Comparing the effects of whey and casein supplementation on nutritional status and immune parameters in patients with chronic liver disease: a randomised double-blind controlled trial.

Protein supplementation may be beneficial for patients with chronic liver disease (CLD). This study compared the effects of whey protein isolate (WP) and casein (CA) supplementation on nutritional status and immune parameters of CLD patients who were randomly assigned to take 20 g of WP or CA twice per d as a supplement for 15 d. Body composition, muscle functionality and plasmatic immunomarkers were assessed before and after supplementation. Patients were also classified according to the model for end-stage liver disease (MELD) into less (MELD < 15) and more (MELD ≥ 15) severe disease groups. Malnutrition, determined by the Subjective Global Assessment at baseline, was observed in 57·4 % and 54·2 % of patients in the WP and CA groups, respectively (P = 0·649). Protein intake was lower at baseline in the WP group than in the CA group (P = 0·035), with no difference after supplementation (P = 0·410). Both the WP and CA MELD < 15 groups increased protein intake after supplementation according to the intragroup analysis. No differences were observed in body composition, muscle functionality, most plasma cytokines (TNF, IL-6, IL-1ß and interferon-γ), immunomodulatory proteins (sTNFR1, sTNFR2, brain-derived neurotrophic factor and glial cell line-derived neurotrophic factor) or immunomodulatory hormones (adiponectin, insulin and leptin) after supplementation in the WP groups at the two assessed moments. WP supplementation increased the levels of interferon-γ-induced protein-10/CXCL10 (P = 0·022), eotaxin-1/CCL11 (P = 0·031) and monocyte chemoattractant protein-1/CCL2 (P = 0·018) and decreased IL-5 (P = 0·027), including among those in the MELD ≥ 15 group, for whom IL-10 was also increased (P = 0·008). Thus, WP consumption by patients with CLD impacted the immunomodulatory responses when compared with CA with no impact on nutritional status.

Eating behaviour patterns are associated with excessive weight gain after liver transplantation.

BACKGROUND: Weight gain and obesity are important issues in liver transplant (LTx) recipients. Although dietary habits are probably related to excessive weight gain after LTx, some studies have failed to demonstrate these associations. The present study aimed to assess eating behaviour and verify its association with weight gain and excessive weight among LTx recipients. METHODS: The investigation comprised a cross-sectional study. Post-LTx patients, aged >18 years were evaluated about their eating behaviour [Three Factor Eating Questionnaire-R21 (TFEQ-R21)]. The scores of the TFEQ-R21 [uncontrolled eating (UE), cognitive restraint (CR) and emotional eating (EE)] were determined. Excessive weight was classified as body mass index ≥25 kg/m² and obesity ≥30 kg/m². RESULTS: In total, 270 patients (age 58.0 years; range 20.0-77.0 years; 64.1% men) were assessed. Average weight gain was 8.0 kg (range -16.0 to 41.0 kg). Of the patients, 64.1% (n = 173) had excessive weight and 23.3% (n = 63) were obese. Post-LTx weight gain was significantly correlated with UE (r = 0.311, P < 0.001) and EE (r = 0.287, P < 0.001). Patients with excessive weight had significantly higher scores than others: CR (61.0; range 0-122.0 versus 44.0; range 0-116.0) (P = 0.003) and EE (11.0; range 0-100.0 versus 0.0; range 0-100.0) (P = 0.030). Patients with obesity had higher scores than non-obese UE (22.0; range 0-77.0 versus 14.0; range 0-85.0; P = 0.028), CR (55.0; range 11.0-116.0 versus 50.0; range 0-122.0) (P = 0.017) and EE (16.0; range 0-100.0 versus 5.0; range 0-100.0) individuals (P < 0.001). The greatest quartiles of weight gain had higher scores on the eating behaviours of UE and EE, especially those with weight gain ≥14 kg. UE was associated with weight gain. CR was associated with being overweight. EE was associated with obesity. CONCLUSIONS: Uncontrolled eating is associated with weight gain, CR was associated with excessive weight and EE was associated with obesity after LTx.

Global Leadership Initiative on Malnutrition (GLIM): Guidance on validation of the operational criteria for the diagnosis of protein-energy malnutrition in adults.

