Functional decline and nutritional status in a hospitalized geriatric population: sequential study

We analyzed the relations between nutritional status and several measures of the ability to perform the normal activities of daily living (ADL) in a long-term institutionalized geriatric population and also studied whether changes in this ability, as found ten months later, were associated with changes in the nutritional status. Nutritional status was assessed using objective anthropometric measurements (triceps skinfold, mid upper-arm circumference, midarm muscle area [AMA], midarm fat area [AFA]) and subjective clinical features (temporal muscle atrophy [TMA] and Bichat's fat atrophy [BFA]). The capacity to perform ADL was analyzed considering ability to eat and to walk, dental status, and mental performance status. Patients with total absence or loss of more than 50% of the teeth showed less AMA and AFA and greater degrees of TMA and BFA; the same happened with regard to deterioration of mental performance status. Those patients fed through a nasogastric tube showed less AFA and serum albumin and also a greater degree of TMA and BFA. Patients unable to walk without aid showed less AMA and AFA. Patients whose capacity to walk improved or whose mental performance status ameliorated showed an increase of their AMA, whereas AFA slightly decreased in those patients whose abilities to eat and to walk deteriorated. Long-term hospitalization in our center led to improvement and to deterioration of ADL in approximately the same number of patients, and similar changes were seen in the nutritional measures.     

Nutritional status of alcoholics of different socioeconomic class.

Most studies concerning the nutritional status of alcoholics have focused on the indigent alcoholic but programs now increasingly consider the working patient. The role of socioeconomic status in determining nutritional status of the alcoholic is further clarified in this study. One hundred patients from an alcoholic population were studied, 50 with low socioeconomic status and 50 with middle or higher socioeconomic status. The nutritional status of these two different socioeconomic groups was examined and compared. The middle-income alcoholic had significantly higher values in weight to height index (P less than .02), the triceps skinfold (P less than .01), the midarm muscle circumference (P less than .05), hematocrit (P less than .01), and epilation force (P less than .001) than the lower-income alcoholic group. Hair-pulling tension was compared in both groups as an index of protein malnutrition. There was a highly significant difference in the two groups.     

The obesity paradox in elderly patients with heart failure: analysis of nutritional status

ObjectiveThe obesity paradox refers to the improved survival of obese compared with non-obese elderly or diseased patients for reasons that are not clear. To assess the relative roles of fat and other factors in this improved survival, we analyzed the prognostic value of overweight and obesity elderly patients with heart failure (HF), controlling for other nutritional data such as midarm anthropometrics, serum proteins, and muscle strength.MethodsTwo hundred forty-four patients (83.2 ± 0.5 y old) hospitalized for HF were included. A nutritional survey was performed in all patients. After discharge, the patients were followed up by telephone.ResultsFourteen patients (5.7%) died during hospitalization. The median survival was 984 d. Patients with better nutritional status as assessed by the body mass index (BMI), subjective score, midarm muscle area, triceps skinfold thickness, handgrip, lymphocyte count, and serum albumin, prealbumin, and cholesterol levels showed better short- and long-term prognoses. Obese patients with a BMI above 30 kg/m² showed a better long-term prognosis than those with a BMI from 25 to 30 kg/m², those with a BMI from 20 to 25 kg/m², and those with a BMI lower than 20 kg/m². However, survival was not significantly related to a triceps skinfold thickness above the 95th percentile. Obese and overweight patients were younger and had better a nutritional status than those with a normal or decreased BMI as shown by the anthropometrics, subjective score, handgrip, lymphocyte count, hemoglobin, and serum albumin, prealbumin, and cholesterol levels. All the nutritional data correlated closely with each other. New York Heart Association class also correlated with nutrition-derived data: as the HF class increased, the nutritional status deteriorated. On multivariate analysis, to predict long-term survival, neither BMI nor triceps skinfold thickness showed an independent predictive value, whereas a larger midarm muscle area did.ConclusionThe obesity paradox was confirmed in this series of elderly patients with HF. Those with a high BMI and improved survival had a better nutritional status and New York Heart Association functional class than those with a lower BMI, which may explain the differences in survival.     

