La nutrition artificielle en periopératoire chez le patient diabétique

The diabetic patients are at high risk of malnutrition. One recommends seeking specific deficiencies (zinc, selenium, vitamins C and E) for malnourished diabetic patients. For the perioperative cares, one recommends to cover their protein needs and their caloric needs and to accordingly optimize the antidiabetic treatment. One should probably use oral supplements or enteral nutrition products with a low glycemic index. The presence of diabetic gastroparesis can make it difficult or dissuade enteral nutrition. The incidence of gastroparesis justifies gastric residue control, the use of prokinetic, and nutrition in postpyloric site. An equivalent parenteral carbohydrate intake has a hyperglycaemic effect more important than with the oral or enteral way. It is recommended to use an infusion pump in diabetic patients to administer parenteral nutrition. Daily use of lipid emulsions is recommended in this context.     

Évaluation de l'état nutritionnel et des besoins de l'enfant et de l'adolescent

Ten to fifteen percent of hospitalized children suffer from malnutrition. Children suffering from chronic diseases are at particularly high risk for malnutrition. A systematic screening for malnutrition and nutritional risk can improve nutritional care in this population. Simple measures (weight and height at admission) can be used to calculate nutritional indices (weight for height ratio or body mass index). Nutritional risk depends on: 1) the severety of the principal diagnosis, 2) the ability to feed oneself, and 3) the pain intensity. The oral or enteral route is preferred when the gut is functional. In all cases nutritional status must be followed throughout hospitalisation. Furthermore, it is preferable to begin nutritional care before malnutrition sets in. Nutritional care can improve the outcome and well-being of hospitalized children.     

Nutrition périopératoire chez la personne âgée. Cas particulier de la fracture de l’extrémité supérieure du col du fémur

Emergency surgery is associated with an increase in the risk of malnutrition in the elderly. Thirty to fifty percent of elderly persons admitted to in surgery are malnourished. In patients for which nutritional status is threatened by both the aging process and comorbidities, the surgical intervention represents an additional stress that will induce or worsen malnutrition. Nutritional care must no be delayed. First choice is the oral route, including protein and energy rich nutritional supplements, and must be a part of multidimensional perioperative care It is recommended to reach 30 to 40 kcal tot/kg/day and 1.2 to 1.5 g of proteins/kg/day. It is recommended to prescribe, during the stay in rehabilitation wards after surgery, oral nutritional supplements. This oral supplementation has been shown to be efficacious in malnourished elderly patients: there is weight gain, a lower risk for complications and a lower mortality rate. However, compliance may be reduced in elderly patients with low appetite, especially in case of dementia, or early medical complications. In order to prevent other falls and fractures, it is recommended to look for vitamin D deficiency and to prescribe vitamin D 800–1200 UI/day.     

Prise en charge nutritionnelle périopératoire du patient obèse

Recommendations for perioperative nutrition in obese subjects require considering the following evidences. Obesity has long been falsely considered a risk factor for poor outcomes from a variety of surgical procedures, yet recent studies of critically and chronically ill patients suggest that overweight and obese patients may paradoxically have better outcomes than normal weight patients. Preoperative weight loss should be considered as a risk factor of postoperative complications in obese subjects as in normal weight patients. Obese patients could be malnourished because of vitamin deficiencies and of sarcopenia. The prevalence of vitamin deficiencies in the morbidly obese population prior to surgery is high, especially for vitamins B1, B12, B9, A, C, D and E. Standard of care should include perioperative thiamine replacement, especially in case of prolonged vomiting. Vitamin B12 deficiency could appear fast after gastric or ileal surgery, and iron deficiency is more frequent. Low caloric diet is not recommended in obese subjects before surgery, especially for the elderly, because of the frequent sarcopenia in this population. Energy and protein recommendations are not easy to be determined in obese subjects. Recommended allowance for protein should be defined according of the fat free mass, which is not easy to evaluate in clinical practice. So it is recommended to use a normalized weigh for a theoretic BMI between 25 and 30 kg/m². The loss of muscle mass can be very fast in the postoperative period in these subjects. The nutritional objective of care is to preserve skeletal muscle mass and to enhance the protein balance.     

