Is serum albumin a good marker for malnutrition in the physically impaired elderly?

BACKGROUND AND AIMS: Although serum albumin is well known as a marker of nutritional status, it has remained unclear whether impaired physical function affects serum albumin concentrations in older people. We examined whether hypoalbuminemia can be used as a marker of malnutrition in elderly subjects with various levels of physical impairment. METHODS: A total of 262 elderly subjects without acute illness were enrolled from various geriatric settings. For the nutritional assessment, serum albumin, total cholesterol, anthropometric measurements, and subjective global assessment (SGA) were determined. Physical function was evaluated by rating score of activity of daily living (ADL). RESULTS: As a whole, participants' serum albumin levels correlated with various nutritional parameters including anthropometric measurements and levels of serum total cholesterol as well as the SGA evaluation. However, after adjusting for age and gender, serum albumin levels in participants with a low ADL function did not correlate with nutritional parameters. Approximately 80% participants with low ADL function who were evaluated as being well nourished according to SGA evaluation had serum albumin levels lower than 35 g/l. CONCLUSIONS: The utility of serum albumin and the traditional cutoff (35 g/l) in older people with low ADL function is questionable even among those without inflammation.     

Nutritional status of surgical patients and the relationship of nutrition to postoperative outcome.

A preoperative nutritional assessment including anthropometry, biochemical indices and global subjective assessment was performed for 127 patients admitted for elective gastrointestinal surgery. Of these, 24 were subjected to minor surgery, 65 to intermediate surgery and 38 to major procedures. Patients were followed postoperatively, recording complications or mortality. Intermediate and major surgery patients had lower triceps skinfold thickness and mid-arm circumference and greater weight loss than did minor surgery patients. Thirty-six percent of the patients suffered complications. No association was found between preoperative nutritional status and incidence of postoperative complications. Six patients died and they showed greater preoperative weight loss (21 +/? 6.5 vs 12 +/? 1.4%) and lower serum albumin levels (25 +/? 4 vs 35 +/? 1 g/l) than patients who survived complications. Global subjective assessment classified 43% of survivors as malnourished, compared to 100% of patients who died.     

Nutritional status of surgical patients and the relationship of nutrition to postoperative outcome.

A preoperative nutritional assessment including anthropometry, biochemical indices and global subjective assessment was performed for 127 patients admitted for elective gastrointestinal surgery. Of these, 24 were subjected to minor surgery, 65 to intermediate surgery and 38 to major procedures. Patients were followed postoperatively, recording complications or mortality. Intermediate and major surgery patients had lower triceps skinfold thickness and mid-arm circumference and greater weight loss than did minor surgery patients. Thirty-six percent of the patients suffered complications. No association was found between preoperative nutritional status and incidence of postoperative complications. Six patients died and they showed greater preoperative weight loss (21 +/- 6.5 vs 12 +/- 1.4%) and lower serum albumin levels (25 +/- 4 vs 35 +/- 1 g/l) than patients who survived complications. Global subjective assessment classified 43% of survivors as malnourished, compared to 100% of patients who died.     

应用主观全面评定法评价维持性血液透析患者营养状况

目的应用主观全面评定法（SGA）对维持性血液透析患者（MHD）的营养状态进行评价。方法对116例MHD患者应用SGA方法进行营养评估，测定肱三头肌皮褶厚度、上臂围、上臂肌围（MAMC）等人体测量学指标和血清白蛋白（ALB）、C反应蛋白（CRP）等实验室指标，并进行相关性分析。结果SGA法的评定结果与年龄、透析时间、肱三头肌皮褶厚度、上臂围、MAMC、体质指数（BMI）、ALB、CRP均有显著相关性（P〈0．01）；与总蛋白、血清肌酐无相关性（P〉0．05）。多因素分析显示，在调节年龄、BMI后，SGA评分与CRP、ALB、MAMC仍存在显著相关性（相关系数分别为0．2816、0．3368、0．6143，P〈0．05）。结论SGA法在我国MHD患者的营养评价中适用，是一种经济、有效的营养评定方法。     

Prevalence and prognostic significance of malnutrition in chronic renal insufficiency.

