Browsing by Subject "Malnutrition"
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Item Open Access A randomized trial of supplemental parenteral nutrition in underweight and overweight critically ill patients: the TOP-UP pilot trial.(Crit Care, 2017-06-09) Wischmeyer, Paul E; Hasselmann, Michel; Kummerlen, Christine; Kozar, Rosemary; Kutsogiannis, Demetrios James; Karvellas, Constantine J; Besecker, Beth; Evans, David K; Preiser, Jean-Charles; Gramlich, Leah; Jeejeebhoy, Khursheed; Dhaliwal, Rupinder; Jiang, Xuran; Day, Andrew G; Heyland, Daren KBACKGROUND: Nutrition guidelines recommendations differ on the use of parenteral nutrition (PN), and existing clinical trial data are inconclusive. Our recent observational data show that amounts of energy/protein received early in the intensive care unit (ICU) affect patient mortality, particularly for inadequate nutrition intake in patients with body mass indices (BMIs) of <25 or >35. Thus, we hypothesized increased nutrition delivery via supplemental PN (SPN) + enteral nutrition (EN) to underweight and obese ICU patients would improve 60-day survival and quality of life (QoL) versus usual care (EN alone). METHODS: In this multicenter, randomized, controlled pilot trial completed in 11 centers across four countries, adult ICU patients with acute respiratory failure expected to require mechanical ventilation for >72 hours and with a BMI of <25 or ≥35 were randomized to receive EN alone or SPN + EN to reach 100% of their prescribed nutrition goal for 7 days after randomization. The primary aim of this pilot trial was to achieve a 30% improvement in nutrition delivery. RESULTS: In total, 125 patients were enrolled. Over the first 7 post-randomization ICU days, patients in the SPN + EN arm had a 26% increase in delivered calories and protein, whereas patients in the EN-alone arm had a 22% increase (both p < 0.001). Surgical ICU patients received poorer EN nutrition delivery and had a significantly greater increase in calorie and protein delivery when receiving SPN versus medical ICU patients. SPN proved feasible to deliver with our prescribed protocol. In this pilot trial, no significant outcome differences were observed between groups, including no difference in infection risk. Potential, although statistically insignificant, trends of reduced hospital mortality and improved discharge functional outcomes and QoL outcomes in the SPN + EN group versus the EN-alone group were observed. CONCLUSIONS: Provision of SPN + EN significantly increased calorie/protein delivery over the first week of ICU residence versus EN alone. This was achieved with no increased infection risk. Given feasibility and consistent encouraging trends in hospital mortality, QoL, and functional endpoints, a full-scale trial of SPN powered to assess these clinical outcome endpoints in high-nutritional-risk ICU patients is indicated-potentially focusing on the more poorly EN-fed surgical ICU setting. TRIAL REGISTRATION: NCT01206166.Item Open Access Food for Thought: The Effectiveness of Inpatient Malnutrition Treatment in the Case of Nutre Hogar in Panama(2009-12) Chou, JuliaA nonprofit nongovernmental organization named Nutre Hogar was founded in 1988 to address the high prevalence of child malnutrition in Panama. Given the context specific nature of malnutrition treatment models, this paper evaluates whether or not Nutre Hogar’s inpatient treatment model is suited to the Panamanian context and whether an alternative model might be more effective. Quantitative data about physical outcomes of treatment were collected from a Nutre Hogar logbook, and interviews with parents of patients and Nutre Hogar staff members were conducted to gather qualitative data on community perceptions of Nutre Hogar. While children gained weight throughout their stay, they left the center still moderately malnourished, raising concerns about the efficacy of treatment. Recommendations include incorporating elements of other malnutrition treatment protocols into Nutre Hogar’s current program, as well as focusing on sustainable solutions for preventing malnutrition in children under five years of age in Panama.Item Open Access Impact of early postoperative oral nutritional supplement utilization on clinical outcomes in colorectal surgery.(Perioperative medicine (London, England), 2020-01) Williams, David GA; Ohnuma, Tetsu; Krishnamoorthy, Vijay; Raghunathan, Karthik; Sulo, Suela; Cassady, Bridget A; Hegazi, Refaat; Wischmeyer, Paul EBackground:Small randomized trials of early postoperative oral nutritional supplementation (ONS) suggest various health benefits following colorectal surgery (CRS). However, real-world evidence of the impact of early ONS on clinical outcomes in CRS is lacking. Methods:Using a nationwide administrative-financial database (Premier Healthcare Database), we examined the association between early ONS use and postoperative clinical outcomes in patients undergoing elective open or laparoscopic CRS between 2008 and 2014. Early ONS was defined as the presence of charges for ONS before postoperative day (POD) 3. The primary outcome was composite infectious complications. Key secondary efficacy (intensive care unit (ICU) admission and gastrointestinal complications) and falsification (blood transfusion and myocardial infarction) outcomes were also examined. Propensity score matching was used to assemble patient groups that were comparable at baseline, and differences in outcomes were examined. Results:Overall, patients receiving early ONS were older with greater comorbidities and more likely to be Medicare beneficiaries with malnutrition. In a well-matched