Éducation des familles et de l'enfant en nutrition artificielle à domicile

The techniques of artificial nutrition came of age since the seventies (1969 for enteral nutrition and 1973 for parenteral nutrition). Artificial nutrition has considerably modified the outcome of a great number of children with severe digestive tract pathologies or many other disorders making impossible or ineffective oral food administration. There are currently two techniques of artificial nutrition: enteral nutrition (the most physiological using the digestive tract) and parenteral nutrition (by central venous line, more demanding and more complications). Home parenteral and enteral nutrition emerged with new realities: increase in the number of children needing a nutritional assistance, increase in the number of indications and a constant need to make autonomous the child and the family leading to a better quality of life. The best care for these children needs a multidisciplinary approach (physicians, nurses, dieteticians, pharmacists, speech therapist, psychologists…) and a close relation between primary care and hospital. This also requires a significant investment of parents who are sometimes assisted by private nurses. Parents are thus educated with techniques of enteral nutrition and parenteral nutrition: use of the material, training with the care, learning the action to be taken in case of problem. They have thus a role of caregiver: heavy responsibility necessary to the return at home of their child. The educational role of the hospital team thus takes a paramount importance with the aim to provide an optimal home return and the most adequate care by the family.     

Lipides et inflammation postprandiale : impact du microbiote intestinal

Obesity and type 2 diabetes are associated with low-grade inflammatory tone. Growing evidence demonstrates that the gut microbiota is involved not only in the host metabolism but also in the pathogenesis of the low grade inflammation associated with obesity and type 2 diabetes. Among the mechanisms, dietary habits and more specifically the nutritional composition of the diet (lipids, non-digestible carbohydrates) have been shown to participate to the modulation of the composition and the activity of the gut microbiota. These questions and mechanisms will be discussed following experimental data.     

Mécanismes de la dénutrition chez l'enfant et l'adolescent

Malnutrition in child and adolescent is observed in various situations where there is an imbalance between the food intakes and caloric and proteic needs. Child is particularly vulnerable because its reserves are weak and its high caloric and proteic needs because of its growth. Various mechanisms leading to malnutrition were brought back and correspond to distinct clinical entities. The situations of malnutrition by exclusive mechanism of intake deficiency meet primarily in third world where they can take the form of starvation, extreme adaptive situation with prolonged fast. During situations known as of aggression like severe sepsis, polytraumatism, extended burn, surgery, malnutrition can settle quickly. Mechanism brought back in situation of acute aggression is defined classically like related to hypermetabolism with hypercatabolism. Kwashiorkor, another type of caloric and proteic malnutrition concerning child in third world, cannot be regarded as a simple caloric and proteic deficiency. It currently seems that a deficiency at the same time in macronutriments and micronutriments plays a part in genesis of this pathology. The glutathion seems in particular, to play a fundamental part in the kwashiorkor's pathophysiology. The most documented hypothesis relates imbalance between production of free radicals and mechanisms of defence. Mechanisms of repair would be insufficient, and persistence of membrane deteriorations would cause anomalies observed in kwashiorkor like oedema, hepatic overload, neurological disorders and diarrhoea.     

Conséquences de la dénutrition chez l'enfant et l'adolescent. Mortalité, morbidité, conséquences médicoéconomiques

In the developed countries, the sick children are at risk of protein-energy malnutrition (PEM). Marasmus is the most common form of severe PEM in such children. Its major characteristics are low muscle and fat masses with the presence of marked facial, axillary and inguinal skinfolds. Furthermore the marastic children are irritable and depressed. When the PEM is moderate, which is more frequent, the affected children present a failure to thrive. Severe and moderate PEM have multiple functional consequences on different systems and organs with an impact on mortality, morbidity and costs. In this paper, the functional consequences on the immune system, digestive tract, liver, lung, heart, kidney, skin, bone and brain are passed in review. To end, some comments are done about the particularities of PEM in mental anorexia and obesity.     

Influence des acides gras polyinsaturés n-3 et des antioxydants alimentaires sur les acides gras de la viande et la lipoperoxydation chez le bovin en finition

