High food wastage and low nutritional intakes in hospital patients.

BACKGROUND AND AIMS: The aim of this study was to investigate the cause of continuing weight-loss in hospitalized patients. We determined 1. whether the hospital menu was able to meet the patients' minimum nutritional requirements, 2. the proportion of food being wasted and 3. the mean nutritional intakes of patients. METHODS: This study was carried out in a University hospital (1200 beds). All the food supplied and wasted was measured over a 28 day period on one ward in each of 4 different specialties. Average food intake per patient was calculated and checked against individual food intake measurements. RESULTS: The hospital menu provided over 2000 kcal/day and could meet patients' nutritional requirements. However, high wastage rates of greater than 40% resulted in energy and protein intakes within all specialties being less than 80% of that recommended. The cost of this waste was 139,655 pounds sterling in these four specialties. CONCLUSIONS: More than 40% of hospital food was wasted. Energy and protein intakes were low and patients did not, therefore, meet their recommended intakes. This helps to explain continuing weight-loss in hospital patients and represents a large waste of resources. Hospital feeding policies therefore need reviewing and made more appropriate to the needs of the sick.

The effect of sibutramine on energy expenditure and appetite during chronic treatment without dietary restriction.

OBJECTIVE: To assess the contribution of a thermogenic effect to weight loss induced by eight weeks treatment with sibutramine (15mg/d) vs placebo in obese subjects. DESIGN: Randomised, placebo controlled, double blind study. SUBJECTS: Thirty-two (7 male, 25 female) healthy obese body mass index (BMI) 33.9+/-0.5 kg/m2 subjects completed the trial. MEASUREMENTS: Energy expenditure (EE) was measured by indirect calorimetry during a 32 h stay in a respiration chamber before and after 8 weeks treatment. Visual analogue scales were completed for assessment of appetite sensation. No dietary restriction was given. RESULTS: Sibutramine caused a significant weight loss compared with placebo (-2.4 kg vs+0.3 kg, P<0.001). Despite the larger weight loss after 8 weeks, 24-h EE did not decrease more in the sibutramine than in the placebo group (-2. 6% vs -2.5%, P=ns). When the changes in 24-h EE were adjusted for changes in body weight, 24-h EE decreased significantly less in the sibutramine group than in the placebo group (0.8% vs 3.8%, P<0.02). Sibutramine significantly decreased both hunger and anticipated food consumption, and increased satiety scores. CONCLUSIONS: The weight reducing effect of sibutramine in humans is caused by a dual mechanism: reduction of energy intake by increasing satiety and decreasing hunger and prevention of the decline in EE that follows weight loss.

Repeatability and methodology of resting energy expenditure in patients with cystic fibrosis.

In this study, intra-individual variation of resting energy expenditure (REE) in adults with cystic fibrosis (CF) and the effect of measurement duration were determined. Twelve adults with CF and chronic Pseudomonas aeruginosa (Ps. aeruginosa) infection and 12 healthy volunteers, matched for age and sex were studied whilst clinically stable on days 1.2, and 15. Respiratory gas exchange was monitored by continuous measurement of oxygen uptake (VO2) and carbon dioxide production (VCO2) using a ventilated hood indirect calorimeter. Coefficients of variation (CVs) were 4.3% in patients and 2.4% in controls comparing days 1 and 2. The CV for patients was 5.0% and for controls 2.9% comparing days 1 and 15. The effect of measurement duration on REE was assessed in eight of the CF patients. REE remained stable for 40 min but tended to rise by 80 min. Plasma catecholamine concentrations were stable between study days in patients but fell with time in controls suggesting some adaptation to experimental procedure. The greater variability of REE in patients was related to change in serum CRP over 2 weeks. REE is a repeatable measurement in clinically stable patients with CF, though variability was greater in patients than healthy subjects. This has implications for the design and interpretation of longitudinal studies of REE in patients with chronic lung disease.

Effects of carbohydrate and lipid on resting energy expenditure, heart rate, sleepiness, and mood.

The effects of gastric infusions of fat and carbohydrate on physiological and psychological measures were compared using a within subject design in 9 healthy subjects (6 males). Each subject received isovolaemic rapid gastric infusions of sucrose solution (100% energy carbohydrate), lipid emulsion (100% energy fat, 20% Intralipid), and a non-nutrient control (0.9% saline) in a randomised order. Nutrient infusions were isoenergetic, containing one-third of an individual subject's estimated daily energy requirements (mean, 3227 kJ; range, 2479-3971 kJ). Measures of heart rate (HR), energy expenditure (EE), mood, and sleepiness were collected before the infusions and every 0.5 h for 3.5 h. Mean postingestive HR, EE, and satiation were significantly greater after the nutrient infusions than after the control. Sucrose induced a rapid increase in HR and EE, whereas lipid had a lesser and more delayed effect. Thirty minutes after the gastric infusions, HR and EE were significantly higher after the sucrose than after the lipid and saline. Hedonic tone was greater and tension lower after the saline and sucrose infusions than after the lipid infusion. From 3 to 3.5 h after ingestion, subjects felt significantly more sleepy after the lipid infusion than they did at these times after the saline infusion, and significantly more dreamy after the lipid infusion than they did after the sucrose infusion. In conclusion, the presence of lipid and sucrose in the intestine induces significant and differing physiological and psychological effects, which are independent of cognitive and orosensory influences.