Discriminant biochemical markers for evaluating the nutritional status of elderly patients in long-term care

To determine the most discriminant serum markers of protein-energy status in elderly patients, we performed a discriminant analysis of 85 subjects grouped according to triceps skinfold and midarm circumference values as compared with reference percentiles. Results indicated that neither the classic serum indices of nutritional assessment nor retinol-binding protein can predict undernutrition. However, creatinine, urea, carotene, complement C3, and prealbumin included in a function enabled high discrimination between groups: 68% of subjects in 0-5th percentile for triceps skinfold and 75% of subjects in 0-5th percentile for midarm circumference are correctly predicted. Lower serum concentration was found in the lower anthropometric percentiles except for serum carotene, which showed an inverse relation not explained by diet. We found that nutritional alterations exist in hospitalized elderly patients. We emphasize the importance of considering several biochemical markers for detection of mal-nutrition and the pertinency of further exploration of serum carotene profiles in undernourished elderly patients.     

A radiographic method of quantifying protein-calorie undernutrition.

Estimation of midarm adipose tissue and muscle by the anthropometric technique is based on the idealized assumption that the arm and its muscle compartments are circular, and that fat is distributed evenly around the arm. We examined the validity of these assumptions by computerized axial tomography of the midarm in 21 subjects ranging from 65 to 255% of ideal body weight. Computerized axial tomography identified three errors inherent in the anthropometric method: 1) The arm and its muscle compartment were rarely circular, but resembled instead an ellipse and "cloverleaf", respectively; 2) fat was distributed asymmetrically around the arm, and furthermore when triceps skinfold was less than 5 mm, no fat was radiographically detectable, and 3) muscle are calculated by the anthropometric method includes bone area. Since bone area was not influenced by nutritional status, anthropometric "muscle area" underestimated the degree of muscle atrophy in undernutrition. Despite these limitations, in subjects 60 to 120% of ideal body weight anthropometric estimates of midarm muscle area (MAMA) and fat area did not differ greatly from the radiographic values. Anthropometric MAMA was consistently greater than the radiographic value by 15 to 25%, while midarm fat area agreed within +/- 10%. The error in the anthropometric MAMA could be nearly eliminated by two types of correction: expressing MAMA as a percentage of normal, and correcting for bone content by subtracting midarm bone area (6.3 and 4.7 cm2 for men and women). In subjects greater than 150% ideal body weight, however, anthropometric estimates of MAMA and midarm fat area differed from the radiographic values by greater than 50% even after the above two types of correction. Midarm computerized axial tomography scan provides an accurate alternative to the anthropometric method for estimating midarm muscle and fat in these obese individuals.     

Hand grip strength--a simple prognostic indicator in surgical patients

This study evaluates hand grip strength as an indicator of nutritional status and a predictor of postoperative complications. Hand grip strength and other parameters of nutritional status, namely, midarm muscle circumference, forearm muscle circumference, triceps skinfold, percentage ideal body weight, serum albumin, and percent usual weight were determined preoperatively in 205 patients. Complications occurred in 28 patients (14%). Patients with at least one abnormal nutritional parameter had a higher incidence of postoperative complications. Their length of total and postoperative hospitalization was greater by 6.2 and 4.6 days, respectively (p less than 0.01). Grip strength was the most sensitive single parameter, but forearm muscle circumference and percentage ideal body weight were the most specific indices. Hand grip strength is a simple measure of nutritional status and an accurate prognostic indicator that requires further clinical evaluation.     

The nutritional effects of endoscopic intubation for carcinoma of the oesophagus or cardia

The nutritional status in 17 patients with unresectable carcinoma of the oesophagus or cardia was assessed before and one month after endoscopic intubation by measurement of body weight, triceps skinfold thickness, midarm circumference and serum albumin concentration. There was a significant increase in dietary energy intake and weight loss was arrested in 10 patients. A weight gain of 3 kg or more was recorded in six cases of which two put on 8.4 and 9.4 kg respectively with concommitant increases in midarm circumference. It is concluded that endoscopic intubation of carcinoma of the oesophagus or cardia commonly benefits nutritional status by relieving dysphagia.     

