Nutritional evaluation in cirrhotic patients

Great importance has been given to nutritional evaluation concerning either diagnosis or prognosis, and also involving nutritional support as therapeutic approach. Nutritional evaluation of 32 cirrhotic patients was performed using anthropometric measures as triceps skinfold and arm muscular circumference, and laboratory data: creatinine/height index, serum albumin transferrin; and lymphocyte number in peripheral blood. Non-caloric stores, evaluated by triceps skinfold were extremely low in 81% of the cases studied, while muscular stores, evaluated by arm muscular circumference and creatinine/height index were depleted in respectively 37.5% and 43.7%. Visceral stores evaluated by serum levels of albumin and transferrin, as well as immunological state, measured by peripheral lymphocytes counts, showed severe depletion in 10 to 15% of the patients. The increasing importance of nutrition in hepatic cirrhosis is stressed and interpretation of the different methods used for nutritional evaluation in chronic liver disease is discussed.     

Assessment of protein-energy malnutrition in children and adolescents with juvenile rheumatoid arthritis

The incidence of protein-energy malnutrition (PEM) in juvenile rheumatoid arthritis (JRA) patients referred to a dietitian was compared with PEM in a nonreferred JRA population. One pediatric dietitian evaluated all 28 patients using a standardized, 11-parameter comprehensive nutritional assessment profile. Thirty-six percent (10) were found to have PEM (≥6 of 11 parameters abnormal as defined for this study), 36% (10) had no abnormal parameters, and 28% (8) had one-five abnormal parameters. Seventy percent (7 of 10) of the patients referred to a dietitian had PEM: 17% (3 of 18) of the nonreferred JRA patients had PEM. PEM was found in all onset types of JRA. In the ten patients with PEM, 80% had weight <5th percentile, 30% had heights <5th percentile, 50% had subnormal visceral proteins, 90% had subnormal somatic proteins, and none showed depletion of subcutaneous fat reserves. The high prevalence of PEM supports the need for greater involvement of pediatric dietitians in the evaluation and treatment of JRA patients.     

Obesity and cardiovascular risk in children and adolescents

The global prevalence of overweight and obesity in children and adolescents has increased substantially over the past several decades. These trends are also visible in developing economies like India. Childhood obesity impacts all the major organ systems of the body and is well known to result in significant morbidity and mortality. Obesity in childhood and adolescence is associated with established risk factors for cardiovascular diseases and accelerated atherosclerotic processes, including elevated blood pressure (BP), atherogenic dyslipidemia, atherosclerosis, metabolic syndrome, type II diabetes mellitus, cardiac structural and functional changes and obstructive sleep apnea. Probable mechanisms of obesity-related hypertension include insulin resistance, sodium retention, increased sympathetic nervous system activity, activation of the renin-angiotensin-aldosterone system and altered vascular function. Adiposity promotes cardiovascular risk clustering during childhood and adolescence. Insulin resistance has a strong association with childhood obesity. A variety of proinflammatory mediators that are associated with cardiometabolic dysfunction are also known to be influenced by obesity levels. Obesity in early life promotes atherosclerotic disease in vascular structures such as the aorta and the coronary arteries. Childhood and adolescent adiposity has strong influences on the structure and function of the heart, predominantly of the left ventricle. Obesity compromises pulmonary function and increases the risk of sleep-disordered breathing and obstructive sleep apnea. Neglecting childhood and adolescent obesity will compromise the cardiovascular health of the pediatric population and is likely to result in a serious public health crisis in future.     

Identifying the elderly at risk for malnutrition. The Mini Nutritional Assessment

