Effect of home total parenteral nutrition on body composition in patients with acquired immunodeficiency syndrome

Malnutrition occurs commonly in patients with acquired immunodeficiency syndrome (AIDS). The efficacy of nutritional support is unknown. A prospective, longitudinal study was conducted to determine the effect of prolonged total parenteral nutrition on body composition in 12 AIDS patients. Five patients were malnourished because of problems with food intake or absorption, while seven had systemic infections, with or without a malabsorption syndrome. The AIDS patients gained body weight and body fat content in response to total parenteral nutrition, while mean body cell mass, estimated as total body potassium content, was unchanged. However, all five patients with altered intake or absorption had significant repletion of body cell mass which was significantly different from the patients with systemic infections. Calorie and nitrogen intake did not differ between the two groups. It is concluded that body mass repletion is possible in AIDS patients in whom malabsorption is the major pathogenetic factor in producing malnutrition and is less successful in patients with serious ongoing systemic diseases. Thus, the response to nutritional support is dependent on the particular clinical circumstances.     

Nutrition support of the pediatric patient with AIDS

Maintaining optimal nutrition in the pediatric patient with Acquired Immune Deficiency Syndrome (AIDS) is challenging, but it may be one of the most effective therapies. Patients experience numerous complications that compromise nutritional status. Infection, fever, diarrhea, feeding problems, and decreased intake all contribute to malnutrition, which in turn predisposes the patient even more to infection and malabsorption. Nutrition assessment should be done routinely so that new problems may be identified and treated. High-calorie, high-protein feedings, vitamin supplementation, and, when necessary, gavage feedings or parenteral nutrition are recommended to improve nutritional status and prevent further deficits. Maintaining optimal nutrition in the pediatric patient with Acquired Immune Deficiency Syndrome (AIDS) poses a significant challenge to the health care team. Patients may experience numerous complications that compromise nutritional status. The patient is at high risk for opportunistic infections, especially of the lungs, central nervous system, gastrointestinal (GI) tract, and skin. Such infections are common causes of morbidity and mortality. Impaired nutritional status may further impair the patient's immunocompetence. A study by Kotler and Gaety demonstrated severe progressive malnutrition in adult AIDS patients, with the lowest measures of lean body mass occurring in those patients close to death at the time of the study. While no studies of children with AIDS have been done to date, we have subjectively observed feeding problems, weight loss, and malnutrition in most of the patients we have seen.     

Nutrition care of AIDS patients

Often the complications of the acquired immunodeficiency syndrome (AIDS) have a negative impact on nutritional status. Weight loss and protein depletion are commonly seen among the AIDS population. Though the relationship between disease progression and nutritional status has not been established, maintaining good nutritional status may support response to treatment of opportunistic infections and improve patient strength and comfort. Increased nutrient needs, decreased nutrient intake, and impaired nutrient absorption contribute to malnutrition in AIDS patients. Causes of decreased nutrient intake and absorption may be poor appetite, oral and esophageal pain, mechanical problems with eating, and gastrointestinal complications (diarrhea and malabsorption). Causes of these impediments to maintaining nutritional status are discussed, and suggestions to overcome them are given. Dietitians working with AIDS patients need to understand how the complications of the disease might affect nutritional status so that strategies for nutrition treatment can be developed. Nutrition care of AIDS patients requires that dietitians and their support personnel provide supportive, nonjudgmental care. The patients should be included in decision making regarding their nutrition care. Caring for AIDS patients in the community and through home care agencies represents an area in need of the expertise of a dietetics professional.     

