Susan Ash

Quantification of lean bodyweight

AbstractBackground: Lean bodyweight (LBW) has been recommended for scaling drug doses. However, the current methods for predicting LBW are inconsistent at extremes of size and could be misleading with respect to interpreting weight-based regimens. Objective: The objective of the present study was to develop a semi-mechanistic model to predict fat-free mass (FFM) from subject characteristics in a population that includes extremes of size. FFM is considered to closely approximate LBW. There are several reference methods for assessing FFM, whereas there are no reference standards for LBW. Patients and methods: A total of 373 patients (168 male, 205 female) were included in the study. These data arose from two populations. Population A (index dataset) contained anthropometric characteristics, FFM estimated by dual-energy x-ray absorptiometry (DXA — a reference method) and bioelectrical impedance analysis (BIA) data. Population B (test dataset) contained the same anthropometric measures and FFM data as population A, but excluded BIA data. The patients in population A had a wide range of age (18–82 years), bodyweight (40.7–216.5kg) and BMI values (17.1–69.9 kg/m2). Patients in population B had BMI values of 18.7–38.4 kg/m2. A two-stage semi-mechanistic model to predict FFM was developed from the demographics from population A. For stage 1 a model was developed to predict impedance and for stage 2 a model that incorporated predicted impedance was used to predict FFM. These two models were combined to provide an overall model to predict FFM from patient characteristics. The developed model for FFM was externally evaluated by predicting into population B. Results: The semi-mechanistic model to predict impedance incorporated sex, height and bodyweight. The developed model provides a good predictor of impedance for both males and females (r2 = 0.78, mean error [ME] = 2.30 × 10−3, root mean square error [RMSE] = 51.56 [approximately 10% of mean]). The final model for FFM incorporated sex, height and bodyweight. The developed model for FFM provided good predictive performance for both males and females (r2 = 0.93, ME = −0.77, RMSE = 3.33 [approximately 6% of mean]). In addition, the model accurately predicted the FFM of subjects in population B (r2 = 0.85, ME = −0.04, RMSE = 4.39 [approximately 7% of mean]). Conclusions: A semi-mechanistic model has been developed to predict FFM (and therefore LBW) from easily accessible patient characteristics. This model has been prospectively evaluated and shown to have good predictive performance.

Malnutrition and pressure ulcer risk in adults in Australian health care facilities.

OBJECTIVE To determine the effect of nutritional status on the presence and severity of pressure ulcer. METHODS A multicenter, cross-sectional audit of nutritional status of a convenience sample of subjects was carried out as part of a large audit of pressure ulcers in a sample of Queensland, Australia, public healthcare facilities in 2002 and 2003. Dietitians in 20 hospitals and 6 residential aged care facilities conducted single-day nutritional status audits of 2208 acute and 839 aged care subjects using the Subjective Global Assessment. The effect of nutritional status on the presence and severity (highest stage and number of pressure ulcers) was determined by logistic regression in a model controlling for age, gender, medical specialty, and facility location. The potential clustering effect of facility was accounted for in the model using an analysis of correlated data approach. RESULTS Subjects with malnutrition had adjusted odds ratios of 2.6 (95% confidence interval 1.8-3.5, P<0.001) of having a pressure ulcer in acute care facilities and 2.0 (95% confidence interval 1.5-2.7, P<0.001) for residential aged care facilities. There was also increased odds ratio of having a pressure ulcer, and having a more severe pressure ulcer (higher stage pressure ulcer and/or a higher number) with increased severity of malnutrition. CONCLUSION Malnutrition was associated with at least twice the odds ratio of having a pressure ulcer of in public health care facilities in Queensland. Action must be taken to identify, prevent, and treat malnutrition, especially in patients at risk of pressure ulcer.

Prevalence of malnutrition in Parkinson's disease: a systematic review.

Parkinsons disease (PD) patients may be at higher risk of malnutrition because of the symptoms associated with the disease and the side effects of the medication used to manage it. A decline in nutritional status is associated with many adverse outcomes related to health and quality of life. It is not clear, however, to what extent this population is currently affected by malnutrition. The objective of this review was to systematically assess the methodology and outcomes of studies reporting the prevalence of malnutrition in PD patients. Studies that attempted to classify participants with PD into nutritional risk and/or malnutrition categories using body mass index, weight change, anthropometric measures, and nutritional screening and assessment scores were included. The prevalence of malnutrition ranged from 0% to 24% in PD patients, while 3-60% of PD patients were reported to be at risk of malnutrition. There was a large degree of variation among studies in the methods chosen, the definition of malnutrition using those methods, and the detail in which the methodological protocols were reported. The true extent of malnutrition in the PD population has yet to be accurately quantified. It is important, however, to screen for malnutrition at the time of PD diagnosis.