In more than 10,000 elderly persons, the mean prevalence of malnutrition is 1% in community-healthy elderly persons, 4% in outpatients receiving home care, 5% in patients with Alzheimer's disease living at home, 20% in hospitalized patients, and 37% in institutionalized elderly persons. In community-dwelling elderly persons, the MNA detects risk of malnutrition and life-style characteristics associated with nutritional risk while albumin levels and the BMI are still in the normal range. In outpatients and in hospitalized patients, the MNA is predictive of outcome and cost of care. In home care patients and nursing home residents, the MNA is related to living conditions, meal patterns, and chronic medical conditions and allows targeted intervention. The MNA has been used successfully in follow-up evaluation of outcome, nutritional intervention, nutritional education programs, and physical intervention programs in elderly persons. The MNA-SF allows quick screening to determine a person's risk of malnutrition. Early detection of malnutrition is important to allow targeted nutritional intervention and should be a key component of the geriatric assessment. The MNA test is a simple, noninvasive, well-validated screening tool for malnutrition in elderly persons and is recommended for early detection of risk of malnutrition. The MNA, as a two-step procedure (screening with the MNA-SF followed by assessment, if needed, by the full MNA), is reliable and can be easily administered by general practitioners and by health professionals at hospital or nursing home admission for early detection of risks of malnutrition. The MNA has the following characteristics: * The MNA is a two step procedure: (1) the MNA-SF to screen for malnutrition and risk of mainutrition; (2) assessment of nutritional status with the full MNA. * The MNA is an 18-item questionnaire comprising anthropometric measurements (BMI, mid-arm and calf circumference, and weight loss) combined with a questionnaire regarding dietary intake (number of meals consumed, food and fluid intake, and feeding autonomy), a global assessment (lifestyle, medication, mobility, presence of acute stress, and presence of dementia or depression), and a self-assessment (self-perception of health and nutrition). The MNA-SF comprises 6 items from the 18. * The MNA is well validated. It correlates highly with clinical assessment and objective indicators of nutritional status (albumin level, BMI, energy intake, and vitamin status). * A low MNA score can predict hospital-say outcomes in older patients and can be used to follow up changes in nutritional status. * Because of its validity in screening and assessing the risk of malnutrition, the MNA should be integrated in the comprehensive geriatric assessment. * In more than 10,000 elderly persons, the prevalence of undernutrition assessed by the MNA is 1% to 5% in community-dwelling elderly persons and outpatients, 20% in hospitalized older patients, and 37% in institutionalized elderly patients.     

Obesity and cardiovascular disease risk in children and adolescents

Obesity is an important risk factor for cardiovascular disease (CVD) that affects health throughout an individual’s life. Despite these well-established associations of risk throughout the life course, debate continues over how to best assess this risk in pediatric populations. This article discusses the state of the art in this field, comprising three areas with clinical and research implications: measurement of adiposity, emerging cardiometabolic risks, and the debates surrounding pediatric metabolic syndrome (MetS). Body mass index for age percentiles remain the most economical assessment option, although other measurements may improve accuracy. Newly discovered fat-derived cardiometabolic factors have the potential to improve risk prediction and become targets for earlier intervention, but more research is needed. Finally, although MetS has received increasing attention, some question its validity and utility as a pediatric diagnosis. While important questions remain, there is consensus that prevention and treatment of childhood obesity should be the first-line approach to reducing the immediate and future risk of CVD.     

Cardiovascular disease risk factors and atherosclerosis in children and adolescents

As more is learned about the natural history of the development of atherosclerosis, it is clear that the process that results in morbidity and mortality in adults has its origins in childhood and adolescence. It is also clear that the traditional risk factors, such as hypertension and dyslipidemia, are important in the early stages of the process. It appears that the prevalence and severity of obesity are increasing in children and adolescents in the United States. This trend is associated with increasing blood pressure and the occurrence of type 2 diabetes mellitus in young individuals. These trends may result in increased cardiovascular morbidity and mortality as these overweight pediatric patients become obese adults. Intervention and prevention strategies should be directed at the pediatric population as a whole, as well as at higher-risk individuals. For the latter, it will be necessary to identify those at highest risk. Both nonpharmacologic and pharmacologic approaches may be necessary for treatment of pediatric patients with hyperlipidemia and hypertension. Studies are needed that evaluate the longer-term impact of intervention on cardiovascular risk factors in young patients.     

Sensibility of anthropometric-laboratory markers of protein-energy malnutrition in cirrhotic patients

AIM: The prevalence and severity of protein-energy malnutrition (PEM) were investigated through the anthropometric (body mass index, triceps and subescapular skinfolds and upper arm circumferences) and blood measures in 117 cirrhotic patients. The sensitivity and specificity of single or combined PEM markers were tested among Child A (n=18), Child B (n=42) and Child C (n=57) adults (51+/-13y). RESULTS: Were calculated as z score and considered deficient when z< or =-1.28SD according to local standards. The most deficient markers where albumin (93%), hemoglobin (90%), upper arm circumference (61%), triceps (55%) and subescapular (53%) skinfolds. By combining upper arm circumference with triceps or subescapular skinfolds, PEM were detected in 63% of patients varying from 39-44% (Child A) to 64-68% (Child B or C). CONCLUSION: Thus the pattern of PEM present in cirrhosis is predominantly in their protein compartment and worsened with the severity of hepatocellular insuficiency. Upper arm circumference can be used as sensitive markers of presence and severity of PEM in cirrhotic patients but showing low specificity for discriminate PEM among Child grades (B and C) of hepatocellular dysfunctions.     

Antituberculosis care of children and adolescents in tuberculosis risk groups

Because of deterioration of epidemiological situation by tuberculosis, individuals from tuberculous infection foci and social risk group require special care. It is important to integrate efforts of phthisiatric and general therapeutic and prophylactic services in detection of tuberculosis in children and adolescents, to create controlled conditions for conduction of antituberculous measures.     

