Validation of a Diet Quality Screening Tool for Use in the Oldest Old.

The oldest old (aged ≥80 years) are often the population subgroup at high nutritional risk due to age-related metabolic changes. We performed a validation analysis of a dietary screening tool (DST) which was developed for older adults among the oldest old. We examined dietary intakes using three 24-hour dietary recalls and the DST among 122 participants (aged 82-97) of the Geisinger Rural Aging Study. DST scores were compared with the Health Eating Index (HEI)-2015 scores, which were calculated based on three-day dietary recalls. Pearson correlations were used to characterize concurrent validity and Bland-Altman plots were used to identify potential bias. DST scores were significantly correlated with HEI scores (adjusted r = 0.68; p < 0.001) in an age- and sex-adjusted model. Those within the not-at-risk DST group had significantly higher HEI scores (adjusted means = 79.6 ± 3.68) compared with those who were in the at-risk (adjusted means = 51.2 ± 1.56) and the possibly-at-risk (adjusted means = 66.3 ± 1.79) groups (p-trend < 0.001). The DST appears to be a valid measure of diet quality in the oldest old when compared with the HEI and may be a potential tool to assess overall diet quality in this population.

GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community.

BACKGROUND: This initiative aims to build a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings. METHODS: The Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications. RESULTS: A 2-step approach for the malnutrition diagnosis was selected, that is, 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 GLIM participants that selected 3 phenotypic criteria (non-volitional weight loss, low body mass index, and reduced muscle mass) and 2 etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least 1 phenotypic criterion and 1 etiologic criterion should be present. Phenotypic metrics for grading severity 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. CONCLUSIONS: A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The construct should be re-considered every 3-5 years.

Nutritional Considerations for Healthy Aging and Reduction in Age-Related Chronic Disease.

A projected doubling in the global population of people aged ≥60 y by the year 2050 has major health and economic implications, especially in developing regions. Burdens of unhealthy aging associated with chronic noncommunicable and other age-related diseases may be largely preventable with lifestyle modification, including diet. However, as adults age they become at risk of "nutritional frailty," which can compromise their ability to meet nutritional requirements at a time when specific nutrient needs may be high. This review highlights the role of nutrition science in promoting healthy aging and in improving the prognosis in cases of age-related diseases. It serves to identify key knowledge gaps and implementation challenges to support adequate nutrition for healthy aging, including applicability of metrics used in body-composition and diet adequacy for older adults and mechanisms to reduce nutritional frailty and to promote diet resilience. This review also discusses management recommendations for several leading chronic conditions common in aging populations, including cognitive decline and dementia, sarcopenia, and compromised immunity to infectious disease. The role of health systems in incorporating nutrition care routinely for those aged ≥60 y and living independently and current actions to address nutritional status before hospitalization and the development of disease are discussed.

Body mass index and all-cause mortality among older adults.

OBJECTIVE: To examine the association between baseline body mass index (BMI, kg/m(2) ) and all-cause mortality in a well-characterized cohort of older persons. METHODS: The association between BMI (both as a categorical and continuous variable) and all-cause mortality was investigated using 4,565 Geisinger Rural Aging Study participants with baseline age 74.0 ± 4.7 years (mean ± SD) and BMI 29.5 ± 5.3 kg/m(2) over a mean of 10.9 ± 3.8 years of follow-up. RESULTS: The relationship between BMI (as a continuous variable) and all-cause mortality was found to be U-shaped (P nonlinearity <0.001). Controlling for age, sex, smoking, alcohol, laboratory values, medications, and comorbidity status, underweight (BMI <18.5 kg/m(2) ) individuals had significantly greater adjusted risk of all-cause mortality than persons of BMI 18.5 to 24.9 kg/m(2) (reference range). Participants with overweight (BMI 25.0-29.9 kg/m(2) ) and class I obesity (BMI 30.0-34.9 kg/m(2) ) had significantly lower adjusted-risk of all-cause mortality. Those with classes II/III obesity (BMI ≥ 35.0 kg/m(2) ) did not have significantly greater adjusted-risk of all-cause mortality. Findings were consistent using propensity score weights and among never-smokers with 2- and 5-year lag analysis and among those with no identified chronic disease. CONCLUSIONS: A U-shaped association was observed between BMI and all-cause mortality with lower risk among older persons with overweight and class I obesity in comparison with those with BMI 18.5 to 24.9 kg/m(2) .