Energy expenditure using isotope-labelled water (2H218O), exercise performance, skeletal muscle enzyme activities and plasma biochemical parameters in humans during 95 days of endurance exercise with inadequate energy intake.

Two men, R.F. and M.S., pulled sledges each with starting masses of 222 kg, 2300 km across Antarctica. Exercise was performed for approximately 10 h each day for 95 days. Despite an average energy intake of 21.3 MJ.day-1 both subjects lost more than 25% of body weight. Energy expenditure was measured using energy balance data (EB) and isotope-labelled water (2H218O). Isotope doses were taken on day 0 and day 50 of the expedition. During the first 50 days both methods gave reasonable agreement, giving energy expenditures of 38.3 (EB) and 35.5 (2H218O) MJ.day-1 in R.F. and 28.6 (EB) and 29.1 (2H218O) MJ.day-1 in M.S. The isotope data for days 20-30 yielded exceptional values of 44.6 MJ.day-1 in R.F. and 48.7 MJ.day-1 in M.S. Estimates of energy expenditure between day 51 and day 96 were much lower and although the methods were in agreement for R.F.-24.1 (EB) and 23.1 (2H218O) MJ. day-1, there was poor agreement for MS-26.8 (EB) and 18.8 (2H218O) MJ.day-1. However, some practical difficulties occurred during this second period and there were also problems arising from marked increases in body water that made estimates of body mass and composition change difficult to interpret. The latter problems were probably due to malnutrition, which may have also been responsible for surprising increases in urinary excretion of 2H and 18O observed in both men at around day 81. These increases may reflect the release of label incorporated into molecules other than water which do not normally freely exchange with the body water pool under the circumstances of marked malnourishment. Following the expedition, both men showed declines in maximal O2 consumption (VO2max, 53.6 to 41.2 ml O2 kg-1.min-1 in R.F., 58.1-46.0 ml O2 kg-1.min-1 in M.S.); maximal voluntary isometric force production in different muscle groups (up to 19.9% in R.F. and 55.8% in M.S.) and both cytoplasmic and mitochondrial skeletal muscle enzyme activities (up to 56% in R.F. and 63% in M.S.). Plasma samples taken during the expedition showed low glucose levels, inappropriately high insulin levels, and declines in testosterone and luteinizing hormone. Thyroxine, cholesterol, albumin and triglyceride levels remained normal.

Tumour necrosis factor-alpha, resting energy expenditure and cachexia in cystic fibrosis.

1. We investigated the relationship between circulating tumour necrosis factor-alpha concentrations, resting energy expenditure, cachexia and altered intermediary metabolism in patients with cystic fibrosis and chronic pulmonary infection. 2. Twenty adult patients with cystic fibrosis and chronic bronchial sepsis covering a spectrum of severity of lung disease (forced expiratory volume in 1 s 30-100% of predicted) were compared with 10 age matched, healthy, non-cystic fibrosis subjects. 3. Circulating tumour necrosis factor-alpha, C-reactive protein and neutrophil elastase-alpha 1-antiproteinase complex concentrations were determined simultaneously with glycerol, non-esterified fatty acids, catecholamines, anthropometric indices and resting energy expenditure (ventilated hood method). 4. Weight, body mass index and arm muscle mass were reduced in patients with cystic fibrosis compared with healthy control subjects (P < 0.01), whereas mean resting energy expenditure was increased [121 versus 101% predicted, mean difference 19.2% (95% confidence interval 11.0-27.4%), P < 0.001]. Circulating concentrations of glycerol (P < 0.01), non-esterified fatty acids (P < 0.01), adrenaline (P < 0.05), tumour necrosis factor-alpha, C-reactive protein and neutrophil elastase-alpha 1-antiproteinase complex (P < 0.01) were increased in patients compared with control subjects [tumour necrosis factor-alpha 96.9 versus 24.7 pg/ml, mean difference 72.2 pg/ml [95% confidence interval 27.7-116.7 pg/ml), P < 0.001]. Resting energy expenditure was significantly related to tumour necrosis factor-alpha levels and forced expiratory volume in 1 s. 5. In patients with cystic fibrosis and chronic pulmonary sepsis changes in resting energy expenditure, body composition and intermediary metabolism are consistent with the systemic effects of the host inflammatory response, which may be responsible for cachexia in adult patients. In particular these changes are consistent with the action of tumour necrosis factor-alpha, which was detected in the circulation during a period of apparent clinical stability.