BACKGROUND: The Global Leadership Initiative on Malnutrition (GLIM) created a consensus-based framework consisting of phenotypic and etiologic criteria to record the occurrence of malnutrition in adults. This is a minimum set of practicable indicators for use in characterizing a patient/client as malnourished, considering the global variations in screening and nutrition assessment, and to be used across different health care settings. As with other consensus-based frameworks for diagnosing disease states, these operational criteria require validation and reliability testing as they are currently based solely on expert opinion. METHODS: Several forms of validation and reliability are reviewed in the context of GLIM, providing guidance on how to conduct retrospective and prospective studies for criterion and construct validity. FINDINGS: There are some aspects of GLIM criteria which require refinement; research using large data bases can be employed to reach this goal. Machine learning is also introduced as a potential method to support identification of the best cut-points and combinations of operational criteria for use with the different forms of malnutrition, which the GLIM criteria were created to denote. It is noted as well that the validation and reliability testing need to occur in a variety of sectors, populations and with diverse persons completing the criteria. CONCLUSION: The guidance presented supports the conduct and publication of quality validation and reliability studies for GLIM.

Perioperative nutritional management of patients undergoing laparotomy.

OBJECTIVES: Lack of routine patient's nutritional assessment and prescription of long fasting periods throughout the perioperative period are still widely prevalent despite the advances in surgical care. Therefore, the aim of this study was to assess nutritional routines in two surgical wards. METHODS: Adult patients undergoing laparotomy at two distinct units (gastrointestinal and gynecologic) in two public hospitals (one of them a university) were enrolled. Patients were divided in minor and major (groups A and B) procedures and were nutritionally assessed at admission. Daily diet intake and a 24 hour recall were performed. Patients rated the quality of the meals, as well as registered the reasons for not ingesting it fully. RESULTS: Patients in group B presented with poorer nutritional status. Group A patients resumed oral diets on the first post operative day and most of them received regular diets (85.5%). In group B, only 4.7% were allowed a regular diet on the first PO day, 7.0% received soft diets, 30.2% full liquid diets, 27.9% clear liquids and the remaining 30.2% were on NPO. Patients in this group had a slower progression of diets from liquid to regular solid meals, with 7% of them still on NPO on the fifth PO day. Contrary to group B, patients in group A did not present with cumulative caloric and protein deficits throughout the postoperative period. Overall tolerance of the early diet was good. CONCLUSION: Malnutrition is still high among major surgical patients. Early oral nutrition can be feasible and well tolerated with few side effects, when prescribed.

GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community.

RATIONALE: This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings. METHODS: In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee and a supporting working group with representatives bringing additional global diversity and expertise. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications. RESULTS: A two-step approach for the malnutrition diagnosis was selected, i.e., first screening to identify "at risk" status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among the GLIM core and supporting working group members. The top five ranked criteria included three phenotypic criteria (non-volitional weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present. Phenotypic metrics for grading severity as Stage 1 (moderate) and Stage 2 (severe) malnutrition are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories. CONCLUSION: A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure further collaboration and endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The diagnostic construct should be re-considered every 3-5 years.

GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community.

RATIONALE: This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings. METHODS: In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee and a supporting working group with representatives bringing additional global diversity and expertise. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications. RESULTS: A two-step approach for the malnutrition diagnosis was selected, i.e., first screening to identify "at risk" status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among the GLIM core and supporting working group members. The top five ranked criteria included three phenotypic criteria (weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present. Phenotypic metrics for grading severity as Stage 1 (moderate) and Stage 2 (severe) malnutrition are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories. CONCLUSION: A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure further collaboration and endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The diagnostic construct should be re-considered every 3-5 years.

Hospital malnutrition: the Brazilian national survey (IBRANUTRI): a study of 4000 patients.