Place de l'impédancemétrie dans le dépistage de la dénutrition à l'hôpitalBio-impedance analysis: Screening of denutrition in hospitalized patients

The prevalence of malnutrition is high in patients and tends to worsen during the hospital stay. In the absence of one reliable method to evaluate patients, the assessment of nutritional status is based on a global approach. Body composition measurement by bio-impedance analysis (BIA) is one of these approaches. Body composition measurements can detect malnutrition or abnormal hydration. Fat free mass, fat mass, and total body water are the main body compartments that are evaluated. Determination of abnormal body composition can then guide nutritional support. The reliability of BIA depends on the equation used to predict body composition and the parameters included in the formula (weight, height, sex, age, race, etc.). These parameters allow to minimize measurement errors. Thus, formula developed for specific populations allow to evaluate the nutritional status with reasonable error rates. BIA has been found to be inaccurate with abnormal distribution of body compartments (ascites, dialysis, lypodystrophy, etc.) or extreme weights (cachexia, obesity). Multi-frequency or segmental BIA was developed to overcome hydration abnormalities and variations in body geometry. However, these techniques require further validation. The BIA seems to have some limitations. This review aims to assess the reliability of BIA to detect protein-calorie malnutrition at hospital admission or during nutritional follow-up of patients.     

Place de l'impédancemétrie dans le dépistage de la dénutrition à l'hôpital

The prevalence of malnutrition is high in patients and tends to worsen during the hospital stay. In the absence of one reliable method to evaluate patients, the assessment of nutritional status is based on a global approach. Body composition measurement by bio-impedance analysis (BIA) is one of these approaches. Body composition measurements can detect malnutrition or abnormal hydration. Fat free mass, fat mass, and total body water are the main body compartments that are evaluated. Determination of abnormal body composition can then guide nutritional support. The reliability of BIA depends on the equation used to predict body composition and the parameters included in the formula (weight, height, sex, age, race, etc.). These parameters allow to minimize measurement errors. Thus, formula developed for specific populations allow to evaluate the nutritional status with reasonable error rates. BIA has been found to be inaccurate with abnormal distribution of body compartments (ascites, dialysis, lypodystrophy, etc.) or extreme weights (cachexia, obesity). Multi-frequency or segmental BIA was developed to overcome hydration abnormalities and variations in body geometry. However, these techniques require further validation. The BIA seems to have some limitations. This review aims to assess the reliability of BIA to detect protein-calorie malnutrition at hospital admission or during nutritional follow-up of patients.     

Selenium deficiency in the acquired immunodeficiency syndrome

Severe protein-calorie malnutrition is common in patients with AIDS (acquired immunodeficiency syndrome). These nutritional deficits are likely to further impair immune responses and other organ functions vital for recovery from serious infectious diseases. Since selenium deficiency is known to be associated with oral candidiasis and abnormal phagocytic function in animals and depressed helper T-cell numbers in man, we evaluated both selenium status and other nutritional parameters in 12 patients with AIDS compared to 27 healthy controls. Selenium was measured by a spectrofluorometric method. The mean (+/- SD) plasma selenium level in AIDS was 0.043 +/- 0.01 microgram/ml vs 0.095 +/- 0.016 microgram/ml in controls (p less than 0.001). Whole blood selenium and red blood cell selenium levels were also significantly reduced in AIDS (p less than 0.005). The mean weight loss in AIDS patients was 35.5 +/- 21.2 pounds. Serum albumin was significantly (p less than 0.01) lower in AIDS patients compared to controls. A good correlation between serum albumin and plasma selenium was noted (r = 0.77; p less than 0.001). We conclude that selenium deficiency is a common component of the malnutrition seen in AIDS patients. Therefore, aggressive nutritional support, including attention to selenium status, should be considered an integral part of the therapy of AIDS patients.     