sample of early ONS recipients (n = 267) versus non-recipients (n = 534), infectious complications were significantly lower in early ONS recipients (6.7% vs. 11.8%, P < 0.03). Early ONS use was also associated with significantly reduced rates of pneumonia (P < 0.04), ICU admissions (P < 0.04), and gastrointestinal complications (P < 0.05). There were no significant differences in falsification outcomes. Conclusions:Although early postoperative ONS after CRS was more likely to be utilized in elderly patients with greater comorbidities, the use of early ONS was associated with reduced infectious complications, pneumonia, ICU admission, and gastrointestinal complications. This propensity score-matched study using real-world data suggests that clinical outcomes are improved with early ONS use, a simple and inexpensive intervention in CRS patients.Item Open Access Leptin directly promotes T-cell glycolytic metabolism to drive effector T-cell differentiation in a mouse model of autoimmunity.(Eur J Immunol, 2016-08) Gerriets, Valerie A; Danzaki, Keiko; Kishton, Rigel J; Eisner, William; Nichols, Amanda G; Saucillo, Donte C; Shinohara, Mari L; MacIver, Nancie JUpon activation, T cells require energy for growth, proliferation, and function. Effector T (Teff) cells, such as Th1 and Th17 cells, utilize high levels of glycolytic metabolism to fuel proliferation and function. In contrast, Treg cells require oxidative metabolism to fuel suppressive function. It remains unknown how Teff/Treg-cell metabolism is altered when nutrients are limited and leptin levels are low. We therefore examined the role of malnutrition and associated hypoleptinemia on Teff versus Treg cells. We found that both malnutrition-associated hypoleptinemia and T cell-specific leptin receptor knockout suppressed Teff-cell number, function, and glucose metabolism, but did not alter Treg-cell metabolism or suppressive function. Using the autoimmune mouse model EAE, we confirmed that fasting-induced hypoleptinemia altered Teff-cell, but not Treg-cell, glucose metabolism, and function in vivo, leading to decreased disease severity. To explore potential mechanisms, we examined HIF-1α, a key regulator of Th17 differentiation and Teff-cell glucose metabolism, and found HIF-1α expression was decreased in T cell-specific leptin receptor knockout Th17 cells, and in Teff cells from fasted EAE mice, but was unchanged in Treg cells. Altogether, these data demonstrate a selective, cell-intrinsic requirement for leptin to upregulate glucose metabolism and maintain function in Teff, but not Treg cells.Item Open Access Mapping local patterns of childhood overweight and wasting in low- and middle-income countries between 2000 and 2017.(Nature medicine, 2020-05) LBD Double Burden of Malnutrition CollaboratorsA double burden of malnutrition occurs when individuals, household members or communities experience both undernutrition and overweight. Here, we show geospatial estimates of overweight and wasting prevalence among children under 5 years of age in 105 low- and middle-income countries (LMICs) from 2000 to 2017 and aggregate these to policy-relevant administrative units. Wasting decreased overall across LMICs between 2000 and 2017, from 8.4% (62.3 (55.1-70.8) million) to 6.4% (58.3 (47.6-70.7) million), but is predicted to remain above the World Health Organization's Global Nutrition Target of <5% in over half of LMICs by 2025. Prevalence of overweight increased from 5.2% (30 (22.8-38.5) million) in 2000 to 6.0% (55.5 (44.8-67.9) million) children aged under 5 years in 2017. Areas most affected by double burden of malnutrition were located in Indonesia, Thailand, southeastern China, Botswana, Cameroon and central Nigeria. Our estimates provide a new perspective to researchers, policy makers and public health agencies in their efforts to address this global childhood syndemic.Item Open Access Mid-upper Arm Circumference (MUAC) and injury characteristics in hospitalized patients in an emergency department of North Tanzania(2021) Ramirez, ThaisBackground: The impact of malnutrition on the outcomes of hospitalized adult patients in resource-limited settings is not fully described. We aimed to report our observation of the comparison made between mid-upper arm circumference (MUAC) and injury outcomes in adults admitted to the Emergency Department of a hospital in Moshi, Tanzania. Methods: This study was a secondary analysis based on an on-going Trauma registry collected by researchers from the Duke Global Health Institute at Duke University in collaboration with the Kilimanjaro Christian Medical Centre (KCMC) from April 2018 until April 2020. Results: Females were significantly more likely to have higher MUAC scores than males (B=1.90; SE=0.49; p-value=0.000). Compared to single patients, those married were more likely to have higher MUAC (B=1.28; SE=0.48; p-value=0.007). Compared to advanced education, patients identified with basic education were less likely to have higher MUAC (B=-1.46; SE=0.42; p-value=0.000). Although glasgow outcome was not significantly associated with MUAC score in our univariate analysis (B=-1.20; SE=1.46; p-value=0.41), in our adjusted model, lower good recovery were less likely to have higher muac scores then other glasgow outcomes (B=-2.02; SE=0.73; p-value=0.000). Conclusions: Undernutrition in hospital patients is often unrecognized and there is a need for simple means of screening to facilitate targeted nutritional intervention. Further research is needed to understand the pathophysiology of malnutrition during acute illness and validate MUAC cut-off points for hospitalized adults.
