risk were 36·1 and 30·6 %, respectively. At multivariable linear regression, functional status was independently associated with age (P=0·045), arm muscle area (P=0·048), the number of co-morbidities (P=0·027) and mainly with the GNRI (P<0·001). During a median follow-up of 4·7 years (25th–75th percentile 3·7–6·2), 230 (66·5 %) subjects died. In the risk analysis, based on the variables collected at baseline, both high (hazard ratio (HR) 1·86, 95% CI 1·32, 2·63; P<0·001) and low nutritional risk (HR 1·52, 95% CI 1·08, 2·14; P=0·016) were associated with all-cause mortality. Participants at high nutritional risk (GNRI <92) also showed an increased rate of cardiovascular mortality (HR 1·93, 95% CI 1·28, 2·91; P<0·001). No association with outcome was found for the BI. Upon admission, nutritional risk was an independent predictor of functional status and mortality in institutionalised elderly. Present data support the concept that the nutritional domain is more relevant than functional status to the outcome of newly institutionalised elderly.

Diabetes and risk of Parkinson's disease

We have recently published a systematic review and meta-analysis on the risk of Parkinson’s disease (PD) associated with diabetes. 1 The analysis of cohort studies has shown that diabetes may be a risk factor for future PD (RR ¼ 1.37; 95% confidence interval [CI], 1.21– 1.55, excluding participants who had vascular disease at baseline and/or who developed vascular disease during follow-up, RR ¼ 1.34; 95% CI, 1.14–1.58), but we have also concluded that further investigations are required to strengthen the evidence. The main limitation of prospective studies investigating risk factors for PD is that the incidence of PD is low and shifted toward advanced age; large populations, a long follow-up, and a large number of cases are required for powered risk analyses. 1 After the date of literature review and the acceptance of the manuscript, another prospective study has been published in Movement Disorders. 2 Because this investigation included a large population (n ¼ 147,096) and showed the lack of an association between diabetes and PD (RR ¼ 0.88; 95% CI, 0.62–1.25), we thought that it would be appropriate to provide an update of risk estimates in order to assess the overall strength of available evidence. In the primary analysis (n ¼ 5 studies), based on adjusted estimates, the pooled risk (using random-effect model to compensate for study heterogeneity) for diabetes was 1.26 (95%CI, 1.03–1.55; z ¼ 4.49, P < .0001; heterogeneity by I 2 statistic ¼ 60.2%, P ¼ .039). Because vascular disease is a common cause of secondary parkinsonism, 3 a secondary analysis (n ¼ 5 studies) was performed using published estimates obtained through sensitivity analyses and performed after the exclusion of participants who had vascular disorders at baseline or who had had a stroke during followup. In this analysis the association found: RR ¼ 1.26; 95% CI, 1.00–1.58; z ¼ 2.96, P ¼ .003; I 2 ¼ 57.0%, P ¼ .054). Finally, in the attempt to control for bias deriving from increased medical surveillance in diabetic patients, estimates were pooled to assess the risk associated with diabetes at baseline and diabetes that developed during follow-up. For baseline diabetes (n ¼ 4 studies) the new RR was marginally significant: 1.25 (95% CI, 0.93–1.68; z ¼ 2.57, P ¼ .010; I 2 ¼ 61.1%,

The Geriatric Nutritional Risk Index predicts hospital length of stay and in-hospital weight loss in elderly patients.

BACKGROUND & AIMS Nutritional derangements are common in elderly patients, but how nutritional risk affects outcome in this subset of hospital inpatients deserves further investigation. We evaluated the impact of nutritional risk on length of stay (LOS) and in-hospital weight loss (WL) in elderly patients (>65 yrs). METHODS Nutritional risk was assessed by the Geriatric Nutritional Risk Index (GNRI) in a prospective multicentre hospital-based cohort study. The outcomes were LOS and in-hospital WL. RESULTS In the whole sample (N = 667), the prevalence of high (GNRI < 92) and mild (GNRI: 92-98) nutritional risk were 33% and 25%, respectively. Patients with a high nutritional risk were more likely (OR = 1.89; 95%CI: 1.22-2.92) to stay longer in hospital (fourth quartile, LOS ≥ 20 days) compared to those without. Other factors associated with prolonged LOS were cancer diagnosis (OR = 2.52; 95%CI: 1.69-3.75), the presence of comorbidities (OR = 1.24; 95%CI: 1.11-1.40) and surgical setting (OR = 1.65; 95%CI: 1.10-2.47). In-hospital WL ≥ 5% was recorded in 75 ambulant patients from a representative subgroup (N = 583). It was independently associated with prolonged LOS (OR = 1.80; 95%CI: 1.03-3.06) and was more frequent among cancer patients (OR = 1.88; 95%CI: 1.09-3.24), in patients with a high nutritional risk (OR = 2.23; 95%CI: 1.20-4.14) or those admitted to surgical units (OR = 1.77; 95%CI: 1.02-3.05). CONCLUSIONS Nutritional risk assessed by the GNRI on admission, predicts LOS and in-hospital WL in elderly patients.

Short-term blueberry intake enhances biological antioxidant potential and modulates inflammation markers in overweight and obese children

Oxidative stress and inflammation together play a crucial role in the obesogenic process, and imbalances in reactive oxygen species, free radicals and antioxidants have been reported as being major mechanisms underlying obesity-related co- morbidities. Obesity and oxidative stress may be present even within the first two decades of life, and chronic exposure to systemic inflammation may contribute to the onset and progression of cardiovascular disease and diabetes. Bioactive compounds present in blueberry have been shown to have many positive effects on human health. The present study was carried out in northern Italy on a population of 24 overweight and obese children (8-13 years), divided into three groups: the first consumed fresh blueberries, the second blueberry puree, while a third control group did not consume any blueberries. The childrens anthropometric measures were taken and serum markers related to inflammation, CRP, ceruloplasmin, and complements C3 and C4 were measured during the eight weeks they ate either fresh blueberries or blueberry puree. BAP test (Biological Antioxidant Potential) values of the three groups were monitored throughout the entire study and correlated with inflammatory, metabolic and anthropometric markers. The results showed a higher increase in antioxidant levels in the group that ate fresh berries than in the group that ate puree, while the control groups BAP values decreased over the eight weeks of the study. Our results show that increased consumption of blueberries, hence antioxidant intake, may also have a positive effect on markers of inflammation and oxidative stress in overweight and obese patients during childhood.