OBJECTIVE: Malnutrition is present in a significant proportion of patients commencing dialysis. However, the prevalence and prognostic significance of malnutrition within the chronic renal insufficiency (CRI) population before the initiation of dialysis is poorly characterized. The aim of this study was to determine the prevalence and prognostic significance of malnutrition in an unselected group of patients with CRI. DESIGN: Cohort analytic study. SETTING: Ambulatory care practice of a university teaching hospital. PATIENTS: Fifty patients with CRI (serum creatinine concentration > or = 1.7 mg/dL) were enrolled. Patients with a recent acute illness, nephrotic syndrome, intercurrent steroid therapy, gastrointestinal disease, or other severe organ failure that may have independently influenced nutritional status were excluded. INTERVENTION: At baseline, patients had a nutritional assessment consisting of subjective global assessment (SGA), measurement of body mass index (BMI), midarm circumference (MAC), serum albumin concentration, total lymphocyte count, and single frequency bioelectrical impedance analysis. Patients received standard medical care and were followed prospectively at quarterly intervals for 12 months. RESULTS: At baseline assessment, 28% of patients had evidence of malnutrition by SGA criteria. The malnourished group of patients had a significantly lower creatinine clearance (18.9 +/- 9.8 v 36.5 +/- 14.0 mL/min/1.73 m(2), mean +/- SD, P <.001), glomerular filtration rate (20.7 +/- 10.9 v 28.5 +/- 12.5 mL/min/1.73 m(2), P =.04), BMI (22.7 +/- 2.9 v 29.0 +/- 5.0 kg/m(2)), and MAC (24.3 +/- 4.9 v 30.7 +/- 4.8 cm, P <.001), but there were no differences in serum albumin concentration or total lymphocyte count between the groups. At the 12-month follow-up, there was significantly increased mortality (21% v 3%, P =.04), composite endpoint of death or dialysis (50% v 11%, P =.02), and likelihood of acute hospitalization (78% v 23%, P =.001) in the malnourished group. A significant association was observed between baseline nutritional status and subsequent admission to hospital and baseline glomerular filtration rate and progression to end-stage renal failure. CONCLUSION: These data suggest that SGA provides a useful means of assessing nutritional status and is helpful in identifying patients with increased risk of morbidity and mortality in the setting of CRI.     

A cross-sectional study comparing the nutritional status of peritoneal dialysis and hemodialysis patients in Korea.

OBJECTIVE: This study was performed to compare the nutritional status of peritoneal dialysis (PD) and hemodialysis (HD) patients in Korea and to validate the nutritional assessment method. DESIGN: For nutritional assessment, we used five nutrition-related indicators, including percentage unplanned weight loss, percentage ideal body weight (IBW), serum albumin, appetite and intake, and any gastrointestinal symptoms affecting intake. A 1-month food frequency interview was conducted by clinical dietitians using food models to estimate energy and protein intake. The validity of the nutritional assessment method was tested by objective measures. PATIENTS/SETTING: A cross-sectional study was conducted in our center for 51 PD patients and 169 HD patients who met the study criteria. In the study, HD patients typically underwent dialysis three times per week, and most PD patients performed four 2-L dialysis exchanges every day. RESULTS: Our data showed a higher incidence of malnutrition in PD patients than in HD patients (33% v 18%) and in diabetics than in nondiabetics. Age, height, and dietary energy intake of the two groups were comparable. In PD patients, however, duration of dialysis treatment (23.9 +/- 19.1 months v 41.8 +/- 31.7 months, P < 0.001) and serum albumin (35.2 +/- 5.0 g/L v 39. 7 +/- 3.4 g/L, P < 0.0001) were significantly lower, whereas percentage IBW (108.1% +/- 12.4% v 96.2% +/- 11.6%, P < 0.0001) and dietary protein intake (1.12 +/- 0.34 g/kg IBW v 0.98 +/- 0.31 g/kg IBW, P < 0.05) were significantly higher than in HD patients. In malnourished PD and HD patients, percentage IBW, serum albumin, dietary energy, and protein intake were significantly lower than in well-nourished counterparts. CONCLUSION: A higher incidence of malnutrition was observed in PD patients than in HD patients. Nutritional profile of PD patients was different from that of HD patients. Higher body weight and lower serum albumin in PD patients did not seem to be related to dietary energy and protein intake. The five nutritional indicators can be used as a simple inexpensive and reliable method for the early detection of malnutrition in dialysis patients.     