PERIPHERAL NEUROPATHY AND MYOPATHY IN CHRONIC ALCOHOLISM

Nineteen chronic alcoholics referred for investigation of theirmedical complications and for alcohol re-education were subjectedto quadriceps muscle biopsy and detailed peripheral nerve electrophysiologicalstudies. Thirteen patients showed type II muscle fibre atrophyby histomorphometric analysis. The presence of atrophy did notcorrelate with peripheral neuropathy as determined by clinicalexamination or with objective indices of nutritional status.There was no association of muscle atrophy with neurophysiologicalevidence for neuropathy and both occurred independently of eachother. It was concluded that chronic alcoholic myopathy wasdue to a toxic effect of ethanol on the muscle fibres and wasnot merely secondary to a peripheral neuropathy.     

The use of a dynamometer in nutritional assessment.

Standard anthropometric techniques may be unreliable in patients with subcutaneous edema or dehydration. In order to circumvent this dilemma, 98 male subjects were studied utilizing a hand-held dynamometer in conjunction with other nutritional assessment techniques. Following a nutritional assessment using anthropometric measurements, patients were characterized as being well-nourished or malnourished using three definitive measures: percentage of ideal body weight, triceps skinfold, and midarm muscle circumference. Once malnutrition was assessed, no attempt was made to distinguish between marasmus, hypoalbuminemia, or mixed marasmus types of malnutrition. A correlation matrix done between the two groups revealed no statistically significant correlation between any of the measured parameters. Analysis of variance revealed statistically significant correlations between patients in both groups (independent variables) with respect to midarm muscle circumference and dynamometer reading in the dominant arm (dependent variables). Further validation of this technique is required before it can become a standard component of nutritional assessment.     

Changes in resting energy expenditure among children undergoing allogeneic stem cell transplantation

BACKGROUND: Because of the effects of chemotherapy and radiotherapy, patients undergoing stem cell transplantation (SCT) are commonly provided nutritional support with parenteral nutrition. The energy and nutrient needs of these patients have not been well studied. OBJECTIVE: The objective was to measure resting energy expenditure (REE), dietary intake, and biochemical and anthropometric changes in children before and after allogeneic SCT. DESIGN: This was a prospective cohort study of 37 children aged 9.1 +/- 6.4 y ( +/- SD) undergoing SCT who were enrolled in an open-label trial of a unique supportive care intervention that included the routine use of oral leucovorin, vitamin E, and ursodeoxycholic acid. Parenteral nutrition was provided to match 100% of measured or estimated REE. REE was measured weekly via indirect calorimetry. RESULTS: Baseline REE was 95% of the predicted age- and sex-matched norms and was significantly correlated with midarm muscle area (r = 0.82, P < 0.001). REE fell to a nadir of approximately 80% of the predicted levels by week 3 after SCT, with a gradual increase in weeks 4 and 5. Arm anthropometric measurements showed no change in triceps skinfold thickness but significant declines in midarm muscle area after SCT. Serum vitamin E remained in the normal range. CONCLUSIONS: Children undergoing SCT show significant declines in REE after transplantation. These changes may be due to alterations in lean body mass. Standard nutritional regimens may lead to overfeeding.     

Ultrasonography as a method of nutritional assessment

The composition of the upper arms of five healthy individuals was measured by anthropometry (AN), ultrasonography (US), and computerized tomography (CT). Measurements of midarm fat area (MAFA) and midarm muscle area (MAMA) by CT correlated well with AN and US, but both AN and US overestimated MAMA by 22.8 +/- 17% and 10 +/- 12%, respectively, (mean +/- SD). The overestimate was largest with AN because with this method bone area cannot be excluded. To evaluate the usefulness of US measurements, 10 patients with advanced liver disease were studied. Measurement of MAFA by US, using triceps skinfold thickness as the standard, was found to be an accurate index of fat stores. MAMA measured by US correlated well with lean muscle mass, using creatinine height index as the standard. Ultrasonography is a reliable method of measuring body fat and lean muscle status.     

