Jeremy Powell-Tuck

A comparison of mid upper arm circumference, body mass index and weight loss as indices of undernutrition in acutely hospitalized patients

A nutritional supplementation trial (Vlaming et al., Clin Nutr 2001; 20: 517) enabled us to assess the nutrition of 1561 patients on emergency admission to hospital. Patients acutely admitted to the 15 relevant medical, surgical and orthopaedic wards were identified. Mid upper arm circumference (MUAC) measurements were obtained in 95% (848 m, 635f) patients. For clinical reasons, Body mass index (BMI) was assessable in only 44% patients (408 m, 285f). Data on three month weight loss were obtainable in 509 patients. These measurements combined to demonstrate that 18.3% of patients were undernourished (At least one of : BMI<20 kg/m(2) or MUAC<25 cm or loss of weight > or =10%). There was a close relationship between BMI and MUAC. Regression equations (excluding age)were for men : BMI=1.01 x MUAC-4.7, (R(2)=0.76), and for women BMI=1.10 x MUAC-6.7, (R(2)=0.76). After adjustment for age, weight loss > or =10% was the most significant of the three as a predictor of mortality. Among patients in whom weight loss was not recorded MUAC was a significant predictor of mortality either alone (P=0.002) or after adjustment for BMI (P=0.007), but BMI was not significant. All three measures, even when adjusted for age and sex, were poor predictors of hospital stay although MUAC was significant in the larger group with a MUAC measure (R(2)=0.7% P<0.001). MUAC correlates closely with BMI, is easier to measure and predicts poor outcome better.

Nutritional interventions in critical illness

The metabolism of critical illness is characterised by a combination of starvation and stress. There is increased production of cortisol, catecholamines, glucagon and growth hormone and increased insulin-like growth factor-binding protein-1. Phagocytic, epithelial and endothelial cells elaborate reactive oxygen and nitrogen species, chemokines, pro-inflammatory cytokines and lipid mediators, and antioxidant depletion ensues. There is hyperglycaemia, hyperinsulinaemia, hyperlactataemia, increased gluconeogenesis and decreased glycogen production. Insulin resistance, particularly in relation to the liver, is marked. The purpose of nutritional support is primarily to save life and secondarily to speed recovery by reducing neuropathy and maintaining muscle mass and function. There is debate about the optimal timing of nutritional support for the patient in the intensive care unit. It is generally agreed that the enteral route is preferable if possible, but the dangers of the parenteral route, a route of feeding that remains important in the context of critical illness, may have been over-emphasised. Control of hyperglycaemia is beneficial, and avoidance of overfeeding is emphasised. Growth hormone is harmful. The refeeding syndrome needs to be considered, although it has been little studied in the context of critical illness. Achieving energy balance may not be necessary in the early stages of critical illness, particularly in patients who are overweight or obese. Protein turnover is increased and N balance is often negative in the face of normal nutrient intake; optimal N intakes are the subject of some debate. Supplementation of particular amino acids able to support or regulate the immune response, such as glutamine, may have a role not only for their potential metabolic effect but also for their potential antioxidant role. Doubt remains in relation to arginine supplementation. High-dose mineral and vitamin antioxidant therapy may have a place.

The quantitative effect of nutrition support on quality of life in outpatients

Abstract One hundred thirty-one poorly rehabilitated patients with chronic disease, presenting sequentially to a nutrition support clinic, were divided into those with a body mass index of less then the desirable range of 20–25 kg/m2 (group 1) and those with an index within the desirable range (group 2). The intention was for weight gain in group 1 and maintenance in group 2. Anthropometric measures and Nottingham Health Profile quality of life scores were recorded at presentation and at subsequent attendances. Nutritional interventions included dietary advice, oral supplements, nasogastric feeding, percutaneous endoscopic feeding and home total parenteral nutrition. Weight gain occurred in 84.6% of group 1 with a mean gain of 4.24 kg (P=3×10−9). Lean body mass increased by a mean 2.09 kg in group 1 (P=0.0008). There was no statistically significant weight change in group 2. For group 1 there was a statistically significant improvement in every category of QOL score (energy P 0.01, emotion P

The thiamin, riboflavin and pyridoxine status of patientson emergency admission to hospital

The aim of this study was to assess the prevalence of thiamin, riboflavin and pyridoxine deficiencies at admission to an acute hospital. One hundred and twenty adult patients were selected at random from those admitted via the Accident and Emergency department over 3 days. Comparisons were made with a group of 80 healthy blood donors sequentially attending a local transfusion centre. The alcohol intake of 500 patients admitted sequentially via the same Accident and Emergency department was also assessed. Erythrocyte transketolase (ETK), glutathione reductase (EGR) and aspartate aminotransferase (EAA) coenzyme activation assays were used to determine thiamin, riboflavin and pyridoxine deficiencies. The prevalences of deficiency states in the inpatient group were 21, 2.7 and 32% for thiamin, riboflavin and pyridoxine deficiencies respectively with 49.2% being deficient in one or more vitamin. The mean alcohol intake in the group of patients in whom this was assessed was 9.7 units per week compared with 10 units per week amongst blood donors.

Insulin reduces leucine oxidation and improves net leucine retention in parenterally fed humans

Protein metabolism during parenteral feeding was measured with and without euglycemic hyperinsulinemic clamping in five healthy human subjects using the primed continuous infusion of [(13)C]leucine (LEU) tracer methodology. All subjects underwent two periods of protein measurement. Subjects were randomized to have the clamp first or second. Two subjects had the clamp first, and they participated in another study in which the measurement period after the clamp was increased by another 2 h. Insulin reduced LEU oxidation (from 26 to 22 microM. kg(-1). h(-1); P < 0.05) and improved net LEU balance (from 3 to 7 microM. kg(-1). h(-1); P < 0. 05). The order of the clamp influenced the effects of insulin. With clamping performed second, insulin reduced LEU flux (from 152 to 134 microM. kg(-1). h(-1); P < 0.01), endogenous LEU rate of appearance (Ra; from 125 to 107 microM. kg(-1). h(-1); P < 0.01), and non-oxidative LEU disappearance (NOLD; from 128 to 113 microM. kg(-1). h(-1); P < 0.01). With clamping performed first, NOLD decreased after insulin was stopped (from 129 to 121 microM. kg(-1). h(-1); P < 0.05), but no change was seen in the flux and LEU Ra, despite the return of plasma insulin and amino acid concentrations to basal levels. The reduction in NOLD was accentuated with time and did not reach plateau even after 6 h and indicated a prolonged carry-over effect for NOLD and Ra. This effect was not seen for leucine oxidation.

Determinants of quality of life in home parenteral nutrition

Purpose of reviewTo highlight the most important and salient articles regarding home parenteral nutrition and quality of life published within the last 3 years. Recent findingsIn recent years, quality of life research in home parenteral nutrition has highlighted the need for a therapy-specific validated questionnaire. Several papers suggest a greater psychological input is required to better understand and evaluate this patient population. Issues surrounding the use of home parenteral nutrition in malignancy have arisen, prompting discussion on ideal timing and candidacy for home parenteral nutrition. Intestinal transplantation is evolving and improving, making it a possible alternative to home parenteral nutrition. Earlier referral is suggested as late referral can result in poorer outcome. SummaryHome parenteral nutrition is a life-sustaining therapy for individuals with intestinal failure. There is now a relatively large amount of research into the quality of life in this population, but more focused measurements (in the form of validated therapy-specific questionnaires) are required to answer questions relating to cancer and intestinal transplantation.