Efficacy and Safety of Glutamine-supplemented Parenteral Nutrition in Surgical ICU Patients: An American Multicenter Randomized Controlled Trial.

OBJECTIVE: To determine whether glutamine (GLN)-supplemented parenteral nutrition (PN) improves clinical outcomes in surgical intensive care unit (SICU) patients. SUMMARY BACKGROUND DATA: GLN requirements may increase with critical illness. GLN-supplemented PN may improve clinical outcomes in SICU patients. METHODS: A parallel-group, multicenter, double-blind, randomized, controlled clinical trial in 150 adults after gastrointestinal, vascular, or cardiac surgery requiring PN and SICU care. Patients were without significant renal or hepatic failure or shock at entry. All received isonitrogenous, isocaloric PN [1.5 g/kg/d amino acids (AAs) and energy at 1.3× estimated basal energy expenditure]. Controls (n = 75) received standard GLN-free PN (STD-PN); the GLN group (n = 75) received PN containing alanyl-GLN dipeptide (0.5 g/kg/d), proportionally replacing AA in PN (GLN-PN). Enteral nutrition (EN) was advanced and PN weaned as indicated. Hospital mortality and infections were primary endpoints. RESULTS: Baseline characteristics, days on study PN and daily macronutrient intakes via PN and EN, were similar between groups. There were 11 hospital deaths (14.7%) in the GLN-PN group and 13 deaths in the STD-PN group (17.3%; difference, -2.6%; 95% confidence interval, -14.6% to 9.3%; P = 0.66). The 6-month cumulative mortality was 31.4% in the GLN-PN group and 29.7% in the STD-PN group (P = 0.88). Incident bloodstream infection rate was 9.6 and 8.4 per 1000 hospital days in the GLN-PN and STD-PN groups, respectively (P = 0.73). Other clinical outcomes and adverse events were similar. CONCLUSIONS: PN supplemented with GLN dipeptide was safe, but did not alter clinical outcomes among SICU patients.

Malnutrition and inflammation-"burning down the house": inflammation as an adaptive physiologic response versus self-destruction?

A summary of my 2014 Rhoads Lecture is presented that explores our progress in understanding the complex interplay of malnutrition and inflammation. A historical perspective is provided that highlights the contributions of some of the key pioneers in the nutrition assessment field. Advances in agriculture, education, public health, healthcare, and living standards have affected traditional settings for malnutrition. The chronic disease, surgery, and injury conditions that are associated with modern healthcare are becoming prevalent settings for malnutrition. One consequence has been a growing appreciation for the contributions of inflammation to malnutrition in these clinical conditions. This recognition has driven a fresh look at how we define and think about malnutrition syndromes. An inflammatory component is included in the definitions suggested by the recent Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition consensus report that also describes characteristics recommended for the identification and documentation of malnutrition. Efforts are currently underway to evaluate the feasibility and validity of this approach. Recent advances in research highlight the profound impact of inflammation-mediated erosion of muscle mass on clinical outcomes. Research to identify better biomarkers of inflammation and malnutrition must be a leading priority. New "omics" approaches are an especially promising avenue of biomarker investigation. Inflammation can be a good thing; let's try to keep it that way.

Diet-related practices and BMI are associated with diet quality in older adults.