尿毒症患者营养评估及相关因素分析

目的 :　了解终末期肾病 (ESRD)患者透析前和维持性血液透析时的营养状态及其相关因素。方法 :　用主观综合营养评估法 (SGA)评估 46例透析前 ESRD患者和 78例维持性血透患者的营养状况及血浆白蛋白 (ALB)等其它营养指标 ,分析了影响透析前后营养状况的有关因素。结果 :　根据 SGA分级透析前组总营养不良的发生率为 65 .2 3 % ,维持性血透组为 5 8.97% ;残肾功能与透析前营养不良的相关性不明显 ,透析组 SGA分级三组之间 ALB、Pre-ALB、Chol、SCr、n PCR、年龄、糖尿病肾病比例、心血管疾病、肝硬化、感染等合并症和并发症发生率有显著性差异 ,而透析时间、KT/ V各组间无显著性差异。结论 :　ESRD患者在透析前和维持性透析时有较高的营养不良的发生率 ,老龄、糖尿病、伴心血管疾病、感染等并发症患者容易出现营养不良     

Nutritional support in alcoholic cirrhotic patients improves host defenses.

BACKGROUND: Malnutrition is usual in patients with alcoholic liver disease and is associated with a poor outcome. Nutritional support decreases nutrition-associated complications. AIM: To demonstrate that nutritional support in ambulatory alcoholic cirrhotic patients improves host defenses. METHODS: Thirty-one male outpatients with alcoholic cirrhosis CHILD-PUGH B or C were included. Twenty-five subjects completed six months consuming daily a nutritional supplement (Ensure, 1000 Kcal and 35 g protein), in addition to their regular diet. At entrance and every three months, a clinical assessment, nutritional evaluation and indirect calorimetry were performed. Liver function tests and LPS-induced monocyte production of cytokines, salivary secretory IgA, lactulose/mannitol ratio and breath hydrogen tests were also measured in these intervals. Delayed cutaneous hypersensitivity and IgG and IgM antibody response to endotoxin were assessed at entrance and at the end of the study. RESULTS: Patients drank 85% of the provided supplement as an average. REE, total body fat and serum albumin increased, basal breath hydrogen decreased and cellular immunity improved significantly during the follow up period (p< or =0.03). All the other parameters remained unchanged throughout the study. Six patients (16.2%) died during the study, five due to upper gastrointestinal bleeding. CONCLUSION: Nutritional support in alcoholic cirrhotic patients improves nutritional status and cell mediated immunity.     

Can malnutrition in predialysis patients be prevented by dietetic intervention?

OBJECTIVE: This study aimed to discover if the documented decline in nutritional status in predialysis patients could be prevented by dietetic intervention. DESIGN: Longitudinal prospective interventional study. SETTING: General hospital nephrology clinic. PATIENTS: Eleven patients with progressive chronic renal failure not yet requiring dialysis, all with creatinine clearance below 25 mL/min were studied. Mean age was 63.9 +/- 14.5 years. INTERVENTION: Patients received nutritional counseling from a renal dietitian on at least 3 occasions over a period of 6 months. Following assessment, patients were advised on dietary changes according to individual need, aiming for adequate energy intake to achieve or maintain a body mass index of 20 to 25 and protein intake of 0.8 to 1.0 g/kg/d. Dietary supplements were prescribed when necessary. OUTCOME MEASURES: Changes in nutritional status were assessed by Subjective Global Assessment, anthropometric measures (weight, triceps skinfold thickness, mid arm muscle circumference, and grip strength), and biochemical markers (serum albumin, serum transferrin, and insulin-like growth factor-1). RESULTS: None of the patients showed decline in Subjective Global Assessment category, and 2 of the patients improved. All anthropometric and biochemical measures of nutritional status were stable or increased over the course of the study, and mid arm muscle circumference increased significantly (P <.05), contrasting with published data showing a decline in these measures in patients not receiving dietetic intervention. CONCLUSION: With dietetic intervention, it may be possible to maintain or improve nutritional status in this group.     

Nutritional assessment in gynecology patients.

A nutritional assessment was performed upon 72 patients admitted for major elective gynecologic surgery for nonmalignant diseases. This nutritional assessment included body weight, triceps skinfold, arm muscle circumference, creatinine-height index, serum albumin and transferrin, total lymphocyte count, and dermal antigen testing. We found that 29 patients (42%) had at least one test result indicating a nutritional deficiency. Of the 72 patients, 19 (26%) experienced a postoperative complication. The occurrence of a complication did not correlate with any nutritional parameter other than albumin (p = 0.013), but even then, the positive predictive value of albumin was only 40%. Age also correlated with complication status (p = 0.002).     