Nutritional status and lymphocyte function in maintenance hemodialysis patients

Nutritional status and lymphocyte transformation were examined in 30 clinically stable men who underwent maintenance hemodialysis for 1 to 141 months. The men displayed decreased relative body weight, triceps and subscapular skinfold thickness, midarm circumference, midarm muscle circumference, serum total protein, albumin, transferrin, IgG, IgA, IgM, and C3 concentrations. There were many abnormalities in the plasma amino acid pattern. Lymphocyte transformation stimulated by phytohemagglutin or pokeweed mitogen was reduced. Many nutritional parameters correlated with each other and with the rate of lymphocyte transformation. There was a tendency (p = 0.06) for higher mortality in the malnourished patients during a mean follow-up period of 43.3 months. These findings suggest that clinically stable men undergoing maintenance hemodialysis are typically malnourished. Poor nutritional status may be a cause of impaired lymphocyte function. Malnutrition or wasting may indicate that the patient is at risk for a higher mortality rate.     

Which nutritional measurements assess protein-energy nutritional status in patients receiving home parenteral nutrition?

Weight, midarm circumference, triceps skinfold thickness, arm muscle circumference, albumin, prealbumin, transferrin and total lymphocyte count were measured at each outpatient visit in patients reveiving home parenteral nutrition from September 1987 to November 1991. Each nutritional variable was analysed for individuals and for the whole group. Group data were expressed using the actual values obtained and successive differences (the change between clinic attendances). Nutritional variables were evaluated using a correlation matrix. Identical analysis of individual and group data demonstrates that laboratory investigations are of little value in the assessment of nutritional status in patients receiving home parenteral nutrition. Anthropometry detected changes in body weight secondary to changes in muscle and/or fat in 80% of patients. Pooling anthropometric data distors the relationship between variables owing to inter-individual variability when actual values are used. The method of successive differences is the preferred method of analysis for group anthropometric data.     

Anthropometric measurements in the elderly population of Santiago, Chile

OBJECTIVE: There are few studies on anthropometry and nutritional status in large and representative samples of elderly populations in Chile and South America. We describe age and sex differences in weight, height, body mass index, knee height, waist circumference, midarm circumference, triceps skinfold thickness, arm muscle area, and calf circumference in Chilean elderly subjects. METHODS: This was a population-based, cross-sectional study. A total of 1220 elderly persons (819 women and 411 men; age range, 60-99 y) were recruited in the city of Santiago (Chile) through a probabilistic sampling procedure carried out from October to December 1999. RESULTS: Men were significantly heavier and taller than women in all age groups, whereas body mass index values were significantly higher in women than in men. All anthropometric variables showed a decrease in average values with aging in men and women. The apparent negative slopes for the decline in average values of body weight with aging was of greater magnitude in women than in men (-0.42 kg/y and -0.54 kg/y in male and female subjects, respectively). However, significant age x sex interaction was detected only for triceps skinfold thickness. In women, quadratic terms for age provided a significantly better fit than did the simple linear model for the association between age and weight, body mass index, waist circumference, triceps skinfold thickness, calf circumference, or midarm circumference. CONCLUSION: These observations indicated that body weight changes associated with aging might be more severe in Chilean women than in men, probably determining a differential pattern of lean and fat mass loss.     

Protein-energy nutritional status of pediatric cancer patients

Surveys of protein-energy nutritional status were conducted in pediatric cancer outpatients (28) and inpatients (71). In the outpatients, the approximate prevalences of severe (greater than 40%) deviations of weight, triceps skinfold, and arm muscle area below the medians for height-age were respectively 0, 14, and 0%. In the inpatients, these prevalences were respectively 1, 20, and 6%. The percentages of inpatients with abnormally low (less than 5th percentile) weight-for-height, triceps skinfold, and arm muscle area were 14, 14, and 20%, respectively. All inpatients with triceps skinfold or arm muscle area less than 60% of the median for height-age had corresponding percentile values of less than 15.     

