Unsatisfactory knowledge and use of terminology regarding malnutrition, starvation, cachexia and sarcopenia among dietitians.

BACKGROUND & AIMS: Clinical signs of malnutrition, starvation, cachexia and sarcopenia overlap, as they all imply muscle wasting to a various extent. However, the underlying mechanisms differ fundamentally and therefore distinction between these phenomena has therapeutic and prognostic implications. We aimed to determine whether dietitians in selected European countries have 'sufficient knowledge' regarding malnutrition, starvation, cachexia and sarcopenia, and use these terms in their daily clinical work. METHODS: An anonymous online survey was performed among dietitians in Belgium, the Netherlands, Norway and Sweden. 'Sufficient knowledge' was defined as having mentioned at least two of the three common domains of malnutrition according to ESPEN definition of malnutrition (2011): 'nutritional balance', 'body composition' and 'functionality and clinical outcome', and a correct answer to three cases on starvation, cachexia and sarcopenia. Chi-square test was used to analyse differences in experience, work place and number of malnourished patients treated between dietitians with 'sufficient knowledge' vs. 'less sufficient knowledge'. RESULTS: 712/7186 responded to the questionnaire, of which data of 369 dietitians were included in the analysis (5%). The term 'malnutrition' is being used in clinical practice by 88% of the respondents. Starvation, cachexia and sarcopenia is being used by 3%, 30% and 12% respectively. The cases on starvation, cachexia and sarcopenia were correctly identified by 58%, 43% and 74% respectively. 13% of the respondents had 'sufficient knowledge'. 31% of the respondents identified all cases correctly. The proportion of respondents with 'sufficient knowledge' was significantly higher in those working in a hospital or in municipality (16%, P < 0.041), as compared to those working in other settings (7%). CONCLUSIONS: The results of our survey among dietitians in four European countries show that the percentage of dietitians with 'sufficient knowledge' regarding malnutrition, starvation, cachexia and sarcopenia is unsatisfactory (13%). The terms starvation, cachexia and sarcopenia are not often used by dietitians in daily clinical work. As only one-third (31%) of dietitians identified all cases correctly, the results of this study seem to indicate that nutrition-related disorders are suboptimally recognized in clinical practice, which might have a negative impact on nutritional treatment. The results of our study require confirmation in a larger sample of dietitians.

Folate absorption from folate-fortified and processed foods using a human ileostomy model.

Data on folate absorption from food from validated human studies using physiological folate doses are still needed to estimate dietary requirements and to formulate recommendations. The aim of the present work was to study the effects from fortified and processed foods on folate absorption in ileostomy volunteers (n 9) using the area under the plasma concentration curve (AUC) and kinetic modelling. Using a standardized single-dose protocol, dairy products fortified with a candidate fortificant (6S)-5-methyltetrahydrofolate ((6S)-5-CH3-H4folate), folic acid-fortified bread and a dessert crème containing natural yeast folate polyglutamates were compared with folate supplements. Absorbed folate was estimated by AUC and a kinetic model, and non-absorbed folate by ileostomal folate excretion. Median apparent absorption from test foods ranged from 55 to 86 %. Added folate-binding proteins (FBP) significantly reduced folate absorption from dairy products, as in the absence of FBP, AUC-dose-corrected ratios were increased and ileal folate excretion decreased. After in vivo gastrointestinal passage of dairy products containing FBP, up to 43 % of the ingested FBP was found in ileostomal effluent. Folate absorption was similar for (6S)-5-CH3-H4folate fortificant from fermented milk and for folic acid from fortified bread. Folic acid, ingested as food fortificant in bread, was significantly less absorbed compared with an isolated supplement. We conclude that all tested foods were suitable matrices for folate fortification. However, dairy products, fortified with the new candidate fortificant (6S)-5-CH3-H4folate, are suitable if no active FBP is present.

Study of wheat breakfast rolls fortified with folic acid. The effect on folate status in women during a 3-month intervention.

BACKGROUND: Folate has come into focus due to its protective role against child birth defects such as neural tube defects (NTD). Swedish authorities recommend all fertile women to increase their folate intake to 400 microg/day by eating folate-rich foods. Because not all women follow these recommendations, there is a discussion today about whether Sweden should introduce folic acid fortification in wheat flour and sifted rye flour. This decision needs knowledge about the bioavailability of folic acid from fortified foods. AIM OF THE STUDY: To investigate effects of two folic acid fortification levels on folate status in healthy female volunteers and to study the folic acid stability during the baking procedure and storage of the fortified breakfast rolls. METHOD: Twenty-nine healthy women were recruited. Folic acid-fortified wheat breakfast rolls were baked with the purpose to contain 200 microg folic acid/roll (roll L) and 400 microg folic acid/roll (roll H). Fourteen women were given one roll/day of roll L (group L) and 15 one roll/day of roll H (group H) during 12 weeks of intervention. Fasting venous blood samples were collected on days 0, 30, 60 and 90. Serum homocysteine concentrations were determined using an immunoassay. Serum and erythrocyte folate concentrations were analysed using a protein-binding assay with fluorescent quantification. The folic acid concentration in the breakfast rolls was analysed by HPLC on days 0, 30, 60 and 90. Total folate concentration was measured with microbiological assay on day 45. RESULTS: Group L Group L had initially an average erythrocyte folate concentration of 577 +/- 93 nmol/L. After 90 days of intervention, an increase of 20 % (p < 0.05) was observed. At day 0, mean serum folate concentrations were 16.9 +/- 4.3 nmol/L. The mean serum folate concentrations increased by 30 % (p < 0.001) after 90 days. At day 0, mean serum homocysteine concentrations were 9.1 +/- 2.0 micromol/L, which decreased by 20 % (p < 0.01) after 30 days. Group H Group H had an initial erythrocyte folate concentration of 784 +/- 238 nmol/L. After 90 days, an increase of 26 % (p < 0.05) was observed. Serum folate increased at least 22 % after 30 days, from a level of 18.7 +/- 4.8 nmol/L at day 0. Thereafter, all women of group H had serum concentrations at or above the upper limit of quantification (23 nmol/L). At day 0, mean serum homocysteine concentrations were 8.4 +/- 1.7 micromol/L, which decreased by 16 % (p < 0.05) after 30 days. The baking procedure resulted in 20-25 % loss of fortified folic acid in the rolls used in the present study. The size of the rolls affected the retention of folic acid during baking. No significant loss was seen in folic acid concentration in the rolls during the intervention period. CONCLUSION: The present study showed that in healthy women, subjected to a 12-week intervention with breakfast rolls fortified with either 166 microg or 355 microg folic acid, serum homocysteine concentration decreased (p < 0.05) and erythrocyte folate increased (p < 0.05). The lower level of fortification seems to be sufficient to improve the folate status. Together with the average daily intake of natural folates, these women reach the recommended intake of 400 microg/day. Folic acid is stable in fortified bread for 90 days storage at -20 degrees C.