OBJECTIVE: To assess the association of diet-related practices and BMI with diet quality in rural adults aged ≥74 years. DESIGN: Cross-sectional. Dietary quality was assessed by the twenty-five-item Dietary Screening Tool (DST). Diet-related practices were self-reported. Multivariate linear regression models were used to analyse associations of DST scores with BMI and diet-related practices after controlling for gender, age, education, smoking and self- v. proxy reporting. SETTING: Geisinger Rural Aging Study (GRAS) in Pennsylvania, USA. SUBJECTS: A total of 4009 (1722 males, 2287 females; mean age 81·5 years) participants aged ≥74 years. RESULTS: Individuals with BMI < 18·5 kg/m2 had a significantly lower DST score (mean 55·8, 95 % CI 52·9, 58·7) than those individuals with BMI = 18·5-24·9 kg/m2 (mean 60·7, 95 % CI 60·1, 61·5; P = 0·001). Older adults with higher, more favourable DST scores were significantly more likely to be food sufficient, report eating breakfast, have no chewing difficulties and report no decline in intake in the previous 6 months. CONCLUSIONS: The DST may identify potential targets for improving diet quality in older adults including promotion of healthy BMI, breakfast consumption, improving dentition and identifying strategies to decrease concern about food sufficiency.

Recognizing malnutrition in adults: definitions and characteristics, screening, assessment, and team approach.

Appropriate recognition of malnutrition in adults requires knowledge of screening and assessment methodologies. An appreciation for the contributions of inflammation has resulted in a new etiology-based approach to defining malnutrition syndromes. The Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) have published a consensus document that extends this approach to describe characteristics for the identification and documentation of malnutrition in adults. Nutrition screening tools are used to identify patients at nutrition risk and those who are likely to benefit from further assessment and intervention. Nutrition assessment serves to guide appropriate intervention. A systematic approach to nutrition assessment that supports the new diagnostic scheme and criteria from the Academy and A.S.P.E.N. has recently been presented. Since screening delays and failures in the diagnosis and management of malnutrition are all too common, a multidisciplinary team approach is recommended to promote improved communication and quality of care.

Interrelationships between tissue iron status and erythropoiesis during postweaning development following neonatal iron deficiency in rats.

Dietary iron is particularly critical during periods of rapid growth such as in neonatal development. Human and rodent studies have indicated that iron deficiency or excess during this critical stage of development can have significant long- and short-term consequences. Since the requirement for iron changes during development, the availability of adequate iron is critical for the differentiation and maturation of individual organs participating in iron homeostasis. We have examined in rats the effects of dietary iron supplement following neonatal iron deficiency on tissue iron status in relation to erythropoietic ability during 16 wk of postweaning development. This physiological model indicates that postweaning iron-adequate diet following neonatal iron deficiency adversely affects erythroid differentiation in the bone marrow and promotes splenic erythropoiesis leading to splenomegaly and erythrocytosis. This altered physiology of iron homeostasis during postweaning development is also reflected in the inability to maintain liver and spleen iron concentrations and the altered expression of iron regulatory proteins in the liver. These studies provide critical insights into the consequences of neonatal iron deficiency and the dietary iron-induced cellular signals affecting iron homeostasis during early development.

A postweaning iron-adequate diet following neonatal iron deficiency affects iron homeostasis and growth in young rats.

Iron deficiency is among the most prevalent of nutrient-related diseases worldwide, but the long-term consequences of maternal and neonatal iron deficiency on offspring are not well characterized. We investigated the effects of a postweaning iron-adequate diet following neonatal iron deficiency on the expression of genes involved in iron acquisition and homeostasis. Pregnant rats were fed an iron-adequate diet (0.08 g iron/kg diet) until gestational d 15, at which time they were divided into 2 groups: 1) a control group fed an iron-adequate diet, and 2) an iron-deficient group fed an iron-deficient diet (0.005 g iron/kg diet) through postnatal d (P) 23 (weaning). After weaning, pups from both dietary treatment groups were fed an iron-adequate diet until adulthood (P75). Rat pups that were iron deficient during the neonatal period (IDIA) had reduced weight gain and hemoglobin concentrations and decreased levels of serum, liver, and spleen iron on P75 compared with rats that were iron sufficient throughout early life (IA). IDIA rats developed erythrocytosis during postweaning development. Further, hepatic expression of hepcidin in IDIA rats was 1.4-fold greater than in IA rats, which paralleled an upregulation of IL-1 expression in the serum. Our data suggest that an iron-adequate diet following neonatal iron deficiency induced an inflammatory milieu that affected iron homeostasis and early growth and development.