Nutritional assessment in gynecology patients

A nutritional assessment was performed upon 72 patients admitted for major elective gynecologic surgery for nonmalignant diseases. This nutritional assessment included body weight, triceps skinfold, arm muscle circumference, creatinine-height index, serum albumin and transferrin, total lymphocyte count, and dermal antigen testing. We found that 29 patients (42%) had at least one test result indicating a nutritional deficiency. Of the 72 patients, 19 (26%) experienced a postoperative complication. The occurrence of a complication did not correlate with any nutritional parameter other than albumin (p = 0.013), but even then, the positive predictive value of albumin was only 40%. Age also correlated with complication status (p = 0.002).     

Preoperative albumin and surgical site identify surgical risk for major postoperative complications

BACKGROUND: Although malnutrition contributes to morbidity, studies of pre- and postoperative nutrition often include well-nourished patients unlikely to benefit from therapy and usually do not stratify by the site of surgical pathology. This study evaluates whether perceived preoperative markers of nutritional status recorded in charts correlates with postoperative complications and resource use in patients who receive no preoperative nutrition support and reinterprets the results of several conflicting randomized, prospective studies in this context. METHODS: This is a retrospective cohort study of 526 surgical patients who had preoperative serum albumin levels measured and were undergoing elective esophageal, gastric, pancreaticoduodenal, or colon surgery between 1992 and 1996 who could have received preoperative nutrition but did not. RESULTS: Most medical records contained inadequate analysis of preoperative nutritional status, but preoperative albumin correlated inversely with complications, length of stay, postoperative stay, intensive care unit (ICU) stay, mortality, and resumption of oral intake. Patients undergoing esophageal or pancreatic procedures sustained a significantly higher complication rate at most albumin levels, whereas colonic surgery resulted in lower complication rates at the same albumin levels. Resource use (eg, length of stay and ICU stay) related to these complication rates; esophageal and pancreatic procedures used the most resources and colon procedures used the fewest at most albumin levels. This lack of appreciation for nutritional risk and operative site can explain discrepancies in outcome noted in several randomized, prospective nutritional studies and must be applied to the design and implementation of new studies. CONCLUSIONS: Elective, non-emergent esophageal and pancreatic procedures performed in patients who could have had surgery delayed for preoperative nutrition, but did not, result in higher risk than colon surgery at any given level of serum albumin below 3.25 g/dL. Patient populations in trials should be stratified by operative site and by markers of nutritional status. Degree of hypoalbuminemia and other potential markers of nutritional status may explain many of the discrepancies between trials of nutrition support. Preexisting hypoalbuminemia in patients undergoing elective surgery remains underappreciated, unrecognized, and untreated in many hospitalized patients.     

L’albuminémie est-elle un marqueur de l’état nutritionnel ?

Serum albumin level is the most widely used diagnostic and follow-up marker of malnutrition. However, there are numerous contradictions between in-practice use of serum albumin and results of scientific studies, exemplified in the fact that serum albumin is used to diagnose malnutrition even though it values are neither correlated to protein mass nor decreased in characterized malnutrition such as marasmus or anorexia nervosa. Furthermore, protein restriction does not systematically lead to hypoalbuminemia, and efficient nutritional management does not always increase serum albumin levels. Serum albumin level is also a marker or morbidity-mortality independently of nutritional status. The serum albumin values used as diagnosis cut-off levels for malnutrition status, as set by health authorities or learned societies, are taken from studies where serum albumin levels correlated to non-anthropometric parameters such as mean hospital stay, infections, bedsores or rehospitalization, making it a marker of morbidity-mortality rather than malnutrition. Nevertheless, serum albumin level should remain part of the nutritional status assessment, either alone or – ideally – as part of a composite body weight index such as the Nutritional Risk Index or the Geriatric Nutritional Risk Index in order to guide the implementation of a nutritional strategy integrating the risks of malnutrition-related complications defined by the index. It is time the French health authority (Haute Autorité de santé [HAS]) recommendations to be updated to take this burgeoning evidence into account.     