174例老年病员营养状况评价

对１７４例老年男性病员进行营养状况评价，结果为：体重正常者占４７．７％，体重过重和不足检出率分别为３１．１％和２１．２％。体重正常者上臂围、上臂肌围、三头肌皮褶厚度低于９０％理想值的分别为６．３％、７．５％和８．６％，血红蛋白低于１３０ｇ／Ｌ者占１３．２％，血清白蛋白低于３５ｇ／Ｌ者占６．３％。体重过重者各项检查指标均正常。体重不足者所有检查指标均低于理想值的８０％。对营养过剩的病员应控制总热能和     

Natural killer cell activity in alcoholic cirrhosis: influence of nutrition

Forty-five patients with alcoholic cirrhosis, 20 chronic alcoholics with normal liver function tests and 36 healthy subjects were investigated. A combined index of nine anthropometric and biochemical parameters (triceps skinfold, arm muscle circumference, mid-arm muscle area, body fat percentage, creatinine-height index, serum albumin, plasma transferrin, prealbumin and retinol-binding protein levels) was used to evaluate nutritional status, allowing a distinction to be made between those patients with adequate nutrition (group I: 40 per cent of cirrhotics and 55 per cent of alcoholics), those with slight malnutrition (group II: 37.7 per cent of cirrhotics and 45 per cent of alcoholics) and those with severe malnutrition (group III: 22.2 per cent of cirrhotics and none alcoholic). Natural Killer (NK) cell activity of peripheral blood lymphocytes was determined using a 51Cr releasing cytotoxicity assay against K562 target cells. This was significantly lower in the cirrhotics than in the controls and chronic alcoholics (P less than 0.001 and P less than 0.01 respectively), but there was no difference between the latter two groups. Natural Killer activity was significantly lower in samples obtained from cirrhotics with severe malnutrition than in those with adequate nutrition, suggesting that malnutrition may play a role in the onset of the immunological disorder. No relationship could be established between nutritional status, NK activity and the clinical activity of the disease using Orrego's index on the liver function tests.     

The evaluation of nutritional status in general medical patients

We have analised the nutritional status of 415 hospitalised patients in an internal medicine service; 240 were males and 175 females; mean age was 56.6 ± 1.1 and 59.2 ± 1.5 years respectively. In these patients weight for height, triceps skinfold, arm muscle circumference, temporal muscle atrophy, Bichat's fat atrophy and serum albumin concentration were investigated.We have considered that a patient was malnourished when three or more of the six criteria mentioned above were affected. The prevalence of undernutrition was 40% (43.2% of the males and 35.2% of the females). We found more undernutrition in the males than in the females (weight for height less than 90% in 32.8% and 16.5% respectively). The prevalence of obesity (weight for height more than 120), was 18%, higher in the females (11.6%) of the males and 27% of the females).Aging was related to poor nutritional status, less caloric and protein intake, loss of the Bichat's fat, temporal muscle atrophy, and lower serum albumin. Smoking and drinking were also associated with a worse nutritional status.Patients with temporal muscle atrophy or Bichat's fat atrophy had a smaller intake of protein and calories, smaller values of the anthropometric parameters (WH, TS, AMC) and lower Hb and serum albumin levels. The relationships suggest that these two ‘simple’ clinical parameters are useful in the assessement of undernutrition.     

Subjective global assessment of nutritional status: further validation.

Subject global assessment of nutritional status was performed on 175 patients admitted to the medical-surgical gastroenterology service of a general hospital by a first-year resident and a specialist in clinical nutrition who were not aware of each other's evaluation. Patients were classified as well nourished or moderately or severely undernourished. Simultaneously, anthropometry was performed, serum albumin measured, and two units of PPD inoculated. A 79% concordance between the global subjective assessments made by the residents and the specialists was found. Patients in the three groups had significantly different weight, midarm circumference, triceps skinfold, and serum albumin values, whereas the total lymphocyte count and the percentage of negative PPD reactions were not significantly different. Subjective global assessment is a useful tool for the evaluation of nutritional status, even when used by inexperienced professionals.