This study aimed at analysing the impact, on beef lipids and fatty acids and on beef colour, of dietary lipid supplements provided by extruded linseeds (rich in n-3 polyunsaturated fatty acids, n-3 PUFA) alone or with extruded rapeseed (rich in n-6 and n-3 PUFA and in 18:1n-9) in association or not with dietary antioxidants in cull dairy cows in finition. Dietary linseeds increased significantly proportions of 18:3n-3 (+56% and +36% respectively), of total trans 18:1 (+66% and +105%); and of 9cis,11trans 18:2 (CLA) (+50% and +41%) in Longissimus thoracis and Semitendinosus muscles, 18:3n-3 and CLA being known to be beneficial for the human health. Antioxidant supplements (association of vitamin E with plant extracts rich in polyphenols, PERP) reinforced the stimulating effect of lipid supplements on proportions of 18:3 n-3, 18:1trans, and 9cis,11trans 18:2 in lipids of the two muscles. Dietary n-3 PUFA reduced the capacity of plasma to resist against lipoperoxidation (−11%) favouring the formation of peroxides such as conjugated dienes (× 1.75) and malonedialdehyde (MDA, ×2). Intensity of lipoperoxidation tended to increase in beef packaged under modified atmosphere rich in oxygen (O₂/CO₂: 70/30) of the linseed group (2.96 μg/g fresh tissue) when compared to that in the control group (2.19 μg/g, p = 0.1). Combined supply of vitamin E and PERP efficiently protected beef against lipoperoxidation, even in beef packaged under modified atmosphere rich in oxygen. Beef samples packaged under air from cows of the linseed group exhibited a more intense red colour than that of cows of the control group. In cows of the linseed group submitted to an emotional stress 2 hours before slaughtering, beef samples packaged under the air or the O₂-rich atmosphere had a red colour with a lower intensity that beef samples from cows of the linseed plus antioxidants group. In conclusion, feeding strategy for finishing cull cows combining lipid (from linseed rich in n-3 PUFA) and antioxidant (vitamin E + PERP) supplements improve the health value of beef fatty acids avoiding the major risks of beef lipoperoxidation and of alteration of beef colour whatever (i) the conditions of beef ageing and packaging (especially with O₂), (ii) the level of emotional stress of animals just before slaughtering.     

De quelques maux de la prévention contemporaine. Le cas de l’obésité et du surpoids

Overweight and obesity are considered major public health issues, and many preventive campaigns are designed to prevent unhealthy eating habits among the French. But these campaigns may be ineffective, and even sometimes counterproductive. Firstly, because prevention is a moral enterprise that can lead to stigmatizing targeted people. Secondly, because the ‘merchandization’ of prevention fuels a ‘dietary cacophony’. Thirdly, the medicalisation of overweight/obesity involves some shortcomings: it can prevent us from understanding eating habits, and many general physicians are insufficiently trained to take care of overweight or obese patients.     

Nutrition et vieillissement osseux: L’ostéoporose

Incidence of osteoporosis increases with ageing, and consequences to mortality, morbidity and quality of life are major. Increasing needs of calcium and decreasing « intakes » of vitamin D lead to osteopenia. Other micronutrients deficiences and decreasing proteic intakes participate to this phenomenon. Risk of fracture could be prevent by adapted dietary councelling.     

Promouvoir l’activité physique, lutter contre la sédentarité et prévenir le surpoids chez l’adolescent, c’est possible : les leçons d’ICAPS

Based on a socioecological approach, the Intervention Centered on Adolescents’ Physical activity and Sedentary behavior (ICAPS), a four-year randomized and controlled trial has shown that prevention of sedentariness and of obesity is feasible in youth thanks the mobilization of several partners including actors in the domains of health, education, physical activity, transport and of community agencies in charge of recreational areas and transportation infrastructures. In this article, we present a synthesis of the key data demonstrating the efficacy of ICAPS at the end of the four years of intervention as well as preliminary results of the six-year follow-up study, i.e. two years after the end of the intervention. We discuss a few tracks on elements that may explain the effectiveness of the strategy implemented.     

Mesures objectives de l’environnement bâti et statut pondéral des enfants et adolescents : revue de la littérature

In the framework of the study of the Environmental links to physical activity, nutrition and health (ELIANE), we performed a systematic review of the associations between objective spatial measurements of the built environment and weight status in youth. Of the 25 identified papers, 18 reported at least one significant relationship, although only almost one-third of the associations tested were significant. Inverse relationships of weight with different walkability indices were the most consistent (7/9 papers). Weight was also positively related to spatial accessibility to convenience stores (3/6 papers), and inversely to the accessibility to recreational physical activity facilities (4/9 papers). Relationships with parks, other food retail outlets and restaurants were inconsistent. Reasons for such discrepant results are discussed. Better-built environment measures are needed. The challenge lies also in better understanding the complex pathways through which the built environment, the socioeconomic context, and the perception of their environment by the subjects impact childhood behaviors and weight status.