综合性营养评估法在维持性血液透析患者中的应用

目的对血液透析患者的几项营养指标进行评估。方法对142例维持性血液透析（MHD）患者进行主观综合性营养评估（SGA）、膳食调查、生化参数的测定。结果依据SGA评分,在营养良好、轻中度营养不良及重度营养不良三组间进行以下指标比较：平均每日每公斤体重能量（DEI）和蛋白质摄入（DPI）、血白蛋白（ALb）,均有显著性差异（P〈0.001～0.05）。但营养良好组的DEI和DPI异常率高达46.0%、49.0%,重度营养不良组中各指标异常率均在80%以上。血前白蛋白（PA）与血ALb有显著相关（P〈0.01）,与DPI、DEI均无相关。结论SGA是评价MHD患者营养状况的简便方法,但还需其它反映营养状况不同侧面指标的补充,如DEI、DPI、血ALb、血PA。     

Serum insulin-like growth factor (IGF)-I concentrations are reduced by short-term dietary restriction and restored by refeeding in domestic cats (Felis catus).

Nutritional modulation of insulin-like growth factors (IGF) and their binding proteins (IGFBP) is well established. The effect of nutritional restriction on the serum IGF/IGFBP system of adult cats was investigated to evaluate serum IGF-I as a biochemical marker of nutritional status. Assays for measuring feline serum IGF and IGFBP were validated and normal ranges established in a study population of 46 healthy nonobese adult cats. Serum concentrations of IGF-I and IGF-II correlated significantly with body weight (r = 0.75, P < 0. 0001 and r = 0.34, P < 0.03, respectively). Serum IGFBP profiles were similar to other species, including humans, dogs and guinea pigs. IGFBP-3 was the predominant binding protein reflecting IGF-I concentrations and body size. Serum IGFBP-2 concentrations were high relative to the normal human serum pool (NHS) control. Food withdrawal for 18 h followed by refeeding did not alter circulating IGF or IGFBP concentrations, including IGFBP-1, in nine cats. Short-term dietary restriction of nine adult cats to supply initially 56% (56%M) and then 42.5% (42.5%M) of calculated maintenance energy requirements for 14 d resulted in a significant weight loss (P < 0.01). However, serum IGF-I concentrations fell significantly (-51%, P < 0.01) only with 42.5%M restriction. Serum IGF-II, IGFBP, insulin and albumin concentrations were not altered during the study. We conclude that nutrition does modulate the adult feline IGF/IGFBP system, but to a lesser extent than in other species. Further evaluation is required before serum IGF-I can be used for the assessment of nutritional status in adult cats.     

Vitamin B12 status in hospitalized elderly from nursing homes and the community

OBJECTIVE: To assess vitamin B(12) status in a large sample of hospitalized, inner-city older adults from nursing homes and communities with low socioeconomic status. To determine additionally if hypoalbuminemia can help identify older subjects who are at risk for vitamin B(12) deficiency. DESIGN: A cross-sectional study of hospitalized, inner-city older residents. SETTING: Acute Care Geriatrics Division, a 75-bed inpatient care service at Our Lady of Mercy Medical Center (OLMMC), a University Affiliate of New York Medical College. PARTICIPANTS: A total of 466 older patients (aged 65 to 102 years) from the community (n = 374) and nursing homes (n = 92) who were admitted to the acute care geriatrics division from 1993 to 1996. MEASUREMENTS: Patients admitted to the hospital had serum vitamin B(12) and albumin levels determined along with other nutritional parameters, routine blood tests, and physical examinations. RESULTS: On admission, 19% of hospitalized subjects had marginal serum B(12) levels (200-350 pg/mL) and 6% had low serum B(12) levels (<200 pg/mL). Mean serum B(12) levels did not differ significantly between patients from nursing homes and those from the community. Sixty-four percent 64% of all patients had low serum albumin levels (alb < 3.5 g/dL), with patients from nursing homes showing significantly lower mean serum albumin than patients admitted from the community (P <.000). We observed no positive correlation between serum albumin and serum vitamin B(12) in our older hospitalized patients from either nursing homes or community. CONCLUSIONS: In this sample of hospitalized older adults, 24% were found to have marginal or low serum B(12) status. Thus, we believe that periodic determinations of serum B(12) would be a useful addition to the general health and nutritional assessment in this age group. Our findings also suggest that hypoalbuminemia is not helpful as a predictor of low B(12) status in older hospitalized persons.     