BIA法评估44例CKD患者的营养状况及分析

摘要:目的　运用生物电阻抗分析（Bioelectric Impedance Analysis,BIA）评价慢性肾脏病（Chronic Kidney Disease,CKD）患者的营养状况,并将其和生化指标评估结果对比,为早期发现CKD患者营养不良状态、及时给予营养干预提供有效参考。方法　随机选择2014年11月-12月期间在某三甲医院CKD管理中心注册的CKD患者57例,根据其浮肿指数、依从性等共纳入研究对象44例,应用BIA法评估研究对象的营养状况并与生化指标评价结果比较。结果　BIA和生化检查营养不良率（含营养不良风险）分别为45.4%和25%,且差异有统计学意义（χ2＝4.034,P＜0.05）。女性身体细胞量、细胞内水分和蛋白质的质量均显著高于男性（P＜0.05）,而男、女性ALB水平差异无统计学意义。在ALB水平正常的CKD患者中,其体细胞量、细胞内水分、蛋白质、骨骼肌、体脂肪均低于正常范围。BIA营养不良的研究对象的骨骼肌量和血清白蛋白（serum Albumin,ALB）水平显著相关（r＝0.58,P＜0.05）。结论　CKD患者营养不良率较高;与生化检查相比,BIA可早期发现CKD患者的营养不良状态和营养不良风险,有利于医生对营养不良患者及时采取有效的营养干预。     

L’évaluation nutritionnelle chez le sujet âgé en 2008

Malnutrition is frequent in elderly patients and results from multifactorial mechanisms, including age-related metabolic alterations, reduction of food intake and intercurrent diseases, especially inflammatory processes, that compromise nutritional status. Nutritional evaluation must be systematically and repeatedly performed and based primarily on clinical parameters such as weight, body mass index, weight loss, anthropometric measurements and dietetic history eventually combined in scores such as the mini-nutritional assessment (MNA). Fat-free mass evaluated by bioimpedance analysis has a prognostic value. Hypoalbuminemia is indicative of bad prognosis and may be combined with weight loss in the geriatric nutritional risk index (GNRI) to assess the nutritional risk. The determination of plasma transthyretin (prealbumin) is especially useful to assess acute malnutrition state and the response to nutritional support. Routine determination of the above criteria may be facilitated by the spreading of simple integrated tools and a better education of health professionals to the screening and active treatment of malnutrition in the elderly.     

Nutrition support of HIV+ patients

Case management strategies for the nutritional support of patients infected with the human immunodeficiency virus (HIV) are evolving as the disease becomes less rapidly fatal and more chronic. Nutritional status changes in advanced HIV infection are similar in many respects to protein-calorie malnutrition. Current clinical effort and research focuses on the beneficial effects of preserving lean body mass and keeping asymptomatic patients in good nutritional status by preventing micronutrient deficiencies and by treating preexisting nutritional problems rather than attempting to intervene late in the disease's course, after secondary malnutrition has already developed. Nutrition support and intervention trials only late in the disease process have not been promising in reversing weight loss once it has occurred. Special diets, such as lactose- or gluten-free diets, may be helpful in some cases as asymptomatic treatment of some opportunistic infections, and such measures may slow additional losses. However, secretory diarrhea, which often seems to be inherent to the disease itself, is not ameliorated by such measures. Current research is focusing on the potential role of glutamine in slowing malabsorption and on combinations of diet and drug treatments. Asymptomatic patients are now the focus of concern. Preserving good nutritional status by attention to preventing weight loss and loss of lean body mass and assuring food safety are primary. Symptomatic patients require specific assistance depending on the presence of opportunistic infections and the drugs required. Specific nutrition support measures depend on whether or not the gut is functional.(ABSTRACT TRUNCATED AT 250 WORDS)     

Magnitude of body-cell-mass depletion and the timing of death from wasting in AIDS

The impact of malnutrition on survival in AIDS was evaluated by examining the magnitude of body-cell-mass depletion as a function of time from death. Body cell mass was estimated as total body-potassium content and determined by whole-body counting. There was progressive depletion of body cell mass as patients neared death. The extrapolated and observed values for body cell mass at death were 54% of normal. Body weight had a similar relationship to death, with a projected body weight at death of 66% of ideal. We conclude that death from wasting in AIDS is related to the magnitude of tissue depletion and is independent of the underlying cause of wasting. The degree of wasting seen in this study is similar to historical reports of semistarvation, with or without associated infections. This observation suggests that successful attempts to maintain body mass could prolong survival in patients with AIDS.     

Nutritional status of adult inpatients in Bujumbura, Burundi (impact of HIV infection).