Item Open Access Nutritional effects on T-cell immunometabolism.(Eur J Immunol, 2017-01-05) Cohen, Sivan; Danzaki, Keiko; MacIver, Nancie JT cells are highly influenced by nutrient uptake from their environment, and changes in overall nutritional status, such as malnutrition or obesity, can result in altered T-cell metabolism and behavior. In states of severe malnutrition or starvation, T-cell survival, proliferation, and inflammatory cytokine production are all decreased, as is T-cell glucose uptake and metabolism. The altered T-cell function and metabolism seen in malnutrition is associated with altered adipokine levels, most particularly decreased leptin. Circulating leptin levels are low in malnutrition, and leptin has been shown to be a key link between nutrition and immunity. The current view is that leptin signaling is required to upregulate activated T-cell glucose metabolism and thereby fuel T-cell activation. In the setting of obesity, T cells have been found to have a key role in promoting the recruitment of inflammatory macrophages to adipose depots along with the production of inflammatory cytokines that promote the development of insulin resistance leading to diabetes. Deletion of T cells, key T-cell transcription factors, or pro-inflammatory T-cell cytokines prevents insulin resistance in obesity and underscores the importance of T cells in obesity-associated inflammation and metabolic disease. Altogether, T cells have a critical role in nutritional immunometabolism.Item Open Access Nutritional Support Should Target the Cause of Malnutrition in Hospitalized Patients.(JAMA network open, 2021-01-04) Evans, William JItem Open Access Poor Nutrition Status and Lumbar Spine Fusion Surgery in the Elderly: Readmissions, Complications, and Mortality.(Spine, 2017-07) Puvanesarajah, Varun; Jain, Amit; Kebaish, Khaled; Shaffrey, Christopher I; Sciubba, Daniel M; De la Garza-Ramos, Rafael; Khanna, Akhil Jay; Hassanzadeh, HamidStudy design
Retrospective database review.Objective
To quantify the medical and surgical risks associated with elective lumbar spine fusion surgery in patients with poor preoperative nutritional status and to assess how nutritional status alters length of stay and readmission rates.Summary of background data
There has been recent interest in quantifying the increased risk of complications caused by frailty, an important consideration in elderly patients that is directly related to comorbidity burden. Preoperative nutritional status is an important contributor to both sarcopenia and frailty and is poorly studied in the elderly spine surgery population.Methods
The full 100% sample of Medicare data from 2005 to 2012 were utilized to select all patients 65 to 84 years old who underwent elective 1 to 2 level posterior lumbar fusion for degenerative pathology. Patients with diagnoses of poor nutritional status within the 3 months preceding surgery were selected and compared with a control cohort. Outcomes that were assessed included major medical complications, infection, wound dehiscence, and mortality. In addition, readmission rates and length of stay were evaluated.Results
When adjusting for demographics and comorbidities, malnutrition was determined to result in significantly increased odds of both 90-day major medical complications (adjusted odds ratio, OR: 4.24) and 1-year mortality (adjusted OR: 6.16). Multivariate analysis also demonstrated that malnutrition was a significant predictor of increased infection (adjusted OR: 2.27) and wound dehiscence (adjusted OR: 2.52) risk. Length of stay was higher in malnourished patients, though 30-day readmission rates were similar to controls.Conclusion
Malnutrition significantly increases complication and mortality rates, whereas also significantly increasing length of stay. Nutritional supplementation before surgery should be considered to optimize postoperative outcomes in malnourished individuals.Level of evidence
3.Item Open Access Preoperative dysphagia risk in community-dwelling adults aged ≥50 years: Prevalence and risk factors.(Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, 2023-02) Canick, Julia; Campbell, James C; Cohen, Seth M; Jones, Harrison N; Leiman, David A; Raman, Sudha; Porter Starr, Kathryn NBackground
Preoperative dysphagia screening is rare. The purpose of this study was to assess the prevalence and potential risk factors of preoperative dysphagia risk in adults preparing for surgery.Methods
The Eating Assessment Tool (EAT-10), Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF), and Sarcopenia Screening Tool (SARC-F) were self-administered in adults preparing for surgery to identify dysphagia, malnutrition, and sarcopenia risk, respectively. Other variables collected include clinical demographics, fall risk, and surgical history associated with increased dysphagia risk. Descriptive summary statistics, univariate analysis, and logistic regression were performed as appropriate.Results