Trial of a mobile phone method for recording dietary intake in adults with type 2 diabetes: evaluation and implications for future applications

We evaluated a mobile phone application (Nutricam) for recording dietary intake. It allowed users to capture a photograph of food items before consumption and store a voice recording to explain the contents of the photograph. This information was then sent to a website where it was analysed by a dietitian. Ten adults with type 2 diabetes (BMI 24.1–47.9 kg/m2) recorded their intake over a three-day period using both Nutricam and a written food diary. Compared to the food diary, energy intake was under-recorded by 649 kJ (SD 810) using the mobile phone method. However, there was no trend in the difference between dietary assessment methods at levels of low or high energy intake. All subjects reported that the mobile phone system was easy to use. Six subjects found that the time taken to record using Nutricam was shorter than recording using the written diary, while two reported that it was about the same. The level of detail provided in the voice recording and food items obscured in photographs reduced the quality of the mobile phone records. Although some modifications to the mobile phone method will be necessary to improve the accuracy of self-reported intake, the system was considered an acceptable alternative to written records and has the potential to be used by adults with type 2 diabetes for monitoring dietary intake by a dietitian.

Randomized controlled trial of nutritional counseling on body composition and dietary intake in severe CKD.

BACKGROUND Progressive loss of kidney function results in an increased risk of malnutrition. Despite this, there is little evidence informing the impact of nutrition intervention on predialysis patients with chronic kidney disease (CKD; stages 4 and 5). STUDY DESIGN Randomized controlled trial. SETTING & PARTICIPANTS 56 outpatients (men, 62%; mean age, 70.7 +/- 14.0 [SD] years) with CKD were randomly allocated to intervention (n = 29) or control (n = 27) by using a concealed computer-generated sequence. INTERVENTION The intervention group, provided with individualized dietary counseling with regular follow-up aimed at achieving an intake of 0.8 to 1.0 g/kg of protein and greater than 125 kJ/kg of energy, or control, receiving written material only. OUTCOMES & MEASURES Change in body composition (body cell mass, measured by means of total-body potassium, in 40 of 56 participants), nutritional status (Subjective Global Assessment), and energy and protein intake (3-day food record). RESULTS During the 12 weeks, the intervention group had 3.5% (95% confidence interval, -2.1 to 9.1) less decrease in body cell mass, 17.7-kJ/kg/d (95% confidence interval, 8.2 to 27.2) greater increase in energy intake, greater improvement in Subjective Global Assessment (P < 0.01), and no significant difference in protein intake compared with the control group (-0.04 g/kg/d; 95% confidence interval, -0.73 to 0.16). The intervention was associated with greater increases in energy and protein intake in women than men (interaction P < 0.001 for both). LIMITATIONS Power to detect change in body cell mass, potential bias in ascertainment of Subjective Global Assessment. CONCLUSIONS In predialysis patients with CKD, structured nutrition intervention had a greater effect on energy and protein intake in women than men. Additional investigations are warranted to determine the impact on body composition.

Malnutrition in a sample of community-dwelling people with Parkinson's disease.

Objective Malnutrition results in poor health outcomes, and people with Parkinson’s disease may be more at risk of malnutrition. However, the prevalence of malnutrition in Parkinson’s disease is not yet well defined. The aim of this study is to provide an estimate of the extent of malnutrition in community-dwelling people with Parkinson’s disease. Methods This is a cross-sectional study of people with Parkinson’s disease residing within a 2 hour driving radius of Brisbane, Australia. The Subjective Global Assessment (SGA) and scored Patient Generated Subjective Global Assessment (PG-SGA) were used to assess nutritional status. Body weight, standing or knee height, mid-arm circumference and waist circumference were measured. Results Nineteen (15%) of the participants were moderately malnourished (SGA-B). The median PG-SGA score of the SGA-B group was 8 (4–15), significantly higher than the SGA-A group, U = 1860.5, p<.05. The symptoms most influencing intake were loss of appetite, constipation, early satiety and problems swallowing. Conclusions As with other populations, malnutrition remains under-recognised and undiagnosed in people with Parkinson’s disease. Regular screening of nutritional status in people with Parkinson’s disease by health professionals with whom they have regular contact should occur to identify those who may benefit from further nutrition assessment and intervention.

Implementation of Standardized Nutrition Guidelines by Renal Dietitians Is Associated With Improved Nutrition Status

OBJECTIVE Standardized nutrition guidelines that focus on a nutrition care process have been used by dietitians treating renal patients in Australia for over 3 years. We show the impact of this implementation on the nutritional status of a cohort of hemodialysis patients. DESIGN We conducted a retrospective observational study, investigating a cohort of maintenance hemodialysis patients after the implementation of a systematic approach to the patients nutritional care. SETTING This study took place in public and private in-center hemodialysis units. PATIENTS Patients included a cohort of 65 maintenance hemodialysis patients (mean age +/- SD, 64 +/- 15 years; 58% male; dialysis vintage median [interquartile range], 22 [10 to 46] months). INTERVENTIONS All participants were provided with a dietary interview at least every 6 months, with intensive follow-up where required, and were monitored monthly regarding weight and biochemistry. Outcomes were assessed annually between May 2004 and December 2006, after the implementation of this model of care. MAIN OUTCOME MEASURE Energy and protein intake according to dietary interview, nutritional status according to subjective global assessment, and data regarding dry weight and biochemistry (including albumin, potassium, and phosphate) were collected by the dietitian at each facility. Change in each outcome measure over time was assessed using repeated-measures analysis. RESULTS The proportion of patients with malnutrition (subjective global assessment B or C) decreased from 14% at baseline to 3% after 2 years. Serum albumin, potassium, and dry weight remained stable throughout the study period, and there was a significant decrease in serum phosphate over time (mean +/- SD,1.8 +/- 0.5 to 1.5 +/- 0.5 mmol/L, P = .004). Dietary energy and protein intake changed significantly over the study period (P = .001 and P = .022, respectively), with the highest mean intake recorded during the final follow-up assessment. CONCLUSIONS The implementation of a systematic approach to patient care, in line with nutrition management guideline recommendations, was associated with an improvement in nutritional status and dietary intake in this cohort of maintenance hemodialysis patients, without the need for increased resources or dietitian time.