OBJECTIVE: To determine the prevalence and analyse the characteristics and causes of malnutrition among inpatients in an HIV highly endemic area. DESIGN: Prospective cross-sectional study. SETTING: Department of Internal Medicine, University Hospital, Bujumbura, Burundi. SUBJECTS: 226 adult inpatients. MAIN OUTCOMES MEASURES: Evaluation of nutritional status using anthropometry. Degree of malnutrition defined by the percentage of body weight loss (BWL), calculated by reference to the usual body weight. RESULTS: Among the 226 patients recruited (mean age: 34.4 +/- 11.9 y, M:F sex ratio: 1.72), 102 (45.1%) were HIV seropositive. 62 (60.8%) of these HIV seropositive were AIDS cases. The AIDS defining criterion was 'wasting syndrome' for 25 (40.3%) and opportunistic infection (OI) for 37 (59.7%) including 34 cases of tuberculosis (TB). The nutritional status of 119/226 patients (52.7%) was normal (BWL < or = 10%). Moderate malnutrition (10% < or = BWL < or = 20%) was observed in 47 (20.8%) and severe malnutrition (BWL > 20%) was observed in 60 (26.5%). HIV seroprevalence and, among HIV seropositive subjects, the percentage of AIDS cases increased according to decreasing level of nutrition (Chi2 for trends: P < 0.001 in both instances). The fat free mass mass of malnourished subjects was lower and the fat body mass was higher among HIV seropositive subjects than HIV seronegative subjects. Among HIV seropositive subjects, malnutrition was associated with TB (P < 0.001) and dysphagia (P < 0.05). Among HIV seronegative subjects, malnutrition was associated with decreased food availability (P < 0.003) and TB (P < 0.05). One week after admission, the mortality rate was higher among HIV seropositive subjects (10.8%) than seronegative subjects (2.4%, P=0.009). Other factors associated with death were decreased fat free mass (P < 0.01) and tricipital skinfold thickness (P < 0.04). CONCLUSIONS: The prevalence of malnutrition is high among the inpatients investigated. Main factors are HIV infection and TB. Strategies adapted to the African context should be developed to prevent, detect and treat malnutrition and associated factors, particularly among HIV seropositive subjects.     

Evaluation of nutritional counselling in HIV-associated malnutrition

In HIV-infected patients, the outcome of counselling as the first step of a nutritional intervention programme was evaluated, in order to identify clinical and nutritional predictors for its efficacy. 75 HIV-infected patients were investigated, most with advanced disease. Nutritional status was determined by body weight, bioelectrical impedance and 7-day food intake record. Prior mean weight loss was 10% (range = +4% to -31%). Counselling facilitated weight gain in 40 75 patients (1-4 months later, overall mean difference +1.4 +/- 6.2%) and in 14 34 patients (8-11 months later, overall mean difference -1.4 +/- 9.0%). Weight changes correlated with changes in body cell mass (r(2) = .69, p < .001) and in body fat (r(2) = .29, p < 0.05), but not extracellular mass. Underlying conditions such as AIDS definition, fever, and diarrhoea correlated to prior weight loss (p < .001) but not to the outcome of counselling. Low energy intake (before counselling, < 31.5 kcal/kg) did not correlate to prior weight loss but it predicted further weight loss (p < 0.05 towards normal intake). High energy intake (> 38.5 kcal/kg) correlated (p < 0.05) with more prior weight loss but not with further weight changes. Nutritional counselling may be an effective first-line intervention for malnourished HIV infected patients. More than half of patients gain weight without other nutritional treatment. Whereas the severity of malnutrition is influenced by the underlying disease, fever, and diarrhoea, the course of weight change after nutritional intervention is not. Counselling may reduce the nutritional impact of these risk factors. In patients with low spontaneous intake, efficacy of counselling alone is limited, but it may help to identify those who require more invasive nutritional treatment.     