OBJECTIVE: We assessed nutrition status and prevalence of malnutrition in hospital patients as determined by the Subjective Global Assessment Form, awareness of patients' nutrition status by health teams, and the use of nutrition therapy. METHODS: We enrolled 4000 hospital patients at least 18 y old who were covered by the Brazilian public health care system in a cross-sectional, multicenter epidemiologic study. We used Student's t and chi-square tests for univariate and multiple logistic regression analyses. RESULTS: Malnutrition was present in 48.1% of patients and severe malnutrition was present in 12.5% of patients. The prevalence of malnutrition was higher in the northern and northeastern regions of Brazil, where per-capita income is lower. Malnutrition correlated with primary diagnosis at admission, age (60 y), presence of cancer or infection, and longer hospital stay (P < 0.05). Fewer than 18.8% of patients' records contained information on nutrition-related issues. Nutrition therapy was used in 7.3% of patients (6.1% enteral nutrition and 1.2% parenteral nutrition). CONCLUSIONS: The prevalence of malnutrition in hospitalized patients in Brazil is high, physician awareness of malnutrition is low, and nutrition therapy is underprescribed.

Peripheral parenteral nutrition: an option for patients with an indication for short-term parenteral nutrition.

OBJECTIVE: The aim of this study was to examine and describe our experience with the use of peripheral parenteral nutrition (PPN). METHODS: Patients with an indication for parenteral nutrition for less than 15 days received it via a peripheral vein via a short, 20 or 22 gauge French polyurethane catheter. Parenteral nutrition had a final osmolality of 993 mOsm/l and was administered by infusion pump. The nutritional status of patients was assessed by the Subjective Global Assessment (SGA) technique. Patients were followed by a trained nutritional team and the access site was changed if problems developed. RESULTS: Fifty-three patients were followed with a mean age of 59.5 +/- 17.5 years. There were 36 males (69.2%). Nutritional requirements were reached in 67.6% of the patients within 2.9 +/- 0.7 days. The mean time on parenteral nutrition was 7.2 +/- 6.6 days. In 74.3% of the cases parenteral nutrition was offered until the end of the planned treatment. Pain at the venipuncture site occurred in 17.1% of the cases, pain and fever in 20% and pain, hyperthermia and edema in 2.8%. No patient developed an abscess. CONCLUSIONS: PPN can benefit a great number of patients without the risks linked to a venous central catheter. Complications associated with PPN are low especially when the care and follow-up are provided by a nutritional support team.

Risk factors for malnutrition in patients undergoing gastroenterological and hernia surgery: an analysis of 374 patients.

OBJECTIVE: The aim of this study was to assess the nutritional status of 374 surgical patients with gastrointestinal disease and hernias of the abdominal wall; to identify risk factors associated with a poorer nutritional status in this group of patients and to assess awareness of the patient's nutritional status by medical teams. SUMMARY BACKGROUND DATA: Malnutrition is prevalent among surgical patients and is associated with higher surgical complication rates and mortality. The major causes of poor nutritional status are related to the underlying disease, socio-economic factors, age, and length of hospitalization. Despite its high prevalence, medical teams often overlook malnutrition, and screening of these patients is not routine. It is of utmost importance to identify patients at risk for malnutrition in order to prevent related complications. METHODS: The 374 patients evaluated in this study were a subgroup of a larger multicenter, cross-sectional, randomized study that was carried out in 1996. Nutritional status was assessed by using Subjective Global Assessment. RESULTS: Malnutrition was present in 55% of the patients, with 19% of the patients severely malnourished. The presence of cancer, infection, age over 60 years, upper gastrointestinal disease, and longer length of hospital stay all negatively influenced nutritional status. Despite the high prevalence of malnutrition, the medical teams only assessed the nutritional status of a few patients. CONCLUSION: Malnutrition was highly prevalent in this setting of patients. Therefore, patients with the risk factors above presented should routinely undergo nutritional screening and/or assessment in order to be able to early diagnose or prevent malnutrition and its correlated morbidity and mortality.

Total nutritional therapy: a nutrition education program for physicians.