Nutritional assessment in cirrhotic patients with hepatic encephalopathy

Hepatic encephalopathy(HE) is one of the worst complications of liver disease and can be greatly influenced by nutritional status. Ammonia metabolism, inflammation and muscle wasting are relevant processes in HE pathophysiology. Malnutrition worsens the prognosis in HE, requiring early assessment of nutritional status of these patients. Body composition changes induced by liver disease and limitations superimposed by HE hamper the proper accomplishment of exams in this population, but evidence is growing that assessment of muscle mass and muscle function is mandatory due to the role of skeletal muscles in ammonia metabolism. In this review, we present the pathophysiological aspects involved in HE to support further discussion about advantages and drawbacks of some methods for evaluating the nutritional status of cirrhotic patients with HE, focusing on body composition.     

Physical activity and cardiovascular disease risk factors in children and adolescents

Cardiovascular disease (CVD) is the leading cause of global mortality, and its precursors have their origin in the first decade of life. The most recognized CVD risk factors are total and central adiposity, insulin resistance, blood lipids and lipoproteins, blood pressure, inflammatory proteins, and cardiorespiratory fitness. Low physical activity is strongly associated with a higher risk of developing CVD in adults, and there is compelling evidence indicating that this is also the case in young individuals. Epidemiologic evidence indicates that a high level of physical activity, particularly vigorous physical activity, is associated with lower total and central body fat in youth. Likewise, moderate and vigorous physical activity rather than low-intensity levels seems to be independently associated with insulin resistance, blood lipids, blood pressure, inflammatory proteins, and cardiorespiratory fitness in children and adolescents. Preventive efforts should start in the first decades of life.     

Cardiovascular risk assessment in children and adolescents with congenital solitary kidneys

Patients with solitary kidneys (SKs) are at risk of hypertension (HT) and associated end‐organ damage. The authors aimed to evaluate whether children with congenital SKs (CSKs) have higher office, ambulatory, or central blood pressure (BP), increased arterial stiffness or left ventricular mass index, or any risk for arrhythmia. With this purpose, patients with CSK and healthy controls being followed up between January 2018 and June 2019 were enrolled in the study. Demographic, biochemical, and office blood pressure (BP) data were recorded. Then, ambulatory blood pressure monitoring (ABPM) and measurements of central BP (cBP), pulse wave velocity (PWV), and augmentation index (AIx@75) were obtained. Ventricular repolarization parameters were acquired by 12‐lead electrocardiography. Left ventricular mass index (LVMI) and abdominal aortic stiffness parameters including strain, pressure strain elastic modulus (Ep), and normalized Ep (Ep*) were calculated with echocardiographic measurements. Finally, 36 children with CSK and 36 healthy controls were included. Serum creatinine, uric acid, total cholesterol levels, ABPM parameters, cBP levels, and PWV values were significantly higher, and eGFR levels were significantly lower in the CSK group. VR parameters, abdominal aortic stiffness indices, and LVMI were similar between the groups. CSK increased the risk of HT in ABPM (HT_ABPM) by 6 times. PWV was significantly correlated with Ep and Ep* in cases with CSK. Determination of cBP and PWV along with 24‐hour ABPM would be a useful tool in children with CSK.     

Predicting body composition from anthropometry in pre-adolescent children

The objectives of this paper were to: a) evaluate the accuracy and precision of previously published pediatric body composition prediction equations and b) develop additional prediction equations from a large, heterogeneous group of Caucasian (n = 133) and African-American (n = 69) children. The combined cohort of 202 children included a wide range of ages (4.0-10.9 y), weights (14.0-70.8 kg), fat mass (FM: 1.2-28.5 kg) and percent body fat (% body fat: 6.2-49.6%). Skinfold measurements were obtained using a Lange caliper and body fat was measured with a Lunar DPX-L densitometer. The previously published equations of Slaughter et al and Goran et al did not accurately predict body fat. The entire cohort was randomly divided into two sub-groups for purposes of deriving and cross-validating a new prediction equation. In stepwise regression analysis in the development group (n = 135), weight, triceps skinfold, gender, ethnicity and abdominal skinfold estimated FM measured by dual energy x-ray absorptiometry (DEXA) with a model R2 of 0.95. The new prediction equation was cross-validated in the control group (n = 67) and each ethnic and gender subgroup. We conclude that a) the equations of Slaughter et al and Goran et al did not accurately predict FM in a heterogeneous group of children and b) a new anthropometric prediction equation is proposed that may provide accurate estimates of FM in both Caucasian and African-American children aged 4-10 y with a wide range of FM and body composition.