Preservation of short-term energy balance in clinically stable patients with AIDS

Malnutrition in patients with acquired immune deficiency syndrome (AIDS) is common and multifactorial. The possible causes of malnutrition were evaluated by performing studies of energy balance in five clinically stable outpatients with AIDS, six seronegative homosexual control subjects, and five seronegative heterosexual control subjects. The AIDS group was significantly depleted of body cell mass compared with the control subjects but the values did not change significantly over 6 wk. Food intake was normal in the AIDS group whereas intestinal absorptions of the pentose sugar xylose and of the triglyceride triolein were both significantly diminished. The AIDS patients were hypometabolic as compared with the control subjects and with predictions of metabolic rate based on the Harris-Benedict equation. We conclude that short-term energy balance can be maintained in clinically stable patients with AIDS. Hypometabolism is an appropriate metabolic response to the combination of body-cell-mass depletion and nutrient malabsorption.     

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

Parkinson's 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.     

欧洲营养不良风险调查方法在中国住院患者的临床可行性研究

目的检验营养不良风险调查(NRS)判定住院患者营养不良及是否需要营养支持的方法在国内的可行性。方法153例新住院患者参加本研究。入院后首先评估是否符合NRS评定条件,符合者第2天早晨进行评定;对不符合入组条件者检查血清白蛋白(sALB),按中国人正常值sALB<35g/L判定为营养不良。体质指数(BMI)采用中国标准,<18.5kg/m2判定为营养不良。NRS方法(欧洲肠内肠外营养学会2002年发布)由体质指数、近期体重变化、膳食摄入、疾病严重程度等4方面构成,其总评分≥3分判定为需要营养支持。结果139例新住院患者可用NRS评定,营养不良BMI<18.5kg/m2者占15.5%。全部对象的总评分≥3分者33.8%。不宜用NRS评定者14例,因无法站立者9例,胸、腹水者5例。此14例均测sALB,营养不良sALB<35g/L者5例(35.7%)。结论结合中国BMI正常值应用NRS来评定营养不良及判断是否需要营养支持是可行的。对因无法站立等原因而无法准确用NRS者,建议参考sALB<35g/L来判定有无营养不良。更大范围的临床实践有待进一步进行。     

Nutritional management of the patient with chronic obstructive pulmonary disease.

The prevalence and prognostic importance of malnutrition in chronic obstructive pulmonary disease (COPD), the factors that contribute to development of nutritional depletion, and the available evidence regarding effects of nutrition support in these patients are the subjects of this review. Nutritional depletion, as indicated by weight loss and loss of lean body mass, is a common complication of advanced COPD (particularly, but not limited to, the emphysematous type). Low body weight or recent weight loss and in particular depleted lean body mass in patients with COPD have been shown to be independent predictors of mortality, outcomes after acute exacerbations, hospital admission rates, and need for mechanical ventilation. The factors thought to contribute to nutritional depletion in these patients include elevated resting and activity-related energy expenditure, reduced dietary intake relative to resting energy expenditure, accelerated negative nitrogen balance, particularly during acute exacerbations of COPD, medication effects, and perhaps most importantly an elevated systemic inflammatory response. Studies to date suggest that, although it can help limit weight loss and negative energy balance in these patients, the effect of nutritional supplementation alone on clinically significant outcomes such as pulmonary function and exercise capacity is minimal. However, nutritional supplementation may have a role in the management of COPD when provided as part of an integrated rehabilitation program incorporating a structured exercise component as an anabolic stimulus.     

