Nutrition et maladie d’Alzheimer

Deterioration of memory function and ultimately establishment of Alzheimer's disease (AD) severely debilitates the affected individual, uncompromisingly decreasing the quality of life of both patients and their caregivers. The global prevalence of cognitive impairment and dementia including Alzheimer's disease is expected to rise significantly in proportion to increased life expectancy. Weight loss is a common problem among patients with AD and is associated with mortality, morbidity, disease progression, and poor quality of life. The aim of this article is: (1) to emphasize the importance of malnutrition in Alzheimer's disease and (2) to review published evidences for the role of nutrition as a risk factor of the disease.     

Nutrition et maladie de Parkinson

About 143,000 patients suffered from Parkinson's disease (PD) in France in 2005. The main nutritional issues are undernutrition, the need of adaptation of protein intakes and the weight gain after deep brain stimulation. Malnutrition is linked to the disease itself and treatments. Handicap, psychological troubles, swallowing disorders, taste and smell disorders, gastroparesis and constipation are the main causes of dietary intake insufficiency. Malnutrition care is not specific. Energy expenditure is probably enhanced by hypertony and abnormal movements, and depends on patient responses to treatments. One out of four PD patients can be undernourished, thus an early screening of undernutrition is mandatory. Body Mass Index (BMI), weight variation and Mini Nutritional Assessment^® (MNA^®) are the tools usually used in PD. Except for protein intakes, nutritional care has no specificity. Indeed, several aminoacids and levodopa compete for intestinal absorption and transport across blood-brain barrier. When treatments have a low efficiency, or if disease worsens, protein intake has to be increased for dinner and limited for other meals, levodopa has to be taken 20 to 30 minutes before meals, and in front of severe neurological troubles, daily protein intake can be decreased. Deep brain stimulation is rapidly followed by an increase in weight, sometimes complicated with dyslipidemia or diabetes. Obesity may increase the handicap. Swallowing disorders are the main cause of mortality. When enteral nutrition is mandatory, the gastrostomy has not to be early discussed.     

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.     

Maladies alcooliques du foie et dénutrition

The aim of this study is to try to answer to four questions from a literature review.

1) What is the prevalence of malnutrition in alcoholic patients with and without liver disease?

2) Is nutritional status independently correlated with survival in patients with alcoholic cirrhosis?

3) Is nutritional supplementation useful in patients with severe liver disease?

4) What energy substrate and nitrogen sources should be used for intravenous nutrition in patients with cirrhosis?

The answers to these questions are:

1) The prevalence of malnutrition in alcoholic patients depends on definition of the studied population. The objective assessment of nutritional status by quantitative clinical and biological parameters is difficult.

2) It has not been demonstrated that nutritional status has an independent prognostic value in patients with alcoholic cirrhosis.

3) The effectiveness of supplementary parenteral nutrition on survival and nutritional status of patients with severe alcoholic liver disease has not been proved.

4) Neither fat emulsions nor conventional amino acids solutions are contraindicated in patients with cirrhosis when parenteral nutrition is necessary.

Aspects métaboliques de la dénutrition au cours de la maladie VIH

The Wasting Syndrome (WS) is one of the major aspects of the acquired immunodeficiency syndrome (AIDS). Fat free mass, the amount of functionnal protoplasm in non adipose tissue is an independent predictor of death in AIDS patients.The deficit of the energy balance could be the result of decreased caloric intake and/or increased energy expenditure. Elevated Resting Energy Expenditure (REE) has been reported in the early stage of the HIV infection. Patients with AIDS who had active secondary infection had a striking average weight loss resulting of the combination of anorexia and dramatic elevated REE. The role of cytokines in the WS was proposed in reason of the in vitro and in vivo metabolic disturbances induced by these cytokines. The difference studies suggest that synergistic interactions between cytokines may be necessary for developping the WS.     