Prolonged impairment of cell-mediated immunity after major abdominal surgery in malnourished patients

The effect of the nutritional status on postoperative impairment of the immune response was studied in adults undergoing major abdominal surgery. The immune function was evaluated by measuring in vitro the lymphocytic response to phytohaemagglutinin (PHA), concanavalin A (Con A) and the purified protein derivative of tuberculin (PPD) in whole blood cultures, and in vivo delayed skin hypersensitivity to candida, mumps, streptokinase-streptodornase and PPD. Nutritional assessment was carried out by evaluating recent weight loss, the weight for height index and by measuring the arm muscle circumference (AMC), triceps skinfold thickness (TSF), the creatinine-height index (CHI) and the serum concentration of albumin and prealbumin. The patient was considered malnourished, if at least three of these criteria were abnormal. The immune parameters were measured preoperatively, at the end of the surgery and five days after operation. Before the operation both malnourished and well-nourished patients had normal lymphocytic responses, but the malnourished patients had a slower recovery of immune responses after the operation and they had an increased number of postoperative complications. No significant differences in the incidence of anergy were observed between the well and malnourished patients pre or postoperatively.     

Vitamin D—risk vs benefit.

That nutritional parameters change with age is a well-known phenomenon. Physical activity, lean body mass, and metabolic rate all decline with increasing age. There has been little work regarding the nutritional assessment of geriatric nursing home patients to determine their nutritional status and to focus attention on their nutritional needs. The purpose of this study was to assess the nutritional status of the residents of two urban nursing homes. The nutritional status of 227 nursing home residents (mean age 72.2 years) was evaluated using biochemical and anthropometric measurements. Midarm muscle circumference, triceps skinfold thickness, weight, height, serum albumin, serum pre-albumin, serum retinol binding protein, and a complete blood count with differential were obtained. The evaluation of this data indicated that there was a 52% incidence of malnutrition. This can be broken down to: 24% hypoalbuminemic malnutrition, 19% Kwashiokor-Marasmus mix, and 9% Marasmus. Twenty-eight percent of all patients were anergic, and 76% of the patients were anemic. In conclusion, there appears to be far more documentable malnutrition than anticipated or previously reported in this population.     

Incidence of protein calorie malnutrition in the nursing home population

That nutritional parameters change with age is a well-known phenomenon. Physical activity, lean body mass, and metabolic rate all decline with increasing age. There has been little work regarding the nutritional assessment of geriatric nursing home patients to determine their nutritional status and to focus attention on their nutritional needs. The purpose of this study was to assess the nutritional status of the residents of two urban nursing homes. The nutritional status of 227 nursing home residents (mean age 72.2 years) was evaluated using biochemical and anthropometric measurements. Midarm muscle circumference, triceps skinfold thickness, weight, height, serum albumin, serum pre-albumin, serum retinol binding protein, and a complete blood count with differential were obtained. The evaluation of this data indicated that there was a 52% incidence of malnutrition. This can be broken down to: 24% hypoalbuminemic malnutrition, 19% Kwashiokor-Marasmus mix, and 9% Marasmus. Twenty-eight percent of all patients were anergic, and 76% of the patients were anemic. In conclusion, there appears to be far more documentable malnutrition than anticipated or previously reported in this population.     

Effect of maternal nutritional status on immunological substances in human colostrum and milk

Substances in colostrum and breast milk confer significant disease resistance to the breast-fed infant. The influence of maternal nutritional status on both immunological and nonimmunological milk factors was studied in a group of 23 Colombian women during the first 2 months of lactation. Maternal malnutrition was characterized by significantly lower weight/height ratio, creatinine/height index, total serum proteins, serum albumin, and serum IgG and IgA. The colostrum of malnourished mothers contained only one-third the normal concentration of immunoglobulin G and less than half the normal level of albumin. Significant reductions in colostrum levels of IgA and the fourth component of complement (C4) were also observed in the malnourished group. No differences were observed in colostral concentrations of lysozyme, C3 complement, or IgM. Titers of antibody in milk directed against respiratory syncytial virus were not influenced by maternal nutritional status. The differences noted above tended to disappear in mature milk, concomitant with improvement in the nutritional status of malnourished mothers during the first several weeks postpartum. We conclude that the protective qualities of colostrum and milk may be significantly influenced by maternal nutritional status.