Iron chelation down-regulates dopamine transporter expression by decreasing mRNA stability and increasing endocytosis in N2a cells.

Cell surface expression of the dopamine transporter (DAT) is determined by the relative rates of its internalization and recycling. Changes in the cellular labile iron pool (LIP) affect many cellular mechanisms including those that regulate DAT trafficking. In this study, we analyzed DAT expression and posttranslational modifications in response to changes in cellular iron in transfected neuroblastoma cells (N2a). Iron chelation by desferrioxamine (DFO) altered DAT protein levels by decreasing the stability of DAT mRNA. Increased phosphorylation and ubiquitination of this transporter protein following DFO treatment were also observed. Cellular iron depletion elevated protein levels of the early endosomal marker Rab5. Moreover, confocal microscopy studies showed increased localization of DAT into the endosomal compartment in DFO-treated cells compared to control. Together, these findings suggest that cellular iron depletion regulates DAT expression through reducing mRNA stability as well as an increasing in endocytosis.

Malnutrition syndromes: a conundrum vs continuum.

This provocative commentary critically examines historic definitions for adult malnutrition syndromes as they apply to developed countries with modern healthcare. To stimulate further discussion, the authors propose an updated approach that incorporates current understanding of the systemic inflammatory response to help guide assessment, diagnosis, and treatment. An appreciation of a continuum of inflammatory response in relation to malnutrition syndromes is described. This discussion serves to highlight a research agenda to address deficiencies in diagnostics, biomarkers, and therapeutics of inflammation in relation to malnutrition.

Inflammation: roles in aging and sarcopenia.

Aging is associated with inflammatory chronic conditions such as obesity, cardiovascular disease, insulin resistance, and arthritis. Sarcopenia-muscle loss with aging-is multifactorial with contributing factors that may include loss of alpha-motor neuron input, changes in anabolic hormones, decreased intake of dietary protein, and decline in physical activity. Research findings suggest that sarcopenia is a smoldering inflammatory state driven by cytokines and oxidative stress. Elevated levels of interleukin-6 and C-reactive protein are often detected. Sarcopenic obesity manifests the added inflammatory burden of adiposity and associated adipokines. Potential interventions for sarcopenia include nutritional supplements, physical activity/resistance exercise, caloric restriction, anabolic hormones, anti-inflammatory agents, and antioxidants. A key question is whether sarcopenia is truly a distinct syndrome or a milder form of a cachexia continuum.

Drug-induced hyperphagia: what can we learn from psychiatric medications?

This brief review examines hyperphagia and associated weight gain as undesirable side effects of psychiatric medications; exploring the scope of the problem, proposed mechanisms, and potential interventions. Mechanisms of action appear to include drug-mediated effects on hypothalamic appetite pathways that have been implicated in other etiologies of obesity. There is great individual variation in response to these medications as well as variation in the degree of weight gain within drug classes. Gene polymorphisms may be a key factor in determining individual variations in response. Better understanding of the underlying mechanisms can guide useful interventions. Medication selection and dosing appear to be important strategies to minimize adverse weight gain.

Weight, dietary and physical activity behaviors two years after gastric bypass.