OBJECTIVE: Almost half of all hospitalized patients are malnourished with low physician awareness or implementation of nutrition support. To address this problem, a 2-day immersion course in clinical nutrition for physicians was developed by the Latin American Federation of Parenteral and Enteral Nutrition (FELANPE) with support from Abbott Laboratories. The goal of Total Nutritional Therapy (TNT) is to help physicians utilize this nutrition knowledge to increase their awareness of malnutrition and implementation of nutritional therapy. Since 1997, over 8,000 physicians have completed the TNT course in 16 Latin American countries. RESEARCH METHODS & PROCEDURES: During 1999 and 2000, 675 participants responded to a survey 6 months after having completed the TNT course to determine what impact the course had on the use of nutrition assessment, nutrition support teams, or nutrition consultations in their clinical practice, and if they had participated in any nutrition association or conferences. RESULTS: The majority of physicians who completed the survey increased their use of nutrition assessment and time dedicated to nutrition therapy, and increased the number of their patients placed on nutrition therapy. CONCLUSIONS: The TNT course has been shown to be an efficient model of clinical nutrition education for general physicians. The course should be considered as part of the training of medical residents.

Effect of a physical exercise program on the functional capacity of liver transplant patients.

BACKGROUND: Recently there has been great concern about the quality of life and health of liver transplant patients (LTP). These patients often present with metabolic disorders, which can improve with regular physical exercise. The aim of this study was to investigate the effect of a physical exercise program on the functional capacity of LTP. METHOD: The distance walked in the 6-minute walk test and the resting energy expenditure (REE) were evaluated in 15 subjects who regularly attend the outpatient Bias Fortes Clinic at Universidade Federal de Minas Gerais. The patients were divided into 2 groups, the Exercise Group (EG) (6 men and 3 women; 52 ± 15 years old, BMI 22.4 ± 4.0 kg/m²) performed 24 sessions of continuous 30 min treadmill exercise. Intensity of exercise was increased from 50%-70% of the maximum heart rate over the training period. A group of 3 men and 3 women (39 ± 15 years, BMI 24.5 ± 4.4 kg/m²) served as controls (CG). RESULTS: After undergoing exercise training, patients in the EG showed a 19.4% increase in the distance walked (pre = 453.6 ± 128.0 m and post = 582.5 ± 90.1 m). Also, there was an increase in their REE (pre = 1,060.0 ± 194.2 kcal and post = 1,375.0 ± 258.6 kcal) (P < .05) indicating an increase in their exercise capacity and metabolic improvements. There were no differences in the distance walked (pre = 516.5 ± 62.0 m and post = 517.7 ± 71.9 m) and REE (pre = 1,393.0 ± 213.3 kcal to post = 1,465.0 ± 170.3 kcal) (P > .05) for CG. Our results are in agreement with previous studies. CONCLUSIONS: We conclude that the exercise program promoted significant improvements in functional capacity. These findings have positive implications for the control of metabolic diseases, which are common in patients after liver transplantation.

Overweight, obesity and weight gain up to three years after liver transplantation.

INTRODUCTION: Previous studies have shown that weight gain commonly occurs after liver transplantation (LTx). Few risk factors have been studied. OBJECTIVES: The aim of this study was to assess the weight changes and incidence excessive weight up to 3 years after surgery. METHODS: Post-LTx patients were assessed for their weight changes and incidence of excessive weight before liver disease; on the first outpatient appointment after LTx; 3 and 6 mo after LTx; 1; 2 and 3y after LTx. Demographic, socioeconomic, lifestyle and clinical variables were collected to assess risk factors for weight gain, overweight and obesity using linear and logistic regression analysis. RESULTS: Eighty patients undergoing LTx between 1997/2006 were assessed. Patients lost an average of 9.1 kg during liver disease. This weight was recovered within 1 year after surgery; after 3 years, patients had gained an average of 11.6 kg. The incidence of excessive weight increased over the years, and 56.4% of patients were overweight in the 3 years after LTx; most of them were obese (30.0%). Risk factors for weight gain on the third year after LTx were greater BMI before liver disease (p < 0.01); former smoker (p < 0.01); family history of overweight (p = 0.04); being hosewife/unemployed/retired (p = 0.08); alcoholic indication for LTx (p = 0.02). Risk factors for incidence of excessive weight on the third year after LTx were being married (RR: 13.13; CI: 1.33-125.0); being former smoker (RR: 4.68; CI: 1.16-18.85); greater age at LTx (RR: 1.1; CI: 1.02-1.20). CONCLUSIONS: Post-LTx patients experienced weight gain after surgery, mainly during the 1 year after operation and increased progressive incidence up to 3 years, due to different risk factors, some of them can be prevented.