Body composition by X-ray absorptiometry and bioelectrical impedance in chronic respiratory insufficiency patients

Nutrition assessment is important during chronic respiratory insufficiency to evaluate the level of malnutrition or obesity and should include body composition measurements. The appreciation of fat-free and fat reserves in patients with chronic respiratory insufficiency can aid in designing an adapted nutritional support, e.g., nutritional support in malnutrition and food restriction in obesity. The purpose of the present study was to cross-validate fat-free and fat mass obtained by various bioelectric impedance (BIA) formulas with the fat-free and fat mass measured by dual-energy X-ray absorptiometry (DXA) and determine the formulas that are best suited to predict the fat-free and fat mass for a group of patients with severe chronic respiratory insufficiency. Seventy-five patients (15 women and 60 men) with chronic obstructive and restrictive respiratory insufficiency aged 45–86 y were included in this study. Body composition was calculated according to 13 different BIA formulas for women and 12 for men and compared with DXA. Because of the variability, calculated as 2 standard deviations, of ± 5.0 kg fat-free mass for women and ± 6.4 kg for men for the best predictive formula, the use of the various existing BIA formulas was considered not clinically relevant. Therefore disease-specific formulas for patients with chronic respiratory insufficiency should be developed to improve the prediction of fat-free and fat mass by BIA in these patients.     

Évaluation nutritionnelle chez l'insuffisant rénal chronique hémodialysé

Malnutrition is common in patients with uremia, and is frequently latent. In hemodialysis patients, malnutrition can be critical, forming one of the main causes of mortality. Anthropomorphic measurements reveal a decrease in lean and fat body mass in respectively 30–50 and 70 % of these patients. The severity of malnutrition during chronic hemodialysis has led to a search for nutritional markers for use in identifying high-risk patients requiring active nutritional management; they include a serum transthyretin value of < 300 mg/l, a serum somatomedin C of < 300 μg/l and a protein catabolic rate of < 1 g/kg/l. Given their simplicity and low cost, serum transthyretin and the protein catabolic rate may be useful for monitoring such patients.     

Body composition studies in patients with the acquired immunodeficiency syndrome

Body composition studies were performed in 33 patients suffering from the acquired immunodeficiency syndrome (AIDS). Studies included measurements of total body potassium, fat, and total body and extracellular water volumes plus serum retinol binding protein concentration, iron binding capacity, and albumin concentration. AIDS patients were underweight (p less than 0.001) and were depleted of potassium (p less than 0.001) with the lowest values occurring in patients close to death at the time of study. Body fat contents also were reduced. Intracellular water volumes were decreased in the AIDS patients (p less than 0.001) with a relative increase in extracellular water volume (p less than 0.001). Serum protein concentrations were decreased in the AIDS patients. Longitudinal studies did not demonstrate tissue repletion in patients with AIDS, despite apparent clinical stability. These studies demonstrate that severe, progressive malnutrition occurs in patients with AIDS. If malnutrition can be shown to have a deleterious effect upon the disease course, therapy of malnutrition may play an important role in the treatment of this disorder.     

Nutritional status of HIV-1 seropositive patients in the Free State Province of South Africa: anthropometric and dietary profile

OBJECTIVE: To evaluate the nutritional intake and status of HIV-1 seropositive patients, as well as the relationship between malnutrition and disease stage. DESIGN: A cross-sectional study. SETTINGS: The Immunology Clinic at the Pelonomi Hospital in Bloemfontein, South Africa. SUBJECTS: Eighty-one HIV/AIDS patients in different stages of disease were recruited consecutively from January to May 1995. Eleven of these patients were followed in 1997. MAIN OUTCOME MEASURES: Anthropometric data including current weight, height, triceps skinfold thickness, mid-upper-arm circumference, body mass index and bone-free arm muscle area were collected. Nutrient intake was estimated using a diet history in combination with a standardised food frequency questionnaire. The patients were divided into 3 groups according to their CD4+ T cell counts. RESULTS: The men were leaner (BMI = 18.9) than the women (BMI = 22.7) and patients with a CD4+ T cell count < 200 (stage III) tended to have the lowest median values for all anthropometric measurements. More than half the patients had a low intake (< 67% of the recommended dietary allowances) of vitamin C, vitamin B6, vitamin D, vitamin A, calcium, iron and zinc. CONCLUSIONS: The results confirms that HIV/AIDS patients from this population are malnourished. There was, however, no association between disease stage and nutritional status. Nutritional supplementation of HIV/AIDS patients should be considered, as this might lead to improved immune function in these patients.