BACKGROUND: This cross-sectional survey was designed to determine the self-reported weight management, dietary and physical activity behaviors of Roux-en-Y gastric bypass (RYGBP) patients who were 1 to 4 years after the RYGBP operation, and to identify gaps in follow-up nutrition-related chronic disease prevention. METHODS: Questionnaires including behavioral items from the 2003 and 2004 Behavioral Risk Factor Surveillance System (BRFSS) were mailed to all RYGBP patients in a clinically active outpatient database. RESULTS: Of 212 patients, 140 (66%) returned completed questionnaires. Responders were 24.2 +/- 7.9 months postoperatively. They were older than nonresponders (45.2 +/- 9.9 vs 38.5 +/- 8.9 years, P<.001). Responders had an average weight loss of 55.8 +/- 15.2 kg, and most (81%) reported that they were still trying to lose weight. The most frequently reported dietary behavior for weight loss was decreasing calorie and fat intakes. However, in addition to avoiding sodas and sweet desserts, responders were also excluding nutrient-dense foods high in vitamins and minerals such as milk and dairy products, red meats, breads, cereals and nuts. Remarkably, only 25 (17.9%) engaged in regular exercise activities before surgery, while 116 (82.9%) indicated a moderate level of current physical activity averaging 54.7 +/- 38.5 minutes per episode. Multivariable linear regression analyses identified age, weight at age 21, pre-surgery BMI and time in regular physical activities as the four significant predictors of BMI after weight loss stabilization. CONCLUSION: Postoperative RYGBP patients engage in various weight management behaviors, some of which could offer greater health benefits with follow-up intervention from dietitians and exercise specialists to prevent adverse outcomes such as weight regain and micronutrient deficiencies.

Obesity is a risk factor for reporting homebound status among community-dwelling older persons.

OBJECTIVE: To test the a priori hypothesis that obesity is a predictor of risk for reporting homebound status. RESEARCH METHODS AND PROCEDURES: A longitudinal cohort study was conducted with 21,645 community-dwelling men and women 65 to 97 years old. A nutrition risk screen was administered baseline between 1994 and 1999 and again 3 to 4 years later. Univariate analyses identified baseline variables associated with subsequent reporting of homebound status. Multivariable logistic regression models were created to identify baseline variables that were significant independent predictors of reporting homebound status. RESULTS: At baseline, 24% of the cohort had BMI > or = 30. There were 12,834 (45% men) respondents at follow-up (68% response). Non-responders at follow-up differed little from responders except for greater baseline age (72.2 +/- 6.2 vs. 71.4 +/- 5.6 years, p < 0.001) and reporting of any functional limitations (9.2% vs. 4.9%, p < 0.001). At follow-up, those who reported homebound status (n = 169) were significantly (p < 0.001) older (80.3 +/- 7.3 vs. 75.1 +/- 5.5 years) and more likely to report functional limitations (83.4% vs. 10.8%). Univariate analyses identified 16 baseline variables that were eliminated stepwise until five significant independent predictors remained: age > or = 75 years (2.21, 1.55 to 3.15/odds ratio, 95% confidence interval), BMI > or = 35 (1.75, 1.04 to 2.96), poor appetite (2.50, 1.29 to 4.86), low income (1.59, 1.00 to 2.56), and any functional limitation (10.67, 7.36 to 15.46). DISCUSSION: Obesity remained a significant independent predictor for reporting homebound status and should be considered in screening of older populations and in the planning, implementation, and evaluation of services for homebound older persons.

Provision of high-protein supplement for patients recovering from hip fracture.

OBJECTIVE: We compared clinical outcomes with a standard (Ensure) or a high-protein (Boost HP) liquid nutritional supplement for older adults recovering from hip fracture surgery in a rehabilitation hospital. METHODS: This randomized, double-blind, parallel-group study compared the clinical effectiveness of a standard (Ensure) with a high-protein (Boost HP) liquid nutritional supplement among patients (n = 46) 60 y or older who recently underwent surgical repair of a hip fracture. Patients were encouraged to drink at least two 8-oz cans (17.8 g/d protein for Ensure versus 30 g/d protein for Boost HP) per day for 28 d. Study measurements included change in Functional Independence Measure between rehabilitation admission and discharge, length of rehabilitation stay, laboratory measures (i.e., serum albumin, prealbumin, and C-reactive protein), physical activity energy expenditure by 7-d triaxial accelerometry, and dietary intake by three random, telephonic, 24-h dietary recalls. RESULTS: There were no significant group differences with respect to age, sex, acute hospital days, hip fracture assessment parameters, or surgical treatment. Consumption of supplement (260 oz/28 d of Ensure versus 239 oz/28 d of Boost HP) was comparable. There were no differences in complication or adverse event rates during the study. The Boost HP group consumed more protein than the Ensure group (63 versus 50 g, P < 0.048) and had a greater improvement in serum albumin over the 28-d supplementation period (+0.7 versus +0.2 g/dL, P < 0.019). The Boost HP group also consumed more fiber (12 versus 8 g), calcium (821 versus 639 mg), vitamin K (66 versus 45 microg), and phosphorus (1035 versus 833 mg) than did the Ensure group. Rehabilitation length of stay was shorter in the Boost HP than in the Ensure group, although this trend did not reach statistical significance (23 versus 28 d, P = 0.27). Outcome differences were not detected in the Functional Independence Measure. CONCLUSIONS: Supplementation was well tolerated in this population and contributed significantly to total dietary intake. Consumption of a high-protein liquid nutritional supplement may offer some benefits by improving visceral protein status.