The median age was 69 years and preoperative dysphagia risk was 9.6%. Among 357 patients completing both EAT-10 and PG-SGA SF or SARC-F, 7.3% had preoperative dysphagia and malnutrition risk and 7.2% had preoperative dysphagia and sarcopenia risk. Preoperative dysphagia risk was 2.7 times greater in those with prior surgical history associated with increased risk of dysphagia, 2.2 times higher in women, and almost twice as high in Black patients and patients with fall risk. Logistic regression revealed significant odds ratios (ORs) for prior surgical history associated with increased risk of dysphagia (OR, 2.95; 95% CI, 1.62-5.40) and male sex (OR, 0.52; 95% CI, 0.29-0.94), and a significant relationship between preoperative dysphagia and malnutrition risk (OR, 4.56; 95% CI, 2.02-10.28) when controlling for clinical variables.Conclusion
The high prevalence of dysphagia risk alone and in combination with malnutrition and sarcopenia risk in community-dwelling adults underscores the need for standardized preoperative screening and optimization prior to surgery.Item Open Access Synergy in Paradox: The Role of Food Aid and Assistance in Addressing the Double Burden of Malnutrition in Ghana(2019-12-05) Torto, NiisojaIn many low- and middle-income countries, the coexistence of undernutrition with overweight and obesity threatens economic development and progress to improve health. This double burden of malnutrition demands a re-evaluation of the roles and responsibilities of nutrition actors, both traditional and nontraditional. The United Nations World Food Programme (WFP) is one nontraditional actor in the double burden debate. Using a descriptive case study qualitative methodology, this paper explores whether WFP’s food aid and assistance has the potential to reach beyond its traditional mandate on undernutrition to also address overweight and obesity. The analysis demonstrates that in the context of Ghana, one country experiencing the double burden, WFP’s food aid and assistance activities do have the potential to serve as a platform on which to address the double burden. Interview insight from key actors in the global nutrition landscape also helped identify challenges that complicate the role of WFP and other players in addressing the double burden in Ghana. The findings suggest that the integration of WFP as a partner in the effort to address the double burden might help amplify progress. Moreover, they suggest that, to better address the double burden, WFP might prioritize retrofitting existing activities rather than implementing new interventions. While this study focuses on Ghana, the foundation of its findings might be applicable in similar contexts.Item Open Access Tailoring nutrition therapy to illness and recovery.(Crit Care, 2017-12-28) Wischmeyer, Paul EWithout doubt, in medicine as in life, one size does not fit all. We do not administer the same drug or dose to every patient at all times, so why then would we live under the illusion that we should give the same nutrition at all times in the continuum of critical illness? We have long lived under the assumption that critical illness and trauma lead to a consistent early increase in metabolic/caloric need, the so-called "hypermetabolism" of critical illness. What if this is incorrect? Recent data indicate that early underfeeding of calories (trophic feeding) may have benefits and may require consideration in well-nourished patients. However, we must confront the reality that currently ICU nutrition delivery worldwide is actually leading to "starvation" of our patients and is likely a major contributor to poor long-term quality of life outcomes. To begin to ascertain the actual calorie and protein delivery required for optimal ICU recovery, an understanding of "starvation" and recovery from starvation and lean body mass (LBM) loss is needed. To begin to answer this question, we must look to the landmark Minnesota Starvation Study from 1945. This trial defines much of the world's knowledge about starvation, and most importantly what is required for recovery from starvation and massive LBM loss as occurs in the ICU. Recent and historic data indicate that critical illness is characterized by early massive catabolism, LBM loss, and escalating hypermetabolism that can persist for months or years. Early enteral nutrition during the acute phase should attempt to correct micronutrient/vitamin deficiencies, deliver adequate protein, and moderate nonprotein calories in well-nourished patients, as in the acute phase they are capable of generating significant endogenous energy. Post resuscitation, increasing protein (1.5-2.0 g/kg/day) and calories are needed to attenuate LBM loss and promote recovery. Malnutrition screening is essential and parenteral nutrition can be safely added following resuscitation when enteral nutrition is failing based on pre-illness malnutrition and LBM status. Following the ICU stay, significant protein/calorie delivery for months or years is required to facilitate functional and LBM recovery, with high-protein oral supplements being essential to achieve adequate nutrition.