Nutrition Prescription to Achieve Positive Outcomes in Chronic Kidney Disease: A Systematic Review

In Chronic Kidney Disease (CKD), management of diet is important in prevention of disease progression and symptom management, however evidence on nutrition prescription is limited. Recent international CKD guidelines and literature was reviewed to address the following question “What is the appropriate nutrition prescription to achieve positive outcomes in adult patients with chronic kidney disease?” Databases included in the search were Medline and CINAHL using EBSCOhost search engine, Embase and the Cochrane Database of Systematic Reviews published from 2000 to 2009. International guidelines pertaining to nutrition prescription in CKD were also reviewed from 2000 to 2013. Three hundred and eleven papers and eight guidelines were reviewed by three reviewers. Evidence was graded as per the National Health and Medical Research Council of Australia criteria. The evidence from thirty six papers was tabulated under the following headings: protein, weight loss, enteral support, vitamin D, sodium, fat, fibre, oral nutrition supplements, nutrition counselling, including protein and phosphate, nutrients in peritoneal dialysis solution and intradialytic parenteral nutrition, and was compared to international guidelines. While more evidence based studies are warranted, the customary nutrition prescription remains satisfactory with the exception of Vitamin D and phosphate. In these two areas, additional research is urgently needed given the potential of adverse outcomes for the CKD patient.

Cost effectiveness of nutrition support in the prevention of pressure ulcer in hospitals

Background/objectives:This study estimates the economic outcomes of a nutrition intervention to at-risk patients compared with standard care in the prevention of pressure ulcer.Subjects/methods:Statistical models were developed to predict ‘cases of pressure ulcer avoided’, ‘number of bed days gained’ and ‘change to economic costs’ in public hospitals in 2002–2003 in Queensland, Australia. Input parameters were specified and appropriate probability distributions fitted for: number of discharges per annum; incidence rate for pressure ulcer; independent effect of pressure ulcer on length of stay; cost of a bed day; change in risk in developing a pressure ulcer associated with nutrition support; annual cost of the provision of a nutrition support intervention for at-risk patients. A total of 1000 random re-samples were made and the results expressed as output probability distributions.Results:The model predicts a mean 2896 (s.d. 632) cases of pressure ulcer avoided; 12 397 (s.d. 4491) bed days released and corresponding mean economic cost saving of euros 2 869 526 (s.d. 2 078 715) with a nutrition support intervention, compared with standard care.Conclusion:Nutrition intervention is predicted to be a cost-effective approach in the prevention of pressure ulcer in at-risk patients.

Evaluation of a mobile phone image-based dietary assessment method in adults with type 2 diabetes

Image-based dietary records have limited evidence evaluating their performance and use among adults with a chronic disease. This study evaluated the performance of a 3-day mobile phone image-based dietary record, the Nutricam Dietary Assessment Method (NuDAM), in adults with type 2 diabetes mellitus (T2DM). Criterion validity was determined by comparing energy intake (EI) with total energy expenditure (TEE) measured by the doubly-labelled water technique. Relative validity was established by comparison to a weighed food record (WFR). Inter-rater reliability was assessed by comparing estimates of intake from three dietitians. Ten adults (6 males, age: 61.2 ± 6.9 years old, BMI: 31.0 ± 4.5 kg/m2) participated. Compared to TEE, mean EI (MJ/day) was significantly under-reported using both methods, with a mean ratio of EI:TEE 0.76 ± 0.20 for the NuDAM and 0.76 ± 0.17 for the WFR. Correlations between the NuDAM and WFR were mostly moderate for energy (r = 0.57), carbohydrate (g/day) (r = 0.63, p < 0.05), protein (g/day) (r = 0.78, p < 0.01) and alcohol (g/day) (rs = 0.85, p < 0.01), with a weaker relationship for fat (g/day) (r = 0.24). Agreement between dietitians for nutrient intake for the 3-day NuDAM (Intra-class Correlation Coefficient (ICC) = 0.77–0.99) was lower when compared with the 3-day WFR (ICC = 0.82–0.99). These findings demonstrate the performance and feasibility of the NuDAM to assess energy and macronutrient intake in a small sample. Some modifications to the NuDAM could improve efficiency and an evaluation in a larger group of adults with T2DM is required.