Noncompliance with body weight measurement in tertiary care teaching hospitals.

BACKGROUND: Body weight provides vital information for patient care; therefore, measurement at hospital admission should be standard practice. Our objective was to test compliance with this standard. METHODS: This was a study of 300 patients, aged > or = 18 years, admitted to general medicine and surgery services of 3 tertiary care teaching hospitals in Nashville, Chicago, and San Francisco. At 24 to 36 hours after admission, participants were queried as to whether they had been weighed, and if not, they were asked whether they had been questioned by nursing personnel about their weight. Subjects were then weighed by research personnel using identical protocol at all 3 institutions. Any admission body weight documented by nursing was noted. RESULTS: Compliance was similar at all 3 institutions, with only 197 (65.7%) of patients reporting being weighed. There were 213 (71.0%) patients who had a weight documented in the nursing record. Of those who had not been weighed, 69 (67.0%) indicated that they had been queried about their weight. Comparison of documented weights in the nursing records with those measured by research personnel revealed that 55 (25.9%) differed by > or = 5 pounds (2.27 kg). Those who had a documented weight in the nursing record but were not weighed by nursing personnel were also more likely to deviate from the weight measured by research personnel by > or = 5 pounds (2.27 kg) in comparison with those who had been weighed by nursing personnel (42.8% versus 21.8%, respectively, p < .0147). CONCLUSION: Overall compliance with weight measurement is poor. Recorded weights are often inaccurate.

Obesity is associated with functional decline in community-dwelling rural older persons.

OBJECTIVES: This investigation sought to examine potential gender differences in the relationship between body mass index (BMI) and functional decline. DESIGN: Cohort study. SETTING: Rural Pennsylvania. PARTICIPANTS: Medicare managed-risk program participants (aged > or =65) in the Geisinger Health Plan. Mean age at study baseline was 71. Final analyzable sample was 2,634 participants. MEASUREMENTS: Self-reported weight, weight change, living and eating habits, alcohol and medication use, depression, dentition, and functional status were obtained upon enrollment and again between 3 and 4 years later. Measured height and weight were also recorded at enrollment. Functional decline was defined as any increase in reported limitations in activities of daily living or instrumental activities of daily living over the study period. Logistic regression was used to evaluate the relationship between BMI, as defined by current National Institutes of Health categories, and risk of functional decline while controlling for age, depression, and polypharmacy. The referent category was BMI 18.5 to 24.9. RESULTS: Women had a higher prevalence of reported functional decline than men at the upper range of BMI categories (31.4% vs 14.3% for BMI > or =40). Women (odds ratio (OR) = 2.61, 95% confidence interval (CI) = 1.39-4.95) and men (OR = 3.32, 95% CI = 1.29-8.46) exhibited increased risk for any functional decline at BMI of 35 or greater. Weight loss of 10 pounds and weight gain of 20 pounds were also risk factors for any functional decline. CONCLUSIONS: Obesity was a risk factor for functional decline in older persons of either gender. Change in body weight did not benefit function for many older persons.