Stress oxydant, fonctions vasculaires et athéroscléroseOxidative stress, vascular function and atherosclerosis

The vascular endothelium plays a major role in the regulation of the vascular tone, in response to several stimuli such as prostacyclin, endothelin and above all nitric oxide (NO^•). Oxidative stress, which is characterized by a relative increased level of reactive oxygen species (ROS), is able to decrease NO^• biodisponibility. This leads to a vascular dysfunction. In addition, ROS (produced in part by NADPH oxidase) participate, either directly or via oxidized low density lipoproteins, to signal transduction in vascular cells. They are thus involved in apoptosis, smooth muscle cell proliferation, monocyte adhesion to endothelial cells or platelet aggregation. Therapeutics which could modulate ROS production in the endothelial cells could be proposed to restore endothelial function.     

Propositions de structuration des commissions de menus en établissements d’hébergement pour personnes âgées dépendantes

Menu Committees (MC) are frequently present in French geriatric institutions like nursing homes, but with variable functioning conditions. Their aims are theoretically to favour communication about food, and to validate menus in each institution. However, statutory frame and bibliography on MC are poor and consequently pragmatic propositions based on daily practice can be made. They give optimal aims of MC, its composition including which role each participant plays and the functioning conditions before, during and after MC. A better satisfaction of residents, medical practitioners and employees, combined with surveys showing improvements in food supply could be signs of a good efficiency for MC.     

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.     

Manifestations digestives et nutritionnelles des déficits immunitaires congénitaux et acquis chez l'enfant

The gastrointestinal and nutritional impact of congenital immunodeficiencies is varied and non-specific (serious refractory diarrhea, exsudative enteropathy, enterocolitis and chronic infections by Cryptosporidium, Giardia, rotavirus, Candida, etc.). Ulcerative colitis and autoimmune diseases are less frequent. Available therapeutic tools (immunoglobulins, implantable venous accesses and BMT) are reasonably effective. AIDS in children can be either rapidly or slowly progressive, and is usually due to maternofetal transmission. Gastrointestinal lesions are non-specific (candidiasis, chronic malabsorptive diarrhea, hepatitis, cryptosporidiosis, CMV, giardiasis, herpes) and cause overall malnutrition. Early nutritional support is indicated, but the modalities and results remain to be determined.     

Nutrition et transplantation hépatique

Protein-energy malnutrition is frequently observed in patients suffering from advanced chronic liver diseases and who are candidates for liver transplantation. This malnutrition may negatively affect the outcome. Moreover, a constant deficit in vitamins and trace elements can affect antioxidant defenses during ischemia-reperfusion injury. Nutritional intervention prior to transplantation is needed.     

Vieillissement humain : évolution démographique et implications médicales

French population ageing is constant since 1960. Even if elderly people quality of life keeps on improvement, population ageing leads to increasing consumption of care. Dementia, dependencies, are more frequent, and lead to many diseases, especially through malnutrition. This phenomenon have to be anticipate with global and coordinated agreement of sanitary, medical and psycho-social organization.     

Stratégies de dépistage de la dénutrition chez l''enfant hospitalisé

Metabolic stress modifies homeostasis, therefore nutrient's metabolism and nutritional needs. Stress is a risk factor of malnutrition, which increases morbidity and short-term mortality, and, in the child, can threaten long-term growth. Nutritional assessment is difficult in critically ill children. Nutritional support must be undertaken early as possible, especially in malnourished children and with severe agression. Enteral nutrition must be privileged. Parenteral nutrition is indicated when enteral nutrition is impossible, badly supported or insufficient to satisfy needs. Monitoring must be rigorous because aggression increases the risk of metabolic complications.     

Place de l’alpha-cétoglutarate d’ornithine dans le traitement de la sarcopénie

Sarcopenia is defined as the loss of muscle mass and function during ageing. Despite its important metabolic and functional consequences, the underlying mechanisms of sarcopenia are poorly understood. A blunted anabolic response to food intake together with a reduction in the peripheral availability of amino acid associated with a greater use by the splanchnic bed likely participate in this phenomenon. In this context, ornithine α-ketoglutarate (OKG), which stimulates the secretion of insulin and growth hormone and the production of amino acids with anabolic function and/or low splanchnic extraction could improve the mechanical and metabolic capacities of muscle in older individuals. If so, the ultimate goal of such treatment should be to improve muscle contractile function and limit the loss of mobility in the elderly.     

Indane-1,3-diones IX, synthèse et activité anti-inflammatoire de 2-polyaza-arylindane-1,3-diones et de leurs dérivés N- ou O-substitués

Les auteurs étudient les voies d'accès à des 2-polyaza-arylindane-1,3-diones et à leurs dérivés diversement substitués sur l'hétérocycle et l'homocycle ainsi que la pharmacomodulation de leur activité anti-inflammatoire. Ces β dicétoénamines fournissent en milieu alcalin des anions multidents conduisant en présence d'agents électrophiles à une C, N ou O-substitution; la mise en œuvre de la réaction de Mitsunobu a abouti à une N-(ω-amino-)-alkylation régiospécifique ou régiosélective. Parmi les diverses modifications structurales, la N-éthylation de la molécule de base, éventuellement couplée avec une méthoxylation en 5 sur l'homocycle s'est avérée efficace pour l'émergence d'une activité anti-inflammatoire en séries pyridazinyle, pyrimidinyle et tétrazolyle. Parmi les 3 molécules les plus actives 31, 43 et 50, la seconde a fait l'object d'une étude plus approfondie.     

Mécanismes d’action potentiels de la glutamine chez le patient agressé

Several controlled studies and recent meta-analysis indicate that glutamine supplementation has beneficial effects on clinical outcome of critically ill and surgical patients. These effects could be explained in part by the role of glutamine as the preferential substrate of rapidly dividing cells but also by its influence on inflammatory and immune response, on oxidative stress, on heat shock protein expression and on glucose metabolism. Indeed, glutamine supports gut barrier function by stimulating gut protein synthesis and epithelial cell proliferation and by limiting apoptosis. In addition, glutamine enhances intestinal and systemic immune response and antioxidant defences such as glutathione pool. Glutamine also induces the expression of heat shock proteins that play a key role in cellular protection. In contrast, glutamine decreases intestinal and systemic inflammatory response by decreasing pro-inflammatory cytokine production but also by increasing anti-inflammatory cytokine production. This effect of glutamine on inflammatory response may be mainly related to its capacity to reduce NF-κB activity. More recently, some data indicate that glutamine may reduce insulin resistance and thus the risk of infectious complications.     

Outils et procédures de dépistage de la dénutrition et de son risque en milieu hospitalierTools and procedures for screening for malnutrition and its associated in risks in hospital

Malnutrition affects on average 20–50% of hospital inpatients and its negative repercussions in terms of morbi-mortality have been fully documented. Although this state of affairs is well known, there is little screening for malnutrition in hospitals. There is no single parameter indicating malnutrition, which instead has to be diagnosed based on anthropometric and biological data, and by multi-factorial indices of nutritional risk. Screening adapted to each of the four main classes of hospital care, acute medicine and surgery, intensive care, geriatrics and paediatrics needs to be systematically performed for every inpatient. To make malnutrition screening a natural part of the practice of care, we need to design training courses, which highlight the benefits in terms of length of stay, morbi-mortality and cost.     

Le droit à la nutrition : un droit de l’homme à promouvoir et à défendre

Nutrition is a special treatment, between care and cure. Besides being a fundamental physiological need, it is a powerful emotional and symbolic vector regardless of age, and a treatment for the sick person. Nutrition, hydration and feeding are natural inalienable rights of the human being and therefore of human rights. Thus, this right has found its place, namely or not, in the Declarations and international Conventions of human rights since 1948. The right to receive adequate nutritional support is part of the fundamental principle of safeguarding the respect of the human being dignity and integrity, entered in French positive law in 1994 (first bioethics law), and since then regularly reaffirmed in all texts. Nutritional treatment is the tool of nutrition right. Badly applied, it needs to be widely recognized, defended, guaranteed and protected. We recount the emergence of this right from its sources, including in international law, and will show how it was introduced in the treatment relation.     

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.